K»lS«W .IH^BssstisismmiSDigmai^s^ssSsm CORNEL L UNIV ERSITY THE Mcmn Urtfrinary Bltbrar^ FOUNDED BY ROSWELL p. FLOWER for the use of the N. Y. State Veterinary College 1897 This Volume is the Gift of ...Dr.,...D....E.....Salmoji... 356 RC 41 si5°™°"""'™"'*>"-"'"T V.3 '^m«m«^lmSiXS?3'..?X9}9P^'^ Inward (one case). Dislocations of Both Bones Backward. — The inward and outward subvarieties are of no practical importance. Symptoms. — The elbow is swelled and partly flexed. The olecranon may be felt displaced backward from the epieondyles and the head of the radius may be recog- nized behind the external epicondyle as a bony point which rotates with the fore- arm. The trochlear surface may be prominent in the bend of the elbow; the tendon of the biceps behind. Passive flexion and extension are moderate. There is abnormal lateral mobility in full extension. The cause is most commonly a fall upon the outstretched hand forcing the two bones backward. The coronoid proc- ess of the ulna is either broken or lifted over the trochlear surface by hyperexten- sion or by abduction, which increases the normal outward deviation of the fore- arm and a twist which swings the process downward and then backward. Pathology. — The internal lateral liga- ment is torn, and the external one either torn or stripped away with the perios- teum from the external condyle. Hence, in old dislocations reduction is effectually prevented by the mass of callus that forms beneath this elevated periosteum behind the external condyle. The front of the capsule is torn, the epitrochlea (internal epicondyle) may be broken by muscular action, or the muscles attached to it may be ruptured. Fractures of the head of the radius and coronoid process are rare. The latter, however, does not interfere with the action of the brachi- alis anticus, as that muscle is attached DISLOCATIONS. ELBOW. TREATMENT. 17 to tlie base of the process: a part not interested in the fracture. Treatment. — Forcible flexion is to be condemned as unscientific and less likely to succeed than pressure on the dislo- cated bones combined with traction of the forearm in moderate extension or hyperextension. Usually the dislocation is easily reduced. Sometimes anaesthet- ics are necessary. After reduction the limb should be immobilized by bandages and a sling for about three weeks, after which mild massage and active motion will gradually remove the stiffness. Early passive motion will not hasten the result, and may even increase the ex- cessive production of callus which, in children, sometimes goes on even after reduction and may cause serious limita- tion to the motion of the Joint. Lateral Dislocations. — Incomplete dis- locations in either direction are said to be frequently overlooked or mistaken for fractures. The cause of lateral disloca- tions is usually a fall upon the hand by which the normal outward angle at the elbow is increased by tearing of the in- ternal lateral ligament and a downward movement of the ulna, directly away ■from the trochlea. The head of the radius then glides either outward or in- ward, as the case may be, the ulna fol- lowing. In incomplete inward dislocations the forearm is pronated and slightly flexed; its long axis parallel to and a little to the inner side of that of the arm. The olec- ranon and external condyle are promi- nent, and the head of the radius can be felt displaced downward and inward, resting below the trochlea (the greater fiigmoid cavity of the ulna embraces the epitrochlea). Flexion and extension are but little interfered with. Eeduction is made by traction and direct pressure. In imreduced cases there is very little disability, and operative interference is probably inadvisable. Incomplete Outward Dislocations. — The forearm is pronated and slightly flexed, and its long axis is to the outer side of and parallel to that of the arm or else in abduction. The ulna is displaced so that the central ridge of the greater sigmoid cavity has passed beyond the outer rim of the trochlea; the radius lies partly below or entirely beyond the ex- ternal condyle. The internal condyle and olecranon are prominent. Treatment. — The ridge of the sigmoid cavity must be unlocked from the groove between the trochlea and capitellum. This is done by traction or hyperexten- sion (or by abduction, if the head of the radius rests below the external condyle and can be used as a fulcrum). Then the bones are pushed easily into place. The broken epitrochlea may lodge in the groove of the trochlea and effectually prevent reduction. Even if the disloca- tion be not reduced, the joint may be quite useful. Complete outward dislocation occurs in three forms. In the simplest form the bones of the forearm are displaced di- rectly outward, the inner edge of the olecranon resting against the outer side of the external condyle. If, now, the forearm is flexed and strongly pronated, the second form (subepicondylar) is pro- duced, in which the anterior surface of the ulna looks inward and its sigmoid cavity embraces the outer side of the external condyle, while the radius lies above it, with its head in front of the epicondylar ridge. In the third form (supra-epicondylar) the dislocated bones are moved still further upward and back- ward, so that their articular surfaces lie external to and behind the supinator ridge. Eeduction is usually easy, owing to the extensive laceration to ligaments; 3—2 18 DISLOCATIONS. ARM. but, even if unreduced^ the elbow re- mains fairly strong and mobile. Forward Dislocation. — This rare in- jury is usually caused by direct trauma to the back of the flexed elbow. The olecranon was broken in about a third of the cases. If this is the case, the ulna and radius are displaced forward and up- ward in the anterior surface of the humerus; but, if the olecranon remains intact, it may rest on the trochlea, or, the triceps being torn away, it may pass to the front of the humerus. Eeduction by traction appears to have been easily accomplished. DivEEGENT Dislocations of the Radius and Ulna. — In the antero-pos- terior variety the ulna lies behind and the radius in front of the humerus; in the transverse the ulna is displaced in- ward and the radius outward. The usual cause seems to be abduction followed by internal rotation and impulsion. Reduc- tion has failed in one-quarter of the eases. Dislocation of the Ulna Alone. — The forearm is usually extended and ad- ducted. Flexion is painful; rotation free. The trochlea is prominent in front and the olecranon behind, while the head of the radius remains in place. The cause of the injury appears to be hyperexten- sion or abduction, followed by adduction and inward rotation. The rational method of reduction is by supination, abduction, and hyperextension (von Pitha). Dislocation of the Radius Alone. —Of the dislocations backward, outward, and forward the last is the most frequent, being, in fact, of not imusual occur- rence in connection with a fracture of the shaft of the ulna from a fall upon the hand. The head of the bone is displaced upward in front of the external condyle. The orbicular and anterior ligaments are torn. Abduction is possible, while supi- nation, flexion, and adduction are all limited. Adduction and pressure ap- pears to be the best method of reduction; but the orbicular ligament may be inter- posed and require operative interference. The backward and outward dislocations are very rare. They necessitate a fract- ure of the ulna or a rupture of the inter- osseous membrane. The downward dislocation (dislocation by elongation, subluxation of young chil- dren) is of frequent occurrence. The clinical history is quite characteristic: a child, usually under three years of age, is pulled by the hand; it cries out, and refuses to use the limb, which hangs with the forearm partly flexed and pronated. The region of the head of the radius is sensitive to pressure, and sometimes an interval can be felt between the radius and the condyle. 'All passive motions, except supination, are free. .On forcible supination a slight click may be felt and the symptoms are at once relieved. Du- verney's theory of downward displace- ment with interposition of the annular ligament is most in accord with the facts. Old Unreduced Dislocations of THE Elbovst. — Adhesions and new bone formation very soon immobilize the joint. If this immobilization occurs in exten- sion, the position may be improved by forcible flexion, with or without fracture of the olecranon. A more accurate method, however, and one likely in many cases to afford fairly-good functional re- sults, is arthrotomy. The chief obstacle to reduction will be found to be the new bone in the great sigmoid cavity. This- may be removed and adhesions divided through two lateral incisions, or a U- shaped incision with division of the tri- ceps or olecranon. Dislocations of the Lowee Radio- Ulnae Joint.— The ulna is spoken of a& DISLOCATIONS. AEM. WEIST. 19 the dislocated bone. It may be dislo- cated forward or backward. The latter variety is caused by exaggerated prona- tion, and the former by direct trauma. Both are easily reduced., Dislocations of the Cahpus feoh THE Eadius. — These may be complete or incomplete; forward, backward, or out- ward. In the incomplete form the cunei- form maintains its relations to the tri- angular fibrocartilage, while the scaphoid and semilunar are dislocated from the radius. In one case the semilunar alone was not displaced (backward). These dislocations may be complicated by fract- ure of the anterior or posterior ("Bar- ton's fracture") lip of the radius; but this fracture in no way complicates the treatment and is a purely secondary mat- ter. The more common Colles fracture of the lower end of the radius was long con- founded with backward dislocation. The differential diagnosis is easily made by attention to the relations of the styloid process of the radius with that of the ulna and with the projecting mass on the back of the wrist (Fig. 10). Eeduction in either case is made by dorsal flexion and direct pressure, and after reduction the differential diagnosis is easy. The spontaneous forward dislocation of Madeburg occurs slowly in adolescents as the result of absorption of the anterior" part of the articular surface of the radius. The ulna is abnormally prominent; dorsal flexion is limited. Dislocations op the Cakpal Bones. Dislocations have been reported of each of the carpal bones except the cuneiform. If the bone cannot be pressed into place, and gives rise to annoying symptoms, it had better be removed. A few dislocations of the second row of carpal bones upon the first have been reported. Cahpo-Metacaepal Dislocations. — The first metacarpal is the one most commonly dislocated; the dislocation is usually backward and incomplete. The base of the dislocated bone forms a dis- tinct prominence on the back of the hand; this is readily reduced, but as readily recurs. To prevent recurrence, extension of the finger (and also abduc- tion, if it be the thumb) and direct press- ure oh the head of the bone must be "maintained by a dorsal splint for one or two weeks. Habitual dislocations of these joints are often quite painful. Fig. 10. — Diagrammatic, to indicate the de- formity in (A) dislocation of the wrist back- ward and (B) Colles's fracture of the radius. {Stimson.) Dislocations of the Thumb and PiNGEES. — Mdacarpo-Phalangeal Dislo- cations of the Thumb. — Lateral (one case) and forward dislocations present no es- pecial points of interest. The latter are easily reduced by hyperflexion and trac- tion. Backward dislocations of this joint, however, have long been the sub- ject of controversy, and are treated in some of our latest text-books in a manner none too accurate. This dislocation may be incomplete, complete, or complex. In- complete backward dislocations may be produced voluntarily by many young persons. It is' reduced at will. In the 20 DISLOCATIONS. FINGERS. PELVIS. complete form the phalanx is carried backward and upward on the dorsum of the metacarpal, usually by forced exten- sion, the anterior ligament is torn away from the metacarpal bone and drawn backward with its sesamoid bones along, and even past, the articular surface of the head of the metacarpal, while the tendon of the long flgxor slips to one side of the head, usually the inner, al- Fig. 11. — Simple complete dislocation of the thumb. (Farabeuf.) though it may exceptionally remain in place. The first phalanx is in extension at a right angle, the terminal phalanx in flexion, and the head of the metacarpal prominent in the thenar eminence (Fig. 11). In the complex form (produced from the complete by forced flexion of the thumb) the glenoid ligament, and the two sesamoid bones with it, are turned upward so as to lie between the phalanx and the head or dorsum of the meta- carpal. The thumb is in straight exten- sion, parallel and posterior to the meta- carpal; its base can be felt as a promi- nence behind, and the head of the meta- carpal protrudes in front. The sesamoid bones stand at a right angle to the ar- ticular surface of the phalanx, and can- not be folded under it, thus offering a great — often insurmountable — obstacle to reduction. The essential point of re- duction, therefore, is to avoid the trans- formation of the complete into the com- plex form. The extension must be main- tained or even increased and the thumb pressed bodily downward until the an- terior edge of its base, following the glenoid ligament, overlaps the articular surface of the metacarpal, when it can be turned into place by flexion. If this fail, a combination of rotation with the downward pressure may succeed: a sort of unbuttoning of the head of the meta- carpal from the grasp of the glenoid liga- ment and the attached heads of the short flexor. If, however, the dislocation has become complex by the interposition of the glenoid ligament, the same method may yet succeed; but much more for- cible downward traction is necessary to carry the edge of the ligament over the end of the metacarpal bone ahead of the phalanx before instituting flexion. If all manipulations fail, the joint must be opened through a longitudinal anterior incision, and the centre of the glenoid ligament nicked deeply enough to allow it to be drawn over the head of the meta- carpal, after which the dislocation may be readily reduced. Metacarpo-phalangeal dislocations of- the fingers present the same features as (L- Fig. 12. — Complex dislocation. {Farabeuf.) those of the thumb, save that they usu- ally have no sesamoid bones. Dislocation of the phalanges may occur in. any direction. Keduction is usually easy, though it is possible that the thick anterior ligament may be interposed, as in the metacarpo-phalangeal joint. Dislocations of the Pelvis and Coccyx.— Dislocation of the pubic and sacro-iliac symphyses occurs in connec- DISLOCATIONS. PELVIS. HIP. tion with fracture of the pelvis, the symp- toms and treatment of which it does jiot materially complicate. The coccyx may be dislocated forward or backward. The pain is usually in- tense. Diagnosis and reduction are ef- fected by rectal touch. The tendency to recurrence can only be remedied by exci- sion of the bone. Dislocations of the Hip. — These form from 2 to 10 per cent, of all dislo- cations; they occur at all ages and are more common in men than in women. The head of the femur may leave its socket in any of the four principal direc- tions, after which it assumes various po- sitions by secondary displacement. In "typical" dislocations the Y-ligament re- mains untorn and determines the char- acteristic attitude of the limb (Bigelow). Compound dislocations are rare. The varieties are as follows : — ("Typical " dorsal (comprising the iliac and ' ' ischiatic, ' ' and those ' ' upon the dorsum ilia ' ' and " into the ischiatic notch " ). r Anterior oblique. Dislocations J Everted dorsal (comprising the Backward | ' ' supraspinous ' ' and some of [ the ' ' supraeotyloid " ) . Dislocations Downward / Obturator, and Inward \ Perineal. Disloca t i o n s 1 f Ilio-pectineal. Forward >• Suprapubic ■! Pubic, and Upward J (_ Intrapelvic. Dislocations directly upward (supraeotyloid or subspinous) . Dislocations downward on the tuberosity of the ischium. Backward Dislocations. — The dorsal form is by far the most common of the dislocations of the hip. The thigh is addueted, rotated inward, and more or less flexed; so that the knee rests upon the front of the opposite thigh when the patient is reciimbent, and there is appar- ent shortening (Fig. 13). The upper and outer part of the thigh is broadened, and the trochanter is above Nekton's line (a line drawn from the antero-superior spine of the ilium to the tuberosity of the ischium). The head of the femur may be obscurely felt in the buttock. The actual shortening cannot easily be determined on account of the difficulty of placing the two limbs in symmetrical positions. Voluntary movement and fric- tion are lost; passive flexion and adduc- tion alone are possible. The characteristic position and limita- Fig. 13. — Dorsal dislocation of, femur. {Cooper.) tion of motion readily distinguishes the dislocation from a fracture of the neck of the femur. Etiology.- — ^The dislocation is usually produced by violence transmitted along the shaft of the femur while the thigh is flexed, addueted, and rotated inward; or the head of the bone may be thrown out of place by exaggerated adduction, in- ward rotation, and slight flexion; or, again, the dislocation may result second- 22 DISLOCATIONS. HIP. TREATMENT. arily from, an obturator dislocation by the same three motions. Pathology. — The head of the bone usu- ally tears through the capsule low down behind, passes below and then upward behind the obturator, and rests finally on that muscle close behind the acetabu- lum, or, more rarely, it leaves its socket higher tip, pushes the obturator ahead of it outward or upward, and lies on the edge of the acetabulum itself. The cap- sule is irregularly torn behind, the liga- nientum teres is ruptured, the quadratus femoris and gemelli are usually torn, the two obturators and pyriforms less fre- Fig. 14. — Dislocation below, and then be- hind and above, the obturator internus. quently. Earely the head of the bone rests on the great sciatic notch or the dorsum ilia. The edge of the acetabulum may be shattered and the head of the bone split. Treatment. — The surgeon must en- deavor to relax the Y-ligament and other untorn portions of the capsule, to bring the head of the bone opposite the rent in the capsule (if necessary) and then to lift or pry it into place. To do this the patient is laid flat on his back and the pelvis steadied by an assistant or by the surgeon's foot. The patient's knee is then flexed at a right angle, the thigh rotated inward and flexed to or a little beyond a right angle, and then lifted bodily upward, rotated a little outward, and extended in abduction. The lifting and outward rotation should replace the bone with a distinct jump. Or the patient may be laid on his face on a table, whose edge comes just above the groin, so as to leave the lower ex- tremities dangling. The sound limb is now held horizontally by an assistant, and the dislocated one allowed to hang vertically downward. The surgeon grasps the ankle of the dislocated limb, flexes the knee to a right angle, and, while diverting the patient's attention, swings the limb gently from side to side. Under the influence of gravity the mus- cles soon relax and the bone may slip into place of itself or aided by a sharp quick pressure downward on the calf. If these methods fail, ether should be administered and reduction attempted several times by the first method. Fail- ing again, try traction in slight flexion and adduction, aided by direct pressure on the great trochanter. If the limb is too strongly flexed or too soon rotated outward the dorsal dis- location may be tranformed into a thy- roid one. If this occurs, the dislocation must be restored to its original form by reversing the movements: flexion in ab- duction and outward rotation, followed by adduction and rotation inward. Everted Dorsal Dislocations. — If the outer branch of the Y-ligament is rupt- ured, the limitation to abduction and outward rotation is, in great part, re- moved, and the head of the bone is free to rise higher than before. Hence, when this rupture occurs, if the head remains behind the acetabulum only slight flexion and adduction persist, while, if it has moved upward and forward near to or above the antero-inferior spine of the ilium (in which position it can be felt), DISLOCATIONS. HIP. 23 there will be extension, abduction, and slight outward rotation: the so-called everted dorsal. Eeduction is effected by converting the dislocation into the com- mon dorsal form and treating it as such. Anterior Oblique Dislocation. — In Bigelow's one reported case the head of the bone was high above the acetabulum and the limb crossed the opposite thigh, everted, and with the Imee extended. Eeduction as for everted dorsal disloca- tion. Dislocations Doivnward and Inward. — In both the obturator — or thyroid — and perineal varieties the head escapes through a rent in the lower and inner part of the capsule to lodge on the ob- turator foramen, or to proceed farther and rest on the perineum. In either case the limb is flexed, abducted, and rotated outward. It cannot be extended and can only be adducted after flexion. The limb is shortened, the trochanteric re- gion flattened, and adduction tense. The head of the femur may sometimes be felt on the foramen, always if it is in the per- ineum, in which latter case the abnor- mality of the position of the limb is much greater. Several patients are reported to have walked immediately after receiving a thyroid dislocation. The common cause is violence received on the back of the pelvis while the thigh is somewhat flexed and abducted; but it may be extreme abduction alone. In perineal dislocations the laceration of the soft parts must be extensive. Eeduction is made by flexion of the hip to a right angle, traction with adduc- tion, and then inward (or outward) rota- tion while lowering the knee. Manipu- lation may succeed with no rotation at all. Dislocations Upward and Forward, and Inward and Forward {Suprapubic). — The limb is extended, markedly everted. and slightly abducted. The head of the femur is commonly to be felt in the groin (ilio-pectineal form) or may be above the pubes. The psoas-iliac and the great vessels are stretched across the head or may be ruptured. The head of the bone may have left the socket at its upper and inner part by hyperextension, or by ab- duction and outward rotation, or the dis- location may be secondary to an ob- turator dislocation. Eeduction. — The head is to be drawn downward past the pubic ramus by di- rect traction in the axis of the limb as it lies; then flexion is instituted while pressure is made against the head to pre- vent its moving upward again; and fi- nally inward rotation replaces the bone. Dislocations Directly Upward {Supra- cotyloid). — In the few recorded cases the head had been forced directly upward and lay just beneath the antero-inferior spine of the ilium. The limb was everted and abducted. Some of the patients have been able to walk with a limp. These cases bear a close resemblance to everted dorsal dislocations. No defi- nite rules for reduction have been laid down. Dislocation Downward Upon the Tuber- osity of the Ischium. — This dislocation is very rare because of the ease with which it may be converted into a dorsal or thyroid dislocation. The thigh is sharply flexed and abducted. Eeduction is easy by traction in flexion. Complications of Dislocations of the Hip. — Compoimd dislocations are very rare. Injury to the femoral vessels may oc- cur in forward and inward dislocations. Fracture of the neck of the femur is usually caused by overzealous attempts at reduction. Ankylosis with the limb in a favorable position is the best that can be hoped for, except possibly in the 24 DISLOCATIONS. KNEE. TREATMENT. young, when excision of the head of the bone may give some useful motion. Treatment of Old Unreduced Disloca- tions. — Of the operative procedures, re- duction by arthrotomy gives a long list of deaths as opposed to two successes (by Parkes), while excision of the head, or of the head, neck, and trochanter, and sub- trochanteric osteotomy have frequently decreased the disability. In many eases, however, the patients do reasonably well without operation, and these persons need expect no cure from the knife. Dislocations of the Knee. — These occur rarely and, in order of frequency, forward, backward, outward, inward, and Fig. 15. — ^Diagram of the various dislocations of the patella. [Stimson.) by rotation. The dislocation is fre- quently compound, and the prognosis rendered much more grave by a compli- cating injury to either of the popliteal nerves or to the popliteal vessels. Even if, after reduction, pulsation reappear in the arteries of the foot, gangrene may supervene from thrombosis caused by laceration of the inner coats of the artery. Forward dislocation may be complete, or, more commonly, incomplete. When complete, the tibia may be displaced some distance upward over the front of the condyles. If the dislocation is com- pound, the wound is posterior and trans-1 verse. The cause is direct violence or hyperextension of the knee. Eeduction is easily made by traction and pressure. Backward dislocations may be com- plete or incomplete. The leg is usually either extended or hyperextended, and may be deviated to one side. The patella may be dislocated outward. The usual cause is direct violence. Eeduction is effected by traction and pressure. Even without reduction a fairly-useful limb has resulted in several cases. Lateral dislocations are outward or in- ward, complete or incomplete. The pa- tella is usually deviated toward the side of the dislocation. The incomplete form is usu.ally caused by abduction or (in- ward) by adduction. Eeduction by trac- tion and pressure. Dislocation by rota- tion is said to be incomplete when one condyle revolves around the other, com- plete when both revolve around a central axis. There may be additional backward or outward displacement. The rotation is said to be outward or inward accord- ing to the direction in which the toes' turn. Eeduction is easy. All knee-dis- locations should be kept immobilized for several weeks after reduction. Dislocation of the Semilunae Cartilages. — Either cartilage may be detached from any of its ligamentous attachments, and so displaced in any di- rection, or it may be lacerated. The symptoms are those of any loose body in the Joint, sudden painful lock- ing, usually after some given movement. The displacement may be recognized by palpation along the articular edge of the tibia. The cause of displacement is a dislocation, a sprain, excessive rotation, or flexion. Treatment. — The locking may be re- lieved by forcible manipulation or by pressure upon the displaced cartilage. Various braces have been devised to pre- vent recurrence, either by opposing the DISLOCATIONS. PATELLA. ANKL:fi. 25 displacement directly or by preventing the motion which occasions the displace- ment. These methods failing, the car- tilage may be removed or sutured into place through an exploratory incision alongside of the patella. Dislocations of the Patella. — The patella may be dislocated outward or in- ward or rotated around its long axis, or the two forms may be combined. Dis- placement upward or downward is purely secondary to rupture of the ligamentum patella or the quadriceps tendon, and need not be here considered. Outward dislocation is complete or in- complete, and accompanied by various degrees of rotation (Fig. 15: 1, 3, and 3). The patella is readily felt in its new posi- tion, though it may be difficult to deter- mine whether the outer or the inner border is directed forward. Muscular ac- tion or direct violence are the causes of the dislocation, and hydrarthrosis and ligamentous weakness are predisposing causes. The fibrous expansion of the vastus internus is ruptured, and the mus- cle itself may be more or less torn. Ee- duction is made by direct pressure dur- ing extension of the knee and flexion of the hips. Incomplete dislocations are those in which, during extension or flexion, the patella moves outward on to the external condyle. Outward, Edgewise, or Vertical Dislo- cations (by Rotation): — In these the pa- tella is moved outward and its inner edge backward into the intercondylar groove; so that its articular surface looks outward and more or less forward, or completely forward (Fig. 15: 4 to 7). The causes and treatment are the same as for out- ward dislocations. Inward dislocations present the same features, mutatis mutandis, as the out- ward, but they are much less frequent. Habitual dislocations are usually the result of some deformity, such as genu valgum. They are controlled by correct- ing the original deformity or by appa- ratus, or by tightening up the loose lat- eral ligaments (by operation). Dislocation of the Fibula. — The upper end may be dislocated outward and forward, or backward, or upward. These dislocations are all rare. The first form seems to be caused by muscular ac- tion of the long extension of the foot; the second (in more than half the cases) by action of the biceps, and the third by an injury resembling Pott's fracture, in which the fibula, instead of being broken, was forced upward. A complicating fracture of the tibia may exist. Eecurrence is likely, al- though reposition is easy, and hence im- mobilization should be maintained for several weeks. The lower end may be dislocated back- ward. This is quite as rare as the dislo- cation outward in connection with Pott's fracture is common. Dislocation" of the Ankle (Tibio- Taesal) Backwaed. — By extreme plantar flexion the lateral ligaments are torn, the foot slips back, and the astrag- alus is caught behind the tibia. (Incom- plete dislocation is a frequent accompa- niment of Pott's fracture.) The malle- oli may be fractured. The lengthening of the heel and shortening of the foot may only be determined sometimes by careful measurement. Forward. — Eare. Caused by pressure on the heel or by exaggerated dorsal flexion. Inward. — -Two varieties. In the one the astragalus is pried out by suppura- tion and adduction, and the foot moved directly inward and forward; in the other (thought to be secondary to a back- ward dislocation) the foot is turned over 26 DISLOCATIONS. FOOT. DYSENTERY. SO that its plantar surface faces directly inward. Eeduction is easy. Outward. — Appears always to be asso- ciated with Pott's fracture. SuBASTEAGALOiD Dislocations. — The other bones of the foot may be dis- located from the astragalus outward, in- ward and backward, forward, or back- ward. The first two are the most com- mon. About 50 per cent, are compound. About 50 per cent, of attempted reduc- tions have succeeded. Complicating fractures are not infrequent. Notwith- standing the persistence of the displace- ment, a good functional result may be obtained in some unreduced cases. Pri- mary and secondary excisions of the as- tragalus and amputations give various re- sults. Dislocations of the Astbagalus. — The varieties are forward, backward, out- ward and forward, inward and forward, and by rotation. There is frequently more or less rotation in connection with the other displacements. Outward and Forward. — This is the most frequent form. The foot is ad- ducted and inverted and the external malleolus prominent. The astragalus rests on the outer cuneiform and cuboid bones, or even on the fifth metatarsal. Its posterior part is still in contact with the articular surface of the tibia. Eeduc- tion by traction on the foot and pressure on the astragalus is tisually easy, unless the bone is rotated. Inward and Forward. — The foot is ab- ducted and everted and the astragalus lies in front or below the malleolus. Ee- duction may be prevented if the tendon of the tibialis anticus embraces the neck of the dislocated bone. Forward. — Very rare. The cases re- ported have no features in common. ' Backward. — There may be lateral dis- placement. In about 50 per cent, of cases the bone was broken at the neck and only the posterior fragment dislo- cated. There may be flexion of the ter- minal phalanx of the great toe. Eeduc- tion was efEected in one-third of the simple cases. Rotatory. — Dislocation by rotation alone may take place about the vertical or transverse axis (in these latter there is always some displacement forward and inward) or about the antero-posterior axis. Dislocations of the Tarsus and Metatarsus. — These dislocations re- semble those of the carpus and meta- carpus (q. v.). The external cuneiform alone has not been dislocated individu- ally. Lewis A. Stimson, Edward L. Keyes, Jr., New York. DYSENTERY.— Gr.,5i;5, difficult, and EVteoov, intestine. Definition. — An atute or chronic in- flammatory disease, which usually affects the large, but sometimes the small, in- testine. The structures implicated are the solitary and more rarely the agmi- nated nodules, and the general enteric mucous membrane. Under this name are described several different forms of intestinal flux, which in the acute stage are characterized by fever and accom- panied by tormina and tenesmus. Varieties. — Several different forms of dysentery are distinguished partly upon anatomical and partly upon clinical and etiological grounds. A division into endemic, epidemic, and sporadic has been made. It is probable that the endemic, or tropical, form owes its origin to a definite species of micro-organism, the amoeba coli. The epidemic and spo- radic varieties are of uncertain etiology. For clinical purposes a separation into DYSENTERY. SYMPTOMS. 27 catarrhal, diphtheritic, and amoebic dys- entery may be made. General Symptoms. — The first symp- toms of dysentery usually set in without prodromata. A natural movement is fol- lowed by several diarrhoeic stools with- out either pain or tenesmus. The size of the movements gradually diminish, they become admixed with mucus and blood, and are accompanied by colic, bor- borygmi, and tenesmus. It sometimes happens that the disease is ushered in with bloody and mucous stools, pain, and tenesmus. In light grades constitu- tional symptoms are scarcely present; in severe ones the disease begins with chill, fever, loss of appetite, nausea, and faint- ness. The evacuations remain diarrhoeic and contain only mucus, when we have to deal with a mild catarrhal inflamma- tion, or they become admixed with blood, pure bloody, pseudomembranous, or pur- ulent, indicating more severe lesions. The several kinds of dysentery present different stages. The epidemic and spo- radic forms may be separated into ca- tarrhal, diphtheritic, and ulcerative stages. The endemic form, and espe- cially the amcebic variety, appears in the uleerative stage almost exclusively. The last also shows a greater tendency to be- come chronic and to relapse. Special Symptoms. — {A) Catarrhal Dysentery. — In this form prodromata, except dyspepsia and slight abdominal pains, are rare. Diarrhoea is the most constant initial symptom and at first it is not painful. The characteristic feat- ures of the disease — colicky and griping abdominal pain, frequent stools, and straining — are usually developed within the first thirty-six hours. The consti- tutional symptoms are, as a rule, insig- nificant; the temperature is little ele- vated; the pulse rarely exceeds 100; the tongue is, at first, furred and moist, but later becomes red and glazed; nausea and vomiting may be present. The ab- domen may be flat and hard and the thirst excessive. There is constant de- sire to go to stool. The stools present the following characters:- During the first twenty-four or forty-eight hours they consist of more or less clear mucus and blood, with small, scybalous masses. Under strict regimen, as early as the second day, they may be composed en- tirely of mucus and blood, and their con- sistence may be so viscid that the bed- pan may be turned upside down in many cases without spilling the contents. The number of stools in twenty-four hours varies from 15 to 200. This condition may persist for one or two weeks, the mucus becoming gradually more opaque, of a grayish-white color, the blood pro- gressively diminishing in quantity, and a little gray, green, or brown pultaceous detritus, or fluid faecal matter, appear- ing in the stools. As the disease sub- sides, faecal matter again makes its ap- pearance, increasing in amount until fully-formed faeces are passed, showing neither mucus nor blood. In the more prolonged cases wholly pultaceous, yel- low-brown or greenish (spinach) evacua- tions may intervene between the bloody, mucoid stools and the passage of formed fffices. Microscopical examination of the stools shows in the first bloody, glairy discharges a predominance of red blood- corpuscles. "With these are associated leucocytes and cylindrical epithelial cells in small numbers, and constantly large round or oval epithelioid cells. In later stages the stools contain fewer red cor- puscles and more leucocytes; in the pul- taceous material cellular elements are scarce. Bacteria are more abundant in the later stages; amoebae are absent; oc- casionally the Cercomonas intestinalis is seen in large numbers. The duration of 28 DYSENTERY. SYMPTOMS. the disease is variable; according to Flinty the milder eases terminate in about eight days; severe ones may last as long as a month. The disease rarely becomes chronic. (B) Diphtheritic Dysentery. — The pri- mary v-ariety presents somewhat difEer- ent symptoms, depending upon the stage ■ — whether acute or chronic — of the dis- ease. In the acute stage the symptoms often from the outset are severe. There may be high fever, great prostration, ab- dominal pain, and frequent discharges, with tormina and tenesmus. The grip- ing pain and straining are the chief sources of suffering. Delirium may set in early, and the clinical features resem- ble severe typhoid. Osier states that he has known this mistake to be made on more than one occasion. The pulse, in the majority of cases, is but little, and sometimes not at all, accelerated. Fever, except in the severe cases, is not a prom- inent feature. Flint states that great frequency of the pulse denotes gravity and danger, but that the converse does not always hold good. The discharges are frequent and diarrhceal in character; blood and mucus may be found early, and sloughs may make their appearance. The presence of pseudomembranes and of necrotic portions of the intestinal coats is characteristic of the diphtheritic form of inflammation. The other in- gredients are common to both the ca- tarrhal and the diphtheritic varieties of inflammation. Upon microscopical ex- amination the cellular elements are found to be relatively few in numbers, those most constantly present being cylindrical epithelial cells, showing more or less fatty degeneration. Eed blood- corpuscles and leucocytes are observed, especially where much blood and mucus are admixed, and large numbers of leucocytes in the purulent discharges. Fibrin also occurs, and bacteria appear in great numbers. When improvement begins feculent matter appear in the stools. The duration of the disease from the date of attack to convalescence varies from four to twenty-one days. When death takes place it usually re- sults from asthenia. The pulse becomes weaker and accelerated, the tongue dry, the face pinched, the skin cool and cov- ered with sweat, and the patient sinks into a drowsy condition. Consciousness may be retained until the end. (C) Chronic Dysentery. — This condi- tion usually succeeds an acute attack. Clinically the chronic forms of diph- theritic are not sharply marked off from those of amoebic dysentery. The latter disease may be subacute from the outset and fail to present an acute period. The lesions in the intestine will depend iipon the origin: if amoebic, then ulceration with little tendency to healing is the rule; if diphtheritic, then pigmented cicatrices or these together with imper- fectly-healed ulcers are met with. The intestinal walls are thickened and the sigmoid flexure may be palpated as a hard, resistant tube. The disease pre- sents protean symptoms and cannot always be sharply separated from chronic diarrhoea.. Its course may extend over months and even years. Many of the characteristics of the acute disease are wanting. The composition of the stools is variable; blood, necrotic tissue, and pseudomembranes are rarely found. There are periods of improvement and exacerbation; the patient loses weight and strength, becomes emaciated, suf- fers from periods of psychical depres- sion, and may become bedridden. The degree of emaciation may be extreme, and a severe secondary anaemia some- times develops. The evacuations — which vary from five to twelve or more DYSENTERY. SYMPTOMS. 29 in the twenty-four hours — take place usually without tenesmus, and with only slight colicky pains. They are fluid, of greenish-yellow or brownish-black .color, now and then admixed with blood and mucus. Sometimes the stools are puru- lent. Indiscretions in diet are followed by an increase in the colicky pains. (D) Amoebic Dysentery. — The symp- toms presented are very yariable. What characterizes the disease are an "irregu- lar course marked by periods of inter- mission and of exacerbation of the diar- rhoea, a tendency to chronicity, and the frequent occurrence of abscess of the liver" (Lafleur). For clinical purposes Lafleur groups the cases under (a) grave or gangrenous forms; (&) dysentery of moderate intensity (showing periods of intermission and of exacerbation); (c) chronic forms. Kartxilis recognizes ca- tarrhal and ulcerative stages in the diseases. The catarrhal stage, in contra- distinction to epidemic dysentery, is relatively of infrequent occurrence. This stage tends to pass into the more severe or ulcerative form. In the ca- tarrhal stage the dejections are yellow, bile-stained, and of mushy or fluid con- sistence. When the stools are small, then mucus, which may be blood-stained, appears. As the intensity of the symp- toms increases clumps of mucus and blood are more abundant; still later the stools present a beef-water appearance, in which clear clumps, resembling frog- spawn, — altered starch-grains, — float. With the advance of the ulceration they become more copious, watery, and less homogeneous; there is less blood and a great deal of shreddy material appears admixed with the mucus. Fragments of necrotic tissue from the bases of the ulcers, — small, grayish-yellow masses, — which always contain amcebffi, are pres- ent. When there is great and rapid sloughing, then the stools are greenish, grayish, or reddish brown and are still more variegated in appearance. In con- sistence they are watery or pultaceous and in odor penetrating and highly offensive. In the chronic form the stools are homogeneous, watery, or gruel-like; they contain few or many flakes of clear mucus, but seldom any blood or necrotic fragments of tissue. The microscopical examination of the bloody, mucoid stools shows red blood- corpuscles, leucocytes, oval and round epithelioid cells, cylindrical epithelial cells in small numbers, crystals of am- monia-magnesian and earthy phosphates, Charcot's crystals, occasionally blood-pig- ment, and amoebfe. At later stages the cellular elements are less numerous, the amorphous detritus increased, and elastic tissue may be met with. In the liquid stools of the chronic form few formed elements except amoebse occur. With each exacerbation there is an increase of the cellular elements. In the grave form the stools are, at first, numerous, twenty to thirty in twenty-four hours; as the disease ad- vances they diminish to a dozen or less, and in fatal cases, toward the end may not exceed three or four. Abdominal pain and tenesmus are fre- quently present at the outset, especially in severe cases, but may be entirely ab- sent. Vomiting and nausea are only oc- casionally observed. Fever is an incon- stant symptom and ranges from 99° to 101° or 102°. With the development of complications (liver-abscess, etc.) it is more persistent and tends to become more regularly intermittent. The pulse, in most instances, follows the variations in temperature. In the fatal stage of gangrenous dysentery the pulse becomes rapid, — 120 to 140 or more — thready, and compressible; and at the same time 30 DYSENTERY. SYMPTOMS. COMPLICATIONS. the temperature tends to fall below nor- mal. Ansemia, of greater or less severity, appears in all cases; albuminuria of slight grade is of frequent occurrence, and hyaline casts are sometimes found in the urine. The examination of the stools for the amoebee coli is very important and should never be omitted. Sometimes a single examination suffices to demonstrate ac- tively-moving amoebffi. In chronic cases, however, repeated examinations may be required. In cases of liver- and of lung- abscess the diagnosis of the intestinal disorder may be established by finding the amoebae in the aspirated contents of the former or in the sputa derived from the latter. In making the examinations for amoebse it is advised that the stools be passed into a warm bed-pan and kept at the body-temperature during the ob- servation. The examination should be made at once or very soon after collect- ing the fasces, and the most favorable parts should be chosen for the examina- tion. A warm stage greatly facilitates the examination. Special symptoms referable to com- plications are apt to arise. Those most commonly met with are in connection with liver- and lung-abscesses, peritonitis with or without perforation of the in- testine, and intestinal hemorrhage. The du.ration of the disease in uncom- plicated cases varies from six to twelve ' weeks. Recovery is tedious, relapses are frequent, and there is a constant tend- ency to chronicity. In uncomplicated cases recovery may be expected when the faeces become formed and amoebae disap- pear from the stools. Complications. — A local peritonitis may arise by extension, or a diffuse in- flammation, which is usually fatal, may follow perforation. A local inflamma- tion about the caecum gives rise to peri- typhlitis; if about the rectum, periproc- titis. The regional lymphatic glands may be swelled and hyperaemic, and rarely do they undergo suppuration. A serious complication is pylephlebitis af- fecting the veins of the intestine and mesentery, owing to the danger of em- bolic abscess of the liver. The abscesses, in these cases, may be single or multiple. Intestinal stricture is a rare sequence; amyloid degeneration of the viscera and dropsical conditions are uncommon con- sequences of chronic dysentery. The dis- eases associated with dysentery which have been noted are rheumatic swelling of the joints, malaria, typhoid fever, pleurisy, pericarditis, and endocarditis. Three cases of paralysis in dysentery and in chronic diarrhoea of warm coun- tries. Peculiarities: it was less and less complete in going from the centre toward the periphery; improvement was in the inverse order from the extremities toward centre; muscles most completely para- lyzed were the last to be cured; paraly- sis was not always complete; frequently paresis only. Due to a lesion of the an- terior oornua of the cord. Pugibet (Re- vue de M6d., Feb. 10, '88) . Seven cases of amoebic dysentery. The nature of the disease being such as to produce very rapid anaemia and wasting, it is necessary to combat these results by the plentiful use of nitrogenous food: meat, fowls, eggs, rich broths, milk, etc.; if restricted to a milk diet, these patients will very rapidly fail. West (Med. Record, Sept. 23, '93). Case complicated with external otitis and phlegmon of the mastoid process 17 days after the appearance of the intes- tinal affection. The bacterium coli was found in the suppuration. Gasser (Archives de M6d. et de Pharm. Milit., No. 6, '95). Case of severe dysentery complicated with infectious pseudorheumatism, ar- thritis, with sero-purulent effusion of the left knee, necessitating arthrotomy and drainage of the articular cul-de-sacs. J. Brault (Lyon M6d., Jan. 27, '95). DYSENTERY. DIAGNOSIS. ETIOLOGY. 31 Three cases complicated with nephritis, diagnosis in two being confirmed by autopsy. Such cases sometimes are so insidious in evolution that the nephritis is unperceived not only during the dys- entery, but even long after the cure of the original disease. On the contrary, in other cases or under less favorable conditions the symptoms cf nephritis are very plain. Troitzky (La M6d. Mod., June 8, '95). Literature of '96-'97-'98. Case in which abscess of the liver oc- curred six years after tropical dysentery. Berger (Gaz. Hebdom. de M6d. et de Chir., July 18, '97). Case of dysentery complicated with in- tussusception; death. Intussusception found to be caused by the invagination of the ileo-cseeal valve into the ascending colon. Extensive dysenteric ulceration was present throughout the length of the large intestine. W. G. Pridmore (Brit. Med. Jour., Apr. 17, '97). Diagnosis. — The diagnosis of dysen- tery usually involves no great difficulty. The characteristic evacuations are path- ognomonic. The diseases from which it is to be discriminated are local affections of the rectum, such as syphilis and epi- thelioma, which may produce tenesmus with the passage of mucoid and bloody stools, and haemorrhoids, and a discharg- ing intestinal abscess, in which certain of the symptoms are simulated. Etiology and Epidemiology. — ^Dysen- tery is one of the four great epidemic dis- eases of the world. In the tropics it destroys more lives than cholera, and it has been more fatal to armies than pow- der and shot (Osier). From the ac- counts furnished by history and the numerous ones supplied by physicians in the last three centuries bearing upon its epidemiology, it may be concluded that, just at present, dysentery has at all times had the widest distribution over the globe and that no considerable part has been exempted from a visitation. To quote Ayres, "of dysentery it may be said that, where man is found, there will some of its forms appear." The present geographical distribution of dysenteric and diarrhoeal diseases is compared by Hirseh with that of the malarial diseases, with which, in respect to the manner of their endemic preva- lence, the frequency of their epidemic outbreaks, and the varying^ severity of their type, they are in correspondence. Like the malarial diseases, they reach the maximum of diffusion and of inten- sity, and more especially their greatest severity as an endemic, in equatorial lati- tudes; in subtropical countries there be- gins to be noticed a decrease in the ex- tent and seriousness of endemic and epi- demic incidence; while in still higher latitudes they almost disappear as en- demic diseases and show themselves merely now and then in epidemics over an area at one time large and another time small. In one point they differ from malarial diseases, namely: that they attain to higher latitudes of the cold zone, appearing as epidemics in re- gions that are quite free from malaria. The endemic form of dysentery has al- ways existed in Africa and India, but the place of its natural home is not known. Its present distribution includes Africa in its entire extent, except for a few lo- calities. Both natives and Europeans are affected. In South Africa it prevails se- verely in Bechuanaland, Natal, and the Transvaal. In the north it appears in Egypt, especially along the coast and the Nile delta. In Asia it prevails to a great extent along the Arabian coast of the Eed Sea as well as of the Gulf of Aden and the Persian Gulf. It exists in Syria, Asia Minor, and extends into Mesopo- tamia and Persia. Endemic dysentery is widely disseminated in India and the Indian Archipelago and exists in China. 32 DYSENTERY. ETIOLOGY. In Japan it assumes a milder form, while the epidemic variety is very destructive. The disease prevails in the tropical and subtropical parts of South America, but it fails to reach the wide diffusion which it presents in Africa and India. In Guiana it is found in the mountainous regions and in the tropical parts of Brazil in a severer form. In Valparaiso and La Serena in Chile the disease has a home. Foci appear in Paraguay and in the tropical provinces of Argentine Ee- public. In Peru it occurs along the marshy districts of the Amazon and in some of the mountainous regions, being endemic in the city of Cero de Pasco at an elevation of 13,000 feet. Venezuela does not escape; in Uruguay it is almost unknown. In Central America the dis- ease prevails in Panama, Costa Eica, Nicaragua, Salvador, Honduras, and Gautemala. It is difEu.sed over Mexico and appears at elevations of 6000 feet. It assumes the severest forms in the West Indies, especially in Cuba and Hayti, and prevails to a greater or less extent in ■Guadeloupe, Martinique, and Barbadoes. In Europe endemic dysentery occurs over limited areas only, and is present in the more southernly-placed countries. Thus it is known in Greece, but is endemic in the Ionian Islands and the Cyclades. In Turkey it is common, in Bulgaria and Eoumania, along the Donau, also, while the southern provinces of Italy and Sic- ily are the most severely affected regions in Europe. Prance, Switzerland, Bel- gium, the ISTetherlands, and Great Britain are free from endemic dysentery. In Germany there are no definite foci of occurrence, but a number of cases of the disease have been observed at "Weimar and Kiel. The same facts are true of Austria, which, in general, has escaped, although cases have been reported from Prague, Graz, and Vienna. The distribution upon this continent, and especially in the United States, of the endemic form of dysentery is, at present, difficult to estimate. If we ac- cept this variety as synonymous with tropical and amoebic dysentery, a much closer study of the disease than yet made will be necessary in defining the limits of its prevalence. Cases have been re- ported from Maryland, Massachusetts, Pennsylvania, Texas, Ohio, Alabama, and Georgia. But it seenis probable that many of the so-called sporadic cases oc- curring in this country, and, perhaps, not a few of the epidemic ones, may be shown to be of this kind. With the exception of the investigations of the disease car- ried out in Egypt, Germany, Austria, and Italy, the American cases above referred to have been the most thoroughly studied. The epidemic form of dysentery is oftenest confined to a single locality, a village or a town, with no extension to the country aroimd. Instances are not rare in which the epidemic attacks a single detached establishment, such as a prison, a hospital, a poor-house, a sol- diers' barracks, or, under certain circum- stances, a ship, while there are no cases of dysentery outside these, or merely oc- casional cases (Hirsch). It happens much more rarely that the disease achieves a greater diffusion, and most rarely do pandemics arise. Mention has already been made of the prevalence of dysentery as an epidemic disease, espe- cially in earlier historical times. Great epidemics have not appeared in recent years. The countries which have been most severely visited are Italy, France, Ireland, Denmark, and Norway and Swe- den. In the United States, dysentery in an epidemic form, except during the War of the Eebellion, has not in late years reached serious proportions. According DYSENTERY. ETIOLOGY. 33 to Woodward, it prevails anmially among the civil populations in all parts of the United States. It occurs both in the form of sparodic cases and of small local epidemics which fasten upon different districts in different years. Sporadic dysentery, which is distin- guishable both from the endemic and the epidemic forms, is of very uncertain oc- currence. This variety of dysentery is attributed by Kartulis to the action of mechanical and chemical irritants iipon the intestine, and arises as a secondary condition in the course of other diseases, such as acute, infectious, and chronic dis- eases of the heart, kidneys, and liver. By most writers the occasional eases of dysentery met with in all countries are included under this term. Various telluric conditions have, from time to time, been supposed to influence the prevalence of dysentery. Of late years the search has been made for micro- organisms to the action of which the disease might be attributed. With what fiuccess this line of investigation has been pursued will be stated in other parts of this article. It is a well-known fact, and one borne out by the best statistics, that both the epidemic and the endemic forms prevail especially during the hot seasons. Oreat diurnal variations of temperature — warm days and cold nights — ^have been supposed to predispose to the develop- ment of the disease, but in Egypt the facts observed are in direct opposition to this view. The degree of atmospheric moisture seems without influence: Hirsch states that, of 126 epidemics of dysen- tery, 65 occurred during moist weather and 61 during continued drought. The elevation and configuration of the sur- face seem also without particular signifi- cance, although low-lying and marshy localities are more subject to visitations than high and dry ones. There is good reason to believe that the dissemination of the virus of dysen- tery takes place, in large part, through the water. And, although the same con- clusive evidence of water-infection has not been brought for this disease as has been brought for cholera, yet there are many convincing observations at hand which bear out this belief. Numerous outbreaks both of the endemic and epi- demic varieties, among troops and in- habitants of towns, have been traced di- rectly to contaminated drinking-water; and the replacement of the polluted by a wholesome supply has been quickly fol- lowed by a cessation in the spread of the disease. Observations which indicated a more contagious character, a transmis- sion from person to person, are not want- ing. But whether, in these instances, the virus may not have been carried by water, wash-linen, or food is not certainly known. The demonstration of parasitic organ- isms bearing an etiological relation to dysentery has been done certainly only for the endemic variety. Several differ- ent bacterial organisms have been de- scribed in association with the epidemic dysentery. The proof of their essential causal relationship with the disease has- yet to be brought. The several micro- organisms will be considered with their respective diseases. Amcebio Dysentery. — This affection is also known as endemic and tropical dysentery, and as amoebic enteritis. It is characterized clinically by irregular diar- rhoea, a variable course often marked by periods of intermission and exacerbation, a special tendency to chronicity, and the development of liver-abscess, and ana- tomically by ulceration and thickening of the large intestine. Morbid Anatomy and Etiology. — This form of dysentery has been known ana- 3—3 34 DYSENTERY. ETIOLOGY. tomically for more than a century: since the writings of John Hunter, who ob- served the disease in Jamaica. The prin- cipal contributions upon its pathology has been made by Councilman and La- fleur,Kruse and Pasquale, Kartulis, How- ard and Hoover, Plexner and Harris. The lesions in the intestine are of two kinds: (1) a general catarrhal inflamma- tion of the large gut, which does not dif- fer from catarrhal colitis due to other causes; (3) the specific focal lesions (ul- ceration) caused by the presence in the tissues of the amoeba coli. The specific lesions are located oftenest in the sigmoid flexure, somewhat less often in the csecum and ascending colon, and more rarely in the descending and transverse colon and rectum (Kartulis). The verm- iform appendix may be the seat of ulcera- tion; most rarely does the dysenteric process pass beyond the ileo-csecal valve and attack the lower end of the ileum. The amcebse are present upon the sur- face of the intestine and in the interior of the crypts, where by continued irri- tation they bring about destruction of the epithelium; they may then be ob- served to penetrate through the inter- glandular tissue into the depth. They set up an active inflammation in the mucosa, shown by the hypersemia, ec- chymosis, and swelling of the glandular epithelial cells. The farther extension of the amoeba takes place after the par- tial destruction of the muscularis mu- cosae. The organisms now reach the submucosa, where the principal damage is inflicted. The number of amcebse in the submucosa is considerable; their presence excites a reactive inflammation, and soon a solution of the tissues in which lie. Thus a cavity is formed which, sooner or later, is followed by ne- crosis and removal of the overlying mu- cous membrane. When this happens, an ulcer is the result. The lymphoid folli- cles are not especially attacked; they simply share the fate of the surrounding tissue. The muscular coat offers some resistance; it is not generally destroyed, but the amcebse pass through it in cer- tain places, enter the intermuscular tis- siie, and there repeat the part they play in the submucous tissue; the structures overlying the infiltration, deprived of their nourishment, undergo necrosis. The ulcers increase by this continual process of undermining; but the typical course and appearance of the ulcer may be completely changed through the ac- tion of the bacteria in the intestinal canal. The ulcers are, for the most part, un- dermined. Often the defect in the mu- cous membrane is small and altogether inconsiderable, while the cavity in the submucosa and deeper tissues is large, and sinuous tracts, sometimes connecting- several ulcers, are met with. Again, sim- ple ulcers, with little or no undermining- of the mucous membrane and limited to- the submucosa, exist. Both forms may be associated. More rarely still, large sloughs, which may consist of the mu- cous or muscular coats, are encountered. The part of the intestine involved be- comes much thickened, partly through the infiltration present in the submucous and other coats, and partly in virtue of a thickening of the peritoneal coat; ad- hesions between adjacent intestinal loops- and deformation also occur. According^ to Councilman, fibrinous exudation upon the surface of the mucous membrane (diphtheritic or croupus membrane) does not take place in uncomplicated cases, while Kartulis describes its occur- rence. The amoebfe occur in greater or less numbers in intimate association with the- ulcers and even in adjacent parts. They DYSENTERY. ETIOLOGY. 35 are fonnd in the tissue-spaces, within the crypts of Lieberknhn, in definite lym- phatic vessels, and in the veins. The mere presence of amosbsB in the stools is not sufficient evidence of the existence of amoebic dysentery. As early as 1870 Lewis and Cunningham found amoebse in the stools of persons sick of cholera in India. They have even been found in the stools of healthy persons (Grassi, Kruse and Pasquale, Mincke and Eoos, Schuberg). Losch (in 1875) gave the first accurate account of the organism which he found in the stools of a dysen- teric patient, and he studied the intestine removed at the autopsy. E. Koch ob- served amcebse in sections of the intestine of a number of cases of dysentery occiir- ring in Egypt and India, and suggested a causal relationship between them. Soon afterward (1885) Kartulis was able to find them in more than five hundred cases of endemic dysentery prevailing in Egypt, while they were absent in other diseases. Similar organisms were also found in the contents or walls of amoebic abscess of the liver. The results of Kartulis's studies have been abundantly confirmed in this country by Osier, Coun- cilman, Lafleur, Simon, Dock, Eichberg, Howard, Musser, Stengel, Flexner, "Wil- son, Harris, and others. The amoebae coli (s. dysenteriEe) re- sembles in many ways the amcebse occur- ring in the stools of healthy beings. The average size of the latter is from 13 to 36 microns, of the former from 10 to 50 microns. The structure of the two forms is also similar. In a state of rest they appear as slightly-refractive and faintly- granular spheres; in the active state a separation into structureless ectoplasm or hyaloplasm and a more refractive, granular, endoplasm or granuloplasm takes place. The pseudopodia are ex- truded slowly and may be easily ob- served; change of position does not al- ways follow the extrusion. Nuclei are present and often visible, even in the fresh state. This description suffices for the non-dysenteric as well as for the dysenteric varieties; in the latter there is found, in addition, contained within the endoplasm, vacuoles, bacteria, and red blood-corpuscles. The chief constit- uent, from a diagnostic stand-point, is blood-corpuscles, as these never occur in the amoebse found in healthy persons; both the vacuoles and bacteria may, how- ever, be present. Nothing definite is known of the mode of propagation, but it is believed that multiplication takes place by division. The amoebae are very little resistant; the stools, etc., mu.st, therefore, be ex- amined soon after their evacuation. Their number quickly diminishes in ma- terial outside the body, and at the end of from six to twenty-four hours they are often no longer to be found. They have not been certainly successfully cul- tivated outside the body in a pure state, although they may have been cultivated along with other micro-organisms (Kar- tulis, Celli, and Piocco). The evidences for the belief in the causal relationship between the amoeba coli and endemic dysentery is summed up by Kartulis as follows: "The con- stant presence of the organism in cases of endemic dysentery (with the excep- tion of the so-called 'Cochin-China diar- rhoea'; see below); its presence in the walls of the dysenteric ulcers and absence from other kinds of intestinal ulcers; the successful production of dysentery in eats by the injection of fsces containing amoebfe into the rectum and even of pus from liver-abscesses free from other mi- cro-organisms; the negative results of similar injections (excepting in the ex- periments of Celli and Fioceo) of other 36 DYSENTERY. ETIOLOGY. micro-organisms obtained* from dysen- teric stools; and, finally, the failure of healthy stools containing amoebEe to pro- 'voke dysenteric lesions in cats." [The recognition of the amoebae in sec- tions of hardened tissues and their dis- tinction from swelled and degenerated tissue-cells are not always easy. Mallory has introduced a special staining method in which thionin is used, and Harris em- ploys tolouidin-blue, in order to differ- entiate these organisms from other cells. Simon Flexneb.] The amoeba dysenterise is distinct from the non-infectious form, or amoeba coli. The former, when coupled with bacteria, is the cause of dysentery and of some liver-abscesses. There still re- main other liver-abscesses which must be classed as idiopathic, and in which cli- matic conditions must be looked on as playing a large part. Among the many questions which are yet to be solved concerning the amcEbse are the following: Whether their virulence is constant or can be lost and acquired; how they gain access to the human body; how the bacteria aid them; where the bacteria come from; how the dysenteric ulcers begin; whether the predisposing causes of cold and indigestion work on the human organism or on the bacteria; whether there is not also a systemic in- fection, as well as a local process; in what way the amoebse gain access to the liver, whether along the portal system, the lymphatics, the peritoneum, or the bile-passages. There are certain eases which point to each mode, but in multi- ple abscesses the propagation is along the blood-current, either from the ulcers or backward from an original single focus. Kruse and Pasquale (Zeit. f. Hygiene u. Infectionskr., Feb. 8, '94). Two cases of dysentery in which the pathogenic character of the amoebse seemed to be undoubted. Besides the ordinary variety, there were encysted forms, which were most frequent after patients had had a course of calomel. Quincke and Eoos (Berliner klin. Woch., No. 45, '93). Amoebce can be found in large quanti- ties in the intestinal glands. Kruse (Deutsche med. Woch., Nos. 15, 16, '93). The endemic dysentery of warm cli- mates is probably generated by animal parasites, is not contagious, and is some- times also found in temperate regions. The amoeba seems to be the principal factor in its causation, and the patho- logical changes produced are most likely due, in part at least, to the bacteria de- veloped in situ or transported there by the wandering amoebae. The direct path- ogenic action of these corpuscles has not yet been satisfactorily established. Wesener (Eivista Inter. d'Igiene, Sept., Oct., '92) . In an etiological study of 10 cases, in only 1 was the amoeba found, and then in but small number; in the remainder the stools did not contain any microbes which could be assumed to be the cause. It is possible that microbes ordinarily present in the intestine, such as the colon bacillus, may take on a virulent property. Laveran (Le Bull. Med., Nov. 8, '93). There are three forms of the organism: (1) the Amceha coli felis (Losch), which is the true ainoeba of dysentery; (2) the Amwla coli mitis, the cause of the diar- rhcEa in the second case; and (3) the Amceha coli vulgaris, the form observed in healthy persons. Calomel in small doses appeared to be the best method of reducing the number of amcebse in the stools. Quincke and Eoos (Berliner klin. Woch., No. 45, '93). Chronic-dysentery am-^bee are not pathogenic to cats except when the in- testinal mucous membrane has been in- jured, as by a sublimate solution. The amoebae are not the cause of dysentery, but irritants which prevent the heal- ing process in lesions already existing. Kovac (Zeit. f. Heilkunde, B. 13, H. 6, '94). Inclination to question the importance of the amoeba as the chief cause of dys- entery. That it is only partly responsible seems confirmed by personal investiga- tions in 153 eases of dysentery, in which the bacillus coli and bacillus pyocyaneus seemed to play a more important rOle. The amoeba coli was present in nearly half of the acute cases and in 13 out of 34 chronic cases, but there was no rela- DYSENTERY. ETIOLOGY". COMPLICATIONS. 37 tion tetween the numbers present and the severity of the case. In the stools of perfectly-healthy individuals, amcebae found in considerable numbers in 20 per cent. The ulceration produced in the colon of a, cat by injecting into it dys- enteric faeces, also produced by injecting sterile vegetable dSbris. Grasser (Ar- chives de M6d. Exper., Mar., '95). The protozoa are of very secondary importance in the etiology of dysentery. On the other hand, the bacterium coli is constantly present, often in pure culture, at other times associated with the pseu- dotyphoid bacillus. Attention called to a variety of the bacterium coli which produces a toxin capable of producing experimentally the lesions of dysentery, when administered by the mouth, rectum, or subcutaneously. A. Celli and K. Fiocca (Centralb. f. Bak. u. Parasit., Mar. 15, '95). Biological and clinical study of 235 eases of diarrhoea and dysentery. The amoeba found 86 times, most frequently in cases of typical diarrhoea, less often in simple catarrhal enteritis, and least frequently in sporadic dysentery, whether mild or fatal. The pathogenic impor- tance of the amoeba denied, experiments upon cats having shown that the amoeba swallowed up numerous microbes, and that, where amoebse were numerous, but a small number of microbes were met with. Opinion expressed that the amoeba prevents the development of bacteria and permits healing of the lesions, thus ex- plaining the vegetating form of the ulcerations observed by Councilman and Lafleur. The amoeba prevents an acute evolution of the process, which, in turn, explains why amcebic dysentery is of a chronic type, as assumed by many authors. Cassagrande and Barbaglio- Eapisardi (Gaz. degli Osp., No. 66, 'S5). Micro-organism found in the faeces, in the wall of the large intestine, mesenteric glands, and spleen. A bacillus with rounded ends, slightly swelled; it de- velops rapidly in gelatin and other cult- ure-media at an ordinary temperature; under cultivation its transverse diameter increases; it has very little movement, and is slightly colored by aniline. In sterilized Seine water it grew rapidly. Guinea-pigs fed with the pure culture show no effect for a few days. If killed in eight days, the stomach is ulcerated; the mucous membrane of the large in- testine is swelled, ecchymosed, ulcerated, and the closed follicles are hypertrophied, as well as the mesenteric glands; be- tween the tubular glands a large number of bacilli are seen penetrating and form- ing groups in the submucous tissue. The liver shows yellowish foci, and in the centre of the portal spaces and in ad- jacent capillaries are bacilli like those which had been injected. Intraperi- toneal injections of the bacillus produced death in two or three days, due to peri- tonitis, pericarditis, and fibrinous pleu- risy. The presence of this bacillus in the stools and viscera of dysenteric patients, its absence from the stools of healthy individuals, and the lesions which it seemed to cause in the organs of the guinea-pig are arguments in favor of the bacillary origin of the disease. Chante- messe and Widal (Gaz. M6d. de Paris, Apr. 21, '88). In sixty cases of acute dysentery the colon bacillus found constantly present. Dysentery experimentally produced with these on dogs, clinically and pathologic- ally. Arnaud (Le Bull. M6d., Mar. 21, '92). Epidemic in the vicinity of Lake Mag- giore in which the liquid stools were found to contain a special diplococeus, which, injected into animals, caused a characteristic diarrhoea. De Silvesti (Riforma Medica, No. 292, '94). Complications. — Involvement of the peritoneum in the chronic cases with deformation of the intestine has already been mentioned; through the formation of adhesions definite kinking of the bowel may result. Perforation of the bowel, leading to peritonitis, is a rela- tively-rare complication, and peritonitis without previous perforation apparently still rarer. Small haemorrhages in the intestinal mucosa, in the region of the ulcers, are frequent, but large haemor- rhages seem uncommon. In one of Coun- 38 DYSENTERY. COMPLICATIONS. eilman and Lafleur's cases about one hun- dred and twenty-five cubic centimetres of clotted blood were passed per rectum on the last day of illness. By far the most important complications are abscess of the liver and of the liver and lung. A very important, but unusual, sequel of liver-abscess is perforation of the inferior vena cava. Plexner has described two such cases. Although the data at hand for computing the frequency of amoebic abscess of the liver in endemic dysentery are, as yet, too few to admit of definite conclusions, yet, according to Kartulis (based on observation of 500 cases of liver-abscess), 55 to 60 per cent, were of dysenteric origin; Councilman and La- fleur found liver-abscess 6 times in 15 cases, Kruse and Pasquale 6 times in 57 cases of amoebic dysentery. Kartulis states that liver-abscess, which is so com- mon a complication of endemic dysen- tery, is infrequent in the epidemic form. Hence the statistics of British and French physicians covering this subject, in which the proportion of 1 case of liver- abscess for every 4 or 5 of dysentery oc- curring in the East, probably relate chiefly to the amoebic form. Hepato-pulmonary abscess occurred four times in Coimcilman and Lafleur's cases. Following pulmonary abscess, pleurisy and pyothorax or pyopneumo- thorax (Flexner) may supervene. The amoebas were found in the contents of the hepatic and pulmonary abscesses and pyothorax. In abscess of the lung the organism appears in the sputa. Kartulis has encountered abscess of the brain and spleen in amoebic dysentery; in neither situation was he able to demonstrate amoebfe. The question of the existence of amoebic hepatic abscess without evidence of previous intestinal lesions is still an open one. Kruse and Pasquale mention two cases, but admit that they are not conclusive. Flexner has described an un- doubted case. The etiology of the so- called idiopathic, or tropical, liver-ab- scess is still wrapped in obscurity. Results of examination in a case of abscess of the liver following dysentery in which the amoeba was found in the pus drained from the abscess. The amoebae from the abscess were somewhat larger than those described by Kartulis; they were circular, sometimes ovoid, but while in movement had an irregular outline. The alterations in contour and change in locality were as remarkable as in some forms of pond amoebae. Motion continued active for hours; in two in- stances for ten hours. In the stools the amoebae were rare in the brownish liquid; more frequent in the small sloughs passed. In form and other characters they were like the organisms in the pus from the liver-abscess. Osier (Johns Hopkins Hosp. Bull., vol. i, No. 5) . Case illustrating the association of symptoms clearly demonstrating the ex- istence of amoebic dysentery with hepatic abscess. Upon opening the latter a pint of the typical chocolate-colored pus was evacuated. Musser and de Forrest Wil- lard (Univ. Med. Mag., Apr., '93). Liver-abscess does not necessarily pre- suppose an attack of dysentery. Seven cases in which there was no history of dysentery; two had never been ill before. In the three fatal cases there was no sign of recent or remote dysentery. Ren- nie (Brit. Med. dour., Aug. 25, '94). Statistics showing that suppurative hepatitis is almost always the conse- quence of dysentery; there is but a single pathogenic element concerned in the production of both diseases. Proof: if dysenteric faeces containing living amoebae be injected into the rectum of cats tj^ical dysentery will be produced, the animals dying usually in from thirty- nine hours to nine days, though some may survive and even recover; 7 out of 11 of those injected showed amoebae in the evacuations. The classical altera- tions of dysentery were found at au- topsy. Zancarol (Le Progrgs Med., June 15, '95). COCHIN-CHINA DIAREHCEA. CATARRHAL DYSENTERY. 39 Cochin-China Diahehcea. — This is a form of dysentery which occurs in Coehin-China and some other tropical countries. Normand in 1876 found, in the stools of soldiers who returned from Coehin-China to Toulon and who were suffering from chronic diarrhoea, two forms of nematodes {Anguillula sterco- ralis and Anguillula intestinalis) after- ward shown by Leuckhart to be the suc- cessive generations of a single species to which he gave the name Rhabdonema strongyloides. Further studies have ren- dered doubtful its etiological relation to the disease. The parasite is often absent at the beginning of the affection, while it is not infrequently found in the stools of healthy persons. Calmette has studied more recently this form of enterocolitis, and has made it probable that the bacil- lus pyocyaneus, alone or in association with the streptococcus, is the cause of many cases. He also demonstrated the bacillus pyocyaneus in the drinking- water at Saigon and Gokong. Calmette was able to produce heemorrhages and ulceration of the stomach and intestine in rabbits by injection of cultures of the bacillus pyocyaneus. L. F. Barker has reported several cases, from the Johns Hopkins Hospital, of enteric infection and inflammation caused by this bacillus. In one instance an extensive diphtheritic inflammation of the oesophagus, stom- ach, and intestine existed. As a cause of diarrhoea and dysentery in infants it has been met with by Adami and Williams in Canada, and of an epidemic of the same diseases in Albany, IST. Y., by Blumer and Lartigan. The combination of the colon bacillus and the proteus bacillus is the essential cause. In northern Europe the epidemic is decidedly diiferent from those seen in tropical climates. Chaltin (Archives M6d. Beiges, Apr., '94) . In the case of Europeans, a, large num- ber of species of micro-organisms found, among which are the colon bacillus and an amoeba. In natives (Cochin-Chinese) the number of species is less numerous, probably as a, result of the more simple and almost entirely vegetable diet. Two species regarded as important found: a coccus having all the properties of the streptococcus erysipelatus and the bacil- lus pyocyaneus. A Calmette (Archives de Mgd. Navale, Sept., '93). Cataerhal Dysentery. — This is a disease of the intestines, affecting princi- pally the large bowel, which occurs spo- radically or epidemically. It is the form of dysentery met with most frequently in temperate climates. Morbid Anatomy and Etiology. — The area of intestine involved may be large or small; sometimes the affection is limited to a circumscribed area or areas, at others the mucosa in its entire extent is in- volved, even including the stomach. The colon is most often the seat of the lesions. "Woodward questioned the existence of an isolated affection of the small intes- tine, while ISTothnagel claims to have met with cases in which the pathological process stopped abruptly at the ileo- cascal valve, the large gut having entirely escaped. The general mucosa and the solitary lymphoid nodules, especially, are affected. In the acute stage the affected part of the mucous membrane is redr dened, especially about the lymphoid nodules and plaques, and small extrava- sations of blood may appear. There is an excessive production of mucus and a rich desquamation of epithelial cells. The villi and solitary nodules are swelled, the latter becoming unduly prominent. The microscopical picture agrees with the macroscopical appear- ances: there is hyperemia, swelling, and desquamation of epithelial elements and round-celled infiltrations of the mucosa. The swelled lymphoid nodules show an 40 DYSENTERY. CATARRHAL. increase in cells, the chief ones being of the large epithelioid variety occupying the germinal centres. Extravasations of blood are present in the mucosa about the nodules. The submucosa shows changes only in the severest grades. In more protracted cases ulceration, limited to the nodules or extending into the ad- jacent mucosa, appear. The chronic eases are characterized by pallor of the general mucous membrane; pigmented spots appear, and at one time the mucous membrane is atrophic, at another hyper- trophic. In the latter instance, in the most marked cases, a polypoid condition of the affected mucous membrane may exist. The causes of this disease are twofold, namely: agents of (A) intoxication and of (B) infection. (A) All caustic chem- ical agents which act directly upon the mucous membrane (acids, alkalies, etc.) and others brought by the blood and eliminated by the intestine (mercury, ricin, etc.) and the more indefinite chem- ical substances which are found, under some circumstances, in the ingested food. (B) Bacteria play an important role in the causation of this disease. Booker's study of the summer diarrhoeas of chil- dren is most convincing in this respect. "No single micro-organism is found to be the specific exciter of the summer diarrhoea of infants, but the affection is generally to be attributed to the result of the activity of a number of varieties of bacteria, some of which belong to well-known species and are of ordinary occurrence and wide distribution, the most important being the streptococcus and proteus vulgaris." As to the mode of entrance into the mucosa, Booker saj's: "In the superficial epithelium of the intestine is apparently to be found the chief protection of the mucosa' against the invasion of bacteria. When the epithelium is preserved, bacteria are not found in the mucosa beneath, whereas they may be seen entering it in places where the epithelium has been lost or injured." Gartner's bacillus en- teriditis is capable of provoking acute en- teritis; and acute enterocolitis is asso- ciated as a secondary affection, with a variety of specific infections (cholera, ty- phoid fever, tuberculosis), intestinal dis- eases, and other infectious processes (sepsis, influenza, pneumonia, scarlet fever, measles, diphtheria, etc.). Report on epidemic of dysentery at Toulon. From May 20th to November 1st there were 212 cases: in May, 1; June, 6; July, 57; August, 62; Sep- tember, 53; October, 20. The conditions which accompanied this outbreak were a high temperature in the last of July and August, 91.4° F., and even 95° F., and lower temperature in September and October; moderate rain-fall; the soil contained various micro-organisms, ex- posure to the foul air of a sewer convey- ing faecal matter and found to contain micrococci and bacilli; the potable water was pure; there was chilling of the pa- tient in 37 cases; excessive fatigue in others. Several of the cases were conva- lescents from typhoid fever and from tropical dysentery. The staphylococcus pyogenes albus or aureus found to be a constant element in the stools of severe cases. Experiments with the cultivated germ failed to produce any effect when introduced into the caecum of a rabbit or when swallowed by a dog. The absence of fever noted in cases of each variety, mild and severe. Bertrand (Archives de M6d. Navale, May to Nov., '88). Epidemic of dysentery which attacked the garrison at Poitiers in 1892. Very unhygienic conditions. The soil was most at fault, having been impregnated by fffical matter; the water was also cer- tainly impure. A number of instances prove the contagiousness of the affection, either direct or indirect; the latter through the fsecal matter drying and being spread about in the form of dust. DYSENTERY. DIPHTHERITIC. 41 Prieur (Jour. Cut. and Genito-Urin. Dis., Mar., '94) . Epidemic of dysentery in the garrisons of Antwerp and Brasschaet during the summer of 1893: 324 cases, 18 ending fatally. In the cases that recovered, the appetite for solid food returned long be- fore the stools lost their dysenteric char- acter; the food was apparently well home. The drinking-water was the prob- able source of infection. Cases of trans- mission by contagion seemed clear. Spruyt (Archives M6d. Beiges, Apr., '94). Epidemic on ship Arahia between Cal- cutta and Demerara. The ship leaking badly, the decks, both upper and lower, were wet day and night, where the pas- sengers (natives) slept. The largest number of cases in any week occurred when the mean night-temperature was the lowest: 66' F. on the upper deck and 78° E. below. Out of 404 persons, 56 were ill. Three deaths occurred from dysentery and one from empyema. Pearce (Provincial Med. Jour., Oct. 1, '90) . Microbes constantly present in the in- testine may oecome pathogenic when the state of the mucous membrane is altered by sudden changes in temperature. Maurel (Le Midi Medical, May 6, '94) . History of an epidemic of dysentery and of diarrhoea among the soldiers quar- tered at St. Stephen's in 1892. The main factors were contagion from water- closets and a warm, damp summer, with sudden changes of temperature. Olivier (Archives de Med. et de Pharm. Mil., June 1, '94). Literature of '96-'97-'98. Outbreak of acute dysentery in five members of a family with two deaths. The features of the disease were almost identical in all. Finny (Brit. Med. Jour., Apr. 11, '96). DiPHTHEEiTic Dtsbntekt. — An in- flammatory disease of variable and un- certain etiology, which afEects especially the large intestine, sometimes involving the small gut, which may or may not be attended with fever; is characterized by mucous, serous, or bloody stools, and is accompanied with tormina and tenesmus. The anatomical lesions consist of necrosis of the mucous membrane, the deposit within its substance and upon its surface of a iibrinous pseudomembrane, and the formation of ulcers. This occurs (a) as a primary disease, in which form it prob- ably gives rise to the great majority of the cases of epidemic dysentery; (6) as a secondary and terminal affection in many acute and chronic diseases, the chief ones being acute general infections and chronic renal, cardiac, and hepatic disease. Certain cases of sporadic dysen- tery, the result of the action of chemicals and metastatic bacteria upon the intes- tinal mucous membrane and indirectly of mechanical irritants (coprostasis, in- testinal worms), belong to this class. Morlid Anatomy and Etiology.- — The pathological process begins with' hyper- lemia and swelling of the submucosa and mucosa. The unique character of the dis- ease begins with the appearance of small grayish-white membranous patches upon the surface of the mucous membrane. These increase in size and become con- fluent. At first they are readily removed with the finger; at a later stage they are more adherent. They tend to appear, by preference, upon the more prominent and projecting parts of the mucosa; thus, in the small intestine along the tips of the valvulse conniventes; in the large, corresponding with the insertion of the longitudinal muscular bands. At a later time and in severe eases the intervening mucous membrane may become covered. Upon microscopical examination, in the earliest stages of the disease the blood- vessels of the submucous and mucous coats are congested and contain an in- creased nu.mber of polymorphonuclear leucocytes; the superflcial epithelial layer is necrotic, and fibrin and leuco- cytes are present on the injured surface. 42 DYSENTERY. DIPHTHERITIC. Somewhat later the necrosis has ex- tended and inTolved the deeper parts — glands and interglandular tissue — and the fibrinous membrane is thicker and intimately bound up with the necrotic tissue. Many kinds of bacteria are pres- ent in the necrotic and exudative ma- terial. The swelling of the submucosa may reach a high degree, due to oedema, cellular infiltration, and a deposit of fibrin. The blood-vessels of the mucous membrane become plugged by hyaline thrombi. The separation of the dead tissue leaves an ulcer behind. The young ulcers do not extend deeper than the submucosa coat; later, and by continued destruction, the musciilar coat may be exposed. Perforation of the intestines is, in this form of dysentery, unusual. Ecchymoses occur in the neighboring mucosa. Even the deepest ulcer may, through the formation of granulation- tissue, heal. In these cases the wall of the intestine becomes thickened; the muscle hypertrophic; the scars have a pigmented appearance, and, through re- traction of the cicatricial tissue, de- formity and often stenosis of the bowel arise. The points of predilection of the path- ological process are the flexures (sigmoid, splenic, hepatic), the ascending colon, and csecum. In the Crimean War the rectum, sigmoid flexure, and descending colon were the principal points of attack. The small intestine is only rarely affected in its lowest parts, and this in severe cases; in certain secondary forms of dys- entery it may be attacked alone. Klebs was the first to describe short bacilli in the crypts of Lieberkuhn in diphtheritic dysentery. Since this time a large number of bacteria have been described in association with the disease. None of these appear to be specific, and the circumstances of the disease make it easy to isolate different bacterial forms. From what has already been said it is not probable that diphtheritic dysentery is caused by a single micro-organism. As regards the question of etiology of epidemics, whether in a given epidemic a single species of micro-organism is to be regarded as the cause, and in different and widely-removed ones the same spe- cies will be found, cannot be answered at present. Thus far a very small num- ber of epidemics have been studied with modern bacteriological methods. Ziegler described small bacilli in the crypts of Lieberkuhn and the underly- ing mucous membrane. Marfan and Lion cultivated from the mesenteric glands, pericardial fluid, and heart's blood of two cases the bacillus coli communis. Babes has cultivated the streptococcus, proteus vulgaris,' and other organisms from dysenteric cases. Maggiori studied, in 1891, an epidemic which occurred in Italy. He found in the mucous stools of all cases the bacillus coli communis, in association with proteus vulgaris. More rarely pyococci, bacillus fluores- cens, and pyocyaneus were obtained. Ogata investigated an epidemic which prevailed in Japan. He found small ba- cilli, which lay in the protoplasm of cells; they were present in the base of the ulcers. Cultures from fifteen cases gave a short, non-pathogenic, liquefying ba- cillus. From eleven cases Ogata culti- vated a bacillus which also liquefied gelatin, but was pathogenic. Guinea- pigs, inoculated subcutaneously, develop hsemorrhages and ulcers in the intestine. Eectal injections produced more pro- nounced results. Condorelli, Maugieri and Aradas describe a bacillus which they obtained from an epidemic and also iso- lated from the drinking-water; Bertrand and Baucher studied an epidemic at Cherbourg and isolated several different DYSENTERY. TREATMENT. 43 bacteria, none of which appear to be spe- cific. Silvestri described diplococci which caused diarrhoea in dogs. Colli and Fi- occo found that in the dejections of dys- enteric persons the bacillus coli com- ijiunis is always present; with it is often associated a typhoid-like bacillus; more rarely the streptococcus and proteu.s ba- cillus. The introduction of this bacillus coh, either alone or in association with the other bacteria, by means of the mouth or rectum, into cats, gives rise to dysen- tery. According to these writers, the association of the bacillus coli communis with the other bacteria mentioned leads to its conversion into the bacillus coli dysenteric. Celli has more recently ex- pressed the idea that the primary in- jury to the intestine is produced by the toxin of the bacillus dysenterie, which is followed by the injurious action of pyor genie cocci contained within the intes- tine. Ciechanowski and Norrak have failed to confirm this view by experi- ments, although they found large num- bers of streptococci in the stools of cases of sporadic dysentery. The bacillus pyo- cyaneus, according to Blumer and Larti- gan, may be associated with epidemics of dysentery in this country. Treatment. — The hygienic rules which are observed in the prevention of other infectious diseases and especially of cholera have been employed with excel- lent effect in controlling epidemics of dysentery. The employment of filtered and boiled water has reduced the num- bers of cases and the spread of the dis- ease in the tropics. The same principles are applicable to the treatment of articles of food (vegetables, fruits, etc.) which come into contact with water. Other prophylactic measures consist in the use of suitable clothing which obviates the injurious influence o'f rapid changes in temperature and humidity of the air and the proper disposition of the dejecta from the sick. The direct treatment is, in part, di- etetic , in part therapeutic. In acute cases the diet is to be restricted to milk, whey, and broths, and during convales- cence great care is to be exercised in pro- viding only the most digestible articles of food. In the use of a diet of milk, which often will be the chief article, the appearance of curds in the stools is the indication to dilute or partially peptonize the milk before it is administered. Di- luted egg-albumin may supplement milk or even take its place for a few days if there is much intolerance to the latter. Sometimes milk is made more acceptable by dilution with lime or Vichy water. The quantity of milk, for an adult, ad- ministered in twenty-four hours should be from 2 to 3 ^/j quarts. Whatever the food, it is advisable to give it iii small quantities and at frequent intervals. The patient even in chronic cases should be confined to bed; in acute cases no especial persuasion will be required. For the relief of the abdominal pain, the external application of fomentations or turpentine stupes will sometimes suffice; but the internal use of opiates may be demanded. When the pain is low down in the bowel then enemata of opium or suppositories containing some form of this drug or of cocaine may be resorted to. When a case is seen early, especially if there has been constipation, a purge should be administered. This can be either castor-oil or, what is preferable, a saline. By this means the faecal contents of the large intestine, which tend to pass continuously over the inflamed area, should be effectually removed. The saline selected should be given in suf- ficient doses to promptly produce abun- dant dejections, and it is then to be dis- 44 DYSENTERY. TREATMENT. continued. There may be a marked dim- inution in the frequency of the dysen- teric evacuations, and great relief of the tormina and tenesmus following the operations of the purgative. The use of a saline is contra-indicated by feebleness of the patient; in such cases castor-oil is to be preferred. Ninety-five cases treated at Hydera- bad, India, by sulphate-of-magnesium method. The number of days under this treatment before the dysenteric symp- toms disappeared was never more than 5, and in many cases 1 or 2 only. Leahy (Lancet, Oct. 4, '90). [Saturated solutions of magnesium sulphate urged by many observers: To an ounce of saturated solution of mag- nesium sulphate 10 drops of dilute sul- phuric acid are added; this is given every hour or two until it operates freely and the stools have become feculent, free from blood and mucus, and the pain and tenesmus are relieved. W. W. Johns- ton, Assoc. Ed., Annual, '91.] Mortality reduced from 5 to 10 per cent, to practically nil, by avoiding all irritants and stimulants; rendering the intestinal canal aseptic by preventing the decomposition of contents; by counter- acting acidity of the blood by alkalies and thus quieting the abnormal action of the intestinal glands. Diet restricted to arrowroot-milk and trinitrate of bis- muth, Dover's powder, and soda inter- nally. Bahadurji (Brit. Med. Jour., Oct. 24, '91). Literature of '96-'97-'98. Drachm-doses of a saturated solution of Epsom salts, in combination with 10 minims of dilute sulphuric acid, every hour, are strikingly effective. V. G. Thorpe (Brit. Med. Jour., Feb. 26, '98). Among the drugs used to combat the disease, ipecacuanha still maintains its reputation in the tropics. It is usually administered after a preliminary dose of laudanum or morphine, which is followed in half an hour by from 20 to 60 grains of ipecacuanha. Should the dose be re- jected, it is repeated in a few hours. This mode of treatment was not satisfactory during the War of the Eebellion, and Osier has failed to see in sporadic cases the marked effects claimed for it by the physicians in the tropics. [Fluid extract of ipecacuanha, 30 to 50 drops in 2 or 3 drachms of water, every 6, 12, or 24 hours, combined with tincture of opium if not retained, is an excellent method of administering this specific remedy. W. W. Johnston, Assoc. Ed., Annual, '89.] The use of ipecacuanha powder which has been deprived of emetine advocated. The ipecacuanhie acid is at first ab- stracted, but subsequently remixed with the powder after the emetine has been re- moved. Patients thus escape the nausea and prostration of powdered ipecacuanha. Harris (Lancet, Aug. 30, '90). Epidemic on ship Arabia, 56 cases, 4 deaths. All treated with ipecac; 20 to 30 grains at the first onset, and in one hour 10 to 20 grains; in another hour 10 grains. Hot-water fomentations were kept over the abdomen. Vomiting rare. Pearce (Provincial Med. Jour., Oct. 1, '90). Ipecac, though valuable, is inferior to bismuth and Dover's powder. Crombie (Indian Med. Gaz., No. 4, '93). Epidemic of dysentery in Alquizar, Cuba; 137 cases under treatment. The mortality among those treated wit3x ipe- cacuanha and calomel, opium, etc., amounted to 9 per cent., while that among those treated by benzonaphthol was slightly above 2 per cent. Forty-five grains per diem were given to adults and but little less to children. Jose A. Clark (Lancet, July 20, '95). Literature of '96-'97-'98. Ipecacuanha and saline purgatives are suitable principally for chronic cases in which malaria has much to do with the condition. Epidemic in a garrison in which the local treatment consisted in warm creasote enemata, made with milk, prepared as follows: — DYSENTERY. TEEATMEXT. 45 IJ Beech-wood creasote, 15 grains. Tincture opium, 10 drops. Boiled milk, 5 drachms. The contents of the bottle poured into a jar containing 7 ounces of boiled water for one enema. Three such enemata to be adminis- tered in the twenty-four hours. Before having recourse to these ene- mata, the rectum should be thoroughly washed out with boric-acid solution con- taining also salicylic acid. Testevin (Med. Week., p. 252, '96). Experience in Bengal has given great faith in ipecacuanha in large doses. Castor-oil should be given the night be- fore and, after the bowels have moved in the early morning, tincture of opium, fol- lowed in fifteen or twenty minutes by ipecacuanha in a dose of 25 or 30 grains. The patient should lie undisturbed for four or five hours. Should vomiting oc- cur, ipecacuanha to be repeated in half an hour and also if the stool has not much changed for the better within twenty-four hours. Ipecacuanha in pill, in doses of from 3 to 5 grains, is utterly useless. W. J. Buchanan {Practitioner, Dec, '97). Ipecacuanha tried several years in Nicaragua, Central America. Notwith- standing its vaunted efficacy, no case de- rived much benefit from it. Patients suf- fering from dysentery cannot always retain large doses, as stated in text- books. Half-ounce doses of a saturated solution of magnesium sulphate and 15 minims of dilute sulphuric acid every two hours, with milk diet, caused all traces of blood to disappear from the stools in twenty-four hours, and there was, of course, a complete absence of the dis- tressing nausea which is always present in the treatment of ipecacuanha. T. R. Wiglesworth (Brit. Med. Jour., Feb. 26, '98). Corrosive sublimate, in doses of ^/loo grain, repeated every two hours, has been recommended by Einger. Bismuth in large doses — -^Z, to 1 drachm every 2 hours, amounting to 12 to 15 drachms in 24 hours — often has a beneficial effect. Its effects are more pronounced in the chronic than in the acute cases. The administration of antiseptic sub- stances by the mouth for the purpose of disinfecting the intestinal canal has been employed. For this purpose benzo- naphthol is the drug to be chosen when there is svTspicion of liver or kidney dis- ease, and in their absence it is as effective as betanaphthol and resorcin, which are also employed as intestinal antiseptics. The dose of benzonaphthol is 40 to 80 grains, given during 24 hours, in divided doses every 2, 3, or 4 hours. Betanaph- thol and resorcin are given in quanti- ties of from 30 to 50 grains in 24 hours in much the same way. The naphthol preparations, being insoluble, must be given in capsules or dissolved in oil and emulsified. Eesorcin is soluble and can be readily administered. E'aphthalin (20 grains per day) and salol (30 to 40 grains per day) are used for the same purpose. Opium is an invaluable remedy for the relief of pain and to quiet the peristalsis, but should be employed cautiously. It is to be administered hypodermically in the form of morphine, according to the needs of the patient. Irrigation of the bowel is both ra- tional and useful. To overcome the ex- treme irritability of the rectum in .the acute cases a suppository or solution (4 per cent.) of cocaine should be intro- duced as a preliminary measure. The irrigation is made with the long rectal tube, the patient being in the dorsal po- sition, with a pillow under the hips. The substance to be injected is water at 100° alone or containing some astringent drug: alum, acetate of lead, sulphate of zinc or copper, nitrate of silver, or tan- nin. Tannin, in 0.5 per cent, solution, is highly recommended by Kartulis, who also uses this drug in combating amoebic dysentery. Osier regards nitrate of sil- 46 DYSENTERY. TREATMENT. ver as the best, although not in the very acute cases. In the chronic form it is, perhaps, the most satisfactory treatment. The solution, in this class of cases, is to be made 20 to 30 grains to the pint, and, if possible, 3 to 6 pints of fluid are in- jected. At times the irrigation causes much pain and is immediately rejected. Large anemata of hot water or ice-cold water relieve tenesmus and diminish the number of stools. An enema of 2 or 3 pints of water, with % to 1 drachm of alum to the pint, once in twenty-four hours, through a soft-rubber tube, intro- duced one foot into the bowel, gives com- fort for the next twelve hours. Editorial (Ther. Gaz., Oct. 15, '88). Use of large and frequently-repeated rectal enemata. The patient should lie on the right side and 1 to 4 pints of water, at a temperature of 100° to 105° F., should be thrown into the bowel with an alpha syringe. Fairbairn (Brooklyn Med. Jour., Oct., '90). Nitrate of silver recommended in acute dysentery. Complete cure obtained in six days. The rectum is first washed out with tepid water, and one hour later 5 ounces of a 2-grain-to-the-ounce solution of the silver salt is injected. Nilkanthrai Dayabhai (Indian Med. Rec, Mar. 16, '93). For destroying the organisms and stim- ulating the ulcers, solutions of quinine, creolin, and silver nitrate tried; the lat- ter gave the best results. West (Med. Record, Sept. 23, '93). Literature of '96-'97-'98. Two severe cases in which 1-per-cent. solutions of creolin used, with excel- lent results, in severe dysentery. A pint and a half of the solution was used night and morning. Creolin is worthy of an extended trial in dysentery. George Johnston (Treatment, June 24, '97). Iodized starch internally tried in more than a hundred cases, giving a mixture of equal parts of iodized starch, oil of cinnamon, and oil of fennel, about 1 grain four times a day. At the same time irrigations with a solution of iodized starch to which are added a few drops of chloroform, tincture of iodine, and oil of cinnamon given. Kotschorowsky (Se- maine Med., No. 62, '96). Antipyrine used in a case of severe acute dysentery, by rectal injection three times a day of a solution of 75 grains dissolved in Vi pi°t of water. Sedative action of the antipyrine greatly allevi- ated the patient, who gained strength and soon recovered. Ardin-Delteil (Bull. Gen. de Th6r., Jan. 30, '98). In amoebic dysentery the use of qui- nine irrigations was introduced by Losch, who found that solutions of 1 to 5000 destroyed the organisms. Stronger so- lutions—! to 3500, 1 to 1000, and 1 to 600 — are borne well and may be injected three or four times a day. Corrosive sub- limate in solution of 1 to 500 or 1 to 3000, and nitrate of silver, 30 grains to the quart, are also beneficial, but must be used more cautiously. H. P. Harris has seen benefit result from the use of hydrogen peroxide in some eases. The ordinary commercial hydrogen peroxide is diluted from four to eight "times with water and about a quart injected twice daily. The treatment is continued for one week and then the quantity gradu- ally diminished. Fifty-four eases treated by enemata of corrosive sublimate, I to 5000, of which 6 ounces were injected three times a day; later on a solution of 1 to 3000 was in- jected twice daily. The fluid was not retained usually longer than ten min- utes. Cases cured in from 1 to 3 days. In no case was there any sign of systemic poisoning. Lemoine (Bull. Gta. de Th6r., Jan. 30, '90). For any of these measures to be efEeet- ive in amcebic cases, they must be con- tinued until the amoebse disappear. In order to decide this an intermission of a couple of days is made in the treat- ment. If at the end of this time amcebfe are still present the procedures must be renewed. In the gangrenous cases little DYSENTERY. DYSMENOERHCEA. SYMPTOMS. 47 good can be looked for from the injec- tions, and, indeed, they are not without danger of precipitating a fatal termina- tion by causing perforation of the al- ready-much-injured intestine. When tenesmus is slight an enema of thin starch containing ^/j to 1 drachm of laudanum affords great relief; for the more severe tormina and tenesmus the hypodermic injection of morphine is the only satisfactory remedy. During the period of convalescence tonics containing some form of iron and a nourishing, but unirritating, diet are to be ordered. The recuperation of the patient's strength is to be facilitated by these and other well-known means. Simon Flexnek, Baltimore. DYSMENOERHCEA. — Gr., Svg, dif&- CTilt-ffiyiviala, menses; and pelv, to flow. Definition. — Dysmenorrhoea is not a disease, it is only a symptom. The term has often been used in a very loose way to signify any or all the painfu.1 or other disagreeable sensations which may be as- sociated with the abnormal performance of the function of menstruation. The headaches, the pains in the joints and muscles, the backaches, the nausea and vomiting which are of such frequent occurrence at the menstrual epoch' do not constitute dysmenorrhoea, though they are doubtless influenced by the same cause which produces dysmenorrhoea. This symptom must be referred to the pelvic organs, to their nervous system, and to their vascular system; in other words, dysmenorrhoea is pain in the pel- vic organs which is experienced in con- nection with the function of menstrua- tion. It is a symptom of a pathological condition. A woman who is in perfect physical condition menstruates without pain. Dysmenorrhoea may, therefore, be de- fined as a deviation from normal men- struation, menstruation meaning essen- tially a monthly congestion of the vascu- lar system of the pelvis in obedience to a recurring impulse, with the shedding of more or less of the endometrium and the discharge of glandular secretions, the tension of the vascular system being re- lieved by the discharge through the uter- ine canal of a greater or smaller quantity of blood. Symptoms. — The pain of dysmenor- rhoea differs as to the time of its occur- rence, its intensity, its duration, and the conditions which produce it. It occurs most frequently during the day or the two or three days which precede the menstrual flow. Literature of '96-'97-'98. In ovarian dysmenorrhoea, usually within twenty-four to forty-eight hours before flow appears the patient is seized with sharp, darting pains in one or both ovarian regions, generally the left. This pain remains constant or increases, until finally a show of blood takes place. The pain is not in the median line, but on either side, and in this respect the pain differs from that due to a uterine cause. Munde (Med. Brief, May, '96). "With many women the beginning of the flow means the relief of tension and the relief also of pain; with others it continues, sometimes diminishing, some- times retaining its acuteness until the pelvic congestion has subsided. Literature of '96-'97-'98. There are two conditions present in anteflexion which are responsible for the pain. One is the swelling of the uterine mucosa which accompanies the flow, the- other the condition of abnormal sensi- tiveness at the internal os. The tissues- at the OS internum are apt to be more rigid than normal and the nerves in ani extremely-hypersesthetic state. The in- 48 DYSMENOERHCEA. SYMPTOMS. creased congestion which accompanies the onset of menstruation and the ten- sion of the tissues generally irritate the nerves and aggravate the pain. This is the case during the first few hours of the flow. Later the tissues become re- laxed, and the canal, to a certain extent, straightened, and the pain disappears. After a time varying from twelve to twenty-four hours relaxation has oc- curred, the flow is more profuse, and the pain has largely ceased. Davenport (Bos. Med. and Surg. Jour., June 2, '98). In intensity it may be a simple ache, a feeling of distension within the pelvis, or it may be an acute, continuous, neuralgia- like sensation. It is often spasmodic in character, with a feeling of contraction or bearing down in the uterus, and may be relieved when a clot or gush of blood is ejected from the uterine cavity. The acuteness of the pain is also governed by the temperament of the patient, a highly- organized sensitive person suffering more than a phlegmatic, insensitive one. It is more frequently experienced in damp than in dry weather, at the sea- shore rather than at the mountains, dur- ing an ocean-voyage rather than on a journey inland. The more scar-tissue there is in and around the uterus, the greater the flexion of the organ, and the narrower the cervical canal, usually the more constant will be the occurrence of pain. The customary classifications which can be verified by anyone with a few years of practical experience are, for the most part, satisfactory, but the writer has adopted the following as the results of his experience, viz.: — 1. Dysmenorrhoea from congestion. 3. Dysmenorrhoea from obstruction. 3. Dysmenorrhoea from neuroses. 4. Dysmenorrhoea from endometrial hypertrophy. 1. Dysmenorrhoea from congestion. This is the simplest of all the varieties. Congestion is always and necessarily a featitre of menstruation; that is, the cur- rent in the pelvic vessels is then more rapid or the tension or volume is greater, or perhaps all these elements are com- bined. When the degree of this con- gestion is greater than can be readily tolerated by the person, pain is one of its results (the other results need not concern us now), and this pain will last as long as the congestion continues, and will recur as frequently. Tolerance of this condition to a greater or lesser ex- tent is acquired by many women, just as other disagreeable experiences become tolerable when habitual and inevitable. In some eases the pain seems limited to one or both ovaries, in others to the uterus, and in others it seems to be dis- tributed through the pelvis. 2. Dysmenorrhoea from obstruction. There has been much discussion for many years concerning this variety, some writers going as far as to say that the vascular system of the pelvis was so ac- commodative that dysmenorrhoea from obstruction was not possible. Clinical facts do not warrant such a statement. Obstruction of the outflow of blood is, perhaps, not so great when the womb is flexed backward or forward as was claimed a few years ago by Sims, Hewitt, and others, especially if coagulation of the blood within the uterus does not oc- cur; but, if such coagulation does take place (and in some cases also in which it does not), dysmenorrhoea will be a very pronounced symptom. "With stenosis of the cervical canal the same difficulty to the outflow of the menstrual product is also frequently ob- served. With imperforation of the hy- men or of the os internum or externum obstruction to outflow is complete. A certain portion of the transuded blood is reabsorbed, but the remainder persists, DYSMENOEEHCEA. SYMPTOMS. 49 distending the vagina or the uterus or both, sometimes producing a very large tumor, and invariably resulting in great pain, which in some cages has led to a fatal result. Pain from incomplete development of the pelvic organs, especially the uterus, is also to be referred to obstructive dys- menorrhoea as its origin, and, as in cer- tain cases of congestive dysmenorrhcea, the bad symptoms are not limited to pain. Dysmenorrhosa from inflamma- tory exudate is an acquired symptom, the exudate binding the pelvic organs into a more or less firm mass, which tends to become firmer as the contraction, which time brings with it, takes place. The pain in such cases is not limited to ob- struction to outflow; indeed, there is no such obstruction apparent in some of the cases, the flow being profuse in some in- stances and scanty or absent in others. The remarks concerning inflammatory exudate will also apply to scar-tissue, which, by its presence, will often effectu- ally obstruct the passage of the menstrual blood-current. To this variety of dys- menorrhcea might also be added those cases which are so often seen that de- pend upon perverted or imperfect nutri- tion and in which constipation is an ever-present accompanying symptom. 3, Dysmenorrhcea from neuroses. There may be at least two types of this variety; in one of them the neurosis is the sole discoverable source of trouble, in the other it is secondary to disease of some other character within the pelvis. Hysteria is at the foundation of many of the cases of the flrst-mentioned vari- ety, the pain connected with menstrua- ation being, to a great extent, simulated or imagined. literature of '96-'97-'98. Too much has been made of the local causes of dysmenorrhcea, as it is most often a symptom of hysteria. Vedeler (Norsk Mag. f. Laegevidensk., No. 10, Oct., '97). When we realize, however, the inti- mate anatomical relations which the sym- pathetic nerves of the pelvic organs bear to the nerves and ganglia of the rest of the organs of the body, we are quite pre- pared to believe that painful sensations in those organs might be transmitted to the organs of the pelvis. So far as I know there have been no exact investigations upon this subject. The referred or re- flected pains from the pelvic to the other organs have been much discussed and a variety of conclusions has been reached. The neuroses in the pelvis or pelvic organs which occasion dysmenorrhcea may constitute a use of language which is somewhat misleading. Of course, all pain is the evidence of nerve-irritation or a neurosis. The form which is here to be considered is that in which, aside from mere congestion or obstruction as an at- tendant of the menstrual experience, there is a direct irritation of nerve-tissue which is not apparent apart from the menstrual epoch. Such, for example, is the case when the unusual pressure due to the congestion of menstruation is ex- perienced by the sacral nerves as they pass through the pelvis, the tissues being already the seat of inflammatory exudate. The tissues are squeezed and contracted by this exudate; but the addition of the menstrual congestion introduces a further element of press- ure, which causes irritation of the nerves which are infringed upon, and pain is experienced, which radiates in the di- rection of the imprisoned nerves. This condition is not infrequently found in insane women; it is probably a factor in producing insanity, and such insanity cannot be expected to ameliorate perma- 3—4 50 DYSMENORRHCEA. ETIOLOGY AND PATHOLOGY. nently until the source of trouble is re- moved. 4. Dysmenorrhcea membranosa. This is a somewhat rare form of dysmenor- rhcea, but one which has long been recog- nized, and is described by all writers of gynfficological treatises. Literature of '96-'97-'98. During ten years' experience, case of membranous dysmenorrhcea never met with. The spasmodic-neuralgic form without any pathological lesion is also extremely rare. The worst cases are usually due to anteflexion. Dilatation gives relief, but must be repeated. There is not any scientific proof that the ovary per se ever caused dysmenorrhcea. When no lesion can be found the fault is in the nervous system, and to this the at- tention must be directed. Fibroma not infrequently causes dysmenorrhcea, even in women under 30. The tumor may be very small and escape notice, unless a careful examination is made under an ansesthetic. Parsons (Brit. Med. Jour., Oct. 24, '97). Dysmenorrhcea membranosa is due to an hypertrophied condition of the endo- metrial decidua; that is, of the exfolia- tive portion of the uterine mucous mem- brane which is shed at each menstrual epoch. This membrane varies in thick- ness and density in extreme instances, showing a perfect cast of the cavity of the uterus. The exfoliated uterine mucosa of mem- branous dysmenorrhcea presents the le- sions of an ordinary endometritis, and can usually, by histological examination, be differentiated from the decidua ex- pelled in early abortion or in ectopic foetation. Sterility is a, usual sequence when the trouble is established early in menstrual life. Medicine is of little use, dilatation and the curette giving the best results. Coquard (Revue M6dico-Chir. des Mai. des Femmes, Aug. 25, '88). Separation of the membrane from its underlying attachment and its expulsion from the uterus mean an unusual amount of uterine work and severe pain as an almost constant accompaniment. It usually occurs, too, in women whose nutrition is defective, and is conse- quently a matter of more serious impor- tance than if it were among the robust and well nourished. It is, of course, a form of obstructive dysmenorrhcea, but its peculiarities are so marked that it may be well to continue to consider it a dis- tinct variety. Etiology and Pathology. — Anything which prevents or disturbs the equilib- rium of the normal conditions described will cause dysmenorrhcea. It is of ex- ceedingly frequent occurrence. It is a matter of great surprise that so many women should present this symptom, which appears with some of them at the advent of puberty and continues with varying intensity until the termination of menstrual life, while with others it disappears with pregnancy, with the physical changes attending mature life, or as the result of surgical treatment. That it should occur so frequently, and especially in communities in which the highest intellectual development has been reached, is not a flattering com- mentary upon the results of modern civilization. Still, this is coimterbal- anced by the fact that dysmenorrhcea is usually curable by judicious and appro- priate surgical means. A disregard of the function of the female organization in the manner of educating girls is a factor in producing this trouble in very many cases. Irregularity occurs in consequence of the demand made upon the vital powers at times when there should rightly be an intermission or remission of labor. Dysmenorrhcea is often accompanied by hysterical conditions, which sometimes pass into insanity, and suicidal mania sometimes occurs at the period when the pain is most severe. Eggers (Annals Gyn. and Ped., Dec. 23, '95). DYSMENOERHCEA. ETIOLOGY AND PATHOLOGY. 51 Women in the savage or barbarous state and women who are constantly en- gaged in out-of-door labor are seldom sufferers from this cause, though their pelvic organs may be defective in struct- ure and though they may habitually be subject to experiences which would un- failingly cause dysmenorrhcea or even complete suppression of the menstrual function in women of less robust organ- ization. This is, in part, owed to the in- creased power of resistance to physical ills which is favored by an out-of-door life, and, in part, to the greater insensi- tiveness to pain of women in the lower strata of social and intellectual develop- ment. With those who are sufferers the underlying causes are various, and demonstrate the important role which the reproductive organs play, not alone in the propagation of species, but in the experiences of daily life. One hundred and twelve cases of dys- menorrhcea examined. One of the moat striking points is the very large num- ber of sterile women; 44, or a fraction less than 40 per cent., belong to this class. Of those who had been pregnant, 12 had never had a child at full term; IS more had had a miscarriage since the last full-term child was born, .leaving less than 37 per cent, of the total num- ber whose last pregnancy had come to full term. These figures would seem to indicate that, in a large proportion of patients suffering from dysmenorrhcea, there were present lesions which also interfered with conception. One hun- dred out of the 112 suffering from pain- ful menstruation were found to have some marked organic lesion of the pelvic organs. William S. Gardner (Atlanta Med. and Surg. Jour., Dec, '95). The causes may be classified as follows, viz.: heredity, disease, occupation, and trauma. 1. Heredity. With many women the defects in the structure of the reproduct- ive organs are congenital and necessitate dysmenorrhcea. Literature of '96-'97-'98. Uterine dysmenorrhcea is caused by a malformation of the uterus, due to want of proper development. To this are added the thickening of the mucous membrane and congestion at the time of the menstrual flow. The bend, plus the thickening of the mucous membrane and congestion, is the cause of the pain. On examination, anteflexion of the uterus is almost certain to be found. Keith (Brit. Gyn. Jour., Nov., '97). It does not avail that the remainder of the physical organization is normally developed; indeed, one frequently sees women of the finest physique and superb presence whose incomplete pelvic appa- ratus condemns them to semi-invalidism during a considerable portion of each month. On the other hand, puny, delicate women with normally-developed pelvic organs suffer with dysmenorrhcea on ac- count of their perverted general nutri- tion, their flabby muscular system, and their low-ebb vitality, to which the re- curring monthly congestion brings a strain which they are ill fitted to bear. The defective organization may in- clude any portion of the genital appara- tus; in the vulva it may take the form of an impermeable hymen, producing an absolute barrier to the discharge of im- prisoned blood; in the vagina it may consist of bands and septa with almost equal obstruction to the outflow of the menstrual fluid; in the uterus it may be an almost-impervious cervical canal, an occluded os internum or externum, less frequently a rudimentary corpus uteri or one with its two halves uncoalesced or its canal obliterated; in the tubes or ovaries the structure may be rudiment- ary or the seat of some form of con- genital disease. 52 DYSMENOERHCEA. ETIOLOGY AND PATHOLOGY. Literature of '96-'97-'98. Stenosis may be due to swelling of the mucous membrane occurring only at the time of menstruation, and consequently impossible to diagnose at other times. Treub (Centralb. f. Gynak., July 17, '97). DysmenorrhcBa should be divided into dysmenorrhceal endometritis and uterine spasm. The first includes all forms in which there is any local mechanical ob- stacle; all other eases are uterine spasm, which affects the sphincter of the uterus, ■ — that is, the cervix. Of 167 patients observed, 37 complained of painful men- struation. In 32 a. local cause was dis- covered, but in the 5 others, virgins, the affection was spasmodic. Besides there were 21 who had manifest stenosis \\ithout painful menstruation. Among these subjected to curetting there were 17 with dysmenorrhosa, but only 1 had marked stenosis. Of these last, 8 were completely cured by curetting; of the 9 others, 7 returned with a relapse of their old trouble, and 2 received absolutely no relief. De Leon (Centralb. f. Gynak., July 17, '97). Painful menstruation often co-exists with acute anteflexion of the uterus. The class of patients who suffer from this type of disease are usually, if mar- ried, sterile, and the supervention of pregnancy often effects a cure. Williams (Brit. Med. Jour., Oct. 24, '97). In all cases thus connected with he- redity, defective organization, etc., recur- ring monthly congestion produces ten- sion in poorly-conditioned structures, and, if the tension in the vessels is suffi- cient to result in transudation of their contents, the outlet being imperfect or wanting, pain will be the inevitable result. 2. Disease. Disease of one kind or an- other may cause dysmenorrhcea, whether the disease occurs before or after puberty. Before puberty there are many forms of disease which arrest the development of the pelvic organs and result in dysmenor- rhcea. The exanthemata seem to be es- pecially productive of this effect. Why this should follow has not been satisfac- torily explained. Measles, scarlet fever, small-pox, all have their victims in whom such a result has been observed. Of the diseases subsequent to puberty which produce dysmenorrhcea there are those which are local and others which are general. Of the former may be men- tioned fibroid tumors either within the uterine canal, in its muscular substance, or within its peritoneum, and inflamma- tory disease of the tubes of the ovaries or of the pelvic peritoneum. All these diseases may, by their obstructive effect, prevent free discharge of blood during the menstrual epoch, and produce pain. Of the general diseases may be men- tioned typhoid fever, certain diseases of the liver and gall-bladder, anaemia, etc. The same result is often seen in cases in which there is excessive development of fat. Women who become very obese are very frequently sufferers from dys- menorrhcea. 3. Occupation. Some occupations are especially prone to result in dysmenor- rhcEa. Those who work in a very hot at- mosphere, like cooks and laundresses; those who are constantly exposed to cold and dampness, like fishwives or workers in mines (unwomanly occupations); those who work in poisonous substances, — copper, arsenic, lead, phosphorus, and sulphur; those who are confined for long hours in factories, stores, and tene- ment-house "sweat-shops" are, in many instances, sufferers with dysmenorrhcea. [It is a pity that civilization, which has done so much to ameliorate many physical evils, has also brought in its wake many others. The field for philan- thropy and preventive medicine, in this direction, is a very wide one, and legis- lation has yet much to do in emanci- pating women from such distressing ex- perience. A. F. CUEEIER.] 4. Trauma. Dysmenorrhcea from this DYSMENORRHCEA. PROGNOSIS. TREATMENT. 53 cause is, in most eases, the result of diffi- cult parturition, the genital organs sus- taining severe injuries and cicatrization and contraction ensuing. The hardened tissues are auEemic and the necessary elimination of blood is accomplished with difficulty and pain. Occasionally there are direct injuries to the genital organs, apart from parturition, which also produce deterioration of the tissues of those organs, and are likewise followed by painful menstruation. Prognosis. — The prognosis in dys- menorrhoea varies with the conditions and varies also with the treatment. If it depends upon structural defects, and those defects are remediable, a cure will result. It sometimes persists during the whole menstrual life, but with many women it gradually becomes tolerable, as all ills which are long endured become tolerable. ' With regard to prognosis much will depend upon the general condition of the subject, great improvement in that direction often leading to menstruation, which is less painful or not painful at all. The prognosis in cases in which drug- treatment alone is used is very uncertain; while such treatment is proper enough simply as a means of relieving or be- numbing pain, it has nothing more thaii a temporary and palliative effect when the pain is due to an anatomical fault or defect. Treatment. — It might be quite appar- ent from the foregoing that, while the treatment may be either medical or sur- gical, the latter, however, will usually give the more satisfactory and radical results. Modern gynsecology is cast in surgical lines, and while it would be folly to deny that many mistakes have been made in its name (for mistakes are al- ways made in the development of a new department of knowledge), it has ap- proached nearer to fundamental condi- tions by directly attacking tissues which are involved in disease than have other methods of treatment which are more circuitous in their course. Considering the subject of treatment, therefore, as divisible into palliative and radical, the former will include the methods by means of drugs (which occa- sionally may produce a permanent re- sult), and the latter (which do not in- fallibly produce a cure) those methods which involve surgical procedures. Of course, a judicious combination of both medical and surgical means will often prove efficacious. Of the drugs which may be given to relieve the pain of menstruation, mor- phine combined with atropine should be reserved for very rare cases whether given by the mouth or hypodermically. It should be given in the smallest possible doses, ^/g grain sufficing to relieve pain in most eases as well as a larger quantity. One must not forget the seductive influ- ence of this drug, especially upon real nervous, hysterical women. Many women find relief from the pain in ques- tion by drinking hot herb-teas: chamo- mile, scutellarium, boneset, fiaxseed, etc. These can do no harm and are innocent as to the formation of drug-habits. More or less meritorious preparations are much in vogue, but in some eases they seem to be entirely inert, either from instability or want of uniformity in the preparation or some peculiarity in the patient. Oxalate of cerium, in 6-grain doses every hour, considered specific for the dysmenorrhcea of well-nourished, robust women, in cases where the pain comna at or before the beginning of the flow. Chambers (Med. Record, July 7, '88). In neurotic cases with considerable general disturbance 20 grains of anti- pyrine work like a charm, the best effect being obtained when the patient lies 54 DYSMENORRHCEA. TREATMENT. with closed eyes in a quiet room for half an hour after taking it. Segur (Proceed. Conn. Med. Society, '88). Pulsatilla in the form of a tincture of the fresh leaves, 10 minims three or four times a day, is particularly praised. Segur (Med. Chronicle, Feb. 2, '89). Apiolin is especially indicated in spas- modic and congestive dysmenorrhoea, in doses of 3 minims in capsules, three times a day. Hill (Med. Standard, June, '91). In non-inflammatory cases viburnum prunifolium gives brilliant results, not to be obtained from any other remedy except morphine. A teaspoonful of the fluid extract three times daily to be given. Schwartze (Ther. Gaz., Aug. 15, '94). Literature of '96-'97-'98. Cases in which the flow is ushered in by severe cramp-like pains for three or four days preceding the menstruation 'A-drachm doses of the fluid extract of viburnum prunifolium in hot water three times a day may be given, and on the morning of the expected period a full dose of magnesium sulphate. If the pain comes on in spite of this, 5-grain doses of antipyrine, repeated every two hours for three doses, if necessary, will often relieve it. Arthur A. Browne (Montreal Med. Jour., Apr., '98). The following formula has given good results: — Ijt Tincture of hydrastis Canadensis, Tincture of viburnum prunifolium, of each, equal parts. M. Ten drops to be taken every two hours. Lutaud (Jour, de Med. de Paris, Jan. 2, '98). Manganese is a most valuable remedy in unmarried women, and a trial ex- tending over three months is recom- mended before relinquishing its use. Its action appears to be upon the nei-ves or nerve-centres concerned in the men- strual function rather than upon the blood. Administration of manganese does not interfere in any way with iron and vegetable tonics, but rather en- hances their effects. The black oxide is the most convenient form of prescrip- tion. If nausea is produced the drug should be given in a small dose: 1 grain at a time gradually increased. A 3-grain dose is found to be as efficacious as a larger one. Charles O'Donovan (Med. News, Nov. 27, '97). The various currents of electricity have all been vaunted as useful means of treatment, and in many cases they are prompt in producing relief. Especially is this true of the faradie current, but if the cause of the trouble lies in a defect of structure it would be unreasonable to ex- pect a permanent result from electrical treatment so long as the cause remains. Good results from a mild galvanic cur- rent passed from suprapubic region to sacrum twice a week for several weeks. Williams (Epitome, Sept., '88). Other palliative measures are warm hip-baths in which the patient may sit ten to fifteen minutes, the temperature of the water being sufficient to produce relaxation of tissue, .and hot mustard- water foot-baths, which must be used only long enough to produce a glow of the skin. Hot salt-baths calm the pains of dys- menorrhoea and notably diminish men- strual flow. Mironoflf (Ejenedelnoya, No. 35, '95). Literature of '96-'97-'98. In ovarian dysmenorrhoea all remedies which are likely to relieve pelvic conges- tion should be employed, such as hot injections and sitz-baths, hot-water bags to the lower part of the abdomen, and saline laxatives. Internal medication is of very little avail. In cases, however, in which menstruation is not profuse the mother-tincture of Pulsatilla in 5-drop doses every three hours is very useful. Munde (Med. Brief, May, '96). With mud-baths and the medicated waters of Kreuznaeh, Aix, Toplitz, Schwalbach, and other well-known Euro- pean resorts useful results have been obtained, but they are not available for the majority of our American patients. DYSMENORRHCEA. TREATMENT. 55 A change of residence, especially from the sea-shore or near the sea-level to an elevation of one or two thousand feet, will often .give permanent relief. The writer has repeatedly seen women who menstru- ate with great discomfort at the sea- shore, while on sea- voyages, or in a damp atmosphere under some other conditions. Of course, if there is no anatomical lesion one usually hecomes habituated to at- mospheric conditions after a few months or years. If the pain is due to a neurosis the treatment should be addressed to the nervous system, — the bromides, hyoscya- mus, aconite, and the coal-tar prepara- tions being employed. If the general nutrition is at fault it is hardly necessary to say that it should be improved by a carefully-selected diet, suitable exercise, cheerful companion- ship, and always and above all by the use of approved laxatives to keep the bowels freely open. Again and again has the writer found a constipated habit at the bottom of a history of painful menstru- ation. The majority of cases of dysmenorrhcea in school-girls is functional in origin. Environment should be such as would he most conducive to their general health. They should be kept out of school dur- ing their first menstrual year, and those of a nervous temperament for a longer period of time. They should have calis- thenic training for the special develop- ment of the muscles of the back and ab- domen, and should be warmly clothed. If there is any tendency to pain during menstruation, the young patient should be put to bed and kept there the entire period. Pine (Northwestern Lancet, Dec. 15, '89). The field of surgical treatment for dysmenorrhoea is a large one and fre- quently will result in the happiest conse- quences. The chief objects of surgical treatment are to relieve obstruction, to produce stimulation, and to improve local nutrition. The causes of obstruction have been mentioned, and should be removed as completely as possible; an imperforate hymen should be divided or dissected away; obstructing bands in the vagina should be cut and a series of vaginal dila- tors worn until the normal caliber of the vagina has been restored. Bands and constrictions at the os externum or in- ternum should be divided, a narrow cer- vical canal should be dilated and cu- retted, especially when the glands are the seat of exuberant or unhealthy secretion. [The most efficient treatment for ordi- nary forms of dysmenorrhoea is careful dilatation, with the steel dilator, to the extent of an inch or an inch and a, quar- ter, using careful antiseptic precautions. After the dilatation it is well to insert an intra-uterine pencil containing 10 grains of iodoform. Munde and Wells, Assoc. Ed., Annual, '89.] Slow dilatation urged as being equally effective and less dangerous than rapid dilatation. Talbot (Amer. Jour. ' of Obstet., Jan., '89). Rapid dilatation for the relief of dys- menorrhoea depending upon flexion or ob- struction is advocated, in the absence of contra-indications. Goodell (Amer. Lan- cet, July, 89) ; Dickman (Kansas Med. Catalogue, June, 89) ; Townsend (Amer. Jour, of Obstet., Dec, '89); Madden (Satellite of the Annual, Sept., '89). Repeated curettings at short intervals advocated for membranous dysmenor- rhoea. After each curetting the canal should be carefully treated to an applica- tion of pure carbolic acid. Reamy (N. Y. Med. Jour., June 10, '93). For membranous dysmenorrhoea, scari- fication of the OS externum at intervals of three or four days between the periods is recommended. Just before the flow is expected the cervix is dilated, the in- terior of the uterus thoroughly curetted, and a spiral-wire stem introduced; this is worn continuously during at least three subsequent periods, the patient be- ing directed to take hot vaginal douches 56 DYSMENORRHCEA. TREATMENT. even when menstruating. Duke (Med. Press and Circ, July 10, '95). literature of '96-'97-'98. The spasmodic variety is by far the most common, as there is frequently lit- tle to be detected beyond the symptom of severe spasmodic pain. Some relief may be obtained by sedatives externally or internally, but there is always the danger of setting up an opium or chlo- ral habit; it is better to dilate the uterus, either by tents or solid instru- ments. The use of tents is not free from danger, both from sepsis and from fracture or tearing away of a piece of the tent upon extraction. To effect rapid dilatation the solid dilator well regu- lated is to be chosen. The uterus can be easily secured by the vulsellum for- ceps if a sound is previously introduced into the cavity, and a series of dilators can then be passed rapidly, with the re- sult that the patient is relieved, at least for many months. Murdoch Cameron (Brit. Med. Jour., Oct. 24, '97). Dysmenorrhoea is successfully treated by applications to the mucous membrane of the uterine cavity. The treatment consists in the injection of 10 minims of 3-per-cent. mixture of Churchill's tinct- ure of iodine and water into the uterine cavity every four or five days during the intermenstrual period, beginning about five days after the flow has ceased, and giving the last treatment !il)0ut five days before the next period begins. As an injector a fine glass tube, curved an inch from one end and ex- panded into a funnel shape at the other, is used. A piece of sheet rubber covers this end, and by the pressure of the finger the contents are passed into the uterine cavity. A speculum is not neces- sary, the inajority of cases being un- married. The pain and exposure made necessary by the use of a speculum is objected to. Langstaflf (Brooklyn Med. Jour., May, '97). In sterile married women prescription of abstinence from marital relations for longer or shorter time, followed by free dilatation immediately before their re- sumption, often proves successful in cur- ing dysmenorrhoea. Bicycling is of ad- vantage, and if growing girls, especially when anaemic, were systematically en- couraged to practice that exercise in moderation, we should by and by have less spasmodic dysmenorrhoea. Connel (Brit. Med. Jour., Oct. 24, '97). In every case, without exception, gen- eral treatment must be most thoroughly tried first. At the time of puberty many girls get far too little exercise, and too little care is taken to keep them warm, especially at night. It is essential that the feet be kept warm during the night whenever there is uterine dysmenorrhoea, or, indeed, whenever there is any pelvic trouble. As soon as there is the slightest appearance of the "period" the girl must be kept rigidly in bed, and not allowed to get up until the pain is entirely gone. A large poultice should be kept over the abdomen. A brisk saline draught at the commencement, or, if possible, twelve hours before, and then a mild diapho- retic, with a small dose of bromide of sodium or potassium, if the patient be strong, or if weak some aromatic spirit of ammonia are best. In regard to the local treatment there is more or less difference of opinion. The stem-pessary is unscientific; it can only relieve, seldom cures, and may do harm. Dilatation consists of two kinds: slight and great. The first is suitable in the case of married women, when the flexion is not great, and it is used in the hope that by distending the canal im- pregnation may take place, and the dys- menorrhoea thus be cured. An anaesthe- tic is not required. Overdilatation may be done with tents or the rapid forcible method. Whatever instrument is used in the rapid method, the stretching ought to be carried out while the uterus is fixed by tenaculum in its natural posi- tion; not when it is drawn to or out- side the vulva. Keith (Med. Press and Circ, Oct. 27, '97). Obstruction from the presence of tumors within the uterus which may cause excessive pain can be relieved only by their removal, and the requisite oper- ations must also be performed if the dys- menorrhoea is caused by displacements of DYSMENOERHCEA. TREATMENT. 57 the uterus or its incarceration by inflam- matory exudate. Any less radical form of treatment for such conditions has, in the experience of the writer, proved to be only time-consuming and futile. Literature of '96-'97-'98. The causes of dysmenorrhoea may be either extra-uterine or intra-uterine. The treatment differs markedly in the two classes of cases, and what would relieve in one would be worse than use- less in the other. Three factors are con- cerned in the production of the pain of dysmenorrhoea, viz.: contraction of the muscular fibres of the uterus or Fallo- pian tubes; increased spasm or blood- pressure in the tissues of uterus or ap- pendages, — congestion; neuralgia of the uterus or the appendages. The cause is to be treated. Nearly all cases are bene- fited by rest at the periods, hot vaginal douches during and between the periods, and, in inflammatory cases, tampons of glycerin and ichthyol, and saline aperi- ents. Morphine and alcohol will give great relief, but must never be recom- mended; the administration of alcohol to young women at such times is to be blamed for much of the secret drinking that prevails. The drugs most useful are bromides and belladonna, antipyrine and cannabis ludica, and both viburnum prunifolium and viburnum opulus. Op- erative measures should only be resorted to when other and less severe remedies have failed. In cases due to spasmodic contraction of uterus or stenosis of cer- vix (if there be no signs of extra-uterine disease) dilatation is often of some serv- ice, but is seldom of more than tempo- rary benefit. In cases due to chronic pelvic peritonitis, binding down and matting together the uterus, ovaries, and tubes, — cases in which the ovaries are cystic and the tubes, perhaps, occluded and the uterus retroverted and adherent to the rectum, — very marked and per- manent benefit results from a "conserva- tive operation" on the appendages. The abdomen should be opened, the uterus, ovaries, and tubes freed from the adhe- sions, and after ignipuncture of the cys- tic or sclerosed ovaries the fundus fixed to anterior abdominal wall. In grave and otherwise incurable lesions of the appendages, such as abscesses of the ovary or pyosalpinx, the removal of the diseased organ is strongly indicated. Martin (Brit. Med. Jour., Oct. 24, '97). The use of pessaries for the relief of displacements, while it frequently modi- fies the dysmenorrhoea, seldom cures the displacements; hence such means are used with far less frequency than for- merly. The same may be said of the cut- ting operations which were once so popu- lar for the relief of dysmenorrhoea sup- posed to be the results of anteflexion of the uterus. Stimulation of the uterus and im- proToment of its nutrition are often effectively produced by the passage of graduated sounds into its canal, the use of the steel dilators, curettage, and oc- casionally by the abstraction of blood from the cervix with leeches, or by punct- ures or scarification, especially when the cervix is congested and the menstrual flow is scanty. AlSTDEEW F. CUEEIEE, New York. DYSPEPSIA. See Stomach, Dis- OHDEES OF. DYSTOCIA. See Paetueition. 58 ECLAMPSIA. SYMPTOMS. EAEACHE. See External Eae, Diseases of. ECLAMPSIA.— Gr., ex'ka^i'ic,, a shin- ing forth. Synonym. — Puerperal convulsions. Definition. — Eclampsia is a symptom- atic disorder characterized by convulsive or epileptiform seizures that suddenly come on prior to, during, or after labor. Symptoms. — The physician who sys- tematically examines the urine not alone for albumin and casts, but also for urea, and who keeps check of the amount of urine passed in the twenty-four hours is not likely to be caught napping even in those cases in which, although there never has been a suspicion of renal im- pairment, the kidneys are nevertheless diseased. Pari passu with diminished excretion of urea the risk of toxaemia increases, and the most dangerous form of eclampsia — that which develops sud- denly (without much premonition) and passes into coma and death — frequently depends on urinary insufBeiency as re- gards excretion. The clinical history of cases of the form of toxffimia under consideration is variable. As a rule, there exists a pre- monitory symptomatology, consisting in cephalalgia and dimness of vision or alteration from that which is normal in the person. Instances of convulsions during preg- nancy observed in which every fit was regularly preceded by transitory amauro- sis, as well as by oedema of the face, which was also of short duration. Two sets of convulsions occurred during preg- nancy: the first about the end of the seventh month, four attacks taking place within twenty-four hours; the second in the course of the eighth month, when two fits were observed. After the last convulsion a healthy child was delivered. The mother made a good recovery. The two prominent symptoms above men- tioned developed before each of the six fits. Olshausen has been able to collect only three eases of eclampsia in which the fit was preceded by an aura, as was this case. Eabczewsky (Przeglad Chlr- urgiczwy, vol. ii, Pt. 3, '95). Literature of '96-'97-'98. Earely are convulsions unheralded. In the vast majority of cases there were prodromal symptoms. Frequent urinary analyses, both qualitative and quantita- tive, should be made, and, if albumin is found or the amount of the solids greatly diminished, suspicion should be aroused. Any abnormal symptoms — such as head- ache, disturbances of vision, or oedema — should put us on our guard. When such symptoms appear the patient must be put on a milk diet with large quantities of sterilized water; hot baths employed, and the bowels kept active by catharsis and saline enemas. The continuance of these symptoms demands induced labor. In post-partum eclampsia, if the pa- tient is plethoric and vigorous, venesec- tion is the best remedy; if ansemie and weak, veratrum, accompanied by the transfusion of the salt solution, is indi- cated. H. D. Thomason (Med. Eecord, May 23, '96). Albumin and casts may or may not be present in the urine according to whether a nephritis complicates the pregnancy or not. Should the premoni- tory symptoms be aggravated elimina- tion of urea is defective, as shown by the recognized tests. Insufficiency on the part of the kidneys may be determined by measuring the amotmt of urine passed in the twenty-foun- hours. Vascular ten- sion is apt to be increased except in women of an anasmic type; oedema, as a rule, accompanies organic renal dis- ease. The symptomatology of the eclamptic seizure is characteristic. The wide-open ECLAMPSIA. SYMPTOMS. ETIOLOGY. 59 eyes, fixed in vacant stare; the contracted pupils, the rapidly opening and closing- lids, the clonic convulsions. These symp- toms accompany, ordinarily, the first seizures. The heart's action becomes ir- regtilar, the face is cyanosed, the breath- ing stertorous. Soon the convulsions be- come tonic in character; the eyes are fixed; opisthotonos may set in. The number of seizures are variable, as many as one hundred and twenty-five in the twenty-four hours have been noted. The duration of the seizures is from about thirty seconds to a minute, and in the intervals the woman is con- scious; or else the first seizure merges into coma and ends in death. Generally, after delivery of the foetus the convul- sions cease. Earely eclampsia develops after delivery. literature of '96-'97-'98. In the course of four and a half years, among 4480 cases of childbirth, the pro- portion of cases of eclampsia was 4.9 per thousand. Of the 4480, 2383 were pri- miparse and 2097 multiparas; 16 of these cases of eclampsia were primiparae, and 6 multiparse; that is, equal to 72.7 per cent, of primiparae to 27.3 per cent, of multiparae. Braun found the percentage of primiparae 86.3; Lohlein, 85.4; Schauta, 82.6; v. Winckel, 76.8; and Olshausen, 74 per cent. Women attacked with eclampsia were, for the most part, young. The first convulsive seizure oc- curred before labor in 2 eases, during labor in 15, and after labor in 5 cases. The extent of the discrepancy as to ante- partum eclampsia is well brought out by the following figures: Lohlein gives 4.7 per cent., Strumpf, 7.4; v. Rosthorn, 9.1; Schauta, 14 ;_ v. Winckel, 23; Braun, 24; and Olshausen, 40 per cent. The convulsions ended at the termina- tion of labor in 8 of the 22 cases. The duration of the convulsions was, on the average, one minute. The severity of an eclamptic seizure is only to be meas- ured by its influence on the respiration and the action of the heart. There was albuminuria in the whole of the cases. Knapp (Monats. f. Geburts. u. Gynilk., B. 3, May and June, '96). Nature frequently teaches us the line of action — spontaneous abortion occur- ring and the eclampsia ceasing. Literature of '96-'97-'98. Inasmuch as convulsive attacks may persist after delivery, or even in rare cases may appear for the first time after delivery is completed, the plan of hurry- ing on labor with the object of cheeking the attacks must necessarily be often completely inefBcacious. We may, there- fore, conclude that it is not in the evacuation of the uterus that the cure for eclampsia is to be sought. The toxic condition of the blood dominates every- thing else, and it is on the degree of toxicity, which is so difficult to de- termine, that the prognosis of the disease depends. Maygrier (Jour, de Mgd. de Paris, Aug. 8, '97). The victims of nephritis who become pregnant rarely go to term, but abort a dead f cetus, the result of interstitial alter- ations in the placenta. Etiology and Pathology. — Modern be- lief teaches that eclampsia is the result of a toxasmia. The acceptance of this broad term has done much toward the adoption of a rational method of treat- ment. The definitions which for long prevailed in medical literature simply complicated the topic. Thus the view that eclampsia depended on pressure of the gravid uterus on the renal ves- sels, while negated by the fact that such pressure exercised by ovarian and fibroid growths was unaccompanied by eclampsia, and, further, that the gravid uterus, when risen above the pelvic brim, exerted no such mechanical interfer- ence with the kidneys, led the mind of the observer far astray from a strong presumptive etiological factor, which is- deficient excretion of toxic products em- 60 ECLAMPSIA. ETIOLOGY AND PATHOLOGY. anating not alone from the kidneys, but also from the liver. There are some cases of puerperal eclampsia due to an organism which causes infectious nephritis, and which appears itself to generate -a, convulsive poison. Blanc (Lyon Medical, May 12, '89). Eclampsia is the result of a, complex irritant poison, which is produced not only by failure of excretion by the kid- neys, but also by failure in the action of the liver, the skin, the lungs, and the intestines. E. P. Davis (Therap. Gaz., July 15, '95). Eclampsia is not properly a disease. It is the culmination of certain conditions, with one constant exciting cause. The great predisposing cause is the retention within the body, not necessarily alone of urea, but of the products of metabolism and decomposition, especially from the foetus. The immediate exciting cause of the convulsions is in the uterus, and, because of their greater blood- and nerve- supply, in the cervix and os. M. A. Southworth (Pacific Med. Jour., Jan., '95). Corpulent women are more subject to puerperal eclampsia than others. Me- chanical pressure from the growing uterus embarrasses the functions of the kidneys and uterus, causing albuminuria where it had not previously existed and aggravating it in eases in which it was present. Simmons (Jour, of Mat. Med., June, '95). Eclampsia is an acute peripheral epi- lepsy, having its origin in the uterus. Santos (Arehiv fur Gynak., B. 32, H. 3, '88). Eclampsia is the result of a disturbed liver-function conditioning an incom- plete oxidation and the consequent pro- duction of carbonic acid. In the body of every pregnant woman, but especially toward the end of gestation, there cir- culate increased quantities of incom- pletely-oxidized substances: leucomaines. These become excessive if the functions of the kidney and liver are faulty. But even this abnormally-large amount of toxic substances will not produce serious symptoms unless the psychical equilib- rium of the subject is disturbed. This explains why eclampsia is mostly found in primiparae, and why hydramnion, multiple pregnancy, pelvic contraction, and abnormal presentations are so ab- normally frequent. Eclampsia is most easily produced in cases in which labor is slow and painful. W. N. Massin (Cent. f. Gynsec, No. 42, '95). In Belgium, Sweden, and the States bordering on the Ohio cases of eclampsia are numerous. The earth in these re- gions is exceedingly calcareous, and perhaps the lime-salts ingested in the drinking-water favor the formation of toxic materials in the blood which, com- bined with the nervous condition pecul- iar to pregnancy, give rise to eclampsia. Raikes (Canadian Pract, Sept. 1, '92). The cause of eclampsia is reflex, cul- minating in a oerebro-spinal centre in close proximity to the disorganized cen- tre which presides over the existence of albuminuria. Albuminuria simply pre- disposes to attacks, but does not act as the exciting cause. Pajot (Med. Press and Circ, Aug. 8, '88). The eclampsia symptom- complex is de- pendent on a peculiar irritation change in the psychomotor centres of the cere- bral cortex (subcortical centres). This zone develops during gestation on an existing disposition, which may be either congenital or acquired. HerfE (Miin- chener med. Woch., No. 5, '91). Eclampsia of pregnancy attributed to a toxin produced by a special microbe, acting upon the nervous system, already prepared by the gravid state. Hferrgott (Kevue M6d. de I'Est., Feb. 1, '93). Puerperal eclampsia is due to the ac- tion on the cerebrum of substances formed in the evolution of a local in- fective process. Jenkins (Glasgow Med. Jour., June, '94). Literature of '96-'97-'98. Puerperal eclampsia originates from a renal insufficiency causing a high arterial pressure, this again reacting on the mo- tor areas of the brain, producing the characteristic epileptiform manifestations in the parts of the body presided over by the centres which are subject to the ab- normal blood-pressure. R. Maxwell- Trotter (Brit. Med. Jour., May 9, '96). ECLAMPSIA. ETIOLOGY AND PATHOLOGY. 61 Eenal insufEeieney cannot be consid- ered as the primary cause of convulsions; but more probably the etiology of the condition is to be found in defective hepatic activity. Tarnier has demon- strated that under normal conditions a certain amount of fatty degeneration of liver-cells is present during pregnancy; and Tibone describes, in the livers of patients dying from eclampsia, marked changes, consisting in capillary dilation and the formation of necrotic patches and infarcts. From the presence of ace- tone in large quantities, it is suggested that there is present an abnormal de- composition of organized proteids, or may be an imperfect elimination of the non-nitrogenous products of retrograde metamorphosis, due to the fatty degen- eration of the liver-cells, whose activity is overburdened by the increase of biliary salts derived from the foetus, and which must be eliminated by means of the ma- ternal liver. From the further decom- position of these retained carbohydrate products, convulsive poisons and acetone are developed; and, at the same time, from the faulty action of the liver not completely changing waste nitrogenous products into urea, bodies which irritate and inflame the kidneys in their elimina- tion cause further insufficiency of renal action. That the bile-acids in the fcetal meconium are probably a factor in the production of eclampsia is strongly sup- ported by the fact that after death of the foetus in utero albuminuria of preg- nancy ceases. Clark and Skelton (Amer. Jour. Obst., Feb., '97). Distinct pathological lesions observed in the liver and kidneys in thirteen eases of fatal eclampsia. Degeneration of the hepatic cells and vessels seems to be the primary change; the haemorrhages noted in the substance of the liver are sec- ondary. Bar and Guyeisse (Annales de Gyn6c. et d'Obst., June, '97). Though the pathogenesis of eclampsia is unsettled, it belongs solely to the preg- nant or puerperal state. It is not apo- plectic, epileptic, or hysterical in char- acter. It depends upon toxaemia due to overproduction of toxins and under- elimination by the emunctories. These toxins probably have their origin in the ingesta, in intestinal putrefaction, in foetal metabolism — one or all — and there is co-existing sluggishness, impairment, ' or suspension of elimination. When the prodromes of eclampsia appear, the kid- ney should be interrogated as to its functions and all symptoms carefully watched. W. W. Potter (Amer. Jour. Obst., Nov., '97). The cause of pregnancy-kidney is prob- ably an autointoxication of the organism by a product of metabolism during preg- nancy. The overloading of the organism with this virus gives rise to eclampsia. The changes which occur in the kidneys, liver, and other organs in the eclamptic are of a secondary character. Saft (Arehiv f. Gynak., vol. li, p. 2). As in the course of more extended knowledge, the etiological factor of eclampsia was recognized as being asso- ciated with hydrsemia of the blood and with toxaemia, not alone has the pressure theory been exploded, but so also have the yague and insufficient terms urmmia and urincBmia been discountenanced by the modern writer, teacher, and practi- tioner. During pregnancy the blood alters both in quantity and quality. There is an increase in the white cells and a de- crease in the red. Albumin and iron fall below the normal. The blood becomes more watery, so to speak. Literature of '96-'97-'98. Careful histological studies ma!de of the various organs in a large number of cases of puerperal eclampsia. In the vessels were found large multinucleated cells, which were considered to be cells derived from the placenta, and also multiple capillary thrombosis. From these facts the conclusion drawn that the disease is essentially due to the pres- ence in the blood of a coagulating fer- ment formed either by the degeneration of the free placental cells found in the blood or by degenerative changes in the placenta itself. Schmorl (Virchow's Arehiv; St. Louis Med. and Surg. Jour., May, '96). 62 ECLAMPSIA. PROGNOSIS. Chamberlent, working under the direc- tion of Tarnier, in 1892 performed a series of experiments on the blood of eclamptic women and published the fol- lowing conclusions: — 1. Pregnancy tends to the retention of poisons in the body, for the urine of the pregnant woman is less poisonous than normal. 2. In eclampsia the elimination of physiological poisons is hindered, and the urine is less poisonous than normal. It is also less poisonous than the urine of normally pregnant women. 3. The blood-serum of the eclamptic is considerably more poisonous than nor- mal, and its toxicity is in direct pro- portion to that of the urine. The poison is by some believed to have its origin in the foetus and placenta; but the commonly-accepted view is that the poison is of maternal origin from im- ■ paired metabolism, together with reten- tion from impaired eliminative capacity of the kidneys. The albuminuria of eclampsia is prob- ably secondary, following the direct ac- tion of the poison on the renal epithelial cells, in the effort at elimination. Its almost universal presence in the eclamp- tic renders it a sign of some importance. Only about one-eighth of eclamptics, sub- sequently develop nephritis, the albumin disappearing from the urine in from a few weeks to a few months after the attack, depending largely on the hygienic conditions which surround the patient. While a patient with nephritis may and does sometimes have eclampsia, it is by no means the invariable rule. J. L. Eothrock (Northwestern Lancet, Nov. 15, '97). That the blood-serum of eclamptics is more toxic than normal cannot be proved; but, on the contrary, the blood- serum of eclamptics produces, when in- jected into animals, the same symptoms caused by normal serum. Both blood-serums produce dissolution of blood-corpuscles and hsemoglobinuria; both affect most powerfully when in- jected continuously. Volhard (Monats. f. Geburts. u. Gynak., B. 5, H. 5, '97). The systemic cell-activity in the pregnant woman is greatly increased. Excrementitious material accumulates rapidly in the system, and at any time the balance between secretion and ex- cretion may become disturbed and a toxffimia or poisoning ensue. If this is apt to occur in a woman conceiving with normal or healthy excretory organs, all the more so is it likely to supervene in a woman who conceives in the presence of an organic disease of one or another of the excretory organs — especially the kidneys. Thus then we may witness eclampsia develop during the pregnancy of a woman with kidneys diseased from the start or in women' in whom possibly there has never been a suspicion of renal impairment. Eclampsia is not common in women the subjects of chronic kidney disease before pregnancy; where kidney symp- toms are present they usually develop suddenly; kidney-lesions may be ab- sent; albuminuria is in many cases the effect and not the cause. The kidneys are not the only excretory organs whose failure to perform elimination properly may produce eclampsia. Ptomaine poi- soning should not be forgotten. J. P. Boyd (Albany Med. Annals, Nov., '95). Prognosis. — The prognosis in modern times has been greatly altered for the better. Whereas formerly the maternal mortality ranged about 30 per cent., now- adays there are series of cases recorded with as low a rate as 5 per cent. Some observers in a limited number of cases report no deaths. The foetal mortality remains about 50 per cent. In 52,328 cases of labor occurring Avithin a period of 2 years there were 325 convulsions. The mortality was 19.38 per cent. Among 248 patients who survived the attacks, 54 subsequently developed other conditions; in 13 there were psychoses, generally ending in re- covery; in 5 pneumonia, 3 pleurisy, and in 22 kidney trouble persisted. In 71.1 per cent, operative interference became necessary, including 108 forceps deliv- ECLAMPSIA. TREATMENT. 63 eries, 19 versions, 13 operations to lessen the size of the child, 2 induced abortions, and 7 Csesarian sections. Lohlein (Wi- ener medizin. Woch., Sept. 19, '91). If the amount of urea in the Wood is twice the normal, recovery is probable, while if it very nearly approach the physiological proportion the termination is generally fatal. This is also, the case when the amount of the urea is five or six times the normal. More importance should be attached to the hepatic than to the renal lesions. Butte (Eevue Mgd. de I'Est, May, '93). Series of 5000 labors in which there were 50 cases of eclampsia, — 42 in pri- miparas. Twelve mothers died: 10 from eclampsia, 1 from nephritis, and 1 from sepsis. Geuer (Centralb. f. Gynak., No. 42, '94). Literature of '96-'97-'98. Maternal mortality in eclampsia, 30 per cent.; foetal mortality, 46.6 per cent. Tarnier (Annual, '96). Series of 42,607 confinement cases 137 — 0.321 per cent, of which suffered from eclampsia, 19 being already unconscious and many others having had many fits before being admitted to the clinic. Of the mothers, 109 — 79.5 per cent. — were primiparae; 113 (97 I-parse) were not more than 30 years old. One only had had eclampsia in a previous (first) con- finement (IV-para; Csesarean section). Twins are noted 12 times; hydro- cephalus, hydramnion, and low lateral placenta, 1 each; abnormal rotation, twice; abnormal pelves, 9 times; 3 breech cases. The attacks commenced before labor in 16.78 per cent., during it in 62.04 per cent., and after delivery in 21.16 per cent, of the cases; and while 53.17 per cent, had less than 5 fits, the average number of fits in 126 was 8. Omitting the 34 children of 29 post-partiim cases, of the remaining 115, 37 — 32.1 per cent. — were stillborn, and 56 — 48.6 per cent. — were premature. In 50.7 per cent, of the whole, or 64.7 per cent, of the cases before delivery, empty- ing the uterus had a good effect. Of 27 deaths (19.7 per cent.), 17 only were due to eclampsia alone (12.4 per cent.). The mortality of multiparse (6 = 21.4 per cent.) was greater than that of primip- arse (21^19.2 per cent.). The relative- mortality of cases commencing before, during, or after childbirth was 30.43 per cent., 18.82 per cent., and 13.79 per cent. The proportion of deaths is compara- tively low, and with the fact shown that delivery without too active interference tends to stop the fits is sufficient to warrant the adoption of conservative treatment for eclampsia. The practice of the Vienna clinic for many years has been a prophylactic milk diet for all albuminuric pregnant women; if this fail, the induction of labor by bougie or colpeurynter. On the outbreak of eclamp- sia hot baths, linden-tea, wet packing, chloroform, and delivery as soon as may be without incisions. Schreiber (Arch, f. Gyn., li, 335, '96). Treatment. — The treatment *of eclampsia may be considered to advan- tage under the following headings: (1) prophylactic; (3) medicinal; (3) sur- gical. Prophylactic Treatment. — If the preg- nant woman has been carefully watched by the medical attendant, only excep- tionally will eclampsia develop, because the institution of certain prophylactic measures or early resort to certain sur- gical measures will nullify or prevent the development of certain phenomena which apparently underlie or enter into the causation. Thus, it is not sufficient, after a perfunctory fashion, to examine the urine for albumin, but the total amount passed and the amount of urea contained in it should be ascertained at intervals. Further still, explicit direc- tions should be given in regard to the necessity of securing free action of the sudoriparous glands by means of fre- quent baths, and thorough action of the intestinal canal should be maintained. "When the escretory organs of the body are acting physiologically those elements of tissue-waste which, retained in the body, favor the development of eclamp- 64 ECLAMPSIA. TREATMENT. sia, are excreted. When skin, bowels, and kidneys are clogged, the reverse holds true, and sooner or later, in preg- nancy, symptoms appear which, if not properly appreciated and when possible eradicated, are forerunners of eclampsia. When urinalysis reveals the presence of kidney disease — whether organic or func- tional — steps should be taken at once to modify the symptomatology for the bet- ter by recourse to hygiene and dietetics, and, such measures failing, after reason- able interval medicinal and surgical treat- ment enter the foreground. Chief among the hygienic measures etand hot baths and gentle catharsis; foremost among the dietetic measures ranks milk diet (associated with the ad- ministration of an assimilable and non- astriilgent form of iron). literature of '96-'97-'98. The prophylactic treatment consists in a milk diet from 2 '/, to 3 litres per diem and some alkaline mineral water, such as Vichy, and the careful regulation of the bowels. Chloroform should be ad- ministered during attacks; but chloral- hydrate per rectum is preferred as the usual sedative. It is given in the follow- ing form: Milk, 1 ounce; the yelk of an egg; and chloral-hydrate, 45 grains. The addition of the milk and egg is necessary, as otherwise the chloral would irritate the rectum, and the enema would not be retained. Brindeau (L'Union M6d. ; Liverpool Medico-Chir. Jour., Jan., '96). Milk treatment is most efficient from a prophylactic point of view, though it , does not necessarily cause the other alarming symptoms, besides the fits, to vanish. The alleged disappearance of albuminuria does not necessarily occur, €ven after prolonged treatment by milk diet. The same may be said of the •oedema; this treatment seems to have no effect on it. The above facts are em- phasized, because some obstetricians have very naturally given up milk diet on account of persistence of albuminuria and oedema. Such a step is a mistake, for, if the treatment be continued, labor will proceed without any fits coming on, though the legs remain swelled and the urine albuminous. Ferrg (L'ObstStrique, Nov. 15, '96). ■ . Where, notwithstanding these meas- ures, the evidences of organic kidney dis- ease become intensified, or where, these evidences lacking, the symptonjs sug- gestive of impending eclampsia develop, time for action has come, justifiable de- lay having reached its limit. In the past and even to-day expectancy has been and is too often the cause of untoward re- sults. With the exception of the fulminating type of eclampsia — where art almost al- ways fails, it may be stated that prompt action, of the nature to be described, will, in the vast proportion of eases, prevent the development of eclampsia. Medicinal Treatment. — In the pres- ence of the prodromal symptoms of eclampsia, but little reliance can be placed on drugs. Where urinary insuffi- ciency exists, indeed, it is very question- able if the routine administration of drugs do not harm. Certainly the potas- sium salts are very likely to irritate the kidneys. The ingestion of large amounts of water by mouth and repeated irriga- tion of the bowel with hot (110° P.) nor- mal saline solution will accomplish more than any and all drugs together. Unless the physician is sure of the form of kidney disease present, morphine had best not be used. Cases of parenchy- matous and tubal nephritis bear mor- phine tolerably well, but the inter- stitial form does not. Tyson (Gaillard's Med. Jour., Aug., '91). In eclampsia following delivery the impaired function of the kidneys greatly increases the danger of poisoning by bichloride and carbolic lotions when used for intra-uterine injection. Frey (Therap. Gaz., June, '91). ECLAMPSIA. TREATMENT. 65 Control of the convulsions by chloro- form inhalation may render subsequent fits more severe, and might then, in the perturbed state of the nervous sys- tem, give rise to what in surgery is called ptimary syncope. Caution should be observed in the administration of chloroform, as it may prove dangerous. E6my (Rev. M6d. de I'Est, Jan., '91). literature of '96-'97-'98. All pregnant women with albuminuria being liable to eclampsia, the urine should always be carefully examined, and, if a trace of albumin be found, ab- solute and exclusive milk diet should be at once adopted. This is the preventive treatment par excellence of eclampsia. In eases where there is oedema without albuminuria it is advantageous, if not absolutely necessary, to prescribe a milk diet. When eclampsia has set in, if the pa- tient is strong, vigorous, and greatly cyanosed, from 9 Vz to 16 ounces of blood should be removed, chloral admin- istered, and milk given by the mouth; if necessary, by means of the oesophageal sound. The attacks themselves should be com- bated by chloroform inhalations, and diuresis favored by subcutaneous injec- tions of artificial serum. If the patient is more delicate, the symptoms of cyanosis but slightly marked, and the attacks less frequent, chloral only should be administered. Whenever possible, we should wait until labor sets in spontaneously and allow delivery to terminate naturally. If, labor being spontaneous, delivery does not terminate on account of too feeble or too slow uterine contractions, the forceps should be applied, or version, followed by extraction, if the child is living; by cephalotomy, basiotripsy, or cranioclasis, if the child is dead. Intervention should be delayed until the condition of the maternal parts is such that no violence will be done to them, and therefore attended with no danger for the mother. Induced labor should be reserved for exceptional cases. Cssearean operation and accouchement ford should not be considered as ordi- nary methods of treatment in eclampsia, but should only be resorted to in cases in which the death of the mother appears certain, and when all other measures have failed. Charpentier (Univ. Med. Jour., Oct., '96). The treatment of eclampsia should be, in the first place, prophylactic. A care- ful examination of the urine at short intervals in the late months of preg- nancy, together with a careful watch for the first evidence of toxsemia, should be the duty of everyone who undertakes the care of these cases. In the attack remarkable results have followed the use of morphine. It acts by promoting dia- phoresis, as well as by lessening the ex- citability of the centres. It must be given in successive large doses until the patient is completely narcotized, in order to get its full effect. Olshausen argues that the lack of success with this drug is due to failure to employ sufficiently- large doses. Chloral must also be given in heroic doses. Chloroform, according to Vinay, has no effect whatever on the attacks unless given continuously for from six to eight hours. Veratrum viride is of great value in controlling the convulsions. Briskly-acting purga- tives should be given as well as hot baths or hot packs. Van Eenssalaer suggests venesection, carried to the point of tolerance, and then followed by the subcutaneous injec- tion of a normal salt solution. This method need not be confined to the plethoric, but even a weak pulse and profound coma do not contra-indicate its use, for the rapid introduction of the warm salt solution following venesection counteracts the effects of bleeding, filling the vessels and stimulating the heart. From a pint to a quart of blood can be safely withdrawn from the veins of a patient of average weight, providing the injection of the salt solution is followed up at once. J. L. Rothrock (North- western Lancet, Nov. 15, '97). The saline irrigation — if a number oi quarts are used at a time — promotes di- uresis and diaphoresis and indirectly en- forces intestinal peristalsis, and such irri- 3—5 66 ECLAMPSIA. TREATMENT. gation should become the established custom not alone in face of impending eclampsia, but also in the presence of eclampsia. Where the pulse of tension exists venesection — too seldom resorted to nowadays — is called for. Literature of '96-'97-'98. Patients with eclampsia are never able to sit while venesection is performed, consequently a larger quantity of blood is required to produce the desired results than if the sitting posture could be as- sumed. It is much/ better not to bleed at all than to bleed inefficiently. While the loss of a small amount of blood will do no harm, it can do no good, and therefore it probably brings the very best life-saving remedy in eclampsia into disfavor and ill repute. J. T. McShane (Indiana Med. Jour., Jan., '96). Bleeding, followed by the subcutane- ous or endovenous injection of normal saline solution, has much to recommend it. The speedy evacuation of the uterus constitutes the most important means of treating eclampsia. Mangiagalli (Annali di Ostet. e Ginecol., Sept., '96). Saline transfusion should be resorted to if the patient is in a collapse and death seems imminent. These hypoder- mic injections of warm sterilized water, salt (1 per cent.) to the amount of one- half pint, into the vascular tissues of the axillse will be readily absorbed. G. Covert (Chicago Med. Times, Apr., '98). Possibly veratrum viride administered hypodermically every two or three hours in the dosage of 10 minims, until the pulse-rate is materially lowered (down to 60 or 40) will accomplish the same result as venesection, and at times the free use of this drug will render unnecessary re- sort to active surgery, except where the symptoms are very urgent, when we are amply satisfied that dallying with drugs should cease. Veratrum viride should not be given hypodermically, but by the mouth, as the stomach will reject an overdose. W. J. Chandler (N. Y. Med. Jour., Nov. 23, '95). After the administration of veratrum viride, the urinary secretion becomes copious and the patient immediately im- proves. C. C. Barrows (N. Y. Med. Jour., Nov. 23, '95). Twenty-six cases with no deaths treated with veratrum viride by the mouth or subeutaneously until pulse had been lowered below 60 and con- vulsions controlled, after which the fol- lowing mixture given: — IJ Aeidi benzoici, 2 drachms. Potass, bicarb., V2 ounce. Spirit, aether, nit., 1 ounce. Spirit. Mindereri, 2 ounces. Syr. limonis, q. s. ad 6 ounces. M. Sig. : A teaspoonful every four hours. E. C. Newton (N. Y. Med. Jour., Dec. 14, '95). Literature of '96-'97-'98. Ordinarily the initial dose of veratrum viride should be at least 10 drops, and repeated within an hour. If powerful sedation is not obtained, and the pulse brought down to 60 or less to the minute, morphine may be combined if it is espe- cially indicated. After labor is com- pleted, and convulsions under control, chloral and bromide are given and from 3 to 5 drops of veratrum — often enough to hold the pulse at about 60 for two or three days, with salines to keep bowels open and flow of urine free. Rogers (N. Y. State Med. Rep., Jan., '96). Excellent results following the admin- istration of veratrum viride. Drs. J. Sellers and C. B. Mulvey (Indiana Med. Jour., Mar., '96). The method by which veratrum viride is supposed to do good in cases of puer- peral eclampsia is a double one. Chiefly from the action of its alkaloid, jervine, it powerfully depresses the circulation, and so bleeds the woman into her own vessels, relieving by this means conges- tion of the cerebral and spinal vessels and reducing in all probability any spasm of the renal blood-vessels which may be present, thereby causing marked increase in the flow of urine. In addi- tion to this action, jervine also acts as a ECLAMPSIA. TREATMENT. 67 powerful sedative to the motor tracts of the spinal cord, and so directly quiets nervous excitation, while the copious sweating which often follows its admin- istration aids in relieving the blood of impurities, the kidneys of congestion, and relaxes the peripheral blood-vessels. Editorial (Therap. Gaz., Mar. 16, '96). Veratrum viride used with marked success. The remedy notably diminishes the frequency of the pulse, and convul- sions rarely occur when the pulse is kept at or below 60. Of 100 patients treated by veratrum viride in the writer's practice, 92 were saved. Parvin {Universal Med. Jour., Oct., '96). Norwood's tincture of veratrum viride, 10 to 20 minims, preferably by hypoder- mic injection, can be safely followed, in from thirty minutes to an hour, if neces- sary, by a dose of from 5 to 8 minims. Bauer (Med. Pec, Nov. 21, '96). Successful treatment of puerperal eclampsia by veratrum viride reported. J. B. Shober (Amer. Jour, of Obst., June, '97). The toxins causing uraemia are varied and numerous. In eclamptics the urine is less toxic than normal, while the blood- serum is more toxic. The foetus is an additional source of waste-products and an additional cause of danger to the mother. The indications for treatment are to remove the toxic materials in every way practicable. Veratrum viride in cases where the pulse is strong enough to warrant its employment will be found useful. The depressing action of pilocar- pine makes it a dangerous drug. Many patients with eclampsia die from over- medication. Labor should be induced or delivery hastened when other methods fail to control the convulsions. P. W. Van Peyma (N. Y. Med. Jour., Feb. 22, '96). Treatment is preventive and curative. Milk diet and distilled water should be given in the pre-eclamptic state to dilute the poison, hasten its elimination, and nourish the patient. Blood-letting should be employed only in plethora or cyanosis. Nitroglycerin diminishes vaso- motor spasm; hence it may be given freely in appropriate cases. Veratrum viride is a cardiac depressant and a dan- gerous remedy if pushed to an extent that will control convulsions. As a primal measure the uterus should be speedily emptied of its contents. W. W. Potter (Amer. Jour. Obst., Nov., '97). We have in veratrum viride an agent the physiological properties of which meet the supposed pathological condi- tions in puerperal eclampsia, namely: increased arterial tension and cerebro- spinal excitement. John Gordon (Lan- cet, Jan. 15, '98). Guaiacol used in two eases with "sur- prising and happy" results. Forty or 50 drops were poured upon the abdomen and gently rubbed in. In a few minutes the pulse became soft, free diaphoresis set in, and the convulsions died away. In both instances there was albuminuria and oedema, and in both the recovery was good. Its physiological effect is to cause rapid and marked lessening of ar- terial blood-pressure, lowering of tem- perature, and free diaphoresis. Appleby (Boston Med. and Surg. Jour., Mar. 18, '97). Nitroglycerin, in the dosage of ^/nj grain, hypodermically, repeated pro re nata will tend to relieve the cephalalgia. When the convulsions appear suddenly morphine, 1 grain hypodermically, is called for until chloroform anaesthesia to the surgical degree is secured; but otherwise opium and its derivatives should not be countenanced, because of their tendency to inhibit secretion from the intestinal canal and from the kid- neys, thus defeating the prime thera- peutic aim, which is to increase secretion and excretion. These few drugs failing to control the premonitory symptoms or eclampsia sud- denly developing, measures of a surgical nature are called for. Surgical Treatment. — Where the symptoms which forebode the develop- ment of eclampsia do not yield to the dietetic, hygienic, and medicinal treat- ment outlined, the surgical measure de- manded is evacuation of the uterus. 68 ECLAMPSIA. TREATMENT. In eclampsia occurring during partu- rition delivery should be effected as quickly as possible under deep anaesthe- sia. When possible, without loss of time, the cervix should be widened by hydrostatic dilators, and the smallest possible incision. When the condition of the cervix is the cause of delay after artificial dilatation, incision as deep as may be necessary should be made. Haemorrhage arising from this cause may be controlled by tampons of gauze or by • pressure- forceps. In such cases, considering the amount of haemorrhage from the incision, there can never be any question of adopting venesection. When the patient is unconscious, no attempt should be made to make her swallow; a suitable stomach-pump should be in- variably used for the introduction of nourishment or medicine. Anaesthetics should be used to the surgical extent only during the operation of emptying the uterus, and either chloroform or ether may be used. The most exact asepsis is required; infection prolongs the convulsion stage of eclampsia. P. Zweifel (Centralb. f. Gynak., Nos. 46 to 48, '95). Literature of '96-'"97-'98. In the Prague hospital the rule is to deliver as rapidly as possible consistent with avoiding injury. A mixture of chloroform, ether, and alcohol is an espe- cially safe preparation, the anaesthetic being administered not only during the operative proceedings, but also to mod- ify the convulsions. Morphine is also constantly employed. The prolonged warm bath and the hot wet pack are very important. The only beverage per- mitted is lukewarm milk. Knapp (Monats. f. Geburts. u. Gyniik., B. 3. May and June, '96). Albuminuria is a premonitory sign too important to be overlooked. Termina- tion of the delivery is in all cases de- sirable, and it must be rapidly brought about in serious cases. Therefore from the beginning of the attacks we must act continuously in that direction. In very urgent circumstances we must not hesitate to dilate the cervix. If this acconclieniciit force is difficult, too slow. or impossible without too much injury, we must have recourse to Cesarean sec- tion. N. Charles (Jour. d'Accouche- ments, Oct. II, '96). In puerperal eclampsia the chief aim is to empty the uterus of its contents as quickly as possible. The cervical canal should be dilated, first by means of Hegar's graduated sounds and afterward with the fingers, until the orifice has attained a diameter of three centimetres. Podalic version, according to the Brax- ton-Hicks method, is then practiced and one foot extracted. This done, the uter- ine orifice is again dilated by separating its edges on one side by means of the child's leg, upon which the hand of the operator exerts (the foot being already extracted from the wound) energetic lateral pressure, and on the opposite side with the hooked index of the other hand. When dilatation of from eight to ten centimetres has thus been obtained, it only remains to extract the child. As soon as the umbilical cord has been severed the placenta should be detached and the uterus compressed with the two hands for about an hour; this com- pression suscitates the uterine contrac- tionSj preventing any serious haemor- rhage. Drejer (La Semaine Med., Oct. 31, '96). Acceleration of labor by safe methods, large doses of morphine to suppress the attacks, avoidance of administering med- icine by the mouth, stimulation of dia- phoresis by external remedies — all these appear to promise most success in treat- ment. J. Veit (Festschrift f. Carl Huge, '96). Whenever albumin is discovered in the urine of a pregnant woman, she should, without delay, be put upon a strict milk diet, for albuminuria is to be regarded as a, symptom of the state of autoin- toxication which results in eclampsia. Tarnier says that he has never seen eclampsia supervene in pregnant women sufl'ering from albuminuria who have been for seven days upon a strict milk diet. During the convulsions the tongue is best preserved from injury by placing a folded handkerchief between the teeth, which pushes the tongue back, and also prevents the teeth from closing. The pa- ■ECLAMPSIA. TREATMENT. 09 tient should be placed immediately under the influence of chlorofoi'ni. A rectal Injection of about 60 grains of chloral should next be given; it is advisable to begin Avith a large dose rather than repeated small doses. If necessary the injection of chloral may be repeated sev- eral times, giving as much as 250 to 300 grains in twenty-four hours. The in- halation of chloroform should be con- tinued during the attacks. Bleeding is reserved for the rare cases which are dis- tinctly "sthenic'' in type. As a diuretic agent, half a pint or more of a saline solution containing 1 per cent, of chlo- ride of sodium, may be injected into the buttock, and the injection repeated sev- eral times. No interference is required until the cervix is fully dilated, when the child may be extracted with forceps or by turning. Delivery by such forcible methods as rapid dilatation or incision of the cervix is condemned. Oui (L'Echo Med. du Nord, May, '97). The treatment consists in controlling the convulsions by profound narcosis, speedy evacuation of the uterine con- tents, and diaphoresis, with a view to re- establish skin function and reduce the tension. Kedarnath Dass (Indian Med. Eec, Apr. 16, '98). The nearer the term, the easier the pro- cedure of emptying the uterus; the same statement applies to the multipara over the primipara. The steps of the pro- cedure are, in brief, the following: Un- der the most absolute asepsis of patient, instruments, and hands of operator and assistants, ordinarily under chloroform anesthesia, the cervix is dilated by the steel-branched or other dilator. Great care is requisite not to rupture the mem- branes. The cervical canal is then firmly packed with sterile gauze, and the upper portion of the vagina as well. The woman is put to bed and if she complain of much pain codeine should be used freely in suppository (gr. ii to iv repeated every four to six hours), for reflex nerv- ous irritability must be controlled. At the expiration of about twenty-four hours, under absolute asepsis and chloro- form anaesthesia, the gauze is removed, and, if the cervix has softened and is dilatable, manual dilatation is resorted to. If the cervix has not softened and the symptoms are not urgent the canal should be repacked for a further period of about twenty-four hours. Dilatation by the hand having been accomplished to the requisite degree — that is to say, until the closed fist can be withdrawn with ease, the membranes being intact, elect- ive version is performed, followed by im- mediate extraction, else the lower uterine segment may close on the foetal head. When the membranes have ruptured de- livery from the brim by axis-traction for- ceps is indicated. After delivery — when the pulse is full, strong, bounding — uter- ine venesection is allowable until the pulse becomes soft. Where, on the other hand, the pulse after delivery is rapid and weak, no time should be lost in the thorough uterine tamponade. Where eclampsia develops without pre- monitory symptoms, or where delay with the premonitory symptoms has ruled, there is no time for the preliminary tam- ponade. Tnder absolute asepsis and chloroform anesthesia manual dilatation is at at once instituted, associated, in very rare instances, with the Diihrssen incisions, the uterus being then emptied. In post-partum eclampsia there is no scope for surgery, and dependence must rest on drugs (veratrum and the nitrites), on repeated high saline rectal irrigation, and in free catharsis, using elaterium or croton-oil. Whether the case be of the sthenic or asthenic type, these rules hold good, except that in the latter type hy- podermoclysis of saline solution should be added, and in the latter venesection. Egbert H. Geandin, New York. 70 ECZEMA. SYMPTOMS. ECZEMA. — Gr., sxgsLV, to boil over. Definition. — Eczema may either be an acute, subacute, or chronic inflammatory disease of the skin, usually characterized in its earliest stages by the appearances of erythema, papules, vesicles, or piistules, or a combination of two or more of these lesions. It is attended with a variable degree of thickening and infiltration of the cutaneous tissues, terminating either in discharge with the formation of crusts or in absorption or in desquamation. Varieties. — The primary, or element- ary, varieties are the erythematous, papu- lar, vesicular, and pustular; or the first outbreak may show a mixture of these several types. In many cases the begin- ning lesions or type soon lose their char- acters and the disease develops into the common clinical varieties: eczema ru- brum or eczema squamosum. Other clinical or secondary types met with are eczema fissum, eczema sclerosum, and eczema verrucosum. Symptoms. — The erythematous type of eczema — also called eczema erythema- tosum — is most frequently seen upon the face, although it may make its appear- ance upon any other region or may be more or less general. It begins as a single hypersemic area, or several areas may appear simultaneously, usually upon one region. The areas may be small or large, irregularly outlined, ill defined, and attended with slight or con- siderable swelling and even oedema. There is more or less itching and burn- ing. The eruption soon becomes pro- nounced, the parts reddened, somewhat thickened, and here and there a little scaly. There may also be, here and there (as a result of rubbing or scratching, or spontaneously) a tendency to serous ooz- ing. The affected skin is harsh, dry, and reddish or violaceous in color. It often persists in this form, and the skin may become considerably thickened and in- filtrated. The swelling and oedema which are often first present may sub- side, to a great extent at least, or these symptoms may reappear from time to time whenever there is an acute exacer- bation. The parts may become quite scaly, and constitute a mild or well- marked scaly eczema: eczema squamo- sum. Occasionally, as a result of con- stant irritation, rubbing, and scratching, or from other causes, the parts become moist, markedly inflamed, with more or less crusting, constituting eczema ru- brum. The papula?- type of the disease, or ec- zema papulosum, presents itself as one or more aggregations of closely-set papules, pin-point to pin-head, or slightly larger, in size. The disease may also show itself as more or less discrete papules, with here and there aggregations. In color the lesions are bright- or deep- red or violaceous, with often a few vesicles or pustules interspersed. Itching is usually intense. The extremities, and the parts, especially about the joints, are its favor- ite sites. The course of this type is es- sentially chronic, some lesions disappear- ing and others appearing, and thus per- sisting for several months or indefinitely. In some instances, especially in some areas, the papules become so thickly crowded that a solid patch results, be- coming more or less scaly— eczema squamosum. Or at times such a patch may develop into eczema rubrum. The vesicular type of the disease, or eczema vesiculosum, may show itself on one or more regions, and consists of ag- gregated or closely-crowded pin-point to pea-sized vesicles, with here and there discrete lesions, and at times with pap- ules and pustules interspersed. It is usually a markedly-inflammatory type, with considerable oedema and swelling. ECZEMA. SYMPTOMS. 71 Solid sheets of eruption may form. The vesicles usually rupture in the course of a few hours or days, new outbreaks oc- curring, or a raw weeping, more or less crusted surface resulting. The oozing may be continuous or the process may decline, to remain quiescent or to break forth rapidly with repeated vesicular 'crops. Considerable thickening may take place and with the oozing and crust- ing make up a picture of the common clinical type: eczema rubrum. The face and scalp of infants, the neck, ilexor sur- faces and fingers are the more common sites for the vesicular type. Its course is usually chronic, with several acute ex- acerbations, or, as already described, it may pass sooner or later into the com- mon chnical type: eczema rubrum. The pustular variety of eczema, or ec- zema pustulosum or impetiginosum, is less frequently met with than the other varieties of the disease. Its common site is the scalp, especially in infants. It may develop from the vesicular variety, or, as more commonly the case, begin as closely-set pin-point to pin-head, or larger sized pustules; or a mixture of vesicles and pustules may be noticed. In symptomatology it is similar to eczema vesiculosum, except that the lesions, in- stead of containing serum, contain pus. As in the vesicular type, the same dis- position to the rupture of the pustules is observed, and there is often a tendency to develop into the type loiown as eczema rubrum. More or less crusting is usually a conspicuous feature. The ill-nourished and strumous persons are its most com- mon subjects. The type is essentially chronic. The squamous type of eczema, or ec- zema squamosum, is a clinical variety frequently met with, characterized by redness, infiltration, and more or less scaliness, with, especially when about the joints, more or less fissuring. The itch- ing is variable, sometimes intense, and at other times slight. This variety is usually a development from the ery- thematous or papular types, and, like other types of the disease, is persistent and chronic. Eczema rubrum, the oozing type of eczema, or somewhat dry, raw-looking type of eczema, usually results from a pre-existing vesicular or pustular eczema. It is characterized by a red, weeping, ooz- ing, raw-looking surface, with more or less infiltration of the cutaneous tissues. In some cases there is a combination of weeping raw surface with crusted areas. In other cases the weeping nature of the disease is a conspicuous feature, crusting scarcely having time to form: eczema madidans. Its most frequent sites are the face and scalp of children and the legs of adults; in the latter in those espe- cially advancing in years. In these cases of eczema of the lower legs varicose veins are often present as a precursory and concomitant condition. It is essentially chronic, showing little, if any, disposi- tion to disappear spontaneously, al- though it may be somewhat variable. The degree of inflammation varies from time to time. The -fissured type of eczema, or eczema fissum or eczema rimosum, is that type of eczema in which cracking or fissuring of the skin is the most conspicuous feature. It is common about the joints, especially about the fingers, and in most cases is a part of an apparently slight erythema- tous eczema. Fissuring may occur in any type of the disease, especially when about the joints; but in most cases it is but slight in character. It is a persistent type of the disease, iTsually disappearing in part or more or less completely in warm weather. A somewhat analogous or allied variety of eczema is the so-called 72 ECZEMA. SYMPTOMS. crackled eczema. This is usually a mild subacute erythematous eczema, involving large regions or the entire surface, numerous superficial cracks through the upper epiderm showing over the fissured surface. Eczema sclerosum and eczema verru- cosum are somewhat rare varieties of the disease. These types are usually seen about the ankles, lower leg, or feet. They commonly result from a pre-existing papular eczema. In many respects these types are analogous in their symptom- atology: there is considerable thickening and board-like hardness, with, as a rule, much infiltration, but with the inflam- matory element slight or comparatively so. The surface is rough, hard, and somewhat horny to the feel, and in the verrucous variety there is added to these several symptoms a variable degree of papillary hypertrophy, the surface hav- ing a distinctly-warty appearance. Both types are essentially chronic and rebell- ious to treatment, demanding the strong- est application. Infantile Eczema. — The disease is common in infants and young children. It is unusual, comparatively speaking, in children past the age of 6. Even in those cases in which the disease begins in the first or second year and is persistent, it tends to decline spontaneously toward the age of 5 or 6, or even earlier; or at least at this period it will usually respond rapidly to any mild or indifferent appli- cation. The disease presents no special characteristics in the young, except that in the majority of such cases the inflam- matory element is apt to be more marked. In by far the larger proportion of cases the face or the face and scalp are the seat of the disease; eczema of the region of the genitalia and anal cleft is also not infrequent. All cases of infantile eczema will usually do well under treatment, al- though a disposition in many cases is shown toward relapse till the age of 4 to 6 is reached. In eczema in infants and young chil- dren occurring about the legs and arms, usually as a vesi co-papular or papular eruption, discrete and patchy, the dis- ease is often obstinate, — much more so, as a rule, than in those cases where the disease is limited to the face or face and scalp. The vesicular, vesicular-papular, and moist or crusted inflammatory type — eczema rubrum — seem most frequent in the young. Regional Eczema. — It is usual to de- scribe eczema as it appears upon different regions, as, for instance, the hands, face, scrotum, legs, etc.; but the disease in reality differs little, certainly not materi- ally, as it occurs upon different parts. The description of the several types of the disease as already given suflices. It is noted that the most common seats for eczema in those of the active age, be- tween 21 and 50, is about the hands, less frequently about the face or the scalp; the scrotum is not an uncommon site, and also the anal region. Literature of '96-'97-'98. There is a remarkably-obstinate form of chronic eczema, which attacks the palms, and, though more rarely, the soles sometimes also. The disease commonly takes its origin in the centre of one palm, though it is generally not long until both are implicated. There are hard, scaly patches of infiltrated skin, involving more or less of the surface; there is ragged and uneven scaling, while in the natural lines of flexion, or inde- pendent of these, are deep and painful cracks. The hands feel hot, and burn and itch at times. This morbid condi- tion advances sometimes along the fingers toward their tips, the pulp remaining, as a rule, immune. A symptom ob- served in the feet which is not so evi- ECZEMA. ETIOLOGY. 73 dent on the palms is the existence of a band of congestion beyond the scaly area, fading imperceptibly into the natural tint of sound skin. Though met with in both sexes, this variety of eczema is most commonly encountered in women, and in them about the menopause. Jamieson (Edinburgh Med. Jour., Jan., '98). In a recent analysis of 10,000 mis- cellaneous skin cases in the writer's pri- vate practice, 32.01 per cent, suffered with eczema. Neurotic eczema is fre- quently observed in infancy in connec- tion with cutting of the teeth; in child- hood it is less common; its most fre- quent time of occurrence is between 20 and 55 years of age. Various forms or phases of nerve disturbance are seen in connection with neurotic eczema, and they may be considered under the fol- lo\\ing heads: (1) neurasthenia, or nerve-exhaustion; (2) nervous and mental shock; (3) reflex phenomena (a) of internal origin or (5) peripheral; (4) neuroses, (o) structural or (6) func- tional. The eruption is apt to come first upon the hands and face, less, commonly on the feet. But from its starting-point it may extend over large surfaces. Neurotic eczema upon the hands is very apt to exhibit vesicles; but on the adult face the eruption is quite as likely to as- sume and maintain the erythematous form, with vesicles, and often without moisture, unless scratched. The groups of lesions have a tendency to be pretty sharply defined, in more or less her- petic patches, which may present mainly solid papules, or, when torn, a raw sur- face. It is intensely itchy, and the spasms of itching are sometimes fearful and utterly uncontrollable. L. Duncan Bulkley (Jour. Amer. Med. Assoc, Apr. 16, '98). In those past the age of 50 the most common site is the lower leg, although eczema of the face is not infrequently met with. General Symptomatology. — The sub- jective symptoms in eczema are itching, burning, and a sensation of heat. These may be severally present, or, as is more commonly the case, one is predominant. The degree varies, sometimes slight and at other times almost unbearable. As a rule, there are no constitutional symp- toms so-called in eczema cases. In ex- tensive general acute eczema there may be slight febrile action and sometimes slight chilliness at the outbreak of the attack. The degree of inflammatory ac- tions varies in the same case from time to time and in different cases. The dis- ease may be acute both in type and its course, running to an end in several weeks or one or two months. As a rule, however, whatever the type of the in- flammatory process — acute, subacute, or chronic — the disease is persistent and long-continued, with, in most cases, little, if any, tendency to disappear spon- taneously. Seasons often have an influ- ence, the disease usually being less active or partly or completely disappearing in the summer weather. On the other hand, there are cases of the disease met with that are at their worst in summer time, and frequently disappear in the colder weather; such instances are, however, exceptional. Etiology. — The consensus of opinion points to both external and constitu- tional causes as active factors in most cases of the disease. The possibility and even probability of this disease's being due to a parasite is more or less seriously entertained in some quarters. A large proportion of the cases of eczema are due to parasites. On the other hand, a large nunjiier depend on some condition inside the body. Some, again, are due to internal conditions with a local factor added. Elliott (Jour. Cutan. and Genito-Urin. Dis., Dec, '95). Cause of seborrhoeic eczema consid- ered as mierobic, the serpiginous char- acter of the eruption, its want of re- semblance to other forms of dermatitis (chemical and mechanical), and the ef- fect of parasitieidal therapeusis all tend- 74 ECZEMA. ETIOLOGY. ing to confirm this view. Unna (Volk- mann's Sammlung klin. Vortrage, Sept., '93). No doubt all kinds of micro-organisms can be found on eezemie patches, but so they can on the normal skin, and it has yet to be proved that they are instru- mental in its production. Hartzell (Jour, of Cutan. and Genito-Urin. Dis., Dec, '95). Eczema depends on a great many con- ditions, both constitutional and local. It can result from heat or chemical agents, and persist after the irritant ceases. In some eases it may be purely a parasitic affection, but it is probably a, constitutional affection with the para- sitic element superadded. Fordyee (Jour. Cutan. and Genito-Urin. Dis., Dec, '95). literature of '96-'97-'98. Seborrhoeio eczema is caused by a spe- cific germ or germs, diplococci, whose life-history is most active at the ordinary temperature and with free access to the air, but which can develop at much higher and lower temperatures and with a scarcity of oxygen. William H. Mer- rill (N. Y. Med. Jour., Mar. 6, '97). Case of so-called seborrhoeic eczema ob- served occurring in a young man, upon a cicatrix the result of a, burn in in- fancy. The occurrence upon a surface where the sebaceous and sudoriparous glands had been destroyed for years is strongly corroborative of the opinion held by the author, that the affection known as seborrhoeic eczema is neither a seborrhosa nor an eczema. As the re- sult of experiments made with this ease, he concludes that so-called seborrhoeic eczema is autoinoculable. Audry (An- nates de Dermat. et de Syphil., No. 5, '97). Among the constitutional influences which are or seem to be of some impor- tance as predisposing or active factors are gout, rheumatism, disorders of digestion or assimilation, dentition, struma, gen- eral debility, and loss of nervous tone. The chief elements of causation in the eczema of elderly people seem to be a debility of tissue and a faulty kidney- action. The urine is scanty and of high specific gravity, and often loaded with urates. Sugar is not uncommon. De- ficient bowel-action is likewise common. These facts give a basis for treatment. Local measures will not be successful if these points are not carefully attended to. Bulkley (Trans. Med. Soc, State of N. Y., '90). Immoderate habits in the use of cer- tain foods, drinks, and drugs also in- directly or directly have an influence, such as alcoholic drinks, narcotic drugs, and excessive tea- or coffee- drinking. Two cases of eczematous erythema ob- served consequent upon applications of salol. Cartaz (Jour, of Laryn., Jan., '92). Overwork, especially of a mental char- acter, in those of hereditary eczematous tendency will often be provocative of an attack. That the hereditary disposition to the disease exists in many families cannot be denied. Proof is abundant and convincing that the tendency to eczema may be heredi- tary. It may prevail in several persons in the same family, and may occur with greater severity in successive genera- tions. The laws under which it is trans- mitted appear to be the same as those of other heritable diseases. The eczema of infants has nothing whatever to do with the child's healtli. The infant is usually quite well up to the time of its commencement, and excepting in so far that the dermatitis may interfere with its comfort and rest it remains so throughout. The dermatitis when at its height is due to the existence of some contagious material which has in some way been generated, and it is only in a very feeble sense of the words a con- stitutional malady. Individual peculiari- ties in the organization of the skin are the fundamental predisposing cause. That there is any one microbe which is the cause of the eczematous process in general appears, in the light of clinical facts, improbable in the highest degree. Hutchinson (Clin. Jour., vi, 275, '95). Among the external exciting factors ECZEMA. PATHOLOGICAL ANATOMY. DIAGNOSIS. 75 may be mentioned cold and heat, espe- cially the former; sharp, biting winds; and too liberal use of certain soaps; the handling of dyestufEs, chemical irritants, and the like; Taeeination, and exposure to certain plants. Having the hands fre- quently in water, as with washerwomen, the handling of sxigar and flour, and re- peated antiseptic cleansing of the hands often bring about the various conditions of eczema of these parts known respect- ively under the names of washerwomen's itch, baker's itch, and grocer's- itch, and surgeon's eczema. So far as known the disease does not possess contagious prop- erties, and in a disease so frequent as this if such existed it would have been clearly demonstrated. In some cases of markedly inflamma- tory eczema, especially when of the pus- tular type, swelling of the neighboring lymphatic glands is noticed, but this rarely leads to suppurative change, the swelling and pain disappearing as soon as the inflammatory symptoms have abated. In some eases of eczema a con- dition of furunculosis is occasionally ob- served. Pathological Anatomy. — Eczema is es- sentially a catarrhal inflammation of the sidn, and is seated chiefly in the rete and papillary layer; in long-continued and severe cases the lower part of the eorium and even the subcutaneous tissue may be more or less involved, but never destruct- ively. Hypersemia and exudation are to be found in all cases, either as punctate, localized, or more or less diffused. The vascular changes are the same as ob- served in all inflammations. Diagnosis. — Eczema is to be distin- guished chiefly from erysipelas, psoriasis, seborrhoea, sycosis, scabies, and ring- worm. Ekysipelas. — Markedly acute eczema about the face sometimes presents early in the course of the attack a resemblance to erysipelas, but in the latter disease the border is sharply defined and elevated; it usually starts from one point and spreads rapidly, and is accompanied by systemic symptoms of more or less violence. Psoriasis as commonly met with is not difficult to differentiate. The numer- ous, variously-sized, sharply-defined scaly patches, of general distribution, of psori- asis make this disease sufficiently char- acteristic. The face and hands are rarely involved, or only to a slight extent, at least, in psoriasis, while these regions are favorite sites for eczema. The psoriasic eruption often is seen most markedly on the extensors of the arms and legs, espe- cially about the elbows and knees; ec- zema is more common in the flexures. Psoriasis is usually markedly scaly, ec- zema rarely so. In occasional instances psoriasis is limited to the scalp, appear- ing here as several or numerous vari- ously-sized scaly areas, resembling squamous eczema of this part. The same differential characters can be here recognized, if the case is studied, as when seated upon other parts. Moreover, a careful examination will usually disclose the presence of several small or mod- erately sized characteristic psoriasic patches on the limbs, especially about the elbows and knees. Eczema of the scaly type is usually seated upon one region, is rarely generalized in its dis- tribution, and the area or areas are rarely sharply defined. Itching is the rule in eczema and is often absent or slight in psoriasis. In many cases of chronic scaly eczema there is often a history of gummy oozing which does not obtain in psoriasis. The eruption produced in the parasitic disease scabies and pediculosis is essen- tially eczematotis in many of its char- acters, but is usually multiform, consist- 76 ECZEMA. PROGNOSIS. TREATMENT. ing of papules and pustules, the latter often being large in size. The distribu- tion of the eruption in these parasitic diseases will often be sufficiently char- acteristic, and suspicion may be con- firmed by the finding of the pediculus in pediculosis or by the burrow in scabies. SeborrhcEa at times bears close resem- blance to a mild eczema, more especially as it occurs on the scalp. The sebor- rhosie disease is, however, rarely inflam- matory, except accidentally so; the scales are greasy, and there is lack of infiltra- tion and thickening. Sycosis. — Eczema of the bearded face may be mistaken for sycosis, but this latter disease is essentially one of the hair-follicles — folliculitis barbje — and limited to the hairy region of the face, and is rarely itchy. Eczema, on the other hand, is seldom limited to this region, but extends on to the non-hairy parts of the face, is not follicular, and is very itchy. Ringworm can scarcely be confounded with eczema, as eczema is seldom sharply defined, rarely ring- shaped, but is diffused, with no tendency to clear up in the centre. In cases of a doubtful character microscopical exam- ination of the scales will be sure to differ- entiate. Dermatitis. — Dermatitis is some- times with difficulty distinguished from eczema, as the symptoms of mild derma- titis are essentially the same as those of eczema; in fact, these eases may be looked upon as artificial eczemas. Ec- zema rarely, if ever, shows large vesicle- or bleb- formation as found in the severe types of dermatitis, more particularly from rhus. The history of the case will often throw light upon the diagnosis. In those eczematously inclined, however, what may be a true artificial dermatitis in the beginning may terminate in a veri- table stubborn eczema. Among other diseases that should not be confounded may be mentioned rosa- cea, erythema, urticaria, herpes zoster, lichen planus, lichen ruber, and impetigo contagiosa. Prognosis. — Eczema, while often most intractable, cannot be said to be incur- able. It may recur like any other dis- ease to which a person may be prone. Under favorable circumstances mild cases yield quite readily. During the course of treatment the disease may show slight relapses, but each succeeding one is usually noted to be of a milder and less obstinate character. It is difficult, in the individual case, to state an opinion, especially as to the duration of treat- ment. Several factors should influence the prognosis: the extent involved, the duration, previous variability, the nature of the exciting and predisposing causes, and whether these can be readily man- aged, and, finally, and of great impor- tance, the care and attention the patient gives to the carrying out of the treat- ment advised. ^ Treatment. — There has been great di- versity of views as to the methods of treatment, — e.g., as to whether it should be external or constitutional. The con- servative course, and that which seems to give the best results, is that which places reliance upon conjoint local and systemic measures. It is not improbable that there are some cases met with which persist without any constitutional cause, or the latter has already disappeared, and in such instances external treatment alone will bring about permanent relief. There are certain general or hygienic measures which should receive attention. The diet should be plain, but nutritious, all fancy dishes and indigestible meats and foods being avoided as much as pos- sible. ECZEMA. TEEATMEXT. Literature of '96-'97-'98. It is very important to watch the di- gestive functions and the action of the liidneys in all forms of eczema. The diet is also very important, and in the majority of cases proper food is the most efficacious internal remedy. The diet should be based somewhat upon the diathesis of the patient, but it mainly consists in the prohibition of all alcoholic beverages save a small quantity of wine with a little water. Coffee and tea are diminished in quantity; fish, crabs, clams, and oysters may be given in pref- erence to red meats. The patient is not allowed to take asparagus or cucumbers. Eggs, milk, and other light articles of diet are exceedingly useful. All fer- mented drinks are absolutely prohibited, and also all acid fruits. Barrazzi (Revue de Therap. Medico-Chir., June 1, '96). Treatment includes both constitutional and local measures. The diet must al- ways be carefully directed, and, for the purpose of furnishing best possible nerve- nutriment, an increase in the digestible fatty matter and phosphates should be ordered. Some caution may be required in regard to the former, but with a little care the amount of fat of meats and oils, and also fresh butter, can be added to the dietary. The phosphates are found abundantly in the preparations of whole wheat, such as crushed wheat, wheat- ena, wheatlets, wheat-germs, Pettijohn's breakfast-food, etc., as also in bread made from the whole wheat-flour, some of which should be taken, if possible, three times daily. Milk, however, if properly taken, proves of the most signal advantage. It should be taken warm, pure, and alone, one hour before each meal, and also at bed-time, if sufficient time has elapsed for the stomach to be perfectly empty, which is at least four hours after a hearty meal. This pre- cludes the possibility of adding liquor or egg to the milk, and especially should there never be a cracker or anything else eaten with or near it. The indica- tions for local treatment differ materially in different cases. L. Duncan Bulkley (Jour. Amer. Med. Assoc, Apr. 16, '98). Pork and salted meats, veal, pastries. strong acids or acid fruits, gravies, cheese, sauces, condiments, etc., and the excessive drinking of tea or coffee are to be eschewed. Beer, wine, and spirits are also to be avoided. Out-door life is to be commended in suitable weather, and exercise, especially systematic in character, are of great value. As to constitutional remedies, it may be said that there are no specifics, al- though arsenic seems at times of special value in chronic, sluggish, papular, and erythemato-squamous types. Each case must be carefully studied, and the pre- disposing factor or factors, if possible, discovered,! and the treatment suitable instituted. When the itching is so in- tense as to prevent sleep, recourse may be had to the bromides, phenacetin, chloral, sulphonal, trional, and the like; opiates are apt to cause aggravation. Literature of '96-'97-'98. In the attempt to get relief from the itching, which can seldom be obtained by local measures alone, the plan of treatment should be a soothing and pro- tective one. Zinc ointment with 1 or 2 per cent, of carbolic acid or creasote, or with 5 to 10 per cent, of ichthyol, or tincture of camphor, is always a, safe and generally beneficial dressing, but to be of service it should be kept thickly applied, spread on lint in most places, and bound on firmly. In the acutely inflamed, and especially in the erythem- atous forms of the eruption, there is nothing better than the well-known cala- min and zinc lotion, freely sopped on many times in the day. In the ery- thematous eczema of the face a tannin ointment, 'A to 1 drachm to the 8 drachms, with 2 per cent, of carbolic acid, is effective. The use of very hot water for a brief application, followed by an appropriate ointment, should never be forgotten. In old eases of eczema of the scrotum the effect of this treatment is sometimes very remarkable. 78 ECZEMA. TEEATMENT. L. Duncan Bulkley (Jour. Amer. Med. Assoc, Apr. 16, '98). If pruritus is present an absolute milk diet must be ordered. No medicine should be given until the case has been under observation for some time, since there are few drugs which may not in- crease pruritus. The urine must be ex- amined for uric acid, sugar, albumin, oxaluria, phosphaturia, and peptonuria, and the patient's organs and functions thoroughly overhauled. The most harm- less cutaneous antispasmodics are asa- fcetida and musk in doses up to 30 grains, and valerian in various forms. Opium is generally contra-indicated, be- ing itself a frequent cause of pruritus. For the insomnia, sulphonal or trional in doses up to 30 grains in twenty-four hours is much surer and generally well borne by the skin. Arsenic is useful in chronic cases, but does not suit acute cases or chronic during subacute ex- acerbations, with the exception of some varieties limited to the extremities or the head. In cases with a gouty diath- esis, bicarbonate of sodium acts well. The dose must be moderate if given for a long time. Sulphur in small doses is very useful with young anasmic, "lym- phatic," or tuberculous patients. It is contra-indicated in neurotic or cardiac cases, or when the eczema is recent and acute. It is best given as natural sul- phur-waters. Besnler (La Belgique M§d., May 6, '97). Among the tonics that are often of value may be mentioned codliver-oil, hypophosphites, quinine, nux vomica, the vegetable bitters, iron, arsenic, and manganese. Arsenic should never be given in the acute type, or in any case in which the disease is of the spreading or active character. Among alkalies, especially useful in gouty and rheumatic cases, may be mentioned sodium salic- ylate, potassium bicarbonate, sodium bicarbonate, and the lithium salts. Case of eczema of scalp in a man of rheumatic tendencies, rheumatism dis- appearing with appearance of eruption; cure by salicylic acid. C. E. Lockwood (Universal Med. Jour., Apr., '95). Among alteratives that occasionally are resorted to may be mentioned calo- mel, colchicum, arsenic, and potassium iodide. In some cases rather free action of the kidneys is desirable, and recourse may be usually had to potassium acetate, potassium citrate, and, in exceptional cases of more or less general eczema, to the oil of copaiba. Laxatives form a very important class in the treatment of this disease, as indigestion with more or less active constipation is often a striking symptom. The various salines, and aperient mineral waters, castor-oil, cascara sagrada, rhubarb, and aloes, and other vegetable cathartics are useful. Eczema is probably an excretory in- flammation; object of treatment to relieve skin by shifting the stress of elimination to sound organs; in gouty persons salines that act on the bowels and kidneys; dermatitis once started, however, becomes complicated by in- vasion of numerous micro-organisms; hence mild local applications, creolin ointment (Vz drachm to 1 ounce of vase- lin), or a weak creolin lotion ('A drachm to the pint of water) will suffice for a cure. David Walsh (Med. Press and Circ, Oct. 23, '95). In this class of cases the several di- gestives and bitter tonics are often pre- scribed with advantage, such as pepsin, pancreatin, papoid, muriatic acid and gentian, quassia, calisaya, and other bit- ter tonics. External Treatment.- — In the local management of eczematic cases soap and water must be used with judgment. In the acute and in many subacute cases these cleansing agents should be em- ployed as infrequently as circumstances will permit. Literature of '96-'97-'98. ■\Vater sometimes not only delays the cure, but absolutely prevents cases from getting well. When it becomes neces- sary, an oily preparation containing a ECZEMA. TREATMENT. 79 few drops of carbolic acid is to be used. John Edwin Hays {Pediatries, Apr. 15, '98). In cleansing eczematous surfaces and removing secondary products plain water or soap and water should be avoided, if possible. If the former has to be em- ployed it should be as hot as can be borne, and the surface over which it has been used should be dried quickly and thoroughly and the selected dressing immediately applied. All detergent fluids should be warmed before use. Olive- or cotton-seed oil will cleanse al- most as well as soap and water, and, if the pa;rt is carefully wiped, but little greasiness remains. Or thin strained rice-milk cleanses well and is soothing to tender and acutely-inflamed surfaces. Before any line of local treatment can be begun all secondary products — crusts, scales, etc. — must be removed. This can be accomplished by saturating them with oil. W. M. Nelson (Mont. Med. Jour., Apr., '98). Cleanliness may often be maintained by gently rubbing off with cold cream, petrolatum, or almond-oil. Even in such cases, however, occasional washing is necessary, both for the sake of clean- liness and in order to get rid of the products of the disease and to remove the messiness which has resulted from the applications. A remedial application should always be made immediately after washing has been employed. In some cases, especially those of a chronic and scaly and markedly-sluggish character the use of soap and water is resorted to frequently and has often a therapeutic value; indeed, in some such cases the green soap — sapo viridis — may be occa- sionally or frequently used with advan- tage. Notwithstanding the nearly univer- sal dictum of the harmfulness of water, the value of baths containing tar, or taken after the latter has been well painted over the affected regions, in- sisted upon. After this is effected Vene- tian talc is to be copiously dusted all over and around the area. Lassar (Der- matol. Zeitschr., B. 2, H. 6, '95). A current of steam of 104° to 122° F. directed to the affected parts of the skin in eczema removes crusts and scales, oc- casions increased scaling of the epider- mis, favors the absorption of superficial and deeper infiltrations of the skin, di- minishes or even entirely stops formation of pus on the surfaces deprived of epi- dermis, and at the same time produces increased regeneration of tissues where, on account of chronic processes, the con- ditions for healing are very unfavorable. A convenient apparatus consists of a, thick copper cylinder containing two or three glasses, the bottom one being heated with an alcohol-lamp. On the top are two openings, — one for pouring in water (closed by means of a screw) and the other for a bent tube. Accord- ing to the sensibility of the skin, the tube is kept three to five inches from it. The siance lasts fifteen to thirty min- utes. A. Liberson (So. Russian Med. Gaz., Nos. 51, 52, '95). Applications are to be made in ec- zema two or more times daily, and when possible the continuous application is to be advised. In the selection of external remedies for a particular case common sense must be employed. In those cases in which the type of disease is acute or subacute mild remedies are to be used. In the milder erythematous variety dusting- powders of zinc oxide, talc, starch, and kaolin are soothing and beneficial; they may be used alone or immediately follow- ing the application of one of the washes named below. The conjoint use of black wash or boric-acid lotion with oxide-of- zinc ointment or any mild ointment may give beneficial results. Or the simple oxide-of-zinc ointment with 20 to 30 grains of boric acid or 3 to 5 grains of carbolic acid to the ounce may be used. A compotmd lotion of calamin and zinc oxide, like the following: — 80 ECZEMA. TEEATMENT. B CalaminEe, 1 ^/j drachms. Zinci oxidi, 1 ^/a drachms. Glycerinae, 10 minims. Acidi carbolici, 20 grains. AqiTse, 6 ounces. — M. is valuable-, and may be dubbed on the surface repeatedly or by means of linen or lint kept wet with it and closely ap- plied to the diseased surfaces; or a boric- acid lotion with 1 or 2 drachms of car- bolic acid to the pint, will be found bene- ficial, and especially applicable if the dis- eased surface is large; or a boric-acid solution (15 grains to the ounce) may be made of the above calamin-and-zinc lo- tion. A so-called salicylic-acid paste, with or without 5 to 10 grains of carbolic acid to the ounce, is often of great ad- vantage: — I^ Acidi salieylici, 10 grains. Amyli, Zinci oxidi, of each, 2 drachms. Petrolati, 4 drachms. M. Make ointment. Literature of '96-'97-'98. In vulvar eczema only emollient prep- arations should be employed — bran- water, marshmallow or chamomile in- fusion; a little boric acid can be added to the boiled water and serve as a basis for these lesions. Following the lotion a cataplasm of corn-starch or potato- starch, made with hot boric water and applied cold, is indicated. Little com- presses of tarlatan soaked in borated bran-water recommended, to be placed between the lesser lips of the vulva. The dressing ought to be renewed after each urination. During the day borated cotton should be applied to the parts. As a curative to be applied during the intervals between acute attacks, the fol- lowing is suggested: — IJ Vaselin, 6Vi drachms. Oxide of zinc, Starch, of each, 1 V, drachms. Salicylic acid, 1 Vi drachms. — M. The parts must have been previously bathed with borated bran-water and dried with cotton. Lutaud (Jour, de Mgd. de Paris, Jan. 12, '96) . The following recommended to allay pruritus in eczema of the §calp: — IJ Acidi salicyl., 6 grains. Menthol, 12 grains. 01. lini, Aq. calcis, of each, 1 ounce. M. Sig.: For external use. Stein- hardt (Amer. Prapt. and News, Mar. 15, '98). A small piece of buckskin placed be- tween the ointment and the other part of the dressing greatly ameliorates the condition. Its good effects are ascribed to the flexibility of the buckskin, which allows it to be molded to every part of the surface; to the ease with which it can be cleansed; to the fact that it does not markedly absorb the ointment used, and that therefore the part remains moist; and to the safety with which it can be removed, the newly-formed epi- dermis not being torn away. Davezac (Jour, de M6d. de Bordeaux, No. 51, '97). An ointment of alumnol, 20 to 40 grains to the ounce of cold cream, or zinc-oxide ointment is also valuable. One containing ^/j to 1 drachm of bis- muth subnitrate is also of benefit. A compound calamin ointment may be used in some eases with great advan- tage: — T^ Calamin, 1 drachm. Amyli, ^/^ drachm. Acidi salieylici, 10 grains. Ung. zinci oxidi, q. s. ad 1 ounce. — M. Diachylon ointment, if a well-made one is procurable, is often serviceable. The soothing salve-mulls of zinc oxide and boric acid are extremely valuable" in some cases. In some cases of eczema in which the grade of inflammatory action is subacute, stronger applications may be resorted to. ECZEMA. TREATMENT. 81 although even in this class of cases it is advisable to begin the treatment with the milder applications already named. These latter may finally, if necessary, be made stronger and more stimulating by the addition of white precipitate, red pre- cipitate, calomel, resorcin, or tar. Of the mercurials, 5 to 30 grains to the ounce is the usual proportion called for; of resorcin, 5 to 20 grains, and of tar, ^/j to 3 drachms of the tar ointment to the ounce of mild ointment. Oil of cade may also be used ^/a to 2 drachms to the ounce of ointment. A tarry ointment such as the following may also prove use- ful in these cases: — ]^ Liquor carbonis detergens, ^/^ to 2 drachms. Cerat. simp., q. s. ad 1 ounce. [Liquor carbonis detergens is made by mixing together 9 ounces of tincture of soap-bark and 4 ounces of coal-tar, allow- ing it to digest for eight days and then filtering. Henky W. Stelwagoh-.] lodol-aristol, 5 to 20 or more grains to the ounce of ointment-base, may also be commended. In some instances pre- liminary paintings for several days with a saturated solution of picric acid has proved of advantage, waiting for the films or scale thus formed to come up, and then applying a mild ointment for a few days, and then resuming the picric- acid painting. literature of '96-'97-'98. Picric acid is indicated in those forms of eczema in which the inflammation is acute and superficial, and where the le- sions are mostly epidermic. The kera- toplastic action of the remedy cannot display itself in the chronic forms ac- companied by induration of the skin and particularly by epidermic thickening; picric acid is incapable of modifying these chronic lichenoid eczemas. On the other hand, the keratogenie properties of the agent find an excellent field of action in acute eczemas with swelling of the integument, superficial ulceration, and weeping. Under its influence the inflammation rapidly subsides, and the acid forms (on contact with the ulcer- ated and oozing surfaces) a protective layer composed of coagulated proteid substances and of epithelial dihris, un- der which healing takes place rapidly. Picric acid has the further advantage that it immediately stops itching; this efi'ect is produced in chronic as well as acute forms of the disease. In acute eczema a, cure is effected in from ten to fifteen days. Aubert (Th6se de Paris, No. 34, '97). Picric acid successfully used in the treatment of eczema. In cases of lich- enoid eczema with a thick epidermis the acid Avas useless, but in acute oozing eczema accompanied by oedema of the skin it was very useful. Immediate re- lief is produced by the application of the picric-acid solution. The treatment is indicated in acute eczema; in the acute attacks of chronic eczema, particularly if there is a tendency to oozing and ulceration of the skin, and in the sebor- rhoeic eczema (impetiginous) of infancy. It is contra-indicated in chronic eczema and generally in all those forms of eczema which are accompanied by a thickening of the epidermis (lichenoid eczema). The method of employment is as fol- lows: A saturated solution of picric acid is painted on the affected parts, the ap- plication extending slightly beyond the limits of the eczematous area, then cov- ered immediately with absorbent wool, or it inay be with a compress soaked in the same solution, over which the wool is applied. This is allowed to remain on for about two days. The skin should be previously cleansed with some anti- septic, so that no suppurative organisms may be allowed to remain in contact with the diseased parts during the time they are covered with the wool dressing. The staining due to picric acid may sub- sequently be removed by washing in a saturated solution of lithia carbonate. M. A. Brousse (Nouveau Montpelier M6d., Sept., '97). 3—6 83 ECZEMA. TREATMENT. In some instances applications of dressings of a more or less fixed character are of advantage, such as the gelatin dressing, tragacanth dressing, and aca- cia dressing. Gelatin Deessing: — 19 Gelatin, 15 to 25 parts. Zinc oxide, 10 to 15 parts. Glycerin, 15 to 35 parts. "Water, 50 parts. To this may be added 2 parts of ich- thyol. This is heated over a water-bath each time it is to be employed, a good coating painted on with a brush, and when partly dry — in one to five minutes — the parts wrapped with a gauze bandage. The whole dressing becomes dry and fixed, and may remain on from two to six days, and then soaked off, cleansed, and a new dressing reapplied. In some cases the larger quantity of gelatin and smaller quantity of glycerin may prefer- ably be incorporated, and then the gela- tin coating will dry more quickly and will form a sufficient dressing without the gauze bandage, although this latter seems to be of real advantage in keeping the gelatin from becoming soiled and from being rubbed off. If the gauze is not used a small quantity of a dusting- powder may be applied over the gelatin. The above is especially applicable in the treatment of eczema of the lower legs. Other drugs may be added, but cer- tain medicaments exercise an inhibitory influence on the setting of the gelatin, and if used should always be used with a dressing more rich in gelatin and with less glycerin and less water; such reme- dies are resorcin, salicylic acid, and car- bolic acid. White precipitate, sulphur, and acetanilid may also be incorporated in such dressings. Tragacanth Dressing. — Pick's trag- acanth dressing — linimentum exsiccans — is also a useful fixed dressing in the cooler weather. It consists of ^ Tragacanth, 5 parts. Glycerin, 3 parts. Boiling water, 95 parts. To this can be added 2 per cent, of boric acid or 3 per cent, of carbolic acid, and 5 to 10 per cent, of zinc oxide or cala- min, or equal parts of both. This is smeared in a thin coating over the diseased area and allowed to dry on, which usually requires several minutes. The parts can then be bandaged or be sprinkled with some indifferent dusting- powder. It is a more simple dressing than the gelatin application, requires no preparation, but is, upon the whole, less useful. Other medicaments may be added in addition to those already named. Acacia Dressing. — This constitutes another fixed dressing that is readily ap- plied and which may be used on dry parts. A good formula is the follow- ing:— ^ Mucilage of acacia, 5 or 6 parts. Glycerin, 1 part. Zinc oxide or calamin, or a mixt- ure of both, 2 parts. Carbolic acid or any other drug may also be added if desired. This is painted on with a brush or smeared over in a thin layer with the finger; it dries in a few minutes. If at all sticky or for further prevention against this, a dry powder of zinc oxide or talcum can be applied over it. Another method of treating these cases which can at times be employed with great benefit is by means of the so- called salve- and plaster- mulls (made by Beiersdorf). These are variously medi- cated. The mild salve-mulls and the ECZEMA. TREATMENT. 83 moderately strong salve-mulls, and the moderate strength plaster-mulls are adapted for the subacute cases. While especially useful in some cases, occa- sionally their action is not so satisfactory. Their disadvantage is their costliness. In eczema of a chronic sluggish type strong applications must he usually made before a result is brought about. The different remedies and combinations referred to in speaking of the treatment of the subacute type may be first tried; later, when necessary, treatment may as- sume a bolder character, various reme- dies being used in stronger proportion. Of value in many of these cases may be mentioned — ointments of calomel, 40 to 80 grains to the ounce; white precipi- tate of about the same strength; salicylic- acid ointment, 20 to 60 grains to the oimce; resorcin, about the same propor- tion; sulphur, 10 to 60 grains to the ounce (used at first with caution); tar ointment, either in official strength or somewhat weakened; or the liquor car- bonis detergens, with simple cerate or as a wash, pure or diluted. An ointment of 20 to 40 grains of pyrogallic acid to the ounce may be cautiously tried in obstinate cases. The same may be said with regard to chrysa- robin; but this latter should not be used about the face. The various fixed dress- ings referred to in the treatment of the subacute variety will also be of value in the chronic type. Collodion may also be used as a basis for fixed dressing in local- ized areas of disease. The stronger salve- and plaster- mulls and the medicated rubber plasters, the latter especially in the sclerous and verrucous forms, are also of distinct advantage in these cases; in sluggish, thickened areas repeated shampooing with green soap and hot water, rinsing off, and immediately fol- lowed by a mild ointment applied as a plaster acts admirably ia some instances. Painting such areas with solutions of cautic potash, 1- to 5-per-cent. strength, allowing to act for a few minutes, then rinsing off and applying a- mild ointment is a somewhat similar method of treat- ment which is serviceable at times. In some obstinate eases thoroughly stirring the skin with a strong remedy, insti- tuting a substitutive inflammation, and then applying mild remedies will not in- frequently bring about the desired result. Literature of '96-'97-'98. Superficial scarification of patches of eczema employed in certain selected cases. The patches are scarified in par- allel lines, one to one and a half milli- metres apart, in one direction only, by a very pointed instrument penetrating to the superficial layer of the dermis. These areas are then encouraged to bleed and bathed with boiled water, and then covered with tarlatan dipped in boiled water. On reaching home cold potato- starch poultices are applied until the next treatment — generally three or four days later. Before beginning the treat- ment the patches are prepared by the ap- plication of continuous cold plain starch poultices. Six to sixteen treatments suffice for a cure. A reaction is set up in the patches, but no sears result. This treatment is to be used only in special cases characterized by isolated disks in limited number. Jacquet (Bull. G6n. de Thfirap., Jan., '98). In infants the face or face and scalp are by far its common site. The disease may, however, occur tipon any part at any age. The treatment in regional ec- zema is essentially the same as the treat- ment of eczema of any part, common sense suggesting selection or avoidance which the character of the region may suggest; as, for instance, upon hairy parts, as the scalp. Ointments containing large percentages of pulverulent sub- stances, such as the so-called salicylic- 84 ELATERIUM AND ELATEEIN. acid paste, should not be employed, as they would tend to produce crusting, matting, and mossiness. Literature of '96-'97-'98. In treating a case of infantile eczema the search for the cause should go hand in hand with the treatment, which is otherwise only palliative; carefully ex- amine both child and mother. In an acute eczema of a few days' standing decided amelioration may be obtained by calomel. Some cases are benefited by judicious use of codliver-oil and iron. The local treatment is very important for the comfort of the patient. The crusts can be removed by salicylated oil. Washing with water should be strictly interdicted, oil being used as a substi- tute. The local conditions can now be treated very happily by Lassar's paste: — B Zinc, oxid., Pulv. amyli, of each, 2 drachms. Petrolatum, 'Z. ounce. In acute eases, boric acid, 10 to 20 grains to the ounce, or in less acute cases salicylic acid, 10 grains to the ounce, may be added. lehthyol, 5- to 10-per- cent, should be added in the older cases, where the skin is thickened and scaling is excessive. In all cases the applica- tion should be changed two or three times daily, every precaution being taken to see that the skin is kept covered and scratching prevented. Alger (Amer. Med.-Surg. Bull., Aug. 1, '96). Hbney W. Stblwagoit, Philadelphia. ELATEEIUM AND ELATERIN. — Elaterium is a sediment deposited from the juice of the squirting cucumber (Ecballium elaterium, A. Eieh). This sediment, when dried, appears in fri- able cakes about ^/lo of an inch in thick- ness, flat or slightly curled, and of a pale-green, grayish-green, or grayish- yellow color, the yellow tinge appearing when the drug is old. Its odor is feeble and its taste bitter and slightly acrid. It is partly soluble in hot water. It is offi- cial in the B. P., but not in the U. S. P. Elaterin (elaterinum— U. S. P., B. P.) is the active principle of elaterium, be- ing found therein in amounts varying from 5 to 40 per cent. It is a neutral principle and appears as small, white, or yellowish-white crystals, without odor, but of a very bitter and acrid taste. It is freely soluble in chloroform, slightly soluble in ether and alcohol, and in- soluble in water. Elaterin is preferred for administration because of the great variability in strength of different speci- mens of elaterium. Dose and Physiological Action. — The dose of elaterium is ^/g to ^/a grain. Elaterin is given in doses of V20 to ^/k, grain, preferably in granules; a tritura- tion of elaterin (10 per cent.) is official, the dose being '■/^ to 1 grain. Elaterium is a decided irritant to the mucous membranes and also to the skin. When given internally its chief action, in man, is to produce profuse watery stools. When given in proper doses, these large water evacuations occur with- out undue pain or any apparent gastro- intestinal irritation, and for these reasons elaterium claims first rank as an hydragogue purge. Poisoning by Elaterium. — In large doses or in debilitated persons its use may produce so much prostration and ex- haustion as to demand the exhibition of stimulants and other supporting meas- ures. In addition to nausea, vomiting, excessive purging, and exhaustion, the use of too large doses of this drug may even be followed by death from gastro- enteritis. Debility from old age or other cause and gastro-intestinal irritation or inflammation contra-indicate its use. The subcutaneous use of elaterium, al- though capable of producing catharsis, is not advised, on account of the severe ELATEEIUM AKD ELATEEIN. ELEPHAXTIASIS. SYMPTOMS. 85 local irritation and inflammation thereby induced. Treatment of Elaterium Poisoning. — ■ The treatment of poisoning by this drug is practically that of gastro-enteritis. Morphine should be given hypodermic- ally, and hot applications (stupes or flax- seed poultices) should be made over the abdomen to allay the pain and control the irritation and diarrhoea. Especial care should be had in the selection of a proper diet. Bland, easily digested, and unirritating articles of food should be selected. Predigested foods are espe- cially useful in these cases. Therapeutics. — In general, elaterium is indicated in conditions demanding fluid depletion; the use should not be continued if the stomach becomes dis- ordered or the appetite impaired. It ought never be used in cases of debility or marked exhaustion, and may be fol- lowed with advantage by alcoholic stimu- lants soon after its action is manifest. Its use is suggested in cerebral conges- tion on account of its depletant and re- constant effects. In poisoning by nar- cotics and in acute alcoholism elaterium is indicated when the emunctories are not acting freely. Ascites axd Deopsical Effusions. — In these affections elaterium is a drug of great value, though one whose use de- mands much care and judgm.ent. In dropsy depending on aortic, obstructive, or regurgitant disease it is especially use- ful, given in small doses at first, about Vs grain, on alternate mornings at say 5 o'clock, so that its action is finished by noon. This is claimed, by Hyde Salter, to quiet the heart, relieve the dyspnoea, lessen the pulmonary conges- tion, and diminish the hydrothorax. UKiEJiiA. — Ursemic poisoning is much benefited through the use of elaterium, as it aids the elimination of the ursemic poison by the bowel. It is especially in- dicated when ursemia is associated with dropsical effusion. Liquid Effusions of Inflammatobt Origin. — Under this head belong piil- monary oedema, pleurisy, and pericardi- tis, in all of which the hydragogue catharsis induced by elaterium may be beneficial. ELECTRICITY. See Appendix, end of sixth volume. ELEPHANTIASIS —Gr., eXecpaq, an elephant. Definition, — Elephantiasis is a chronic endemic and sporadic hyperplasia of the skin and siibcutaneous tissues, following an inflammatory embolus of the lymph- and blood- channels, and resulting in an inordinate enlargement. Symptoms. — The legs are involved most frequently; the genitalia of both sexes follow closely, while many other parts — the face, body, and extremities — are occasionally attacked. Case of congenital elephantiasis. Men- tal development considerably below par. Had congenital hypertrophy of the face, eyelid, and scalp, confined to right side. The right eye had become diseased in early childhood, and had been removed. The hypertrophy seemed confined chiefly to the skin and subcutaneous tissue; the upper eyelid was greatly thickened and pendulous, reaching down to the upper , of the alee nasi. There was a well- marked, irregular depression in the re- gion of the squamous portion of right temporal bone, and in one place a slight loss of bony substance. Over the poste- rior portion of the right parietal bone was a soft, flabby tumor of the scalp about the size of a small hen's egg, freely movable, and covered with a nor- mal growth of hair. Coley (N. Y. Med. Jour., June 20, '91). Three cases of elephantiasis of the upper lid, in one of which both eyes 86 ELEPHANTIASIS. SYMPTOMS. were affected. Goraud (Annales de la Polyclin. de Bordeaux, Apr., '92). The right leg is more often attacked than the left, occasionally both are in- volved; the scrotum is affected with greater frequency than the penis in the Congenital elephantiasis of the face and scalp. (Goley.) male, and the labia majora and minora than the clitoris in the female. Case of a man, 19 years old, in whom the foreskin and scrotum began to en- large at the age of 4, continuing until it had reached the enormous size shown in illustration. Operation successfully performed. Uthemann (Deutsche med. Woch., Dec. 5, '95). Elephantiasis of the vulva observed in a mulatto woman who was four months pregnant. The tumor encroached upon the vaginal orifice so much (the clitoris and labia majora and minora being all involved) that delivery at term would have been impossible. Hence the mass was removed with the knife, being first constricted with an elastic ligature tied under three long pins passed beneath the tumor. Bleeding vessels were thus se- cured separately and the wound closed by sutures. Pregnancy was not dis- turbed. Mundg (Amer. Jour, of Obstet., Oct., '95). Literature of '96-'97-'98. Form of chronic enlargement of the testes frequently met with in the inhab- itants of warm countries, and associated, in many instances, with elephantiasis of the scrotum and lower extremities. This form of testicular enlargement, which is associated with swelling and induration of the epididymis and spermatic cord, even when existing alone, is held to be invariably of the nature of elephantiasis, Case of elephantiasis of the scrotum. (Vtliemann.) and not due to any malarial influence. After castration and during an opera- tion for hydrocele, it has been found that this condition is the result of a dis- tension of the lymph-vessels of the tunica albuginea, epididymis, and cord, and of an excessive proliferation of the con- ELEPHANTIASIS. SYMPTOMS. 87 nective tissue. The fllaiia undoubtedly plays a considerable part in the genesis of such morbid conditions. Le Dentu (Eevue de Chir., Jan., '98) . No inconvenience or pain accompanies the disease in the majority of cases, but Tery often when the scrotum is the part attacked stomachic and nervous distress is encountered. Eadiating pains may be observed in the seminal nerves, thus causing intense nausea and vomiting. Hydrocele may be induced. The prodromie stages differ according to whether the elephantiasis occurs in hot or cold climates. In hot countries there appears a preliminary fever termed "elephantoid fever," which is preceded by pains of great intensity in the lumbar region, accompanied with retching and vomiting, cold shiverings located along the spine, followed by fever and profuse perspiration in successive alternations. The colder atmospheres do not occasion such marked distress during this early stage. In patients suffering from elephantia- sis once or twice a month there is an excess of fever. The local symptoms ac- companying the fever are those of lym- phangitis with ganglionic enlargements. These attacks of lymphangitis with fever coincide with the invasion of the con- nective tissue of the hypoderm and of the associated lymph-channels by mi- crobes. The visible lesions are the result of hundreds of febrile crises, each accom- panied by a fresh advance of cedema. Each new oedematous deposit is prob- ably followed by local organization of the emigrated embryonal cells in adult connective tissue. Tropical elephantia- sis is usually due to the Filaria san- guinis hominis. Sabouraud (Annales de Derm, et de Syphil., May, '92). The course of the affection, whether occupying the leg or elsewhere, is char- acterized by frequent exacerbations. Deeply-seated, recurrent forms of derma- titis, or attacks of an erysipeliform (or true erysipelas, the streptococcus of erysipelas being found in some cases) in- flammation, with, at times, involvement of the lymphatics (from which milky or chylous discharges may be noted with or without puncture) are encountered. While these phenomena are primarily localized in the deeper tissues, the skin does not seem to be attacked until later, when it presents nodular increase in size. With proper measures these symptoms abate, only to reappear at some later period. At each successive attack the part is noted to have increased in size to an appreciable extent. These recur- rences of fever and oedema may appear at intervals of weeks only, while months or years may intervene between each recru- descence. At times the recurrences of these phenomena may be so frequent or so close that the previous inflammation has not had time to disappear. As each attack leaves an increase in size we may, after a time, find a gigantic enlargement of the part involved. These inflamma- tory phenomena may not always be ob- served, as the part may often be found to increase in size without their apparent assistance. It is difficult to cause pitting in these structures, owing to the general hyperplasia. The skin, as previously noted, does not appear to participate in this process early, but later it becomes likewise affected. It is tightly stretched, glossy or waxy, with pigmentary changes of color varying from brownish red or pinkish red to one of dusky brown. Upon its surface may be seen an accumu- lation of sebaceous material, with here and there desquamations of epithelium. The linear fissures of the skin may in- crease so greatly that enormous sulci may be formed. Hard or soft tubercles may appear upon its surface at various parts, either showing some scaly desquamation at their summit or becoming denuded of ELEPHANTIASIS. DIAGNOSIS. epithelium; they present numerous bleeding-points or the top of the tuber- cles may be one bleeding surface. In fact, many cases seem to present a chronic eczema upon the skin of the thickened part, and this appears to fol- low its usual characters. In other cases shallow ulcers, which resemble ordinary breaks of continuity, may be found at points over the affected skin. The parts around the joints form decided strictures, and the overlapping enlargement thus causes deep fissures in which a milky or chylous exudation, intermixed with se- baceous discharge, cause painful macera- tion of the inclosed skin. At certain points the lymphorrhagia may be so ex- cessive as to cause great depression of vitality. While this increase occurs in the softer parts of the affected structures, the bones alike share the enlargement in all their dimensions, and glandular involvement is often noted. The leg resembles closely its counterpart in the elephant both ex- ternally and in size-proportion. The wfeight becomes out of all proportion to other parts of the body, and while sub- jective sensations are, for the most part, encountered during the inflammatory attacks, they may be observed after the affected portion has been allowed to re- main in one position for an indefinite period. Pain is then foimd to follow ex- cessive fatigue, and tearing, stabbing sensations are reverberated throughout the affected leg. When other parts- such as the scrotum and penis or the labia and clitoris — are involved, the same process intervenes and the enlargement hangs down between the legs, and may weigh many pounds. The penis usually becomes indistinguishable in the large mass and an opening or groove is left through which the urine trickles. The face (cheeks and nose), shoulders, arms. forearms, and the hands may share in the tumefaction, but do not show the same complications observed when the leg or genitals are involved. Other en- largements of enormous extent are de- scribed, such as the elephantiasis telangi- ectodes of Virchow, which is of congen- ital origin and affects the vascular tissues. Case of elephantiasis telangiectodes and molluseum fibrosum in a small, rather deficient man who showed a number of sessile tumors, more or less subcutaneously movable, over the body and limbs. Patient's mother and father had also suffered from small subcutane- ous tumors. There was inequality of the lower extremities, and marked irregular hypertrophy of the left femur, and on the left tibia was a large osteal growth. Large, loose folds of elephantiasie growth existed on the left thigh. The case illustrated the hereditary character of the affection; its occurring in one some- what imperfectly developed in mind and body indicates the connection between elephantiasis and molluseum fibrosum and a condition analogous to the fibro- vascular hypertrophy of the subcutane- ous connective tissue taking place in the osteal tissue. Calwell (Brit. Med. Jour., Jan. 4, '90). Diagnosis. — Cases of elephantiasis after reaching their full development are easily recognizable. The enlargement, with difficulty to cause pitting; the ap- pearance of warty or keloid-like tumors; the history of repeated attacks of ery- sipelas, deep dermatitis, or a recurrent eczema, should be sufiicient to draw at- tention to this affection. Care should be taken not to confound elephantiasis with pendulent tumors, such as overhanging forms of fibroma, which may closely resemble the enlarge- ment found in the former affection. En- largements due to eczema or syphilis will usually present symptoms of both of these conditions sufficient to prevent error if care be taken. Acromegaly and ELEPHANTIASIS. ETIOLOGY. 89 mycedema present symptoms which will be sufficient, if carefully studied, to make a proper diagnosis of these conditions. Constriction of a limb by means of band- ages happens very frequently, and, as en- largement may follow, close examination will reveal the reason for this increase. In fact, close attention to every detail should be carefully studied, when the diagnostic differences of the several simi- lar affections may easily be detected. Etiology. — While the affection may be observed in any country, certain regions, owing to their climate, are noted for the prevalence of an endemic type of ele- phantiasis, while sporadic types prevail in other countries. It attacks both sexes, although the male, however, three times more frequently than the female. Age does not seem to influence its appearance, but middle or adult life shows the largest number of cases. Congenital types may be noted. [The appearance of four cases in one family has been recorded by Nonne (Virchow's Archives, 125), who referred to their attacking both limbs. J. Abbott Canteell.] The influence of heredity has been shown by many recorded cases. Change of climate seems to lessen the tendency of the disease, and eases are beneflted in which the affection has proceeded for some time. Unhygienic surroundings — such as malarious districts or parts bor- dering upon the sea — exert a deleterious influence. The fair types of mankind do not show as marked a tendency to the affection as do the darker types. The mosquito is thought to play an important part in the production of elephantiasis. Encroachments of large ttimors, as well as pressure of various kinds, upon the veins and lymphatics are also considered as predominating eti- ological factors. Case of a man "who suffered from elephantiasis of twelve years' growth consequent upon a burn. Berry (Pro- vincial Med. Jour., May, '89). Case of elephantiasis of leg in a woman, aged 36, whose right foot was crushed, a condition of elephantiasis of the leg gradually setting in. A year afterward the leg was amputated. CEdema of the left leg commenced a few months later. It is much enlarged and in a condition of solid cedema, but the skin is smooth and shows no lymphatic enlargements. The disease never ex- tended beyond the knee in either leg. The accident probably set up a chronic erysipelatoid inflammation, which gradu- ally passed into elephantoid cedema, and the inflammation spread by the lym- phatics, and crossed the pelvis, thus pro- ducing a similar condition in the other leg. Hutchinson (Clin. Jour., Nov. 6, '95). Case of elephantiasis of the penis sub- sequent to a. gonorrhceal lymphangitis. Humbert (La Semaine Med., May 25, '94). Case of elephantiasis of the female ex- ternal genitalia. The diseased portion was removed, the operation being ulti- mately followed by recovery. Micro- scopical examination of the parts re- moved led to the conclusion that the origin of the alterations could be carried back to an attack of acute gonorrhoea. The gonorrhoea had given rise to chronic inflammation of the lymphatic vessels of the vulva, which inflammation became the starting-point of the tumors. In consequence of the great cell-production of the lymph-ducts, the structure of the epidermis and of the corium were over- grown; they then became atrophied and disappeared little by little, either through hyaline degeneration or through formation of connective tissue. The ves- sels were also obliterated in this manner, and not by endarteritis obliterans. Earner (Miinch. med. Woch., May 7, '95). Case in which, two years before, the patient had acquired syphilis and suf- fered from suppurative buboes in both groins, the left side being the worse; she treated the affection herself. A 90 ELEPHANTIASIS. PATHOLOGY. year later she first noticed an increase in the labium majus of the left side, and this has steadily gone on until it is the size of the fist. In both groins there are scars, that on the left being deeper and more extensive. This case regarded as having an important bearing on the treatment of bubo. The extensive de- struction of the inguinal lymphatic ves- sels was the result of neglect of early incision and antiseptic treatment of the suppurative buboes. The elephantiasis described is due to the obliteration of Unilateral elephantiasis of the face and neck. (Monoorvo.) the lymphatics. M. Schreider (Derm. Zeit, B. 2, H. 5, '95). Three cases of persistent oedema and elephantiasis observed following the ex- tirpation of lymphatic glands. ' Eiedel (Archiv f. klin. Chir.," B. 47, Nos. 3, 4, '94). Literature of '96-'97-'98. Case of elephantiasis observed in a little girl 3 years old. Her grandmother had had several attacks of lymphangitis of the legs, followed by elephantiasis. The mother of the child never had either of these diseases or erysipelas. A fall upon the abdomen is thought to have an etiological relationship to the disease of the child. When the baby was botn a deformity of the face was found which Aias due to an abnormal production of a soft, elastic, uniform, and indolent tis- sue, which spread from the zygoma to the external commissure of the eyelids and back to the insertion of the ear posteriorly from the mastoid process to the inferior border of the thyroid carti- lage. A number of these cases observed, and the explanation advanced is that, streptococci having found their way into the fostal circulation through the pla- centa, an inflammatory process was set up in the foetal tissues, resulting in the overgrowth of tissue. Moncorvo (Pedi- atrics, Dec. 1, '97). Pathology. — The changes of elephan- tiasic areas are more directly located in the subcutaneous tissues, the upper and lower strata alike sharing in the charac- teristic phenomena. The skin, although presenting these changes, is more mark- edly affected where papillary outshoots are observed. Upon cutting into the affected areas there is observed a yellow- ish or grayish mass, which in some places shows a resemblance to fatty or larda- ceous deposits, while in others gelatinous formations are simulated. Exuding lymph may be observed at many points. The changes from the normal are of a distinct hypertrophy: there is decided proliferation of the epidermis, with hy- ■ perplastic increase of the corium, while the fibrous elements of the subcutaneous tissue are observed in hardened bands or meshes or noted to be soft or liquefied. • Distended lymph - spaces are found throughout the microscopical section. All the soft parts, the blood-vessels, lymphatics, nerves, and their component parts, as well as the bony structures, share in the general enlargement and cell-infiltration. At times, the muscles and the glandular structures of the skin participate in the increase of size. ELEPHANTIASIS. TEEATMENT. 91 Obstruction is clearly the influence in the production of elephantiasis. The presence of the Filaria sanguinis liom- inis in the lymph-vessels is directly the cause in endemic varieties of this condi- tion. Manson states that the parent- worm occupies some portion of the lymph-trunk, at which point it dis- charges the ova into the stream of lymph; these are then carried forward to some of the grandular structures, in which they find a lodgment. When hatched they enter the general circulation. Abstracted from the blood by the mosquito, and •deposited again into a water-stream, the ova again reach man when contami- nated water is employed. The more ag- gravated the symptoms, the more numer- ous are the parasites in the lymph-chan- nels. Haemorrhage and discharge of iymph may be observed in these types. In sporadic types of the affection, in which the obstruction may be induced through encroachment of large tumors ■or other forms of pressure upon the veins and lymphatics, the same features are developed. Although they are indistin- guishable, there is no mistaking the con- dition. Eczema of a most chronic vari- ety, frequent attacks of erysipelas or other forms of deep dermatitis, as well as tight bandaging of a part may also be the inducing factors. Prognosis. — Although the disease does not tend to shorten life, much discom- fort, as well as intercurrent maladies, may place the affected person in an un- enviable condition. Endemic cases may be greatly benefited by a change from a malarious or sea district. Sporadic types are likewise improved by change of climate. The discomfort may alone be caused by the weight of the affected part, which may often be removed by surgical measures, thus insuring relief. Early cases should be immediately removed to other regions; if this is done, a favorable result will be reached early. This step often arrests even cases of long-standing. Treatment. — In endemic cases which are preceded by the preliminary fever, with its accompanying phenomena, re- course must be had to the measures gen- erally adapted to most febrile manifesta- tions. Salines, acetanilid, quinine, and cinchona, which influence miasmatic fevers and their consequent complica- tions, should be administered. Tonics will be demanded in many cases in which the depressing effects of recurrent at- tacks of erysipelas or deep inflammations are experienced. Codliver-oil, with or without the hypophosphites, iron, strych- nine, certain mineral acids (hydrochloric or sulphuric), and possibly arsenic may be found beneficial. Again, all complica- tions should be remedied as they appear in the several cases encountered. All cases of this affection should be removed from countries in which the disease is endemic or where malarial or other miasmatic atmospheres are found. Spo- radic cases are to be removed as well to some healthy climate. Iodine (or its preparations) and mercury have been recommended for their absorbent quali- ties. Sterilization of drinking-water at all times may have an indirect influence in the prevention of this disease. Surgical interference, of one kind or another, may be productive of some fairly-good results. Large growths of enormous weight have been removed by this nieans. The penis and testicles have been restored to their normal conditions in a large number of cases. Literature of '96-'97-'98. Series of sixty operations successfully performed. The weight of the tumors varied from one and a half to thirty- nine pounds. The usual incision is made along the penis, which is thoroughly de 92 ELEPHANTIASIS. corticated; and by vertical incisions over the cords, down to the fundus of the tumor, the testicles are enucleated, and, all blubbery material being care- fully removed, the organs are placed on the pubes in a wrapping of gauze. The upper ends of the vertical incisions are joined to the vi^ound over the penis. Lateral oblique incisions are made through healthy skin and fat along the sides of the tumor; they pass down- ward, so as to meet just in front of the anus. The mass is then carefully dis- sected ojff, exposing, on its removal, the accelerator urinse in the middle and the limbs of the pubic arch at the sides. All bleeding vessels are ligatured. One now sees the decorticated, but turgid, penis; the testes with cords of, it may be, eighteen inches' length; and a large triangular wound, fairly representing the superficial dissection of the anterior half of the perineum. The skin and fat bounding the wound on either side are raised up from the fascia lata, over the hamstrings, for a distance of about three inches. The testes are united to each other in the middle line by three or four interrupted sutures. The edges of the sliding lateral flaps are then brought together over the testes by a series of strong quilt-sutures. The penis is covered by the anterior end of the thigh-flaps, and by flaps raised from above the pubes, with or without the addition of Thiersch grafts. The whole wound-area is dusted with iodoform, and covered with suitable dressings. It is essential that the dressings be kept in place by well-applied bandages. Heal- ing takes place throughout by first in- tention in about eight days. Havelock Charles (Indian Med. Eec, No. 5, '97). The cicatrical tissue following this treatment always gives a protective cov- ering to the structures. Surgeons have abandoned the use of the ligature be- cause of the likelihood of causing more disturbances to the already-obstructed circulation. The method of treatment generally resorted to by surgeons at the present day is compression. This may be considered as equal in value to ligature, EMPYEMA. but it is less likely to provoke other con- ditions likely to promote enlargement. Pressure may be applied by the use of some form of bandaging. Elastic band- ages, such as those advocated by Martin, or ordinary muslin of close texture, to in- sure firmness, may be applied to the en- larged areas, beginning at its lower and approaching the upper part in gradual pressure. This means has been followed, however, by untoward consequences, such as gangrene at one point or an- other, and should be carefully watched. J. Abbott Canteell, Philadelphia. EMPHYSEMA. EASES OF. See Lungs, Dis- EMPYEMA, THORACIC. — Empyema: Gr., sfinvElv, to siippurate. Definition. — Empyema is an accumu- lation of pus in the pleural cavity inde- pendent of the lung- tissue. _ Varieties. — The various kinds of sup- purating pleurisies are pulsating em- pyema, mtiltilocular empyema, tubercu- lous empyema, double empyema, putrid empyema, and interlobular pleurisy. When a collection of pus is so situated as to be synchronous with the heart-beat, it is denominated pulsating. In cases of pleuritic adhesions and the circumscribed diaphragmatic pleurisy, we often have encysted collections, which are usually many in number. Tubercu- lous empyema occurs in scrofulous sub- jects and is often localized, with caseous masses. Double empyema occurs simul- taneously on both sides, while interlobar pleurisy is the inflammation in the vis- ceral pleura, or that covering the lung, and pysemic exudation accumulating in the interlobar fissures. The interlobar empyemas are not pri- marily abscesses of the lungs, but of the EMPYEMA. SYMPTOMS. pulmonary pleura; but necessarily as- sume the form of abscesses of the lung if not circumscribed by adhesions or evac- uated early. The putrid empyema is a form resulting from neglect and long ex- posure to the various pyogenic micro- organisms, such as saprophytes, and the streptococci and staphylococci, resulting in pysmia and septicemia. Symptoms. — In most cases of empy- ema there is a history of exposure to dampness or overheating. A chill comes on, then fever, and pain in the side. The disease may not have been regarded as serious or a relapse may have occurred. In a few days dyspnoea and unusual restlessness call the attention of the pa- tient again to his chest. In a month or two the clinical picture has gradually changed; the patient, perhaps florid and plethoric, may have become emaciated and morose, a short loose cough suggest- ing the presence of consumption, which apparently becomes confirmed when night-sweats are noticed. The aspect of the Jace and the posture is that of ex- treme exhaustion. The physical signs are pain in the side affected. This may be one of the first symptoms; but the most marked of these is discomfort due to dyspnoea and to the absorption of pus. The skin may be clammy and bathed in a cold perspiration. The respiration is about 40 to the minute; temperature from 103° to 105°. There is dullness on the affected side, with change of sound under auscultation and percussion when sitting, when lying down on the back, or if the patient be turned on one side. Twenty patients examined with spe- cial care in regard to the change of level of a pleuritic exudation as the patient's position is altered. Anything that might, by acting as a damper upon the thorax- wall, give rise to apparent dullness, such as pillows, mattress, supporting hands placed against the back, etc., was avoided, many of the apparent changes in the level of dullness being, due to these agents. The thorax-wall must be set in vibration and give character to the percussion-sounds. If a damper is so applied as to stop these vibrations, a dull note results. A normal thorax, if percussed in the position a pleuritic pa- tient assumes, will give a dull note on certain lines. In only one case out of the twenty did the examination reveal any change in the line of dullness. Strauch (Virchow's Archiv, June 1, '89). In children there is not so apt to be a bulging in the intercostal spaces on the diseased side; the lung, beirig soft and compressible, offers the point of least resistance to the pressure of the fluid. Chapin (Archives of Pediatrics, June, '90). Skodaic resonance is a term used to indicate Skoda's discovery of an area near the clavicle which is always free from the extreme flatness found in em- pyema, — unless this area be also invaded in cases where the dullness is found in all portions of the chest, in which case the cavity is full of pus. This is also accom- panied by a disappearance of the vocal fremitus on the affected side. If a finger-tip of the left hand is held in an intercostal space over the region and a finger-tip of the right hand is held in a corresponding intercostal space on the sound side, and the patient is told to count audibly, no sound-waves seem to be transmitted to the finger placed in the intercostal space on the affected side, and the finger on the sound side feels the im- pact or vibratory motion communicated through air by the sound-motion. The symptoms of serous effusion vary slightly, and yet this wave-motion may be com- municated better by serum than by pus. The variety of sounds heard in the early stages of pneumonia upon ausculta- tion is followed by a complete loss of sound on the affected side in empyema. The respiratory murmur is nil. The 94 EMPYEMA. SYJIPTOMS. bronchial murmur above may be per- ceptible. The most-marked cases are the only ones in which all of these signs and symptoms obtain; for, with a small ac- cumulation of pus, Tery little more than the rise of temperature and dyspnoea exists. The final termination of a case not recognized and treated would be a pointing and rupture externally or in- ternally. The most usual points of rupt- called the region of Traube. (See wood- cut.) Literature of '96-'97-'98. [The spontaneous discharge of em- pyema without any untoward results was observed by me in the case of a young girl, aged 8 years, who had been attacked with influenza, and, later, with severe pleurisy, accompanied by high temperature, weak and rapid pulse, night-sweats, and hectic, showing great absorption of pus. In the course of time. Lower part of thoracic walls on the right side. A, pectoralis major; B, pectoralis minor; C, serratus magnus; D, external oblique; E, rectus ab- dominis; 3, third costal cartilage; 4, fourth costal cartilage; 5, 5, fifth costal cartilage; 6, 6, sixth costal cartilage; 7, seventh costal cartilage; 8, eighth costal cartilage; 9, ninth costal cartilage; *, placed just above Mr. Marshall's spot; tj aponeurosis, common to external oblique and pectoralis major and covering rectus; \, xiphoid appendix. ure have been the weakest and least re- sistant: i.e., internally, above into the bronchi or trachea; and, externally, at the free spots of Marshall or of Traube. The point on the right side which is com- paratively free from muscular covering is called the free spot of Marshall, while that on the left side, as in this case, is a prominence about the size of a hen's egg was noticed on the right side near the costal cartilage. After a simple in- cision the pus was fully evacuated through the opening, which remained patulous for about three years. The ex- amination of the patient now shows a slight lateral curvature of the spine, with a lack of development of the mam- EMPYEMA. DIAGNOSIS. 95 mary gland on the right side, but with a considerable chest expansion and very slight impairment of the lung. The pa- tient is rapidly developing into woman- hood and has regained her health and strength. The discharge of pus in the left side was observed by me in a boy at Annis- ton, Ala., in whom a serous pleural ef- fusion had been aspirated, and had been treated by medication also. The degen- eration of serous exudation into pus was verified in this case. Osier has stated that he has never seen a case of sero- fibrinous effusion degenerate into puru- lent pleurisy, but, according to W. M. Pirt, literature shows many similar eases. The region at which the pointing oc- curred in this case was in the left inter- costal space, immediately below the apex of the heart. I performed the operation of resection of a portion of the sixth costal cartilage on the left side, and se- cured drainage with a strip of gauze passed daily through the fistulous tract. The patient made a good recovery, also; and, being young and vigorous, over- came the tendency to scoliosis. The last report from him showed that there had been no redevelopment of pus, and that the fistula had been closed. J. Mc- Fadden Gaston.] The Marshall and Traube regions are points of least resistance and, although higher than the pus sometimes reaches, may be considered the most available for spontaneous discharge. It is for this reason, and because the region of Traube is least liable to complications with the diaphragm, pleura, and abdominal wall, that Jaecoud, of Paris, selected it for the introduction of a trocar. J. H. Cox has reported a case in which spontaneous evacuation took place in front between the sixth and seventh ribs. Recovery followed. Case of a young lad in whom there was no history of an injury; so that the development of empyema was thought to be due entirely to a latent cause. The head of the abscess appeared to the right and an inch below the left nipple. At this point an incision was made obliquely to the ribs. The pus ,was allowed to be pumped out by the breath- ing of the patient, and a large quantity was evacuated. A second incision was made about six inches below and to the left of the first, and a drainage-tube was inserted, passing through both incisions, so as to secure a free and thorough drain- age off of the pus. The cavity was washed out with a solution of the bichlo- ride of mercury. The incisions were closed with silver sutures and dressed antiseptically. The patient's tempera- ture did not exceed 100°, and had run down to 97° He had a good appetite all the time, and had made no serious complaint, notwithstanding the extensive extravasation of pus. John Ashhurst (Times and Register, Aug. 31, '89). The pus may discharge through the intercostal spaces, but fail to reach the surface at the point on account of mus- cles; then it burrows beneath them. In regard to the spontaneous escape of pus in thoracic empyema, a case has been re- ported in which it took place at the um- bilicus. This location of the weak point is a corroboration of the theory that pus escapes at the point of least resistance, and not always at the point of the lowest pressure. (J. G. Willis.) [I witnessed the case of a man at the Atlanta Polyclinic, who had a whole quart evacuated from the incision made into an axillary abscess communicating with an empyema. The patient was lost sight of after the first evacuation by me, and it is supposed that he must have been relieved by the use of a gauze drainage and packing at that time. J. McFadden Gaston, Jk.] Diagnosis.— The diagnosis may be made from the extreme dullness and lack of respiratory sounds, when the tempera- ture remains elevated. But an explora- tory puncture is advisable to determine definitely a case of empyema. Subphrenic pyothorax can be recog- nized by the results of high and low aspiration, in a large percentage of all 96 EMPYEMA. ETIOLOGY. PATHOLOGY. cases. Pligh punctures, in the fifth inter- costal space, show a collection of pus or serum, while low punctures, as the eighth intercostal space, yield pus which is always ichorous. Scheurlen (CharitS- Annalen, vol. xiv, p. 158, '89). i Two cases of pulmonary abscess simu- lating empyema. Kauffmann (Birming- ham Med. Review, Oct., '93). Literature of '96-'97-'98. Case of subdiaphragmatic abscess con- taining pure culture of bacillus coli communis observed which simulated em- pyema. F. Tilden Brown (N. Y. Med. Jour., Feb. 29, '96). Pleitritic effusion and a carnified or hepatized lung should be borne in mind, and they may be excluded when the ex- ploring needle reveals pus. At times eases of empyema may be Vi {^ Oj. ■/-, ert Immerwater (ArCblv f. jC!yn'./'K'Q'-3,' t^^., p. 406, '96). "^^n. '"-^ C^^/- ^ Traumatism or reinfection may'- protected by rubber tissue or varnish. The toes and fingers should always be left exposed, and they should be fre- quently inspected during the first few days in order that the splint may be re- moved in case it interferes with the cir- culation. If the patient is then to pass from the constant observation of the sur- geon he should not be allowed to go until he has been watched for twenty-four hours with his limb as dependent as it will be during the convalescence. Then he and his friends must be carefully in- structed as to the dangers of which cold- ness, swelling, and discoloration of the digits are the forerunners, and warned to report before gangrene has set in. Sub- sequently it will be well to inspect the splint once a week in order to be sure that the limb has not shrunk enough to allow motion at the seat of fracture. A good routine rule is that the splint shall be reapplied every ten days. AiiBULATOKT Splints. — We seem to have seen the crest of the wave of the "ambulatory" treatment of fractures, in which, as in all things else, there is some measure of virtue. In a certain sense every patient who walks on crutches is receiving an ambulatory treatment for his broken leg, but in that there is noth- ing new, nor in .the application of one of the many forms of hip-traction splints, so long used for the treatment of disease in that joint, to fractures of the femur. The novelty, the real "ambulatory" splint, is a heavy plaster-of-Paris band- age splint reinforced with a ring of sev- eral extra turns of the bandage just under the tuberosities of the tibia and usually strengthened by incorporated bands of iron or strips of wood in such fashion that the weight of the body is transmitted from the head of the tibia to the groimd, not through the splint, the foot being elevated by a sole of cotton or wool at least two inches thick or by a steel "stir- rup," which is incorporated into the plaster and upon which the patient walks. The advantages claimed for this method of treatment are that it avoids the risks of confinement in bed and shortens con- valescence by lessening the atrophy of 286 FRACTURES. TREATMENT. the muscles and the stiffness of the Joints. On the other hand, such spHnts cannot be used with safety in every oblique fract- ure or in fractures that allow any great mobility, and they certainly increase the danger of mobility within the splint. Moreover, some patients absolutely re- fuse to "amble," and those who will walk are usually able to get as much comfort out of a light, comfortable plaster splint and a pair of crutches as they can from such a cumbersome appliance. That they cannot get out of bed sooner than with crutches is evident, and that the convalescence is shortened by walking on the ambulatory splint does not seem to have been absolutely proved; yet in some eases they may prove very satisfactory. Teaction. — Continuous traction must sometimes be combined with immobiliza- tion, notably in fractures of the thigh. Elastic traction involving complicated apparatus and exercising an indefinite force has been superseded by the weight and pulley. As the various apparatus are designed only for fractures of the femur, they will be described under that title. DiEECT Fixation. — Very rarely nec- essary or advisable except in compound fractures, in fractures of the patella (and possibly of the olecranon), and in cases of delayed union. Of course, if, for any other reason, such as the removal of a fragment, it is desirable to cut down the seat of fracture, it is but discreet to throw a few supporting sutures about the bone- ends to insure their more accurate appo- sition. In so doing the one important caution to be borne in mind is that any bone transfixed or constricted by a me- tallic peg, plate, or suture is liable to become necrotic. Consequently some ab- sorbable gut or silk is the only form of suture material that may be used with safety. And, as a matter of experience. it may be added that periosteal sutures of stout catgut seem to last long enough to fulfill every requirement. It is true, however, that wire sutures may be used if their ends are left long, so that they may be untwisted and extracted at the end of ten days or two weeks. Massage. — In the first week massage hastens the disappearance of the swell- ing, and if used during the whole con- valescence notably lessens the subsequent stiffness and atrophy (Lucas-Champion- niere), but the expense of such treatment as well as the danger of disturbing the fragments nullifies these slight advan- tages in most cases. Management of the Joints. — Dur- ing the early stages of convalescence the joints should be immobilized and sub- jected to massage and elastic compression if they show any marked inflammatory reaction. Later, when the acute stage has passed they may be subjected to sys- tematic passive motion, the massage and pressure being continued. Passive mo- tion should never be insisted on, how- ever, as long as its use causes persistent pain or increases the stiffness. Indeed, ordinary use is the best form of exercise. Forced passive motion (brisement force), with or without anaesthesia, should never be attempted, for it is sure to be detri- mental, unless the obstruction is a single -slight band whose rtipture would not be followed by any great reaction: a rela- tively rare condition. If gentle passive motion prove ineffectual, the joint may be subjected to dry heat (300° F.); and, this means also failing, if greater mo- bility is absolutely essential, recourse may be had to open arthrotomy with systematic division of adhesions or the removal of any obstructing callus. In addition be it noted that in the larger joints stiffness rarely persists, but in the smaller ones it may be permanent. This FRACTURES. TREATMENT. 287 is Botably the case with the extended fingers. Fingers shoiTld always be im- mobilized in the fixed position, and pas- sive motion on them never postponed beyond the end of the second week. Compound Fbactuees. — -If the wonnd leading to the fractiire is small, clean, and not contused, as is nsiially the case, in compound fracture by indirect vio- lence, the wound and any projecting ends of bone should be thoroughly cleansed, the fracture reduced with as little enlargement of the external wound as possible, the wound loosely sutured, and primary union expected. In case the wound heals aseptically the course is that of a simple fracture, but, if suppuration sets in, the wound must be promptly opened up, thorough drainage provided for at dependent points, and irrigation instituted either continuously or, at least, often enough to keep it mechan- ically clean until healthy granulations occur, after which the healing is con- cluded under local treatment appropri- ate to granulating wounds. If, on the other hand, suppuration has already set in or seems inevitable from the contusion or the dirty condition of the tissues, provision must be made at once for .thorough drainage, and the preliminary irrigation must be copious, better results being obtained from irri- gation with large quantities of a weak solution than with smaller quantities of a stronger one, whose irritating proper- ties kill the tissues as well as the bac- teria. Yet even the most desperate cases may do' well if after this extensive cleansing they are left alone for five or six days in the hope that during that time partial healing may at least di- minish the size of the abscess-cavity and perhaps shut off the bone from it en- tirely. Of course, in the presence of evi- dences of existing suppuration, the sur- geon may not hesitate to institute the most vigorous antiseptic treatment, but in doubtfid cases the disturbance inci- dent to frequent changes of dressing will certainly result in suppuration, while the expectant treatment may have a happier issue. The necessity of removing detached fragments of bone depends almost en- tirely upon the prospect of suppuration. In a clean wound fragments that are entirely detached may lie, while in the presence of pus even the ends of large fragments will be cast oS. To estimate the amount of sloughing that .will occur Esmarch's artificial is- chfemia is a safe guide, those parts being doomed to which the blood does not flow on the removal of the bandage. But it is inadvisable to attempt any exten- sive clearing away of dead tissue until the bone has begun to granulate and the line of demarkation has formed. The suture of periosteum, fascise, mus- cles, nerves, and tendons and the ligation of bkeding vessels merit no especial no- tice here. As to the indications for resection or amputation, no definite rules can be laid down. In cases of doubt, however, it is always safe to delay amputation until it is clearly impossible to save the limb. Thus the patient is given every chance and the surgeon may avoid being sued for malpractice. As to suppurating compound fract- ures of the larger bones they need al- most never be despaired of, from twelve to eighteen months being none too long for their ultimate and satisfactory re- covery. PSEUDAHTHROSISjOE DELATED UnION. — When on account of a constitutional taint (e.g., syphilis), a drain on the sys- tem (pregnancy, lactation), a cachectic condition, or most commonly an imper- 288 FRACTURES OF THE SKULL. A'ARIETIES. feet reduction or inefficient immobiliza- tion of the fragments, the fibrous callus which unites the fragments fails to ossify after a sufficient length of time has elapsed, the bone-formation should be stimulated by attention to the patient's general condition and such measures as will produce local irritation. Among the local measures the most successful have been the production of congestion by occasionally constricting the limb above the point of fracture for a suffi- cient time to cause decided venous con- gestion, the injection of a few drops of a 10-per-cent. solution of the chloride of zinc into the callus; the use of electricity with one needle in the callus and the other on the surface of the limb, or the wearing of a splint loose enough to allow a slight amount of motion at the point of fracture. These failing, the only al- ternative is to cut down on the fracture, to cut away the callus, and suture the bones into place with catgut. If a gap remains this is to be filled by decalcified or powdered bone. A gap in the tibia may be done away with by removing a section of the fibula. The use of wire is contra-indicated here as elsewhere, ex- cept for temporary service. One need scarcely add that if the defective union is due to the general condition of the patient, no amount of operating will make the fracture unite so long as that condition persists. Nearthrosis, a very rare condition, in which the bone-ends are separated by a joint-cavity, demands operative inter- ference. Faulty or angular union may be reme- died by osteotomy. Special Fractures. Fractures of the Skull. — Vahieties. ■ — Instead of dividing these fractures, according to their location, into fract- ures of the vault and of the base, it is more intelligible to speak of 1. Circumscribed fractures, with little injury to the brain. 2. Fissured fractures, usually associ- ated with serious brain-lesions. 3. Intermediate and irregular fract- ures — the intermediate fractures that combine some of the features of each of the above varieties. Circumscribed fractures being usually caused by a sharp blow from some pointed object, the skull is crushed locally, without any great injury to the underlying parts. In typical cases, after the shock of the blow has passed off there is no further danger or inconven- ience, except the danger of infection, for almost all fractures of the skull are compound. Sometimes the outer table alone, again (but rarely) the inner table alone, and usually the whole thickness of the skull is depressed. Yet there may be no depression, the skull being simply split (locally) at the point of fracture. The diagnosis may be easily made by inspection and palpation. If, however, the fracture is not compound, a ridge of clotted blood may feel like the over- hanging edge of the uninjured bone over a depression; but in the case of the clot the finger goes up one side of the ridge as well as down the other, and does not simply slide over the ridge, and firm pressure will indent the clot, but not the skull. FissuEED Fractuees. — These fract- ures are caused by the binding" or "bursting" of the skull under pressure applied broadly. They are the "indi- rect" fractures of the skull, just as the circumscribed fractures are "direct." Consequently fissured fractures are much more common in the base, and circum- scribed fractures more common in the vault. The bursting force may make FRACTURES OF THE SKULL. 289 itself felt in a radial direction or in a direction at right angles to this, and the fissures are therefore usually dispersed in one of these two directions, although the irregular thiekness and elasticity of the skull, especially its base, is liable to impart to the fissure a ziz-zag course. The fissure may occur only at some point quite distant from the point of impact and is there often termed a contrecoup, a misleading term, for there is no contre- coup. On the other hand, the fissure may be so extensive as to allow the two halves of the skull to be freely movable upon each other. Since the cause of those fractures is generally a blunt in- strument, they are less often com- pounded than the circumscribed fract- ures. These fissures being due to a bursting of the skull on account of a sudden change of shape of the whole globe, it is readily understood that the associated lacerations of and haemorrhage into the contained structures are likely to be very extensive and to prove rapidly fatal, not in any sense on account of the fracture, but on acount of the trauma that caused the fracture. Diagnosis. — Fissures in the vault are often compounded and thus readily diag- nosed. Care must be taken not to mis- take a lacerated aponeurosis -for a fissure of the skull. In fissures of the base, however, the diagnosis can rarely be made except by inference. As these fis- sures often involve the petrous portion of the temporal bone, rupturing the tym- panum, haemorrhage from the ear, mouth, or nose is a fairly-accurate diag- nostic sign of fracture of the base. The 'diagnosis is, however, of very little im- portance. Intermediate and Iekegulae Feactuhes. — Most fractures of the skull are, in a sense, intermediate between the 3- two great divisions of circumscribed and fissured fractures, for with every sharp blow there is seen to be some compression of the whole globe, and even the blunt- est force, if applied with sufficient mo- mentum, will cause a local crushing. But an understanding of the two great classes will elucidate all such cases. Ex- ceptionally the brain is compressed by the blood effused beneath a circum- scribed fracture, and its evacuation is followed by immediate relief of symp- toms; but, we repeat, such, cases are ex- ceptional. Punctures. — Those which cause a local fracture are very liable to produce a local brain-lesion and to lead to infec- tion; hence they present special thera- peutic indications. EiNG EEACTUEES around the foramen magnum are caused by a sudden blow upon the buttocks which forces the spine up into the skull, carrying a ring of the basilar portion of the occipital bone along with it. Pathology. — A piece of depressed bone may lacerate both dura and pia and even the brain. In so doing it may tear the great sinuses or the middle menin- geal artery. If the fracture involves the ijiner ear, the hearing may be perma- nently lost. Various nerves and vessels and the cord itself may be torn at their points ot exit from the skull. Any amount of brain-laceration may accom- pany the fracture. Process of Repair. — Most of the mem- brane-formation is done by the diploe, the osteopoietic faculties of the peri- cranium and dura being very slight. Consequently there is very rarely any superabundant callus, and consequently, too, if a piece of skull is removed it will be replaced only by fibrous tissue, and not by bone. Peognosis. — The gravity of the prog- 19 290 FRACTURES OF THE SKULL. TREATMENT. nosis depends on two things, either of which may exist without any fracture at all, namely: the damage to the brain and its adnexa, and infection. The im- portance of depressions of small areas of the yault has been unduly magnified. Stimson strongly advises against med- dling with simple depressed fractures unless focal symptoms present them- selves. It is certainly absurd to suppose that the depression of a square inch of bone to the depth of half an inch or so could cause the severe and lasting shock that is so often attributed to such an in- jury, nor should the elevation of such a splinter be expected to relieve these grave disorders. Tbeatitent. — Simple Fractures. — At- tend to the general condition of the patient and leave the fracture alone un- less focal symptoms present themselves, as the result of a depression or a hsemor- rhage from the middle meningeal artery. In such cases operate to elevate the de- pression or to stop the haemorrhage. Many surgeons hold that all depressed fractures should be elevated at once. As the choice lies between the problem- atical danger from the existing depres- sion and the real danger from possible infection, the question cannot be said to be definitely settled. Compound Fractures. — Operate im- mediately for the purpose of cleansing the wound. Fill the wound itself with gauze wet in bichloride 1 to 10,000, then shave and cleanse the whole scalp, or at least half of it. Next enlarge the skin- wound if necessary in order to catch all bleeding-points and to expose the lacera- tion of the soft parts. If there is any depressed bone it can usually be elevated by prying up the most elevated corner and extracting this piece by gentle ma- nipulation with the forceps, after which the rest will follow easily. Occasionally the chisel or trephine may be necessary; but in all compound fractures the bone must be elevated for the purpose of as- suring the asepsis of the subjacent tis- sues. Having elevated and removed the splinters the whole wound is copiously irrigated with "normal" salt solution. If any intracranial hsemorrhage persists, the wound must be left packed with sterile or iodoform gauze for forty- eight hours, after which it may be closed. If there is no bleeding the dura is sutured; if torn, and the pericranium, aponeurosis, and skin sutured in layers, the first three with catgut, the last with silk. An aluminium, silver, or celluloid plate or a sheet of gold-foil or rubber tissue may be interposed in the gap left by the removal of fragments of bone in order to strengthen the scar. If a fissure of the skull appears in the wound, it should be thoroughly cleansed as far as infection may have traveled, the wound being slightly enlarged and the edge of the fissure chiseled away for this purpose, if necessary. There is no object in endeavoring to find the limits of the fissure, which may extend half- way around the skull or even farther. If from the force of the blow a depres- sion of the inner table seems possible, that is no indication for increasing the patient's risks of brain-infection by tre- phining. Such depressions are extremely rare, and unless they give rise to focal symptoms they are innocuous. Punctured wounds should always be opened up, the punctured part of the skull being entirely removed by the tre- phine and the whole wound then irri- gated and drained. Bullets located near the surface may be removed at once; if deeper and not to be touched by gentle probing, they had best be left alone, as their presence does not materially influ- ence the prognosis. If they give rise to FRACTURE OF THE VERTEBRA. 291 symptoms later, they may be located by the X-rays and their removal attempted with a greater prospect of success. In- fection from the air-passages in fractures of the base cannot very well be guarded against. It is futile to render the middle ear aseptic when germs may con- stantly reach it through the Eustachian tube. Fracture of the Vertebras. The importance of fractures of the vertebrse, like those of the skull, is de- pendent almost entirely on the amount of damage done to the inclosed nervous tissues; on this the symptoms, progno- sis, and treatment depend. Symptoms. — The symptoms are mainly those of an injury to the spinal cord. If the displacement is such as to com- press or tear the cord, paraplegia results, with loss of control over the vesical and anal sphincters, and in the male priapism usually occurs. Locally there is tender- ness and pain, increased by motion, ecchymosis, and deformity, and crepitus in some eases. Diagnosis. — Except the deformity and crepitus, any or all of the above symptoms may be caused by injury to or disease of the cord without any fracture of the spine. Hence the diagnosis is generally obsciire; but no manipulation should be undertaken for the purpose of elucidating it, for fear of precipitating a fatal issue. Fracture and dislocation are usually associated, and their diflferen- tiation is of no clinical importance. In estimating the location of the in- jury, it must be remembered that the pressure symptoms may be due as well to haemorrhage or inflammation as to the displaced bone, and also that it may take twenty-four to forty-eight hours for the paralytic symptoms to appear at their distinctive level. Hence the local symp- toms of pain, tenderness, and deformity are much better guides to the level of the lesion than the paralytic and anaes- thetic symptoms. Etiology. — Indirect violence by caus- ing an excessive bending of the spine is the common cause of fracture. Such violence may be applied by a fall of the subject himself or by some heavy body falling upon him. Less frequently mus- cular violence produces a fracture of the spine, the usual location of such fract- ures being the cervical region and the usual cause a sudden jerking backward of the head: as to avoid striking the bottom when diving in shallow water. Pathology. — The crushing force which causes the fracture is very likely to cause a simultaneous dislocation. The bodies of the vertebrae are the parts most affected, except in the cervical region, where the transverse and articu- lar processes are more frequently in- jured. Direct violence occasionally tears away the spinous process. There is no regularity about the fractures, how- ever, every conceivable variety having been observed. The upper fragment is usually displaced forward on the lower one and the cord is compressed, rarely torn across, between the two. Subdural haemorrhage or secondary meningitis may give rise to still further compression. The nerves that make their exit at that particular segment are usually torn, as are the attached muscles and ligaments. Peognosis. — Fractures of the Lower Three Lunibar Vertebrce. — In fractures of this region only the cauda equina is liable to compression, and its individual components can usually slip aside from any obtunding fragment, and thus there will be no pressiire symptoms. Under appropriate treatment the bones unite and the patient may recover entirely or with a weak back, or with paralysis or pain from pressure in some of the nerves. 292 FEACTURES. VERTEBE.E. NASAL BONES. Fractures Above the Second Lumbar. — The prognosis as regar^ds life and death varies with the amount of damage done to the cord. If the cord is permanently damaged, the patient may continue to live as long as two months, only to die finally of exhaustion or of septic infec- tion from bed-sores or catheterization. Death may be instantaneous from shock or from involvement of the phrenic nerve in the laceration. In fractures high up in the cervical region, even of the atlas and axis, death is not always instanta- neous, but the least movement or Jolt may be enough to bring fatal pressure to bear on the cord. Treatment. — In all manipulations the greatest care must be exercised to avoid the production of farther displace- ment. The patient must be kept upon a water-bed, catheterization must be con- ducted with every precaution, and the bladder irrigated daily with a saturated watery solution of boric acid, or, if cys- titis supervenes, with a 1 to 4000 solu- tion of nitrate of silver. Pressure must be taken ofE spots where bed-sores threaten, and, if they occur, they must be kept clean and dry by antiseptic pow- ders. Nor must the patient's general vitality be neglected. As long as there is any hope of recovery electricity and massage to the paralyzed muscles are ad- vantageous, and the strictest cleanliness must be insisted upon. The curative measures are mechanical and operative. Mechanical Treatment. — This origi- nally consisted in traction upon the head and feet by two assistants while the surgeon endeavored to reduce the fract- ure by direct manipulation. More re- cently suspension and the application of a plaster jacket, as for Pott's disease, has afforded some good results, and a similar treatment is that of Dr. Woodburj^'s, who applied the jacket to a child upon whom traction was being made while it lay face down upon a hammock of cheese-cloth. Dr. Stimson advocates suspension along a plank, the plaster being applied while pressure is main- tained on the protuberance. Operation. — The so-called laminec- tomy is done through a long vertical in- cision with its centre over the fractured vertebras. The bone is bared and the spinous processes of three or four of the vertebrte removed. Then with Eongeur forceps the laminae are divided on either side as close as possible to the transverse processes. The dura is then exposed and if distended with pus or blood it is incised and drained. Otherwise it is gently retracted and the bodies of the vertebrae are palpated. Any unevenness in them is removed, the straightening of the whole column attempted, and the wound closed without drainage, unless haemorrhage or suppuration demand it. The results of operation have been so unsatisfactory even at the hands of its most earnest advocates, and the effect of traction and the plaster jacket so mani- festly advantageous, that the mechanical method is the treatment of election even though operation has occasionally dis- closed and remedied pathological condi- tions upon which no manipulation could have exercised a beneficial influence. Fracture of Nasal Bones. — The nasal bones, cartilages, and septum may each and all be fractured. Such fractures may be followed by tedious suppuration, facial emphysema, plugging of the lacry- mal canal, and, as the displacement is always backward, some subsequent de- formity is inevitable, unless they are re- placed. Diagnosis. — By endeavoring to move the upper and lower parts of the nose laterally upon each other, false motion and crepitus will thus be elicited. FRACTURE OF THE JAWS. 293 Teeatmext. — This miTst be begun promptly, for osseous union has been known to occur by the tenth day. By means of a director passed within the nostrils the bones are replaced. The only retentive apparatus of any value is a long pin passed directly through the nose and resting on either cheek, the nose being covered with a piece of ad- hesive plaster. As a general rule, how- ever, there is no tendency to reproduc- tion of the deformity, and, even if such a tendency does exist, freqiient reposition will appeal to the patient rather than the transfixion treatment. In old unreduced fractures an artifi- cial bridge of aluminium celluloid, or gutta-percha may be introdticed and is well borne. Fracture of the Malar and Superior Maxillary Bones. — Fractures of these bones beyond the subsequent liability to suppuration and emphysema are of no particular importance. If a fracture of the zygoma threatens a serious de- formity, it may be remedied by inserting a sharp hook under the process and so elevating it. Fractures of the alveolar process of the jaw with displacement should be treated by wiring the teeth, or by an interdental splint {vide infra). Fractures of the Lower Jaw. — The body, , the ramus, the condyle, or the coronoid process may be fractiired. Fractures of the body are, by far, the most common. They are almost always compoimd and occur usually in the middle line or else .are double, one on each side. Unilateral fractures are com- paratively infrequent. The displace- ment is usually vertical and from before backward, as well. It may be appre- ciated by the finger inside the mouth. In fractures of the ramus there is little or no displacement. In those of the con- dyle that process is usiially drawn for- ward on to the eminentia articularis, the lower fragment slipping up into the glenoid cavity and so causing the chin to deviate to that side. The diagnosis is easy except in fract- ure of the ramus, where local tender- ness and pain on closing the jaws may be the only symptoms. Teeatment. — A mild antiseptic wash should be employed frequently to lessen the danger of infection and to clear the mouth of the foul and acid discharge from the wound. Under such treatment with efficient immobilization the wound Fig. 2. — Four-tailed bandage for fracture of lower jaw. (Stimson.) may be expected tO' heal kindly, though occasionally it is impossible to prevent suppuration and necrosis. Immobilization. — Though reduction is easy, the deformity tends to reproduce itself, to overcome which tendency a great number of mechanical devices have been introduced. The principles em- ployed are external pressure, exemplified by the four-tailed bandage (Fig. 2), wir- ing of the bone or teeth (several on either side lest they pull out), and the interdental splint. This is a piece of gutta-percha or vulcanized rubber 294 FRACTURES. LARYNX. STERNUM. RIBS. CLAVICLE. molded tO' fit between the upper and lower teeth and of such width as to hold the jaws slightly separated so that fluids may he introduced through a hole bored in its centre. This is applied and the jaw bound firmly by a four-tailed band- age. The first two methods may prove satisfactory; but the dental splint, though more complicated, is quite sure to give satisfaction if it is made by an expert dentist. Fracture of the Hyoid Bone, the larynx, and Trachea. — These rare fract- ures are usually caused by direct vio- lence, as in strangulation. They may be recognized by direct palpation. They endanger life by obstructing respiration. If the symptoms are urgent, tracheotomy should precede attempts at reduction. Fracture of the Sternum. — This acci- dent is very rare. It is usually caused by the strain of bending forward or back- ward. The symptoms and treatment are those of dislocation (q. v.). Fractures of the Ribs, — These are fre- quent, though often multiple, and occur usually between the fifth and ninth. The upper and lower two ribs are almost never fractured. In single fractures there is, as a rule, no displacement; but multiple fractures may give an angular displacement, or, if sufficiently exten- sive, a caving in of the whole side of the chest. The fracture may be located by a localized point of tenderness (and crepitus), which may be elicited by press- ure on the shaft of the bone at a dis- tance from the fracture. Crepitus may also sometimes be elicited by deep in- spiration, which is painful. If the lung is pierced there may be cellular emphy- sema, haemoptysis, and later a pneumo- thorax. Treatment. — Displacement having been corrected, the bone is immobilized by strapping the chest with adhesive plaster. During expiration a strip of plaster two inches broad is applied, be- ginning over the sternum and following the curve of the ribs over the point of fracture, and around to the opposite axilla. If several ribs are broken they are covered from above downward by similar strips overlapping. Fracture of the Costal Cartilages. — See Dislocations. Fractures of the Clavicle. — They are very frequent in children, being caused by a fall upon the arm which in an adult would be more likely to dislocate the shoulder. They occur usually in the middle third of the bone, are not infre- quently incomplete, but very rarely com- pound. Fractures of the middle third are transverse or oblique, from above down- ward and inward. The shoulder, losing its anterior support, drops downward, inward, and forward, the posterior border of the scapula is raised outward and its lower angle rotated slightly upward and backward. If the fracture is oblique the outer fragment slips below and behind the inner one, whose edge is prominent under the skin. Transverse fracture may give rise to angular deformity, the angle pointing upward and backward. If the fracture is comminuted the small fragments are markedly displaced; if it is bilateral the weight of the two shoul- ders on the chest may cause iirgent dyspnoea (relieved by dorsal decubitus). Injuries to the great vessels, nerves, and limgs are rare complications. The arm can be moved forward or backward, but cannot be abducted on account of the pain rather than the musclar disability. In fractures of the outer third the line of fracture is usually transverse and the displacement angular, with the apex backward. Disability and deformity are not great. FRACTURE OF THE CLAVICLE. 295 In fracture of the inner third the outer fragment passes below the inner one or is accompanied by it, producing angular deformity. Prognosis. — ^Union is almost certain to take place at the end of four weeks Fig. 3. — Sayre's adhesive-plaster dressing for fracture of clavicle. First piece. (Stimson.) whether the fracture is immobilized or not. Some persistent displacement is the rule, especially in adults. Treatment. — Eeduction is efEected by pushing the shoulder upward, out- ward, and backward. Manipulation of the arm or simple dorsal decubitus will effect this. To maintain perfect reduc- tion dorsal decubitus with the head slightly raised and the forearm resting across the chest is usually essential. In the green-stick fractures of children a simple sling may be sufficient, and the same dressing may be applied to all pa- tients who are impatient of restraint in the more complicated dressings and are willing to accept the subsequent de- formity. In other cases Sayre's or Velpeau's dressings will produce an sesthetically satisfactory result. Sayre's dressing (Figs. 3 and 4) re- quires two strips of adhesive plaster, each three inches broad and long enough to reach one and a half times around the body. The end of one strip is fixed loosely about the arm on the injured side just below the axilla. It is then carried around the back and across the chest in such a way as to hold the elbow a little behind the axillary line. The other strap is then carried from the un- injured shoulder across the back and the point of the elbow and back to the point of starting, carrying the elbow forward, upward, and inward. Thus the shoulder is carried upward, outward, and back- ward. The axilla and the whole inner surface of the arm and forearm should Fig. 4. — Same as Fig. 3. Second piece. {Stimson.) be well padded with cotton or wool, and the bony points of the elbow should be protected in like manner. The band had best be left uncovered and the whole dressing supported by a few turns of a roller bandage. 396 FRACTURES OF THE SCAPULA. Velpeau's dressing, as shown in Fig. 5, holds the elbow pressed against the front of the chest. It is made with a roller Fig. 5. — "Velpeau's dressing for fracture of the clavicle. (Stimson.) bandage. Padding should be applied as noted above. Moore's ingenious combination of a Fig. 6. — Moore's dressing for fractured clavicle. [Stimson.) posterior figure-of-S bandage to both shoulders and one elbow with a sling (Figs. 6 and 7) is effective, but uncom- fortable, and unless carefully padded is likely to interfere with the circulation of the arms. Fracture of the outer third is best immobilized by Stimson's dressing for dislocation of the outer end of the clavicle (q. v.). To avoid deformity displaced com- minuted fragments may be removed through a small incision. Fractures of the scapula are divided into fractures of the body, of the lower Fig. 7. — Moore's dressing for fractured clavicle. (Stimson.) angle, of the spine, of the acromion, of the coracoid process, of the surgical neck, and of the glenoid fossa. Feactuees of the body and in- FEEiOE ANGLE may be partial or com- plete, simple or comminuted. When the angle is torn away it is drawn forward by the attached muscles and cannot be replaced. In fractures of the body dis- placement is usually confined to overlap- ping of the fragments. The diagnosis is made in either case by palpation, and FRACTURES. ACROMION. HUMERUS. 297 the sole treatment is immobilization by plaster strapping, as for fractures of the ribs, and support of the arm by a sling. The only complication to be feared is suppuration in the deeper planes, which may follow even a simple fracture if the contusion has been severe. Fracture of the acromion may be caused by external violence acting di- rectly or through the humerus, or else by contraction of the deltoid. The fracture is usually beyond the attach- ment of the clavicle. Non-union of the epiphysis may occur. Bony union can rarely be obtained, but no disability fol- lows fibrous union. Treatment. — A'elpeau's dressing (Fig. 5). Fractuee of the coeacoid peocess may be caiTsed by external violence or muscular action and is often complicated by other injuries. Abnormal mobility, with or without crepitus, may be ob- tained by pressure on the tip of the process. Fibrous union without dis- ability is the rule. Treatment. — Treatment is by immobil- ization of the arm in slight hyperexten- sion. Feacttjee of the Suegical Neck.' — Either the whole of the glenoid fossa or only a part of it is torn off with the long head of the triceps attached to the fragment. The support of the triceps being lost, the whole shoulder sinks downward and the displacement re- sembles very closely a subcoracoid dis- location. The arm, however, is not ab- ducted nor is there any characteristic restriction of motion; a lump may be felt in the axilla, and the deformity may be reduced (with crepitus) by lifting the arm, but immediately recurs. Treatment. — The treatment is as for dislocation of the outer end of the clav- icle; bony union may be expected. Feactuee of the Glenoid Fossa. — The rim is often broken, with disloca- tions of the shoulder- joint. Stellate fractures have been found post-mortem. Fractures of the Humerus. — These may be conveniently grouped into fract- ures of the upper extremity, of the head, anatomical neck, through the tuberosi- ties, of either tuberosity, of the surgical neck; and separation of the epiphysis, of the shaft, and of the loiver extremity; supracondyloid, intracondyloid, of either condyle, or epicondyle; and separation of the epiphysis. Feactuee of the Head. — This is very rare, excepting the splitting that may accompany dislocation, and cannot be recognized clinically. Feactures of the Anatomical Neck and theough the Tubeeosities. — These present the same clinical feat- ures and can rarely be differentiated be- fore death; indeed, the line of fracture is likely to be so irregular as to be partly through the neck and partly through one or other tuberosity. These lower fractures are certainly more fre-' quent than simple fractures of the ana- tomical neck. Most cases occur in con- nection with anterior dislocation. There may or may not be impaction. If the head is dislocated forward it may be felt, and its independent mobility recognized when the shaft of the bone is rotated. If the head is not dislocated, pain in up- ward pressure on the elbow may be the only symptom. Treatment. — If the head is not dislo- cated, treatment is by immobilization with slight traction. If it is dislocated, alternatives present themselves: The surgeon may maintain the two fragments in apposition, hoping to obtain union, and then at the end of five weeks to at- tempt reduction by manipulation, or, this failing, by operation. On the other 298 FRACTURES. HUMERUS. hand, he may, and this seems the Letter plan, attempt reduction at once. If his manipulative efforts do not succeed, he may attempt operative reduction, laying bare the head, boring a hole in it, and then reducing it by means of a stout right-angled hook (McBurney) inserted into this hole. Failing in this, he may exsect the head. In any case the area should be immobilized for five weeks. The theory that the head subsequently atrophies has no very good foundation in fact. On the contrary, very good func- tional results are obtainable. Feactuees of the tubeeosities oc- cur in connection with dislocation of the shoulder forward (greater tuberosity) or upward (lesser tuberosity). As the fract- ure is often incomplete, bony union with- out much deformity is the usual result. Separation of the epiphysis may occur at any time during the first two decades of life. The most common mechanism of its production is prob- ably hyperabduction in the efforts to pull down the arm during labor. The line of separation runs just below the tuberosi- ties and the usual displacement is of the lower fragment more or less completely to the inner side and in front of the upper one, which is tilted outward. The edge of the lower fragment may be felt or even seem close under the skin in front. Crepitus is slight, owing to the cartilaginous nature of the edges. Ee- duction is by manipulation or by forced abduction, which brings the lower frag- ment in line with the upper one. Union may be irregular if the periosteum slips between the fragments. Immobilization must be maintained for five weeks. Per- sistent displacement or premature ossi- fication of the epiphysial cartilage may arrest the growth of the limb. Feactuee of the surgical neck is by far the most common of the fract- ures of the upper extremity of the humerus. Under this head are classed all fractures between the line of the epi- physial junctures and the insertion of the pectoralis and teres major. They are caused by direct violence or a fall upon the elbow. The displacement is usually slight, but the lower fragment may be drawn up and to the inner side of the upper one, which is then held in abduction. The diagnosis is made by eliciting abnormal mobility and crepitus when the tuberosities of the humerus are firmly grasped and the arm gently rotated. In impacted fractures there is a tender spot just below the tuberosities and the arm is usually held in slight ab- duction. Treatment. — If there is much over- riding, reduction can only be effected by traction in extreme abduction. If the fragments are impacted in fair position, or if there is no displacement, as is often the case, any immobilizing dressing will be sufficient. Usually, though, there is some tendency to shortening to be over- come by traction and often some abduc- tion in the upper fragment that cannot be overcome. To meet these indications various splints have been devised. For abduction of the upper fragment the best treatment is generally to keep the patient in bed and traction by weight and puUy (see Feactuees of the Thigh) on the arm held in partial abduction by being bandaged on a triangular pad or a bent metal band fitted into the axilla. After two weeks sufficiently firm union will probably have taken place for the arm to be abducted. In this position it is maintained for three or four weeks longer, by a plaster mold or circular splint of which the upper edge is molded well over the shoulder to immobilize the joint and which is made light over the forearm (the elbow being bent to a right FEACTUEES. HUMERUS. 299 angle) and heavy over the arm. The whole is honnd lightly to the chest and the wrist ahove supported by a sling, in order that the weight of the arm may tend to prevent shortening. Any short- ening that may occur will be indicated by a rising of the shoulder-cap and must be compensated by weights attached to the elbow. During all this time frequent exercise of the wrist and fingers must be insisted upon. A variation of the above line of treat- ment should be effective in any case. Ambulatory treatment with the arm in abduction is possible, but irksome. A simultaneous dislocation of the head is treated as above indicated. Feactuees of the Shaft. — These are caused by external violence or by muscular action. All varieties of fract- ures and displacements are seen here. The vessels or nerves may be injured, notably the musculo-spiral, which may be torn across, pressed upon by the cal- lus, or caught between the fragments. Union is more likely to fail in this than in any other bone: a fact that has been explained by deficiency of immobiliza- tion, for, since the hand is supported by a sMng, every jnotion of the head and neck imparts a slight movement to the fragments. The treatment is along the same lines as that of the surgical neck. Shorten- ing must be carefully watched for and prevented. SUPEACONDTLAE FeACTUEE. — The line of fracture passes through the lower part of the humerus, just above the con- dyles. The joint is usually not involved, but may be opened by an additional in- tercondylar fracture or fracture of the olecranon. The line of fracture is usually from behind downward and for- ward, and consequently the lower frag- ment is displaced upward and backward. The sharp point of the upper fragment may pierce the skin in front; more rarely the fracture is compound from behind by the lower one. If the swelling is not too great the displacement can be seen as well as felt, and false motion and crepitus elicited by moving the condyles on the shaft. Dislocation is ruled out by the normal relation of the- olecranon and epicondyles, as compared with the other arm, and intercondyloid fracture by the absence of its typical symptoms (q. v.). Treatment. — Same as for fractures of the lower part of the shaft: immobiliza- tion with the elbow flexed at a right angle and the forearm in semipronation. A sufficient weight, usually five pounds, should be suspended at the elbow to pre- vent shortening, and the hand alone sus- pended in a sling. Suspension of the whole forearm gives rise to angular de- formity with adduction of the forearm. Treatment by extension may be ad- vantageously combined with suspension of the limb in a vertical position for the first fortnight of treatment of a com- pound fracture; but as this position tends to tilt back the lower fragment it should never be employed except as just mentioned and then only for the ad- vantages of elevation in the healing of the wound. Intehcondtloid Feactueb (T- oe Y-feactuee). — This differs pathologi- cally from a supracondylar fracture only in the additional line of fracture separat- ing the condyles. The additional force usually required to produce such a fract- ure is such that the displacements are varied and likely to be marked, and the fracture is often compound and asso- ciated with injuries of the adjacent ves- sels and nerves. In doubtful cases the characteristic symptoms to be sought for are mobility of the condyles upon each other, usually with crepitus, and, in still 300 FRACTURES. HUMERUS. more obsciire cases with no displacement, simple tenderness when the two condyles are pressed against each other. The treatment is that of supracon- dylar fracture with additional care in the immobilization of the fragnients. An- terior and posterior plaster splints are usually satisfactory. In compound fract- ures, where the joint is widely laid open, Kocher advises the removal of the exter- nal condyle to facilitate drainage and to produce a fairly strong and movable joint. In some cases it may be neces- sary to remove both condyles with the risk of substituting a flail joint for an ankylosed one. In all compound fract- ures the fragments should, of course, be retained in place by suture or temporary pegging with a nail or drill. Feactuee of the Epiteochlea, oe Inteenal Epicondyle. — This occurs in connection with dislocation of the elbow or as the result of direct violence. The fragment is left more or less closely at- tached to the condyle and its mobility may be readily recognized. Paralysis and neuralgia from pressure on the ulnar nerve have been known to follow this fracture. A spontaneous cure may generally be expected. Treatment. — Direct pressure with im- mobilization of the forearm in flexion to relax the attached muscles. Two or three weeks' treatment suffices. Feactuee of the External Epicon- dyle. — This is caused by direct violence and is extremely rare. The mobile frag- ment is easily recognized and immobil- ized. Feactuee op the Internal Con- dyle. — This is caused by indirect vio- lence through forcing upward the con- dyle with the ulna attached to it. The line of fracture runs from the inner side of the humerus downward and outward to the centre of the trochanter or be- tw-een it and the capitellum. Ligament- ous attachment to the ulna usually pre- vents any marked displacement, and the swelling all about the joints usually ob- scures such displacement as there is. The forearm is adducted, however, and abnormal adduction and abduction are possible at the elbow. (These move- ments can only be distinguished from ro- tation of the humerus when the joint is in full extension: a position but rarely obtainable except under anaesthesia.) Independent mobility of the fragment and tenderness on transcondylar press- ure should be sought for. Coincident dislocation of the radius backward from the external condyle leaves that part of the humerus prominent anteriorly (see Dislocations). Unless such disloca- tion is present, the altered relations of the epicondyles and olecranon are likely to be distinguishable through the swell- ing. The treatment is by immobilization in the usual semiflexed position. The posi- tions of extreme flexion or extension which have been advocated are incon- venient and present no advantages. If the fragment will not remain in place, it must be cut down upon and fixed by suture. Angular deformity is liable to ensue from suspension of the elbow, as in supracondylar fracture, and may occa- sionally follow premature ossification of the epiphysial cartilage after fracture of the internal condyle in the adolescent. Excessive formation of callus is likely to impair the functions of the joint, esps; cially in the young. Feactuee of the Exteenal Con- dyle. — The fragment consists of the external condyle, the capitellum, and part of the trochlea. The symptoms are the same, mutatis mutandis, as those of fracture of the internal condyle, but the disability is usually less. As more or FKACTURES. HUMERUS. RADIUS AND ULXA. 301 less rotation of the fragment is liable to occur, the most difficult part of the treat- ment is reduction, for which an opera- tion may be necessary. Under such cir- cumstances Kocher has exsected the condyle, -n-ith good results. After re- duction has been accopiplished there is little difficulty in retaining the frag- ment in place, and three weeks in a pos- terior molded splint with the joint at midiiexion suffices for a cure. Excessive callus may interfere with the function of the joint. Sepaeation of the Epiphysis. — This accident is very rare. The epicon- dyles may or may not remain attached to the upper fragments. The chief symptoms are pain on pressure of the forearm against the arm, abnormal mo- bility, and cartilaginous crepitus. The treatment is the same as that of supra- condylar fracture. SuBEPicoNDTLAE Feactuees. — Thcse usually involve both trochlea and capi- tellum, very rarely the trochlea alone. If there is no deformity, the fracture may be trusted to heal under immobiliza- tion. But if there is persistent displace- ment the fragment or fragments should be excised. The fluoroscope may be of great assistance in diagnosing obscure lesions about the elbow-joint, but most cases can be diagnosed and treated with- out its aid. AfTEE - TEEATSIEXT OF FeACTUEES ABOUT THE Elbow. — After the three or four weeks that are necessary to obtain union of the fracture, the elbow will be found quite stiff. If this stiffness is due solely to adhesion and capsular retrac- tion, it may be expected to disappear after some weeks of natural use of the limb. Excessive callus, too, will dimin- ish rapidly, and it is doubtful whether any treatment will hasten its absorption. Forcing of the joint is harmful, as a rule, and if convalescence is too slow elastic traction to increase flexion and a weight on the hand to increase exten- sion may hasten matters a little by sup- plementing the patient's own efforts. Osteotomy or arthrotomy may be re- sorted to after several months have elapsed; but the more conservative the treatment, the better will be the results. Fractures of the Radius and Ulna. — Feacxuee of the Oleceanon". — This may be at the tip or near the base. The mechanism is usually indirect violence combined with the action of the triceps, the olecranon being broken across tlie trochlea as a stick would be across one's knee. Aponeurotic and periosteal lacer- ations are usually slight, and conse- quently there is little or no displacement. The mobility of the fragment is readily recognized. Treatment. — If the displacement is slight, and is not increased by flexion the elbow may be immobilized midway between full extension and flexion at a right angle. In other cases the elbow must be retained in full extension, and it may even be necessary to pull the olec- ranon down. The simplest method of traction is by a narrow strip of adhesive plaster running up the side of the fore- arm over the upper border of the olec- ranon and down the other side. Mal- gaigne's patellar hooks and a figure-of-8 bandage have also been employed. An anterior molded splint gives satisfactory immobilization and permits observation of the displacement. Union is likely to be fibrous, and, in those cases in which this greatly impairs the use of the limb, the fracture may be freshened and sutured. Feactuee of the coronoid process is extremely rare except as a complication of dislocation. As the brachialis anticus and capsule are attached to the bone be- 302 FRACTURES. RADIUS AND ULNA. low the process, its displacement is slight and it unites kindly under immohiliza- tion at a right angle (to prevent recur- rence of the dislocation). Feactuee of the head and neck of THE RADIUS is usuallj associated with the last-mentioned lesion as a complication of backward dislocation of the elbow. If the fracture can be clearly made out the fragments should be removed, for they are likely by their malunion to in- terfere with supination; but if the diag- nosis is not certain the operation may safely be postponed until it is demanded by impairment of function. Only one case is reported of fracture of the neck of the radius alone. Fractuees of the Shaft of One oe Both Bones. — Fracture is usually in the middle or lower third of the forearm, and the radius is usually fractured at a higher level than the ulna. Fracture of a single bone is most frequently due to direct fracture of both bones to indirect violence. Green-stick fractures are more common in the radius than in any other bone. Displacement in any direction may occur, and, if unreduced, is of spe- cial importance as affecting the rotation of the forearm. A peculiar displacement is that of supination of the upper frag- ment of the radius by the biceps when the bone is broken above the insertion of the pronator teres. According to most authors, unless the limb, in such case, is immobilized in extreme STipina- tion a permanent loss of that motion will result.. Practically, however, the im- ];airment to supination when the limb is kept in the usual semipronated position is unimportant. Of far greater impor- tance is the total loss or rotation that follows fusion of the two bones even when a lateral enarthrosis appears in the callus, as is rarely the case. The points that favor such a fusion are: (1) persistent displacement of the bones toward each other, (2) excessive callus from insufficient immobilization or im- perfect reduction, and (3) the rare oc- currence of fracture in both the bones at the same level. In fractures of a single bone the dis- placement is usually slight, and the di- agnosis may be difficult. A point of local tenderness may be found with either crepitus, false motion, or irregu- larity of the surface of the bone. In fractures of the ulna alone the head of the radius is often dislocated forward and upward. Teeatment. — Eeduction by traction and local pressure, special attention be- ing paid to the correction of any dis- placement of the bones toward each other, forcing them apart by deep press- ure with the finger-tips on the front and back of the forearm. Green-stick fractures must be reduced by forcible bending, even completing the fracture, if necessary. Circular constriction of the limb should never be applied, for this is a most fruitful source of gangrene. The best splint is made of two well- padded boards a little broader than the forearm, the anterior one to extend from the elbow to the roots of the fingers (a roller bandage in the palm will prove grateful) and the posterior one from el- bow to wrist. These are retained snugly by adhesive plaster strips, thus forcing the muscles between the bones. Angu- lar deformity is avoided by slinging, not the forearm alone, not the hand alone, but both, comfortably and in the same palm. Such a sling also immobilizes the elbow: an essential to the treatment. Pressure of the anterior splint on the brachial artery at the elbow and press- ure on the bony points must be avoided. At the end of two or three weeks a plas- ter splint may be substituted for the FRACTUEES. RADIUS AND ULNA. CARPUS. 303 wooden one, and in any ease daily exer- cise of the fingers must be insisted on after the tenth day. Firm union should occur in a month, but delayed union is quite frequent. Feactuee op the Lower End of the Radius (Colle's Feactuee). — This is, after fracture of the ribs, the commonest of all fractures. It is generally pro- duced by a fall upon the palm of the hand. The line of fracture runs irregu- larly across the bone within an inch of its articular edge. In the young it com- monly follows the epiphysial line. The lower fragment is tilted back and im- pacted. It may be comminuted. The upward displacement is not great, but the tilting and crushing carry the styloid process of the radius to a higher level than that of the ulna, which is made prominent by the shifting over of the carpus. The periosteum on the back of the radius remains untom. The styloid process or shaft of the ulna may be broken. Earely the internal lateral liga- ment is torn. The characteristic symptoms are the so-called "silver-fork" deformity, a back- ward displacement of the whole hand and the lower end of the radius, producing a swelling over the back of the wrist and a deep crease in the front. The styloid process of the ulna is prominent and lower than that of the radius. Crepitus and mobility are usually absent. There is a line of tenderness along the line of fracture. The diagnosis from dislocation is given under that heading. Treatment. — The simplest way to break up the impaction is for the sur- geon to grasp the forearm firmly just above the fracture. "With the other hand he then grasps the injured hand, placing his thumb lightly on the back of the lower fragment. Dorsal fiexion is made until the patient complains of pain, and then with a su.dden movement the dorsal flexion is increased and simultaneously strong pressure is made on the lower fragment. In a moment the fracture begins to give, the dorsal is quickly ex- changed for palmar flexion, the wrist being pried backward, and the resultant crepitus announces the dissolution of the impaction. Inspection should then show that the "silver-fork" deformity has dis- appeared. The impaction once thor- oughly broken up, the bones tend to re- main reduced, and should be immobil- ized by anterior and posterior wooden splints, which need not extend so far up the forearm as for fractures of the shaft (g. v.). Massage is very useful to shorten the convalescence and can best be used if, instead of wooden splints, molded plaster ones are used, extending from the middle of the forearm to the metacarpo- phalangeal joint both in front and be- hind. The hand is most comfortable in slight dorsal fiexion. Its position bears no particular reference to that of the fragments. A simple band of adhesive plaster around the wrist is said to de- crease the prominence of the ulna, and, indeed, seems to be the only splint neces- sary in some few cases. The fingers must be exercised after the tenth day. Othee Feactuees Neae the Weist. — Cases have been recorded of reversed Colles's fracture from a fall on the back 'of the hand. The lower end, or styloid process, of the ulna may be fractured alone. The so-called Barton fracture of the anterior or posterior lip of the articu- lar surface of the radius is merely inci- dent to dislocation of the carpus {q. v.). Fractures of the carpus are very rare and usually compound. Metacaepal feactuees usually oc- cur in the third and fourth bone and are caused by direct or indirect violence.. 304 FRACTUEES. PELVIS. FEMUR. The injury is readily recognized. The tendency to displacement is slight. A favorite splint is made by fastening the hand over a soft ball by means of a strip of adhesive plaster. An anterior splint well padded up in the palm serves equally well. Phalangeal fractures are usually com- pound. The hand may be bound over a roller bandage by means of several strips of adhesive plaster, one for each finger. Straight posterior splints may also be used. Fractures of the pelvis may be grouped under seven heads: — Fbactuees of the Eing. — Under this title are grouped all fractures that dissolve the continuity of the pelvic ring. Such fractures must, of necessity, be ver- tical in the main. They are usually caused by a crushing from before back- ward. The line of fracture usually runs through the upper (just internal to the pectineal eminence) and lower (near its junction to the ischium) rami of the pubic bone. Siich a fracture may be bilateral, and associated with a vertical fracture of the sacrum, a separation of the sacro-iliac synchondrosis, or a fract- ure through the ilium behind the ace- tabulum. These are the double vertical fractures of the pelvis. This double fracture may also occur from a fall on the foot, or the same cause may dislocate the OS innominatum at both symphyses. Or it may cause a radiating fracture of the acetabulum with or without penetra- tion of the femoral head through the bone. Fractures of the ring are usually comminuted. Displacement of small fragments or a, general mobility, with crepitus, of the whole pelvis may often be recognized. In double vertical fract- ure the fractured bone is often tilted; so that the superior strait is widened, the inferior strait narrowed, and the limb apparently shortened. Complications are usual and severe. Eupture of the membranous or prostatic urethra is al- most inevitable, and the other common injuries are rupture of the pelvic vessels, the rectum, the bladder, and the ureters. Treatment. — The associated injuries demand immediate attention. For the fracture itself rest in bed with even com- pression all around the pelvis is all that can be done, except in cases of tilting of the OS innominatum, in which traction should be made as after fracture of the thigh. Thansvbese eeactuhe of the sa- CEUM results from direct violence. The angular displacement forward may be corrected by pressure from within the bowel. A tendency to recurrence has been prevented by the adaptation of the urethral striated cannula to the rectum. Coccygeal feactdee resembles dis- location. It is rarely observed. Feactuees of the ilium are com- paratively frequent and the result of di- rect violence. The crest of the various spinous processes may be broken. The treatment is rest in bed. Feactuees of the ischium in any of its parts is rare, as is Feactuee of the pubes not extend- ing across both rami. Feactuee of the Acetabulum. — Fracture of the rim may complicate dis- location of the hip and may be so ex- tensive as to favor recurrence. Stellate fracture may be indicated by pain on pressure through the thigh. If the head of the femur has perforated the acetabu- lum it should be replaced by traction. Fractures of the Femur. Feactuee of the jSTeck of the Femue. — The division of these fractures into intracapsular and extracapsular has no clinical value and is not borne out by post-mortem findings. The more accu- FEACTUKES. FEMUE. 305 rate classification is: (1) fractures through the (narrow part of the) neck, and (2) fractures at the base of the neck. Clin- ically, it is often impossible and never necessary to distinguish between the two. Symptoms. — The chief deformity is shortening of the limb with eversion. The eversion is usually slight, often ab- sent, and rarely exchanged for inversion. The shortening may appear at once or may only come on gradually. In the latter case, under appropriate treatment the shortening may never appear at all. In measuring for shortening the greatest care must be taken to compare the limbs when placed in exactly similar positions. There is also a fullness in the outer part of Scarpa's triangle, and the fascia lata above the great trochanter is relaxed, as compared with the other side, on account of the elevation of the trochanter. For- mally the upper border of the great tro- chanter just touches Nelaton's line drawn from the anterior superior spine of the ilium to the tuberosity of the ischium {A-B, Pig. 8). In fracture of the neck, with shortening, the trochanter rises above this line, and the amount of dis- placement may be measured by means of Bryanf s ilio-femoral triangle, variations in the length of the line C-D (which is at right angles to A-C, a perpendicular dropped from the anterior superior spine of the ilium) indicating the displacement of the trochanter. If the trochanter is split, it is broadened in comparison with its fellow. Crepitus can rarely be obtained. Pain may be diffuse, but pressure over the neck of the femur is likely to be painful, as is upward pressure of the femur. A few cases are reported in which the patient has walked on the limb, but usually loss of function is complete and all the move- ments of the Joint restricted. The history of a typical case is as 'fol- lows: An elderly person, preferably a woman, while walking about, stumbles and falls to the floor, fldth perhaps little violence. She cannot rise, and com- plains that every movement of the hip is painful. Examination will reveal symp- toms as indicated above. Diagnosis. — The diagnosis between the fractures through the neck and those at the base is often impossible. Splitting of the trochanter is a sure sign of the latter, while after the former it is be- lieved that shortening is more likely to be secondary. In dislocation the motions of the limb are restricted in certain definite direc- tions and the head can be felt while in the usual dorsal dislocation; the empti- Fig. 8. — A-C-D, Bryant ilio-femoral triangle. A-B, Nglaton's line. (Owen, "American Text- book of Surgery.") ness of the acetabulum may be deter- mined by pressure on Scarpa's triangle. In subtrochanteric fractures the tro- chanter does not share in gentle rotation imparted to the shaft. In old persons it is not rarely an abso- lute impossibility to differentiate con- tusion of the hip from fracture of the neck of the femur. In such a case, when the sole symptoms are pain and disabil- ity, treatment for fracture should be in- stituted without the slightest hesitation, the patient being bedridden in any event, and this treatment should be continued for at least three weeks and until all pain and soreness have disappeared. Thus, if it turns out to be a contused hip, the 306 FRACTURES. FEMUR. patient has not been unduly inconven- ienced, while if it be a fracture, he has been given the best chances of recovery and the surgeon has, perhaps, avoided a suit for malpractice. Etiology. — As has already been indi- Prognosis. — The prognosis, even as regards life, is far from cheering. The aged and feeble patient is liable to pass into a cachectic or demented state and thus to fade away, often with hypostatic pneumonia. Fig. 9. — Adhesive plaster cut for Buck's extension. (Stimson.) cated, fractures of the neck of the femur is usually caused by a comparatively slight injury to an old person, usually a woman. In the young a much greater amount of violence is required to break the bone. Or he may die in a few days by the shock. After he has passed the third week, however, the prognosis is good. As to union, it may be fibrous or fail entirely, such a result entailing in some cases no disability to speak of beyond the Fig. 10. — Adhesive plaster folded for Buck's extension. {Stimson.] Pathology. — In fractures through the neck the cancellous tissue is crushed, but impaction is rare. The head of the bone may be splintered. As a portion of the periosteum habitually remains un- torn, the vitality of the head is insured inconvenience of a shortened limb, while in others locomotion may be entirely lost. Treatmmt. — The first indication is to save the patient's life, and to this all else must be subordinate. Such splints Fig. 11. — Adhesive plaster applied for extension. (Stimson.) thereby, and union, fibrous at least, may be expected. Fractures at the base are likely to be impacted and the line of fracture may split the great trochanter. The greatest impaction is usually behind; hence the thigh tends to rotate outward. The callus is often excessive. should be applied as will most promote the patient's comfort, and the disturb- ance of repeated measurement and re- dressing avoided. Careful nursing, feed- ing, and stimulating are of capital im- portance. Premonitory signs of demen- tia must be watched for, and if the pa- FRACTURES. FEMUR. 307 tient seems to be failing he must be gotten out of bed, whether his thigh has united or not. In this event the hip should be disturbed as little as possible and the patient allowed to recline in a wheel-chair. Pressure over the trochan- ter will encourage union, the pressure to be made by a pad under a pelvic band worn as tight as is compatible with the patient's comfort. Energetic manipulations either for the purpose of eliciting crepitus or cor- but Hodgen's is more convenient for the patient, and should be preferred for the aged. In Buck's extension the traction is made by weight and pulley over the foot of the bed, which may be raised for coun- ter-extension. It is applied as follows: A strip of stout adhesive plaster (the so- called "moleskin-diachylon" plaster, al- though it is rather difficult to apply, re- quiring to be heated before it will adhere, — and if overheated it will blister the Fig. 12. — Volkmann's sliding rest for fracture of the thigh. {American Text-book of Surgery.) recting deformity have a tendency to tear the periosteum still farther and to sepa- rate impacted fragments. Such shorten- ing or eversion as cannot be overcome by the traction splint is best left uncor- rected, lest non-union be courted. Trac- tion should be continued for at least five weeks and the patient kept in bed a week longer. The best traction-splints are Buck's and Hodgen's. Buck's is the more convenient for the surgeon, permit- ting accurate examination and measure- ment without disturbing the dressing; skin, — is least irritating), four inches wide and long enough to reach from well above the knee loosely around the sole of the foot and back above the knee again, is cut as shown in Fig. 9, and a small perforated block of wood placed at its centre. Through the hole in the wood and a corresponding one in the plaster a cord is passed, so knotted at the end that it cannot slip through. The edges of the plaster are now turned down over the block and each other (Fig. 10). A roller bandage (preferably of flannel) is applied 308 FRACTURES. FEMUR. to the foot and lower third of the leg, the adhesive plaster applied to the sides of the leg and thigh above it, and the band- age continued up over the plaster (Fig. 11). The cord is then carried over the pulley at the foot of the bed and attached to a weight of from 5 to 20 pounds, the heavier weights only being applied to robust and young patients whose short- ening is not done away with by the lighter ones. Outward rotation is pre- vented by employing Volkmann's sliding under the limb, and pinned to the other in such a way as to- give uniform support to the limb when it is raised from the bed. The apparatus is supported by two loops tied to a cord which is attached to a crane at a point at least four feet above the bed and at an angle of about ten degrees from the vertical. Traction hip-splints, such as are used in hip-joint disease, have also been ap- plied here. Their use is certainly a great convenience and will doubtless be more Fig. 13. — Hodgen's splint. {American Teset-iook of Surgery.) rest (Fig. 12), and sand-bags along the outer side of the thigh. Hodgen's splint (Fig. 13) consists of two iron rods slightly bent at the connec- tion of their upper and middle thirds and attached together by a straight bar at the lower ends and a curved one at the upper. The limb being attired as for Buck's extension (Fig. 11) the cord is attached to the straight cross-bar and a number of narrow compresses or pieces of bandage are pinned to one rod, passed frequent in future. Unfortunately, how- ever, they cannot be used by the very ones who need them most — ^the aged and infirm. When the shortening has once been reduced some surgeons prefer to apply a plaster splint from waist to ankle at once. With such a splint pressiire may be made over the trochanter through a fenestra to encourage union. Excision of the head for non-union has been done with varying success, but FRACTURES. FEMUR. 309 should not be attempted until the failure of a prolonged course of treatment by ambulatory traction, combined with firm pressure over the trochanter (Schaefer), has shown that union is impossible. Feactuees of the Geeat Teochax- TEE. — The trochanter alone may be sepa- rated by direct violence, or the line of fracture may pass through the neck above the lesser trochanter and thence through the lower part of the great trochanter. In such eases there are the usual signs of fracture of the neck, to which are added independent mobility of the trochanter and a prominent tender spot in front of it. Treatment. — Hodgen's splint. Feactuee of the Shaft. — ^Under this head may be included both "subtrochan- teric" and "supracondylar" fractures. The line of fracture is usually oblique and there is both overriding and angular deformity. As the line of fracture usu- ally runs downward and forward the angle is made by the posterior fragments being drawn up behind it. The upper fragment is often rotated outward. In fractures of the upper third the upper fragment is usually abducted. In those of the lower third its sharp point is liable to pierce the quadriceps and even the skin. The shortening may be deter- mined by measurement, the abnormal mobility by gently elevating the limb beneath the point of fracture. The tro- chanter is not displaced upward. A com- plicating synovitis of the knee is com- mon, laceration of the great vessels rare. Prognosis. — Shortening of about an inch should be expected. Treatment. — Eeduetion is to be made gently. In fractures of the lower third if the upper fragment has pierced the quadriceps and cannot be disengaged by traction with the knee and hip strongly flexed, reduction must be made through a free incision. Immobilization is best made by Hod- gen's splint, which, while it does not im- mobilize quite as fully as Buck's, per- mits much more liberty to the patient, and can be adjusted in such a position as to avoid deformity more surely, namely: flexion and abduction of the hip for high fractures and flexion of the knee for low ones. "With Buck's extension it is par- ticularly essential that the bed should be made flat by a "fracture-board" placed under the mattress. If the fracture is near the centre of the shaft coaptation splints may be used with advantage. In England a long side-splint with trac- tion is a favorite dressing. It is very in- convenient. The tendency to outward rotation in the upper fragment is best opposed by a hard cushion under the great trochanter. Traction should be maintained for six weeks, the patient being kept under constant observation. Then he should be kept on crutches with a plaster-of-Paris splint from waist to ankle for about three weeks longer. If union is fibrous the irritation of walking in a plaster splint should be beneficial, but great care must be taken to avoid angular deformity. Ambulatory treatment as for fractures of the neck of the femur has proved satis- factory. Children under 10 are best treated by vertical suspension of both legs. The pelvis should rest lightly on the bed, thus making counter-extension. For compound fractures the double- inclined plane (Fig. 14) is often most convenient. It affords no traction, but the loss of bone-substance by comminu- tion usually renders traction unneces- sary. In other cases Smith's anterior splint, which acts like a suspended double-inclined plane, is more appropri- ate. 310 FEACTUEES. FEMUE. PATELLA. Pbactuees of the Lower End of THE Femur. — Epiphysiolysis is more fre- quent here than at any other point. It occurs as late as the twentieth year, usu- ally from torsion or hyperextension of the leg. Associated injury to the vessels is common. The treatment is the same as for fractures of the shaft. Fracture of one condyle is usually due to direct violence. Immobilization should be made with the knee extended. Intercondyloid fracture presents the same features as intercondyloid fracture of the humerus. Treatment. — Any fracture of the femur involving the knee-joint should be immobilized in extension. A molded posterior splint and slight traction will readily palpable, but is usually small at first, for the lateral ligamentous attach- ments of the upper fragment prevent the quadriceps from drawing it up the thigh. The joint becomes distended with'eflEused blood. The periosteum over the patella is torn irregularly and a fringe of it drops between the fragments. Prognosis. — In the absence of treat- ment or from its inefficient application the two fragments will be drawn farther apart by the retraction of both the liga- mentum patellee and the quadriceps. Adhesions from organized blood-clot and lacerated ligaments immobilize the joint more or less completely, and extension is still farther impaired by adhesions be- tween the upper fragment and the femur Fig. 14. — Esmarch's double-inclined plane. {Esmarch and Kowalzig.) usually prove satisfactory as far as the fracture is concerned; btit the chief dan- gers are gangrene from injury to the popliteal vessels, and ankylosis or sup- puration in the knee-joint. Some sub- sequent stiffness in the knee is always to be anticipated. Fracture of the Patella. — This is com- mon between the ages of 20 and 50. It may be comminuted when due to direct violence. Earely it is vertical. Ordi- narily it is transverse and due to mus- cular action, as in jumping or avoiding a fall. The sudden pull of the quadri- ceps snaps the bone. The snap and a sharp pain are felt by the patient, and extension of the leg is almost completely lost. The gap between the fragments is and by the loss of coaptation between the patella and the condyles. Treatment. — Non-operative treat- ment consists in causing the absorption of the fluid in the joint by pressure (massage is of little service) and then immobilizing the fragments xmtil union has taken place. A Martin bandage should be applied with as much pressure as the patient can bear for four to six days, and may be continiied for a fort- night if it holds the fragments in good position. During this time the patient is kept in bed with the knee extended. A posterior molded splint is then applied from the ankle to near the hip and is bandaged in place as shown in Fig. 15, the turns of the bandage about the knee FRACTURES. PATELLA. 311 pressing the tissues above and below the fragments toward each other, — these may be reinforced by strips of adhesive plaster, — and finally a few turns are taken over the fracture to prevent tilting forward of the fragments. The dressing must be worn for a month and fre- quently inspected and altered if neces- sary. At the end of this time an immo- bilizing plaster bandage is applied, and the patient allowed to go about on crutches. This splint must be worn for a month, not that union will become much firmer, but so as to accustom the patient to walking about, and to loosen the adhesions a little, that the bone may fragments in apposition by means of sharp hooks, which may be inserted into the upper and lower edges of the bone and drawn together by a screw. The danger in their use is that suppuration provoked at the points of puncture may travel, into the joint either through the lymphatics or the cellular plains, espe- cially if there is much effusion of blood. Finally, aspiration has been used — with strictest asepsis — to empty the joint more rapidly than is possible by pressure. Operative measures include various sutures, — mediate, immediate, subcuta- neous, — the trimming off of the fringe interposed between the fragments, and Fig. 15. — Hamilton's dressing for fracture of the patella. The final turns of the roller in front of the knee are not shown in cut. {American Text-book of Surgery.) not be refractured by another fall or slip. During this time massage may prove use- ful, and to that end the splint may be split anteriorly, removed' daily, the limb massaged, and the splint replaced and held firmly by a roller bandage. At the end of the second month the patient is discharged, but advised to walk with care. Various spHnts have been devised to secure immobilization of the knee and coaptation of the fragments, but they present no advantages over the above method. A plaster bandage should never be applied until union has taken place. Malgaigne's hooks and their various mod- ifications have had great vogue. The principle involved is the holding of the washing out the joint. The following operation is preferred, — if operative treatment is elected: Through a median incision extending a little above and be- low the fragments, sharp hooks are in- serted into each fragment, drawing them apart, and the joint is flushed with sterile "normal" salt. The whole line of fract- ure is now exposed by lateral retraction of the flaps, and, without touching the tissues with his fingers, the surgeon ele- vates any interposed fascia and perios- teum and holds them and the fragments in place with a few fine catgut sutures. A suture or two may also be taken in the capsule of the joint, if it is widely torn. These sutures may be reinforced 312 FRACTURES OF THE LEG. by a single silk or stout catgut suture passed through the quadriceps tendon and the ligamentum patellse and crossing the front of the bone. The skin is then sutured with silk. Ko drainage. A plaster bandage is applied and the patient sent to bed, where he remains with his foot elevated for a week. The splint is then removed, the skin sutures taken out, and the splint reapplied. A few days later the patient gets up on crutches. These and the splints he wears for a month. The splint is then cut down again, and he weqrs it in the day-time alone for another month. No further treatment is required. The operation may be done under cocaine. The reasons for preferring this operation to any other is that it fulfills the indications of wash- ing out the joint, complete reduction, and firm immobilization in a thoroughly aseptic manner, and leaves behind no foreign body in the joint to set up sup- puration or irritation. By keeping his hands from contact with the tissues the surgeon makes the operation as safe as, and safer than, any subcutaneous one, as has been borne out by the experience of ninety consecutive cases without suppu- ration (Stimson). The Choice of Treatment. — The results of immobilization vary from a perfect functional result with about one-fourth inch separation to absolute loss of func- tion with wide separation or stiffness in the joint. Such results are attained within about six months. Operation may give a perfect result with linear union, but, on the other hand, post-oper- ative suppuration in the knee-joint may prove fatal. If the operation is success- ful the patient saves about two months of convalescence and a great many of the doubts and annoyances incident to me- chanical treatment. Therefore the oper- ation is to be preferred, if the risks of suppuration can be absolutely eliminated. Such is the case only when the surgeon is sure of his own cleanliness, as well as that of his assistants and instruments, is conversant with operative and aseptic technique, and is sure to keep his hands out of the wound. Under such condi- tions operation is to be elected, with the patient's concurrence. If function is impaired by failure of union, operation is the only resource. For lengthening the contracted quadri- ceps its tendon may be nicked at the more tense places, and its lower fibres may be elevated from the femur. Care must be taken, however, not to impair the vitality of the tendon and the fragment of the patella a'ttached to it. Fractures of the Leg. — Uppee End. — Both bones may be fractured, or else the tibia alone. The avulsion of the spine of the tibia by the crucial liga- ments is merely a complication of dislo- cation. A few cases of epiphysiolysis and longitudinal fracture of the tibia have been noted. If the line of fracture rims into the joint its functions may be im- paired, and a tendency to displacement with a resultant genu varum or valgum must be foreseen and prevented by im- mobilization. Permanent traction may be necessary when there is much commi- nution. Avulsion of the tubercle of the tibia is caused by muscular action quite as is fracture of the patella. Recovery of function may be expected if the leg is immobilized in extension on the poste- rior molded splint and the fragment re- tained in place by adhesive plaster. Shaft. — The usual seat of fracture is at the junction of the middle and lower thirds, the fibula being fractured higher than the tibia. The tibia lies so near the surface of the limb that a diagnosis of its fractiTres is usually to be made by palpa- FRACTURES OF THE LEG. 313 tion. This subcutaneous situation also serves to make compound fractures fre- quent. If the tibia is fractured an accu- rate diagnosis of fracture of the fibula, often Tery difficult without the aid of the fluoroscope, need not be made. Fracture of the fibula alone may be made out by a localized point of tenderness elicited by direct pressure or pressure elsewhere along the shaft of the bone. (Edema and neuralgia are exception- ally likely to complicate convalescence from fractures of this region. Treatment. — Seduction is accom- plished by traction with the knee flexed to relax the gastrocnemius. A simple method of treatment is to keep the limb in a Volkmann splint for a few days until the primary swelling has disappeared, when a plaster bandage is applied from the toes to the knee, and changed every ten days until union takes place, — ^the sixth week. If bony union is delayed, the irritation of bearing some weight on the limb in its plaster incasement may prove beneficial. From the time of the appli- cation of the plaster splint the patient gets about on crutches. If it is wished to have him about from the first the Volkmann splint may be replaced by a twin posterior molded splint, the two halves of which, when they reach the ankle, diverge to cross each other on the dorsum of the foot. The subject of ambulatory treatment has already been dealt with in the chap- ter on general treatment. Compound fractures are best dressed through a Volkmann or fenestrated plaster splint. LowEH End. — Fracture of the shafts of both bones Iqw down and irregular comminuted fractures require immobil- ization with the foot at right angle to the leg. Primary amputation is indicated for badly-comminuted compound fract- ures. The common fractures here are fractures by eversion and abduction (Potts) and fractures by inversion (ex- ternal malleolus and rarely the internal one). Pott's Feacture. — This is the com- monest fracture of this region. It is caused by eversion and abduction of the foot. The outward and backward dis- placement of the foot is typical (Figs. 16 and 17). Lateral mobility in the ankle- joint, combined with points of tenderness over the internal malleolus, over the lumen, tibio-fibular articulation in front and over the fibula above the malleolus Fig. 16. — Pott's fracture, showing outward displacement. [American Text-iook of Sur- gery.) are pathognomonic signs of this fracture. These tender points lie over the then typ- ical lines of fracture, as shown diagram- matically in Fig. 18. The posterior por- tion of the articular surface of the tibia may also be crushed. Eupture of the deltoid and tibio-fibular ligaments may replace the tibial fractures. The typical deformity is caused by the loss of the normal support to the inner side of the foot, and tibio-fibular diastasis, which allows the astragalus to slip backward, sometimes so far that it may be quite behind the tibia. If the displacement is not great the patient can walk, though 314 FEACTURES. LEG. FOOT. painfully. The fracture of the internal malleolus may be compound. Treatment. — To effect reduction the foot must be forced forward and inward, and immobilized in inversion. To main- tain reduction posterior and external plaster-of-Paris splints are very service- Fig. 17. — Pott's fracture, showing also back- ward displacement. (American Text-iook of Surgery.) able, the former to extend from the upper third of the leg to the toes, the latter from the same level down to and around the foot, ending at the outer side of the dorsum, the so-called "stirrup-splint." In uncomplicated cases the patient may be allowed to get about on crutches as soon as the primary swelling has abated — a new splint being then necessary — and after that need only be seen often enough to forestall any recurrence of the deformity. It is in Pott's fracture that ambulatory splints are most likely to be of practical use. Some patients can walk with only the support of a shoe, for, as we have seen, the deformity is angular, outward, and backward, and as long as this angular deformity is prevented the functions of the limb are but little im- paired. A plaster incasement fortified on the outer side and behind may meet the indications very satisfactorily. It should extend from the toes almost to the knee and be firm and heavy. If the fragment of the internal malleo- lus cannot be reduced the knife must be resorted to. "While the results that follow careful treatment are perfectly satisfactory, old unreduced fractures are very trouble- some. They may be improved and some- times cured by supramalleolar osteot- omy, or better still by opening both sides of the joint, chiseling through the old lines of fracture, removing obstructing callus, and reducing the fracture as though it were a recent one. Fkactuee of the External Malle- olus. — This occurs by the opposite force from that which produces Pott's fracture, namely: inversion of the foot. If, as is usually the case, the fibula alone is broken, or the fibula and the tip of the internal malleolus are broken, it is suffi- cient to immobilize the foot while it is pressed well inward to prevent widening of the mortise. But if the lower end of the tibia is broken obliquely across, as sometimes occurs, special attention Fig. ife. — Usual three lines of fracture in Pott's fracture at ankle. (Stimson.) should be paid to the backward displace- ment. Fractures of the Foot. Feactuee of the Asteagalus. — This is usually associated with fracture of the OS calcis, being caused by a fall on the foot. If there is no displacement the FRACTURES OF THE FOOT. GAULTHERIA. 315 sciagraph is required for diagnosis, and the only treatment is immobilization of the foot. If, however, a fragment is dis- placed and cannot be reduced, or if the bone is crushed, the fragments had best all be removed, a complete excision of the bone giving a very satisfactory result. Fractuee of the Calcaneum. — This may occur from direct violence, from strain on the plantar ligaments, and from forcible action of the muscles of the calf, putting the tendo Achillis on the stretch. Three weeks are required for solid union. If the fracture separates the sustentac- ulum tali, the limb must be immobilized with both knee and ankle flexed. Metataesal Feactuees. — Eest, ele- vation, and massage will suffice for the cure of single fractures. Multiple fract- ures require a splint. Lewis A. Stimsox, Edwaed L. Keyes, Je., New York. FRIEDREICH'S DISEASE. See Pa- EALTSES. FROST-BITE. See Peenio. FURUNCULOSIS. See Abscess. GALLOPING CONSUMPTION. See Phthisis. GALL-STONES. See Calculi, Bil- lAEY. GANGRENE. See Vasculae Dis- eases. GASSERIAN GANGLION. See Tic Douloueeux. GASTRALGIA. See Stomach, Dis- OEDEES OF. GASTRIC CATARRH, ACUTE. See Stomach, Disoedees of. GASTRIC CATARRH, CHRONIC. See Stomach, Disoedees of. GASTRIC FISTULA. See Stomach, Disoedees of. GASTRIC ULCER. See Stomach, Disoedees of. GASTRITIS. See Stomach, Disoe- dees OF. GASTRODYNIA. See Stomach, Dis- oedees OF. GASTROPTOSIS. See Stomach, Dis- oedees OF. GAULTHERIA.— The Gaultheria pro- cumbens, or winter-green, is a small, shrub-like evergreen plant, bearing a small, red berry (called teaberry, checker- berry, partridge-berry, boxberry, or deer- berry) which is edible. It is indigenous to the woods of the United States, from the extreme north down to the Caro- linas. The leaves alone are used for the two preparations which are official in the U. S. P. By distillation of the leaves a volatile oil (oleum gaultheria, U. S. P.) is obtained. This oil is of a light-straw color, which becomes darker on exposure to the air. It possesses a peculiar pene- trating odor, a sweetish, pungent, aro- matic taste, and a slight acid reaction. It 316 GAULTHERIA. GELSEMTUM. contains a hydrocarbon (gaultherilen) and an acid (methsalicylic acid); consists almost entirely of pure methyl-salicylate (99 per cent., according to Merck). It is soluble in alcohol, ether, chloroform, and carbon disulphide. Besides having me- dicinal virtties, it is often used as a flavor- ing substance to render mixtures more palatable. Preparations and Dose. — Oleum gaul- therise, 5 to 30 minims. Spiritus gaultherias, 5 to 30 minims. Physiological Action. — The physiolog- ical action of gaultheria is almost iden- tical with that of salicylic acid; in small doses it is a stimulant and carminative. In larger doses it is an antiseptic, anti- pyretic, antirheumatic, and analgesic. Hare and Wood have shown that in thera- peutic doses the oil is entirely decom- posed in the system, although in tonic doses it may escape in part unchanged by the urine. Poisoning by Gaultheria. — In slightly tonic doses there is produced a marked tinnitus .aurium, nausea, vomiting, and rapid pulse. One ounce of the oil has proved fatal. In this case the principal symptoms were profuse diaphoresis, pain in the head and abdomen, purging; fre- quent, painful, and at last invohintary micturition; with- convulsions, tonic spasms, dilated pupils, lessened arterial pressure, abolition of sight and hearing, rapid respiration, depression of the heart's action, and finally death by re- spiratory failure in fifteen hours. Ten to 20 xninims of the oil every 3 to 4 hours found to produce a marked ringing in the ears and subsidence of pain in 24 to 48 hours. In one instance of very painful muscular rheumatism V2 drachm given every 2 hours, and 5 to 6 doses taken before the stomach rebelled. Excessive einchonism was produced, with nausea and rapid pulse, but the pain dis- appeared. Dercum (Jour, of Nervous and Mental Dis., Jan., '88). Treatment of Poisoning ty Gaultheria. — The stomach should be evacuated by means of an hypodermic injection of apo- morphine (^/jo to ^/^ grain), or if con- scious by any available emetic. Cardiac and respiratory stimulants (ether, caf- feine, strychnine) are then indicated, using artificial respiration, and convul- sions or spasms by the hypodermic ad- ministration of morphine. Therapeutics. — The therapeutic uses of gaultheria are similar to those of salicylic acid. The oil utilized is prin- cipally in the treatment of acute artic- ular rheumatism in doses of 5 to 30 min- ims, in capsules, in emulsion, or dropped on sugar, three or more times daily, as the case may require. Lint saturated with oil, wrapped around the part affected, and covered with a piece of thin rubber cloth or rubber tissue to prevent evaporation, may be used, as suggested by Lannois and Limousin, in cases of acute and chronic rheumatic joints. Literature of '96-'97-'98. Attention called to the value of salic- ylate of methyl (oil of gaultheria) in rheumatic affections. In two eases the rheumatism was gonorrhoeal, and in both these cases the treatment did good. The part which is affected is sur- rounded with lint which has been moist- ened by the application of 1 or 2 tea- spoonfuls of the oil; this is then covered with a sheet of gutta-percha, and the entire limb carefully wrapped in an out- side bandage, which is applied in such a way as to prevent the heat of the body from vaporizing the drug and permitting it to escape into the air. Locally, this treatment may produce reddening of the skin, and, if it is continued for some time, actual desquamation of the cuticle; but this is not painful, since anaesthesia is developed. Editorial (Therap. Gaz.,. Feb., '97). GELSEMIUM.— Gelsemium, U. S. P., or yellow jasmine, is the dried rhizome GELSEMTUM. POISOXIXG. 317 and rootlets of the Gelsemium semper- virens, a climbing plant indigenous to the sputhern United States. The odor is aromatic and oppressive and the taste bitter. Gelsemium contains a resinoid, gelsemin; an acid, gelsemic or gelseminic acid; and an alkaloid, gelseminine, which occurs in small, white, microscopical crystals which have no odor, but an in- tensely-persistent, bitter taste. The al- kaloid forms salts which are freely sol- uble in water. The alkaloid itself is soluble in alcohol, ether, and chloroform. Preparations and Dose. — Extract of gelsemium, fluid, 2 to 3 minims. Tincture of gelsemium, 2 to 15 min- ims. Gelseminine (alkaloid and salts), ^/lao to Vso grain. Physiological Action. — Preparations of gelsemium do not produce gastric irri- tation. The active principle diffuses into the blood with great facility. In moder- ate doses gelsemium causes a feeling of languor and calm, slowing of the heart- action, drooping of the eyelids, dilatation of the pupils, and some feebleness of mus- cular movement. In larger doses gelse- mium causes vertigo, amblyopia, diplo- pia, paralysis of the muscles of the upper eyelid so that it cannot be raised, dilated pupil, labored respiration, slow and feeble action of the heart, great muscular weakness, and diminished sensibility to pain and touch. These effects follow in a half-hour after stomach ingestion and last two or three hours, when they sub- side. (Bartholow.) Case in which 10-minim doses of the fluid extract of gelsemium caused marked reduction of the pulse; it was then brought to 42 by an ll-drop dose. J. A. Muenich (Med. "World, Aug., '91). Poisoning by Gelsemium. — ^Tien lethal doses are taken the physiological effects are intensified. A staggering gait is followed by a loss of muscular power and a sense of general numbness over the whole body. The eyelids close, the mus- cles being paralyzed; the pupils become widely dilated and fail to respond to the stimulus of light; vision is lost. The lower jaw drops, the tongue becomes paralyzed, and speech is lost. The respi- rations are irregular, shallow, and la- bored. The heart-action is feeble and intermittent. The skin is generally cov- ered with a profuse perspiration. The body-heat is markedly lowered. Internal strabismus is apt to occur (paralysis of sixth pair); the face becomes pinched and anxious. Death occurs from centric respiratory failure. Case of poisoning observed from the tincture of gelsemium administered to a woman, aged 40, suffering from severe neuralgia; 10-minim doses every two or three hours were given the first day, and, no relief being obtained, 20-minim doses were administered for another twenty- four hours. Symptoms of poisoning then came on, consisting in a total loss of power in the tongue, alteration in vision, with widely- dilated pupils, and uncertain power of the muscles of the hand and arm. The patient was perfectly con- scious. Then ^/la, grain of strychnine was injected, and in ten minutes a change for the better was noted. The vision was not perfectly restored for some hours. Edward Jepson (Brit. Med. Jour., Sept. 19, '91). Though consciousness is present for a long time, drowsiness or stupor finally appears. Treatment of Gelsemium Poisoning. — The evacuation of the stomach by means of emetics or the stomach-pump should be followed by the use of cardiac stimu- lants (ammonia and digitalis), the appli- cation of artificial respiration, external heat, and the hypodermic administration of atropine and strychnine to stimulate the respiratory centre. The maintenance of the horizontal posture is desirable 318 GELSEillUM. THERAPEUTICS. Faradization and the hot and cold douche are to be borne in mind. Therapeutics. — Exaltation of sensory or motor function is an indication for the use of gelsemium. Small doses should be used at first, imtil the susceptibility of the patient is ascertained. Ptosis, or drooping of the upper eyelid,. gives warn- ing that the physiological action of the drug is present. Ceeebeal Disoedees. — In mania with great motor excitement and wake- fulness, Bartholow considers gelsemium superior to conium. To produce the best results, sufficiently large doses should be given to produce definite physiological effects: dilated pupil, drooping of the eyelids, and a feeling of languor. The excitement inci- dent to acute alcoholism, simple wake- fulness, and the insomnia following too great mental or physical activity are often benefited by gelsemium. In men- ingitis and cerebro-spinal meningitis, Bartholow recommends the fluid extract in 5-minim doses every two hours to maintain the physiological effect. There is no drug equal to gelsemium in those crises of cerebral excitement which were formerly combated by asa- foetida and valerian. It should be pushed until heaviness of the lids and diplopia result. It is also useful in the early stages of acute bronchitis and in neuralgias. For the latter affection 3 to 5 drops should be given every Vi to 1 hour, according to the intensity of the pain. The remedy can be used in all forms of organic disease of the heart without danger in ordinary doses. G. M. Garland (Boston Med. and Surg. Jour., Sept. 13, '88) . Spasmodic Disoedees. — In spasmodic cough, with little or no secretion from the bronchial tubes, gelsemium generally gives prompt relief. It has been recom- mended as a viseful remedy in the spas- modic stage of pertussis, the nervous cough of hysteria, the nagging cough of phthisis with scanty secretion, and in reflex cough from irritation of the laryn- geal nerves. Hysterical spasms are eon- trolled by gelsemium, the patient becom- ing calm and tractable. Gelsemium recommended to control an hysterical patient or relieve a, cough. The tincture of the green root, in doses of 2 to 20 drops, has proved most reli- able. G. F. Schreiber (Peoria Monthly Med., Dec, '89). Chorea, laryngismus stridulus, and spasmodic dysuria have yielded to gelse- mium in many cases. Torticollis and localized facial spasm may be relieved by the drug. Netiealgias. — Facial, intercostal, ovarian, and other neuralgias have proved amenable to gelsemium. Large doses are sometimes necessary, relief not appearing until the characteristic drooping of the eye, dilated pupil, and muscular languor appear. From 5 to 20 minims of the fluid extract every three hours may be required. Gelsemium considered the remedy par excellence for neuralgias of the lower jaw and the acute congestive stage of cold in the head. Fifteen to 25 minims of the fluid extract taken at night upon re- tiring will dispose of the latter affec- tion. It is useful in dysuria from what- ever cause, as well as in the treatment of gonorrhoea when given in full doses and combined with an alkali. W. F. Jackson (Therap. Gaz., Nov. 15, '88). Fevees. — Bartholow has witnessed ex- cellent results from the use of gelsemium in pneumonia and pleurisy. In the former it diminished respiratory activity, affording rest to the inflamed organ; it allays cough, lessens stasis of the pul- monary capillaries, and lowers the tem- perature. He suggests 5 to 10 minims of the fluid extract every two hours to maintain a safe, constant effect. The same method is employed in pleurisy. GENTIAN. THERAPEUTICS. 319 Given in small doses, — that is, a. tea- spoonful of a solution containing 5 drops of the fluid extract in 4 ounces of water, — gelsemium has produced excel- lent results in cases of pneumonia; these were even more satisfactory when the drug was combined with aconite in the same proportion. J. Lindsay Porteous (Edinburgh Med. Jour., Dec, '90). In remittent and intermittent fevers, when the temperature is high, the pulse rapid or full, the pupils contracted, breathing rapid, full doses of gelsemium should be given. J. F. Griffin (Med. Summary, Aug., '91). Bilious and malarial fevers have been treated by the administration of gelse- mium, especially in the Southern States, where it has enjoyed the reputation of a specific. Its utility is probably due to its antipyretic action. Skin Disoedees.- — Buckley has rec- ommended gelsemium for the relief of itching in eczema: 3 to 10 drops of the tincture are given and increased every half-hour until the physiological effects are observed or the patient relieved. Not more than 1 drachm should be given in all within two hours. t Mtdeiasis. — Gelseminine in watery solution (1 to 64) has been recommended by Tweedy for use as a mydriatic. He believes it equal to atropine. The effects disappear more rapidly. Its use is not without danger; it has not come into general favor. C. SUJINER WiTHEESTINE, Philadelphia. GENERAL PARESIS OF THE IN- SANE. See IlTSAlTITT. GENTIAN.— Gentian (Gentiana, TJ. S. P.) is the root of the Gentiana lutea, or yellow gentian, indigenous to Europe. The root contains a bitter principle, gen- tianin, and an acid, gentianic or gentisic acid. Preparations and Doses. — Gentiana, 5 to 30 grains. Extract of gentian, 5 to 10 grains. Extract of gentian, fluid, 10 to 30 min- ims. Tincture of gentian comp., 1 to 8 drachms. Physiological Action. — Gentian in- creases the flow of saliva and the secre- tion of the gastric juice. Increased appe- tite follows its use. Authorities believe this favorable influence on the appetite to be due to two factors: the sense of bitterness, which increases the desire for food, and the improved digestive powers which, enabling more food to be dis- posed of, postpones the sense of satiety. Gentian is capable of exciting the automatic centres of the stomach, and of thus exaggerating its movements. FeWay (La Tribune M6d., May 28, '91). It favors assimilation by removing morbid conditions of the intestinal mu- cous membranes. This healthy stimula- tion ceases after long use, and the effect* of overstimulation are observed. Therapeutics. — Gentian i^ a valuable bitter tonic. It is indicated in convales- cence from acute maladies, in atonic dys- pepsia, in chronic gastric catarrh, in ma- larial fevers, and in chronic malarial poisoning. The compound tincture of gentian (gentian, orange-peel, and car- damom-seeds) is a very useful stomachic. Gentiana quinqueflora is a reliable prophylactic against abortion and all uterine disorders. It is especially valu- able in menorrhagia or metrorrhagia de- pending wholly upon systemic causes. The author uses a tincture prepared as follows: Gentiana quinqueflora, bruised fine, 4 ounces; alcohol, 24 ounces; pure distilled water, 8 ounces. The mixture is allowed to stand for fourteen days; it is then filtered and ready for use. The tincture is given in doses of a tablespoon- ful every four hours. J. E. Cross (Med. Brief, Mar., '92). 330 GLANDERS. SYMPTOMS. DIAGNOSIS. GENU VALGUM AND VARUM. See Joints, Deformitibs of. GERMAN MEASLES. See Eubblla. GESTATION, ECTOPIC. See Peeg- NANOY. GLANDERS, or FARCY. Definition. — This disease develops pri- marily in the nasal passages and bron- chial tubes of horses and cattle, produc- ing a mucous flow. It has been found to be due to the bacillus mallei. Large nodules form in the respiratory passages, and metastatic nodules in the liver, spleen, etc. Symptoms. — In man the disease does not often present itself. However, vet- erinary surgeons, butchers, and those surrounded with horses are likely to con- tract the disease. It occurs in the con- junctiva and on the skin after some in- significant injury. Nodules result and the disease sometimes takes an acute form, beginning generally with malaise, pain in the limbs and back, and termi- nates in the breaking out of several ab- scesses over the body. Case of chronic glanders in which the patient's body was covered with hard swellings. After a period of illness char- acterized by fever, prostration, diarrhoea, and bloody passages, he died from ex- haustion, none of the surface lesions having ulcerated. Editorial {Brit. Med. Jour., July 28, '88). Bacilli of glanders can gain access to the body through the unbroken skin, penetrating the hair-follicles, traversing the epithelial cells, and producing the in- duration which characterizes the papules of the incipient disorder. Bab6s (Lan- cet, Aug. '25, '88). Case of a coachman observed into whose system the glanders bacilli gained entrance by means of a wound of the finger. Multiple abscesses appeared in all parts of the body. Not till a few days before death was there a moderate discharge from the nose and increased salivary secretion. The patient died from exhaustion in six months. Proust (Eevue d'HygiSne et de Police Sanitaire, Jan. 20, '88). Glanders is allied to the chronic and infectious diseases, and its normal host is probably one of the domestic animals; the bacillus is a parasite of its host; and it resembles morphologically the other bacterial parasites that produce chronic diseases in man, especially tuberculosis and leprosy. Holmes (Jour, of the Amer. Med. Assoc, Aug. 12, '93). Case of glanders which was remark- able for the fact that the large joints — i.e., the elbow, the knees, and the ankles — showed suppurative inflammation, while the multiple abscefeses in the mus- cles were absent. Errich (Zeitr. z. klin. Chir., vol. xvii, sec. 1). Literature of '96-'97-'98. Case of acute glanders characterized by the development in all the extremi- ties of fluctuating tumors that contained hsemorrhagic pus. There were numer- ous broncho-pneumonic foci in the lungs. Toward the end of the disease a general pustular eruption appeared, and perios- titis developed over the frontal bones. The diagnosis was confirmed by bacterio- logical investigation. Forestier (Lyon M6d., No. 6, '97). Diagnosis. — When the disease occurs in the mouth or nose bacilli can be found in the mucous flow. "When the disease starts internally the bacillus may be found in the sputum, or when the sec- ondary abscesses form. It is of the greatest importance that these should be early recognized. Case of perforating ulcer of the hard palate, with foul discharge from the nose and ear and gumma-like indurations ap- pearing in various parts of the body, treated for some time as syphilis, till, after several months, the characteristic farcy-buds containing the glanders ba- cilli made their appearance. Death oc- GLAXDEES. GLYCERIN. 321 curred from exhaustion. Editorial (Brit. Med. Jour., June 16, '88). Case in which the rapid diagnosis of glanders was made, after the method of Straiis, by the inoculation of the sus- pected material into male guinea-pigs, which presented, after the second or third day, a marked glandular affection of the testicles, which is a, special form of localization for this material. Sil- veira (La Semaine Med., June 17, '91). The surest means for tlie diagnosis of pulmonary and nasal glanders is to in- oculate some of the morbid products into cats and guinea-pigs, and to make con- trol experiments with cultures on potato. If the animal dies of glanders, and the culture consists of the malleus bacillus, there is no longer any doubt about the disease; but this as a, diagnostic means is not always easy. Helman has found a simpler means, in an extract of the malleus bacillus. This extract, called mallein, produces on horses attacked with glanders an elevation of tempera- ture of from 0.9° to 5.4° F., and forms, at the seat of inoculation, a tumor which increases rapidly for two or three days and then disappears. Glanders is pres- ent whenever the above symptoms ap- pear in the horse after the injection of mallein. This diagnostic procedure has already been adopted in the German army. Semmer and Wladinirow (Revue Internat. de Bibliog., June 25, '93). Treatment. — Wlien the cause is local, energetic measures should be pursued. The erosion or seat of infection should be completely removed by means of the knife, and cauterizing by means of the thermocautery. Constitutionally, the administration of mercury has been ad- vocated, but it is doubtful if the case would not prove fatal before the proper constitutional remedies could be had. Owing to the certain amount of an- alogy between glanders and tuberculosis, the authors have used the creasote treat- ment, as well as Lannelongue's chloride of zinc, in glanders. The results have been found most satisfactory. Claudius and Michel (La Semaine M6d., Aug. 24, '92). Three cases of human glanders, one generalized and affecting especially the • thorax, the other two localized, treated by gray ointment. The first case died the day after examination by the author. In the other two the abscesses were in- cised and disinfected, and friction with the gray ointment, 1 drachm daily, pre- scribed. Cure resulted in both. Gra- levsky (Wratsch, No. 25, '93). The injection of the serum of horses affected with glanders causes less rise of temperature in animals with the dis- ease than the injection of mallein. Serum has been used for protective and curative, as well as for diagnostic, pur- poses. In one troop of cavalry twelve horses were injected, and after this no more cases of pulmonary glanders ap- peared. Repeated injections are neces- sary for protection. Schneidemuhl (Brit. Med. Jour., Apr. 29, '93). Ernest Laplace, Philadelphia. GLOSSITIS. See Tongue, Disoedees OF. GLOSSO-LABIO- LARYNGEAL PA- RALYSIS. See Pahalyses. GLOTTIS, (EDEMA OF. See Laetn- GITIS. GLYCERIN. — Glycerin (Glycerinum, U. S. P.) is a colorless, syrupy liquid, of a sweet, warm taste. It is obtained by the saponification of fats. It is soluble in water and alcohol. Exposed to the air it does not become rancid or undergo fermentation, and it increases in weight on account of its great hygroscopic pow- ers. Glycerin possesses decided antisep- tic and solvent powers. Preparations and Doses. — Glycerin, 5 to 120 minims. Glycerite of carbolic acid, 2 to 5 min- ims. Glycerite of tannic acid (tannic acid, 20 per cent.), used locally. 322 GLYCERIN. THERAPEUTICS. Glycerite of starch, used locally. Borogljeeride. Glycerite of hydrastis, used exter- nally. Glycerite of vitellis (glyconin), used for emulsifying. Glycerin suppositories. Physiological Action. — Glycerin in the pure state is slightly irritating when applied locally to the skin or to the mu- cous membranes; it excites the secre- tions and causes an increased flow of blood to the parts; in some subjects it produces pain and decided irritation. The ingestion of glycerin causes no ap- preciable systemic effects. It sometimes acts as a laxative, but does not seem to affect digestion. Injected into the cir- culation in large amounts, glycerin causes convulsions, due to its hydro- scopic powers (Hare). Although Pavy asserts that the ingestion of glycerin by diabetic patients increases the polyuria, others believe the contrary to be true, and find advantage in its use. The glyc- erin in stores other than responsible pharmacies is apt to contain arsenic. Vegetable glycerin should be preferred Case in which glycerin was taken for diabetes, in large quantities". Symptoms similar to cholera nostras appeared. The diagnosis was obscure until a publication by Ritzert showed that the common glyc- erin of the shops contained large quan- tities of arsenic. Jaroschi (Wiener med. Presse, June 9, '89). Only the vegetable glycerin should be employed, as that derived from the ani- mal fats is thoroughly impure. Animal glycerin has not the same solvent pow- ers, and is, moreover, liable to become rancid. The failures of various observers to corroborate the claims made for glyc- erin in phthisis and in diabetes has been due to the fact that they failed to use vegetable glycerin. For topical treatment, too, the animal glycerin is much inferior, since it dries more quickly. W. H. Morse (Maryland Med. Jour., Dec. 31, '87). Glycerin will stop the souring of milk, and is therefore a valuable aid to the diet of bottle-fed children. W. B. Moore (Maritime Med. News, July, '89). Therapeutics. — Good results have been obtained in the use of glycerin as a substitute for sugar in the alimentation of diabetic patients, but care must be taken that pure glycerin be adminis- tered. Certain forms of glycosuria may be cheeked by glycerin. It acts more effi- ciently when introduced into the alimen- tary canal than when injected subcu- taneously. It checks glycosuria by in- hibiting the formation of sugar in the liver. By this means glycerin increases the quantity of glycogen found in the liver. Ranson (Jour, of Physiology, vol. vii, p. 202, '89). [According to the clinical researches of Pavy, glycerin increases the polyuria of diabetes almost one-half, and for this reason he thinks it is not to be employed in this class of cases as a substitute for sugar. The quantity of glycerin recom- mended to be given, clinically, is 1 drachm, diluted with water at least one- half. H. A. Hare, Assoc. Ed., An- nual, '90.] Constipation. — In constipation the use of gylcerin suppositories is followed by excellent results, but a too long-con- tinued use may produce rectal irritation. When suppositories are not available, or for any other reason, glycerin may be given by rectal injection, 1 to 4 drachms being used. Glycerin enemata tried in a long series of cases with good results. In patients with hsemorrhoids, however, the inser- tion of any syringe may be productive of pain. In 20 cases hollow suppositories of cacao-butter employed, each contain- ing 15 minims of pure glycerin. This dose was found sufficiently large, and acting in fifteen to twenty minutes. It was never necessary to use more than one suppository, though there would be no objection to giving two. Boas (Deutsche med. Woch., No. 23, '88). Suppositories prepared by the addition GLYCERIN. THEEAPEUTICS. 323 of stearin and those put up with cacao tried. With the first preparation, in 208 cases, in -which the results were noted, in 136 the desired effect was obtained and in 72 there was failure. The second kind of suppositories yielded better re- sults, there being only 53 failures out of 230 trials. M. Schmelcher (Therap. Monats., June, '89). Glycerin enemata tried in 26 cases, be- sides children, and it was found that 50 minims at once produced a copious evacuation, without leaving any dis- agreeable sensation. In no case did the drug lose its effect, though sometimes given regularly for many months. Seifert (Miineh. med. Woch., Xo. 9, '88). Toxsemic symptoms may be suddenly produced by the use of ordinary enemata. A solution of some of the products of de- composition may take place, and a dif- fusible septic poison thus be introduced into the system by means of the lymph- and blood-vessels in that neighborhood. A rash may appear in these post-enemal cases, and, from appearances, cases have been pronounced scarlatina, or rotheln. Xo such symptoms or rash, however, have been observed in glycerin enemata, the amount injected being too small. G. H. Burford (Lancet, Dec. 15, '88). The use of glycerin enemata in in- ternal haemorrhoids not approved. E. Lepine (La Semaine Med., Jan. 30, '89). [In a few cases there has been ob- served a stinging in the rectum attend- ing .the injection, or a burning sensation, lasting a few minutes after the bowels were opened. It was found that this did not occur if the glycerin were mixed with a small quantity of water. In a, few other instances there was actual rectal pain, due not so much to the action of the glycerin as to the passage of insuffi- ciently softened fseces. J. P. C. Gkip- riTH, Assoc. Ed., Annual, '89.] Injections of glycerin act very well in habitual constipation due to sedentary life, alimentation, etc. They are of little value, however, in cases where there is mechanical obstruction, and in cpnstipa- tion following febi'ile, cerebral, or medul- larj' affections. Glycerin injections are of value in irreducible hernia, and should be used from the beginning. In- jections of glycerin are superior to sup- positories. If made for some time at a given hour of the day, spontaneous evacuation of fseces will eventually take place and the glycerin can be suspended. The injections are also useful during parturition, hastening the pain and the conclusion of the labor. In certain cases from 5 to 10 drops of glycerin are suffi- cient for an injection. A syringe should not be used, as there is danger of wound- ing the mucous membrane. Glycerin when thus employed, even for long periods, gives rise to no unpleasant symp- toms. Anacker (Deutsche med. Woch., Xo. 19, '93). In acute coryza glycerin (1 part to 4 or 5 parts of water) may be used in spray or applied to the nares by a camel's-hair pencil. Diluted with equal parts of water, it is useful as a mouth-wash; it may be applied on a swab to relieve the dry mouth of typhoid fever or to facili- tate the removal of sordes. If the sweet taste is objectionable Kinger suggests a mixture of equal parts of glycerin and lemon-juice. This is also useful in the last stages of chronic diseases, as phthi- sis, to relieve the dry, shiny condition of the mouth and tongue. Glycerite of carbolic acid is a useful application to foul-smelling ulcers and open sores. Glycerite of tannic acid is a useful application in follicular tonsilli- tis and pharyngitis. Glycerite of starch is used as a vehicle for cutaneous reme- dies and as a bland protection to super- ficial abrasions and irritated surfaces. Glycerite of boroglyceride, an excellent dressing for ulcers, contused and lacer- ated wounds, etc., also does good service as a depletant to the cervix uteri, a tam- pon, being soaked in it, applied locally to the cervix and renewed daily. In pelvic congestion the application of the tampons should be made two or three times daily, each application being pre- ceded by a copious hot-douching. 324 GLYCERIN. GLYCOSURIA. If the vaginal secretions be scanty the local use of glycerin increases them, but if the secretions be abundant they are not affected by the application of the glycerin. Herman (Brit. Med. Jour., Dec. 15, '89). Literature of '96-'97-'98. Intra-uterine injections of sterilized glycerin in cases of fibTomyoma recom- mended. A little over a drachm is slowly injected every two or three days, the vagina being subsequently tamponed with cotton or gauze saturated with boroglyceride. The effect of the drug is to cause dryness and atrophy of the en- dometrium, and hence diminution of the tumor. Chfiron (Rev. Internat. de Mgd. et Chir. Prat., No. 6, '96). The accidents that have occurred in the induction of labor by the injection of glycerin were caused by the drug's being used in large doses for hygroscopical pur- poses, and not with the more physiolog- ical purpose of stimulating the unstriped muscle. The writer has used glycerin in- jections in two cases with marked suc- cess. He concludes that the injection of 5 cubic centimetres of glycerin into the cervical canal will bring on strong pains without leading to nephritis or any ■other ill-effect. It is free from danger of infection which attends injection into the uterine cavity. The introduction of a colpeurynter into the vagina serves to keep up the pains when they have started, and, therefore, makes further in- jection of glycerin unnecessary. Koss- mann (Therap. Monats., June, '96). Glycerite of egg-yelk, or glycerin, be- sides being useful in preparing emul- sions, is an excellent application for chapped hands or face. For this latter purpose glycerin, diluted wi^h 1 to 3 parts of rose-water or orange-flower water, is an elegant preparation. Glyc- erite of hydrastis is a soothing and alter- ative application to unhealthy and sloughing sores, . old leg-ulcers, and sloughing cancerous growths. C. Sumner AYitheestine, Philadelphia. GLYCOSURIA. Definition. — Evacuation of urine con- taining sugar in sufficient quantity to be revealed by the ordinary tests. Symptoms. — Glycosuria is a symptom occurring under various conditions and compatible with perfect health; transi- tory glycosuria does not give any morbid symptoms and is only revealed by exam- ination of the urine. Literature of '96-'97-'98. Case of a man, aged 25, who accident- ally discovered the presence of sugar in his urine. He had no symptoms what- ever of diabetes. He was the oldest of 11 children, and examination of the speci- mens from the other 10 showed high spe- cific gravity and the presence of more or less sugar in all. They were all healthy and passed a normal quantity of urine. The patient passed about 10 per cent, of sugar a day, but this quantity could be somewhat reduced by an exclusive milk diet. L. C. Wadsworth (Med. Rec, May 29, '97). The amount of sugar contained in the urine may be determined by various tests {vide Diabetes Mellitus), of which Tromner's and Pehling's are commonly preferred. Etiology. — Glucose, or dextrose, is a constituent of normal iirine, but it is present in too small a quantity to be dis- covered by the ordinary tests. By the aid of the phenylhydrazin test, however, the presence of a small amount of glu- cose may be revealed in every sample of urine. Pavy estimates the quantity of sugar formed in healthy urine to be 0.5 per mille. The quantity of sugar con- tained in the urine is dependent on the amount of sugar present in the blood. According to experiences of Pavy, normal blood contains 0.6, — 1 per mille of glu- cose; V. Koorden states that the urine will contain sugar enough to be revealed by the ordinary tests as soon as the GLYCOSUEIA. ETIOLOGY. 335 amoTint of sugar in the blood exceeds 0.2 per cent. This may be obtained experi- mentally by ingestion of large quantities of sugar, and in this form of glycosuria — alimentary glycosuria — the variety of sugar in the urine is always identical with that ingested: By ingestion of dextrose, glycosuria, or dextrosuria, is caused; by the ingestion of lactose, lactosuria; sac- charose, saecharosuria, etc. The amount of sugar necessary to pro- duce glycosuria in a healthy person has been found to be: — Of dextrose, or glucose, more than 180- 250 grammes. Of saccharose, more than 200 grammes. Of leTulose, more than 200 grammes. Of lactose, more than 120 grammes. AATien the stomach is full even larger quantities can be absorbed without caus- ing glycosuria. Alimentary glycosuria cannot be produced in healthy persons by ingestion of starch, [iliura (Zeits. f. Biol., B. 32) took one morning 1200 grammes of rice cooled in water — containing 308 grammes of starch; he experienced no consecutive glycosuria. F. Levison.] Physiological glycosuria can be differ- entiated from the pathological variety by the administration of a starch, such as that contained in white bread. It al- ways causes an increase in the glucose in the urine of diabetics, but does not influence the sugar in normal cases. Eosenfeld (Deutsche med. Woch., Xos. 23, 24, '88). In the urine of lying-in women lactose generally appears between the second and fourth days of lactation; it again dis- appears after a short time. When the secretion of milk is suddenly stopped large quantities of lactose are for some time excreted with the urine. [Zuelzer administered sugar of milk to lying-in women ("Inaugural Disserta- tion," Berlin, '95) and found that this substance is more easily eliminated in the puerperal state than in the normal state. F. Leviso>-.] In women during gestation the admin- istration of 100 grammes of grape-sugar followed by appearance of from 1 to 18 grammes in the urine. Alimentary gly- cosuria frequently found in the course of traumatic neuroses, and in cases of phos- phorus poisoning, in which fatty de> generation of the liver has occurred, 20 per cent, of the sugar administered is ex- ereated in a few hours. V. Jaksch (Cen- tralb. f. innere Med., May 25, '95). In various diseases alimentary glyco- suria is more easily produced than in health; this has been tried by giving small quantities of sugar (less than 150 grammes of glucose) to patients suffering from various diseases. The result of these experiences has been very unsatis- factory. Diseases of the brain, the spinal cord, the peripheral nerves, the muscles, and functional neuroses do not seem to predispose to alimentary glycosuria. [Chvostek found that in exophthalmic goitre (Wien. klin. Woch., '92) alimen- tary glycosuria was more easily pro- duced than in the normal state. In dis- eases of the heart and lungs the result was negative and in disease of the liver it was inconstant. V. Jaksch (Brager med. Woch., '95) found alimentary glycosuria in acute poisoning with phosphorus and in a case of icterus with hsemorrhagic diathesis and atrophy of the liver. F. Levison.] Experiments with 50 patients to deter- mine the limit of assimilation for grape- sugar; that is, the quantity that can be given before glycosuria, in some cases of which the quantity necessary to produce glycosuria was very small. Intestinal, circulatory, and respiratory diseases, as well as those affecting metabolism or the liver, did not exercise much influence. Bloch (Zeit. f. klin. Med., B. 22, H. 525). For each person and for each sugar there is an individual "co-eflScient of util- ization," increasing within certain limits with the quantity of ingested sugar. Linossier and Roque (L'Union Med., No. 13, p. 150, '95). 326 GLYCOSURIA. ETIOLOGY. Experiments showing that when 5 to 10 ounces of syrup were taken in the day, alimentary glycosuria was present in 11 out of 21 cases of lead colic. As a rule, the glycosuria disappeared with the colic. This glycosuria is especially frequent in those who have worked for a long time in lead. Lead acts directly on the nutrition of the hepatic cell. The glycosuria is fleet- ing because the lesion to the cells is slight. That some patients with mild colic do not have alimentary glycosuria must depend on individual peculiarities. The glycosuria is frequently accompanied by urobilinuria. Brunelle (Brit. Med. Jour., Jan. 2, '95). Alimentary glycosuria is a constant symptom of some functional neuroses, such as Charcot's grand hysteria and traumatic neuroses; in the latter affec- tion it may also be of value in diflferen- tial diagnosis from simulation. Jakseh (Inter, klin. Eund., Sept. 15, '95). Literature of '96-'97-'98. Acute febrile conditions favor the oc- currence of alimentary glycosuria. Croupous pneumonia seems especially prone to this, though typhoid fever, an- gina, articular rheumatism, and scarla- tina also furnish examples. Poll (Fort- schritte der Med., No. 13, '96). Glycosuria can be produced in a healthy man by giving a large quantity of glucose early in the morning, the stomach being empty. The quantity of glucose necessary to produce this effect varies from 4 '/^ to 5 ounces. It is neces- sary that this quantity be given all at once. The occurrence of this so-called alimentary glycosuria depends not only on the quantity of glucose taken, but also on the rapidity of absorption. In cases of marasmus, anaemia, cir- rhosis of the liver, progressive muscular atrophy, and arteriosclerosis no dimin- ished power of sugar destruction could be detected. But in cases of neurasthenia or traumatic neuroses there was a dimin- ished power of sugar destruction, and glycosuria could be induced more readily than in health. In cases of habitual drinkers of large quantities of beer, gly- cosuria could be readily induced by 3, 2 V:, or even 1 Vz ounces of grape-sugar. The same condition the author discovered in some cases after the drinking of an excessive quantity of beer (2 quarts) rapidly. Alimentary glycosuria does not occur in all great beer-drinkers. A. Striimpell (Berliner klin. Woch., No. 46, '96). Examinations made on Jena students. The proportion of these in whose urine sugar appeared varied much with differ- ent kinds of beer; but was much greater after the morning drinking. Out of 14 who drank bock or export beer in the morning, 5 had glycosuria. After the evening drinking, amounting in one case to seven litres, out of 19 only 1 had sugar in the urine, or with Bavarian beer 1 out of 11. The individual disposi- tion was very evident. Not those who drank most had glycosuria. The differ- ence between morning and evening drinking was probably due to variations in the absorption. Krehl (Centralb. f. innere Med., No. 40, '97). Transitory glycosuria has been ob- served after concussion of the brain and apoplexy, after violent neuralgia and mental sufferings. Glycosuria produced in dogs by irri- tating the peripheral end of the pneumo- gastric nerve. Generally the symptom appears in three or four days after the injury. Arthaud and Butte (La Tribune Med., Feb. 19, '88). Glycosuria produced in a rabbit by daily puncture of the floor of the fourth ventricle. Laborde (La Semaine M6d., Feb. 29, '88). Case of occlusion of the nares, attended with various trophic disorders and with glycosuria, in which the symptoms dis- appeared after the removal of the nasal obstruction. The occurrence of the gly- cosuria is ascribed to the diminished oxi- dation and the circulatory disturbance resulting from interference with respira- tion and to a reflex effect upon the medulla oblongata. Bayer (Wiener nied. Presse, No. 15, '94). Case of urticaria seen in which gly- cosuria was a marked symptom. Bill- stein (Med. News, Sept. 15, '94). GLYCOSURIA. ETIOLOGY. 327 Case of glycosuria in which death fol- lowed speedily after the passage of a sound employed to search for vesical cal- culus. Glycosuria may cause localized urinary symptoms, thus causing danger of vesical instrumentation in these cases. Bazy (Archives G6nerales de M6d., June, '95). Case of glycosuria apparently depend- ent upon the presence of numerous thread-worms in a child of 5 years. After expulsion of the worms by san- tonin the glycosuria disappeared and the child regained its former health. Parry (Brit. Med. Jour., June 8, '95). Study made of 211 cases of head- injuries in order to determine the fre- quency of traumatic glycosuria and its possible relation to the nature of the lesion. There were in the 211 cases 20 that presented glycosuria. Conclusions: 1. After head -injury sugar may appear in the urine as early as six hours and disappear within twenty-four, the average time for its ap- pearance, however, being from eight to twelve hours; for the disappearance of the same, from the fifth to the ninth day. 2. A small proportion of the cases may exhibit a permanent glycosuria from the date of injury to the head. 3. Acetone and diacetic acid are rarely, if ever, found in such cases, excepting where the condi- tion becomes a permanent glycosuria, and even then probably only after a number of months or years. 4. Of the 20 sugar cases here recorded, 11 (55 per cent.) had received an injury to the right side of the head; 5 (25 per cent.) to the left side; 3 (15 per cent.) to the occiput; and in 2 (10 per cent.) there were no external evidences of violence. 5. Of the 20 cases, 8 died, — 6 deaths be- ing the direct result of severe injuries, 1 from intercurrent disease, and the third probably from alcoholism. In the 211 cases, 16 were fatal, 50 per cent, of these having glycosuria. Higgens and Ogden (Boston Med. and Surg. Jour., Feb. 28, '95). Literature of '96-'97-'98. In frogs with a normal liver glycosuria constantly follows tying all four limbs with the animal lying on its back; in ' the prone position it is evoked only by very powerful traction. If the liver is not normal the glycosuria does not occur, and it can be prevented in any ease by division of the sciatic nerves. Confine- ment of a frog head downward in a nar- row cylinder so that it is unable to move entails glycosuria, which is here also pre- vented by section of the sciaties. Extir- pation of the liver inhibits this "restraint glycosuria." Restraint glycosuria is un- affected by stimulation of the sciaties, which of itself tends to cause the ap- pearance of sugar in the urine; similar effects follow section of the cord above the entrance of the roots of the sciatic and also perforation of the lumbar cord. Bilateral extirpation of the lungs or ob- struction of the air-passages causes gly- cosuria. Hence restraint glycosuria may originate from an unusual position of the body, from powerful motor-nerve stimulation, and from great diminution of the respiratory capacity. Velich (Wien. klin. Rund., May 17 and 24, '96). Temporary glycosuria may result from strangulation of the duodenum or je- junum in man, but that this condition exerts no unfavorable influence upon the course of the wound, and affords no con- tra-indication to general anaesthesia. F. Neugebauer (Wien. klin. Woch., Sept. 10, '96). Glycosuria is a symptom of cancer of the pancreas. It only shows itself in the early period and disappears toward the end. Frangois Guillon (Gaz. M6d. de Nantes, July 23, '98). (See Diabetes Mbllitus for pancre- atic glycosuria.) It is also seen consequent to poisoning by various poisons: morphine, prussic acid, mineral acids, nitrite of amyl, car- bonic oxide, chloralamid, nitrobenzol, secale cornutum, etc. [V. Mering (Congr. f. innere Med., '86) and Minkowski (Berl. klin. Woch., '92) demonstrated that it is possible by in- jection or ingestion of phloridzin, a gluco- side contained in the root-bark of apple- trees, to provoke a marked glycosuria in animals or in man. F. Levison.] While in toxic doses the salicylates 328 GOITEE. VARIETIES. cause the appearance of glycosuria, be- fore the deafness, tinnitus, and concomi- tant symptoms no sugar can be detected, although salicyluric acid is present in ap- preciable quantity. Burton (Lancet, June 2, '88). [By extirpation of the pancreas of dogs, Minkowski (Arch. f. exper. Path, u. Pharm., '93) was able to produce not only glycosuria, but all the symptoms of diabetes mellitus. F. Levison.] When the pancreas is completely ex- tirpated glycosuria results, though, if even a small portion of the pancreas re- mains in the abdominal cavity, this re- sult does not appear. Hedon (Archives de Physiol., Normale et Path., p. 788, '94). literature of '96-'97-'98. Case of glycosuria for which no ade- quate cause could be found, but which was evidently associated with consider- able gastro-intestinal disturbance. At the autopsy it was found that the pan- creas had been almost entirely destroyed by a large suppurating cyst. M. Mac- intosh (Lancet, Oct. 24, '96). P. Levison, Copenhagen. GOITRE.— Lat., guttur, throat. Definition. — The terms "goitre," "bronchocele," and "struma" include all those conditions in which there is a per- sistent enlargement of the whole or a portion of the thyroid gland. Such enlargement, most often lenign, may, however, be also brought about by malignant growth within the organ, and, in that case, one speaks of malignant goitre; but it may be laid down that, in all the conditions included under this term, there is some hypertrophy or over- development of one or other of the tis- sues of which the gland is composed. Thus, in a goitre, we may distinguish: 1. A general hyperplasia of the gland, all the tissues having undergone over- growth. 2. "We may find the follicles showing marked hypertrophy, with or without distension of their lumina with colloid material (parenchymatous and colloid goitre). 3. "We may have to deal more espe- cially with overgrowth of the interstitial substance (fibrous goitre). 4. Or, again, we may have to deal more especially with great distension of the vessels, more frequently of the veins, though some rare cases are recorded of aneurismal dilatation of the arteries (vas- cular goitre). Such changes may either involve the whole of one or both lobes, or be confined to isolated portions of the gland. In the former case we have to deal more espe- cially with the vascular and hyperplastic forms. In the latter tha change most often begins with the parenchyma and the goitre develops in a nodular form. But both in the hyperplastic as in the nodular parenchymatous goitre the shape and appearance may be profoundly influ- enced by cysts. These cysts may attain considerable size and may be single or multiple. Varieties. — ^Wolfler, who has written the fullest work upon the pathological anatomy of goitre, gives anatomical divi- sions which, however, are too elaborate for practical purposes. For the clinician this classification may be greatly simpli- fied. [WoMer's classification is as follows: — I. Congenital. — 1. Hyperplastic. 2. Telangiectasic. 3. Cystic. 4. Adeno- matous. II. Htpeeplastic. — 1. True. 2. Col- loid. III. Adenoma. — 1. Faital Adenoma. — Formed of embryonal cells not differ- entiated in the vesicles, forming nodules varying in size from a pin-point to a hen's egg, and tending to haemorrhage and development of large cysts. He fur- ther distinguishes several varieties of GOITRE. VAEIETIES. 339 fhis form, namely: the vesicular, the acinous, the myxomatous, the fibrous, the angiocavernous, and the papillary form. 2. Adenoma Gelatinosum. — There is general enlargement of the lobe or of the whole gland. Two forms of this may be distinguished: (a) the acinous, quite the most common form of goitre, in which there is a, growth of new gland-tissue with development of vesicles between the existing acini, which also undergo con- tinued growth. In the vesicles new and old there is abundant development of col- loid material. (6) The cyst-adenoma, in which the individual vesicles become greatly distended and may be the seat of intravesicular papillary growth either exogenous or endogenous; this form tends toward malignancy. 3. Myaomatons. — Here the normal fol- licles present contain little or no colloid, but are surrounded by an excessive hya- line or myxomatous stroma; the areas showing this change are nodular. 4. Adenoma Cylindro-celhilare. IV. JlALiGNANT Adexoma. — Under this heading "Wolfler includes the follow- ing forms: Growths within the gland having a carcinomatous appearance, but characterized by absence of metastases. Simple typical adenoma of the gland with adenomatous metastases. Simple gelatinous goitre with metas- tases. V. CaScinoma Peoper. — (a) Alveo- lar; (6) cylindrical; (c) squamous celled ; this last apparently a modification of the previous form in which the cells are flat- tened instead of being cubical. VI. COXXECTIVE-TlSSUE GROWTHS. — (a) Fibroma. (6) Sarcoma, of which the following varieties have been described: Fibrosarcoma, round-celled, giant-celled, angiocavernous, and spindle-celled sar- coma. VII. Ixflammatoky Exlaegembnt (Abscess -EORMATiox) . — Abscess-forma- tion is very frequently metastatic (pyaemia) ; some cases are recorded of idiopathic abscess -development; other cases are recorded in which there has been difl'use infiltration of pus through the lobe of the organ between and in the alveoli and vesicles. VIII. HEMORRHAGIC ENLARGEMENT. Such hsemorrhages are very extensive; they may be said always to occur in gland-tissues already the seat of the goitrous change. J. George Ad ami.] We may recognize the following forms: (A) Acute Goithe. — This form comes on very suddenly and is characterized by rapid enlargement of the gland, due pri- marily to vascular dilatation, found more especially among women. (B) Chbonic Goitee. — I. Congenital. — This may be of very varying forms, as above indicated in Wolfl.er's classifica- tion. It is relatively rare. II. Vascular Goitre. — This is most frequently due to a distension of the abundant venous plextTS of the gland; the organ is generally enlarged and is liable to press upon the trachea, causing modification of the voice and not infre- quently paroxysmal attacks of dyspnoea simulating asthma. As above stated, this form may develop acutely. III. Parenchymatous Goitre. — ^Under this heading is to be grouped the vast majority of cases of the disease. "We have to recognize that, both in the gen- eral hyperplastic form and in the nodu- lar, there may be great variation in the changes which occur. But these changes appear to be essentially connected with alterations in the structure and functions of the follicles. 1. Thus in one large class of cases there is, as the most prominent feature, a great storing up of the colloid material within the follicles, of isolated lobules of one lobe, or of the whole organ, and even in the lymph-spaces and — some would say' — -the blood-vessels of the gland. This is a form generally spoken of as colloid goitre, of struma gelatinosum. 2. Adenomatous Goitre. — -In other cases we have to deal with the very opposite condition of marked overgrowth of the glandular epithelium in the more or less 330 GOITRE. VARIETIES. embryonic condition with little develop- ment of colloid. 3. Cystic Goitre. — Whether we are dealing with the colloid or adenomatous type, there is a liability to cystic forma- tion. In the colloid variety occasionally such cysts may be of the nature of reten- tion-cysts and may resemble in their development the emphysematous bullae met with in the lung, several follicles, through atrophy of their walls, fusing into one. But more frequently such cysts, as was pointed oiit years ago by Eokitansky and of late by Bradley, are of hsemorrhagic origin, the new growth in the gland being very vascular and the position of the organ and its varying blood-supply rendering the vessels pecul- iarly liable to rupture. Hence, are pro- duced smaller or larger spaces filled with albuminous fluid, more or less tinged with modified blood-pigment, corre- sponding in every respect to the cysts which may develop in the brain after haemorrhage in that organ. Case of acute enlargement of the thy- roid gland in chronic parenchymatous nephritis. The enlargement was due to a dropsy of the gland. The serous cavi- ties were free from effusion. This con- dition regarded as a, vasomotor neurosis in association with Bright's disease. W. A. Edwards (Inter. Med. Mag., Apr., '92). Further changes may occur in such parenchymatous goitres: there may be hyaline or mucoid degeneration, calcifi- cation, intra-acinous growth, or the eventual development of cancer. 4. Malignant parenchymatous goitre, or primary carcinoma of the thyroid, as above stated, would seem almost to orig- inate in a gland which may, for years, have been the seat of a more or less sta- tionary parenchymatous goitre. IV. Interstitial goitres are relatively rare. 1. Among the benign forms may be recognized the myxomatous goitre, which is, in general, a parenchymatous or adenomatous goitre in which the inter- stitial tissue has undergone mucoid de- generation. 2. Fibroid goitre is always nodular, the nodules being recognized by their peculiar firmness and hardness. 3. Malignant interstitial goitre, or sarcoma, which is relatively rare, is characterized by its peculiarly rapid growth and by its tendency to ulcerate and to extend into the trachea or externally. AccESSOEY Thyroid Bodies. — Lying in the tissues between the hyoid bone and the aortic arch are occasionally to be found certain small bodies which at first sight may be mistaken for lymph- glands, but upon microscopical examina- tion are seen to be of the nature of thy- roid tissue. Gruber distinguishes be- tween them the superior, inferior, and posterior glands. These accessory glands occasionally become the seat of adenomatous or even carcinomatous enlargement, and may cause great difficulty in diagnosis. The posterior group, more especially lying behind the oesophagus or between the trachea and the oesophagus, must be kept in mind from the grave disturbances which may be caused, either in degluti- tion or in respiration, through their over- growth. Case of migratory goitre caused occa- sional attacks of cyanosis and dyspnoea. A small, movable tumor was seen on the right side of the neck. The tumor mi- grated at times toward the mediastinum, compressing the trachea and right in- nominate vein. Removal of a few adenomatous nodules and fixation of right half of thyroid resulted in a. cure. M. A. Wolfler (Revue G6n. de Clin, et de Thgrap., Sept. 26, '89). Case of accessory thyroid in the base of the tongue, removed for great dys- phagia. Recovery. Wolff (Gaz. M6d. de Paris, Oct. 10, '91). GOITRE. SYMPTOMS. 331 Case of intralaryngeal thyroid tumor. There are only five or six such cases in literature. The patient complained of dyspnoea. On laryngoseopical ex- amination a tumor could be seen under the right vocal cord. Three months later abscesses appeared in the left lobe of the thyroid, the patient finally dying of general septicsemia. On post- mortem examination the tumor was found to consist of thyroid tissue and to be connected with that gland. E. Pal- tauf (Wiener med. Woch., May 16, '91). Symptoms. — Acute Goitee. — This form differs from the main mass of eases in that, within the course of a few days or even a few hours, the thyroid may so swell as to produce peculiarly severe symptoms, more especially of impeded respiration, prolonged inspiration, and paroxysmal dyspncea; it may be followed by evidences of bronchial catarrh. Koe- nig notes that during the menstrual period, during which, as already stated, some hypersemic enlargement of the thy- roid may be noted, it is not uncommon for there to be a peculiarly raw cough and distinct modification of the voice directly due to this enlargement. In the more severe cases the " respiratory dis- turbance may lead to death from as- .phyxia. Where death does not occur, the gland may gradually lessen in size and the goitre disappear. Cheonic Goitee. — In goitrous re- gions it is a matter of common observa- tion that the localized or generalized en- largement of the gland may, during a course of years, attain a very large size without causing its owner anything more than the discomfort attached to its weight and its position. If the gland undergoes a general slow hypertrophy, the firm growth of the whole, by form- ing, as it were, a well-built arch sur- rounding the trachea, may lead to sin- gularly little disturbance, and, where there is disturbance, it is more often due. not to growth inward, but to the pressure brought to bear upon the enlarged gland by the muscles' passing over its surface, On the other hand, a relatively-small enlargement of the gland may, by press- ure, bring about a very considerable dis- turbance; much depends upon the exact position of the growth. [Thus, only recently, at an autopsy upon the body of a woman who had for some years past suffered from occasional paroxysms supposed to be asthmatic, and who died almost suddenly from ex- treme dyspnoea, I found that all the trouble was due to a localized enlarge- ment of the isthmus of the gland, an en- largement which from the general stout- ness of the woman had not been recog- nized during life. Dr. Anderson, of Toronto, recently exhibited, at a meet- ing of the Ontario Medical Association, a very similar case. J.. George Ad ami.] As might be expected from its posi- tion, it is in connection with the trachea that most often the first symptoms arise, pressure upon this leading to some em- barrassment in respiration. The par- oxysms of dyspncea, which not infre- quently occur, are ascribed to the catar- rhal condition of the mucosa secondary to the pressure; but in some cases it would seem to me that the paroxysms are directly due to the pressure and con- nected with sudden enlargement of the organ, either through hypersemia or, again, through haemorrhage into the organ. Case of wandering thyroid. It arose from the right lobe, lay behind the ster- num, and caused paralysis of the right vocal cord by pressure on the right re- current laryngeal nerve. The tumor could , be brought above the sternum by coughing. Reuter (Deutsche med. Woch., July 23, '91). Literature of '96-'97-'98. A person who has goitre, but who has not suffered from dyspnoea at all or who 333 GOITRE. SYMPTOMS. has only suffai-ed moderately, may have a sudden attack which may be fatal. A very few cases have been caused by hsemorrhage into the goitre; but this condition is excessively rare. The theory of Eose is that the pressure of the en- larged thyroid makes the tracheal rings non-resistant, so that the trachea is apt to be bent and its lumen become ob- structed. He thinks that in these cases of sudden dyspnoea the trachea becomes kinked from relaxation of the muscles, which maintain the head in such a posi- tion as to keep the tube open, and that this is probably brought about either during sleep or anaesthesia. These eases do not occur always during sleep or anaesthesia. Very .urgent dyspnoea is rarely brought on by the relaxation of the muscles during sleep, for if the posi- tion of the neck were the cause of the dyspncea alternation of the position should relieve it, yet this is not the case. Charles A. Morton (Bristol Med.-Chir. Jour., Sept., '96). Where there is gradual compression upon the trachea, it is in general lateral, and it may be so extreme that the side- walls are pressed together and a trian- gular or even flat-sided tube be produced. The alteration in the voice not infre- quently met with in the goitrous is to be ascribed in different cases to two different causes: (1) to actual pressure upon the cricoid and thyroid cartilages, causing impediment in their proper action; and (2) to compression of the recurrent laryn- geal nerves. There may also be press- ure upon the phrenic and sympathetic nerves. By the very size of the organ obstruc- tion may be brought about in the veins of the neck and upper half of the chest, leading to chronic congestion of the upper portion of the body, so that the skin assumes a dusky appearance. It has been noted by several authorities that in general the jugular veins are dragged .in- ward, while the carotids are dislocated outward. Earely the parts supplied by the bra- chial plexus of nerves show the result of pressure upon that plexus, and we meet with paralysis of certain muscles of the arm, numbness of the fingers and other portions of the upper extremities. Such disturbances occur in growths of large size tending to spread downward beneath the clavicle and sternum. It is rather remarkable that there is rarely any description of disturbances of deglutition; it would seem that, where there are large growths in the neck, the oesophagus easily adjusts itself to one or other side. Apart from these symptoms due to local pressure, there are other symptoms which have been too much neglected, to be made out more especially in younger women, and of the same class as the psychoses seen in exophthalmic goitre. There may be no palpitation nor tachy- cardia and no exophthalmos, but, as Dr. Shepherd has pointed out to me in con- nection with the numerous cases occur- ring in the neighborhood of Montreal, very frequently the patients are of a nervous disposition, fearful, and unable to settle down to sustained work; tremors are very rarely observed. An interesting fact, however, is to be made out: that, upon enucleation of the cysts or enlarged adenomatous masses in the gland, the nervous condition almost immediately becomes so much improved that evi- dently these symptoms are allied to those of hyperthyroidism and exophthalmic goitre. Subjects of goitre become insane about ,nine times as frequently as normal sub- jects. The degenerative and puerperal forms of insanity predominate in goitrous cases. Goitrous patients, with curable forms of insanity, recover as frequently as do non-goitrous; nor is there any special difference in the duration of the disease. The thyroid gland, they con- clude, has a direct action upon the cen- GOITRE. SYMPTOMS. 333 tral nervous system. Marzoechi and An- tonini (Eevue of Insanity and Nervous Dis., June, '92). Still more rare^ thoiigh occasionally recorded in those especially of middle life, is the supervention of symptoms pointing to atrophy of the gland-tissue and the definite development of myxce- dema. The heavy appearance and dis- position of many middle-aged goitrous subjects is very probably due to relative incompetency of the thyroid. It must be kept in mind that such symptoms of disturbed function of the gland deserve to be carefully sought out and recorded, for up to the present time little or noth- ing has been systematically accomplished either to distinguish the functional dis- turbances broiight about by one or other form of "ordinary" goitre or to co-ordi- nate the symptomatology of ordinary and exophthalmic goitre. Diagnosis. — If we leave out of account the enlargement of accessory thyroid bodies, the diagnosis of goitre (apart from that of the various forms of this condition) is a relatively simple matter, and from the position of the thyroid and the ease with which it can be palpated there is little likelihood of mistaking the persistent enlargement of this organ for any other condition. Where accessory thyroids are enlarged, it is practically impossible to arrive at an exact conclu- sion as to the nature of the enlargement, unless, indeed, this takes on the char- acter of malignancy, and then the evi- dence of secondary growth afEecting the bones, recognizable in some rare cases, would give a certain amount of support to the belief that the primary growth in the neck region originated in the thyroid tissue. Between the forms of goitre, save as between benign and malignant, up to the present time very little stress has been laid upon difEerential diagnosis. If, in the first place, the whole of the lobe or the gland be uniformly enlarged, it is necessary to differentiate between the vascular and general hyperplastic goitres and the condition of acute suppurative interstitial thyroiditis. This last condi- tion is rare, and the evidence of sepsis alone and the local evidence of inflamma- tion will distinguish this from other forms. Vascular goitre is characterized by the fact that pressure upon the organ leads to marked diminution in its size, the organ soon returning to its former di- mensions after the pressure has been re- moved. In its slighter conditions simple hypertemia of the gland leads merely to the rounding of the neck. In the very rare condition of struma aneurismatiea there is marked pulsation, and upon aus- cultation arterial murmurs are to be made out. Goitre. Aerial Tumor. Nob affected in volume hj respi- Cliani^es in volume ; increases ration. with expiration, cough, etc.; diminishes in deep inspiration and forced extension of the head. More or less firmness. None. Bi- or tri- lobed, sometimes with No such appearances, prominences or large vessels on surface. Does not disappear on oompres- Disappears on compression. sion. No alteration in voice. Frequent modification of voice. Dullness. Kesonaace on percussion. Puncture will aid in diagnosis, a, jet of air showing the nature of the malady. Aneurismal goitres are at times reducible a third or two-thirds, but not more. L. E. Petit (Eevue de Chir., Feb., Mar., May, June, '89). With general hyperplasia there is ab- sence of all these features, the organ is generally firm and enlarged, and there is a history of gradual development. Where the enlargement is of the colloid or gelatinous type certain observers as- cribe to it a more doughy feel. In the nodular forms of benign goitre it must be remembered that in a very large number of cases we have to deal with quite a series of different conditions. Some of the nodules may be firm and 334 GOITRE. SYMPTOMS. ETIOLOGY. fibroid, others again, of various sizes, may present purely parenchymatous changes either of the colloid or of the adenom- atous type, while, further, here and there throughout the gland some of the larger rounded nodules may present more or less evidence of fluctuation and, in short, may be cystic. Where such cysts are present, it may be laid down that we have always the indication of a previous and existing condition of par- enchymatous hyperplasia or adenoma at the region where the cyst has developed. Following points noted in diagnosis of a polycystic tumor of the thyroid: The , rounded form, not at all recalling that of the thyroid in its normal state; the tendency to ascend, whereas hyper- trophied lobes of the thyroid tend to descend. To assure one's self of its con- nection or otherwise with the trachea, the head is extended as far as possible to immobilize the larynx and trachea. A movement is then made to raise the tumor. If even a slight displacement takes place the tumor is enucleable with- out the trachea's coming into great dan- ger. Sometimes, however, the trachea is so softened that several rings can be dragged with the tumor, so that caution is necessary. Tillaux (Revue G6n. de Clin, et de Thfirap., Sept. 26, '88). As between the benign and malignant goitres, the main point of distinction is the rapid progressive growth of the latter form. But, here, warning must be given that hfemorrhage into a goitre — a not infrequent occurrence — may lead to rapid localized enlargement. Such en- largement, however, is of sudden devel- opment, and after its first appearance it remains stationary; it is not progressive. Malignant tumors of the thyroid, though rare, are more common in men than in women, and usually develop from pre-existing goitres. E. N. Wolfen- den (Med. Press and Circular, Dec. 12, '88). Case of a man with a tumor of the neck of five years' standing. It was soft. solid,' slightly lobulated, and occupied the whole space between the sternum and the thyroid cartilage. A parenchy- matous goitre was diagnosed, but, on re- moval, the growth was found to be a fatty tumor, adherent to the anterior wall of the trachea. Alex. P. Matveieff (Brit. Med. Jour., Sept. 12, '91). Literature of '96-'97-'98. Case of woman who has had a tumor in the neck for a number of years. It has gradually increased in size. It is hard, dense, lobulated, and apparently fixed, although it is not adherent to the skin. The patient has a peculiar stri- dent croupy cough, labored respiration, and swallows with some difficulty. Enu- cleation was performed. The patient re- covered promptly after the operation. The tumor was a sarcoma of the thyroid. George P. Shears (Clinique, June 15, '98). As between the cancerous and the sar- comatous goitres the distinction has been made that carcinoma tends to affect the surrounding lymph-glands and is pecul- iarly liable to have associated with it metastases in the bones, whereas sarcoma of the thyroid undergoes more local ex- tension with a tendency to invade and ulcerate into the trachea, as again to in- filtrate the skin and cause extensive malignant ulceration of the neck. In some rare cases, it should be men- tioned, where there is a localized goitrous enlargement confined to the isthmus, my experience would show that there is a danger of the condition's being over- looked. The same is true with regard to retro-oesophageal accessory goitres. Thus, in paroxysmal dyspnoea affecting more especially females, any possibility of such localized enlargement should be borne in mind. Etiology. — We are as yet wholly ig- norant as to what is the immediate cause of ordinary parenchymatous goitre, and, while very numerous apparently predis- GOITRE. ETIOLOGY. 335 posing causes have been adduced, not one of these, so far as I can see, can be said to be in action in every case. In- deed, at the present time too little care has been taken to distinguish between the various forms of goitre and to deter- mine whether the sporadic cases are anatomically of the same character as those met with in regions where the con- dition is endemic. It is, in fact, the ex- istence of these sporadic cases which, to a large extent, renders it difficult to de- termine the etiology of the condition.. Certain conclusions can, however, be gained from a study of these predispos- ing causes: — ■ In regions where goitre is endemic — and it has been noticed both in Europe and on this continent (Michigan, — Dock; Ontario, — Clark, quoted by Osier) — the domestic animals, dogs and horses, also present the condition. Goitre occurs in all parts of Michigan. It is most prevalent in the northern part. Fifty-two reporters give a total of four hundred and seventy-seven cases. Lower animals almost always have goitre where it is common to man. George Dock (Boston Med. and Surg. Jour., July 4, '95). No race appears to be exempt; the con- dition has been found in all parts of the world, affecting all peoples. In America Munson has recently studied the prev- alence of goitre among the Indians of the United States, and finds that the Crows, the Menoninees, and the ISTorth- em Cheyennes are particularly liable. At the same time among these tribes the disease is regional. Of 147,873 Indians included in those reported on, 77,173 were inhabitants of goitrous tracts, in whom 1823 cases of bronchocele were found, or 2.36 per cent. This may be considered a, minimum per- centage, and the following conclusions are arrived at from the facts quoted: — 1. There is a, strong racial disposition to goitre among the Indians. 2. It is a distinctly localized disease. 3. It does not appear to be caused by high altitudes, climate, or water contain- ing excess of calcium-salts. 4. It is favored by unsanitary condi- tions, constitutional depression, and im- proper and excessively nitrogenous diet. 5. Hereditary influence is strongly marked. 6. Sex and puberty have a marked in- fluence. 7. Cretinism and Graves's disease are rare; the former the rarer. 8. The tumors are smaller than among the whites, and treatment is unsatisfac- tory. E. L. Munson (N. Y. Med. Jour., Oct. 26, '95). There can be no question that goitre manifests itself much more frequently and in general attains to a much greater size in the female than in the male. Sta- tistics upon this point are very variable; St. Sager gives the proportions of 44 to 1; but this would appear to be excessive in most localities. Fischer has collected statistics showing that from 80 to 90 per cent, of all cases of goitre — and of cases of myxcedema, 86 per cent. — occur in women, while exophthalmic goitre seems to attack the same sex chiefly. As above stated, the condition may be congenital. In the absence of clear evi- dence that a goitrous mother living in a non-goitrous region may give birth to children showing an already-developed goitrous condition, I am doubtful whether the condition can be truly said to be hereditary. In 117 families in which one or more members suffered from goitre, all patients observed living in the town of Hamar and its environs, where the disease is frequently met with without being en- demic, the disease had most frequently commenced in childhood, and rarely after the age of forty. In 74 of the 117 families several mem- bers suffered from goitre, and in 48 of these the disease appeared in the di- rect ascending or descending line, while it appeared only in the lateral branches 336 GOITRE. ETIOLOGY. in but 26 cases. Hemicrania, and this only in its typical form, Nvas a symptom very frequently met with — both in the patients with goitre and in their rela- tions with no goitre. Goitre considered as being of vasomotor origin. Vet- lesen ("Etiological Researches Concern- ing Goitre," '87). Literature of '96-'9r-'98. Seven cases of goitre observed in the same family. L. F. Mial (Jour, of Laryng., Mar., '96). Kocher, who regards goitre as the first stage on the road leading to cretinism, holds similar yiews with regard to the congenital as opposed to the inherited nature of that disease. As already stated, there appears to be a very close relationship between disor- ders of the thyroid and the sexual func- tions. "We are as yet wholly ignorant as to what iS the nature of this relationship. It is suggestive to note that, as pointed out by Gaskell in his address in the Physiological Section at the meet- ing of the British Medical Association in Liverpool in 1896, in forms which may be regarded as occurring along the line of vertebrate ancestry, the primal sexual organs lie in immediate connection with the laryngeal depression or groove from which the thyroid is developed; indeed the thyroid in these is a sexual organ. Certain it is that the thyroid ia liable to show marked enlargement at the time of puberty, during menstruation, and dur- ing the period of child-bearing, and, again, that a very large number of cases of goitre are traced back, both in man and woman, to the time of puberty or of other marked disturbance in the sex- ual organs. The slighter sexual disturb- ances of the thyroid are apparently of the nature of an hypersemia. This hy- persemie condition if continued would seem to lead to more extensive parenchy- matous changes. Thyroid enlargement is very frequent in women who have uterine fibromyoma. In 56 cases of a gynaecological affection with enlarged thyroid, 44 times the for- mer was a fibromyoma. Freund (Gaz. M6d. de Paris, Oct. 10, '91). Two cases in which hypertrophy of the spleen coincided with an increased vol- ume of the thyroid gland. The functions of the spleen were destroyed by disease. The hypertrophy of the thyroid is in re- lation with the abolition of the function of the spleen. Cardone (Archivii Italiani di Laringologia, Pt. 4, '88). In a, case of sarcoma of the thyroid, in which tracheotomy failed to relieve dyspnoea, caused by pressure on the pneumogastries, irritation of the mu- cous membrane of the trachea gave tem- porary relief. J. Solia-Gohen (N. Y. Med. Jour., Aug. 10, '88). Case of supposed goitre which was found to be a great hypertrophy of both stemo-mastoid muscles resulting from extreme dyspnoea, due to a post-manu- brial tumor (probably enlarged glands) pressing on the bifurcation of the trachea. A. Foxwell (Brit. Med. Jour., Apr. 18, '91). Goitre, common in a certain district, ascribed to increased blood-supply to the thyroid, due to the exertion consequent on carrying water in vessels upon the head. Thomas A. Glover (Brit. Med. Jour., July 13, '95). In Switzerland Kocher finds, in study- ing no less than 76,000 school-children, that before the seventh and eighth years gotire is an exception, the condition in- creasing in frequency up to the thir- teenth and fourteenth years. It is equally clear that goitre in gen- eral is endemic and that' the vast major- ity of cases occur in certain well-defined areas. More especially is the condition found in mountainous regions, but not all; for example, it is not found in the Jurassic regions, or, again, according to Bircher, where the rocks are of fresh- M^ater formation. Bircher's map of the distribution of goitre in middle Europe shows this relationship to mountainous districts very clearly, but shows, also, that the presence of high mountains and GOITEE. ETIOLOGY. deep valleys is far from necessary for tlie development of endemic goitre. Fre- quent cases are found in the flat coun- try stretching from the north of Paris toward Belgium and along the valley of the Thames. On this continent Mich- igan and the Island of Jlontreal, where cases are very frequent, are in general flat and low-ljang districts, nor is the goitrous area in Ontario mountainous. Dock points out that in America goitres are found as well with drift as on the Laurentian and many intermediate for- mations. In certain provinces of Bolivia the In- dians suffer much from goitre. These same Indians are elay-eaters; the clay is composed of silica, alumina, lime, mag- nesia, protoxides of iron and manganese, potash, water, and organic matter. Al- bert S. Ashmead (N. Y. Med. Jour., Aug. 24, '95). Numerous authorities have attempted to show that the composition of the water ordinarily drunk bears a direct re- lationship to the development of goitre. But here again the evidence is very con- flicting. It may be briefly stated that the presence or absence of chalk or of magnesia or iron and other mineral con- stituents, the carrying of heavy loads upon the head, intermarriage and sev- eral other factors due to surroundings and habits of life, must all be given up as possible factors in the causation of ■ this disease. Yet there can be little doubt that the water consumed is an important factor. In Switzerland Kocher found that in the affected districts competent inhabitants are able to point out foun- tains whose water without exception has caused goitre in children who drank it, while families which had a private water- supply were free from the affection. In one village, too, he was able to distin- guish those who drank from one supply from those who obtained their water from another by the existence or non- existence of goitre. The following conditions accompany the production of goitre: (1) absence of hygienic care, material and intellectual poverty; (2) age — 12 to 15 years; (3) presence in the water of notable quanti- ties of lime and magnesia (not absolutely general); (4) altitude; (5) carrying large burdens causing bending of the head, and bending of the head during work; (6) acute phenomena which seem to indicate an infectious origin. Venous stasis is a predisposing and infection a determining cause (existing in the waters or air of certain countries). The infec- tion may run an acute course. Froelich (Revue Med. de I'Est, Nov. 15, '91). Goitre in England is most prevalent in the carboniferous lime-stone regions. James Berry (Brit. Med. Jour., June 13, 20, 27, '91). In a district having a population of about two thousand, the writer has had fifty-five cases of goitre under his care in the past two and one-half years. The soil of the district is excessively chalky, and, with few exceptions, the water- supply is obtained from deep wells sunk into the chalk. ' When the springs are low the water is drawn up and even con- sumed while still milky in color. The people who live on the tops of the hills and who drink stored rain-water are not affected with the disease. H. C. L. Morris (Brit. Med. Jour., July 6, '95). In the hills of Cumberland and West- moreland, where goitre is endemic, iron, copper, and lead are found in large quan- tities. Paracelsus and other physicians of the sixteenth and seventeenth cent- uries accused metallic waters of causing the neck to swell, and even mention iron pyrites as a cause of goitre. Louis E. Stevenson (Lancet, Dec. 14, '95). literature of '96-'97-'98. More than 76,000 school-children be- tween the ages of 7 and 16 reviewed with their parentage and antecedents. The investigations were principally made in the Canton of Berne, Switzerland. The formulated results may be briefly stated as follows: The female is more 338 GOITRE. ETIOLOGY. frequently the victim of goitre than the male. In children between the ages of 9 and 14 years goitre reaches its highest degree of frequency, and rarely appears before they are sent to school, where the position of the head in writing and reading gives a tendency to the ailment. There is, therefore, a school-goitre. The secondary changes in the thyroid are proportionate to the advanced age of the subject. Congenital goitre is extremely rare. A still greater exception is con- genital atrophy of the thyroid. The districts supplied with water from the fresh-water sandstone showed a preva- lence of goitre, while in the districts in which the water originated from salt- water sandstone goitre was infrequent. The prevalence of goitre depended upon the abundance of organic elements in the water rather than upon its source, and that neither deficient nourishment, un- healthy dwellings, nor wretchedness and poverty is a direct causation. Often the districts rich in goitre are separated by narrow limits from those free from the disease and in goitre-laden localities were oases free from goitre. There were actual goitre-fountains, the water of which almost invariably produced goitre in the children that drank it. On the other hand, in localities where goitre was prevalent families who had a, private water-supply were sometimes free from infection. Brooks and rivers and long open conductors of water were unfavor- able. Kocher (Correspondent of Boston Med. and Surg. Jour., June 24, '97). Study of causation of goitre in a dis- trict in India 2000 feet above sea-level. Strong evidence pointing to an organic rather than a mineral cause. The soil is extremely porous. The water contains no more than a moderate amount of organic matter and mineral constituents, is soft or moderately hard, and, except for minute traces, is free from iron. The inhabitants, who live under the same climatic conditions, but with differ- ent occupations, may be divided into two classes: the native Bhutias and the Sepoy troops from the northwest prov- inces. The former are omnivorous, but, by reason of poverty, mostly vegetarians. Their chief diseases are goitre, syphilis. and malaria. The temporary inhabi- tants, the Sepoys, are all vegetarians, and are healthy, practically free from syph- ilis, and living under excellent hygienic conditions. Examination of 169 Bhutias showed that over 75 per cent, had goitre; nearly 90 per cent, of those over twelve years of age were afflicted. Of 380 Se- poys examined, 54 per cent, had goitre. The Bhutias say that their goitres in- crease during the rainy season. All the British officers, also, during the preceding rainy season had suffered from enlarged thyroids. Iron is present in the water only in very minute quantities. As to lime as a cause, it appears that many of the Bhutias without goitres are great lime- eaters, while of the Sepoys, who never touch it, over 50 per cent, had developed goitres within twenty months after ar- rival. The theory that the disease is due to carrying heavy loads up and down hills might satisfy in the case of the Bhutias, but not in that of the Sepoys, who, though not carriers, yet have goitre. Fifty-five per cent, of children under twelve had no goitres after living there always, or about the same percent- age as did develop them among the Se- poys after a visit of only twenty months. E. E. Waters (Brit.- Med. Jour., Sept. 11, '97). More recently, Klebs, Kocher, Waters, and others have attempted to find a microbic causation for the disease. Thus, Kocher points out that goitre-water dif- fers from free water in containing many more micro-organisms. And Waters contends that there may be micro-organ- isms of the amceba type resembling the malarial organisms with a selective power for the thyroid and its secretions. Tavel, working for the Swiss Commit- tee of Twenty-five Physicians, and com- paring waters which were found to in- duce goitre with goitre-free waters, found that, while both were, upon chem- ical analysis, pure, the former contained numerous microbes. One form common to two goitrous waters inoculated into GOITRE. ETIOLOGY. 339 guinea-pigs resulted in the hypertrophy of the thyroid, but the same form had no effect upon dogs. Attractive as this theory may seem, however, in the ab- sence of any other satisfactory explana- tion, two facts seem to be strongly op- posed to it: — 1. That goitre affects females so greatly in excess of males. 3. That the disease, at least in its early stages, may be arrested and, in- deed, cured by the removal of the patient from a goitrous to a goitrous-free district. If microbes play any part in inducing goitre it would seem from these consider- ations that they do not directly infect the organism, but by their products of growth, contained in the water in which they grow, they must induce a form of intoxication capable of affecting the female rather than the male. It will be seen that the whole subject of etiology is thus still in a very vague state. The drinking-water carries the harm- ful agent. "Goitre-water differs from goitre-free water in containing many more micro-organisms." Theodor Kocher (Wiener med. Woch., Aug. 15, '91). Case of thyroiditis of spontaneous de- velopment. The gland was not enlarged prior to the attack, although it had for- merly heen considerably hypertrophied. Bacteriological examination of the pus, withdrawn under strict antiseptic pre- cautions, revealed the presence of pneu- mococci. It is the first case of the kind on record. Gerard-Marchand (Le Bull. Med., June 21, '91). Cases of metastatic thyroiditis operated on by Kummer and examined bacterio- logieally by Tavel. In the first the goi- tre had existed for fourteen years. The patient was attacked with diarrhoea and fever; two days later, severe pains in right side of neck. The thyroid became inflamed and respiration was impeded. Right half of the thyroid removed, which was found to contain two cysts, — one colloid, the other inflamed. The latter was found to contain the typhoid bacil- lus (of Eberth). This established the nature of the original disease. The sec- ond case was one of post-puerperal thy- roiditis. In the pus were numerous strep- tococci which had, doubtless, invaded the organism at the time of labor. Both cases recovered. Nicaise (La Semaine Med., May 27, '91). Case of a young man who had a goitre which had given him very little trouble. After an attack of typhoid fever an abscess formed in the gland, which was opened aseptically. A microscopical ex- amination and a culture showed the presence of the typhoid bacillus in a pure state. F. Colzi (La Semaine MSd., Aug. 19, '91). Observations in the valley of Aosta, where goitre is endemic. Conclusions: (1) all the examinations of water used for drinking purposes by the subjects of endemic goitre revealed the presence of numerous bacteria; (2) the constant presence, in variable quantity, of a bacil- lus which liquefies gelatin, and has spe- cial morphological and biological charac- ters; (3) this water, given to horses and dogs in a district exempt from goitre, produced an enlargement of the thyroid; (4) it is not yet proved that elimination of the microbes destroys the power of the water to cause goitre. Lustig and Carle (Med. Bull., July, '91). Literature of '96-'97-'98. The disease believed to be due to an organism of an amoeba type, and resem- bling the malarial-organism, with a, se- lective power for the thyroid or its secre- tion. For a time the system opposes it, and sometimes successfully, but, when it overpowers the phagocytic resources of the system, the thyroid enlarges in the effort to combat the poison. Under thyroid feeding (two 5-grain tabloids daily) the records show a weekly diminution of a quarter to half an inch in the circumference of the Sepoys' necks, and when the treatment ceases the gland again increases in size. That is to say, additional resisting power is adminis- tered in the shape of thyroid tabloids, which keep the poison in check and allow the gland to recover its normal size, but on withdrawing the accessory agent 340 GOITRE. PATHOLOGY. there is diminished resistance and again an increase in size. E. E. Waters {Brit. Med. Jour., Sept. 11, '97). The only two predisposing factors that stand out at the present moment as likely to be predisposing are, indeed, altera- tions in the sexual function and the na- ture of the drinking-water. Attempts have been made, both in the Pyrenees and again in Michigan, to cure or arrest the onset of the condition by boiling or filtering the water. Kocher recommends the same. So far adequate evidence as to the effect of these measures is lacking. Pathology. ■ — • To discuss at all ade- quately the pathology of goitre, the minute anatomical differences between the various forms of goitre alone would take up far too much space. But there are certain points which must always be kept in mind. The first of these is the remarkable vascularity of the normal thyroid. As Councilman has pointed out, the size of the thyroid arteries is larger than that of those going to the brain. This, in itself, indicates that the blood-supply must be relatively enor- mous, and that the functions of the gland must be relatively very important to the economy. The second is with regard to the nature of the secretion into the ves- icles. The evidence at present before us would appear to show a close relationship between the lymphatics and the cavities of these vesicles. What that relationship is has not been adequately proved, but it would seem that the colloid material is formed by an inspissation and possibly a modification of the excretion from the epithelial cells lining the vesicles; and inasmuch as numerous observers have pointed out the presence of similar col- loid material in the lymphatics in the immediate neighborhood of the vesicles, it is very possible that normally the lymphatics carry away the material elab- orated by the cells. That this material is of importance to the organism has been abundantly demonstrated in the last few years by the researches of Baumann and Eobert Hutchinson. The latter has con- clusively proved that the albuminous col- loid material carries or contains what may be termed the active principle of the gland, and that, if this colloid material thus isolated be given to myxoedematous patients, it has all the good effects of the full extract of the gland. And he has shown that combined with it there is iodine; in fact, that Baumann's thyro- iodine obtained from the whole gland is evidently the active albuminous sub- stance in this secretion. Primarily, the parenchymatous goitre would seem to be an overgrowth of the gland with overactivity, although such overgrowth may eventually give place to atrophy and inactivity of the specific glandular substance. It is very suggest- ive that, in a large proportion of cases where the goitre is not of too long de- velopment and is of the parenchymatous type, the iodine treatment has for long years been found to give good results. We are, in short, only just now seeing the beginning of a knowledge of the rela- tionship of parenchymatous disturbances in the thyroid to disturbances of the gen- eral body-metabolism, and at the present we can do little more than carefully note the nature of the anatomical changes of the organ, without being in any way sure of their bearing. Literature of '96-'97-'98. Tn a study of the histology of the vas- cular system of thyroid in goitre the author has examined twenty-eight glands taken from subjects varying in age from a foetus of the fourth month to an adult of 68 years. Death in these cases was due to a variety of causes. In GOITRE. PATHOLOGY. PROGNOSIS. 341 teries were found In which there were well-marked proliferations of the endo- thelium in localized areas, forming bud- like projections. In one specimen these proliferations frequently occluded the artery. The groups of cells fonning these buds may cause little or no pro- jection of the intima, but may develop outwardly at the expense of the muscu- lar coat. The size of the buds varies much within certain limits. As buds have been found containing colloid, they would seem to have the power of producing this material. The larger arteries are almost or altogether free from these changes. R. M. Home (Lancet, Xov. 26, '92). Goitre-formation apparently begins by a growth of processes of the normal glandular epithelium. The first clearly- risible beginning of the nodular goitre consists of single processes of differen- tiated epithelium in the secondary lobules. These processes gradually sup- plant, metaplastically, the normal tissue of a secondary or even a. primary lobule. The lobules thus changed form, as they increase in volume and supersede the surrounding tissue, the smallest true goitrous nodules. Neighboring lobules changed in this way form multiloeular goitrous nodules, either blending by a growth through the intervening septa or flattening where they come in contact. Finally, the outer compressed lobules surround the central, more vigorously growing ones like a shell. The metaplas- tic growth ends when the boundary of the primarily-affected lobule is reached, growth then taking place by displace- ment of the surrounding tissue. Diffuse goitre consists of a uniform proliferation in all the lobules. Nodular goitre arises through a variation in the vitality of neighboring parts. There exist a great variety of intermediate forms. T. Hitzig (Schmidt's Jahrbucher, July, '94). The most frequent fact observed in ten cases was the presence of fine granu- lar matter in the follicles, and in such quantity that in some cases it surpassed that of the homogeneous colloid masses. These granulations are of the greatest importance in explaining the formation of colloid matter, for they form one of the preliminary stages, and the progress- ive transformation from one to the other may often be seen in the same follicle. In this transformation there is not only a modification of density, but a change of color also. The origin of the granular matter is located in certain large round or oval elements, larger than the epithe- lial cells, with pale protoplasm, but formed by the same fine granular masses as the rest of the follicular contents which surround it. These are considered to be only modifications of epithelial cells. The special point of interest in this process is the complete absence of homogeneous drops, of irregular balls or masses, giving birth to colloid matter by their confluence. The formation of col- loid substance in goitre should, there- fore, be considered as a purely degener- ative process. Reinbach (Beitriige zur path. Anat., etc., B. 16, p. 596, '95). Prognosis. — Upon the whole, save in malignant forms of the condition, the prognosis must be regarded as favorable. Even where no steps are taken to arrest the growth, it is a matter of common observation in goitrous districts that persons for long years may bear tiimors of great size without pronounced ill effects. Occasionally, however, severe, not to say fatal, respiratory disturbances may supervene in those with compara- tively-small goitres, either from haemor- rhage into the gland or from develop- ment of nodules in such a direction as to press on the trachea. Lucke has noted that occasionally after acute febrile dis- ease a goitre may entirely disappear, and this vascular form, if of recent develop- ment, may spontaneously diminish in size. Even where the goitre is of consider- able duration, removal to a non-goitrous region may be followed by rapid dimi- nution of the tumor, save where cysts are present; in young people and chil- dren such removal may, with fair cer- tainty, be depended upon to cure the 342 GOITRE. TREATMENT. MEDICAL. state. Failing this, the medical treat- ment about to be described leads to marked improvement in the majority of cases. While, again, failing this, resort may be had to surgical means, and very little danger need be anticipated of any untoward result. Treatment. — Treatment of the condi- tion may he divided into medical and surgical. Medical. — The use of iodine and the various preparations of the same is quite the most valuable. According to Koenig, this drug is more especially of use in the hypertrophic and follicular forms, not so much in the colloid; especially in re- cently-developed goitre is it useful. It may be employed either externally over the goitre or in the form of potassium iodide given in large doses by the mouth. In this use there is some danger that the symptoms of iodism may supervene, but, as Koenig points out, we may not truly be dealing with iodism, but with symp- toms of cardiac stimulation and rapid emaciation due to the rapid reabsorption of the colloid material into the blood. Dangers of potassium iodide referred to in treatment of goitre. Goitrous sub- jects are particularly susceptible to iodism. M. Ferrand (Le Progr6s M6d., Nov. 23, '95). Where cysts are present, iodine is use- less and surgical means must be em- ployed. Mosetig-Moorhof has used injections of iodoform with slight constitutional re- action and excellent results, more espe- cially in the soft varieties of goitre. Kapper, Frey, and Eosenberg all con- firm the value of this method. Soft varieties of goitre treated by author for the past ten years by injec- tions of iodoform, with slight constitu- tional reaction and excellent results. The fono\ying solution was used under the strictest antiseptic precautions: — R Iodoform, 1 part. Ether, 5 parts. 01. olivEB, 9 parts. Or R Iodoform, 1 part. Ether, 01. olivse, of each, 7 parts. Beginning injection is 15 Vz minims; the author has injected as much as 62 minims at one time, injected in two places. Intervals should be five to eight days. Five to ten injections, according to the size, etc., of the tumor, are neces- sary for a cure. Mosetig-Moorhof (Inter. Jour, of Surg., Mar., '90). In 65 cases treated by the Mosetig- Moorhof method not the slightest bad symptom obtained. Good results noted in cystic and even fibrous goitres. Frey (Wiener med. Presse, Oct. 12, '90). Fifteen cases of parenchymatous goitre treated with injections of iodoform after the Mosetig-Moorhof method with the most gratifying results. In one hundred and fifty injections there was not the slightest unpleasant symptom. F. Kap- per (Deutsche med. vVoch., July 9, '91). Literature of '96-'97-'98. The following solution, which should be kept in a, glass-stoppered bottle, recommended : — R Iodoform, 15 grains. Ether, 105 grains. Sterilized olive-oil, 105 grains. The skin of the neck is carefully disin- fected, a needle plunged into the goitre, and the injection made. Half a syringeful may be injected at first, increasing gradually to an entire syringeful. At first the injections should be practiced every fourth day; later, every second or third day. The injections produce usually a slight sensation of burning, which ordinarily disappears in a few minutes, but some- times persists for several hours. Complete cure experienced in nearly 45 per cent, of cases, and decided improve- ment in about 50 per cent. Usually, at least twenty-five injections are required. Rosenberg (Lyon Med., Jan. 9, '98). GOITRE. TREATMENT. MEDICAL. 343 Another treatment which has of late years been tested with promising results in a certain proportion of cases is the administration of preparations of the thyroid gland. Issai, Vas, and Garg found that in three cases the use of thy- roid tablets led to diminution in the size. Serapin confirms this obserTation. Stabel in twenty-six cases of goitre found that thyroid medication was beneficial. The best effects were obtained by the use of the fresh gland. Bad effects were noted in several instances from the use of the tablets, though Ewald came to con- trary results, obtaining better results with the tablets than with the fresh gland. The parenchymatous form of goitre in young chlorotic girls was most benefited. Mendel obtained no improye- ment by use of tablets, and had to aban- don treatment on account of the palpita- tion and emaciation which it caused. Perhaps the largest series of cases is that quoted by Angerer of 78 cases treated with raw gland. Only 4 or 5 remained uninfluenced. The hard fibrous growths remained totally unaffected, and, like other observers, he found that it is the small, soft, parenchymatous goitres, more especially in young people, that are most favorably influenced. , On the whole, therefore, the employ- ment of fresh sheep's gland would seem to give the best results, and more espe- cially in young persons and those suffer- ing from the softer parenchymatous forms of the disease, whether diffuse or nodular. What the exact method is in which the thyroid taken leads to favor- able results is a matter of doubt. To state that it causes physiological rest to the gland is, perhaps, begging the ques- tion. It is further to be noted that only in early cases does it appear to result in complete cure, and where cysts are pres- ent these are in no wise reduced in size. although, through the shrinking of the surrounding tissue, they may become more easily enucleated. (See Animal EXTEACTS.) Twelve cases in which the thyroid- gland extract Avas used. In 5 cases ob- served in the hospital and in 5 out- patient oases a definite influence of the treatment could be observed; the goitres markedly decreased in size, but in no case disappeared. Nearly the same effect is obtained by the well-known iodine treatment. The experience of many j'ears shows that nearly 90 per cent, of all the cases can be improved by the use of iodine; only in 10 per cent, does surgical treatment become neces- sary. The new treatment will probably have no great practical value in the treatment of goitre. Kocher (Corres. f. Schweizer Aerzte, No. 1, '95). Administration of fresh thyroid gland or dry extracts of the gland to patients suffering with psychoses in association with parenchymatous goitre, while fol- lowed by pronounced diminution in' the size of the enlarged gland, is unattended with any influence upon the mental state. On the other hand, the medication also occasioned no unpleasant effects. Reinhold (Miinch. med. Woch. No. 52, p. 1205, '95). Results of treatment of sixty cases of goitre with thyroid. Cases of benign parenchymatous goitre were put under treatment without any selection. Cystic cases and those of malignant disease were excluded, as were also eases of ex- ophthalmic goitre. Instead of raw thy- roid, tabloids were used in the dose of 2 daily to adults, 1 to children. Un- pleasant symptoms, such as palpitation of the heart, nausea, diarrhoea, tremor, headache, etc., were treated by tempo- rary withdrawal of the remedy. The duration of treatment was from three to four weeks on the average. In young children complete recovery was the rule. In older children marked diminution in the size of the goitre was observed, with cessation of symptoms. In adults re- covery was rare and less common in pro- portion to age. Complete return of the 344 GOITRE. TREATMENT. MEDICAL. thyroid to its normal size is not to be expected later than the twentieth year. Mild relapses were seen only three times, and in each ease rapidly relieved by renewal of treatment. Bruns (Amer. Jour. Med. Sci., May, '95). Dififerenees exist in diflferent patients in respect to the effect of thyroid treat- ment upon metabolism. Albuminuria and glycosuria are regarded as unfortu- nate effects; the former is rare. Den- ning (Munchener med. Woch., Apr. 23, '95). Literature of 'Qa'ar/' 97-'98. Thirty cases of goitre observed in which sheep's thymus was used, some- times in its natural state and sometimes in the form of pastils of English manu- facture. The thymus was administered in the form of hash spread on bread, in quantities of 150 grains for children and 225 grains for adults, three times a week. The effects of the treatment were ordi- narily manifested at the end of three or four weeks, and the results remained the same when the treatment was continued * for a longer time. Three patients, chil- dren 10 and 12 years of age, were com- pletely ciired anatomically. In 18 cases there was considerable amelioration, with diminution in the size of the tumor and in the symptoms provoked by it. In 10 cases the treatment failed completely. In none of the cases were toxic symp- toms. The effects of the medication are particularly appreciable in diffuse, sim- ple, hyperplastic goitre. Eeinbach (Mit- theilungen aus der Grenzgebeiten der Med. u. Chir., i, p. 202, '96). The fresh glands selected with care and preserved on ice do not give rise to the toxic symptoms so frequently re- ported. In 25 cases of simple goitre of parenchymatous and fibrous character improvement was noted in 23, while in 2 the disease seemed completely arrested or cured. The treatment must, however, be continued to maintain the results ob- tained. Tablets of thyroidin found con- siderably less advantageous than the fresh glands. Stabel (Berl. klin. Woch., Feb. 3, '96). Better results obtained with the tab- lets than with the fresh gland, the most remarkable effects being observed in young chlorotic girls suffering from parenchymatous goitre. Complete re- covery, however, did not take place, but slight symptoms of thyroidism, as moderate albuminuria with casts, noted, disappearing as soon as the treatment was suppressed. Ewald (Univ. Med. Jour., Apr., '96). Use of tablets noted in three very care- fully observed cases; the conclusions are as follow: 1. The goitre has diminished in size. 2. The body-weight is dimin- ished, the most marked result being ob- tained after long-continued use, and is in proportion to the amount of the gland- substance taken. 3. The amount of urine is increased. 4. The nitrogenous excretion in the urine is increased. 5. The balance of nitrogenous excretion is a negative one, i.e., more is excreted than is taken in. 6. The uric-acid excretion is increased, especially during the first days of the treatment. 7. The excretion of sodium chloride and of phosphoric acid is in- creased. A. Issai, B. Vas, and G. Garg (Deutsche med. Woch., No. 28, s. 439, '96). No improvement obtained in ten cases in which tablets were tried. The treat- ment was abandoned on account of the palpitation and emaciation which it caused. Mendel (Univ. Med. Jour., Apr., '96). Under thyroid treatment the goitre diminishes in size, and may even some- times return to its normal condition. When the treatment is carefully carried out and the effect watched, no complica- tions occur. It has also a beneficial in- fluence upon the nervous system. K. P. Serapin (Wratch, No. 5, Feb., '96). One hundred patients treated with thyroid extract, 78 of whom suffered from goitre. The raw sheep's gland, finely minced, brought directly from the slaughter-house to the hospital by one of the attendants and there carefully ex- .amined, so that any diseased tissue may be at once detected and rejected, em- ploj'ed. Many of the toxic phenomena following its exhibition are due to early putrefaction. Of the 78 cases treated only 4 or 5 remained uninfluenced. A few showed such excessive reaction after GOITRE. TREATMENT. SURGICAL. 345 its use that it had to be discontinued. In the majority the goitre soon showed distinct signs of retrogression. Only the hard fibrous growths remained totally unaffected. In cystic goitres the sub- stance of the gland atrophied around, while the cyst remained distended, but seemed to become more superficial, so that its subsequent enucleation was much more simple. The same result oc- curs in the adenomatous growths, the isolated tvimor or knots coming to the surface and being much more distinct than formerly. It is the simple, soft goitres that are mainly influenced, and especially those occurring in young people. The bleeding in subsequent oper- ations is much less than when thyroid extract had not previously been em- ployed. One unfortunate result is pro- duced, viz., a certain amount of heart- weakness, Avhieh becomes very marked during and after the administration of the ansesthetic. Relapses also sometimes occurred after the cessation of the thy- roid treatment. 0. Angerer (Miinchener med. Woch., Jan. 28, '96). In the tetanic condition toxins are found in the blood which are rendered innocuous by the antitoxin — "thyreo- antitoxin" of Frankel — which is formed in the gland-alveoli. In the myxoedema- tous condition, on the other hand, a poisonous proteid "thyroproteid" is formed in the tissues, passes into the blood, and is fixed by the thyroid. Here it is rendered innocuous by the action of an enzyme which splits it up into two parts, — a proteid constituent which unites with "thyro-iodine," and the other a carbohydrate. Notkin (Vir- chow's Archiv, Suppl., H., B. 144; Edin- burgh Med. Jour., Mar., '97). lodothyrin used in four cases of goitre. The dose employed was 4^/2 grains per day during extended periods, varying from one to three months. In three of these cases, subjects from 12 to 18 years of age, who presented small recent fleshy goitres, which were accompanied by intense respiratory symptoms, the medication caused a rapid disappearance of the dyspnoea. After having been five months under treatment they are considered completely cured. Poucet (Revista de Laring., Otol., y Rin., No. 11, '97). Case of goitre cured in a newborn in- fant by submitting its wet-nurse, who also had a goitre, to the thyroid treat- ment. Every day during five days a tab- let containing 22 grains of the gland was taken by the nurse; after an interval of five days the treatment was resumed, and so on until the treatment was dis- continued. The infant's goitre disap- peared after six weeks' treatment, that of the nurse became considerably smaller. Mosse (Brit. Med. Jour., Apr. 23, '98). SuEGiCAL. — If, after treatment with iodine or with thyroid extract, no effect is produced, then operation becomes ad- visable. Three months considered ample time for the exhibition of drugs, when, failing improvement, operation becomes advis- able. Pressure on the trachea causing dyspnoea, and on the recurrent causing hoarseness, indicate early operation. John B. Roberts (Amer. Lancet, Feb., '95). The surgical treatment of bronehocele has for many years been a subject of great interest, and to Kocher, Socin, and the Swiss surgeons much credit is due for the gradual deyelopment of success- ful methods of operation. As above in- dicated, it is more especially in the cystic forms that nowadays there is need to operate. Several methods have been suggested, the earlier being either in- cision of the cyst (Beck) or puncture, followed by injection of iodine. Goitre the size of a hen's egg reduced to that of a small nut in nine months with one hundred injections of 5-per- cent, iodoformed ether. Terrier (Le Pro- grSs M6d., Dec. 1, '88). Referring to treatment by puncture and injection of iron, the substitution of rubber for metal cannulse recommended on the third or fourth day, so as to do away with the risk of irritating the walls of the goitre. Thorton (Lancet, Feb. 18, '88). Four cases of cystic goitre successfully 346 GOITRE. TREATMEXT. SURGICAL. treated by evacuation and injection of a few drops of chromic acid in an ''acid- carrier." E. Woakes (Lancet, June 21, '90). Case in which a goitre had diminished one-third after injection of tincture of iodine twice a week for four months. The last injection was followed by con- vulsions and death, due probably to thrombosis. Sixteen cases of death after parenchymatous injections collected. Heymann (Med. News, Nov. 23, '89). Interstitial injection of pure tincture of iodine is the most efficacious and least dangerous of all methods of treat- ment for ordinary cystic goitre. Schwartz (Revue G6n. de Clin, et de Thgrap., Mar. 23, '89). Following directions given for the use of tincture-of-iodine injections: 1. Be sure that the needle is in the body of the tumor before injecting. 2. Avoid, as far as possible, the veins distributed in the cellular tissue over the tumor. The syringe must be aseptic; it must be plunged slowly, but without hesita- tion, into the gland. The syringe must then be taken off to see that no blood flows from the needle. This precaution is necessary to avoid injecting into a vein. Inject very slowly; 8 minims is enough for the first injection. If this is well borne {i.e., only slight pain with little swelling is caused), 15 minims can be used next time. One should wait a few seconds after making the injection before removing the cannula; only one injection to be made at a sitting, and an interval of four or five days to elapse before the next. There is considerable radiating pain for a short time after the injection, also a metallic taste in the mouth for a few hours. Tincture of iodine is the best substance for injection. Terrillon (Bull. G6n. de Thfirap., Sept. 30, '89). Iodine injections should not be used on account of the danger connected with them, and on account of the periglandu- lar adhesions which they cause. These adhesions afford especial difficulties in the event of a surgical operation's be- coming necessary. G. Naumann (Cen- tralb. f. Chir., July 9, '92). Injections of iodine are only efficacious in recent parenchymatous goitres, but in these they are of great value. Brunet (Archives Clin, de Bordeaux, Feb., '95). These methods are often followed by reaccmniilation of fluid or haemorrhage into the the cysts, and extirpation of the cyst as first suggested by Juillard and Ivottman, now as modified by Socin into his method of enucleation, gives excel- lent results both in the case of cysts and in that of nodular parenchymatous growths. In this country. Shepherd, following Socin's method, has had singularly good results in enucleating both cystic and nodular colloid growths. In the cystic forms he taps the cyst and evacuates some of the contents, and then the cyst- wall can be peeled off from the gland- tissue with the fingers or the raspatory much as an adherent ovarian cyst is peeled off from its surrounding struct- ures. Should a vessel come to view, it is easily tied. Thus the operation is made one that is almost entirely external to the neck. It is remarkable how rapidly healing takes place after these opera- tions, even when a huge cyst has been removed. Case of cystic goitre treated by what the author terms "shelling out." An ex- ploring needle having been introduced, it was ascerta,ined to be a single cyst and to contain a reddish fluid. The cyst was "shelled out" without any difficulty through an incision about two and a half inches long over its most prominent part. The patient made a good recovery. Haemorrhage is the chief source of dan- ger in this operation. Vachell (Bristol Medico-Chir. Jour., Dec, '87). Conclusion, from results of operation in 77 cases of goitre, that intraglandular enucleation of one or several goitrous nodules is usually practicable, except in cases of malignant struma, diffuse parenchymatous or colloid hypertrophies of the gland, exophthalmic goitres, or goitres with numerous disseminated nodules. GOITEE. TREATMENT. SURGICAL. 347 The probability of recurrence is not greater than in partial extirpation. In no case were unfavorable results, as tetany or cachexia, observed, and in none of the cases of partial extirpation did the tissue left behind disappear. Bally (Med. News, June 13, '91). Enucleation favored where it is pos- sible. J. Boeckel (Gaz. M6d. de Stras- bourg, June 1, '93). In cases of diffuse enlargement of the ■n-liole gland such, enucleation is, of course, out of the question, and while complete extirpation of the whole organ is now never dreamed of on account of the imminent danger of development of myxoedema, observers have with a greater or lesser success performed a partial ex- tirpation either of a whole lobe or a por- tion of a lobe. Kocher especially has em- ployed this method, and his results, both by enucleation and by extirpation, have been remarkable. Results obtained in one thousand cases of goitre. Excluding the operations undertaken for malignant tumors and exophthalmic goitre only 3 patients had been lost out of 900 cases operated on during the last twelve years. One case of surgical myxoedema had resulted, and that was due to the fact that the half- gland that was left behind had become atrophic, — a point not noted until the removal was accomplished; the symp- toms soon disappeared with the use of a sheep's thyroid. In the last 200 eases not a single patient was lost. Kocher (La Semaine Med., Apr. 24, '95). Indications for surgical interference in goitre are: (1) tracheal stridor; (2) dyspnoea; (3) dysphagia; (4) a rapidly- growing goitre, particularly downward; (5) deformity. As regards the last indi- cation, the author thinks thyroidectomy of unilateral goitre justifiable if the patient is of suitable age and in good health and the deformity of the neck is greatly objectionable. J. B. Deaver (Jour. Amer. Med. Assoc., Aug. 8, '91). Goitre remarkable for its extraordi- nary size extirpated. It was a cystic tumor reaching nearly to the umbilicus, and its antero-posterior diameter was twice as great as that of the chest. Ow- ing to the weight of the tumor the trachea was bent forward, the cervical spine was lordotic, and the thorax flat- tened. Thyroid vessels were tied before extirpation. Cure. Bruns (Deutsche med. Woch., Apr. 23, '91). Shrinking of the portion of a goitre re- maining after operation is a rule with- out exception. J. Wolff (Deutsche med. Wooh., Dec. 31, '91). Sudden death occurring during or im- mediately after the extirpation of a goitre may be due to asphyxia caused by a collection in the pharynx of mucus coming from the stomach. In one case the writer removed a quantity of this mucus from the pharynx, with immedi- ate relief of the symptoms of suffocation. Wolff (Deutsche med. AVoch., Mar. 16, '93). Operated upon 202 cases of goitre. Of these 11 were malignant, 5 dying as a direct result of the operation. Of the 19] benign cases, nearly two-thirds were women. All cases showed more or less dyspnoaa. Total extirpation was done 7 times; partial, 133 times; enucleation, 50 times (46 in cystic cases) ; intracap- sular ividemeiit, once. There were 9 deaths. Sudden death in cases of goitre is caused by suffocation due to sudden increase of the pressure of the goitre against the softened tracheal wall. E. U. Kronlein (Schmidt's Jahrbiicher, Mar. 15, '93). Interstitial injections condemned and surgical intervention advocated. In 292 cases opei-ated upon the mortality was 1.36 per cent. Respiratory diffi- culties, impeded deglutition, and cardiac troubles regarded as indications for in- tervention. In 104 cases ablation by Kocher's method was practiced, and in 73 enucleation by Soein's procedure. Roux (Annales des Mai. de I'Orielle, du Larynx, du Xez, et du Pharynx, Sept., '95). Tetany following thyroid extirpation is very, dangerous. Of more than 30 cases following thyroidectomy recorded there were 7 cures, 13 deaths, and 3 cases in which the disease became chronic. In 53 total extirpations in Bill- 348 GOITEE. GOLD. roth's clinic the affection appeared twelve times, of which 8 were fatal, 2 chronic, and 2 recoveries. Total extir- pation to be avoided. In 115 partial ex- tirpations in Billroth's clinic no case of tetany appeared. V. Eiselsberg (Schmidt's Jahrbilcher, Apr. '90). Literature of '96-'97-'98. Case in a woman, aged 33, who had a large tumor in the neck as long as she could remember. Latterly it had greatly increased. On two occasions it had been tapped. Tumor extended from the chin to the sternum in the middle line, later- ally to points well behind the posterior margins of the sterno-mastoids, down- ward behind the sternum. The chin rested in a sulcus on the upper margin of the tumor. There had been some diffi- culty in swallowing. Removed under chloroform; the trachea was left bare, and a large cavity behind the upper mar- gin of the sternum, in which the trans- verse arch of the aorta could easily be seen. Recovery. As the removal of the thyroid gland was apparently a complete one, thyroid extract in small quantities daily were ordered. Nine months after- ward condition quite satisfactory. Sir William Stokes (Lancet, Jan. 4, '96). Three hundred operations for goitre performed in the Tubingen clinic. The proportion of females to males is 2.5 to 1, and in the male sex goitre is apt to begin between the fourteenth and seventeenth years and in the female between the twelfth and sixteenth years. The ma- jority of goitres occur in people who are obliged to perform hard, manual labor. The list contains only two cases of com- plete extirpation. The operation of choice has been intraglandular enuclea- tion; but there are a, number of ex- amples given of extracapsular extirpa- tion. These two methods may often be combined with advantage. Non-malig- nant goitre which is increasing rapidly in size ought to be operated upon, but one should never operate simply to re- lieve disfigurement. Bergeat (Annals of Surg., Mar., '97). J. George Adami, Montreal. GOLD.- — Metallic gold is not official in the IT. S. P. Only one preparation is recognized: the chloride of gold and sodium (auri et sodii chloridi, U. S. P.), which is given in doses of ^/ao to ^/i|> grain. Twenty-seven cases of pulmonary tuberculosis treated with gold and so- dium chloride, used hypodermically, in doses of ^Ao grain to Ve grain, during ' three to eight months, with gradual de- crease of temperature and disappearance of cough and bacilli and increase in weight. Gibbs and Shurley (Ther. Gaz., Apr. 15, '91). Case of phthisis apparently cured by the use of gold and sodium chloride. Pepper (Univ. Med. Mag., Dec, '95). Literature of '96-'97-'98. The best vehicle with which to com- bine gold and sodium chloride in cap- sule is tragacanth or guaiac resina; neither of these decomposes it. The time for administration should be one hour after eating, or, better still, one hour be- fore eating. The ideal method for ad- ministration is by hypodermic injection, the solution used being made with equal parts of aqua destillata and glycerina. Daniel R. Brower (Jour. Amer. Med. Assoc, Oct. 1, '98). Gold is far more eflicient than any other drug I know of in sclerosis. W. H. Walling (Med. and Surg. Reporter, Phil- fidelphia, vol. Ixxvi, '97). Physiological Action. — The chloride of gold is a caustic irritant. In small medicinal doses the preparations of gold sharpen the appetite and promote diges- tion. If long continued, symptoms of overstimulation follow their use. Con- stipation is usually present. The mental functions become more active. Increased venereal desires are attributed to the use of gold. In men priaprism is not uncom- mon. In women the menses are in- creased. Poisoning by Gold. — The acute form GOLD. THERAPEUTICS. 349 of poisoning follows the ingestion of a tonic dose and naanifests itself by a vio- lent gastro-enteritis, accompanied by cramps, convulsions, trembling, insom- nia, priapism, and insensibility. In the chronic form, there develops a fever ac- companied by sweating, a very abundant flow of urine, and salivation, without tenderness or ulceration of the gums. Epigastric heat and oppression, headache, dryness of mouth and throat, with gastro- intestinal irritation. Treatment of Acute Poisoning ly Oold. — The principles of treatment are the same as poisoning by corrosive sublimate. The contents of the stomach should be evacuated after the free administration of albumin, eggs, milk, and flour. Ex- ternal heat should be applied and stim- ulants administered by the mouth, the rectum, or by hypodermic injection. Morphine is useful if shock be present. Atropine will diminish the salivary se- cretion, and astringent (tannin) or dilute- acid mouth-washes will relieve the sali- vary symptoins. Therapeutics. — The preparations of gold are not as much in favor as formerly. Jfervous dyspepsia is relieved by small doses C^/go to ^/,4 grain) given three times daily. Mills regards it as a valu- able tonic in hysteria and other disor- ders dependent upon depravity of the nervous system. Nephhitis. — In diseases of the inter- nal organs associated with sclerosis, as nephritis, cirrhosis of the liver, etc., the persistent use of gold and sodium chlo- ride has given excellent results. In con- tracted Iddney a pill of chloride of gold has been recommended by Dana. Phthisis. — Gibbs and Shurley, of De- troit, laboring under the impression that gold and sodium chloride possessed bac- tericidal powers in this disease reported a number of cases in which satisfactory results were obtained. Syphilis. — In old secondary and ter- tiary cases where mercurials and the iodides have been long in use, gold will yield beneficial results, as in gummata, syphilitic pharyngeal ulcerations, spe- cific ozsena, etc. Ingals has found chlo- ride valuable in syphilitic laryngitis. Hale White finds the sodium chloride preferable to corrosive sublimate in the tertiary form, especially when the osse- ous system is involved. Effusions. — Gold has yielded good results in ascites due to chronic hepatitis, post-scarlatinal dropsy, and in ovarian dropsy. Gynecological Disoeders. — Amen- orrhoea, sterility due to coldness, ovarian torpor, and the tendency to habitual abortion have been benefited by the use of chloride of gold. Mental Disoedees. — Good results have been obtained from the use of gold in melancholia and hypochondria accom- panied by depression. Vertigo, when due to gastric disturbance, is often re- lieved by small doses of gold chloride, but when cerebral congestion or plethora is present, the use of gold is contra-indi- cated. Inebeiety. — Chloride of gold has been recommended in the treatment of chronic alcoholism (see Alcoholism, volume i). Literature of '96-'97-'98. Gold, whose effects are unknown and even to its defenders are surrounded by- mystery, cannot possibly be of any serv- ice in cheeking an unknown disorder. Its use must be empiric and irrational always, except as a mental remedy to iniluence the mind. The checking of the drink symptom is the same as using opium for pain, leaving the cause un- influenced. Gold or any single drug can have no specifie influence in cases of in- 350 GOUT. SYMPTOMS. ebi-iety. T. D. Crothers (Jour. Amer. Med. Assoc, Oct. 1, '98). C. SUMNEE WlTHEESTINE, Philadelphia. GONORRHCEA. See Ueethea, Dis- eases OF. GONORRHCEAL ARTHRITIS. Joints, Diseases of. See GONORRHCEAL OPHTHALMIA. See Conjunctiva, Diseases oe. GONORRHCEAL RHEUMATISM. See Ueethea, Diseases of; Complications. GONORRHCEAL VAGINITIS. See Vagina, Diseases of. GOUT. Synonyms. — Podagra; arthritis urica-. Definition. — Gout is a constitutional disease manifesting itself in various ways and attacking various tissues and parts of the body, but most frequently the ar- ticulations. It occurs in an acute and a chronic form, both of which are charac- terized by the deposit of urates in the affected parts. Symptoms. — An attack of acute gout may occur without any precursory symp- tom in persons who, before, felt quite well; but this mode of development is not usual. Generally, premonitory signs are experienced some time in advance, espe- cially in the digestive and circulatory system and in the kidneys. The patients have frequently led a luxurious life, have been accustomed to excessive consump- tion of food, especially of animal food, have indulged in alcoholic drinks, and taken little or no exercise. They are often obese, with red and flushed face, complain of heart-burn, sour eructations, flatulency, and other indications of a dys- peptic derangement. [Another form of gout — poor gout — is met with in persons living badly and ex- posed to cold and dampness; these pa- tients are ordinarily lean, with sallow faces. F. Levison.] Immediately before an attack of acute gout the dyspeptic symptoms become aggravated; the bowels are obstinately confined; hsemorrhoidal pain and haem- orrhage is observed. The patients com- plain of headache, vertigo, drowsiness; sleep is-^disturbed by pain or cramps in the calves and elsewhere; there is pain in various articulations; parsesthetic sensa- tions, such as numbness of the fingers, chilliness, etc. Irregularity of the action of the heart is often observed and the pulse is ordi- narily firm and tense; the morbid state of the nervous system manifests itself by mental depression, irritability, bad temper; severe neuralgia is a freqilent precursory symptom, and severe pains of the lumbar region are frequently com- plained of. In spite of all these manifes- tations, the appetite is generally good and the venereal desire is frequently in- creased. The urine is in most cases con- centrated and scanty; in others the mic- turition is free, acid, and abundant, the urine being clear and watery. Just be- fore the attack all the precursory symp- toms commonly disappear and a general sense of well-being may be experienced. Although some of these precursory symptoms are observed in most cases, an attack of gout may well occur without warning; when the first attack sets in the patient may believe that he suffers from a sprain of the affected joint or that the pain is of rheumatic nature and only by repetition of the attack does the real nature of the disease become apparent. In the majority of cases of acute gout the metatarsal phalangeal joint of the great toe is the articulation first attacked; generally on one side, but sometimes on GOUT. SYMPTOMS. 351 both; in subseqiient attacks other articu- lations become involved either of the foot (podagra) or of the hand (chiragra). Almost all articulations may successively or simultaneously be affected, even the articulations of the Jaw and of the spine; the hip-joint and the shoulder-blade are very rarely affected. The attack itself has been vividly de- scribed by Scudamore, Sydenham, and other classics of gout: "The patient has gone to bed without any particular dis- turbance of health and often feels better than for some time; after some hours' sleep he is awakened, ordinarily between 12 and 3 o'clock, by a very intense pain in the great toe. The attack sometimes begins with a slight rigor. The pain soon increases to complete agony, there is much restlessness, and in vain some re- lief is sought by changing the position of the foot. The patient complains of extreme tension and throbbing in the affected joint; the pain, which has been compared to that caused by a tightly- drawn thumb-screw, is aggravated by the slightest touch or vibration, and becomes so intense that nothing at all like it oc- curs in any other joint-disease. "After some hours of this excruciating pain, some relief is obtained, coming gradually or quite suddenly, perspiration occurs, and sleep follows. On the follow- ing day the affected joint is found swelled, red, tense, shining, and tender. Some pain continues all the day, and toward evening it becomes aggravated, reaching almost the same intensity as in the preceding night." The temperature is somewhat elevated; it reaches 102° F., but seldom higher; the pulse varies from 80 to 100. For some days the symptoms may recur in the same manner, then some oedema appears around the affected joint, and successively increases to the fourth or fifth day, when the pain finally commences to decline; the swelling of the affected joint then diminishes, and this is commonly followed by cracking and peeling off of the cuticle: a process accompanied by intense itching. When the great toe-joint or similar small artic- ulations are affected no effusion in the joint can be felt; when larger articula- tions, such as the knee-joint, are at- tacked, this sign is frequently observed. During the attack there is commonly thirst, but no appetite; the patient feels even aversion to solid food and some nausea; vomiting very rarely occurs; the tongue is furred and the bowels consti- pated, or there may be some pale and offensive stools. The urine is scanty, concentrated, and a copious sediment of urates and uric-acid crystals is precipi- tated. When the attack has passed away, the patient often feels better than before it; some weakness, tenderness, and stiffness of the affected joint remains for some days, then complete recovery is estab- lished. The duration of the whole at- tack varies from six to ten days, and may even reach some weeks; in that case there are numerous remissions and exacerba- tions of the attack. All attacks of acute gout do not, how- ever, pass off suddenly; they may super- vene gradually and increase in severity until they reach the true classical form. Sometimes the first attack is more vio- lent, but as the malady progresses the accesses become more prolonged and are not so painful; at first the attack gener- ally comes on once a year, — in the spring; then twice a year, — in spring and au- tumn; afterward at more irregular inter- vals. Only rarely does the malady show itself by one attack only; that may occur when the patient alters his whole manner of life, renounces the use of alcoholic 352 GOUT. SYMPTOMS. stimulants, lives on very frugal diet, etc. As the attacks become more frequent, asthenia increases, the pain is less vio- lent, the duration of the access is longer, the stifEness of the affected joints does not completely disappear, and they re- main enlarged, red, and tender even after the attack has passed away; smaller or larger hard nodules (tophi) are found in the tissues around the joints and else- where, — the case is passing over in the chronic stage. Fig. 1. — Gouty fingers. (Pfeiffer.) As already stated, the first attack of acute gout ordinarily affects the meta- tarso-phalangeal articulation of the great toe; in some cases the knee or the elbow- joint is attacked at the onset. Garrod and other authors state that an injury, such as a sprain or a contusion, may deter- mine the localization of the gouty proc- ess to the inj^ired joint. Charcot ob- served that the articulations of paralyzed extremities were particularly liable to be involved by gout. Cheonic Gout. — Chronic gout may occur as the result of a long series of acute attacks which gradually have weak- ened the constitution of the patient, or it may appear in feeble subjects as the only manifestation of gout. In both cases the joints successively get enlarged, deformed, stiff, — even immovable, — ^nod- ulated, owing to the deposition of urates in their structure. The skin covering them is congested and thin, with large, blue veins; ultimately it may rupture, and discharge whole chalky masses of urates, — tophi,^sometimes followed by suppuration and ulceration. The de- formities of hand and foot are caused by partial dislocations of the phalanges, with deflection of the fingers in various directions; when the affected articula- tions are moved, a scraping sound is heard and felt. In the most advanced cases not only fingers and toes, but also wrist and elbow, ankle-joint, and Imee are stiff and deformed, and at last the patient may be obliged to remain immov- able in his chair or in his bed as an im- potent cripple. In chronic gout urates may be depos- ited in different structures, such as tendons (especially the tendo Achillis), bursse, aponeuroses, and periosteum; in the cartilages tophi may be found, very frequently in the ear, but also in the eye- lids and on the nose. These tophi are generally of the size of a pin's head or a bead; at first they contain a whitish fluid containing crystals of urate; ultimately they become solid and form small, hard nodules. Two cases in which the nails of the big toes were more or less raised, through the increase of the epidermic cellular layer under the origin of the nail ; their free edge was somewhat bent downward. The interior and posterior parts alone remained flat on their beds. At the same time an inspissation manifested itself GOUT. SYMPTOMS. 353 from the anterior end of the matrix to the free end. On scraping out some of the accumulated material it was found to contain crystals of urate of soda. Both patients were subject to plain attacks of the gout. G. Linden (Pacific Pec. of Med. and Surg., Oct., '91). Finger-nodes are divisible into two classes: In one class the nodosities are Achillis. It is sometimes difficult to tell whether they are syphilitic or gouty in origin. 9. The indurations in the skin of the hands, which constitute the "Judson Bury" group. These occur with in- herited gout. 10. The livid indurations in the skin which have been described in sarcoma Fig. 2.— Gouty fingers. {Pfeiffer.) true osseous enlargements, and are of rheumatic origin; in the other class the nodes are composed of urate-of-soda de- posits and are connected with the true gouty diathesis. The outward appear- ances are illustrated by the accompany- ing cuts (Figs. 1 and 2), while the osse- ous enlargement of .the ends of the bones in the rheumatoid eases is seen in Fig. 3. Emil Pfeiffer (Lancet, Apr. 11, '91). Literature of '96-'97-'98. Varieties of nodules that may be met with: — 1. Non-calcareous nodules in the ears in the subjects of declared gout. 2. Fibroid thickenings and little lumps in the hands of those who suffer from' gout. ■ 3. Fibroid thickening of bursse. 4. Gelatinous deposits, sometimes di;E- fused and sometimes nodular. These are much softer than the fibroid variety. 5. The rheumatic nodules of Barlow. 6. The nodules met with in sclero- derma. These are similar to the "rheu- matic nodules," and possibly identical with them. 7. The lumps which often accompany Dupuytren's contraction of palmar fascia. 8. Lumps developed in tendons. These occur most frequently in the tendo melanodes. These occur in adults with inherited or acquired gout. J. Hutchin- son (Hutchinson's Archives of Surg., Apr., '96). In the skin tophi are more rarely foundj btit have been observed in the face. ■ The urine in chronic gout is Fig. 3. — Osseous enlargement in gout. A represents the phalanges from the back, and B the side-view. For purposes of comparison a delineation is given of the dorsal surface of a normal phalangeal joint, — shown in C. (Pfeiffer.) ordinarily pale and watery, sometimes slightly albuminous, and commonly abundant; it contains always casts of renal tubuli, hyaline or granulated. The patients are weak and pale, suffering 354 GOUT. SYMPTOMS. from disorders of digestion; they are sub- ject to cramps, neuralgias, and other nervous disorders. Ieeegular Gout. — Besides the symp- toms directly dependent on or associated with the deposition of urates in the artic- ulations and in other structures, many morbid symptoms have been observed in the course of gout and have more or less correctly been named symptoms of irreg- ular gout: these symptoms may alternate with the regular attacks, and their grav- ity is frequently in inverse proportion to the violence of the true gouty attacks. Symptoms of irregular gout may occur, — an imperfect development of the at- tack, or suppressed gout, — or when in- flammation of the joint from some cause or other (improper treatment) unduly subsides, — retrocedent gout. Almost all internal organs may become the seat of disorders which have been ascribed to gout. Case of obstinate gout in which, dur- ing the attack (the disease involved the penis), continuous priapism resulted, which lasted for twenty-one days. Pathology of the attack believed to be thrombosis in the corpora cavernosa. D. Duckworth (Brit. Med. Jour., Jan. 16, '92). literature of '9G-'97-'98. The absence of excessive heat in joints affected with gout and the fact that some observers have found such joints lower in temperature than surrounding parts, together with the early turgescence of the veins, the redness, and the pain, indicate that the cause of the attack is thrombosis of the vessels about the joints. Balfour (Edinburgh Med. Jour., June, '98). The gouty kidney presents the same signs as the ordinary granular-atrophic kidney, and cannot be distinguished from it, neither by the symptoms nor by the anatomical examination. It will be shown later on that a certain degree of granular atrophy of the kidney is found in all cases of gout; when the renal changes are fully developed, the urine becomes clear and watery, contains urea and uric acid and in deficient quantity, and the patients may die from renal in- sufiicieney. Gouty persons often suffer from gravel and calculosis; oxaluria is frequently met with; chronic cystitis and urethritis may be observed, especially in old persons suffering from gout. In the direction of the nervous system many symptoms of morbid derangement may be observed, such as headache, hemi- crania, vertigo, fainting, sudden delir- ium, mental depression, epileptic fits, and apoplectic attacks. All kinds of neu- ralgia, especially gouty sciatica and costal neuralgia, have been described, and symptoms of disorders of the spinal cord and the meninges and paresis or parses- thesia at the peripheral nerves have also been noted. The vascular disorders are generally caused by atheromatous changes of the large vessels and followed by hyper- trophy and fatty degeneration of the heart. Severe palpitations, intermittent and irregular cardiac action, and weak, very slow or rapid pulse are frequent symptoms in gout. There may be dysp- noea and a feeling of constriction, and true attacks of angina pectoris are not uncommon. Phlebitis, especially of a recurrent form, has been observed among the symptoms of gout by competent ob- servers. Although the digestive system is very commonly deranged, the stomach and the bowels are not liable to specific gouty changes; fatty liver and a tendency to cholelithiasis is frequently observed; severe pain in the stomach or in the bowels may occur, but these seem to be of neuritic origin. The skin is frequently affected. GOUT. SYMPTOMS. Among the diseases of the skin allied to gout may be named erythema, eczema, urticaria, psoriasis, prurigo, and acne. Literature of '96-'97-'98. A patch of eczema, of spontaneous de- velopment, signifies the existence, in the person possessing it, of a gouty diathesis. As it happens, the floor of the external auditory canal is apt to be the first spot on the surface of the body where an eo- zematous inflammation develops. This condition constitutes a valuable guide- post, pointing, as it does, at a very early stage to the existence of a gouty diath- esis. A. H. Buck (Amer. Jour. Med. Sci., Mar., '98). Bronchitis and asthma are often met with in gouty patients; there seems to be a certain antagonism between gout and tuberculosis; at least, it has been asserted by many authors that tiiberculous changes develop very slowly in gouty patients. Persons affected with gout rarely be- come tuberculous, and some patients with tuberculosis have had that disease decidedly checked on the supervention of an attack of gout, because uric acid and urates are antagonistic, not only to the pyogenic micro-organisms, but to the bacillus tuberculosis. MoUiere (Le Bull. Med., No. 18, '88). Obesity and diabetes mellitus are often associated with gout. TJratic deposits have been found in the cornea and con- junctiva; uratie keratitis and iritis and gouty inflammation of the vitreous body have been observed. Case of a gouty patient, of 54 years, who presented, in the anterior elastic lamina and in the proper tissue of each cornea, several opaque foci, connected by anastomosing lines. These opacities were proved to be due to a deposit of ui-ate of soda. Chevallereau (Recueil d'Ophtal., Apr., '91). Following conclusions reached after careful study of five cases of gouty reti- nitis and neuroretinitis : 1. The changes in the fundus are always bilateral, though rarely symmetrical in the two eyes. 2. The degeneration in the walls of the blood-vessels and in the retina caiise marked impairment of central vision, little or no loss of peripheral vision, and never end in blindness. 3. The loss of central vision is always pro- gressive up to a certain point, unless the cause of the lesion is recognized early in the onset and immediately and properly handled. Improvement in the vision after the disease is established can- not be expected. 4. Hsemorrhages into the retina are rare except in the early stage of the disease. 5. The most marked feature in the fundus is the de- velopment of arteriosclerosis and phlebo- sclerosis. 6. Another almost equally pathognomonic symptom is the peculiar, yellowish, granular exudation in the retina, located by the ophthalmoscope around the posterior pole of the eye and generally leaving the macula intact. 7. The changes in the optic-nerve fibres seem to be almost entirely intra-ocular, and cannot be traced for any great dis- tance back of the eyeball. Bull (N". Y. Med. Jour., Aug. 12, '93). Gouty eye diseases occur intermit- tently, often once a year, — are very pain- ful, but subside completely after it time. The subjects are usually adult men, who, though not liable to gout, have suffered from sciatica and the like. A somewhat peculiar form of destructive iritis, usually symmetrical, is occasionally met with in women who inherit gouty tend- encies and have arrived at the climac- teric period. It is sometimes almost painless. In men, the subjects of ac- quired gout, we sometimes see acute and very painful ulceration of the margin of the cornea of a definitely gouty nature, and curable by treatment suited to that diagnosis. Jonathan Hutchinson (Ar- chives of Surg., July, '95). Literature of '9G-'97-'98. The changes induced by the gouty diathesis may consist in seroplastic in- fiammations, with or without perceptible excretion of uric acid. As examples are reported cases of scleritis, iridocyclitis with deposits between the choroid and 356 GOUT. SYMPTOMS. retina, nodules within the sclera, and one typical instance of episcleritis periodica fugax. Moreover, gout may be the indi- rect cause of ocular affections, especially in consequence of certain vascular changes, particularly precocious ather- oma. To this category belong cases of severe relapsing disease of the vitreous humor, which finally leads to cataract, detachment of the retina, and retinitis heemorrhagica. Certain sclerotizing af- fections of the cornea come under the same head. Some cases of glaucoma ex- hibit a relationship to gout. Wagen- mann (Deutsche med. Woch., No. 36, '96). A frequent lesion is an insidious variety of exudative choroiditis, which appears under the clinical picture of so- called serous iritis or iridochoroiditis, usually occurring during the intervals between acute attacks. Of all the obscure ocular lesions caused by an outbreak of gout this is the most treacherous. This lesion of the uveal tract is the most frequent expression of the gouty diathesis. Another less frequent lesion is iritis, associated with zona ophthalmiea, or her- pes zoster of the eye. Another rare expression of goutj' di- athesis appears under the guise of a low grade of iritis, or of the iridochoroiditis referred to, the process being secondary to degenerative changes which affect the retina, and finally resulting in glaucoma. The gouty diathesis is also one of the causes of glaucoma. Robert Sattler (Med. News, Jan. 22, '98). AVhen uratic deposits occur in the mas- toid cells or in the csecnm tympani they ■ may cause deafness. Literature of '9G-'97-'98. Gout is a cause of ear disease, espe- cially producing earache at night and tinnitus aurium without deafness. A ■Baum (Phila. Polyclinic, July 24, '97). Ehinitis and parotitis urica have been mentioned, and also xerostomia, i.e., extreme dryness of tongue and mouth lasting for months. Angina and oesoph-; agismus have likewise been noted. Attention directed to the frequent con- nection between gout and irritation of the mucous membrane, more especially as seen in hay fever and chronic nasal and pharyngeal inflammations. William Davis (Omaha Clinic, Apr., '92). Literature of '96-'97-'98. The symptoms of gouty affections of the throat are very similar to rheumatic affections, though the pain may be more intense. Small tophi have been seen on the vocal cords and at the cricoarytenoid joint, though this condition is exceed- ingly rare. Gouty deposits in the laryn- geal mucous membrane have been diag- nosed as cancer. Watson Williams (Laryngoscope, Apr., '98). The urine of gouty patients is of vary- ing aspect and nature; in persons dis- posed to gout the urine is ordinarily con- centrated, loaded with urates, and a sedi- ment of urates and uric acid is deposited; during the gouty attack the urine pre- sents commonly the same character. In other cases the urine is pale and watery; there is diminution of its principal com- ponents, and traces of albumin may be found. In "poor gout" and in chronic cases which have weakened the constitu- tion of the patient the watery, pale urine is frequently observed. From the investigations of Vogel, Schmoll, Laquer, and Magnus-Levy it appears that before the attack and in the free intervals between them nitrogen is constantly retained in the body, whereas during the attack this is reversed, urea and also uric acid (His, PfeifEer) being excreted at this period in quantities even exceeding the normal. It is only the great proneness of the urine of persons subject to gout to part with its uric acid which is characteristic of that disorder, and not the mere ab- straction itself. While from 3'/s ounces of the urine of healthy persons 30 to 45 GOUT. SYMPTOMS. DIAGNOSIS. 357 grains of uric acid are obtained, from the urine of gouty persons the same quantity of urine only produces 3 to 7 Vs grains. Emil Pfeiflfer (Lancet, Jan. 3, '91). Persons suflFering with gout, acute or chronic, have almost an immediate pre- cipitation in the urine after passing it. If this precipitate is examined chemic- ally, it will be found to differ from uric acid in its ultimate composition. This acid is only found in the urine during an attack of gout, and always in a free or uncombined state, while the uric acid remains in the urine as a, urate and in solution. To this acid, and not to uric acid, the attack of gout is due. C. J. Eademacher (Amer. Pract. and News, June 21, '90). Excretion of the alloxuric bodies (uric acid and xanthin bases) in gouty pa- tients does not exceed that for the nor- mal person unless possibly at the onset of an acute attack. Eommel (Zeitschrift f. kliu. Med., B. 30, H. 1 and 2). Literature of '96-'97-'98. Although there is some increase of the alloxuric substances in the urine during acute attacks of gout, this increase does not overstep the physiological limits. Malfatti (Wiener klin. Woch., vol. ix, p. 723, '96). In gout no increase of the alloxuric substances at all found, and the re- lation between the excretion of uric acid and xanthin bases was normal. E. Schmoll (Zeits.. f. klin. Med., xxix, p. 510, '96). Inability to confirm the statement that in gout the amount of the xanthin bases and uric acid together is increased, or that there is any constant relative ex- cess of the xanthin bases as compared to the uric acid. Laquer (Verhandlungen des Cong. f. innere Med., vol. xiv, p. 333, '96). As already mentioned, a slight albu- minuria may be occasionally found; but, even if that be not the case, symptoms of a disease of the kidneys are never failing in gout. I have examined many samples of urine from gouty patients and found that by the use of a centrifugal appara- tus and a microscope I was always able to detect hyaline and granular easts in it, and am of the opinion that this indica- tion of a morbid state of the kidneys is a constant symptom of all stages of gout. Diagnosis. — The diagnosis of a typical attack of gout is easy not only as regards the localization of the morbid process, but also as to the development of the affection. Chronic gout may be con- founded with other chronic affections of the joints of gonorrhoeal, tuberculous, or neuropathic origin. Generally the diag- nosis is facilitated by the clinical history of the complaint and by the examination of the affected articulation. Eheuiiatoid Aetheitis. — It may in many cases be difficult to distinguish between the chronic gouty affection of a joint and the morbid change caused by rheumatoid arthritis,' — or, as it is more properly called, the polyarthritis defor- mans, — which disease attacks the car- tilages, as well as the bone, and leads to destruction of the cartilage, to prolifer- ation and thickening of the ligaments, and frequently to growths of osseous protuberances. In this malady there is no trace of uratic deposits. The chief points of difference between gout and polyarthritis deformans are the following: In gout hereditary predispo- sition is commonly observed; the disease occurs more frequently in the latter classes than among the poor; it is most prevalent among males; in the clinical history there is often a record of abuse of alcoholic stimulants, beer, or strong wines; the patient may suffer from lead poisoning. Irregular or atypical gout may be known (1) by demonstration, if possible, of uricacidsemia ; (2) the supervention of an attack of regular gout; (3) his- tory of former attacks of regular gout; (4) hereditary tendency to gout; (5) exposure to lead poisoning; (6) 358 GOUT. DIAGNOSIS. ETIOLOGY. habits of life; (7) presence of urine of high specific gravity with latericious sediments; (8) presence of gouty gly- cosuria in the family; (9) chronic in- terstitial nephritis; (10) the result of therapeusis. James Tyson (Jour. Amer. Med. Assoc, June 8, '95). In many cases the appearance of gout has been preceded by repeated attacks of renal colic or by long-continued evacua- tions of iiric-acid sand in the urine. Eenal gout is distinguished from renal calculi by the attacks commencing gen- erally with a chill, the pains always bi- lateral, and the passage of bloody urine is not painful. Mabboux (University Med. Mag., June, '95). literature of '96-'97-'98. Thirty-four cases of gout compared with 49 eases of rheumatism. In the for- mer the attack is more apt to be mon- articular, the pulse is almost invariably of high tension, tophi can be occasionally observed, and in all cases of inflamma- tion of the joints the points of greatest tenderness to pressure were the condyles or malleoli. In the latter disease the pulse is most frequently of low tension; the heart is commonly affected; a num- ber of cases exhibit tonsillitis or pleurisy, and the first attack is nearly always polyarticular. When the joint is acutely inflamed there is much more superficial tenderness, and at the same time there are points of special sensitiveness, usually situated over the tendons in most immediate relation to the joints. When the hips and shoulders are affected it is exceedingly difficult to make, out special points of tenderness in either con- dition. W. H. Thomson (Amer. Jour. Med. Sci., Aug., '96). Frequently (but by no means always) gout begins with an acute attack; tophi may be found on the external ear or else- where. The urine is usually found de- ficient in urea and uric acid by treating it in the centrifugal apparatus, while by examination of the sediment with the microscope, casts of the tubuli, hyaline or granular, will always be detected in quantities more or less great. After the discovery of Eoentgen the X-rays have been used as a diagnostic means; various investigators, especially French, have demonstrated that the uric-acid com- pounds offer no resistance to the X-rays. In a Eoentgen photogram of a hand or foot affected by gout the clear lines be- tween the bones indicating the articula- tions appear quite unaltered, and the extremity resembles very much a healthy extremity and differs only from it by the enlarged outlines of the fingers and toes. Greater deposits, such as tophi, are quite invisible in Eoentgen photograms. The reproduction of a hand or foot affected by polyarthritis deformans presents quite a different aspect; all the articula- tions affected by the disease, even if it be not developed far enough to cause stiff- ness or enlargement of the Joint, have lost their clear, transparent appearance, and are of an obscure, almost black, color. When the joint has been affected for some time, it is absolutely impossible to discern the exact place of the articu- lation, the bones seem soldered together, and that even in cases where a rather good mobility of the articulation still exists. When all these facts are united, the clinical story, the examination of the joint and of the urine, and the aspect of the Eoentgen photogram of the affected parts, the diagnosis will in most cases offer no insuperable difficulty. Etiology and Pathogeny. — Gout is a markedly-hereditary disease affecting men much more frequently than women. As it often occurs in subjects having pre- sented indubitable signs of gravel or uric-acid calculi, it seems to be in some way related to that complaint; it has often been observed that, in a family dis- posed by inheritance to gout, cases of GOUT. ETIOLOGY. PATHOGENY. 359 this malady alternate with cases of uric- acid gravel or calculi; hence the conclu- sion was drawn that both diseases had a common origin: the xirie-acid diathesis. Developed gout is rarely met with before the thirtieth and fortieth years; it begins rarely after the forty-fifth year, but may in hereditary cases even affect children. Typical ease of articular gout in a girl of only 11 years of age. Mabboux (Lyon Med., Oct. 23, '92). Persons who live freely, eat much meat, indulge in alcoholic drinks, and take little or no exercise are most siibject to the disease; but it may also be observed in nervous, lean, underfed subjects, espe- cially when they take much ale or porter and by their employment are exposed to cold and dampness. All sorts of ex- cesses and overwork, bodily or mental, seem to be apt to provoke the attack of gout. Sydenham states that he always had an attack of gout following pro- longed mental labor. "Workmen employed in lead-mills, painters, plumbers, and all persons ex- posed to absorption of lead are extremely disposed to be attacked by gout. (Gar- rod, Lancereaux, and others.) Diffusion of lead in the system inter- feres with disassimilation, or retrograde metabolism, and thereby favors the for- mation of the uric acid and urates of gout. Georges Lemoine and P. Joire (Gazz. Med. de Paris, Jan., '92). literature of '96-'97-'98. The clinical course of lead-gout shows several peculiarities different from those of an ordinary gout: (a) The attack occurs, as a rule, in a person relatively young. (6) Lead-gout has a tendency to spread rapidly over many joints of the body, (c) The localization of the joint- affection has the peculiar characteristic that frequently joints are attacked which in the ordinary gout are never, or but rarely, affected, (d) The tendency to tophi-formation and deformative changes is, in lead-gout, much more marked than in common gout. The prognosis of lead- gout is always unfavorable. Luethje (Zeits. f. klin. Med., B. 29, p. 266, '96). The disease prevails chiefly in cold and temperate climates, especially when the latter is at the same time damp and changeable; gout may, however, be found also in countries where the climate is warm and equal. Cantani found it to be not uncommon in Najjles, and it is fre- quently observed among the Arabs of Algiers. Indulgence in alcoholic drinks and ex- cessive consumption of animal food pre- disposes to gout; it has therefore been called a disease of the well-to-do classes. Of alcoholic drinks, Avines containing a large percentage of alcohol — such as sherry, port, and champagne — have the worst effect; the lighter wines, as claret or Ehine wine^are not so hurtful. Among the malt-liquors ale and porter are reputed to be much more conducive to the development of gout than the lighter kinds of beer; distilled alcoholic beverages — such as gin, brandy, and whiskj' — are by many authors believed to be less liable to cause the development of gout than beer or strong wine. Although gout is a malady which has been known to physicians for thousands of years, its pathogeny and real nature is still a subject of debate. As already stated, the deposition of urates in different structures is the most characteristic feature of gout; the origin of these deposits has consequently been investigated' by many observers. Garrod, in his celebrated work on gout, demonstrated that the blood of gouty patients contains more uric acid than in the normal state. [This was done by mixing a few cubic centimetres of blood-serum or fluid from a blister with 10 or 12 drops of acetic 360 GOUT. KTIOLOGY. PATHOGENY. acid. Threads of cotton were placed in this mixture; this was covered by a watch-glass and left alone for from twenty-four to forty-eight hours. After that space of time the thread was thickly covered with characteristic crystals of uric acid, when the blood was taken from a gouty patient, especially immedi- atejy before an attack. The blood of healthy persons or of patients suffering from diseases not accompanied by uri- csemia does not give the same results. P. Levison.] The experiments of Garrod have been repeated by other observers, and it is now generally accepted that in gout, uric acid, in the form of urate of soda, is found in the blood in excess. DifEerent questions now arise: How and where in the body is the uric acid formed and what is its physiological significance? Which is the uric-acid compound circulating in the blood and excreted in the urine, and how are these deposited to form tophi, etc. ? What is the origin of the uricsemia in gout, and, if uric acid may also be found in excess in the blood in other dis- eases, why are deposits of uric-acid com- pounds only formed in gout? The first question was, until the last few years, generally answered by the statement that uric acid, as well as urea, were products of the metabolism of pro- teids; the normal result of the complete oxidation of these was urea, only a small amount of proteids being left in a state of lower oxidation and excreted as uric acid. In some persons suffering from a slow and incomplete metabolism — retar- dation of metabolism — the oxidation of proteids was less perfect, and a larger quantity of uric acid was formed than in health. In gout the process of nutrition is pri- marily at fault, and conspicuously that part of it which consists in the retro- grade changes and elimination of tissue- products. O.xidation in its various stages and degrees is not thoroughly carried out, and the products of the waste and decay of the tissues, not being sufficiently transformed, linger in the blood and sys- tem, and appear to take an active part in the disturbances which arise. William Savory (Lancet, Jan. 13, '94). Much labor has been spent in calcu- lating the normal proportion of uric acid as to urea in the urine; this has been es- tablished by Haig as 1 to 33. According to this author, every departure from this proportion is pathological. The old theory of the pathogenesis of gout contended that, when retardation of metabolism took place, much more uric acid than normally was formed; the uric acid accumulated in the blood, and when the blood had thus been loaded with the compounds of uric acid, it de- posited them in the articulations, etc. This theory has been overthrown by recent investigations. Kossel, Horbac- zewski, and many other investigators have shown that uric acid is not a prod- uct of the metabolism of the proteids, but that it is formed by the oxidation of nuclein — an albuminous compound which differs from the proteids in that it contains a greater proportion of phos- phorus. The nuclein is contained in the nuclei of cells, and may be prepared from all cellular structures, such as the spleen, the thymus gland, etc. It has further been demonstrated by many experiments that the excretion of uric acid in the urine is increased or diminished by all factors (diseases, medi- cines, poisons, etc.) which give rise to a more rapid or slower disintegration of the cellular elements of the body and especially of the leucocytes. The inges- tion of food causes a temporary leucocy- tosis (digestive) followed by an increase of the formation and excretion of uric acid. The amount of uric acid excreted in twenty-four hours is not much influ- enced by the nature of the food (animal GOUT. ETIOLOGY. PATHOGENY. 361 or vegetable); there is, however, this dis- tinction noticeable: that the more easily digestible animal proteids set up digest- ive leucocytosis and formation of uric acid much quicker than the vegetable albumins, which are difficult to digest. Uric acid and urate of sodium are the direct exciting causes of gout. By repeated experiments it is demonstrated that the production and elimination of urate of sodium is influenced both by food and certain drugs. When the diet was chiefly of meat or animal food the elimination was diminished, causing the urates to accumulate in the system, while the reverse occurred under a vege- table diet. A. Haig (Brit. iled. Jour., July 7, '88). Literature of '96-'97-'98. The theory must be considered as proved which attributes the formation of uric acid in the body to a process of leucolysis, following on a leucocytosis. A review of the literature upon tissue- necrosis in gout leads the writer to state definitely that the process is caused by a poison, probably a nucleic acid, acting in a similar way to that in which tissue- necrosis is caused by lead in plumbism. Froelich (Jour. Amer. Med. Assoc, Jan. 3, '97). While it is easy to increase the quan- tity of urea excreted in twenty-four hours by the ingestion of large quantities of proteids, the excretion of uric acid is not much influenced in that way. Wein- traub. Umber, and Kiihne have demon- strated that the excretion of uric acid may be increased to 2 or 2.5 grammes in twenty-four hours by giving large quan- tities of nuclein, — for instance, 500 grammes of the thymus gland, — whereas the normal excretion of uric acid varies from 0.4 to 1 gramme per day. The augmented formation of uric acid will, of course, lead to a temporary uri- csemia, which usually does not cause any morbid symptoms, but is only character- ized by an extraordinary increase of the excretion of uric-acid compounds in the urine. By chemical investigation of the gouty deposits, these have been found to 'con- sist of an acid compound of uric acid with soda, the so-called biurate, and it has commonly been stated that this was also the composition of uric acid circu- lating with the blood. Roberts has re- cently thoroughly investigated this ques- tion. [Roberts's results have quite over- thrown this theory. In text-books on chemistry, uric acid U=^(CjH2Ni03) is described as a dibasic acid, which can form a neutral (JI.U) salt and au acid salt biurate (MHU). The neutral salt can only be prepared by dissolving pure uric acid in a solution of caustic soda and evaporating to dryness, without the entrance of air. It can never exist in the body and we need not refer to it again. The biurate is the chief compo- nent of the tophi and was supposed also to be contained in the blood and the urine, and under circumstances to be pre- cipitated as a brick-dust deposit. By ex- amining this sediment Roberts found it to be an unstable compound which easily decomposes into uric acid and a soluble compound; by chemical investigations of different order it was demonstrated that the deposit formed by the urine cannot be regarded as a biurate, but is a quadri- urate; i.e., a compound of four equiva- lents of uric acid with one equivalent of soda or potash; its chemical formula is consequently H^u, MHu. This quadri- urate is a very unstable compound, liable to be decomposed into biurate and uric acid; this decomposition is effected by adding distilled water to the sediment and by many other fluids. The gouty tophi consist of biurate, but this salt is almost insoluble in serum, — even, at the body temperature, only in the proportion of 1 in 10,000. F. Levison.] The researches of Eoberts establish that, normally, uric acid exists in the blood as a quadriurate; under special cir- cumstances the quadriurate may be trans- 362 GOUT. ETIOLOGY. PATHOGENY. formed in the blood to a biurate, which gives rise to the deposition of this com- pound in different parts of the body; the more uric acid is dissolved, the more quickly occurs the formation and deposit of biurate, but in all cases the uric acid cannot remain long in solution; if it is not quickly eliminated by the kidneys, transformation of the quadriurate and deposition of biurate is the consequence. In serum rich in soda salts the biurate crystals are more easily separated than usual; irrespective of the acid with which they are combined, the salts of lime and magnesia, of lithia and piperazin do not affect the rapidity and the degree of dep- osition, whereas all salts of potash de- lay the deposition of crystals of biurate from blood-serum. literature of '96-'97-'98. The granular urate is ahrays the pre- cursor of the crystalline form, and in the body-fluids the uric acid circulates in the form of invisible granules of sodium urate. Gouty deposits are only met with in non-vascular tissues, and, as acids and acid salts diffuse more rapidly and read- ily than alkalies and alkaline salts, we must suppose that the alkalinity of the non-vascular tissues is less than that of the blood. Hence if a transudate almost saturated with urate enters such a less alkaline tissue, the solution becomes supersaturated and granular urate is precipitated in the tissue, the precipita- tion being favored by such additional factors as lowered temperature or in- creased concentration of the fluids of the tissue. The precipitation of the granular urate in the spaces of the interstitial tissue and in the lymph-channels is the cause of the various phenomena of gout. In the course of time the urate deposited becomes converted into acieular crystals of sodium biurate, or, under favorable conditions, may be redissolved and dis- appear, and with them disappear the lesions to which they gave rise. C. Mordhorst (Zeits. f. klin. Med., p. 65, '97). The researches of von Jaksch have shown that in various diseases the blood contains an abnormal quantity of uric acid, and different authors have proved this to be the constant result of an in- creased disintegration of leucocytes. A physiological leucocytosis has been ob- served in the first daj^s of life, amounting to the double or triple, followed in the fifth day by a sudden fall of the number of leucocytes almost to the normal; this is accompanied by an excessive formation and excretion of uric acid, giving rise almost constantly to the excretion of uric-acid sand and frequently to the for- mation of uric-acid infarctus in the kid- neys (Gundobin, Fleusburg). Bartels, Laache, Ebstein, and various other iii- vestigators found an extraordinary in- crease of the daily excretion of uric acid in leukaemia; von Jaksch, Lsehr, and Ewing observed a hyperproduction of uric acid and leucocytosis in pneumonia, and similar results have been found in the first stage of carcinomatous and all other diseases accompanied by leucocy- tosis. In all these maladies the hyper- production of uric acid is distinguished only by the increase of the excretion of this compound, but the existing uricse- mia is not conducive to gout or any of the S3'mptoms of this complaint. The pathogenesis of gout is consequently not depending on uricffimia alone, and it is necessary to examine the special condi- tions under which uricEemia may pro- duce gout. Various theories have been proposed to explain this. The best supported of them shall now be shortly discussed. According to Garrod, gout depends on a temporary or continuous decrease in the ability of the kidneys to excrete uric acid, by which an overcharging of the blood with uric acid is caused. Gout, in his opinion, is never caused by hyper- GOUT. ETIOLOGY. PATHOGENY. 363 production of uric acid, but by retention of it, although the progress of the dis- ease is accelerated by temporary hyper- productions. Literature of '96-'97-'98. Uric acid is not present under normal conditions in the blood of man or other mammalian animals, or in the blood of birds, but is normally formed in the kid- neys alone probably by conjugation of urea Tvith glycocin. In gout uric acid is present in the blood as the soluble sodium quadriurate, and in this form has no toxic action. It is deposited from the blood as sodium biurate, and this crystal- line deposit acts passively and physically as a foreign body in the affected tissue or organ. The presence of uric acid in the blood in gout is due to deficient ex- cretion by the kidneys and its subse- quent absorption into the blood from those organs ; and in all probability such accumulation is always preceded by an affection of the kidneys either functional or organic, the most likely seat of which is the epithelium of the convoluted tubules. There is a second source of uric acid in the system, and that in such dis- orders as leucocythaemia it is formed from nuclein also, and passing into the blood is rapidly eliminated by the kid- neys. A. P. Luff (Lancet, vol. i, pp. 857, 933, 1069, '97). Garrod found a distinct diminution of the percentage of uric acid in the urine as well in chronic gout as in the acute cases, except during the attacks, when more uric acid than commonly was ex- creted; he, therefore, regarded the gouty attack as a salutary process which tends to deliver the system of its surplus of uric acid. It is to be regretted that the analytical methods used by Garrod (Heintze's method and the thread method) are not reliable enough to give full evidence to the correctness of his statements. [Dyce Buckworth ("A Treatise of Gout," London, '90) and various other authors believe the cause of gout to be a functional disorder of a definite tract of the nervous system; this is, however, only a supposition, and, even if his state- ment be accepted, it only removes the question to another field as long as the origin of the nervous derangement is not elucidated. Ebstein ("Xatur u. Behandlung d. Greht") agrees with Garrod in the belief that in gout the blood is overcharged with uric acid, but he does not think that this arises from an affection of the kidneys. According to Ebstein, a pri- mary gouty affection of the kidneys is a very rare occurrence; most frequently the kidneys remain for a long time healthy, and are only affected in the course of the disease in the same way as the articulations, etc. Ebstein's theorj' is that in gout uric acid is formed in excess in the body and that the hyper- production also takes place in regions which ordinarily do not produce uric acid — as for example, the bone-marrow, the cartilages, etc. When the blood and the lymph are overcharged with uric acid, it may act as a chemical poison, causing morbid processes in the tissues and giving rise even to necrobiotic changes; when these have reached a cer- tain degree the biurate is deposited in the necrotic parts of the structures, whereas such deposition is never found elsewhere. The theory of Ebstein must now be abandoned, as various authors, — such as Roberts, Cornil, and Eiehl, — have found the crystals of biurate in comparatively healthj' tissue, and have demonstrated that, after redissolution of the crystal needles, it was in many eases impossible to discover traces of necrobiosis in the structures in which the crystals had been imbedded. Moreover, experiments conducted by Ebstein and Nicolaier have demonstrated that it is impossible to in- ject large quantities of dissolved uric acid in the veins of animals or in their peritoneal cavity without causing serious damage; the kidneys, which are obliged to excrete such excessive quantities of uric acid, are alone irritated mechanically by the crystalline uric acid precipitated in them. Pfeiffer (Berliner klin. Woch., '92; 364 GOUT. ETIOLOGY. PATHOGENY. "Handbuch der specieler Therapie," B. 1) believes that the precipitation of urates in gout and of uric acid in the kidneys in gravel are caused by a com- mon uric-acid diathesis in which uric acid is produced in the body in a modi- fied, almost insoluble form. In gout the uric acid is deposited as biurate without causing any morbid symptom, but when from any cause — as, for example, by the ingestion of alkaline drugs — the alka- linity of the blood becomes so great that the blood redissolves the urates, they give rise to irritation and inflammation. The experiments of Pfeiffer, as well as his conclusions, have been contradicted by Roberts and many other observers. The urine of gouty patients is not al- ways more liable to precipitation of uric acid than normal urine, and, as Preud- berg states, the alkalinity of the blood varies but little and cannot be modified by the commonly used doses of alkalies or acids. Van Noorden ("Pathologic des Stoff- wechsels,'' Berlin, '93) has proposed a new theory without trying to prove it. In his opinion gout is an inflammation of nervous structures caused by an un- known irritant; by this inflammation a fermentation is set up, giving rise to a local formation of uric acid in the dis- eased tissues. Another theory is proposed by Kolisch (Wien. med. Woch., '95). This author admits that the uric acid cannot be regarded as an irritating poison causing inflammation and necrobiosis, but he points to the fact that, when uric acid is formed by the disintegration of nu- clein, it is always combined with a series of basic products, — the alloxur bases (xanthin, hypoxanthin, adenin, guanin), — which, by injection in the veins of ani- mals, manifest violent toxic effects. In Kolisch's opinion, the alloxur bases are changed into uric acid by the healthy kidney and excreted as such; in the uric-acid diathesis the alloxur bases are formed in excess in the body, the kidney is overcharged and cannot convert them into uric acid; the alloxur bases are excreted in abnormal quantity and set up irritation of the kidneys as well as of the various structures of the body, and only when this inflammation has taken place the deposit of biurate occurs as a secondary symptom. This ingenious theory has already been abandoned, many observers having found that the chemical method (Kruger-Wulff) by which Kolisch demonstrated the excess- ive excretion of alloxur bases in gout, was not reliable, and that, moreover, the excreted quantity of alloxur bases varies so much as well in health as in disease that no conclusion can be drawn from their quantitive estimation. F. Levi- SON.] The phenomena of gout cannot be ex- plained by a mere crystallization of urate from the blood or by the production of necrotic changes due to its presence in the circulation, seeing that in other con- ditions in which uric acid is present int excess in the blood — such as leucocy- thsemia and chronic nephritis — neither uratic deposits nor necrosis of cartilage are met with. Some unknown sub- stances produce in gouty persons inflam- mation and necrotic changes in various tissues, and the necrosed tissues possess the power of attracting to themselves the excess of uric acid in the blood, while the chemical affinity of the necrosed parts for uric acid prevents the deposits from being redissolved by the blood. G. Klem- perer (Deutsche med. Woch., xxi, p. 655, '95). Although in the light of all the the- ories on the pathogenesis of gout dis- cussed above and of the observations of innumerable investigators, many ques- tions regardiilg the real nature of this complaint are still left unanswered, some facts are nevertheless settled beyond all doubt. It is proved that in various diseases the blood contains an excess of uric acid and that gout is one of these diseases; secondly, it is certain that an excess of uric acid does not cause the deposit of biurate as long as the kidneys are healthy and their action normal. In all described cases of gout, in which the post-mortem examination is men- GOUT. ETIOLOGY. PATHOGENY. 365 tionedj the kidneys have been found dis- eased, and in almost all cases they were suffering from granular atrophy. Ebstein reported two clinical cases of gout in which the kidneys had been found healthy, but close investigation revealed the fact that the cases were so incom- pletely described as to be utterly value- less in that respect. In all cases of granular atrophy of the kidneys, the power of elimination of the kidneys as regards uric acid, as well as various other substances, is diminished. Charcot found it defective under the administration of turpentine, which does not give the urine the characteristic odor ■ of violets when the Iddnej^s are granular atrophic. The consequence of this de- fective elimination of uric acid is its re- tention in the blood (von Jaksch), and various observers (Ord and Greenfield, Norman-Moore, Levison, Luff) have demonstrated that in granular atrophy of the kidneys deposits of biurate in the joints are very frequently foimd, even when no symptom of gout has been mani- fest during Life. Lead poisoning resembles gout in giv- ing rise to an excess of uric acid in the blood, although it is not accompanied by leucocytes or increased disintegration of whole blood-corpuscles. Now it ap- pears from experiments on animals (Charcot, Binet, Coen, and d'Ajutolo), as well as from observations of persons exposed to lead poisoning, that one of the earliest and most constant symptoms of this disease is a pathological change of the renal tubnli conducive in rather short time to granular atrophy of the kidneys. This accords very well with the fact that lead poisoning is very liable to give rise to gout, and that Gar- rod, Lancereaux, and various other ob- servers have found that a large percent- age of their gouty patients suffered also from the consequences of lead poison- ing. It has been proved by many experi- ments that continued irritation of the Iddnej^s by chemical or mechanical irri- tants leads to inflammatory processes and formation of new connective tissue, resulting in granular atrophy. When the kidneys of patients suffering from gravel and calculi for some time are ex- amined granular atrophy is always found. AVhen gouty persons are attacked by an intercurrent disease causing a tem- porary hyperproduction of uric acid, — as, for instance, pneumonia, — they are sure to get an attack of acute gout in connection with it. When all these facts are combined and confronted they seem without exception to point to a theory of gout closely allied to the views proposed by Garrod. Gout and its principal symptom — the deposition of biurates — occurs when the blood remains for some time overcharged with uric acid which cannot be elimi- nated by the kidneys on account of a decrease of their secretory power, which, in turn, is caused (with very few excep- tions) by granular atrophy more or less distinctly developed. In all cases of gout the kidneys are diseased, and the gout can never develop as long as the kidneys remain healthy. The morbid state of the kidneys may either be due to inherited predisposition (gout in chil- dren, early gout hereditary in families) or be acquired by chronic irritation (lead poisoning, abuse of alcoholic stimulants,, uric-acid gravel and calculi). As long as the deposition of biurates progresses very slowly no symptom whatever is caused by it, and it is even possible that the deposits may be redissolved without hav- ing caused pain or injury at all; but when the deposits grow too large or when from any cause (excesses of every kind, 36G GOUT. PATHOLOGY. intercurrent diseases, etc.) the produc- tion of uric acid gets very large, the de- posits increase quickly, the lymphatics are obstructed, and a genuine attack of acute gout is produced. Injudicious therapeutics, such as the abuse of alka- line remedies or springs, are liable to produce attacks of gout by the ingestion of large quantities of sodium salts, which have a distinct deterrent influence on the solution of the quadriurates in the blood. This theory does not explain all the various and anomalous symptoms of gout, and the question is left unanswered as to why all patients suffering from granular atrophy of the kidneys are not attacked by gout; but it has the advan- tage that it brings into one category all the etiological and pathogenic factors with which we are acquainted, and gives a plausible explanation of the origin of gout as well of the rich and overfed classes as of the poor and badly nour- ished. By this theory the close alliance of uric-acid gravel with gout becomes intelligible, and the enigmatic gout caused by lead impregnation has a ra- tional explanation. Pathology. — The most characteristic pathological change found in gout is the presence of deposits of biurate in various tissues. The order of invasion is fairly constant: the diarthrosial cartilages are the first to be affected; then the liga- ments, tendons, and burste; next the con- nective tissue and the skin become im- pregnated. Of the articulations the metatarso-phalangeal joint of the great toe is generally first affected, then the different metatarso- and metacarpo- pha- langeal articulations, the tarsus and carpus, and next the larger joints; but their order is not constant. Almost all joints are attacked by gout, — perhaps with the exception of the hip-joint. The deposit first occurs in the superficial part of the cartilage close under its surface, in the form of fine, crystalline needles forming a more or less close net-work and presenting different degrees of opacity; sometimes it may be so small as to require the aid of a microscope for its detection. At first the central parts of the cartilages only are impregnated, whereas the peripheral tissues are free from deposits, but present some vascu- larization. Subsequently the fibrocar- tilages, ligaments, and synovial mem- branes become involved with white chalk-line deposits consisting of biurate; the synovial fluid may also contain crys- tal needles. The articulations become stiffened or fixed and ultimately they are greatly distorted and nodulated. The skin covering the affected joint becomes distended, and it may even be destroyed, exposing chalky masses, which break down and are successively evacuated, frequently giving rise to suppurative and ulcerative processes of the skin. It does not mean that the deposit is specially in- filtrated in the cells, but rather that it pushes its way without special regard as to the component elements of the car- tilage. The periosteum and bursse may also be implicated, and some authors have even believed that the bone itself may become affected. Virchow has described isolated infiltrations of biurates in the spongy tissue of the phalanges, and in the marrow of the bones ' deposits may occur, mostly, but not always, in the neighborhood of incrusted cartilages. llarchand and Lehmann have made chemical analysis of bone-tissue of gouty patients, and found that when the car- tilages and the periosteum were removed the osseous tissue itself did not contain uric acid. Garrod observed that in gout of long standing the osseous tissue of the phalanges may become rarefied and the GOUT. PATHOLOGY. 367 vacuoles filled witli fat; by this process the bones are rendered more fragile than in the normal state. Heberden observed a knotty or bosse- lated condition of the terminal phalan- geal joints; this pathological state of the fingers has been known as Heberden's finger. In Heberden's opinion, the knots are not of gouty origin, but caused by arthritis deformans; a similar formation of the phalanges may, however, also be observed in gouty patients in very ad- vanced life. Deposits may be found in various other parts of the body, siich as the ex- ternal ear, eyelid, nose, and larynx; they form there nodules — tophi — which at first contain a liquid, but after some time get hard. Garrod evacuated from a single tophus of the hand 60 grammes (2 ounces) of biurate. The muscles of gouty patients are or- dinarily atrophic, especially when the extremities get stiffened and immovable. The heart is frequently hypertrophic; myocarditis may occur, leading to the formation of fibroid or fatty degenera- tion of the mxiscles. The endocardium is sometimes in a state of chronic in- fiammation, and uratic deposits have been observed in it. In the aorta arte- riosclerotic changes and uratic deposits have been noticed. Literature of '96-'97-'98. In the concretions in sclerosed aortic valves urates can sometimes he demon- strated by the murexide reaction, along with calcium phosphate and carbonate. More frequently gout causes valvular lesions indirectly as the result of sclerotic changes, but in this process other factors, such as abuse of alcohol or tobacco, lues, or overeating, assist. Gout is more prone to cause motor and sensory cardiac neu- roses. Beginning with palpitation, soon followed by tachycardia, dilatation of the ventricles develops, with all its con- sequences. The sensory disturbances vary from mild, pricking pain in the region of the apex or more severe radi- ating pains to paroxysmal pain, with tenderness on pressure over the sternum or the base of the heart. The latter con- dition is often associated with symptoms of heart-weakness and can lead to angina pectoris. The prognosis in pure cases, not too far advanced, is good under proper treatment. Th. Schott (Berliner klin. Woch., Nog. 21 and 23, '96). In the digestive tract congestion and a catarrhal state are found^ as well as ulceration of the mucous membrane; but, as the ulcerations are observed only when the granular atrophy of the kidneys is fairly developed, they are probably caused by the renal disease and cannot be regarded as directly gouty. The liver is commonly enlarged and in a state of fatty infiltration or of inter- stitial hepatitis; when this is the case, the spleen may also be enlarged. The kidneys are always more or less pathological. In the large majority of cases they are granular, — atrophic: the kidney is contracted with a rough and granulated surface, small cysts are com- monly seen on it, the capsule is adherent in different places, the color of the organ is red, the cortical substance warty and granular, and the walls of the arteries generally thickened; in short, the gouty kidney is identical with the small, granu- lar kidney. In some cases deposits of bi- urate are found in the tubuli or between them, appearing as whitish points or lines in the red structure of the organ. Uratic deposits may also be found in the pelvis and in the bladder. literature of '96-'97-'98. In connection with the atheromatous changes which take place in the arteri- oles in gout is the gradual progress of the renal disease, the organ being af- fected in spots, with intermissions in the degenerative changes which are micro- 3C8 GOUT. PKOGNOSIS. TREATMENT. scopical in size, until finally large areas are involved. In those eases the glome- ruli and tubules are attacked in a way at times to cause scarcely an appre- ciable symptomatology, whereas the same change coming on suddenly, as in cases of a different etiology, cause strik- ing clinical and urinary manifestations. The arterial changes in the nervous sys- tem lead to various nervous disturbances by interference with the nutrition of nerve-centres. Cerebral manifestation may arise from uraemia or from throm- bosis of the cerebral arteries. N. S. Davis, Jr. (N. Y. Med. Kec, July 10, '97). A few observers have noticed the pres- ence of urate deposits in the meninges of the brain and in the neurilemma of periplieral nerves. Prognosis. — Acute gout is rarely im- mediately fatal; the attacks are very liable to return, but much depends on the mode of living adopted by the patients. Chronic gout decidedly shortens the life of the patients and often results in crip- pling them completely. The kidneys are always diseased in gout, and, when the granular atrophy of the kidneys devel- ops to its utmost, there may be serious danger from the retention of the con- stituents of the urine, and gouty patients may die from uraemia. Gout diminishes the power of resist- ance against acute disease and injuries; many gouty patients, nevertheless, reach an advanced age. The prognosis of gouty heart is de- cidedly good. T. Mitchell Bruce (Prac- titioner, Jan., '95). Treatment. — Prophjdactic treatment of gout is of the greatest importance, not only to prevent the first attack in the case of hereditary disposition, but also after the first attack to prevent or at least delay recurrences. Gouty patients should avoid all aliments containing much nuclein, which, necessarily, tends to increase the percentage of uri.e acid in the blood; hence are contra-indicated all glands and internal organs composed chiefly of cells, such as brain, kidney, liver, and especially thymus gland; also meat-extracts contain much nuclein and are not to be allowed. Eggs do not con- tain nuclein, but paranuclein, which in the body is not decomposed into uric acid, and moderate quantities of eggs, therefore, can be eaten by the patients. As the proteids do not change into uric acid, there is no reason to prohibit meat or fish in moderate quantity; about 200 grammes daily is quite sufficient, and a larger quantity will only tax the digestion and the secretory power of the kidneys. Every influence which may lead to irri- tation or injury of the kidneys must be eliminated, and in particular alcohol and diet that might increase the amount of irritating alloxins must be interdicted. Among the latter are flesh rich in cellu- lar constituents, while muscle, particu- larly such as has been boiled, is permis- sible. The carbohydrates and fats may be allowed. Milk and eggs are entirely unobjectionable, as the nucleins con- tained do not form alloxins. Of the veg- etables, salads and greens, excepting such as asparagus, are useful. Overexercise should be avoided on account of the tendency to increase the alloxin produc- tions. Kolisch (Wiener klin. Wooh., No. 45, '95). Literature of '96-'97-'98. In various cases of gout the prolonged administration of only red meat and hot water has resulted in marked improve- ment, which persists in spite of gradual return to an ordinary dietary. It is the complex chemical changes brought about by the admixture of red meats with car- bohydrates and sugar that causes the excessive formation of uric acid. The pa- tient is given daily allowance of from 1 to 4 pounds of lean beef-steak, minced and cooked in various ways, the patient drinking from 1 to 5 pints of hot water, GOUT. TREATMENT. 369 and avoiding all starchy, saccharin, and fermentative articles of food. This treat- ment is indicated in obstinate chronic gouty arthritis, in recurrent urie-acid calculi, in frequent and intractable mi- graine, and in cases of persistent gouty dyspepsia. This treatment should be prescribed but rarely, and then only under the most careful supervision in cases in which the heart or kidneys are discussed. Used with due care, it is a most efiBcient and brilliant addition to the therapeutic measures. Armstrong (Brit. Med. Jour., May 1, '97). The uric acid taken in the food consti- tutes the bulk of the uric acid elimi- nated. The avoidance of animal food containing xanthin compounds or uric acid, and also tea, coffee, and cocoa, whose alkaloids are similar xanthin com- pounds, will gradually eliminate excess of uric acid in the system. The time when this may be accomplished may be deter- mined by administering a dose of salic- ylate of sodium. If any of the excess of uric acid still remain in the system, this drug will cause an immediate great increase of the uric acid as compared with the urea. If anyone taking a dose of salicylate of sodium gets as a result an excretion of uric acid greatly above the relation to urea of 1 to 30, such per- son is not free from uric acid. A. Haig (Brit. Med. Jour., Mar. 27, '97). All sorts of farinaceous aliments, bread, milk, and vegetables of every kind are to be allowed. For gouty patients a diet of fresh vegetables and fruits, with meat spar- ingly, and the exclusion of sugars and starches recommended. To remove the diathesis active physical exercise, alka- line baths followed by friction, and the use of lithium salts well diluted. Noth- nagel (Internat. klin. Rundschau, Feb. 14, '92). Literature of '96-'97-'98. Administration of milk increases the excretion of xanthin bases and reduces that of uric acid. Increased quantity of liquid (water) in the diet increases the alloxin bodies (uric acid and xanthin bases) in healthy persons. Fatty milk, according to Gartner's formula, is recom- mended as a suitable diet for all cases of gout. Laquer (Berliner klin. Woch., Sept. 7, '96). Tliere are three great manifestations of the same condition. These are rheuma- toid arthritis; podagra, or true gout; and articular rheumatism. One must not attempt to treat gout, but treat the subject who comes before him. There is no diet for the gout, but there is a diet for the patient. Xevertheless, in the large majority of cases sugars and starches must be cut off. But in spare gouty subjects farinaceous diet may be essential. Milk probably suits the largest number of gouty patients. Pa- tients who can take but little exercise at first can gradually be led up to the point of taking a great deal of exercise, and this is essential for prevention of further attacks. Strontium salicylate is less disturbing than salicylate of soda. In some instances it agrees better with the patient when combined witli digitalis and strychnine. Medicines, however, will not eradicate tlie diathesis. H. C. Wood (X. Y. Med. Eec, July 10, '97). It is useful to prescribe rather large quantities of inoffensive beverages, such as pure water and milk, especially skim- milk or butter-milk, to favor the free action of the kidneys. The quantity of urine per twenty-four hours ought to be about 1500 to 2000 grammes (3 to 4 pints). Alkaline springs have been niuch recommended, and when they do not contain too large quantities of soda they may be taken in moderate doses. Their use, however, should not be ex- aggerated, as the ingestion of much soda in the blood is liable to accelerate the deposition of biurate, and thus provoke an attack of gout. The light wines — such as Bordeaux, Mosel, and Ehine wine — may be allowed in small quantity; the stronger wines — such as sherry, port, champagne, etc., as well as ale and porter — are to be 370 GOUT. TREATMENT. strictly prohibited. The pernicious effects of the stronger alcoholic drinks are proved by numerous observations, and are probably due to the power of alcohol to increase the formation of uric acid and to facilitate the deposition of urates. The deleterious effects of alcoholic liquors in producing gout depends very much upon the incompleteness of the process of fermentation by which they are produced. The sugar alone is not claimed to be injurious, but only when taken with the alcohol or some other article of diet that induces it to foment in the digestive organs. Editorial (Nice-mfid., July, '92). Literature of '96-'97-'98. Attention called to the fact that those accustomed to a, saccharin diet have no special tendency to gouty arthritis, and that the urine of herbivorous animals, in whose diet sugar plays an important part, is alkaline in reaction. The re- lation of champagne to gout is difficult to determine, as the constituents of vari- ous preparations vary greatly. Of its constituents, sugar is, according to the author's view, the least and acetic acid .the most harmful. G. Harley (Lancet, Aug. 1, '96). Open-air exercise is very useful in the treatment of gout, and, when possible, gouty patients ought to spend their holi- days in regular active exercise, such as walking, cycling, riding, etc. Tbeatmext of the Acute Attack. — Abortive treatment of an acute attack of gout has repeatedly been tried, but it is not to be recommended, being attended with great risk. The method proposed has been snapping the affected joint with adhesive plaster; the application of snow or ice; the hypodermic injection of morphine; large doses of colchicum, etc. Undoubtedly the attack may be stopped short by these methods, but very danger- ous symptoms, such as fainting, disorder of the action of the heart, etc., have been observed as the immediate result of these procedures. Although medicine has now abandoned the old maxim that during the attack the affected joint was only to be treated "with flannel and patience," the treat- ment of the attack ought not to be too active. The patient should remain in a recumbent position, though not neces- sarily in bed, for some days; the affected limb should be raised and supported, kept warm, and protected from pressure. The pain is relieved by warm alcoholic lotions, application of opium ointments or liniments; menthol in an alcoholic solution. Ointments of ichthyol are also to be recommended. In mild attacks of acute gout, abso- lute rest, diluent drinks, and the applica- tion to the affected joints of an ointment composed of sodium salicylate, 1 'A drachms, and lanolin, 1 '/j ounces, recom- mended. W. Morain (Bull. G6n6ral de Th6rap., July 30, '95). Most of the remedies are useful, mainly through the suggestion of relief they afford to sufferers. Blood-letting and blisters were formerly in use, but are now generally abandoned. English practitioners often begin the treatment of an attack of gout by the administration of a free purgative: calo- mel and jalap or mistura senna com- posita. Best results obtained from giving fractional doses of calomel at the begin- ning of an attack of gout until it freely moves the bowels. F. Grimm (Le Pra- ticien. May, '93). Of remedies directed toward the gouty process itself colchicum is the most effect- ive; its mode of action is obscure, but it seems to relieve the pain better than any drug; colchicum is ordinarily prescribed as wine of colchicum and may well be combined with tincture of aconite; 25 GOUT. TREATMENT. sri minims of wine of colehicnm with 3 to 5 minims of tincture of aconite may be given three or four times daily. The use of colchieum ought only to be continued from four to six days, as it is liable to produce nausea and diarrhoea, and even paralysis of the nervous centres when taken too long a time. A very active principle of colchieum — the colchicine— has also been employed. As soon as the anodyne effect of colchieum has been reached the use of the drug is to be dis- continued. Under any circumstances, however, it should no longer be given when nausea or diarrhoea sets in. Colchieum is par excellence the specific for gout. Lecorchg (La Jled. Mod., July 14, '94). Literature of '96-'97-'98. To cheek the excessive formation of uric acid, liver-metabolism should be promoted, and congestion of the portal system relieved by regulating the diet and regimen. Colchieum and guaiacum, as stimulants of hepatic metabolism, are very useful in many forms of gout. Con- stipation and the congestion of the por- tal system may be relieved by occasional doses of blue pill followed by an Epsom- salt purge. To promote the elimination of the quadriurates formed in the kidneys and so prevent their absorption into the blood is to strike at the primary evil in the causation of gout. To promote this, diu- resis should be increased and the acidity of the urine diminished. Citrate of potassium is a good diuretic which not only increases the solubility of the quad- riurates, but also diminishes the acidity of the urine, and should be pushed until moderate alkalinity of the urine is pro duced. The removal of uratie deposits and the elimination of quadriurates and biurates from the system may be attained by free diuresis, baths, and suitable exercise, and the careful selection of a mixed diet with a fair amount of vegetable food, since the mineral constituents of certain vegetables — such as Brussels sprouts, cabbage, French beans, spinach, turnips, and turnip-tops — possess to a remarkable degree the double function of inhibiting the conversion of sodium quadriurate into the biurate and increasing the solu- bility of the latter; but the idiosyn- crasy of each patient to various articles of diet must be made the subject of care- ful observation. Luif {Indian Med. Rec, July 1, '98). Although the salicylates are certainly inferior to the colchieum, it is advisable to try them when colchieum is not well borne or when it fails to alleviate the pain. Generally the salicylate of sodium is used; the salicylate of lithium has also been recommended. Literature of '96-'97-'98. Sodium salicylate causes an increased excretion of uric acid, because it eauses an increased formation. Bohland (Cen- tralb. f. innere Med., vol. xvii, p. 70, '96). The clearing of the system of uric acid by alkalies or salicylates leaves the prin- cipal part of the work undone, which is the use of suitable remedies to correct the faulty metabolism in whatever sys- tem the disease first arose. M. A. Boyd {Lancet, Aug. 8, '96). When the pain has subsided and the swelling of the joint is somewhat dimin- ished, gentle use of the joint and careful (but not energetic) massage are useful. In the interval between the attacks the tendency to renewed attacks by the prolonged use of alkalines is of impor- tance. Of these the carbonates and the phosphates of sodium and potassium and the carbonate of lithium have been most employed, but their use is now known to be based upon fallacious deductions. [The administration of alkalines is based upon the theory that gout is caused by a lessened alkalinity of the blood. The alkaline remedies, by aug- menting the alkalinity, would increase the power of the blood to dissolve uric acid and thus prevent the deposit of biurate. 372 GOUT. TREATMENT. The experiments of Roberts have quite destroyed this fundamental hypothesis by proving that in gout there exists no abnormal aeiditj' of the blood and that addition of carbonates or phosphates of alkalines to blood-serum impregnated with uric acid does not retard the pre- cipitation of biurate; the alkalines are consequently without power to prevent the formation of uratic deposits, and salts of soda may even prove directly per- nicious when taken in large doses. Carbonate of lithia was introduced in the therapeutics of gout by Garrod ex- pressly on account of its chemical action. A solution of carbonate of lithia has great solvent power on uric acid, and from this fact it was inferred that lithia administered internally might communi- cate its power to the urine and the blood, and that in this way as well the formation of uric-acid gravel as the dep- osition of biurates in gout might be / prevented. Neither of these inferences are justi- ' fled. Mendelsohn (Berl. klin. Woch., '93) has shown by numerous experiments that the urine of persons to whom car- bonate of lithia had been freely admin- istered did not dissolve more uric acid than normal urine, and he observed, moreover, that the addition of normal urine to a solution of uric acid, effected by the aid of carbonate of lithia, was sufficient to precipitate almost all the uric acid contained in it. When carbon- ate of lithia has some value in the treat- ment of gravel it is only on account of its action as a powerful diuretic. Roberts demonstrated that the addition of carbonate of lithia to blood-serum or to synovia has not the slightest effect to enhance the solvent power of these media on sodium biurate or in retarding its precipitation from serum or synovia im- pregnated with uric acid. F. Letison.] Various basic organic products — piperazin, lycetol, lysidin — have recently been recommended as specifics for uric- acid gravel and gout on account of their power to dissolve uric acid. Mendelsohn has tried the effects of all these eom- potmds, and found that urine saturated with them does not dissolve uric acid any more than normal urine, and they are, of covirse, still more ineffective when circulating in feeble concentration with the blood. In an old gouty case, by daily injec- tion of 5 minims of hydrochlorate of piperazin, the uric-acid deposit in the urine was very materially lowered. Bar- det (Munch, med. Woch., June 16, '91). Piperazin highly recommended in the treatment of both acute and chronic gout. It may be given to the extent of 15 grains per day, largely diluted with water. Sehweininger (Jour, of the Amer. Med. Assoc, Sept. 24, '92). Lysidin has proved to be a powerful remedy for gout, the pain ceasing soon after its use is begun, the joints becom- ing supple and the tophi diminishing. E. Grawitz (Deutsche med. Woch., No. 41, '94). Literature of '96-'97-'98. In acute gout piperazin causes a rapid amelioration of the pain and a, progress- ive diminution of the swelling and red- ness. In chronic gout it appears to have an elective action upon tophi and upon the articular stiffness. The author has seen voluminous tophi disappear and de- formed Hmbs assume an almost normal aspect, due to the persistent usage of the remedy, which is possible by its harmless action upon the organism. Delmis (Gaz. des Hop., Mar. 5, '96). Uricedin, a new remedy proposed by Mendelsohn, is a combination of citrate of sodium, sulphate of sodium, and small quantities of common salt and citrate of lithium. It may be of use in the treat- ment of uric-acid gravel, but in gout it is about on a level with the other com- pounds of soda. Mineral Sphings. — A considerable number of springs to which gouty pa- tients commonly resort are strongly im- pregnated with the salts of soda; it is not, therefore, surprising that not .infre- quently the first result of the cure is to GOUT. TREATMENT. 373 provoke an acute attack of gout or to aggravate the symptoms with which the patient was suffering. The physicians practicing at these resorts are accus- tomed to consider this aggravation as of good augury. Perhaps they are riglit, as it does happen that a patient, who for some time has been laboring under the preliminary symptoms of goiit, feels better when the attack has passed over and a large quantity of uric acid has been removed from the blood; but it is a rough mode of cure, and many physicians, es- pecially the English, now advise the pa- tients to avoid strong alkaline springs or to take them very sparingly. Eoberts resumes his opinion of the strong alka- line springs (Vichy, Carlsbad, etc.) in the treatment of gout in the following words: "It is difficult to believe that they can do any direct good, and easy to believe that they can do direct harm." In cases of gout in which the urine constantly precipitates crystals of uric acid, it is advisable to prescribe some alkaline remedy or alkaline spring-water, to prevent the precipitation and the irri- tation of the kidneys caused by it; the doses should, however, be regulated by the degree of acidity of the urine, and not more of the alkaline drug is to be taken than necessary to reduce the acid- ity of the urine to the normal level and thus render it limpid and without deposit of crystals. Some springs are devoid of the dan- gers dependent on the use of the strong alkaline waters, as they do not contain the salts of soda or only very small quan- tities of them; they are either aerated, contain but little besides the pure, warm water, or they contain some carbonate of lime or sulphate of lime; in many cases the free use of these springs, combined with 'douches, moor-baths, massage, and hydrotherapeutics in its different appli- cations will be useful, especially against the stiffness of the joints remaining after acute attacks. Hydrotherapy recommended in the treatment of gout, but not during the attack. Eubino (Blatter f. lUin. Hydro- therapie und verwandte Heilmethoden, June, "93). Among the most renowned springs of this kind may be mentioned Buxton and Bath, in England; Aix-les-bains and Contrexeville, in France; Wildbad, Gas- tein, and Pfeffers, in Germany and Swit- zerland; and Sandifjord, in Norway. Of the drugs which have been recom- mended against goiit, guaiac merits special mention. It was introduced by Garrod, and is administered in a dose of 7 to 10 grains of the resin daily, ordi- narily combined with iodide of potas- sium or quinine. It seems to have a very good effect in many cases, as it is well supported by the patients, even under protracted use. It seems to retard the return of the gouty attacks. Literature of '96-'97-'98. Guaiac does not effect the formation of uric acid, but acts directly upon the kidneys as a stimulant, enabling it to get Tid of any accumulation in the tubules, thus preventing absorption from them into the blood. Garrod (Med. Rec, July 4, "96). Edison, and after him Labatut, Lev- ison, Chauvet, and Gilles, have advo- cated the electric treatment against the stiffness of gottty joints; by this treat- ment remedies are introduced through the skin by the aid of a galvanic current. The experiments of Labatut and other scientists have demonstrated that the alkaline substances enter in the body with the positive current, whereas the acids are introduced with the negative. The remedy employed in this way against the gouty affections is lithia, which is 374 GOUT. TREATMENT. liberated by the decomposition of the salts of lithia by the electrolytic efEect of the current and enters through the skin in the nascent state, and consequently in a very effective condition. Labatut con- ducts the dielectric treatment in the fol- lowing way: A 2-per-cent. solution of chloride of lithia is rendered alkaline by addition of some caustic lithia or car- bonate of lithia, and the hand or foot which is to be treated is placed in a saucer filled with the solution, into which also the positive conductor is plunged, taking care that the conductor does not touch the skin; the negative conductor (both conductors are made of charcoal) is placed in another saucer filled with a feeble solution of common salt, and some part of the bod}', hand or foot, is put in contact with this liquid. A current of 15, 20, or 25 niilliamperes is used, ac- cording to circumstances, and each seance is of 30 minutes' duration. By the continued use of this method, I have in many instances succeeded in restoring to gouty joints the mobility which had been lost for several years. While it is also possible to dissolve tophi, some part of the swelling caused by the deposits will, however, always remain, as the tophi do not consist only of biurate of soda, but contain also new-formed con- nective tissue, which cannot be dissolved by the lithia. Electricity recommended for promot- ing the removal of gouty concretions. Thomas A. Edison (Brit. Med. Jour., Aug. 10, '90). Literature of '96-'97-'98. Static electricity is the best treatment in hereditary gout, and will prevent at- tacks, if used judiciously at the right time. Static electricity and other elec- tric currents will cure many of the other varieties of gout. Static electricity acts as a general tonic. It replaces exercise and acts as passive motion. R. Newman (Med. Eec, Dec. 11, '97). Another new and valuable addition to the therapeutics of gout is the hot-air bath. In all the different forms of bathsy mineral bath, moor-baths, Turkish, and Eussian baths, which have been em- ployed for a long time with varying suc- cess against gout, the heat is the common active principle. It is difficult to bear more than 50 or at most 60 degrees of Celsius when the heat is applied as vapor- bath, moist air, or hot water; but when the heat is administered by means of dry air, a far higher temperature is borne without pain or damage. Tallermann, of Sheffield, and Betz, of Chicago, have invented ingenious appa- ratuses, by which an arm or foot may be exposed for from 30 to 50 minutes to a current of dry air heated to 100-150° C. and even more, and many observers (Ivnowsley, Sargent, Mendelsohn, Levi- son) have noticed the good effects of this treatment against the stiffness of gouty articulations, especially when it is com- bined with the use of massage. Literature of '96-'97-'98. Attention called to an apparatus which has been employed in a series of cases in the University Hospital, where some 300 baths were given to test its efficiency. It was found to be most satisfactory. The required temperature can be obtained quicklj', in fi'om 10 to 15 minutes, and the aparatus is substantially but simply constructed, and involves nothing that can get out of order or require repair. The cases that were treated included acute and chronic articular rheumatism, gonorrhoeal rheumatism, gout, traumatic arthritis, synovitis, tenosynovitis, and fibrous ankylosis. The method of administering the bath is as follows: The patient's pulse and temperature were first taken and re- corded. The limb, first being completely enveloped with a piece of lint, which was GOUT. TREATMENT. 375 wrapped loosely about the part, was then placed in the cylinder. The time al- lowed for each bath was from three- fourths of an hour to an hour. At in- tervals of 20 minutes the door of the cylinder was thrown open momentarily to allow of the ingress of a fresh supply of air. If the patient perspired freely, this opportunity was taken advantage of to wipe the limb thoroughly dry. If this precaution is not taken and the limb is allowed to remain bathed with sweat, there is the possibility, if the tempera- ture is exceedingly high, of a superficial burn resulting. This happened in several cases where the precaution was not taken. The degree of temperature em- ployed varied, some patients bearing with perfect comfort a degree of heat which would be extremely painful to others. The average was about 300° F., although in one case the temperature reached 375°, to which the patient seemed quite indifferent. The frequency with which the baths were given varied with the .severity of the case; usually, however, they were administered on every other day. Certain physiological phenomena fol- lowed the application of heat, such as increased arterial tension, elevation of the blood-pressure, dilatation of the lu- men of the blood-vessels, diminution of the erythrocytes, decrease of haemoglobin, increase in the elimination of nitrogen, and increase in frequency of the heart's action. In cases in which there is a diathesis, either rheumatic or tubercu- lous, this treatment can have no bene- ficial constitutional effect. Permanent cures of local lesions, symp- tomatic of diathetic diseases, are not to be looked for from the employment of hot-air baths, but for the relief of Joint affections of traumatic origin this method of treatment is most useful and sometimes indispensable, and the re- sults obtained can be called permanent. C. H. Frazier (Annals of Surg., Oct., '97). A year's experience with the Sprague hot-air therapeutic apparatus has dem- onstrated that it has not often been dis- appointing in its action in the usual types of gout or rheumatism. Even where tophi have formed, the solidifica- tions are frequently softened and car- ried off through the excretory organs. The skin and kidneys are stimulated by the hot blood, and circulation is re- stored to the affected part. All cases, as far as heard from, have kept what they gained, excepting in so far as they have returned to errors of diet and lack of exercise. As a matter of course, the originating causes may in- duce a return of the trouble. The failure of an apparatus to run to a \ery high temperature must certainly curtail its usefulness. This mode of treatment becomes a most useful adjunct to medical and surgical treatment. A. Graham Reed (Phila. Polyclinic, Aug. 6, '98). To sum up, the principles of the treatment of gout are these: In all eases the diet is to be regulated with a view to sustain the forces of the patient with- out allowing any excess of food; the patient is to be advised to limit the use of alcoholic stimulants and to avoid equally excess of work and of enjoy- ments, whereas bodily exercise and open- air life are useful. The patient ought to drink pure water of some aerated spring in sufficient quantity to keep the daily excretion of urine from 3 to 4 pints; if the urine be strongly acid and liable to precipitation of uric-acid crystals, the administration of small doses of some alkaline drug or spring should be re- sorted to to diminish the acidity and render the urine limpid. The gouty attacks are treated by rest, somewhat reduced regime, anodynes, if necessary, and colchieum; in the free intervals the resin of guaiac will be of use. The stiffness of the gouty joints and the tophi are treated by the dielec- tric introduction of lithia, by the hot-air bath, and by massage. A visit to some spring where the appli- cation of hot baths, doiiches, and mass- age are combined with the use of some aerated spring and good vivifying air will 376 GRINUELIA. THEEAPEUTICS. be of use to restore the forces and the spirits of the patient. Also a sojourn in some dry and hot climate is advisable as well for the specific gouty symptoms as for the disease of the kidneys, which is the constant companion of gout. The obscure symptoms of the so-called visceral gout require very different treat- ment after their nature, but in all cases it must be remembered that gout is only to be treated suceessfiilly when great care is given to the dietetic and hygienic treatment of the whole system. This cannot be regulated by one common rule, but it must be carefully adapted not only to each patient, but to the different stages and periods of the malady. F. Levison, Copenhagen. GRAND MAL. See Epilepsy. GRANULAR KIDNEY. See Kid- nets, Diseases of. GRANULAR LIDS. See Lids, Dis- eases OF. GRAVES'S DISEASE. See Esoph- THALMIC GOITEE. GRINDELIA.— Grindelia is the leaves and flowering tops of Grindelia robusta and Grindelia squarrosa, which are her- baceous perennial plants indigenous to Mexico and the Pacific coast of the United States. They contain a resin, a volatile oil, and an alkaloid (grindeline). Preparations and . Doses. — Grindelia (leaves and tops), V4 to 1 drachm. Extract of grindelia, fluid, ^/^ to 1 drachm. Physiological Action. — Grindelia has an acrid, bitter taste. Wlien chewed it excites the secretion of saliva. It is an antispasmodic, motor depressant, and has light expectorant and diuretic ac- tion. It slows the heart and increases the blood-pressure. It stimulates the bronchial membrane and the kidneys, and is eliminated by them. When given in large doses, it induces paralysis of the peripheral sensory nerves, the sensory centres in the spinal cord, and later the motor centres and nerve-trunks; the pupils become dilated and renal irrita- tion is produced. Literature of '96-'9r-'98. In warm-blooded animals the phe- nomena which grindelia robusta produces may be ascribed to an exciting action upon the bulbar centre of the pneumo- gastric, which, when a large dose is in- troduced at one time into the circula- tion, appears to be paralyzant. The ef- fects upon blood-pressure are that with small doses there is a slight rise, which is more evident with medium doses; but as the amount is increased the pressure gradually and continually falls during the same time that the oscillations are shorter. When its effects on the pneumo- gastric are considered and also its power of contracting bronchial muscles and its action on the heart it is likely, in proper doses, to be of value as a remedy for the symptom of asthma. The drug contains an active principle, likely terpene, which benefits the asso- ciated catarrh. The drug apparently possesses a paralyzing action on the thermogenic centre. The secretions are changed as follows: The urine is in- creased by small and diminished by large doses, partly from changes in blood- pressure and partly from direct action on the renal epithelium. The saliva and bile are increased. Both urine and saliva are of greenish tinge. Luigi d'Amore (Giornale della Aasociazione Napoletana di Medici e Naturalista, Puntata 5a e 6a, p. 331, '96). Therapeutics. — Spasmodic asthma and bronchitic dyspnoea may be relieved by the fluid extract of grindelia in doses of ^/i to 1 fluidrachm, every three or four GUAIAC. THERAPEUTICS. 377 hours, given preferably in a little sweet- ened water or milk. In recurrent asthma it often affords prompt relief, but it does not prevent the return of the paroxysms. It is also beneficial in spasmodic coughs, pertussis, chronic bronchitis, and in hay fever. The leaves of grindelia soaked in a solution of nitrate of potash and dried may be burned or smoked, and the fumes inhaled. literature of '96-'97-'98. In emphysema grindelia robusta facili- tates the respiration and expectora- tion. In simple cardiac hypertrophy and in dilatation it has all the advan- tages of digitalis without any of its drawbacks. It relieves pulmonary con- gestion and the palpitation associated with cardiac hypertrophy, emphysema, asthma, and incipient tuberculosis. The following formula is useful: — IJ Tincture of grindelia, 6 parts. Tincture of convallaria, 2 parts. Tincture of squill, 1 part. Fifteen drops three times a day. Huchard (Jour, de i\16d. de Paris, No. 16, '98). In chronic cystitis it gives relief by stimulating the mucous membrane of the bladder. The fluid extract diluted with water (1 to 10) is a very valuable lotion in poison-oak or poison-ivy eruption, and in pruritic skin affections. C. SUMNEE WlTHERSTINE, Philadelphia. GRIPPE, lA. See Influenza. GUAIAC. — Guaiac-wood (guaiaci lig- num, U. S. P.) is the heart-wood of Guaiacum officinale (Lignum vita). It is employed as scrapings or chips, of olive, brown, or yellow color, very hard, and having a faint, aromatic odor and a pungent acrid taste. It enters into the composition of the compound syrup of sarsaparilla. The wood furnishes a resin (resina guaiaci, U. S. P.) which is brittle and breaks with a bright, lustrous fract- ure. Its odor and taste are the same as that of the wood. Its powder is grayish, but becomes green on exposure to the air. It is soluble in alcohol, ether, and alka- line solutions, but very slightly so in water. Guaiac resin is an ingredient of Plummer's pills (pilulse antimonii com- positffi, U. S. P.). Preparations and Doses. — Eesin of guaiac, 10 to 30 grains. Tincture of guaiac, ^/j to 1 drachm. Tincture of guaiac, ammoniated, ^/„ to 1 drachm. Physiological Action. — Guaiac taken internally causes a sense of warmth in the stomach, and increases the secretion of the digestive fluids. In large doses it gives rise to gastro-intestinal irritation and produces active purgation. A well- marked rash, attended with great itch- ing and resembling that of copaiba, some- times follows the use of guaiac. Best use of guaiac is as a laxative or purgative. In one case in which this drug was prescribed a well-marked rash, resembling that of copaiba, covered the arms and legs of the patient. It was accompanied by intense itching, and dis- appeared upon the withdrawal of the drug. William Murrell (Medical Bulle- tin, Jan., '91). literature of '96-'97-'98. Guaiac possesses none of the proper- ties which are essential to its use as a laxative; the dose required to produce the desired effect is too large to be safe or agreeable, and the action of the -drug in this direction altogether too uncertain. Combemale (Rev. Inter, de M6d. et de Chir., Feb. 25, '96). Therapeutics. — Guaiac given early in a 30-grain dose, either in powder or in emulsion with the white of egg, will often abort an attack of acute tonsillitis or of acute pharyngitis. Eheumatism of 378 GUAIAC. GUAIACOL. subacute or chronic type, gout, and rheu- matic pharyngitis may be relieved by the administration of either the tincture or the ammoniated tincture of guaiac; but, on account of its disagreeable character, other remedies are preferred. Literature of '96-'97-'98. Guaiac is valuable in many gouty and rheumatic conditions. It possesses the following advantages: 1. It is innocu- ous, and may be taken for, an indefinite length of time. 2. It possesses consider- able power, but less than colchicum, in directly relieving patients suffering from gouty inflammation of any part; it may be given whenever there is but little fever. 3. Taken in the intervals of gouty attacks, it has a considerable power of averting their occurrence; in fact, it is a very powerful prophylactic. 4. It does not seem to lose its prophylactic power by long-continued use. 5. There are a few patients who cannot continue its use_. Guaiacum does not affect the forr mation of uric acid, but acts directly on the kidneys as a stimulant, enabling them to get rid of any accumulation in the tubules, thus preventing absorption from them into the blood. Sir Alfred Garrod (Med. Eec, July 4, '96). Amenoerhoja. — In amenorrhoea not associated with anaemia, the administra- tion of 10 grains of guaiac, stirred in milk, before breakfast, will give good results if continued for some weeks. Painful menstruation may be relieved by the ammoniated tincture in doses of ^/a to 1 drachm every two or three hours. C. SUMNEE "VVlTHEESTINE, Philadelphia. GUAIAC 01.— Guaiacol (monomethyl- catechol, methyl-ether of pyrocatechin; methylpyrocatechin) is a highly-refract- ive, colorless, oily liquid, having a char- acteristic aromatic, agreeable odor, and is obtained by fractional distillation from beech-wood creasote. It may also be ob- tained by the dry distillation of gua- iacum, or produced synthetically by the action of methyl-sulphuric acid upon pyrocatechin. It is freely soluble in alco- hol, ether, and carbon disulphide, and in 85 (Helbing) or 200 (Merck) parts of water. It also occurs in colorless crys- tals, which are freely soluble in glycerin, alcohol, ether, and slightly soluble in water. It forms salts with the acids; the carbonate and salicylate is a white, in- sipid crystalline substance, with the odor of salol, and soluble in alcohol. lodoguaiacol is best prepared by add- ing 62 grains of iodine to 8 'A drachms of guaiacol and applying a gentle heat. After the iodine is dissolved, 50 ounces of pure olive-oil are added. W. H. Gregg (N. Y. Med. Jour., Nov. 21, '91). Attention called to a new pulmonary antiseptic, which is obtained from guaia- col by the action of caustic soda; the sodated guaiacol thus formed being afterward precipitated by a watery so- lution of sodated iodine, a guaiacol bi- iodide is obtained. The new drug occurs as a brownish-red powder, soluble in al- cohol and in the oils. Vicario (Eevue Inter, de Bibliographie, Mar. 25, '92). Although guaiacol has hitherto been described as a liquid, the pure synthetic product is a solid body, crystallizing in colorless prisms, which melt at 83.3° F., boiling taking place at 369° F. It is readily dissolved in pure, undiluted glyc- erin, the solubility in water being only 1 to 50. Liebreich (Ther. Monats., May, '93). Crystals of pure guaiacol are white and hard. When melted, the guaiacol remains in fusion for an indefinite time. It is soluble in most of the organic solvents, even in benzin; it is also solu- ble in petroleum-ether, and crystallizes very well on the evaporation of this solvent. Anhydrous glycerin dissolves crystalline guaiacol in large proportions. Gilbert and Morat (L'Union Med., p. 753, '93). Absolutely-pure, crystalline guaiacol has little taste or smell. It can be ob- tained in an absolutely-pure condition GUAIACOL. POISONING. 379 from a commercial sample by cooling with a mixture of ice and salt, and then separating the crystals which have formed. S. Winghoffer (Pharm. Zeit., No. 34, '94). Preparations and Doses. — Guaiacol (liquid), 2 minims, gradually increased to 16 minims. Guaiacol (solid), 12 grains, gradually increased to 15 grains. Guaiacol-carbonate, 3 to 8 grains, in- creased to 90 grains. Guaiaeol-einnate (stjTacol), 5 grains. Guaiacol-salicylate (guaiacol-salol), 15 grains; maximum daily dose, 150 grains. Guaiaeol-benzoate (benzoyl-guaiacol; benzosol), 3 to 12 grains. Guaiacol-biniodide, 2 grains, increased to 15 grains. Physiological Action. — The physiolog- ical action of guaiacol is similar to that of its congener, creasote, although its effects on the gastro-intestinal tract are not so irritating. The respiration and pulse are only temporarily afEected. The blood-pressure is slightly increased, and there is slight contraction of the arte- rioles. Large doses produce a burning sensation in the stomach, nausea, etc.: symptoms of gastro-intestinal irritation. Guaiacol is excreted principally by the kidneys, as guaiaco-sulphuric ether, but also by the skin and the salivary glands, and in small measure by the lungs. Guaiacol administered by the alimen- tary tract is only partly absorbed. It is more readily absorbed in healthy than in sick persons. For its absorption it is sufficient to give it in daily doses of 7 '/, grains. Administered in such doses, it does not cause nausea, and is well borne by patients. Guaiacol is not eliminated as such by the urine, but in the form of a body giving the reaction of phenol. Poggi (Riforma Medica, Aug. 10, '92). The effect produced by guaiacol is not due to its action on the digestive organs. In combination with the blood guaiacol has no such action. The medicament is eliminated as a salt of ethyl-sulphuric acid, and thus, when absorbed into the blood, it must have combined with al- buminous bodies, and chiefly through the sulphur present in the albumin molecule. In the blood of phthisical pa- tients there are, in addition, other al- buminous bodies, namely: the products of the growth of the bacilli. The ab- sorbed guaiacol combines with these products and renders them harmless, and they are further changed by oxidation, the guaiacol being liberated as a salt of ethyl-sulphuric acid, and the other de- composition products being eliminated in the urine. Hollscher and Seifert (Berliner klin. Woch., Jan. 18, '92). Guaiacol acts by influencing the pe- ripheral ends of nerves, and, through them, the thermogenic centre, on its ap- plication to the skin. The presence of guaiacol in the urine is attributed to the absorption of the vapors through the respiratory organs. The influence , of guaiacol is cliiefly seen in febrile condi- tions. Guinard (Bull. G6n. de Ther., Oct. 30, "93). After painting the skin with 31 grains of guaiacol, elimination by the kidney is manifested in a quarter of an hour; the proportion in the urine is greatest in from one and a, half to four hours after and reaches 50 grains per quart. It de- creases rapidly in six or seven hours, and in twenty-four hours there is no further trace in the urine. It is necessary in ex- ternal application of the drug to cover the painted surface with an imperme- able layer of taffeta. Linossier and Lannois (La Med. Moderne, Feb. 7, '94). Pure guaiacol passes rapidly into the urine, while after tne application of a mi.xture with glycerin it appears much more slowly. Almond-oil interferes much less with absorption than glycerin. Stourbe (Lyon Med., July 15, '94). Poisoning of Guaiacol. — A case of poisoning, in a child 9 years of age, has been reported by Wyss, in which 1 ^/^ drachms were accidently taken. In a short time she became unconscious and cyanotic. The conjunctivse became in- 380 GUAIACOL. THEEAPEUTICS. jeeted, the corneal reflexes diminished, and the pupil contracted and inactive. Vomiting (ejecta had odor of guaiaeol) and profuse salivation were present. The pulse became rapid and weak and the breathing irregular. Cutaneous sen- sibility was diminished. Later on blood and bile-stained mucous were vomited. The urine was dark colored, of an aro- matic odor, and contained bile-pigments and a small amount of albumin. The cyanosis gradually diminished and was followed by a deadly pallor. The respira- tions became frequent. Jaundice ap- peared and the patient died on the third day. The autopsy revealed an acute gastro-enteritis and parenchymatous de- generation of the liver and heart-muscle, acute hemorrhagic nephritis, enlarged spleen, and ecchymosis in the pleura, peritoneum, endocardium, and pericar- dium. Several cases of death have been reported following the hypodermic ad- ministration of guaiaeol, the patients dying within an hour in profound coma with every symptom of cardiac paralysis. Even when ingested in toxic quanti- ties, the drug is but slightly eliminated by the expired air. Small amounts of the drug, however, may be met with in the lung- tissue. Paul Binet (Revue M6d. de la Suisse Rom., June, July, '93). After 15 Vj-minim doses of guaiaeol, slight appearances of poisoning may supervene. These are characterized by a burning feeling in the stomach, nausea, etc. Kobert ( "Intoxicationen," '94). Fifteen and a half minims of a mixt- ure of guaiaeol, 150 parts, and iodoform, 20 parts, injected into the knee-joint of a girl of 8 years suffering from fungous arthritis. Cyanosis, dyspnoea, loss of consciousness, nausea, and temporary amaurosis supervened. Von Mosetig- Moorhof (Deutsche med. Woch., Ko. 7, '94). Treatment of Guaiaeol Poisoning. — Soluble sulphates (Epsom or Glauber's salt) may be given freely in conjunction with mucilaginous drinks. Digitalis and strychnine hypodermically injected are useful, associated with heat to the extremities and counter-irritation ap- plied on the abdomen. Emetics and the stomach-pump are valuable if used early, before the drug has been absorbed. Therapeutics. — Guaiaeol has been chiefly used as a remedy in tuberculosis, as an antipyretic in fevers. It may be given in pill, in capsule, in an alcoholic or oily solution, or by hypodermic injec- tion, dissolved in sweet almond-oil (equal parts), or in sterilized neutral olive-oil (1 to 5). Liquid guaiaeol may be admin- istered by inhalation, its volatility adapt- ing it for that purpose. It may also be given by inunction; the part being cleansed and dried, the guaiaeol is painted over the surface, and after being left for about ten minutes the part is well rubbed and covered with some im- permeable dressing. Its absorption is very rapid, guaiaeol being found in th^^ urine fifteen or twenty minutes after it is applied to the skin. External applications of guaiaeol in- crease the utilization of albuminoids by the organism and absorption of fat and diminish oxidation. Caporali (Riforma Mediea, No. 175, '94). TuBEECULOSis. — In the early stage of this disease guaiaeol reduces the fever, restores the gastric and intestinal func- tions, and improves the condition of the patient. In tuberculosis V2 to 2 "A drachms ap- plied to the extremities, back, and ab- domen, and covered with cotton and gutta-percha. The action of the drug is manifested even in fifteen minutes. There is no irritation of the skin if the drug is of pure quality. S. Sciolla (Deutsche med. Woch., No. 22, '93). Four cases of tubercular disease in which the local application of guaiaeol caused a marked reduction of the tem- perature. Guaiaeol may be painted over GUAIACOL. THERAPEUTICS. 381 the thigh or the back, the part being covered with an impermeable towel. Dosage can thus easily be managed. The quantity at the beginning was '/» drachm, this amount being decreased at each treatment. The antipyretic action of guaiacol, employed as described, is not confined to tuberculous cases, but has given the same satisfactory results in pyrexias of erysipelas and pneumonia. L. Bard (Lyon M6d., June 4, '93). The principal results of clinical re- search may be summarized as follows: 1. Guaiacol is an excellent antipyretic. 2. The drug does not give rise to col- lapse, even in phthisical subjects with large cavities. In these patients, how- ever, the application is almost invariably followed in from two to four hours by perspiration and rigors. 3. Compresses are the best mode of application. 4. Chemically-pure crystalline guaiacol should be preferred to the ordinary fluid preparation. S. T. Bartoszewicz (Yujno- Eusskaia Med. Gazeta, Nos. 23, 24, '91). Literature of '96-'97-'98. Carbonate of guaiacol, a 20-per-cent. solution in olive-oil, recommended in all forms of cystitis, but especially in the tuberculous variety. From 15 to 30 minims to be used once or twice a day; the addition of iodoform, 1 per cent., in- creases the efficacy. Colin {Jour, de M6d., Jan. 26, '96). Schetelig's method of giving pure guaiacol subcutaneously in acute pul- monary tuberculosis tried; 3 hypodermic doses, 1 of 15 minims and 2 of 10 minims, at four hours' interval, in one case brought the temperature from 104° to normal, with rapid amelioration of all the symptoms. Guaiacol is especially useful in the fever of the suppurative stage of the disease. A moderate per- spiration usually follows the injection. Coghill (Brit. Med. Jour., Mar. 7, '96). From 1 to 1 Vz drachms of the follow- ing solution may be injected at a dose without danger: — B Iodoform, 15 grains. Guaiacol, 75 grains. Sterilized olive-oil, 3 ounces. — M. There were 424 injections given to eighteen patients suffering from pulmo- nary tuberculosis; the effects are dis- tinctly favorable. The injections should be given into the loose connective tis- sues of the back, shoulder, or thigh. Careful asepsis should be maintained. A. Breton (Jour, des Praticiens, Dec. 19, '97). The action of guaiacol injections in surgical tubercle studied. The liquid is used as a 1-in-lO to l-in-20 solution in sterilized olive-oil. Rigid antiseptic pre- cautions are required for the injections, the latter being made with a Roux syringe deeply into the granulation- masses, Vs to 1 cubic centimetre of the solution being injected at three or four different points. This may be repeated once or twice every week, provided there has not been much irritation. Number of observations of white swell- ing, etc., in which an extremely favor- able result was obtained. Guaiacol may also be used in the form of a dressing in certain open tubercu- lous conditions: thus gauze steeped in guaiacol solution (in olive-oil 1 in 10) and applied to the surface causes de- crease of pain and the healthy condition of the tissues. Grggoire (ThSse de Paris, '97). Fevee. — Guaiacol possesses strong an- tipyretic powers. It is perhaps best used by painting over the skin of the abdo- men, the chest, or the internal aspect of the thigh, 30 or 40 drops being used for this purpose, as described above. These applications may be repeated. The de- cline in temperature is often great and rapid, but after reaching the lowest point the temperature will more rapidly attain its former height. A great feeling of depression is experienced by the patient and profuse sweating occurs. The tem- perature has reached the minimum, and chills at this time are not uncommon. The use of this drug for itg antipyretic effect is not devoid of danger, and its action is not as lasting as that produced by the cold bath and by numerous other antipyretic remedies. Guaiacol-carbon- 383 GUAIACOL. THERAPEUTICS. ate has been used in typhoid fever, for its antiseptic action in the bowel, biit such use is not to be advised. Applications of guaiaeol over the spleen recommended in intermittent fever A^'here quinine is not well borne or as an adjunct to the latter drug. Kohos (Gaz. des Hop., Oct. 30, '94). Guaiaeol mixed with tincture of iodine used in the treatment of pleurisy, in the following proportions: Tincture of iodine, 385 grains; guaiaeol, 75 grains. The chest is thoroughly painted with it every night. The application is followed by a fall of the temperature, profuse perspiration, diuresis, and by a resorp- tion of the fluid. Casavovici and Miron Sigalea (N. Y. iled. Jour., Mar. 3, '94). Guaiaeol applied externally is readily absorbed; its application is followed in most instances of fever by a gradual re- duction in temperature, which reaches its lowest point between three and four hours after the application; the fall of temperature is almost always associated with profuse sweating; at a variable period, usually a short time after the lowest point is reached, the temperature rises rapidly, generally with marked chilly sensations, if not with an actual chill; the amount applied should rarely exceed ^Z, drachm. Similar results fol- low the absorption of guaiaeol through any other channel. Owing to the weak- ening effects of its continued use and the disagreeable effects of its immediate application, its use as an antipyretic will be very limited. Thayer (iled. News, Mar. 31, '94). Guaiaeol has more effect in modifying the temperature about the beginning than toward the end of the acute fever. C. A. Dana (Med. Record, June 22,- '94). On painting the skin with guaiaeol in a case of typhoid fever, the temperature fell from 105.4=' to 98.0° F. in three and ' a half hours without any disturbance of the circulatory or nervous system. After- ward the drug was used about twice daily, a fall of temperature occurring each time. The antipyretic effect is slower than that of the bath, but more permanent. After washing with soap and water, 30 drops should be slowly rubbed in the skin of the abdomen or thigh or painted over the surface, then covered with lint or wax-paper. Fifty drops should be a maximum amount. The urine should be watched carefully. The unpleasant odor caused by the drug may be to some extent overcome by the addition of oil of cloves. Da Costa (Med. News, Jan. 27, '94). This drug has a powerful antipyretic action. In all cases the reduction of temperature is accompanied by profuse diaphoresis, which may or may not be accompanied by a chill or chilly sen- sation. Great exhaustion is frequently produced. The effects may be obtained from 30 to 50 drops, and great care should therefore be exercised, the drug being applied but once or twice daily, the initial dose not exceeding 30 drops. Its effect differs from the stimulating cold bath in being depressant. The main indication for its use is in diseases ac- companied by high fever in which the cold bath cannot be applied, as well as in all other diseases accompanied by high fever in which irritability of the stomach prevents the use of other anti- pyretics. Friedenwald and Hayden (N. Y. Med. Jour., Apr. 14, '94). Use of guaiaeol not recommended, as, although the fall of temperature is very marked, the sweating and rigors are very severe, and the influence on the disease is not lasting. Stolzenburg (Berliner klin. Woch., Jan. 29, '94). The external application of guaiaeol may be dangerous, first, by the sudden fall of temperature which immediately follows the application, and, second, by the nervous depression produced by re- peated applications. In typhoid fever the method should not be employed on account of the long duration of the dis- ease; in erysipelas and pneumonia, on the other hand, it is very useful. In tuberculosis its effect is favorable only in u. certain number of cases of inter- stitial granular formations without com- plications. Baird (La Semaine M6d., Aug. 17, '95). Guaiaeol internally excellent as an antiseptic in the typhoid fever of chil- dren. The following formula employed: GUAIACOL. THEEAPEUTICS. 383 IJ Guaiacol, 1 drachm. Glycerin, 2 drathms. Alcohol, 2 drachms. M. Sig.: 1 to G drops in whisky and water every two hours, according to the age. This treatment is continued through- out the course of the disease, the dose of guaiacol being increased or decreased ac- cording to the severity of the symptoms. Under this plan of treatment intestinal antisepsis is evidenced by the slight de- gree of tympanites, absence of sordes, and especially by the character of the stools, which are much less frequent and practically destitute of the very disagree- able odor that characterized the passages of patients before the introduction of treatment directed toward intestinal antisepsis. Konig (Jour. Amer. iled. Assoc, Oct. 5, '95). Literature of '96-'97-'98. Guaiacol deemed by many to be a de- pressant and a dangerous remedy where the circulation has suffered from long- continued fever. The writer has used it in a number of cases of typhoid fever with only the happiest results. When given internally guaiacol does not reduce the temperature to the same degree as when applied to the skin. McCormick (Brit. lied. Jour., Mar. 7, '96). Guaiacol used in the treatment of malarial intermittent fevers; 15 minims were rubbed into the axilla and covered with cotton. The average fall of tem- perature in V4 hour was 1.6°, in 1 V4 hours 2.3°, and after 4 hours the average fall Avas 3°. The fall of temperature was accompanied by a free perspiration and a mai'ked improvement in the condition and comfort of the patient. Xo depres- sion was noticed. Rogers (Ind. Med. Gaz., Jan., '98). Eeraarkable success with guaiacol in many cases of cough of long standing, in which no tuberculous element could be recognized. A. Goldhammer (Med. Record, Oct. 23, '97). Eleven cases of serous pleurisy treated with a mixture of guaiacol, 1 part, and tincture of iodine, 4 parts, with favor- able results. A drachm of this mixture was applied once daily to the affected side, which was then covered with wajc- paper, cotton, and then with a bandage. Besides this treatment the patients re- ceived only small doses of codeine or Dover's powder. In all eases the exudate became absorbed more quickly than was observed by the author under any other method of treatment. By irritating the peripheral nerve- endings the guaiacol acts on the thermal and vasomotor centres; hence the reduc- tion in temperature and increased ab- soi-ption-power of the pleura. Besides, it acts in the blood-current directly as an antiseptic. Brosorowsky (Medizinskoje Obosrenije, Xo. 1, '98). Paixful Disoedehs. — The analgesic effects of guaiacol have been utilized in the treatment of arthritis deformans, acute articular and muscular rheuma- tism, sciatic coxalgia, and pains of a superficial or deep-seated nature. The pains of orchitis and epididymitis are relieved by applying guaiacol in oily solu- tion or in ointment (1 part to 10 or 15 of vaselin or lanolin). "\Tlien analgesic effects only are sought, the guaiacol should be used with equal par.ts of glycerin; but if it be de- sired to produce an antithermic action, the drug ought to be used pure or else mixed with some vehicle that lends itself readily to dermic absorption. Ferrand (Provincial Med. Jour., July 2, '94). In the treatment of epididymitis, an ointment composed of 2 to 5 parts of guaiacol and 30 of vaselin used with ad- vantage. These good results may be ex- plained by local action exercised upon the cutaneous nerve-endings, and the re- flex action upon the cord and testicle, rather than by the absorption of the drug. Balzer and Lacour (Le Bull. M6d., Apr. 11, '94). Guaiacol recommended in cases of gon- orrhceal orchitis. Crystalline guaiacol after previous melting may be applied to the affected part and to the groin by a brush; 31 to 46 grains may be used each time. A guaiacol ointment may be made thus: — 384 GUAIACOL. THERAPEUTICS. 5 Guaiaeol, 1 V* draehnjs. Vaselin, 1 Va ounces. Tavitian (Eevue Gen. de Clin, et de Th6r., Mar. 30, '95). Guaiaeol used to relieve pain in acute articular rheumatism, tubercular caries of the wrist, hysteria, locomotor ataxia, arthritis deformans, with excellent re- sults and without the development of disagreeable symptoms. The painful part is first cleaned, then from 0.75 to 1.5 cubic centimetres of guaiaeol are rapidly applied with a camel's-hair brush. After employing gentle friction the part is covered with a piece of gutta-percha. In some cases relief was permanent; in others the pain returned the next day. Brill (Centralb. f. innere Med., Nov. 24, '94). Good results obtained in sciatica and intercostal neuralgia from painting a mixture of equal parts of guaiaeol and glycerol over the course of the nerves. No ill effects were noted. Eerrand (Jour, des Prat., No. 30, '94). Guaiaeol recommended in pultaceous angina, phlegmonous tonsillitis, etc., in which diphtheria does not play any r81e. Equal parts of glycerin and guaiaeol for adults; 2 parts of glycerin and I of guaiaeol for children. Affected parts to be painted four times in twenty-four hours, making the last application late at night and the first early in the morn- ing. Darbouet (Jour, de M6d. et de Chir. Prat., Jan. 10, '95). Literature of '96-'97-'98. Results from the. use of guaiaeol in 52 cases of epididymitis, 50 of which were of gonorrhceal origin. A 10-per-cent. oint- ment made with vaselin or a 5-per-cent. used if the skin of the scrotum is ten- der. The scrotum is first washed with soap and with ether. This ointment is ap- plied during the acute stage, and in from three to five days the fever, pain, and swelling disappear. In subacute stages the action of guaiacol^is less active and very slight in chronic cases. After the acute stage it is best replaced by a 1- or 2-per-cent. ointment of extract of bella- donna, with equal parts of simple oint- ment and unguentum diachyli. Salol internally, 15 grains ter die, is a, useful adjunct to the treatment. Lenz (Wiener klin. Eunds., Nos. 4, 5, 6, '98). AisTiESTHESiA. — As an anaesthetic gua- iaeol may be used in minor surgical oper- ations. A dose of 1 or 3 drops dissolved in sterilized oliye-oil is sufficient to ob- tain ansesthesia; five minutes should be allowed to elapse after the injection. Championniere considers guaiaeol supe- rior to cocaine, because much larger doses may be used with safety. No acci- dents were noticed except slight slough- ing of the gums where it had been used for the extraction of teeth, which he attributed to a faulty method of injection or to a defective solution. Guaiaeol recommended as a local anal- gesic. Applied to burns in solution, 10 per cent., in olive-oil, it causes a disap- pearance of the pain. It has been used with absolute success in the extraction of teeth. Anaesthesia is less rapidly pro- duced than with cocaine, being complete only after seven or eight minutes ; on the other hand, however, it appears to be much more durable. Ansesthesia is in- duced even in inflamed tissue. Lucas- ChampionniSre (Le Bull. M6d., July 31, '95). ■ As a local antesthetie in ocular opera- tions guaiaeol recommended as vastly superior to cocaine in benumbing sensa- tion. A solution of pure oil of guaiac, 1 part, to sterilized olive-oil, 15 parts, is free from noxious effects. Anaesthesia appears in from 8 to 10 minutes after its use and continues 25 to 30 minutes; 2 or 3 drops are sufficient for most opera- tions. Bellencoutre (Jour, de M6d. de Paris, Dec. 22, '95) . Literature of '96-'97-'98. A 5-per-cent. solution of guaiaeol upon a pledget of cotton may be applied to the nose, causing complete anaesthesia, and it may be used in the ear when perform- ing paracentesis. Newcomb (Amer. Med.- Surg. Bull., May 16, '96). Guaiacol-oil is made by purifying olive- oil with chloride of zinc, then washing with alcohol and maintaining for some GUAIACOL. GUAEANA. 385 time at 100 degrees. The solution to be used is 20 per cent. The method of procedure for the nose and throat is to apply the solution sev- eral times to the affected part by means of a piece of cotton-wool impregnated with the oil, and for the ear it is advised to instil 5 or 6 drops of tepid guaiacol-oil, after practicing a preliminary injection of tepid water, followed by the applica- tion of "phenosalyl." After instilling the drops, a plug of cotton-wool is in- serted to absorb the redundant liquid. The anaesthesia takes longer to obtain with this agent than with cocaine, and no retraction of the tissues occurs. Guaiacol-oil is equal to cocaine in its analgesic properties, while the danger of the shocks is absent. Laurens (Ann. Mai. de I'Oreille, Jan., '96). Guaiacol recommended as a substitute when cocaine is contra-indicated. Used 36 times in the nose, pharynx, and larynx, and on the average obtains anaes- thesia in 10 minutes. Ttie following so- lution recommended: To olive-oil add 10 per cent, of dry zinc sulphate; heat over a water-bath one hour and add 12 'A per cent, absolute alcohol; shake several times during twenty-four hours; decant and add 5 per cent, guaiacol. W. G. HoUoway {Internat. Med. Mag., June, '96). Eetsipelas. — Guaiacol dissolved in alcohol or oil has been employed as an application in this disease. Twenty or 30 drops may be painted over the infected area and slightly beyond. The pain is promptly relieved and the temperature lowered by this method of medication. C. SUMNEK WlTSEESTINE, Philadelphia. GUARANA. — Guarana is a dried paste, consisting chiefly of the crushed or pounded seeds of Paullinia cupana (Paullinia sorhilis): a climbing plant in the eastern part of South America, and especially in Brazil. It contains an alkaloid, guaranine, which is identical with caffeine, and theine. Guarana is slightly soluble in water as well as in alcohol. Preparations and Doses. — Guarana, V^ to 2 drachms. Extract of guarana, fluid, V^ to 2 drachms. Physiological Action. — Guarana has a slightly bitter and astringent taste. It contains sufficient tannin to give it a slight astringent action. Farther than this, its physiological action is that of cafEeine. Therapeutics. — It is most frequently given for sick headaches or migraine. It is especially recommended when the pain affects the right side of the head. It shortens the attacks and increases the interval between them. From 30 to 60 grains of the powder, or an equivalent of the fluid extract, may be taken every night and every three hours during the attack. It is also given as a tonic when nerve-action is impaired, as in convales- cence from acute disease, debility, etc. C. SUMNEE WlTHEESTINE, Philadelphia. GUNSHOT WOUNDS OF ABDOMEN. See Abdomen. GUNSHOT WOUNDS OF BRAIN. See "Wounds. GUNSHOT WOUNDS OF THE HEAD. See Wounds. GUNSHOT WOUNDS OF THE JOINTS. See Wounds. GUNSHOT WOUNDS OF THE SPLEEN. See Wounds. GUNSHOT WOUNDS OF THE STOM- ACH. See Wounds. 386 H^MATOPORPHYRINUKIA. HiEMATUEIA. H H^MATOPOEPHYKINURIA. Definition. — Evacuation of urine con- taining hffimatoporphyrin, i.e., a color- ing matter resembling hsematin, but con- taining no iron. Symptoms.— The urine is dark-red or brown (resembling port- wine). The or- dinary reactions for hsematin or haemo- globin do not give positive results. Ex- amination by means of the spectroscope reveals characteristic absorption-bands. Etiology. — Hsematoporphyrinuria is the consequence of prolongated use of sulphonal. F. Levison, H.a;MATOSALPINX. Diseases oe. Copenhagen. See OvAEiES, H-ffiMATURIA. Definition. — Evacuation of urine con- taining blood. Symptoms. — Urine containing but a little blood may not give any indication of its presence to the naked eye; but, when the quantity is larger, it presents a characteristic smoky appearance; when more abvindant the fluid has a more or less pink or red color, while the surface presents a tinge of green; in extreme cases it looks almost like pure blood. After a time a brownish or grayish, gum- mous, flocculent sediment is deposited. When the blood is abundant it often separates from the urine in distinct clots. Although the appearance of the urine is very characteristic, various other coloring matters may be contained in the urine and give rise to delusions. These are phenol, santonin, bile-pigment, the coloring matter of rhubarb, senna, etc. Attention called to the haematuria which not infrequently follows the too- free use of rhubarb. The origin of the hsemorrhage in these cases is due to actual renal lacerations in the excretion of the crystals of oxalate of lime, in which substance this plant is particularly rich. Boyd (Lancet, Oct. 24, '91). Tests. — The presence of blood may be proved by different tests. 1. Heller's Test. — A few cubic centi- metres of urine are rendered alkaline with caustic soda and heated in a test- tube to the boiling-point; when blood is present the fluid becomes dark green; the phosphates are deposited as a floccu- lent sediment carrying with them the coloring matter of the blood by which they are colored red, or, rather, rusty brown. The alkaline solution of haemo- globin is dichroitic; it shows a green tinge in thin layers and a red in larger ones, while in the alkaline solution of santonin the coloring matter of rhubarb, senna, etc., are not dichroitic and take on a violet hue after a time. 2. The Guaiac Test {Almen-Bchon- lein). — One cubic centimetre of recently- prepared tincture of guaiac is carefully mixed with an equal volume of ozonized oil of turpentine, i.e., turpentine-oil which has for some time been exposed to the influence of air. The mixture is cautiously poured upon the specimen of urine to be tested and will superpose itself forming on the point of contact a gray or greenish layer; when blood is present a beautiful indigo-blue stratum will appear immediately above the gray ring; when shaken the mixture will take a light-blue color. The guaiac test is very delicate, indicating blood in the proportion of 1 to 2000 or more. 3. The Hcemin Test {Terchmann). — Some of the sediment of the urine or of KiEMATXJEIA. SYMPTOMS. 387 tlie red phosphates deposited after ad- dition of caustic soda is collected and dried. A small amount is placed on an object-glass and completely dried by slowly warming. When it is fixed on the surface of the glass, some common salt is rubbed on it, a fine hair is placed across the preparation, a few drops of glacial acetic acid are added, and the whole is eoTered with a cover-glass. The object-glass is slowly heated to the boil- ing-point of the acetic acid and then cooled. When blood is present the char- acteristic small, reddish-brown crystals of hsemin will appear, which are easily detected by the aid of the microscope. 4. Spectral Analysis. — • Examination of urine containing oxyhagmoglobin in the spectroscope reveals two distinct ab- sorption-bands between the lines D and J^ of Frauenhofer; recently-passed urine never contains oxy haemoglobin, but methsemoglobin (a modification of haemo- globin containing more oxygen than hiemoglobin, but less than oxyhsemo- globin). By decomposition of the urine or by addition of a solution of ammonia the methsemoglobin is reduced to hsemo- globin, which again forms oxyhsmo- globin when shaken ' with air. The methsemoglobin gives rise to the same two absorption-bands as the oxyhemo- globin, but, besides, to a characteristic band in red, between and D 5. Microscopical Examination. — This is the most reliable test for haematirria. The urine is treated in a centrifugal ap- paratus and the sediment examined; even when the amount of blood is too small to alter the color of the urine the corpuscles of blood are easily detected by this method. Ordinarily the cor- puscles are normal in appearance, but they do not accumulate in rolls; when the urine is dilute or alkaline, they are large, spherical, and almost colorless. commonly very transparent, whereas in concentrated urine their contour is ir- regular and indented; in some cases the corpuscles are broken up (fragmented); in others, casts of renal tubuli formed by blood-corpuscles may be seen.. The admixture of blood to the urine may take place in the kidneys, the ure- ters, the bladder, or the urethra; in order to ascertain the origin of the blood, it is necessary to subdivide the urine when voided into several parts. The first portion voided may contain blood of urethral origin, and the urine last voided show none whatever. When the portion last obtained con- tains much more blood than the first, the bladder probably is the seat of the bleeding. The endoscope will then gen- erally allow the direct inspection of the bleeding-point of the mucous membrane of the bladder. Too much value should not be placed upon so-called typical cell-elements in determining, by microscopical examina- tion, the source of the haemorrhage. It is often impossible to distinguish be- tween deep urethral and vaginal cells, between the latter and superficial vesical cells. Transitional cells are often mis- leading, and the typical caudal cell from the renal pelvi^ is rarely seen. Charles Smith (Boston Med. and Surg. Jour., July, '93). When the bleeding is caused by le- sions of the ureters or of the calyces, cylindrical coagula or casts of the calyces may be found in the urine. When the bleeding has taken place in the kidneys the blood is very intimately mixed with the urine; the corpuscles are often broken up or massed together, and casts of the renal tubes are commonly found. AVhere the specific gravity of the urine is low the hsemorrhage is apt to be renal; flhere it is high, the lower urinary pas- sages are usually the seat of origin. 388 HEMATURIA. ETIOLOGY. Otis (Jour. Cut. and Genito.-Urin. Dis., Nov., '91). Literature of '96-'97-'98. If the bleeding is from the urethra it may ooze between the periods of micturi- tion; if from the neck of the bladder, it is more particularly noticed at the end of micturition; if from the bladder, it is usually very abundant, persistent, and more likely to clot, and accompanied by bladder irritability; if from the kid- ney, the blood is generally mixed with the urine, although, if the quantity is large, characteristic urethral clots may be found. F. R. Eccles (Brit. Med. Jour., June 5, '97). The recognition of blood-casts in the urine forms the most conclusive proof of the renal origin of hsematuria. L. J. Harvey (Med. News, June 25, '98). Haemorrhage due to renal calculus is usually small in amount and appears at more or less prolonged intervals; it is increased by movements of the body, and is appreciably diminished by rest in bed. Haemorrhage from a renal tumor is gen- erally more profuse and less transient than from a calculus, and in some eases it is so copious as to cause marked ansemia. Unlike the hsematuria of renal calculus, that following tumors is more likely to occur during the night while the patient is in the recumbent posture. The presence of a persistent swelling in the renal" region, associated with con- siderable hsematuria, is of significance, and may be held as clearly indicating the presence of a neoplasm in the kidney. Hsematuria from tuberculous disease is frequently absent for long intervals, is seldom so severe as from stone, and is not increased by exercise. In addition to the presence of tubercle bacilli, it has been noticed that the quantity of albu- min is generally In excess of that ac- counted for by the blood, and in the later stage, when pus appears in con- siderable quantity, the pus and blood are not so rapidly or so completely pre- cipitated in the urine as in the presence of calculous pyelitis. Newman (Lancet, July 9, '98) . Etiology. — HEematuria is more fre- quently obseryed in men than in women or children. The blood in hsematuria may come from the kidneys, their pelves, the ureters, the bladder, or from the ure- thra. Bleeding from the urethra may be caused by acute or chronic gonorrhoea, by traumatism (calculi, introduction of catheter), by polypoid excrescences, or malignant tumors. It has been observed as a result of venereal excess or as an accompaniment of the first coitus after a long period of abstinence. Three cases of hsematuria reported due to prostatic engorgement. Lydston (Atlanta Med. and Surg. Jour., Apr., Literature of '96-'97-'98. Case of hsematuria, at first paroxysmal and later more constant. Fibrous clots were frequently present, and tlie first portion of the urine was often more deeply colored than the later portion. An operation showed that the condition was caused by numerous small varicose veins in the prostatic portion of the urethra. Krauss (Wiener klin. Woch., July 9, '96). The causes of bleeding from the blad- der are traumatism (calculi); diseases of the bladder, acute or chronic; varicosi- ties of the veins (vesical hsmorrhoids); ulcerations of the mucous membrane, diphtheritic or tuberculous; tumors, es- pecially cancer of a villous and fungous nature; parasites, such as Distoma hwmatohium, or Bilharzia, and Filaria sanguinis; it may also occur in hsemor- rhagic diathesis, in hemophilia; and also in infectious fevers, variola, etc. Two cases of hsematuria of vesical origin, caused, respectively, by papilloma and epithelioma of the bladder. Hill (Lancet, May 20, '88). Case of hsematuria observed in a sickly boy of 9 years, due to rhabdites. The organisms were found only in the urine. H-EMATURIA. ETIOLOGY. 389 Peiper and "Westphal {Centralb. f. klin. Med., Feb. 25, '88). The invasion of Bllharzia, licematoliia is purely a local one: the parasite lives and breeds solely in the urinary tract, and not in the circulatory system. The condition is found especially in boys who bathe in muddy pools. The prepuce is probably the primary lodging-place of the parasite. Allen (Practitioner, Apr.. '88). Hsematuria is a common disorder in and about Zanzibar, both among the na- tives and Europeans. Both parasitic and non-parasitic forms are met. All parasitic cases are directly traceable to drinking-water from two small rivers. Castle (Lancet, Apr. 25, '91). Case of boy, 15 years of age, affected with hsematuria from the influence of the Distoma hwmatoMum. Besides this boy an older and a younger brother also suffered from a similar affection. Refer- ence to the neoplastic formation caused in the bladder (and sometimes in the lower intestine) by the ova and embryos of the parasite. This view is corrobo- rated by Virchow, who states that he had witnessed a bladder showing large polypoid excrescences caused in this manner. Nitze (Deutsche med. Zeitung, Feb. 5, '91). Case of a married woman who had noticed blood in the urine for about six months. The hEemorrhages became so profuse that she became very anaemic and entered the hospital. Cystoscopical examination made, when it was found that the mucous membrane of the blad- der was covered with an incrustation of uric-acid crystals, with sharp corners and points. They .seemed to be deeply wedged in the mucous membrane, which was red and congested. Under anaes- thesia a Bigelow evacuator was intro- duced, and with every aspiration of the pump a great number of crystals came out. This was continued until the liquid came away clear. From the moment the crystals were removed no more blood appeared in the urine. Jacob Frank (Wiener klin. Eund., xl. No. 48, p. 786). Attention called to a. rare case of ex- trarenal hseniaturia. The lesions which provoke the haemorrhage appear as ecchymoses, nipple-like prominences, dis- crete or grouped ulcerations, and gan- grenous patches in the mucous mem- brane of the bladder. L6tienne (La M6d. Modeme, Dec. 18, '90). Case of intermittent haematuria ob- served, the attacks being separated by several days or several months, each last- ing from several hours to fifteen or twenty days. They followed fatigue or emotion and ^^ere preceded by a painful spasmodic sensation. Twice the haema- turia was replaced by epistaxis. The case diagnosed as haematuria of neuro- pathic origin through paralysis of the vasomotor of the cystic veins. Rho (Giornale Medico del Eealo Esercito e della Eeala Marina, Sept., '93). Bleeding from the pelves or the ure- ters is generally caused by calculi or by tuberculous disease, also by acute infec- tious diseases of hsemorrhagic character; by parasites (distoma and filaria). Bleeding from the kidneys is fre- quently due to irritating poisons, such as cantharides, turpentine, etc.; very large doses of quinine and salicylic acid are said to have produced renal haema- turia. Different diseases of the renal blood-vessels may cause bleeding; for instance: embolism of the renal artery, thrombosis of the veins, aneurism; trau- matism; parasites {Distom'a Ticematobium — Filaria sanguinis — echinococcus); also more rarely acute nephritis, especially scarlatinous. In Bright's disease haema- turia is observed also when malignant neoplasms are present. Eenal haema- turia may be caused by scurvy, haemo- philia, etc.; it occasionally accompanies infectious diseases, such as variola, mor- billi, scarlatina, typhoid fever, cholera, exanthematous typhus, recurrent fevers, yellow fever, erysipelas, etc.; it is rarely seen in syphilis, but in intermittent fever it is a frequent symptom (see Malarial Fevers). Case of hematuria seen in a young girl. The girl had been exposed to 390 HJi;MATUKIA. HiEMOGLOBINUEIA. typhoid infection; she presently was taken severely ill, and for thirty-five days hsematuria ran along with a high temperature, and upon the fall of fever disappeared entirely and completely. Oliver (Brit. Med. Jour., May 26, '88). In some cases the hematuria is idio- pathic, and is not to be explained by any of the above-mentioned etiological fac- tors. Hsematuria in a male with regular monthly occurrence. This was regarded as of an essential nature, established for the relief of plethora. This condition continued for nearly a year, but finally stopped by the use of gallic acid before and during the expected period. Chapin (N. Y. Med. Jour., Apr. 6, '89). Case of a man in whom hsematuria came on from walking or other muscular fatigue, without any assignable lesion of the bladder, ureter, or kidney. Lannois (Lyon Mgd., Dec. 20, '91). Literature of '96-'97-'98. Hsematuria observed consecutive to mountain-sickness. Luzzatto (Gazz. degli Ospedali, May, 1, '98). Prognosis. — The prognosis of hEema- tiiria depends on the quantity of blood lost and the gravity of the disease which causes the bleeding. Treatment. — In all forms of hema- turia rest and cold are the most impor- tant therapeutics; in bleeding from the urethra and the bladder cold may be applied by injections of ice-water or ex- ternally; in bleeding from the urethra compression may be useful; also astrin- gent injections have been employed (nitrate of silver, acetate of lead, tannic acid, perchloride of iron, etc.); when the bleeding is accompanied by painful mic- turition, narcotics are recommended. In cases of vesical haematuria, injec- tions into the bladder, after it has been thoroughly cleared of blood, of Vim solu- tion of tannin, recommended. Donna- dieu (Med. Chronicle, July, '93). Bleeding from the ureters, pelvis, or kidneys is treated by rest, cold, and in- ternal medication of secale, ergotine, tannic acid, arbutin, acetate of lead, per- chloride of iron, fluid extracts of hama- melis Virginica or of hydrastus Cana- densis. In chronic cases of haematuria the balsams may be tried. In a case of hsematuria a successful re- sult obtained from ergot. Bauer (Med. Chips, Nov., '88). Method of treatment for malarial hsematuria in which quinine does not have a part, and which has been used with entire success. This consists of the use of oil of tur- pentine to stop the haemorrhage, mag- nesium sulphate in ^/.-ounce doses every four hours until six large evacuations are secured, liquid nourishment, and Fowler's solution to combat the malarial element. Guice (Amer. Medico-Surg. Bull., Sept. 1, '94). Oil of turpentine successfully used in hsematuria and cases of haemoptysis. Sasse (Ther. Monat, Feb., '95). When the bleeding is caused by calculi or by tumors these are to be removed by operation, if possible; when the blood comes from the kidneys and only one kidney is diseased, it may be necessary to remove the diseased kidney; in some in- stances only an exploratory incision has been made, the kidney has been replaced after a careful examination by which no reason for the bleeding was found, and the operation has resulted in complete recovery. (For the treatment of malarial haematuria see Malarial Fevers.) F. Levison", Copenhagen. H^MOGLOBINUEIA. Definition. — Evacuation of urine con- taining the coloring matter of blood (but no corpuscles). Symptoms. — The urine varies in color from smoky to pink or red, sometimes HEMOGLOBINURIA. ETIOLOGY. 391 almost black; the color has been com- pared to that of porter, cofEee, or port- wine. The urine is ordinarily turbid, acid, of variable specific gravity, and highly albuminous; it deposits after some time an abundant, chocolate-colored, grumous sediment, which microscopic- ally is seen to consist chiefly of granular hEemoglobin, mixed with renal casts, hyaline and fatty, sometimes also with crystals of hfematoidin, uric acid, and oxalate of lime; occasionally a few cor- puscles of blood may be found. The presence in the urine of haemoglobin, or more correctly of methsemoglobin, is demonstrated by difEerent tests, as Hel- ler's test, the guaiac test, the microscop- ical examination, and spectral analysis (see Hjematueia). By spectral analysis two absorption-bands are found between D and E and a third between C and D of the Frauenhofer lines. Idiopathic, or paroxysmal, haemoglob- inuria is characterized by attacks of hEemoglobinuria separated by free inter- vals of days, weeks, or months. Two attacks have rarely been observed in one day; they are ordinarily caused by cold, especially to exposure of hands or feet (Pavy, Muiri, Lichtheim, Eosenbach). The attacks last from three to twelve hours, and are preceded for a brief pe- riod by a chill or rigor, itching of the skin, languor, a sense of weight or dull pain over the kidneys, aching pain or stiffness in the legs, and nausea or vomit- ing. Shivering sets in and generally there is fever with rise of temperature to 40° C. (104° P.) and still higher. The fever continues for some hours and ends with profuse perspiration. The attacks are sometimes followed by an eruption of urticaria. The urine, which was normal before the attack, becomes dark and re- mains so during some hoiirs, after which it gradually resumes its normal appear- ance. The liver and the spleen have in most cases been found swelled and tender. After the attack the patient is very much exhausted for some time, the skin and the mucous membranes being pallid. Study of 12 seizures of hsemoglobin- uria in a man, aged 43 years, without syphilis or any tubercular taint. Of these, 8 began with a chill, 1 with fever, and 3 without prodromes. Five were caused by exposure to cold, 3 by excess- ive exertion, 1 by exertion and wetting, and 3 apparently without cause. The temperature rose to fever-height in 10 cases; the higher the temperature and longer its duration, the more intense the hEemoglobinuria. The staining occurred at the height of the fever. During the seizure the heart's action increased, the pulse was small, the respiration dis- turbed, and nervous symptoms mani- fested themselves. Prior (Miinch. med. Woch., July 24, Aug. 7, '88). Case of paroxysmal hsemoglobinuria due to cold. The case was peculiar in that, in summer, when the patient was free from the ordinary attacks of hsemo- globinuria, he was troubled by cerebral symptoms in the shape of disturbances of sleep, fright, hallucinations, etc. His sufferings were great, and could not be influenced by medication. L. F. Bishop (Med. News, May 16, '95). Etiology. — HEemoglobinuria can ex- perimentally be' caused by injection, into the veins of animals, of dissolved haemo- globin or of substances which disinte- grate and dissolve the corpuscles of blood, such as water, glycerin, and the salts of the bile-acids; the same result may be obtained by inhalations of arseniuretted hydrogen, sulphuretted hydrogen, ether and other poisons, or by ingestion of poisons such as arsenic, chlorate of po- tassium, etc.; transfusion of blood or serum of another species of animal also causes hsemoglobinuria. 1. In man hEemoglobinuria is caused by poisons, i.e., sulphuric acid, hydrochloric 392 H^MOGLOBINUEIA. ETIOLOGY. acid, arsenic, chlorate of potassium, py- rogallic acid, naphthol, nitrobenzol, poisonous mushrooms, etc. [Carre (Bull. Gen. de Th6r., '92) con- tends that large doses of quinine are capable of producing a condition of methsemoglobinuria. F. Levison.] Sulphite of quinine, in doses of 7 ^U grains or more, has produced a heemo- globiiiuria lasting twenty-four hours. Cinehonine or antipyrine should be em- ployed in cases having an idiosyncrasy to quinine. Pampoukis and Chomatianos (Le Progrfes M6d., July 7, '88). Six cases observed in which hsemo- globinuria repeatedly followed the ad- ministration of quinine. Coromilas (Jour, de M6d. de Paris, Jan. 25, '91). Case of hsemoglobinuria due to qui- nine, which was followed by an acute, al- buminous nephritis. Kanellis (Bull. G6n. de Thgr., Jan. 30, '95). [Sharp and Summerskill observed a ease of a child of 8 years (Lancet, ,'93 ) which they attribute to sewer-gas. F. Levison.] Those cases of hsemoglobinuria de- pendent upon a haemoglobinsemia do not occur as the paroxysmal variety, but at the beginning or in the course of certain affections, and are followed by a congest- ive nephritis. Eobin (La Semaine M6d., May 18, '88). Case of probable infectious origin oc- curred in a child, aged 2 years, who, two days after performance of ritual circum- cision, sickened, developed hsemoglobin- uria and jaundice, refused nutrition, presently manifested grave respiratory symptoms, and died. Baginsky (Deut. med.-Zeit, Jan. 24, '89). Two cases of hsemoglobinuria in which the patient became suddenly ill with jaundice and hsemoglobinuria. The lat- ter lasted three days, then the urine be- came normal. Jaundice and distinct swelling of the spleen continued for seven days longer and the aspect of the case in general was that of an acute in- fection. No micro-organism could be found in the blood; but the patient had eaten blood-sausage the evening be- fore his illness, and it is not unlikely that intoxication occurred in thisi way. Klemperer (CharitS Annalen, 20, p. 131). 2. It may be caused by extensive burns, insolation, transfusion of lamb's blood and occur as a symptom of severe infectious diseases (scarlatina, typhoid fever, diphtheria, intermittent fever, icterus). HEemoglobinuria has been ob- served by Winckel as a special disease of the newborn. In severe malarial fevers with icterus, hsemoglpbinuria has often been noticed; these fevers occur mostly in tropical climates in the three conti- nents; when the patient returns to a temperate climate the hasmoglobinuria ordinarily ceases; the cases may be light or severe; the severe cases end lethally either by exhaustion, by complete cessa- tion of the secretion of urine or by caus- ing a ursemic condition of the patient. Case of hasmoglobinuria of hsematog- enous origin from the effects of an intra- uterine v^ashing with carbolic acid. On the eleventh day the patient died, after a number of rigors having appeared on different days. On section there was found a putrid endometritis and acute parenchymatous nephritis, with infarc- tion of the urinary tubules with hsem- oglobin. Krukenberg (Centralblatt ftir Gynak., Aug. 1, '91). Hsemoglobinuria observed in Rou- manian cattle, ascribed to the activity of a micro-organism, a diplococcus. The diplococcus is to be met within the red blood-cells, not to any extent in the large vessels, but in certain of the paren- chymatous organs. It is always found in greatest degree in the kidney, in the tufts. It does not leave the kidney in any great numbers, as a rule, but may be found in the liver and spleen, and oc- casionally in the vessels. The parasite apparently finds a favorable site for de- velopment in the waters of badly-kept wells and ditches, and is taken into the alimentary tract of the animal, thence into the lymphatic circulation and hsematic system. Bab6s (Virchow's Ar- chives, Jan., '89). Case of hsemoglobinuria observed in h.5;moglobinueia. etiology. 393 a rheumatic woman of 60 years. Andre (Le Midi M6d., Apr., '93). Hsemoglobinuria observed in a girl of 16 years, ill four days Avith pneumonia. The crisis occurred on the seventh day, and at the same time the urine began to clear. Nash (Lancet, Xc 3643, '93). Typical attacks of hsemoglobinuria produced in a phthisical patient by slight cold. Brunelle (Bull. M6d. du Nord, Jan., '93). In Greece hsemoglobinuria (of malarial origin) has an average mortality of 22.4 per cent. It is especially met with among those persons who have been long infected by the miasm. Canellis (Ar- chives de MSd. Xavale, June, '88). Malarial hsemoglobinuria is more com- mon in males than in females, and is rarely met among negroes. Long resi- dence in malarial districts is necessary to development of this condition. Chambles (Med. Brief, May, '91). Hsemoglobinuria occurs at periods of an asstivo-autumnal type, from the cir- cumstance that the destruction of red blood-corpuscles is more extensive than in malarial seasons during spring. Bas- tianenelli and Bignami (Eiforma Med., June 7, '92). Three cases of transient hsemoglobin- uria from muscular exertion. In two the cause was a foot-race; in the third, a game of lawn-tennis. The blood was healthy, but the corpuscles were de- stroyed by some product of the unusual muscular exertion, probably carbonic acid. L. Dickinson (Brit. Med. Jour., May 19, '94). Instance of hsemoglobinuria met with brought on in a young man by walk- ing. Eobin (La Semaine Med., Apr. 18, '88). 3. Hasmoglobinuria is caused by dis- solution of blood, i.e., in scurvy, purpura, rubrum maculosus, variola hsemor- rhagica, and may also be seen in typhus. 4. The intermittent, or paroxysmal, hsemoglobinuria is a distinct affection which has especially been studied in the last years. It has commonly been ob- served in men, seldom in women. [Armaud, Siredey, and Garnier (Bull. M6d., '95) relate a ease of paroxysmal hsemoglobinuria in a woman 37 years old. F. Levison.] The attacks, which have already been described, vary much in frequency, are usually traceable to exposure to cold, especially of hands or feet. The disease is characterized by intermittent disso- lution of the red corpuscles of the blood during the attacks. Ehrlich proved this by placing a ligature around the finger of a patient and exposing it to cold; in healthy persons this procedure does not alter the composition of blood, but in patients suffering from paroxysmal hsemoglobinuria the blood drawn from a finger treated in this way will be dis- integrated, the blood-corpuscles will be broken up, and the haemoglobin dis- solved in the serum, which therefore has a pink instead of a yellowish color. Literature of '9G-'97-'98. Case of paroxysmal hsemoglobinuria which was apparently caused by sudden exposure to cold water in bathing, and which subsequent examination showed to be due to cold, as the blood of a ligated finger which had been exposed to freezing was greatly disintegrated and not unlike that found in the urine. Sweet (New Zealand Med. Jour., Oct., '96). During the attacks the number of the red corpuscles is diminished; after the attack many small red corpuscles and hasmatoblasts appear in the blood. Literature of '96-'9T-'98. Hsemoglobinuria is rarely pure; it is generally accompanied by n real destruc- tion of red blood-corpuscles at the mo- ment of the attack. 2. The loss of hsemoglobin greatly sur- passes the loss of red corpuscles, as in one ease the loss of hsemoglobin equaled one-third of the normal, while the loss of red corpuscles only equaled one-ninth of the normal. 39-± HEMOGLOBINURIA. PROGNOSIS. TREATMENT. 3. The resistance of the blood is much diminished at the time of the attack. It is found that the red corpuscles de- stroyed at the end of twenty-four hours during the attack are equivalent to one- third of the total count, while during the normal state not one-quarter of the normal count are destroyed. 4. The so-called paroxysmal hfemo- globinuria being only a, symptom, and not a morbid entity, it is important to examine in every ease the modifications in the blood in order to find out if dif- ferent varieties of hsemoglobinuria are associated Avith different changes in the blood. Vacquez and Marcano (Archives de M6d. Exper., Jan., '96). Probably the paroxysms are in some cases caused by the presence of parasites in the blood; in animals (oxen, horses) a similar disease has been observed. Kro- gins and Ton Hellens found in the blood of diseased oxen parasitic corpuscles anal- ogous to the Plasmodium of malaria. Systemic origin of the paroxysmal variety of hsemoglobinuria insisted upon. LSpine (La Semaine Mgd., Feb. 24, '88). While admitting a class of haemo- globinurias of toxic nature due to sys- temic blood solution, the paroxysmal hEemoglobinurias a friyore regarded as invariably of renal origin. Hayem (La Semaine M6d., Feb. 24, '88). Case of Raynaud's disease with parox- ysmal hsemoglobinuria seen in a child of 6 years. In this case both symptoms probably depended upon excess of uric acid in the blood. Haig (Trans. Med. Soc. of London, '92). Various authors have observed inter- mittent hasmoglobinuria in connection with syphilis. Post-mortem upon an artisan with a syphilitic history, subject to paroxysmal hsemoglobinuria, first brought on after a, severe chilling three years before. The kidneys were found in a healthy condi- tion except for some amount of hseraic pigmentation of the tubular epithelial cells, and a coagulation-necrosis of a number of the renal cells, causing the appearance of vacuolization. Germoing (Med. Press and Circular, Aug. 29, '88). Typical case of paroxysmal hsemo- globinuria which occurred in a man who acknowledged the three taints of ma- larial fever, syphilis, and alcoholism. For eight years, every winter, upon the least chilling, occurred paroxysms of hsemoglobinuria. The paroxysms began with chilly sensations, followed by fever and sweat. Brunelle (Le Bull. M6d., June 10, '91). Four cases of paroxysmal hsemo- globinuria a frigore in children. Three of them were caused by heredity syphilis. Comby (Revue Internat. de M6d. et de Chir., July 10, '95). [Courtis-Suffit (M6d. Moderne, '95) observed a case in a child of 5 years who showed indubitable signs of inherited syphilis. Parry (Jour, of Railway-sur- geons, Fort Wayne, '94) and Gubarew (Petersburg, med. Woch., '94) also men- tion cases of intermittent hsemoglobin- uria in syphilitic patients. F. Lbvison.] Prognosis. — In the hsemoglobinuria caused by poisons, infectious diseases, septic diseases, etc., the prognosis is de- termined by the gravity of the primary disease; the intermittent hsemoglobinuria is for a long time compatible with life; the patients never die during an attack; recovery has been observed, but often the disease continues for many years. Prognosis regarded as grave in hsemo- globinuria. Potain (Internat. Med. Mag., Nov., '93). Treatment. — When hsemoglobinuria is a symptom the treatment must be di- rected toward the fundamental disease; in cases connected with syphilis an anti- syphilitic treatment has been of use, as well as quinine in hsemoglobinuria of malarial origin. In malarial hsemoglobinuria use of atropine and strychnine commended as a basis of treatment. The remainder of the treatment is symptomatic. Stamps (Jour, of Med. and Dosimetric Therep., Dec, '88). In malarial hsemoglobinuria in the early and free use of quinine depends the safety of the patient. As a first dose, H.-EMOPHILIA. SYMPTOMS. 395 if the temperature be above 103° F., 20 grains recommended, continuing its ex- hibition in 10-graiu doses every three hours afterward for twenty-four hours, then dropping to 5 grains every three hours. If quinine blindness follow, the drug is to be stopped. With each of the first two doses are combined 2 grains of calomel, followed, in ten hours after the last dose of calomel, by a Sedlitz powder. To allay the vomiting bismuth and opium are used. Chambles (Med. Bull., May, '91). Case of so-called essential hsemoglobin- uria, in a man of 35 years, cured by in- jections of mercury. Koster (Therap. Monat, Feb., '93). In every instance ol hsemoglobinuria, so-called essential, occurring in a child, the specific treatment should be em- ployed even in the absence of any sign of hereditary syphilis. Courtois-Suffit (La M6d. Moderne, Mar. 2, '95). In. paroxysmal haemoglobinuria change of climate, dietetic treatment, iron, qui- nine, and arsenic have been recom- mended. F. Levison, Copenhagen. H.a;MOPHILIA. — Gr., al^a, blood, and ^t/letv, to love. Definition. — Hsemophilia is an in- herited or acquired disorder of the vas- cular system characterized by an abnor- mal liability to severe and sometimes imeontrollable haemorrhages. Symptoms. — The condition is gener- ally discovered by accident, a slight wound, the extraction of a tooth, the application of a leech, vaccination, etc., being followed by profuse and sometimes dangerous bleeding. Epistaxis is of fre- quent occurrence. In women this is es- pecially the ease, because the hsemophilic process mainly manifests itself through the mucous membranes, and menor- rhagia, metrorrhagia, post - partum haemorrhage, etc., are often suffered from. Pregnancy and labor do not present the danger for an ha2mophilic woman that might be supposed. Of 130 cases, the death of the mother occurred only in 3 and abortion in only 16 cases. R. Kolster (Wratsch, No. 28, '95). Literature of '96-'97-'98. Case of a girl, aged 11 months, in whom from the third week of life there had been continuous and spontaneous hsemorrhages from the nose, mouth, and rectum, and into the substance of the skin, without, however, impairing in any manifest way the child's development. There was a history on the father's side of hsemophilia, but not on the maternal side. The patient was the only living one of their children; there had been two other girls who had died in infancy, but had not shown any signs of hsemo- philia. Comby (Bull, et Mem. de la Soc. Med. des H6p., June 25, '97). Patients subject to hasmophilia con- stantly exhibit mental peculiarities of definite form. The most important and the most common mental peculiarity is an inability (it is more than unwilling- ness) to tell the truth about their condi- tion, even when they have had repeated and alarming experience of their defect. Frequently they will persist in obstinate denial of their liability to bleed, even when the haemorrhage is going on, and resisting all efforts to check it. 0. T. Dent (Brit. Med. Jour., Apr. 23, '98). In men arthritic symptoms are fre- quently observed, especially during cold and damp weather, the knees being most prone to pseudorheumatie manifesta- tions which are sometimes accompanied by fever. The joint-symptoms are often the precursor of an approaching hasmor- rhage. Hsemophilia does not always manifest itself by external hsemorrhage. The arthritic complications of hsemophilia are generally the result of hsemorrhage into the joint-cavities, but there is no 396 hji;mophilia. etiology, pathology. antagonism between haemophilia and articular rheumatism. Frederick S. Eve (Lancet, Nov. 16, '89). Three stages described of joint-troubles in haemophilia: (1) the stage of haem- arthrosis; (2) stage of inflammation; (3) stage of retrogressive changes with deformity. The painless, sudden onset in pale young men marks the first stage. Haemorrhages in the skin would com- plete the diagnosis. The second stage is strikingly similar to the white swelling of tuberculous arthritis. The author has three times made a mistaken diagnosis, two of the three cases having suffered death in consequence, from haemorrhage after operation; the third recovered. Koenig (L'Encfiphale, June 25, '92). Etiology. — According to Henry, hsem- ophilia is the most hereditary of all diseases. Although a iixed law, such as Nasse's — namely, that transmission of the disease through females that are themselves not hemophilic — cannot be accepted as universal, 30 per cent, of the cases studied by Kolster, for instance, were found to be governed by this pecul- iar form of heredity. It is generally possible to demonstrate the hereditary character of this affection, which is the most hereditary of all dis- ease. E. P. Henry (Boston Med. and Surg. Jour., Mar. 14, '95). The most remarkable family of bleed- ers of which we have any account is the one living in Tenna, Switzerland. It springs from a couple of the same name, presumably relatives, who lived nearly three hundred years ago, and during this period there have been bleeders among the male descendants. The females, as a rule, remain exempt, the disease being transmitted through them to their male children. Anton Hoessli (Zeit. f. klin. Med., B. 15, H. 3, '88). Case in a 12-year-old boy whose five brothers and sisters had died of haemo- phila. Furth (Inter, klin. Bund., Sept. 16, '88). Case of retinal haemorrhage seen in a patient giving a family history of haemo- philia for four generations. The right eye, blind for eight years, showed the remains of an old haemorrhage into the vitreous. In the left eye there was a small, recent haemorrhage of the retina, with apparently miliary aneurisms on the retinal artery. Recovery of sight in the left eye was attained by absolute rest, milk diet, and the administration of iodide of potassium internally. Vialet (Reeueil d'Ophtal., June, '95). Among other etiological factors con- sidered are a lack of fibrin or fibrinog- enous elements and neurasthenia bear- ing mainly upon the vasomotor constric- tors. Case of a young woman who suffered from epistaxis, menorrhagia, metror- rhagia, haemorrhagic diarrhoea, etc., al- ways accompanied by great mental strain, fits of crying, fright, anger, and the like; at times, death seemed immi- nent. Anderson (Med. and Surg. Rep., Mar. 28, '91). Case of u. girl of 16 years, in good health and with no marked history of hysteria, who began to bleed from the pulp of her fingers. This occurred with- out provocation and without rupture of the skin, and was not attended by any further symptoms, excepting despon- dency, almost amounting to melancholia. Yahoubian (Gaz. M6d. d'Orient., Mar. 15, '91). Pathology. — The prevailing view is that haemophilia is mainly due to a mor- bid condition of the vascular walls, and affecting especially the middle or mus- cular layer. According to Kuhlmann, the changes are such as to seriously com- promise the anatomical and physiological functions. These changes are: Granu- lation-necrosis occurring in tuberculosis, syphilis, leprosy, etc., and due to direct chemical changes between the physi- ological products of certain organisms and the protoplasm of the histological elements; amylosis occurring during ex- tensive suppuration processes, and due to a similar direct change; coagulation- necrosis or mucoid degeneration occur- ring in cancerous and diphtheritic proc- H.EMOPHILIA. PEOGNOSIS. TREA'TMEXT. 397 esses; liquefaction - necrosis occurring in typhus, variola, etc.; fatty and calca- reous degeneration, in which the proto- plasm is replaced by fatty granules and crystals of carbonate and phosphate of lime. The vasomotor system doubtless plays a part in the process. It is possible that abnormal all\:alinity of the blood may, by impairing the ca- pacity of the blood for coagulation, assist in the production of haemorrhages. In a ease of repeated and excessive epistaxis in a man of 49 years lime-water in liberal quantity caused the haemor- rhage to cease and remain absent until the patient neglected the use of the remedy. Watkins (N. Y. Med. Jour., Aug. 13, '92). All the hsemorrhagic diseases are but alterations of one form, viz., scurvy. W. Koch (Jahrb. fur. Kinderh. phys. Erziehung, B. 32, H. 1, 2, '91). Essence of hsemophilia believed to lie in a heightened activity of the blood- making organs, the haemorrhages into the joints and elsewhere being regarded as discharges, or eliminations of super- fluous blood. M. Cohn (Centralb. fur klin. Med., Oct. 12, '89). Syphilis may manifest itself in an haemorrhagic diathesis. Gregorio Cosella (Archivii Ital. di Clin. Med., July, '89). Prognosis. — Haemophilia is particu- larly to be feared when it occurs in chil- dren in an aggravated form. In slight cases the disease frequently disappears at puberty. The haemorrhages are usually more dangerous in boys than in girls; uterine haemorrhages, though copious, seldom endanger life. Case in which the family history showed no haemophilia on either the father's or mother's side as far back as the fourth generation. Of their five children, however, the second at 3 'A years developed hydrocephalus and suf- fered from frequent severe and uncon- trollable haemorrhages from the nose, of which he finally died. The third child showed no evidence of haemophilia, but died of malignant scarlet fever at 2 years of age. The fourth child had severe hsemorrhage when he began cut- ting teeth, and at the eruption of the molars he bled to death. Judson Daland (Boston Med. and Surg. Jour., Mar. 14, '95). Treatment. — The treatment of hsemo- philia mainly consists in the avoidance of exciting factors. The extraction of teeth should especially be guarded against and preference be given to meas- ures, such as gradual loosening and evic- tion with rubber, of a tooth, rather than to the forceps. Scratches,, cuts, etc., should be avoided; hence an occupation exposing the sufferer to solutions of con- tinuity becomes dangeroiis. Violent ex- ercise is occasionally the only exciting factor. Fatal case of haemophilia, following extraction of a tooth, in a young man. Bates (Annals of Surg., May, '94). Prophylactic treatment between at- tacks is also indicated. Of all the prepa- rations, hydrastis Canadensis has proved most successful, when administered in large doses, 10 to 15 drops of the fluid extract, three times a day. Large doses of fluid extract of hydras- tis (20 drops) advised in hsemophilia. Delafield (Med. Age, Apr. 11, '92). The various preparations of iron have been recommended; ferratin is probably the most useful preparation at our dis- posal. The perchloride has been recom- mended by Legge. Strychnine is . indi- cated on account of the involvement of the vasomotor system. Saline purga- tives, by reducing the arterial tension, are valuable when prodromic symptoms are noticed. Literature of '96-'97-'98. Case of a woman who, because of haemophilia, suffered from very excessive anasmia. She was treated by the various haemostatics, and by repeated injections of ergotine, without much result. Finally 398 H.EMOKRHOIDS. SYMPTOMS AND DIAGNOSIS. 3 capsules of thyroid gland were given each day, with the result that the loss of blood was immediately arrested. The patient gained in weight, the purpuric spots disappeared, the gums became firm, and some color began to appear in the face. Cardiac palpitation was decreased. At no time was the dose greater than 3 capsules a day. Delace (Jour, de M6d. de Paris, Jan. 23, '98). In the treatment of haemopMlic haemorrhage the recumbent position (ex- cept when the bleeding is at the nose) is of primary importance to reduce cardiac action. In women an alum plug inserted in the vagina, as recommended by Bev- erly Cole, is an efficient means. Lime- juice internally and hypodermic injec- tions of ergot should supplement the use of local styptics, the best of which are turpentine and perchloride of iron when these can be used. When the haemor- rhage is from the nasal cavities, the vari- ous measures recommended under Epi- STAXis are recommended. Transfusion sometimes becomes necessary, but it should be conducted with unusual care, owing to the morbid condition of the vascular walls. The best haemostatic is the transfusion of entire blood, of which but a small quantity will sometimes stop an other- wise uncontrollable haemorrhage. Hayem (Le Bull. M6d., Sept. 16, '88). HEMORRHOIDS.— Gr., from al^a, blood, and op^otg, pertaining to. Definition. — A vascular tumor of the mucous membrane of the rectum, the anus, or both. Varieties. — Haemorrhoids may be classified into two varieties: external and internal. They are called external when the skin alone is involved, and the tumor is ex- ternal to the external sphincter muscle, while the internal are covered by the mucous membrane. It often happens. in long-standing cases, that internal piles protrude outside the anus, yet, when they are returned into the bowel, they will remain for a short time, at least; but the external cannot be pushed up into the bowel. Should only a portion be returned while the other remained on the outside, it might properly be termed a combination pile. Symptoms and Diagnosis. — There is usually a sense of fullness and heat, throbbing pain, tight sphincter, with irresistible tendency to strain, and some- times an itching sensation. When in- flammation is present to any degree, the patient will be uncomfortable in any position he may assume, and may also have a slight elevation of temperature. The following are the diseases which resemble haemorrhoids most: 1. Polypi. 3. Villous tumors. 3. Malignant growths. 4. Prolapsus. 5. Pruritus ani. 6. HEemorrhages. Polypi can be differentiated from haemorrhoids by their soft, smooth, elas- tic feel, pyrif orm shape, and long, slender pedicle. Villous tumors by their broad base, slow growth, spongy feel, dark-red color, and frequent haemorrhages. Malignant growths in the early stage present a number of hard nodules on the side of the rectal wall; at a later date they become larger and break down, after which the diagnosis is made without dif- ficulty. Prolapsus involves the entire circum- ference of the bowel. The tumor is cone- shaped, with a slit in the centre, and has a velvet-like appearance, while piles are distinct tumors. NPruritus ani is frequently called itch- ing piles. This is not warranted, since there is an absence of both tumors and hasmorrhage, while the itching is caused, in a large percentage of cases, from some HEMORRHOIDS. ETIOLOGY. 399 irritating discharge from the rectum, thread-worms, neuroses, or eczema of the skin. Haemorrhages of all kinds from the rectum are usually attributed to piles, but may be due to ulceration, injury, fissure, and malignant growths. Etiology. — Xeither sex nor station in life is a bar against the production of haemorrhoids. The erect position man occupies is, from gravity alone, conducive to them. The rectum is abundantly sup- plied with veins, which enter into the formation of the htemorrhoidal plexus. A portion of this blood is returned through the internal iliac to the inferior cava, the remainder by way of the in- ferior mesenteric to the liver; and these veins, like others of the portal system, have no valves. The branches of the superior hsemorrhoidal veins in their journey upward pass through little slits in the muscular wall, and therein, Ver- neuil claims, is to be found the principal cause of this disease. He believes that the dilatation is due to the obstruction of the calibre of the veins from the mus- cle's contracting on them as they pass through it. While this anatomical fact undoubtedly tends to dilatation under certain conditions, it does not seem to be sufficient of itself to account for the enlargement of the veins in all cases. It is well known that the rectal and anal plexuses have no valves, and, further, that, when a patient afflicted with pro- lapsed piles is requested to strain down, they at once become engorged with ve- nous blood as a direct result of the press- ure of the abdominal muscles. It is not at all unreasonable, then, to suppose that the pressure from the above muscles on the blood-column or the pressure from a pregnant uterus of some growth might be productive of haemorrhoids by inter- fering with venous circulation. Some of the common causes of this disease are morbid growths of liver, spleen, uterus, ovaries, and prostate by causing venous obstruction. Hsemorrhoids and painful fissure are often associated ivith uterine disease, either inflammatory in nature or due to the pressure of tumors. Murray (Ar- chives of Gynsec, June, '91). Constipation, stone in the bladder, urethral obstruction, and purgatives are also conducive to piles from the intense straining which they induce. Congestion of the liver, obstructive diseases of the heart, improper diet, alcoholism, ' and irregular habits, as well as inherited pre- disposition, may all be said to be etiolog- ical factors. Many railway-employees suffer from haemorrhoids as a result of irregularities in living, combined with the jarring motion of the train. The causes of hemorrhoids are: 1. Diminution of the forces that normally move the venous blood from the rectum to the heart. 2. Obstruction of the venous outflow from the rectum. 3. Pre- disposition. From these views of the etiology of hsemorrhoids may be easily deduced the principles of prophylaxis. Wallace A. Briggs (Occidental Med. Times, Dec, '95). The cutaneous variety of external pile is classifled as redundant, hyperplastic, or hypertrophic. The distinctive feature of the redundant pile is the superabund- ance of the anal integument brought about by the stretching it receives from the subadjacent varicose external hsemor- rhoidal veins when they are fully dis- tended, as during defecation. The hyperplastic pile appears in the form of a pendulous cutaneous tag, associated with an abrasion, fissure, or ulceration of the anal verge, and is the result of an inflammatory hyperplasia; while the term hypertrophic indicates that the swelled, thickened, radiating anal folds associated with the eczematous inflam- mation are the result of an inflammatory 400 HJ^":MOERHOIDS. EXTERNAL. TREATMENT. or irritative hypertrophy. J. Walter Otis (Amer. Jour. Med. Sci., Feb., '95). Literature of '96-'97-'98. Haemorrhoids consist essentially in the new formation of young blood-vessels by a process of germination from the older vessel-walls and the consequent forma- tion of a cavernous tissue. Inflamma- tory changes, such as thrombosis and endophlebitis, may also occur within the neoplasm, but are absent in the majority of cases. Venous stasis has nothing to do with haemorrhoids, being at most a secondary phenomenon. George Rein- bach (Beitrage zur klin. Chirurgie, vol. xix, No. 1, '97). External Haemorrhoids. External piles are so common that few persons arrive at middle age without hav- ing suffered from them. They are classi- fied into thrombotic and cutaneous va- rieties. Thrombotic or venous piles consist of elevations of skin near the anal margin, oval in form and of a livid color or slightly tinged with blue, iilled with a hard clot of blood inclosed in a sac. The amount of pain depends upon the inflam- mation. Usually it becomes severe and will continue until the clot is turned out or suppuration takes place. These tumors form quickly, and present them- selves during the act of defecation, fol- lowing an attack of constipation, neces- sitating great straining. They have the appearance and feeling similar to that of a bullet beneath the skin, and are gen- erally single. They are caused by excess- ive eating, irregular habits, and any- thing that is conducive to constipation. Unless external haemorrhoids become irritated or inflamed they will cause little inconvenience; in fact, many persons go through life with them and suffer very little. When the parts are not properly attended, they frequently become acutely inflamed and cause much pain and an- noyance until they are removed. Treatment of External Haemorrhoids. — The treatment of external piles may be palliative or operative. The latter is always to be preferred unless the patient refuses to submit to a trivial operation. In such a case much relief is to be had from the use of certain palliative meas- ures. Palliative Teeatment. — In all cases attention should be paid to the diet. The use of highly-seasoned food and stimu- lants, such as tobacco, whisky, wines, and beer, should be discontinued, and a simple diet substituted. The bowels should be kept open by the use of Vichy, Plunyadi, Freidrichshall, or some other mineral water. If there are symptoms of a congested liver, a few calomel par- vules, ^/lo grain, or the blue pill properly administered will prove beneficial. Fre- quent hot baths should be taken, and the anus washed with Castile soap and water. If the pile belong to the first variety, containing a hard clot, frequent applications of an ointment composed of I^ Morphine sulphate, 6 grains. Calomel, 13 grains. Vaselin, 1 ounce. will soothe the parts and reduce the in- flammation. The old-time lead-and- opium wash, either hot or cold, applied constantly, affords great relief: — 1^ Lead-water, 4 drachms. Tincture of opium, 2 ^/^ drachms. Distilled water, enough to make 4 ounces. — M. The lead Solution mixed with the sugar of milk forms a very soothing ap- plication. Hot poultices of any kind, if applied constantly, will prove valuable in relieving pain and reducing inflam- mation in either variety. HAEMORRHOIDS. EXTERNAL. TREATMENT. 401 In the medical treatment of haemor- rhoids daily action of the bowels should be obtained. Sponging the anus and sur- rounding parts with soap and cold water is a very efficient application. Less meat and more vegetable food is to be eaten and physical exercise taken daily. In- jections beginning with lukewarm water and gradually changing to cold often afford great relief. Those who suffer from haemorrhoids should, if possible, give up taking stimulants entirely. Thomas (Lancet, Jan. 31, '91). Tar warmly recommended in the treat- ment of haemorrhoids. The following ointment may be used: — R Tar, Extract of belladonna, of each, 46 minims. Glycerin, 1 fluidounee. M. Sig. : To be applied locally morn- ing and evening. Laeruz (Revista de Med. y Cirujica Practicas, Apr. 7, '94). The pain and irritation accompanying inflamed haemorrhoids may be quickly re- lieved by local washing with a weak so- lution of bichloride, — about 6 ounces of a 1 to 10,000 solution. Immediately after this the patient should introduce a tampon of cotton impregnated with the following ointment: — R Lanolin, 1 Vz ounces. Vaselin, 5 drachms. Distilled water, 1 fluidounee. M. Sig.: For external use. These applications should be made a number of times each day. lUinsky (Re- vue Internat. de Med. et de Chir., Dec, '94). Literature of '96-'97-'98. External piles and anal pruritis treated by the application of collodion. This causes the pile to contract and supports the contracted pile. The collodion is applied on a little cotton-wool each morning after defecation. D. W. S. Samways (Brit. Med. Jour., Nov. 21, '96). Following ointment employed in the treatment of haemorrhoids: 2 ounces of camphor-lanolin; 3 drachms of castor- oil; IV2 drachms of precipitated chalk; 30 grains of hydrobromate of cicutin. Monin (Med. Mod., Nov. 4, '96). Opeeative Tbeatment. — In the thrombotic variety the tumors should each be incised, the clot turned out, and some escharotic or packing applied to the inside of the pile to insure the clos- ing of any rent in the vein. The patient should then be placed in bed to remain there for several hours to prevent the tumors' filling up again. The surgical treatment of the cuta- neous variety differs somewhat from the one just referred to, in that the tumor is seized with a pair of catch-tooth for- ceps and then snipped off with a pair of curved scissors, care being exercised not to remove any more of the skin than is absolutely necessary, lest too much con- traction follow the operation. When there is considerable space between the edge of the skin and the mucous mem- brane, it is best to unite them by catgut sutures. If the sphincter has been pre- viously divulsed, little pain will follow the operation. When there is only one tumor and that small, it can be removed with comparatively little pain after an injection into it of a 6-per-cent. solution of cocaine. It does not make any differ- ence, from an operative point of view, whether the pile is inflamed or not; it should be operated upon just as soon as the patient's consent is obtained. Cases of stricture from operations for extreme hemorrhoids have been re- ported, but they are rare and follow only where an excessive raw surface is left after removal of swelled tumors. Cutaneous Hsemorrhoid, or Hypertro- phied Skin. — This variety consists of hypertrophied prolongations of the skin. Cutaneous piles are frequently a result of the other variety, a fold of skin being left after the clot has been out-turned or absorbed. They may be single or mul- tiple, but usually retain the natural color of the skin, which has become thickened. 403 H/EMOERHOIDS. INTERNAL. TREATMENT. They are much aggrayated by improper diet, irregular habits, and uneleanliness. Internal Haemorrhoids. Internal hsemorrhoids are developed, in many respects, like the external va- riety, and the causes which produce the one may also produce the other. In cases of long standing they remain outside the anus nearly all the time and frequently become ulcerated, causing much pain and bleeding. It is not uncommon to see both external and internal piles pres- ent at the same time, thus necessitating a combination operation to insure a good result. The internal variety is due to certain changes which take place in the blood-vessels in and beneath the mucous rqembrane. Symptoms. — Some patients have in- ternal piles for years and suffer very little annoyance from them, while others suf- fer greatly from the first. Frequently strong men and women become emaci- ated and nervous from an apparently simple case, — so much so that they are totally unable to attend to their ordinary duties. The most prominent symptom of this variety of piles is the bleeding, and from this fact they are frequently referred to as "bleeding-piles." The bleeding is usually preceded by the pro- trusion of the tumors during the act of defecation, and may be slight or pro- fuse. Sometimes the haemorrhages are suf&cient to induce fainting. When the piles are not inflamed, the only incon- venience is a sensation of heat and full- ness; but when they become swelled or strangulated and the inflammation be- comes active, the sphincter alternately contracts and relaxes on them, thus pro- ducing most excruciating pain, which lasts until they slough off, have been operated on, or are relieved by palliative remedies. In cases of long-standing, the walls of the piles become tough and hypertrophied. The bleeding, in the vast majority of cases, is of a venous * character. Cripps believes that the spurting, in cases which appear to be arterial, is due to the blood's being forced as a regur- gitant stream through a rupture in the vein by the powerful abdominal muscles. In some instances, however, others have witnessed haemorrhages wherein the blood presented the appearance of that coming from an arterial twig. Internal haemorrhoids may be divided into two classes, viz.: capillary and venous. Capillary. — The capillary tumors are rare, smaller than the, venous, spongy in texture, are formed by the superficial vessels of the mucous membrane, and re- semble strawberries. They may appear alone or be present with the venous va- riety. They rarely protrude and scarcely ever give pain, but always bleed pro- fusely. Venous. — This variety is of more fre- quent occurrence than the capillary; the tumors are large and vary in size from one-half to one inch across their bases, are covered by mucous membrane, hav- ing a glistening appearance, are a bluish or livid color, and are formed as a result of a dilatation of the veins in the mucous and submucous tissues. Treatment of Internal Haemorrhoids. ■ — Palliative. — Palliative measures afford relief in many cases, while in a few they may reduce the piles altogether. When these are small and cause but little suffering, the treatment is simple. In the first place, errors in diet and habits of living should be corrected. When piles are protruded and inflamed the patient should assume the recumbent position and keep perfectly quiet, and soothing or astringent lotions and oint- ments should be applied constantly. HiEMOERHOIDS. INTERNAL. TREATMENT. 403 When these fail relief can often be had from ice and poultices made of flaxseed, corn-meal, and onions. The symptoms of a congested liver should at once be counteracted. When piles are not large_ or strangu- lated they can be made to contract by the application of pure nitric acid. The tumors must be returned above the sphincter at the earliest opportunity. If the patient must work he may get some comfort from a pile-supporter. The bowels should be kept open at all times and the patient instructed to cultivate regular habits as to the time his bowels should be moved. In haemorrhoids large injections of cold water at 40° to 50° F., either plain or containing boric aeid or antipyrine, are productive of much good in the abate- ment of inflammation, congestion, and in arresting small bleedings. J. E. Davis (N. Y. Med. Jour., June 15, '95). For internal haemorrhoids excellent re- sults obtained from tincture ferri per- chloridi and hazelin, 20 drops of each in an ounce of water internally, twice daily, and injections per anuin of tincture ferri perchloridi, 4 drachms, and hazelin, 4 drachms. The injection is best given at bed-time, so that it may be retained. N. C. Mitra (New Orleans Med. and Surg. Jour., Nov., '95). SuBGiCAL Teeatment. — Operations when properly performed always effect a permanent cure, and in a shorter time than is required for even temporary relief by palliative measures; the suffering is much less when there are no complica- tions. The operation is a trivial one, in- suring complete cure; it should be rec- ommended, and performed at once, re- gardless of any inflammation. When an operation is necessary, that best suited for the case under advisement should be selected, no single operation being adaptable to all cases. The general health of the patient should be looked into, and improved, if need be, by appropriate measures. The virine should be carefully examined to detect the presence of any kidney com- plication. On the morning preceding the operation 2 teaspoonfuls of com- pound licorice-powder should be given, and one hour previous to the same the surrounding parts should be cleansed, shaved, if necessary, and the rectum thor- oughly washed out. Opeeations. — Many operations, more or less valuable, have been devised for the relief of haemorrhoids. Dilatation of the sphincter has met with some success by French surgeons, who originated it. Dilatation of the anus. In the first stage of hsemorrhoids — that of inter- mittence, where the attacks occur but three or four times a year and are ac- companied by a slight burning sensation and pruritis of the anus, with a small flow of blood — gentle purgatives are ordered, applications of very warm water, enemata at the same temperature, and applications of plugs of cotton steeped in a 1-per-cent. solution of co- caine. In the second stage, where the piles are procident and the rectal vari- cose veins are very painful, forcible dila- tation gives unvarying success. Before employing the speculum, local anaes- thesia of the parts is produced in the following manner: The patient being placed in the classical position on the side, with one leg extended, the other bent on the thigh and on the abdomen, an assistant exposes the anal region. The operator takes in a forceps a small plug of cotton, steeped in a 1-per-cent. solution of cocaine, and passes it into the rectum as high up as possible; this plug is followed by another a little larger, and yet a third and a fourth, in- creasing in size until he can insert one as large as a walnut. He then takes an ordinary Pravaz syringe flUed with the same solution and inserts the needle into the perineum, half an inch from the anus, and injects slowly the contents, taking care to turn the needle in differ- ent directions, and by this means one- 404' HyEMOREHOIDS. INTERNAL. TREATMENT. fourth of the circle limiting the rectal orifice is ansesthetized. The injection is renewed in the second quarter, and. so on until the circle is completed, each syringe containing V4 grain; it is thus that 1 grain of cocaine has been injected. But in order that the dilating process should be painless the sphincter must be anaas- thetized, and for this purpose the oper- ator passes the index finger of the left hand into the rectum and plunges the needle through the skin up to the mus- cle, guiding it with the finger; he empties half of the syringe at that point and the remainder as he is withdraw- ing it. Twenty-six patients operated upon in this way without any accident. In the third stage, where the veins form a tur- gescent mass, they should be removed with the bistoury, without dissection of the mucous membrane. Paul Rgclus (La Semaine M6d., Nov. 28, '94). Experience lias sliown, however, that dilatation offers only temporary relief. The crushing method of Mr. Herbert Allingham is occasionally used in Eng- land, but rarely in this country. And it may be said that of all the oper- ations proposed, but four operations are entitled to consideration. They are: the injection. Whitehead's, ligature, and clamp and cautery. Injection. — A few years ago the treat- ment of piles by this method was quite in vogue, but specialists have practically discarded it. Experience has shown that the results are not permanent and that annoying complications frequently arise. This method is attractive to the laity because, no knife is used; it is sometimes painless, and does not detain them from their business. This is true when a per- fect result is obtained. On the other hand, when extensive inflammation and sloughing occurs they will suffer more pain and be detained longer than if a better and more radical operation had been made. It certainly is not the best operation for the average case of piles and is suited only for the small, distinct, pendulous piles situated above the grasp of the sphincter-muscle that bleed freely. Piles should not be injected when in- flamed, strangulated, large and hyper- trophied, or external. When they are injected promiscuously the treatment will frequently be followed by great pain, swelling, sloughing, abscess, fistula, phle- bitis, pyemia, long delay from business, partial cure, and occasionally death. When used in selected cases, however, a citre is obtained quickly with little pain. The preparations are the same as for any other rectal operation. It is well to warn patients when they have several tumors that two or three treatments may be necessary to effect a complete cure. An ordinary hypodermic syringe and a small speculum are the only instruments required. To avoid accidents it is well to observe the following rules: — 1. Cleanse the anus and surrounding parts. 2. Place the syringe and needle in boil- ing water until everything is in readi- ness. 3. Accurately gauge the amount to be injected. 4. Force the air out before introduc- ing the needle. 5. Inject the fluid slowly in the pen- dulous portion. 6. Inject from 2 to 5 drops in small and 5 to 10 in large piles. 7. Leave the needle within until the pile turns white. 8. Da not inject the tissue beneath the pile. 9. As the needle is withdrawn make pressure with the index finger to prevent the escape of the fluid and arrest hsemor- rhage. 10. Promptly return all tumors. 11. Make a fresh solution for each in- jection. H-^EMORRHOIDS. INTEE^AL. TREATMENT. 405 12. Keep the patient in the recumbent position one-half hour after the opera- tion. 13. Only a fluid or semisolid diet should be permitted for a few days. 14. Weak in preference to strong solu- tion should be employed. 15. Inject only one or two piles at a sitting. As to the solutions to be injected, almost all the caustics in the yegetable and mineral kingdoms have been tried, with varying success. The most success- ful results have been obtained, however, from carbolic acid in combination with glycerin, alcohol, olive-oil, and water. Experience has shown that the weaker solutions cause fewer complications and give better results than the stronger. The following formula is very satisfac- tory:— 19 Carbolic acid, 12 grains. Glycerin, 1 drachm. Water, 1 drachm.- — M. Iodine, iron, ergot, and ergotine have been extensively used, but have no ad- vantages over carbolic acid. Injections of iodoform tried in twelve eases of hsemorrhoids with excellent re- sults. After having prepared the patient by cleansing the bowels thoroughly with repeated irrigations of a solution of sali- cylic acid about fifteen minutes before the operation, a suppository containing 2 grains of cocaine and from ^A to 'A grain of morphine is introduced into the rectum. If the patient is extremely sen- sitive at the beginning of the operation a I-per-cent. solution of cocaine should be injected into different portions of the mucous membrane. After the introduction of an iodoform- gauze tampon through a small speculum the tumors are brought intft view with- out grasping them with a forceps. Two drops of a saturated solution of iodo- form in ether are then injected into the cellular tissue adjoining each nodule. In place of the gauze tampon a supposi- tory containing 2 grains, of salicylic acid is now substituted, and bismuth and. opium are given to prevent a movement of the bowels. On the third day 2 ounces of olive-oil are injected into the rectum, and castor-oil is given per OS. This oper- ation does not prevent the patient from attending to his daily work. Beck (N. Y. Med. Jour., July 21, '94). An excellent method of treating haemorrhoids consists in dilatation of the anus, followed by injections of 2 drops of a solution of glycerin and carbolic acid — 50 to 80 per cent. — into each of the tumors. A piece of iodoform gauze coated with vaselin and boric acid is placed in situ and maintained by a T-bandage. The next day the haemorrhoids are found to be hard, but not painful, and in a few . days they contract and disappear. Rest of one or two days in bed completes the treatment. G. Roux (Ther. Monat., Mar., '95). An ordinary case of haemorrhoids can be cured by injection and the patient still be able to Avork. It is an error to use oil in any injection. The author uses for a single syringeful 1} Acid carbolic, 2 to 5 drops. Alcohol (pure), 10 to 20 drops. Distilled water, enough to make 1 drachm. — M. Two to 3 minims to be injected along- side each pile as the needle is withdrawn. The syringe and rectum should be clean and not more than three haemorrhoids injected at once. One must be careful not to enter the vessel with the needle. If a man is at work, one hasmorrhoid at a time should be treated every four or five days. Car- ter S. Cole (The Post-graduate, Nov., '95). Whitehead's Operation. — Mr. White- head describes his operation 'as follows: "By the aid of scissors and a pair of dis- secting forceps the mucous membrane is divided at its junction with the skin around the entire circumference of the bowel, every irregularity of the skin being carefully followed. The external 406 HAEMORRHOIDS. INTERNAL. TREATMENT. and the internal sphincters are then ex- posed by rapid dissection and the mucous membrane and the attached hsemor- rhoids, thus separated from the submu- cous bed upon which they rested, are pulled bodily down, any undivided points of resistance being snipped and the haem- orrhoids brought below the margin of the skin." The mucous membrane above the haemorrhoids is now divided trans- versely in successive stages and the free margin of the severed membrane above is attached, as soon as divided, to the free margin of the skin below by a suitable number of silk sutures, which he does not remove. He prefers the lithotomy position and uses torsion to arrest haem- orrhage in preference to the ligature. Mr. Whitehead claims that piles are not individual tumors, but that they are only a part of the general plexus of the veins associated with the superior hsemor- rhoidal, each radicle being similarly, if not equally, affected by the initial cause, either constitutional or mechanical. He believes that all vessels should be ex- posed, and that the entire pile-bearing area should be removed. The operation has not becojne general either in this country or in England; in fact, few, if any, perform it either in an ordinary or a severe case. The operation under consideration certainly deserves a place in rectal sur- gery, but not so prominent a one as Mr. ■\Vhitehead grants it. It is not suited for the treatment of ordinary or even severe cases, for two reasons: first, they can be cured by a less difficult operation; sec- ond, complications frequently accom- pany and undesirable results may follow the operation. The operation is indi- cated in long-standing cases, accom- panied by frequent haamorrhages, where there are no distinct pile-tumors, but where the veins of the entire rectal wall are engorged and extensively dilated from the external sphincter upward for two or three inches. When such a con- dition is present nothing short of the removal of the entire disease area will effect a cure. Whitehead's operation is an ideal one in certain cases. It is only indicated, however, where the entire, or nearly the entire, circumference of the pile-bearing portion of the rectum is involved. M. Borts (Cleveland Med. Gaz., Feb., '95). Literature of '96-'97-'98. Whitehead's treatment of hsemorrhoida regarded as method of election in cases of large internal or externo-internal piles forming a prominent circular mass. In eighteen cases thus treated by the author the results were very satisfactory. The cure is a radical one, provided the gut be incised above the zone of venous dila- tation. Delorme (M6d. Mod., Oct. 31, '96). It is necessary to emphasize the danger of stricture's following this operation; I have had 15 such cases come under my care within the past five years. Persons thus mutilated not only suffer from the constriction and ulceration, but in addi- tion from an unbearable pruritus that is being irritated constantly by the dis- charge. All these untoward conditions are the result of non-union and retrac- tion of the mucous membrane. Opinion of a large number of surgeons, both in this country and Europe, secured in regard to the disastrous results that are apt to follow Whitehead's operation. The replies include 200 cases, of which the following is a summary: Loss of the special sense by which the patient should be warned of a coming evacuation and enabled to prepare for it, 8 cases; in- continence of flatus and f feces, 23 cases; paralysis of the sphincter, 4 cases; chronic inflammation of the rectum, 1 case; failure of union of the wound by first intention, with retraction of the edges of the wound, forming a contract- HJSMORRHOIDS. INTERNAL. TREATMENT. 407 ing, tubular ulcer with stricture, 9 cases; other ulcers, 2 cases; irritable and pain- ful anus, 12 eases; eversion of the mu- cous membrane, 4 cases; neuralgia of the pelvis and inferior extremities, 2 cases; general neurasthenia, 1 case; fatal peritonitis, 1 case; non-fatal septic re- sults, 5 cases; fistula in ano, 1 case; re- ported as having bad results without ac- curate description, 127 cases. Total, 200. Andrews (Columbus Med. Jour., No. 3, '95). If, in the statistics given by Andrews, the names of the operators were men- tioned, most of the disastrous results will be found to have followed the work of incompetent men. The writer's own re- sults have been excellent in those cases in which he had done the Whitehead operation, slightly modified by himself. Marcy (Jour. Amer. Med. Assoc, Sept. 14, '95). literature of '96-'97-'98. Whitehead's operation (complete re- section) considered rather formidable, with loss of time, considerable haemor- rhage, and danger of sepsis; AUingham's (ablation and ligation) excellent in most cases, but takes longer, involves a greater loss of blood, and is followed by more post-operative pain than the clamp and cautery. In recommending the latter the necessity of stretching the sphincter, applying the clamp in the long axis of the bowel, and using the cautery at a dull red heat emphasized. Parker Syms (N. Y. Med. Jour., Feb. 12, '98). Ligature is pre-eminently the best for ordinary cases of piles, with one excep- tion, namely: the clamp and cautery. The results that haye followed both have proved that they are deserving of the highest praise and a detailed consider- ation. The reader may choose the one he can perform with the most satisfactory results, with the assurance that a radical cure will be effected. Surgeons differ as to the best method of applying the ligature. The majority, however, prefer the operation which was devised by the late Mr. Salmond and popularized by Allingham, Sr. The patient, having been previously prepared by purgation, is placed on the right side of a hard couch in a good light and is completely anaesthetized. The sphincter-muscle is then completely, but gently, dilated. This completed, the rectum for three inches is within easy reach, and no contraction of the sphinc- ter takes place; so that all is clear like a map. The haemorrhoids, one by one, are taken by the surgeon with a vulsellum, catch-tooth, or Pratt's "T" forceps, and drawn down. He then, with a pair of sharp scissors, separates the pile from its connection with the muscular and sub- mucous tissues upon which it rests. The cut is to be made in the sulcus, or white mark, which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel and parallel to it to such a distance that the pile is left connected by an isthmus of vessels and mucous membrane only. There is no danger in making this incision, be- cause all the larger vessels come from above, running parallel with the bowel, just heneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, thin, plaited silk ligature (Turner's, No. 8) is now to be placed at the bottom of the deep groove made, and the assistant then draws the pile well out. The ligature is tied high up at the neck (see Fig. 1) of the tumor as tightly as possible. Great care must be exercised in tying the ligature. The operator should be equally careful to tie the second knot so that no slipping or giving way can take place. If it is advis- able, tie a third knot, for the secret of the well-being of the patient depends greatly upon this tying, — a part of the operation by no means easy to effect. If this is done, all the large vessels in the 408 HJi:MORRHOIDS. INTERNAL. TREATMENT. piles must be included. The arteries in the cellular tissues around and outside the lower bowel are few and small, and do not assist in the formation of the pile, being outside it. The silk should be so strong that the operator cannot break it by fair piilling. If the pile is Yery large, a small portion may now be cut off, tak- ing good care to leave sufficient stump beyond the ligature to guard against its slipping. When all the haemorrhoids are omy position, with the limbs well flexed on the abdomen and held in position by Clover's crutch, presents a better view of the parts after the sphincter has been divulsed. Sitting upon a high stool in front of the patient, the operator has the free use of his hands and can apply the ligature with more ease and in a shorter time than when the patient is placed on the side. After all of the piles have been ligated and those portions external to the Fig. 1. — Correct method of applying the ligature. {Gant.) thus tied they should be returned within the sphincter. After this is done any superabundant skin which remains ap- parent may be cut off; but it should not be too freely excised, for fear of contrac- tion when the wound heals. A pad of gauze is then placed over the anus; this is covered with a tight T-bandage, as it relieves pain most materially and pre- vents any tendency to straining. To secure a cure by the ligature it is not essential to follow in detail the va- rious steps as just recorded. The lithot- ligature cut off, the stump should be placed within the bowel. Patients suffer considerably for the first twenty-four hours because the sen- sitive nerves have been included in the ligatures. The pain during the second and third days is frequently quite annoy- ing, though in some cases it will be very slight. The lower part of the rectum presents a sensation of heat and fullness. Patients are often awakened after the operation by sudden contractions of the levator ani, and the strangulated stumps H-EilORRHOIDS. INTERNAL. TREATMENT. 409 seem to act as foreign bodies, keeping up irritation. The ligatures will ordinarily slough off from the seventh to the ninth day, but now and then they have to be removed by the- surgeon. This compli- cation occurs more frequently than the friends of the ligature would have us be- lieve, and in such cases increased pain and delayed healing are always notice- able. The time required to remain in- doors in such cases varies from three to six weeks. As a rule, patients operated on by the ligature are able to be about from ten days to two weeks, although the ulcera- tion may not be entirely healed. Many other operators have met with equally good success. This fact, coupled with the permanent cure which follows this operation, has won for it a very enviable reputation. At the same time there is one other operation — the following — that will be succeeded by jiist as good results, from which patients suffer much less, recover more quickly, and with as few bad results as follow the ligature, namely: the clamp-and-cautery opera- tion. Bloodless method for treating hsemor- rhoids, each hsemorrhoid being seized close to its base between the tips of the thumb, index, and middle fingers. It is put upon the stretch and twisted and finally so completely crushed that it is pulpified, and none of the investing tunics remain except the mucous mem- brane and its understratum of fibrous tissue. Thirty-two cases treated success- fully by this method. Manley (Boston Med. and Surg. Jour., Feb. 1, '94). Literature of '96-'97-'98. Recovery followed all of the 269 cases treated in Dittel's service by Dittel's elastic ligature for hsemorrhoidal nod- ules. Twelve days was the average time. No anaesthesia is used except Schleich's local infiltration. The curved polypus- forceps are guided by a finger of the left hand inserted into the rectum. By turn- ing the forceps ninety degrees the nod- ule is brought up out of the anus, and with the surrounding mucosa is then ligated with an elastic cord stretched to its utmost. The nodules lose their vitality in eight to ten days and drop off", leaving a clean, granulating surface. The external anal skin must not be in- cluded in the ligature. Editorial (Jour. Amer. Med. Assoc., Nov. 6, '97). The clamp-and-cautery operation was originated by Mr. Cusack, of Dublin, and brought prominently before the pro- fession in England by Mr. Henry Smith. In America it is a question which is the more popular, the clamp-and-cautery or the ligature, both having advocates of equal ability. I have previously indi- cated my preference for the clamp-and- cautery operation. At present there are at our command many admirable clamps, the very popular Paquelin cautery, and the cautery irons. By the aid of these the operation can be performed with rapidity; and, when u.sed with care, it is not a barbarous procedure, as is often claimed, but a scientific stirgical opera- tion, whereby only the diseased tissue is removed. The pain which follows the clamp-and-cautery operation is less than that of any other operation for piles. There are four steps in the operation: 1. The sphincter-muscle should be thor- oughly divulsed in every direction (Fig. 2). This will cause the piles to come quite prominently into view. Each in turn is seized with a vulsellum or catch- tooth forceps and drawn well down. 2. The mucous membrane and skin should be severed and the pile dissected upward (Fig. 3). 3. The clamp should be ad- justed firmly in the incision at the base of the tumor; that portion external to the clamp is then excised with a pair of scissors. 4. Every portion of the stump 410 HAEMORRHOIDS. INTERNAL. TREATMENT. should be thoroughly cauterized with the cautery-point at a dull-red heat, after which the clamp should be loosened to see if bleeding occur (Fig. 4). If it does, the operator should readjust the clamp and cauterize all bleeding-points. After all the piles have been removed in this way the rectiim should be irri- gated and a wedge-shaped compress placed over the anus and kept in place by a well-adjusted T-bandage. When the piles are small or situated high up and cannot be drawn down and the patient's suffering is less and re- covery is several days earlier than after the ligature. When the ligature has been applied ordinarily it will not slough off before the eighth day; and, when it does, it leaves an ulcer with irregular edges, which not infrequently has a tendency to become chronic. At best, patients are rarely able to be about the room before the tenth day, and frequently not for two weeks; while after the cautery method the ulcer will be clean and smooth shortly after the oper- Eig. 2. — Dilatation of the sphincter ani. (Gant.) and clamped,- the narrow cautery-blade should be drawn once or twice across each pile; this will cause them to shrink up. The cautery may be applied, if used with discretion, to any dilated veins pres- ent that might at some future time form piles. This operation is preferable to the ligature; not because the cure is more effective, or the operation less difficult to perform, but because of the facts that the operation can be performed more quickly, with greater ease and accuracy. ation, and will be practically healed by the time the ligature has sloughed off. Patients can sit up on the third or fourth day, and it is a rare occurrence if they are detained from business more than a week. In many cases the time that is saved is represented by the length of time that it requires for the ligature to come away. Granting that some healing takes place while the ligature is sloughing, it will require as long for the remaining portion of the ulcer to heal as after the cautery H^MOEEHOIDS. INTERNAL: TEEATllENT. 411 operation; for the ulcerated surface after the latter seems to heal more readily than after the former operation. The pain after the cautery operation is insig- nificant if care has been used to avoid cauterizing the skin; but when it has been touched, if only slightly, the pain is ex- ceedingly annoying. Eetention of urine occurs sometimes, but not so frequently as after the ligature. Slight bleeding sometimes occurs at non-cauterized points when the clamp has been removed. of sepsis has been minimized by searing the exposed surfaces. So far as a radical cure is concerned, the cautery and the ligature operations are on a level, for when either one has been performed as previously described a permanent cure will follow in every case. One hundred to one hundred and fifty hasmorrhoid cases seen both during and after the operation with clamp and cau- tery. Apart from the fact that none of them had a single bad symptom of any kind, there were three points chiefly re- Fig. 3. — Severing the mucous membrane from the skin. {Gant.) but it will not do any harm when a firm wedge-shaped compress is placed over the anus and supported by a well-ad- justed T-bandage. Experience has shown that haemor- rhage will occur just as frequently from the slipping of the ligature, when it or the stump has been severed too closely, as after the clamp-and-cautery operation. It is not probable that either tetanus or pysemia will follow the cautery oper- ation, for there is no constriction of ter- minal nerve-filaments, and the danger markable about them. First, the ex- tremely small amount of blood lost; secondly, the trivial degree of pain after- ward; third, the short time during which treatment lasted. Burghard (Lan- cet, Apr. 6, '93). There is a decided advantage in favor of the clamp and cautery. Earely, after this operation, is it necessary to pre- scribe an opiate. J. E. Davis (N. Y. Med. Jour., June 15, '95). Clamp-and-cautery method considered preferable to all others. H. R. Colston (Virginia Med. Monthly, Apr., '95). The clamp-and-cautery operation can 412 HAEMORRHOIDS. INTERNAL. TREATMENT. be done expeditiously and with little loss of blood; the cauterized base of the pile is rendered aseptic by the cautery; there is no pain following the operation; re- tention of urine is extremely rare; con- valescence is brief and uninterrupted, — confinement in bed from three to seven days is sufficient. Trowbridge (Boston Med. and Surg. Jour., May 30, '95). [In two hundred and sixty-seven cases treated during five years at the N. Y. Post-graduate Hospital, the elamp-and- cautery method employed and preferred to all other procedures. Charles B. Kelsey, Assoc. Ed., Annual, '96.] from which the patient recovered is recorded, and a few slight haemorrhages; and, so far as can be ascertained, there have been no recurrences. Vaux (Ca- nadian Pract., Dec, '96). The writer's objection to the clamp- and-eautery operation is that in haemor- rhoids having a broad base the damp picks up the haemorrhoids and also a large portion of the mucous membrane, and on the removal of the clamp the edges of the mucous membrane separate and leave a large uleer, which is slow to heal. George W. Crary (N. Y. Med. Jour., Feb. 12, '98). Pig. 4. — Cauterizing the stump. (Gant: literature of '96-'97-'98. Advantages of the clamp and cautery: It is antiseptic; there are no sloughs to separate as in the ligature operation; there are no ligatures or sutures to offer any chance for infection; it is a radical cure; the operation is a rapid one; the time of convalescence can be definitely fixed — the eighth day. The record of haemorrhage, pyaemia, or death is almost negative. In five hun- dred cases operated upon in Mt. Sinai, by the above method, there has not been a single death. One case of pyaemia Clamps. — Until recently pile-clamps on the market were constructed like scissors. When that portion of a tumor external to the clamp was cut off, tissues except those nearest the heel slipped through before the operator had a chance to cauterize them. In this way patients were subjected to a serious, if not fatal, hemorrhage. Some three or four years ago the writer constructed a clamp with the blades at right angles to the handle (see HAEMORRHOIDS. INTERNAL. AFTER-TREATMENT. PROGNOSIS. 413 Fig. 5). This insures the blades' remain- ing parallel, distributing equal pressure, no matter how far apart they are, so that not the slightest portion of tissue can slip through and escape cauterization. When this clamp is used haemorrhage is im- probable, if not impossible. Aftee-treatment. — After any oper- ation for piles a well-adjusted pad to the anus, held in place by a T-bandage, sup- ports the parts and renders the patient more comfortable, and tends to arrest any bleeding that might otherwise take place. I do not use suppositories, al- though many high in authority recom- mend the immediate employment of sup- positories containing morphine, opium, belladonna, etc., for the relief of pain. As a rule, they produce an uncomfort- able feeling and cause the patient to strain in his endeavors to force them out. When I am compelled to use anything for the relief of pain I prefer an hypo- dermic injection of ^/ ^ grain of mor- phine. Ordinarily, this will not have to be repeated. When the pad applied to the anus becomes dry and hard, the anus should be sponged off with warm water and a new pad applied. If the patient has been purged before the operation, it is not necessary to check intestinal action with opium, for no movement will occur before the third day. In case it does not, a Sedlitz pow- der or a dose of salts should be admin- istered. If there is reason to believe the fffices are hard, an injection of soap-suds should be given to soften them. Patients should be urged to remain in bed until the ulcerations have almost or entirely healed. Then, when they begin taking active exercise, the danger of the ulceration's becoming chronic will be slight. The ulcerated surfaces should be cleansed daily, and, if there is the least tendency to become chronic, an applica- tion of calomel or silver nitrate (15 grains to the ounce) will stimulate them. In case of retention of urine, hot stupes or poultices should be applied over the pelvis. This will frequently en- able them to void urine independent of the catheter. If a catheter is used, a soft-rubber one is preferable, but should be cleansed in boiled, filtered water be- fore and after each introduction. The diet after an operation should be limited Fig. 5. — Gant's pile- and polypus- clamp. The letters show the different clamps and their clamping power. A, Gant's; S, Kel- sey's; C, Smith's; Z>, Langenbeck's. to liquids and semisolids for the first four or five days; but patients should have nourishing soups, beef-tea, and soft- boiled eggs. Prognosis. — In cases where bleeding, inflammation, and strangulation have been relieved by palliative measures, pa- tients should be warned that they will probably have another attack. On the 414 HJilMOIlRHOIDS. POST-OPERATIVE HJEMOERHAGE. other hand, when all piles, dilated veins, and redundant tissue have been removed by the clamp-and-cautery or ligature operation, it is safe to tell them that they will not have a relapse. Post-operative Hsemorrliage. — Occa- sionally after the best operations for piles the dressings will be saturated with blood. This, as a rule, need not cause Fig. 6. — Gant's self-retaining speculum. uneasiness, for when due to bloody water left in the rectum after irrigation or from a superficial cut in making the muco- cutaneous incision it will not amount to anything. On the other hand, when in- ternal bleeding is suspected, the patient should be requested to empty the rectum. If bleeding has occurred, clots of blood will be discharged with the faeces. When Eig. 7. — Drainage-tube wrapped with gauze. there is reason to believe that the bleed- ing is due to a small vessel or to oozing, it can frequently be arrested by simply tightening the bandage. If this fail, the rectum should be irrigated for several minutes with cold or qiiite hot water, or with some one of the various astringent solutions, as alum-water, the infusion of black-oak bark, etc. Astringent pow- ders dusted over the bleeding parts, tan- nic acid, gallic acid, zinc, Monsell's powder, and other powders known to have a contracting effect on the tissues have all been recommended. Monsell's powder has been used more frequently than the others, but it has proved very undesirable, not because it did not arrest the bleeding, but on account of the filthy condition in which it leaves the wound. When the hasmorrhage is profuse, time should not be wasted on injections and powders. The rectum should be exposed by means of a speculum and the bleed- ing vessel searched for until it is found and ligated or seared over with the Paq- uelin cautery (Fig. 6). If 'the operator be Fig. 8. — Vulcanite drainage-tube. not so fortunate as to have one of these instruments, a poker or a curling-iron may be heated to a red heat and used as a substitute. In case the vessel is situ- ated so high that a ligature cannot be applied, it should be seized with a pair of artery-forceps and thoroughly twisted, and the forceps left on if necessary; for in cases of profuse hsemorrhage of the rectum the patient's life not infrequently depends upon the thoroughness of the work. In case the bleeding-point cannot be located packing of the rectum should be resorted to. This must be done carefully, however. Gauze or other packing loosely inserted into the rectum does not arrest the bleeding. HAMAMELIS. HEAD, INJURIES. CEREBRAL CONTUSIONS. 415 The majority of operations for haem- orrhoids are performed on the lower inch and a half of it. When bleeding occurs in this locality it can be speedily arrested by inserting into the rectum a firm piece of rubber tubing, three inches long and three-fourths of an inch in diameter, around which has been wrapped several layers of gauze. It can be kept in place by placing a safety-pin through the outer end and into a T-bandage. This makes a desirable compress and at the same time allows the escape of wind and dis- charges, and warns the attendant in case the bleeding has not been arrested (Fig. 7). Vulcanite tubes (Fig. 8), which are kept at most any instrument-dealer's store, act in the same way. The main factor in arresting hasmorrhage after any operation about the rectum, where the cautery or ligature cannot be used, is to make firm and constant pressure over the bleeding-points, so that not a single point of the rectum will be exempt from the pressure; when this has been accom- plished, we can, retire with the assurance that our patient is perfectly safe and that all bleeding has been arrested. S. G. Gant, Kansas City. HAMAMELIS. — Hamamelis, or witch- hazel, consists of the leaves of Hama- melis Virginiana, a North American shrub growing east of the Mississippi River. The leaves, collected in the au- tximn when the twigs are flowering, have an odor resembling that of tea and an astringent, bitter taste. It contains about 10 per cent, of tannin, bitter and odorous extractives, and a trace of oil. Preparations and Doses. — The fresh leaves (hamamelis, U. S. P.) are used to prepare the fluid extract, which, al- though chiefly used as an external appli- cation, may be given internally in doses of ^/j to 1 drachm. Therapeutics. — Hamamelis is htemo- static, astringent, and tonic in its action. Containing considerable tannin, it coag- ulates the albuminous elements of the tissues, when applied locally, and dimin- ishes the blood-supply and secretions. In HiEMOERHAGE. — The fluid extract has been given internally for the relief of pulmonary, renal, and uterine hsemor- thage; purpura, hsematemesis, varicose veins, and hsemorrhoids. The local ap- plication of hamamelis has been used for recent wounds, sprains, bruises, superfi- cial hemorrhage, haemorrhoids, epistaxis, and for bleeding or discharges from the natural cavities or openings of the body. As AN Astringent. — Hamamelis is used, in diluted form, as a mouth-wash, as a gargle in chronic pharyngitis, and in spray after attacks of acute coryza (1 part to 8, or 1 part to 24). In relaxed conditions of the mucous membranes generally it is beneficial. Peristalsis and the secretions of enteritis are checked.. It is of value in diarrhoea and dysentery. HAY FEVER. See Nasal Neuroses. HEAD, INJURIES OF. See also Cerebral Abscess, Enceph- alitis, Fractures, and Wounds. Cerebral Contusions. A contusion of the brain always ac- companies any serious injury to the cra- nium. Such contusion can exist without necessarily having a fracture of the skull;, but, on the, other hand, a fracture of the- skull is always accompanied by cerebral contusion. Symptoms. — ;The symptoms of contu- sion of the brain, referring to loss of function, are characterized by their dif- fuse or generalized condition. Hence, they differ materially from those of com- 416 CEREBRAL CONTUSIONS. PATHOLOGY. pression, which refer absolutely to dis- tinctly-localized lesions. Vomiting often occurs after the injury. Eespiration is superficial, but may be deep and sterto- rous. Fever has been observed in con- tusion of the brain, especially in case of injury or irritation of the median portion of the corpus striatum, and the mesen- cephalon, such as the posterior corpora quadrigemina and the sensory nucleus of the fifth nerve (Kocher). It has long been a mooted question whether contusion could always be dif- ferentiated from concussion of the brain by any special symptom. Clinically this does not exist. In a general way the symptoms of concussion, resulting from a lighter form of traumatism, produce less material disturbance and are there- fore more transitory, whereas in severe contusion the symptoms persist and are sometimes aggravated, because of the possibility of an encephalo-meningitis complicating the case. Loss of con- sciousness, partial or complete. Paraly- sis more or less complete of different por- tions of the body. A cold, clammy con- dition of the skin, a feeble, fluttering lieart. After a few days these symptoms disappear gradually, depending upon the absorption of the extravasated blood. After recovery the patient may suffer for a time from vertigo, headaches, and loss of memory, in addition to a general de- bility and malaise. literature of '96-'97-'98. Case of a boy, 15 years of age, who had fallen from a height on the left side of the head. He was never unconscious at any time, but aphasia with pain in the head gradually supervened, although vomiting never appeared. On the third day spasmodic cramps along the entire right side of the body commenced, but gradually disappeared. On the seventh day motor aphasia Avas established, with difficulty in -writing and general disturbance of the muscular movements of the right side, while the sensory function was unaffected. At this time paralysis of the right facial and hypoglossal nerves was observed, with pain and jerking of the right hand. Over the suture corona there was a ten- der area, about the size of a shilling, which was slightly depressed. Three days later the whole condition of the patient rapidly improved, and he began to speak as fluently and write as correctly as ever he did, while all spas- modic jerking and pain left him. The writer could put no other con- struction on these remarkable circum- stances than that a contused condition of the brain was the result of the injury which gradually brought about the paralysis by an effusion of blood from the median artery of the meninges that subsequently became absorbed as other hsematoma. The rapidity of the recovery in this case lends weight to the expres- sion that many of the cranial operations performed are quite unnecessary, as they would recover more satisfactorily if let alone. Frey (Med. Press and Circular, Aug. 19, '96). Pathology. — Contusion does not nec- essarily bear a direct relation to the seat of injury. Bergmann maintains that when the traumatism has been applied over a large area, and violent enough to depress the skull, not only is there severe contusion, or laceration of the subjacent brain-structure, but the corresponding portion of the brain on the opposite side has likewise undergone considerable con- tusion, by the force's being transmitted through the brain, against the skull op- posite the seat of injury. The superficial layers of the brain are most likely to be affected, especially since the gray cortical substance is the most plentifully supplied with blood-vessels. In fractures at the base of the skull con- tusion of the brain exists mostly at the temporo-sphenoidal lobes. The occipital lobes are not so readily affected, on ac- CEREBEAL CONTUSIONS. TREATMENT. 417 count of the protection ofEered them by the cerebellum. The following distinc- tion exists between a spontaneous cere- bral capillary hsemorrhage and that re- sulting from a contusion, yIz.: In con- tusion the arachnoid is likewise a seat of haemorrhage, owing to its share in the effects of the traumatism, while in spon- taneous cortical hemorrhage the men- inges are not afEected. According to the violence of the in- jury will the character of the capillary hffimorrhage, destriiction of tissue, and corresponding impairment of function vary. The haemorrhage might be dis- seminated and punctiform, or more pro- nounced, giving a dark area with lighter boimdary. Such a lesion as this, if ex- amined microscopically, would give evi- dence of minute destruction of cerebral substance by the blood disseminated in the tissues. Literature of '96-'97-'98. A blow to the head produces a mo- mentary increase of intracranial tension and consequent compression of the brain as a whole. The effect of this compression would be to cause an interference with the blood-supply to the entire brain, and this is sufficient to account for the primary symptoms of cerebral concussion. The so-called syncopic death after se- vere concussion is produced by a paraly- sis of the respiratory centres, the cardiac centres remaining, intact. This fatal re- sult may in many eases be prevented by the ■ prompt institution of artificial res- piration. S. P. Kramer (Annals of .Surg., Feb., '96). Contusions may be limited to the meninges, or to the brain, or may in- volve both ; there is no destruction of tissue and only slight extravasation of blood. When recovery occurs it is by absorption, not cicatrization. D. W. Day (Northwestern Lancet, Apr. 15, '98). If left untreated such a condition would tend toward a process of absorp- tion and gradual restoration of impaired function, provided there be no infection, either directly, because of the trauma- tism, or indirectly, on account of a lateiit diathesis which could, perhaps, implant itself on this locality. The minute haemorrhages become encysted and dis- appear. In other words, should there be no fracture leading to a possible infection from without, or lurking diathesis lead- ing to an infection from within, these contusions of the brain rarely lead to sup- puration or violent encephalitis. (See ENCEPHALITIS and Cerebral Abscess.) Prognosis. ■ — The prognosis depends altogether upon the presence or absence of infection and the general health of the patient. Should no disturbance be feared from these two causes, a gradual recovery is to be anticipated. On the contrary, should the destruction of brain- tissues have become infected, we may expect encephalitis and its results. If the patient survive twenty-four hours, recovery is likely to take place, so far as the direct effects of the concus- sion are concerned. Hutchinson (Med. Press and Circular, Dec. 20, '93). Treatment. — Since the danger' from contusion of the brain results from a per- manent destruction of function, on the one hand/ and infection on the other, the treatment will be directed toward obviat- ing the possibility of these accidents. Our guide will, therefore, be the vio- lence of the symptoms. Should these indicate no absolute gravity from loss of function, such as complete unconscious- ness, great depression, and paralysis, the reaction which the contusion necessarily creates in the cerebral tissues must be met as follows: Complete rest; head slightly elevated. The depression must be relieved by hypodermic injections of strychnine sulphate, ^/^o grain every three hours until reaction takes place in the pulse. Hot-water bags are applied. 418 CEREBRAL CONTUSIONS. TREATMENT. As soon as the patient is able to swal- low, he should be given purgatiTes, which will, by depleting the circulation, pro- mote the absorption of effused serum following the contusion of the brain. In treating eases of concussion where there is great depression, ammonia- fumes to the nose, tickling of the nos- trils, stimulants (brandy and warm water and black coffee per rectum), hot applications over the prsecordia, and rubbing of the surface of the body are advised. In cases of great prostration life may be awakened by lowering the head, and, after sufficient recovery, remedies by the mouth may be given. Stimulants should be employed only dur- ing the period of depression, the inflam- matory symptoms, which usually appear after a few days, being then controlled by proper measures. Frequently two or three months are required for the entire recovery of the patient, and for a yet longer period limited exercise of the body and mind should be enjoined. Lane (Jour. Amer. Med. Assoc, July 14, '94). Literature of '96-'97-'98. In the after-treatment of injuries of the cranium the main points to bear in mind are antiseptieism and rest. It must be premised that, so far as any wound is concerned, that has been treated by one of the methods of modern asepticism; but for general antisepti- eism one of the first considerations is to clear out the digestive tract, and for that purpose nothing is better than the calomel purge. AVhatevcr the nature of the injury, as soon as reaction has set in, the intestinal tract should be cleared ; and, if the lower bowel is loaded, a stimulant purgative enema is of great use. The bladder must be looked after, and, if necessary, the urine drawn off. If the temperature should run high, and the skin be very hot, and the patient be very thirsty, diaphoretics may be ad- ministered and fresh lemonade or some cooling mineral water allowed, but nothing else. Very light dietary of great importance. In some cases, especially where brain has been lacerated, small doses of mor- phia subcutaneously are very useful. The head should be kept as cool as possible, by shaving or cutting the hair short, and by evaporating lotions or by ice; it should also be rested on a hard pillow, and is best kept well raised, and the room should be kept darkened. Chauncey Puzey (Liverpool Medico-Chir. Jour., July, '96). Should there be the slightest abrasion or wound of the scalp, even if unaccom- panied by fracture of the skull, the strict- est antiseptic precautions should be pre- served, lest any infection from without provoke a meningitis. Case of boy, aged 15, who fell fourteen feet upon a horse in stall below, and from thence to the ground, the horse kicking him several times. Patient found unconscious seven hours later; scalp, back of line drawn from tip of one auricle to the other, was 'torn off and hanging down upon neck, wound filled ^■^•ith manure, straw, hair, etc. Washed thoroughly with warm water, irrigated with bichloride 1 to 2000; put in sixteen stitches, and ten days later removed same. No pus, pain, nor fever. Recovery. J. N. Barney, Jr. (Va. Med. Monthly, Aug., '95). Literature of '96-'97-'98. Case of white girl, 2 Vz years old^ A large farm-bell, on a post twenty feet high, fell, striking her head on the right side in front of tne motor region. The bones were drivwi into the brain, to the depth of one and one-half inches, making a large jagged wound in both the dura - and brain. There was not much haemor- rhage. Considerable bloody brain-tissue came way when the 'vound was wrshed out. The ragged edges of the dura were trimmed smoothly, but could not quite be brought together. All depressed bone was elevated or cut away. A drainage- tube was passed doAvn to, but not into, the wound of the brain. No fever and an uninterrupted recovery. Da\id Y. Winston (Can. Lancet, Dec., '97). CEKEBKAL COKCUSSION. SYMPTOMS. 419 If the symptoms are much aggravated in a few days, showing cerebral oedema, and consequent autoeompression of the brain against the skull, the indication then is to trephine over the seat of the injury and if necessary incise the dura for the relief of intrameningeal pressure. The trephined opening may be en- larged by means of the Eongeur forceps, if the size of the contused area warrant the procedure; it is remarkable how much drainage of serum and possibly cerebro- spinal fluid takes place under the cir- cumstances, followed by gradual disap- pearance of the pressure symptoms. The subsequent treatment would then be as in less aggravated cases. Cerebral Concussion. Symptoms. — It is very difficult to es- tablish clinically a distinction between concussion and contusion of the brain. However, concussion conveys the idea of the brain, as a whole, having been vio- lently shaken under the effect of a trau- matism, resulting in a disturbance of function, without any appreciable lesion of the brain-substance. The boundary between the two conditions must, there- fore, be more imaginary than real. Symptoms of concussion produced in animals without causing visible anatom- ical lesions in the brain or skull. Koeli and Filehne (Archiv f. klin. Chir., vol. xvii, p. 190). In the mildest grade of concussion there is a brief diminution of the blood pressure in the part; its tension is tem- porarily lowered. If the violence is somewhat greater, then there is super- added to the former condition a disturb- ance of the cellular constituents com- posing the surface of the brain. A jostling or displacement of the molecular elements of these cells, even though it be microscopically minute, must suffice to induce functional derangement. If the violence is still greater, then, besides the abolition of the thinking faculty', the cardio-pulmonary functions are dis- turbed, depending, doubtless, on the lesions of the centres at the base of the brain. In the still-higher grade the functions of life permanently cease at once, or within a few minutes after the receipt of the violence. Lane (Jour. Amer. Med. Assoc, July 14, '94). Concussion, due to a single blow or to repeated blows, is accompanied by the same effects upon the nerve-centres. If diflerences are manifest at the moment of the blow they can be readily explained and simply confirm this general law; the clinical condition is identical in the two cases. The analogy is visible even in the minutest detail that there is nothing to be added to the bulbar symp- toms. Violent concussion produces great rapidity of heart-action. Nerve-centres under the influence of anaemia suffer the same changes as under the influence of concussions. In conclusion, two facts are to be con- sidered: first, the action of the violence upon the nervous centres; second, the vascular change produced by the effect of such violence upon the vessels. Where the latter is slight, great violence may do much less harm than a. light blow under reverse circumstances. Death may even ensue without any actual discoverable lesion. August Polls (Revue de Chir., Aug., '94). The symptoms of concussion merge into those of contusion of the brain. In a word, they are milder and more transi- tory. There is a dazed condition, at the worst amounting to semiconsciousness, but at all times the -condition is one from which the patient can be aroused on loud command or address. The pulse is rapid, there is general irritability and jactita- tion, deep sighing, and cold, clammy skin. Miles has found from experiments that there is a temporary aneemia of the brain in concussion. This is the reflex result of the stimulation of the restiform bodies, and perhaps other important cen- tres in the region of the bulb. These parts are stimulated by the cerebro-spinal 420 HERNIA. SURGICAL ANATOMY. fluid which rushes through the aqueduct of Sylvius, the foramen of Magendie, and the subarachnoid space to that of the concussion when a severe blow is dealt over the head. Hence this cerebro-spinal fluid will disturb the equilibrium of the ultimate nerve-cells throughout the nervoiis system. Treatment. — The treatment resolves itself into meeting the indication, ac- cording to the symptoms of the partic- ular case, as described under CoiTTUsioisr. Latterly it has been suggested to aban- don the term "concussion" for that of "laceration" of the brain, inasmuch as it has been ascertained that minute lesions disseminated throughout the brain can be observed, where formerly there was supposed to be no appreciable lesion. (Phelps.) Literature of '9G-'97-'98. In the milder cases of concussion of the brain scarcely anything is to be done further than to make the patient lie down a short time, with possibly a little cool water or cold compresses to the fore- head. In severer cases the patient Is to be put to bed with cold cloths or cold coil to the head, milk diet for a day or two, bowels kept open, absolute quiet en- joined, and, if needed, bromides or small doses of morphine given for rest and sleep. David Y. Winston (Can. Lancet, Dec, '97). Ernest Laplace, Philadelphia. HEAT-STROKE. See Insolation AND HeAT-STEOKE. HEMIPLEGIA. See Paealyses. HEPATITIS. See Livee, Diseases OF. HEENIA. Definition. — The term hernia is used to denote the protrusion of one or more of the abdominal viscera, and is synony- mous with the ordinary term "rupture." Varieties. — If the protrusion occurs through openings in the abdominal wall which, normally patent in foetal life, through some defect in development have failed to close at birth, the hernia is said to be congenital. The protrusion may also occur at other points in the abdominal wall, by nature weaker than elsewhere, namely: in the femoral re- gion, in the inguinal canal, and at the umbiliciis. In these cases the rupture may be said to be acquired. In addition to these varieties we have ventral hernia following abdominal in- cisions or accidental wounds. This va- riety is frequ.ently known as traumatic. A hernia takes its name from the site of the opening through which it protrudes. The common forms are: inguinal, fem- oral, umbilical, and ventral. The rare forms: diaphragmatic, lumbar, obturator, ischiatic, pudendal, perineal, properito- neal, and retroperitoneal. Distinction is often made between ex- ternal hernia, including all the varieties above mentioned, and internal hernia, by which latter is meant the protrusion of a viscus through some anomalous ppuch in the peritoneum. Surgical Anatomy. — A hernia consists of a sac, the coverings of the sac, and contents. The sac is always a prolon- gation of the parietal peritoneum; it varies in size and shape according to the stage of the hernia. At first it is merely a pouting or bulging into the hernial ori- fice; narrow at the end, wide at the base. As the hernia extends and emerges from the orifice, the sac is elongated, and from the pressure of the contents the lower portion becomes globtilar or pyriform in shape. The narrowest part of the sac is called the neck, and the external, or distal, portion is called the fundus. A Plate 1. Surqical Anatomy of Inguinal Hernia. Fiq,l,€i. Internal Oblique. 6. Internal Ring, c.Spfirmatic Cord. d.Sartarius Muscle, riq.2. a Internal Aspect of Abdominal Drifice. Kq. 3, A' Internal Aspect of Permeable Region in Abdomen. Hq.4,a.lnternarQblique. 6.lnternal Rinq c.Fascia of External Oblique rf.Transversalis Fascia, e.Crural Arch and Rinq. /! External Rinq, jr.Sartonius Muscle. HERNIA. ETIOLOGY. 421 sac formed in this way — namely, by a gradual pushing forward of the parietal peritoneum — is said to be acquired, while a congenital sac is preformed, the pro- trusion occurring in the open tunica vaginalis or through the patent navel. A congenital hernia, while it may appear late in life, is dependent upon conditions which existed at birth. Adhesions may occur between the sac and its contents. The sac may become greatly thickened and opaque, — usually owed to the irritation of an ill-fitting truss, — and may undergo calcareous or malignant degeneration. Certain her- nias are said to have no sac, — as, for in- stance, hernia of the bladder, sigmoid flexure, or CEecum. This is not entirely true; a sac exists, but the peritoneum does not completely surround the viscus. The coverings of the sac are made up of the different layers of tissue outside of it. These, of course, vary according to the site of the hernia. An accurate knowledge of these layers is becoming more and more necessary to the surgeon, owing to the increasing importance given to modern methods for radical cure. {See Colored Plate.) Every viscus, except the pancreas, has been found in some variety of hernia. The contents are usually made up either of intestine or omentum, or both. If the hernia is reducible, the bowel and omen- tum present a normal appearance; but if irreducible and the hernia is of long duration, numerous pathological changes are likely to occur. The omentum be- comes thickened and adherent to the sac, usually at the neck, or to the bowel, if that be present. A small amount of serous exudate is not infrequently pres- ent in an irreducible hernia. If the her- nia contains omentum alone, it is called an epiplocele; if bowel alone, an enterocele; if both are present, enterorepiplocele. Etiology. — About 25 per cent, of per- sons with a rupture give a family history of hernia; while 40 per cent, are rupt- ured before the age of 35, 60 per cent, after that age. Family history of hernia has not often been brought forward. Case in which patient's both parents had been affected, — the father with the right scrotal her- nia common to his father, brother, and son; the mother also had a femoral her- nia. It would seem most probable that the lad inherited his defect — overpatent inguinal rings — from his father, but the laxity of tissue present in his mother's case and shared by his sister, as shown by their possession of femoral hernias, may have counted for something in the size of the protruded mass. J. Kynaston Couch (Lancet, Oct. 26, '95). The occupation is an important factor in causing hernia; those trades requiring the most severe muscular efl:ort having the highest proportion of persons rupt- ured. The increased liability to mus- cular strain in men is undoubtedly an important factor in explaining the greater proportion of ruptures in male than in female subjects. Parturition is a frequent cause in the female, especially of umbilical hernia. There were 7433 cases of hernia met with in the male and 2534 in the female during a period of three years' consulta- tion at the Central Bureau of Assistance in Paris, among patients applying for bandages. Inguinal hernia constituted 96 per cent, of these cases, 6220 of the men suffering from this form, double in 4126 cases, and single in the rest, occupy- ing the right side in preference to the left in proportion of 1.46 to L Of all the cases a congenital origin could be definitely ascertained in only 479 cases. Berger (La Sem. M6d., Oct. 26, '95). The frequency is independent of race, but appears to be in relation to easy circumstances or the reverse. Among members of the literary profession her- nia is rare. Between ages 5 and 15 the condition is uncommon. After 40 years 433 HERNIA. REDUCIBLE. DIAGNOSIS. of age the proportion rapidly increases. Bertillon (Le Bull. Mgd., Dee. 4, '95). Literature of '96-'97-'98. Inguinal hernia is much more common in the male, and the reason for this is undoubtedly the fact that in man the inguinal canal is so much larger than it is in woman on account of the passage of the spermatic cord through this canal. On the other hand, femoral hernia is much more common in women because of the relaxation of the abdominal wall in all directions, due to child-bearing, and also because of the difference in anatomical structure. The female pelvis , is much flatter and more horizontal than that of the male, consequently Poupart's ligament is relatively longer and tends to make the femoi-al canal wider and consequently weaker. Garrigues (Med. News, Jan. 22, '98). Anything that tends to weaken the abdominal walls may be the indirect cause of hernia; for example, traumatism followed by the formation of cicatricial tissue, contusions, obesity, ascites. literature of '96-'97-'98. Hernia may be caused by obesity. Recent deposits of fat are composed of a material which at the temperature of the human body is liquid, and is, there- fore capable of transmitting pressure in every direction, which transmission is . eminently favorable to the expansion of canals and the yielding of weak parts. In very stout subjects the subperi- toneal fat occupies much of the abdom- inal cavity, compressing and displacing its normal contents, and hindering their expansion. Marked obesity produced rapidly in a subject between 15 and 30 years of age should excite dread of the existence of hernia, and lead to an examination of the Inguinal and crural rings. Course of preventive treatment recom- mended: a spare mixed diet, active ex- ercise, attention to the renal functions, frequent and regular purgation, strict abstinence from alcohol, and the frequent administration of iodide of potassium in small doses. Lucas-Championnifire (Bull, de 1 Acad, de MSd., No. 33, '90). The chief exciting cause of hernia is a sitdden strain; the larger proportion of hernias, especially in adult life, come on soon after some unusual effort. The hernia generally begins with a slight fullness over the canal, often associated with a little soreness or feeling of dis- comfort. In rare cases a fully-developed hernia may immediately follow sudden strain. Two cases in which strangulation oc- curred simultaneously with the first ap- pearance of the hernia are quoted by Bull and Coley (Dennis's "System of Surgery,'' vol. iv). Indirect causes of hernia are chronic bronchitis, pulmonary affections in gen- eral, and habitual constipation. Reducible Hernia. Diagnosis. — A reducible hernia usu- ally presents the following signs: A soft tumor or swelling is found in one of the hernial openings; this swelling disap- pears on lying down, or on moderate pressure. It gives a distinct impulse on coughing, and itsually it is seen to in- crease in size during the act of coughing or straining of the abdominal muscles. In most cases there is a history of grad- ual development with sensations of dis- comfort in the region of the swelling, especially noted after long standing or walking. In the early period of develop- ment nothing more than a slight full- ness may be found; but as the hernia descends it becomes a well-defined tumor. The character of the swelling varies ac- cording to the contents of the sac. If it contains bowel alone, it feels smooth and elastic; the impulse on coughing is well marked and reduction is often accom- panied by a gurgling sound. Percussion yields a tympanitic note distinctly dif- HERNIA. REDUCIBLE. TREATMENT. 423 ferent from the flat sound produced in omental hernia. If the contents con- sist of omentum alone, the tumor is more uneren in outline, gives a lobulated feel- ing and is entirely without elasticity. Both bowel and omentum may be pres- ent, in which case there may be a com- bination of the physical signs already de- scribed. Not infrequently the bowel is perfectly reducible, while the omentum is adherent to the sac. The sensations of discomfort and the dragging pain, which may be very slight in a rupture of small size, may become very marked in a large hernia, especially if the latter be not controllable by truss. Treatment of Reducible Hernia. — The various methods for the treatment of hernia may be classified as either pallia- tive or operative. Palliative, or mechan- ical, treatment includes all the various appliances by means of which an effort is made to restrain the contents of the abdomen within the hernial orifice. In the majority of cases mechanical treat- ment does not aim to close the orifice, though in children and young adults such a result is often obtained, thus effecting a permanent cure. Teusses. — No description need be given of the great variety of trusses. The object to be accomplished by a truss should be the complete retention of the hernia without causing discomfort to the patient; there are many forms of trusses which fulfill this object satisfactorily. A good truss should consist of a pad to cover the hernial orifice and a spring or band to hold the pad always in the proper position. Steel is, I believe, the best material for this purpose. A spring should surround the pelvis entirely or in part, and should be so constructed as to retain its place either by its own elastic- ity or by the aid of a strap. The two forms of trusses which I consider to best meet the requirements of an ideal truss are the so-called Knight, or cross-body, truss and the Hood. Both these varie- ties may be used for single or double truss, and the Knight is quite as satis- factory in femoral as in inguinal hernia. The Hood pattern can be iised only in inguinal. The pad may be made of hard rubber, celluloid, cork, or of wood, covered with leather. Some cases not retained by this variety of pad may be satisfactorily con- trolled by the substitution of a so-called water-pad. These trusses may be made of any size and may be used in the young- est infants without discomfort. In in- fants and children great care should be taken that the spring be not too strong. The spring itself may be protected by leather, rubber tubing, or hard rubber. In rare cases — for example, emaciated infants — the worsted truss may serve a useful, but temporary, purpose. For routine work it is much inferior to a properly-constructed steel truss. The truss should be so applied that the pad rests over the internal ring rather than upon the pubic bone. In scrotal hernia it is better to apply the truss in the horizontal position, care being taken that the contents of the rupt- ure be entirely reduced before the truss is put on. In incomplete rupture this is not so important. In infants and young children the truss should be worn both day and night. In adults it may be, in most cases, removed with safety on re- tiring. Careful attention to the skin beneath the pad is important, especially in children; frequent bathing with alco- hol will be found of great service. One cannot state definitely how long a truss should be worn. It depends largely upon the age of the patient and the size of the rupture. A very large proportion of infants and young chil- 424 HERNIA. IRREDUCIBLE. dren may be cured if treatment is carried out under favorable conditions. Literature of '96-'97-'98. Under 12 months of age the cure by truss is 58 per cent.; from 1 year to 5 years, only 10 per cent., and after that practically nil; in acquired hernia the truss-cures at 15 years are 5 per cent., and at 30 years only 1 per cent. C. H. Golding-Bird (Practitioner, Jan., '96). After puberty cases of cure become fewer in number, and beyond 20 years of age it may be safely stated that there are few permanent cures by means of a truss. At the Hospital for Euptured and Crip- pled a truss is seldom left off in children until a period of two years has elapsed after the last appearance of the rupture. In infants under 1 year of age the truss may be left off sooner. In young adults the period should be lengthened rather than shortened, and after the age of 20 few cases will be found in which it is safe to discontinue the use of a truss. There is a certain class of eases in which no form of truss will retain the rupture. This applies to very large, scrotal her- nise with opening sufficiently large to admit four or five fingers. These her- nise are usually found in middle-aged and elderly people. Operation is in the ma- jority of such cases contra-indicated, and the most we are able to do in the way of affording relief is a scrotal bag made of stout material and supported from the shoulders. When a truss satisfactorily keeps up a hernia no surgical interference is neces- sary, and there is no doubt that well- trussed hernias in children have a strong tendency to become cured. Rushton Parker (Brit. Med. Jour., Sept. 21, '95). The following conditions may give rise to persistence of symptoms after the ap- parent reduction of a hernia, and may demand the performance of median ab- dominal section: (1) reduction en masse; (2) non-recovery of gut with consecu- tive enteritis; (3) gangrene of bowel; (4) an internal strangulation within a hernial sac, the taxis having overcome the external stricture; (5) hour-glass contraction of sac and reduction of her- nia from the outer compartment into the inner, but not from this into the peri- toneal cavity; (6) the presence of a sec- ond hernia which has escaped observa- tion. Mayo Robson (Practitioner, June, '93). The mechanical treatment of umbil- ical hernia differs with the age of the patient. In infants and young children no form of belt or truss is satisfactory, for the reason that it seldom retains its place for any length of time. The treat- ment used at the Hospital for Euptured and Crippled is to apply a small pad, con- sisting of a wooden biitton-mold covered with leather, to the hernial orifice. This is held in place by a strip of rubber plaster two inches in width, which en- tirely incloses the abdomen. Care should be taken that the plaster be not applied too tightly and it should be changed at least every ten days. It seldom causes excoriation, and in most cases the rupt- ure will be found to have disappeared at the end of six months or a year. Very few cases go beyond puberty without being cured, and hence the impropriety of operating upon these eases. Irreducible Hernia. Any form of hernia may become irre- ducible. This condition is, however, more frequently found in umbilical than in any other variety of hernia. It is ex- ceedingly rare in children and young adults, and most frequently found be- tween the ages of 30 and 60. In irre- ducible hernia the contents are most fre- quently omentum, omentum alone oc- curring in 90 per cent, of the cases. Omentum with bowel — entero-epiplocele — occurs next in order of frequency. Enterocele — bowel alone — may become HERXIA. IRREDUCIBLE. TREATMENT. 425 irreducible with niTmeroxis adhesions, but this condition is rare. Clinicalh', irreducible hernia difEers but little from reducible hernia, which has already been described, except in the fact that the contents of the sac cannot be replaced in the abdominal cavity. Persons suffering from this form of her- nia are liable to frequent attacks of colic, and are almost always subject to consti- pation. In this variety of hernia inflam- mation and strangulation are more likely to occur than in reducible hernia. Treatment of Irreducible Hernia.^ — If the hernia is not too large and the pa- tient is a good subject for operation, an attempt may be made to effect a radical cure. Mechanical measures are, as a rule, very unsatisfactory. No form of irre- ducible hernia can be treated with an ordinary truss without much discomfort. A truss fitted with a concave pad often proves satisfactory in irreducible hernia of small size; in umbilical and ventral, a stout abdominal belt with a circular, flat pad, with a slightly-concave pad in hernise of larger size, will furnish all the relief we are able to give for this class of cases. If the hernia has been down but a few days and there are signs of local inflam- mation, the patient should be kept in bed for a few days and an ice-bag applied. In using an ice-bag in these cases where the vitality of the skin is more or less impaired, one should always see that the ice-bag does not rest directly upon the skin, otherwise serious sloughing may ensue. Gentle taxis may be used during the course of this treatment, but it should be of only brief duration and never vio- lent. In very many cases of irreducible hernia a larger or smaller quantity of serous exudate accumulates in the sac. This has been removed by aspiration. Still, while there is no objection to with- drawing the fluid by means of a small needle if the hernia is purely omental, little is to be gained by this procedure. If the rupture cannot be reduced in one or two weeks, it may be regarded as per- manently irreducible, and either opera- tion or suitable mechanical support should be employed according to the nature of the case. [ilacready's tables show that 53 out of 85 cases of inguinal hernia were ve^ duced within, on an average, of 51 days; 32 within, on an average, of 2.8 years. These results show the advantage of operation, unless there is some decided contra-indieation. William B. Coley.] In irreducible inguinal and femoral hernia a very large number of patients are good subjects for operative treat- ment; that is, they are under 50 years of age and the hernia is of moderate size, varying between that of a hen's egg and two flsts. The results of operation in these cases are extremely satisfactory, and, as far as my personal experience goes, results have been as good as in re- ducible hernia in patients of similar age. On the other hand, not a few cases, espe- cially of umbilical and ventral hernia, are old epiploceles of very large size in very stout women with a great excess of fat in the abdominal walls. In such pa- tients, as well as in those who are weak- ened by disease of the thoracic or abdom- inal viscera, operation should not be re- sorted to, and our efforts should be confined to preventing the rupture from increasing in size. I have always be- lieved that there was great risk in oper- ating upon very large irreducible hernia. This opinion is supported by the early experience of Banks and the recently- published results of Barker. I have known of several unpublished cases of this kind in which death resulted from the operation. In addition to the great 426 HERNIA. STRANGULATED. risk there is little prospect of a perma- nent cure. Strangulated Hernia. The term "strangulated" is applied to an irreducible hernia in which the loop of bowel is so constricted as to prevent the passage of fsecal contents and to in- terfere with the circulation. The most common causes of strangula- tion are heavy lifting, severe coughing, and straining. It may also be produced by a blow or a fall. Study of statistics of 1491 cases of .strangulated hernia. Up to 20 years strangulation is rare, but gradually in- creases until between 50 and 70 the largest number occur. The causes of Double direct hernia. strangulation are severe cough or bodily exercise, defecation, pregnancy, and diflB- cult labor. Strangulation occurs more frequently in crural than inguinal hernia, .57.6 per cent, to 40.2 per cent., respectively; 51.2 per cent, of the hernial sacs contain small intestine only, 5.4 per cent, only omentum, 29.8 per cent, contained both of these. Lipomata found in 9 per cent, of the cases. Oscar Henggeler ("Statis- tics of 27G Cases of Strangulated Hernia Operated upon in the University Clinic at Zurich from 1881 to 1894"). In irreducible hernia strangulation often results from inflammation or en- gorgement of the contents of the sac, or from adhesions formed between the sac and its contents. It is unnecessary to mention the va- rious theories that have from time to time been offered in explanation of the way strangulation is brought about. The best and simplest explanation is that of venous engorgement: the walls of the veins being more compressible than the walls of the arteries, blood continues to flow into the imprisoned loop of bowel long after its return has been cut off. This produces great engorgement and rapid exudate of serum into the hernial sac, which makes reduction more and more difficult. The bowel first becomes of a brighter red, later bluish, then ma- hogany, and, finally, just before gan- grene sets in, of a dull slate color. The exudation, which at first is clear, after a longer or shorter interval becomes turbid. Gangrene may occur at varying intervals, depending upon the tightness of the constriction, the earliest time within which it has been observed being four hours and tlae latest two weeks. The fiuid in the hernial sac frequently contains bacteria, although in the larger proportion of cases thus far investigated, it has been sterile. Bacteriological study of 9 cases of strangulated hernia. In 6 cases no bac- teria had apparently traversed the intes- tinal wall. In 3 bacteria were found in the fluids of the hernial sac. In the 6 eases in which no bacteria were found, strangulation had existed 8, 18, 24, 30, 40, and 132 hours, respectively. In 1 case the intestine had undergone marked alteration. Conclusions that in non- gangrenous hernia bacteria are seldom found in the fluid. The intestines may undergo very grave changes and still be impervious to bacteria. Sjunggren (Re- vue Inter de Bibliographie, Mar. 10, '94). Literature of '96-'97-'98. ' Study of a number of strangulated hernias, with reference to the bacterio- logical contents of the hernial fluid, in HERNIA. STRANGULATED. SYMPTOMS. DIAGNOSIS. 427 the cases occurring in Koerte's wards in Berlin: — 1. The water of strangulated human hernia contains micro-organisms much more frequently than we have been justi- fied in supposing from previous publica- tions. 2. The bacteria of hernial water are frequently few in number and exist in a condition of diminished vitality, perhaps as the result of the bactericidal action of the water. 3. As a result of this action of hernial ^^•ater upon the micro-organisms, proper, investigation presupposes a cultivation upon a fluid nutrient medium. 4. The presence of the bacteria in her- nial water appears to stand in close rela- tion with all the factors which threaten the vitality of the strangulated parts in a special way. Brentano (Deut. Zeitsch. f. Chir., B. 43, H. 3, '96). Symptoms of Strangulated Hernia. — The first symptom is usually pain, re- ferred to the irreducible tumor at the site of the hernial orifice. Upon exam- ination the tumor is found tense, and very tender on pressure; it gives no im- pulse, or, at most, a slight impulse on coughing. If the strangulation has ex- isted but a short time, the tumor will give a resonant note on percussion. Later this sign may be absent, owing to an accumulation of fluid in the hernial sac. In some cases the pain is referred to the umbilieiis rather than the hernial tumor. Of all symptoms, vomiting is the most important. Vomiting is always persist- ent, occurring at longer or shorter inter- vals. At first the vomitus consists merely of the contents of the stomach; if the hernia is not reduced, it contains bile, mucus, and finally becomes sterco- raceous. Complete constipation is al- ways a symptom of great importance. In rare cases diarrhoea may occur as an early symptom. There is always an increase in the pulse-rate and usually slight ele- vation of temperature, especially in the early cases. Later on temperature may become subnormal. In strangulated omental hernia, with strangulation of omentum alone, — an extremely rare condition, — all of the symptoms are milder in character. Con- stijoation may or may not exist. [I have recently observed one ease of acute strangulated omental hernia in which operation was performed on the third day. William B. Coley.] Diagnosis of Strangulated Hernia. — There is no condition likely to be met with in surgical practice in which it is more important to make an early and correct diagnosis than in strangulated hernia. In typical cases, fortunately, the diagnosis is attended with little diffi- culty. In a hernia previously irreducible, the condition of obstruction or inflam- mation of the hernial contents may cause one to suspect strangulation. In ob- structed hernia, however, the impulse is usually present; pain is less acute and the other symptoms are much less marked than in the case of true strangulation. The same is true of inflamed hernia. Strangulation sometimes occurs syn- chronoiisly with the development of a hernia; I have observed two such cases. Given a patient with the symptoms of intestinal obstruction, careful examina- tion should be made of all the sites at which a hernia might occur. Htdeocele of the Coed. — In the young there is a condition to which atten- tion has been seldom called, and that not infrequently in the hands of the general practitioner causes a mistaken diagnosis of strangulation. This condition is hy- drocele of the cord. In this disorder the swelling is more tense and cystic to the l;ouch: it is more freely movable, more globular in outline, and has a more sharply-defined upper border, which, 428 HERNIA. STRANGULATED. TREATMENT. upon carefiil examination, shows that it does not enter the abdominal cavity. In a very few cases it may be difficult to differentiate between the two conditions from physical signs alone, but invariably the clinical history of the swelling will render the diagnosis easy. If hydrocele of the cord, there will be absolutely no general symptoms, and, if the statements of the parents be of any value, it will be found that the swelling has existed for several days or weeks, which shows the impossibility of its being a hernia. [I have operated upon seven eases of strangulated hernia in infants, and in every ease the general symptoms have been so well marked that mistaken diagnosis would have been impossible. ■William B. Coley.] Treatment of Strangulated Hernia. — Taxis. — Taxis and operation comprise the only methods of treatment to be con- sidered. Taxis judiciously applied should always be used before operation is ad- vised. Various positions of the patient are supposed to be of advantage in per- forming taxis. In inguinal hernia the pelvis should be elevated and the thighs flexed; in femoral hernia the thighs should be flexed and slightly rotated in- ward; in umbilical hernia both thighs should be flexed in order to relax the abdominal muscles. Traction on the tumor, followed by pressure, will often aid in reduction. [Some, notably Hern, advocate with- drawing the fluid from the hernial sac by means of a fine hypodermic syringe prior to taxis. Out of 33 cases thus treated reduction was accomplished in 29. He advises this method only in cases of recent strangulation and which refuse operation. It certainly should not be ad- vocated as a routine treatment. Will- iam B. Coley.] In 63 eases of strangulated hernia 53 were reduced by local etherization. The patient is laid on the back, pelvis slightly elevated, and thighs bent, the parts around being protected by abundant smearing with olive-oil; every ten min- utes or so a tablespoonful of sulphuric ether is poured on the hernial ring and tumor, until the latter loses its tightness and diminishes somewhat in size, when it returns spontaneously, or with slight help. Omental hernise will not yield to this treatment. Finkelstein (Berliner klin. Woch., No. 19, '91). Ether irrigations advocated as an ex- cellent means for reduction of strangu- lated hernia. A teaspoonful of ether is poured over the hernial tumor every quarter or half hour, keeping it covered with compresses during the interval. As a rule, after 3 or 4 tablespoonfuls, the in- testinal loop slips into the abdominal cavity. In incarcerated scrotal hernia it is advisable to irrigate with a mixture of ether (20 parts) and hyoscyamus-oil (4 parts). Drakin (Proceedings Krakow Med. Soc, No. 10, '88). General anaesthesia should, as a rule, be avoided in cases of strangulated her- nia in old and exhausted subjects. Keet- ley (N. Y. Med. Jour., Nov. 18, '93). For the performance of taxis it is bet- ter to place the patient on a table so slanted as to raise the hips; to crowd the abdominal contents toward the chest; to apply one hand to the neck of the tumor and the other to its body, and to draw it down so as to lengthen it out, at the same time compressing it. The utmost gentleness is essential. De Gar- mo (The Post-gi-aduate, Sept., '92). In strangulated hernia the patient should be placed in a hot pack, with ice over the hernia, '/, grain of morphine being given by suppository. If, after three hours, a gentle attempt at taxis fails, herniotomy should be resorted to at once. Morison (Birmingham Med. Review, Sept., '92). Violent or prolonged taxis is attended with great risk; the bowel may be lacer- ated or so severely contused that gan- grene ensues. Often the sac has been ruptured by too forcible taxis. Methods of taxis which were perfectly justifiable twenty years ago when the mortality HEENIA. OPERATION FOR STRANGULATED. 429 from operative treatment was very high, are no longer to be tolerated. [Frikhoffer gives a mortality of 14.9 per cent, in 308 eases of femoral hernia successfully treated by taxis; 7.8 per cent, in 518 cases of inguinal hernia. William B. Coley.] In cases that have been irreducible prior to strangulation — as is generally the case in strangulated umbilical hernia —taxis is clearly indicated. In cases where strangulation has lasted for twenty-four hours or longer, no attempt should be made to reduce the hernia. Taxis should seldom be employed longer than from three to five minutes, and then only moderate force should be used. The application of an ice-bag (hot cloths are preferable in children and old people) may facilitate reduction. In in- fants and young children it is a good rule, after an unsuccessful attempt to reduce the hernia by taxis, to immedi- ately prepare for operation, and then, if reduction under an anesthesia be not successful, operation may be at once per- formed without subjecting the patient to a second anaesthetization. Operation for Strangulated Hernia.— Incision. — Instead of the old incision ■ over the most prominent part of the tumor, usually the upper scrotum, even now employed by many surgeons, it is much better to make the ordinary Bas- sini incision, parallel to Poupart's liga- ment, extending only slightly beyond the external ring. This incision is car- ried down to the aponeurosis of the ex- ternal oblique, which, is slit up about two inches. Sac. — The sac is next exposed by care- ful dissection and opened by a scalpel or scissors. On opening the sac a smaller or larger quantity of fluid almost always escapes. The character of this fluid should be carefully noted, inasmuch as this gives an important indication as to the condition of the bowel. If the bowel is simply congested, the fluid will be clear; if inflammatory changes have taken place, it will be turbid, but free from odor; if the intestine is gangrenous the fluid is sero-purulent and almost always has an intestinal odor. DiYisiox OF CoX'STEiCTiON. — Before attempting to reduce the bowel the con- striction must be divided. This may be either the neck of the sac or the fibrous structures forming the external ring, which have already been slit up. [The older writers on strangulated hernia have uniformly regarded the neck of the sac as the chief cause of the con- striction, and, with the methods of per- forming herniotomy formerly employed, it is easy to see how difficult and almost impossible it was to tell definitely whether the constriction was caused by the neck of the sac or by the external ring, both being cut at the same time by the old-fashioned herniotomj' - knife. William B. Coley.] Literature of '96-'97-'98. Strangulated hernia in infants is not unlikely to occur while the infant is at rest, and in infants vomiting it is so common that ii strangulated hernia may easily be overlooked. The scrotum may be congested or inflamed very early, even though the bowel be but slightly damaged. Especial care is becessary in the operation on account of the extrenre thinness of the sac and the very small quantitj' of fluid in it. The return of the bowel after division of the stricture may be helped by lifting the child's feet. The bowels are likely to act soon after the operation, and to be somewhat re- laxed for a few days. In every case -a radical cure should be made at the time of the operation, unless the child is so collapsed that it is dangerous to prolong the operation even for a few minutes. Paget (West London Med. Jour., Apr., '97). By performing the operation as indi- 430 HERNIA. OPERATION FOR STRANGULATED. cated, the constriction caused by the ex- ternal 'ring disappears with the slitting up of the aponeurosis of the external oblique. [If the real cause of the constriction were due to the neck of the sac, it would still be impossible to reduce the hernia. In every one of my seven cases (in children) the aponeurosis was widely opened, and this alone was sufficient to render reduction of the hernia easy, which would have been impossible had the constriction been due to the neck of the sac. This view, as I have stated, is directly contrary to the teachings of most writers. Tariel states that, out of 81 cases of strangulated hernia in chil- dren which he collected, the neck of the sac was regarded as the cause of the constriction in 58 cases. William B. COLEY.] Management of the Contents. — The bowel should be treated with the utmost gentleness, and a warm towel should be frequently applied until it' is reduced. If the serous coat is still smooth and glistening, it may be safely reduced; purple or mahogany color — provided it has not lost its elasticity — is not a con- tra-indication for replacing it in the abdominal cavity. In cases of doubt as to the propriety of returning the bowel, it is well to apply a hot towel for a few minutes, the constriction having been re- lieved. If the circulation materially im- proves, it can be returned with safety. If the peritoneal coat is granular and devoid *of lustre and remains cold after the division of the constriction, it would be the better plan not to return the intes- tine, but to allow it to remain in place, protecting it by -a sterile dressing. Exam- ination a few hours later will determine whether it has sufScient vitality to per- mit of its being returned with safety into the abdominal cavity. If the bowel is gangrenous, and there is no doubt that it is unsafe to return it, two methods of procedure may be adopted: Primary lesection may be per- formed, or the gangrenous knuckle may be left in place. If left in place, there is no need of siitures, as the adhesions will be sufficient to prevent it from slipping back into the abdomen. The gut may be simply opened and the wound fully protected with antiseptic dressing, tl:^e gangrenous knuckle may be removed, and the cut ends of the gut fastened to the skin by means of sutures. [It is very difficult to lay down any absolute rule as to which mode of pro- cedure should be adopted. While col- lected statistics somewhat favor the operation of primary resection, it is prob- able that the cases treated by artificial anus were the more desperate. William B. COLEY.] In the choice of procedures much must be left to the judgment of the operator himself. If he is a surgeon possessing the requisite technical skill, and the pa- tient's condition does not contra-indicate a prolonged operation, it is probable that primary resection will give the better result. This is especially true if the amount of intestine is small. Primary resection and suture favored in gangrenous hernia. Lockwood (An- nals of Surg., Dec, '90). Primary resection and suture regarded as the ideal operation in gangrenous her- nia. Ransohoff (Jour, oi the Amer. Med. Assoc, Aug. 13, 20, '92). One hundred and sixty-eight cases of gangrenous intestine in strangulated her- nia collected in which either resection of the gut or the establishment of an arti- ficial anus was adopted. From these it would appear that the results of the for- mer course (a mortality at 47.1 per cent.) are far more favorable than those of the latter (76.6 per cent.). Mikulicz (Schmidt's Jahrbiicher, May, '92). Two hundred and eighty-nine resec- tions for gangrenous hernise compared with two hundred and eighty-seven cases in which an artificial anus was estab- lished. The mortality in the former HERNIA. RADICAL OPERATION IN CHILDREN. CONTRAINDICATIONS. 43 1 group is 49 "/loo per cent.; in the latter, 74'Vioo per cent., or 25 per cent, greater. In analyzing the causes of death, the advantage is, in each instance, in favor of primary resection. Diffuse peritonitis and profound collapse regarded as almost the only contraindications to resection. Zeidler (Centralb. f. Chir., Jan. 21, '93). Literature of '96-'97-'98. Case of rapid gangrene of a hernial sac. The patient, aged 48, had a re- ducible liernia for nine months, and had worn a truss. After a full meal he sneezed and suflfered agony, having rupt- ured the bowel into the sac. An oper- ation performed four hours later showed the sac to be perfectly black. The bowel was simply congested, and a tear 'A inch long was found in it. The gan- grene was strictly limited to the sac. There was no strangulation of the sac or contents. Robert Jones (Brit. Med. Jour., Feb. 1, '96). In patients suffering from prolonged strangulation and who are much pros- trated, or when the amount of intestine is very large, it is much safer to leave the gut in place to be dealt with at a subse- quent operation. If the operator has had little experience in intestinal sur- gerj', there is no room for debate as to which is the safer procedure. In many cases of femoral hernia the artificial anus has been known to close spontaneously. [In 382 cases treated from 1822-1858, Frilihoffer found the mortality to be 19.4 per cent, in cases strangulated 1 day or less; 49 per cent, in cases strangu- lated 2 days. Habs Reichel, in 129 cases operated upon under aseptic conditions, found a mortality of 12.5 per cent, in eases that had been strangulated 1 day: 26.1 per cent, in those that had been strangulated for 2 days. William B. COLEY.] The mortality following operation in strangulated hernia in the leading Eng- lish hospitals is given as upward of 40 per cent. In 940 oases treated at St. Thomas's, Guy's, and St. Bartholomew's it was 43 per cent. At the London Hospital it was nearly 50 per cent. Even in recent years the mortality in the four largest hospitals in London is not less than 40 per cent. This high mortality is not ascribed to the operation, but to the time allowed to elapse between strangulation and operation. In cases operated upon during the first twelve hours the mortality is trifling. Bowlby (Lancet, May 20, '93). Literature of '96-'97-'98. After the first twenty-four hours after operation for strangulated hernia, sips of warm water are given. Should flatus continue until this period, starvation is persisted in until it passes off. If flatus is passed, half a pint of beef-tea is granted during the next twenty-four hours; then, if all goes well, half a pint of milk is added the next day, increased by half a pint daily until two pints of milk and half a pint of beef-tea are reached, generally by the sixth or seventh day. The patient is kept upon this until the bowels act. If by the ninth or tenth day no action of the bowels has taken place, a dose of com- pound licorice powder is given. The diet is now increased by the addition of fish, then beef-tea, chicken, a chop, and com- mon diet by the end of the second week. Patients are kept in bed for six weeks. Thomas (Lancet, Apr. 11, '96). Accounts of one hundred cases of strangulated hernia in infants under 1 year, all of which were subjected to operation. There were twenty deaths. Death after operation in these cases is almost invariably due to delay. Charles N. Dowd (Archives of Pediatrics, Apr., '98). Indications and Contra-indications for the Radical Operation. — Children. — The indications for operation may be classed as follows: — 1. Cases of adherent omentum. 8. Cases complicated with reducible hydrocele. 3. Cases irreducible and strangulated. 4. Cases unable to obtain the care and 432 HERNIA. INGUINAL. RADICAL OPERATION. attention requisite for successful mechan- ical treatment. 5. Cases over 4 years of age, where mechanical treatment has been faithfully tried for a number of years without bene- fit. 6. Femoral hernia in children, which, though rare, cannot be cured by trusses. I believe it is seldom necessary to op- erate upon children under 4 years of age, and the practice of some surgeons of Femoral hernia in cliild aged 7 years. operating upon infants under 1 year is open to serious question. Umbilical hernia in children should, with very rare exception, never be oper- ated upon, for the reason that they are almost invariably cured either sponta- neously or by means of mechanical sup- port. Adults. — 1. In a general way, the younger the patient the better the chances of radical cure. 2. Operation is indicated in all young adults, inasmuch as there is little pros- pect of cure by a truss after the age of maturity. The operation in skilled hands is attended with almost no risk and the chances of a cure without the further need of a truss are excellent. 3. All cases of irreducible omentum in patients that are fit subjects for an ab- domical operation. 4. All cases of femoral hernia if no contra-indication is present. CoNTHA-iNDiCATiONS. — Yery large irreducible hernia in stout persons should not, as a rule, be operated upon. The risks are large and there is little prospect of permanent cure. Radical Operation for Inguinal Her- nia. At present the weight of evidence is strongly in favor of the superiority of Bassini's method in operations for in- guinal hernia. This method, first per- formed by its author in 1884, was intro- duced to the profession in 1890. Bas- sini published 251 cases with but 1 death and 7 relapses. It is performed in the following manner: The canal being laid open to the internal ring, the sac is sepa- rated, drawn down, ligated, and resected. The closed peritoneum is then returned, the spermatic cord is pushed aside, and the posterior margin of Poupart's liga- ment is exposed. The border of the rectus and the edges of the internal oblique, the transversalis, and the trans- versalis fascia are then sutured to Pou- part's ligament under the cord. The latter is then placed upon the layer of the abdominal M^all thus formed, and the border of the external is sutured to Pou- part's ligament over the cord, avoiding compression of the latter. A new canal is then formed for the cord. The wound is then closed. Halsted's method, while it closely re- sembles that of Bassini, differs in the Fir/ / Plate Dissection of Inguinal Hernia. Fig. l.rV.Sac and Qverlyinq Fascia, //.Spermatic Cord Fiq Z, a! Fascia. Hr Sac. r. Bowel Fig 3,fi.lnfundibuliform Fascia overlyinq the Sac and Sac, (/.Arched Fibres nf External Rinq, t^.Qmentum, /IGut, //.Fascia of E/ternal Oblique Fiq.l.ri.Sac. <■, Bowel, c;.Qm entum, i/.Arched Fibres of External Rinq, (/.Epigastric Vessels. Hia;XIA. INGUINAL. IIADICAL OPERATION. 4-33 direction of more complicated teelmique. The published results, though excellent, are inferior to those of Bassiui. [Halstead. instead of tiviiig to repair the old eanal and the internal abdominal ring, makes a new canal and a new ring. The latter should fit the cord as snugly as possible, and the cord should be as small as possible. The skin incision ex- tends from a point about five centimetres above and external to the internal ab- dominal ring to the spine of the pubes. The subcutaneous tissues are divided so as to expose clearly the aponeurosis of the external oblique muscle and the ex- ternal abdominal ring. The aponeurosis of the external oblique muscle, the in- ternal oblique and transversalis muscles, and the transversalis fascia are cut through from the external abdominal ring to a point about two centimetres above and external to the internal ab- dominal ring. The vas deferens and the blood-vessels of the cord are isolated. All but one or two of the veins of the cord are excised. The sac is carefully iso- lated and opened and its contents re- placed. A piece of gauze is usually em- ployed to replace and retain the intes- tines. With the division of the abdominal muscles and the transversalis fascia the so-called neck of the sac vanishes. There is no longer a constriction of the sac. The sac having been completely isolated and its contents replaced, the peritoneal cavity is closed by a few fine silk mat- tress-sutures, sometimes by a continuous suture. The sac is cut away close to the sutures. The cord in its reduced form is raised on a hook out of the wound to facilitate the introduction of the six or eight deep mattress-sutures which pass through the aponeurosis of the external oblique, and through the internal oblique and transversalis mus- cles and transversalis fascia on the one side, and through the transversalis fascia and Poupart's ligament and fibres of the aponeurosis of the external oblique muscle on the otlier. The two outer- most of these deep mattress-sutures pass through muscular tissues and the same tissues on both sides of the wound. They are the most important stitches. for tlic transjilantcd cord passes out be- tween tliem. If placed too close together the circulation of the cord might be im- periled, and if too far apart the hernia might recur. The precise point out to \\ liicli the cord is transplanted depends upon the condition of the muscles at the internal abdominal ring. If in this situ- ation they are tliick and firm, and pre- sent broad, raw surfaces, the cord may be brought out here, lint if the muscles are attenuated at this point, and present thin, cut edges, the cord is transplanted farther out. The skin-wound is brought together by buried skin-sutures of very fine silk. He uses an uninterrupted buried sl-cin-suturc witliout knots, which Double inguinal hernia (inoperable). is withdrawn after two or three weeks. The transiilanted cord lies on the apo- neurosis of the external oblique muscle and is covered by skin only.] The Bassini and lialsted methods have given such satisfactory results, w"ith so small a mortality, that the writer believes that simple reducible her- nia should be included among the in- dications for operation. J. B. Deaver (Amer. Jour, of the iled. Sciences, .lune, '95). Literature of '96-'97-'98, Two hundred and fifty Bassini opera- tions for the cure of inguinal hernia without mortality. These operations 434: HERNIA. INGUINAL. RADICAL OPERATION. were done upon 216 patients, 34 having been operated upon on both sides. Fifty-two of the cases were females and 164 were males. The ages of the pa- tients varied from 5 months to over 80 years. Fifty-five of the operations were on patients under 14, 16 of them were patients over 60, and 2 were on patients over 80. The cases operated upon in the extremes of life were those of irredu- cible or strangulated hernia. W. B. de Garmo (Va. Med. Semimo., June 25, '97). The brilliant results of Macewen have not been generally obtained by other sur- geons, while the transperitoneal method very recently introduced by Dr. George E. Fowler, which may be, in some re- spects, preferable to other methods, is as yet too recent to warrant passing judg- ment upon. In radical operation for hernia six weeks in bed and two weeks more of abstinence from physical exertion should be the minimum period allowed. Kooher (Corr. f. Schweizer Aerzte, Sept. 15, '92). Literature of '96-'97-'98. In any operation aiming at radical cure it is necessary to support and strengthen fascia transversalis. The most frequent cause of recurrence after some of the recent operations is owed to neglect of this point. Heuston (Brit. Med. Jour., Apr. 18, '96). A method has been employed in about 60 cases by Bull and Coley during the past six years, which they have named "suture of the canal without trans- plantation of the cord," the other steps being identical with Bassini's operation. The results, thus far, have been nearly, if not quite, as good as in Bassini's, though the number is as yet too small to estimate its comparative value; its only advantage lies in the direction of greater simplicity in the technique. All methods in which the sac is allowed to remain behind to be disposed of in various waj's should be abandoned. If the sac is left behind there is less chance of securing primary union, and it affords no additional security against relapse. Results of Operation. It must now be admitted that hernia can, for a considerable time at least, be cured by operation. Whether these cures will prove permanent cannot, as yet, be stated positively, for a permanent cure, strictly speaking, would mean freedom from relapse until the death of the pa- tient. Although no definite time-limit can be laid down beyond which relapse may not occur, nevertheless a careful study of cases operated upon up to the present time enables us to arrive at cer- tain fairly-definite conclusions. There were 360 eases of relapsed her- nia following various methods observed at the Hospital for Ruptured and Crippled. An analysis of these cases- throws much valuable light upon the question as to when relapse is most likely to occur. In 80 per cent, relapse oc- curred during the first year after opera- tion; 64.5 per cent, during the first 6 months after operation; 11.9 per cent, occurred after a. period of 2 years; 5 occurred from 10 to 22 years after opera- tion. There were 31 femoral cases and 329 inguinal. Bull and Coley (Annals of Surgery, Nov., '98). In view of these facts it may be stated in a general way that, if a rupture is sound at the end of one year after opera- tion, there is a strong probability of per- manent cure, while, if it remains well for two years, the chances of relapse are very small. Xinety-five per cent, is a conserv- ative estimate of cures following Bas- sini's operation if the operation has been properly performed. This estimate pre- supposes a judicious selection of cases. [Some operators openly state that they never select their cases. There is no field in surgery, I believe, in which there is gi-eater need for the exercise of good judgment than in that of opera- HERNIA. INGUINAL. EADICAL OPERATION. 435 tions for the radical cure of hernia. William B. Coley.] The practice- of operating upon all cases of hernia, irrespective of the age of the patient and the size of the hernia, cannot be too strongly condemned. Eoux, of Lausanne, Switzerland (per- sonal communication), has operated upon 1398 cases, with 5 deaths. [Results of 1042 operations for radical cure performed since 1888 by Bull and Coley; 522 hy Dr. Bull, including 66 children, and 531 by myself, including 365 children. Of Dr. Bull's cases, 134 \\ere operated prior to 1890 by the Czerny and Soein methods, and show the great superiority of the Bassini method. Out of the 134 eases operated upon prior to 1890, only 49 healed by primary union; 40 per cent, relapsed within two years after operation, and most of these relapses occurred during the first year after operation. It should be noted that of the 134 cases only 16 were in children under 14 years of age. In regard to the suture material, silk was used in 12 cases, and in every ease traced a sinus developed after a longer or shorter interval after operation, re- maining open until one or more sutures were finally discharged or removed. The silk was prepared by boiling in a 5-per- cent, carbolic-acid solution just before using it. The mortality (3 deaths) was con- siderably higher than that in the later cases. Death was caused in 1 case by ligature of the omentum too close to its attachment to the bowel; 1 died of hsemorrhage and 1 of peritonitis. Of the total number of eases, — 1053, — 924 were inguinal, 94 femoral, 19 um- bilical, and 15 ventral; 100 of the cases were females, 461 were children between 4 and 14 years of age, and 592 over 14 years. Bassini's method was employed in 618 eases, with 12 relapses. Of these eases 371 were children under 14 years of age, with 3 relapse^, or % of 1 per cent.; 247 adults over 14 years, with 9 relapses, or 3.7 per cent. In the 60 cases in which the cord was not transplanted, but in which the other steps of the technique were the same as in Bassini's method, there were 4 relapses. Of Dr. Bull's cases, 170 were operated upon by Bas- sini's method, and of Dr. Coley's cases, 448 were operated upon by Bassini's method. Broca, of Paris, has operated upon 1064 cases by his own method, with 9 deaths; a large proportion of these cases were children. The number of cases traced is not stated. Halsted has oper- ated upon 309 eases with 1 death. In 205 operated upon by his own method, there were 12 relapses. Macewen has operated upon 224 by his own method, with 2 deaths. Of this number 107 were traced with 15 relapses and 93 cases well from two to ten years after operation. William B. Coley.] Analysis of 133 cases of hernia oper- ated upon for radical cure with no mor- tality, and, as far as traced (78 eases), only 6 relapses. One-third of the entire number had been under observation ten years. The writer attempts to recon- struct the canal, and uses buried sutures of kangaroo-tendon, to which he at- tributes, in great measure, his very ex- cellent results. Marey (Lancet, Aug. 19, '93). There were 477 operations for radical cure in children under the age of 15 years, — 14 for umbilical hernia, 41 for inguinal hernia in girls, and 395 for in- guinal hernia in boys. Of all these cases, a single one, a boy, died from septic peritonitis. Although strangulation, which is not common in very young children, yields readily to taxis, as a rule, operation should nevertheless be performed, especially when associated with ectopia. Of 250 cases seen after six months, only 3 had had a relapse; 2 of these had again been ojJerated on and definitely cured. Several of the children had had whooping-cough after the oper- ation. Broca (Nouv. Arch. d'Obstet. et de Gynfic, Aug., '95). Literature of '96-'97-'98. Report of 324 cases which, with but one exception, were traced beyond two years. Two hundred and seventy cases 436 HERNIA. DANGERS OF RADICAL OPERATION. remained cured, while 54, or 16.7 per cent., were found to have relapses. There were 288 cases of inguinal hernia; of these 48, or 16.7 per cent., relapsed. Of 22 cases of femoral hernia, 6 relapsed, or 27.3 per cent. Fourteen cases of umbil- ical hernia showed no relapses, but are all presented as cures. Another series of cases were operated upon between 1890 and the middle of 1894. Analysis of these showed that the percentage of final cures bears a direct proportion to the age of the patient. The younger the pa- tient, the better the result. The cases over 40 years of age show six times as many relapses as those under 10. Two hundred and thirty-five cases were operated on by the method of Ferraro slightly modified: free dissection of the hernial sac and high ligation beyond the neck. The anterior pillars are then sutured with silk without transplanta- tion of the cord; 53 only operated upon by Bassini's method, substituting the purse-string suture for the interrupted sutures employed by Bassini and using silk. Conclusion that the suture of the anterior pillars is by far preferable to Bassini's method. Results also confirmed the opinion held by most surgeons at present, that primary union is of great importance in securing good and perma- nent results. Roux (Rev. Med. de la Suisse, vol. xvii, July, '97). Cure of hernia cannot be considered radical until a period ot two years has elapsed since operation, and even after three, four, or five years there may be re- currence. Of the three varieties of abdominal hernia commonly encountered the um- bilical is most readily cured. The crural is the one in which failure is most fre- quent. The likelihood of cure is propor- tionate to the youth of the patient. Taillens (Revue Med. de la Suisse Ro- mande, July 20, '97). [Barker (Brit. Med. Jour., Sept. 10, '98) reports 200 consecutive operations for the radical cure of hernia; of these 50 ^\■ere reported in 1890, But 3 deaths in 200 eases, 1 of which was due to ether poisoning. In both of the other fatal cases the hernia Avas a large, irreducible sigmoid hernia. In 21 out of 200 cases, sutures came away either while the patient Avas in the hospital or later at home. (This affords further evidence in support of the opin- ion frequently expressed by Dr. Bull and me, that non-absorbable sutures not in- frequently cause troublesome sinuses.) Own method employed in 79 cases; in 57 Bassini's; in 7 Kocher's; in 2 Mac- ewen's. Bassini's operation, when care- fully carried out, regarded as the best operation yet devised. Statistics of Kocher's operations (Deutsche Zeit. f. Chir., B. 48, H. 5, 6, S. 538, '98) for radical cure of hernia. Since 1893 he has operated upon 163 pa- tients, with 197 hernise. Of these, 148 were inguinal, 17 femoral, 18 umbilical, ventral, and epigastric. The youngest Avas 1 year, and the oldest 71 years. Of inguinal 26 were under 1 year; 78, 1 to 10 years; 38 over 10 years. William B. COLEY.] Dangers and Complications Associated with the Radical Operation. The chief dangers to be guarded against are pneumonia and wound-infec- tion. Prior to 1890 in the larger propor- tion of fatal cases death was due to wound-infection; but at present, with the gradual perfection of technique, I con- sider pneumonia from the anaesthetic the greater source of danger. The mortality has been gradually reduced from about 6 per cent., in cases prior to 1890, to less than 1 per cent, in cases operated upon during the last decade. Dr. Bull and I have collected 8000 eases operated upon since 1890, showing a mortality of less than 1 per cent. Peecautions. — The greatest care should be exercised in cleansing the skin of the patient, as well as the hands of the surgeon and assistants. Some form of absorbable material, sufficiently durable to permit of tendin- ous union, should be used for all the buried sutures. Kangaroo-tendon, on account of its strength and pliability, HERNIA. INGUINAL IN THE FEMALE. 437 may be regarded as superior to chromi- cized catgut. Catgvit, if properly chro- micized, may be nearly as good, but, as usually prepared, it is more harsh than the tendon and is more likely to cause irritation and subsequent production of a sinus, as is so frequently the case with non-absorbable suture-material. My ob- jections to non-absorbable sutures, in- cluding silk, silk-worm gut, and silver wire (formulated by me in 1895) were based upon the observation of 16 cases in which the use of sutures was followed by the formation of sinuses and extrusion of sutures. These sinuses often required many months to heal, and the prolonged suppiTration so weakened the canal that in most cases relapse followed. This opinion has been further confirmed by more recent obsetvations of Dr. Bull and . me, 26 cases having been personally observed. Fine catgut is employed for the liga- ture of the arteries and for closing the skin. Catgut is prepared by boiling it in absolute alcohol under a temperature of 210°. Both catgut and tendon that I have employed during the past seven years have been prepared by Van Horn & Co., of New York. Bacteriological tests have invariably proved the suture- material sterile. Complications. — Orchitis occasion- ally follows operation, especially if the hernise have been of the congenital type and of large size. The application of an ice-bag for a few days always relieves this condition. In adiilt cases it is of great advantage, immediately after oper- ation, to apply a strip of rubber plaster, about two inches wide, across the thighs in such a way as to form a support for the testes. It prevents any dragging on the cord and adds much to the comfort of the patient. Injury to the Cord. — If the operation is performed with due care, there is no danger of injuring the cord, even in chil- dren. If the bleeding vessels are at once caught and tied, the wound kept clean, the different layers of tissue can be recog- nized as easily as in a dissection on the cadaver. Bassini's operation cannot be properly performed unless this be done. Atrophy of the Testis. — When Bassini's operation was first introduced, atrophy of the testis was regarded as a possible danger, and this deterred some surgeons from employing the method. Not a single case of atrophy of the testis has been observed by Dr. Bull and me in over 650 of Bassini operations. Cases of atrophy have been occasionally ob- served after Halsted's operation, by Dr. Halsted himself, as well as by other sur- geons. O'Connor very recently reported 20 per cent, of atrophy of the testis in 129 cases operated upon by Halsted's method. Inguinal Hernia in the Female. The operative treatment of inguinal hernia in the female has received but little attention from most surgeons. Championniere was the first to urge it. His method was to excise the round liga- ment with the sac; but this we believe to be entirely unnecessary and not with- out objection. The method we have employed has been practically Bassini's method for the male, with the single step of the transplanting of the cord omitted. The incision through the aponeurosis is the same; the same tissues are included in the deep layer of sutures. The round ligament can, in all cases, be freed from the sac, and when this has been done and the sac has been dissected high up beyond the internal ring, it is ligated and excised; the ligament is al- lowed to drop back into its original place and the tissues are sutured over it. In the cleep layer interrupted sutures of 438 HEKNIA. FEMORAL. kangaroo-tendon are employed, and in the aponeurosis a continuous suture of the same material. [Including adults, Dr. Bull and I have operated upon 100 cases of inguinal her- nia in the female. Of these 53 were adults and 47 children. Of the adults, 23 were well up\\ard of 2 years; 15 from 1 to 2 years; 5 not traced; 8 operated on less than 1 year. Of chil- dren, 17 were well upward of 2' years; 26 were well over 1 year. Total female adults and children, 60 cases were well over 1 year; 40 cases were well over 2 years. William B. Coley.] Femoral Hernia. In this variety of hernia the bowel protrudes through the femoral ring un- derneath Poupart's ligament. It pene- Femoral hernia. • trates the crural femoral or crural canal, the small space extending from the femoral ring to the saphenous opening of the fascia lata. On its inner side is Gimbernat's ligament; on the outer the femoral vein and its floor, as found by the pubes, covered by the pectineus muscle. The peritoneal sac of a femoral hernia is always acquired. When it ad- vances beyond the saphenous opening it usually becomes much larger. The hernia proper is formed by the skin, the superficial fascia, the cribriform fascia, the sheath of the vessels, the septum cru- rale, and the peritoneum. Its neck is at the femoral ring, where constriction occurs from the edge of Gimbernat's lig- ament. Although generally small, it occasionally attains large proportions. Besides intestine, the omentum is often found in the hernial cavity. Femoral hernia seldom occurs before puberty, and is much more common in women than in men. Diagnosis. — When a femoral hernia is not strangulated, an impulse may be felt when the patient coughs. The tumor is generally tense, small, and round, and can be pushed to the outside of the spine of the pubes. Inguinal Hernia. — From, this variety the distinction is sometimes difficult, especially in women; but the neck of a femoral hernia is always helow the spine of the pubes and to the outer side. Enlarged Lymphatic Glands. — These possess no neck, and several glands more or less enlarged can often be felt. Gurg- ling cannot be detected; fluctuation through the presence of pus sometimes renders the diagnosis difficult. Psoas-ahscess. — Gurgling is also ab- sent, but cough also causes an impulse, and the abscess often disappears as in hernia when the recumbent position is assumed. Spinal symptoms usually com- plicate such eases, however. If a psoas- abseess, deep pressure in the iliac fossa will detect the tumor after apparent re- duction. Varix of the femoral vein is sometimes misleading, but pressure over it from below upward, sliding the finger over the vein until the femoral ring is reached, causes it to become emptied, but it may be seen to quickly refill from below, — the differential feature. Cysts are reducible, but coughing pro- duces no impulse. Lipomata are bosselated, have no im- pulse on coughing, and are more doughy to the touch. Hydrocele and a thicl-ened empty sac are HERXIA. FEMORAL. RADICAL OPERATION. 439 difficult to differentiate, and sometimes require an exploratory incision. Treatment of Femoral Hernia.^ — Re- ducible. — An appropriate truss involv- ing the principles as to pressure, etc., already outlined, should be employed. A truss is not curative in the case of fem- oral hernia, however, and is often held in place with considerable difficulty. It should press diagonally upward toward the spine. Compression of the femoral vein, which lies externally to the hernia, must be avoided. Strangulated. — A strangulated fem- oral hernia may sometimes be reduced by taxis when the thigh is flexed and ro- tated inward, which position causes the saphenous opening to be relaxed periph- erally. No excessive compression or upward pressure should be . exercised, however, operation being less hazardous than such a proceeding. Radical Operation for Femoral Hernia. — Until very recently femoral hernia has been regarded as less amenable to radical cure than inguinal; but the statistics would tend to disprove the correctness of this idea. [There are, as yet, few statistics from ■which to estimate the value of operation for femoral hernia. I have collected 221 eases, exclusive of 91 operated upon by Dr. Bull and me, with 3 deaths. Bas- sini operated upon 54 cases with no deaths and no relapses in 41 which were traced from 1 to 9 years. Ktister oper- ated upon 34 cases with no relapses; Kocher reports 18 cases with no relapses. I personally have operated upon 36 cases, with 1 relapse. This was the only case in which I failed to secure primary union. William B. Coley.] Numerous methods have been from time to time brought out; many of them are complicated and the majority of them have been supported by a very small number of cases. The inguinal method for the cure of femoral hernia, in which the opening is made in the inguinal canal and the femoral opening closed within the abdominal cavity, has been employed by a number of surgeons. It is, I be- lieve, unnecessarily complicated, and, as long as almost perfect results can be obtained by the simpler methods, I think it should have no place in surgery. There is the additional risk not only of having a recurrence in the femoral region, but throiTgh the opening made in the in- guinal canal. Various osteoplastic oper- ations have been introduced by means of which the femoral opening is closed by a bony flap. Most cases of femoral her- nia, I believe, can be cured by one of the two following methods: 1. Pulse-string suture of kangaroo-tendon. This suture is introduced first through Poupart's lig- ament, the outer part of which forms the roof of the crural canal, then passes through the pectineal fascia, the fascia over the femoral vessels, and lastly up- ward through Poupart's ligament, emerg- ing about Vi inch from the point of entrance. When this suture is tied it brings the floor of the canal into contact Vith the roof and completely closes the opening. It is very important to thor- oughly free the sac before applying the ligature. I have employed this method in 25 cases with not a single relapse, and 10 cases were traced from 2 to 6 years. This method I believe sufficient for fem- oral hernia in children and the great majority of adults. If the opening is very- large Bassini's method, which has given siich admirable results for femoral hernia, may be em- ployed. An incision is made parallel with Pou- part's ligament and over the centre of the tumor. This is the same incision that I employ in the purse-string suture. The sac is dissected free from the canal and ligated as high up as possible; with 440 HERNIA. UMBILICAL. a curved needle six or seven sutures are inserted so as to unite ■ Poupart's liga- ment with the pectineal fascia, thus accomplishing the same object that the purse-string suture does. The first suture is placed near the spine of the pubis; the second half a centimetre ex- ternally; the third one centimetre from the femoral vein, and the remaining sutures are so placed as to bring together the anterior and posterior walls of the canal. Umbilical Hernia. Vabieties. — Three forms of umbil- ical hernia are usually recognized: the Large umbilical hernia in infant. congenital, due to faulty union of the vis- ceral plates in the middle line; the infan- tile, which occurs soon after birth as a result of yielding of the umbilical cica- trix after separation of the umbilical cord; and the adult, which usually pre- sents itself late in life in women who have borne many children. Congenital Umbilical Hernia. — In this variety the contents can often be seen through the hernial coverings, owing to the thinness of the layers. The hernia, though usually very small, is sometimes quite large from the first, and contains the greater part of the abdom- inal organs. Child, twenty-four hours old, with a congenital umbilical hernia containing the whole of the liver. Operation. One year later the child was in good health and had no hernia. C. i-i. Scudder (Bos- ton Med. and Surg. Jour., Jan. 4, '94). Strangulation may occur at the neck through compression of the surrounding tissiies, but it has also been caused trau- matically by means of the cord applied around the funis at birth, leading to a fatal issue if much intestine is involved. A fsecal fistula results if but a small por- tion of gut is lost. Treatment. — Immediate reduction should be practiced if possible, and re- tention of intestine insured by the appli- cation of adhesive strips over a small pad placed over the opening. Many surgeons advise the immediate closure of the edges of the ring by catgut sutures. The oper- ation is simple and effective. Successful operation performed for the relief of a defective closure of the um- bilical opening in a, female child 1 day old. The liver, several loops of intestine, and some ascitic liquid were contained in the protrusion, the walls of which were exceedingly thin. Chloroform was used. The operation was a very simple one, and by the fifteenth day union was complete. Salmon (Gaz. des H6p., p. 1219, '92). There were 13 cases of congenital um- bilical hernia collected, 10 of which were treated by laparotomy, freshening the edges of the hernial opening, and suture under antiseptic precautions; 3 were treated by the expectant method. Of the 10 treated by surgical procedure, 7 recovered and 3 died. Of 3 treated by expectant plan, 2 died. Operative treat- ment may be instituted as early as the second day of life with success. Lind- fors (Anier. Jour. Med. Sci., Oct., '89). Infantile Umbilical Hernia. — This form of hernia, though freely met with, never leads to strangulation, and HEENIA. UMBILICAL. 441 quickly subsides by contraction of the opening if, after reduction, appropriate retentive measures are resorted to. Treatment. — The hernia should be re- duced, then held in place by means of a cork pad wrapped in cotton wadding, held in situ by adhesive strips. When these irritate the skin, or the hernia seems rebellious, a light truss can be util- ized instead. literature of '96-'97-'98. In umbilical hernia during the first months of life no operation is necessary, for, as a rule, the hernia is reduced by contraction, tightening, and obliteration of the umbilical ring. In older children it is important to insure the reduction of the tumor, as hernia developed in such children does not tend to spontaneous recovery. After 7 years of age operation is the only likely method of cure. S6bi- leau (Sem. M6d., Jan., '97). Adult Umbilical Heenia. — This variety of hernia protrudes through the linea alba, not far from the umbilicus, and is generally observed in stout people, especially in women. Umbilical hernia in the adult may attain enormous proportions, hanging down like a large pouch if allowed to go untreated. The omentum, transverse colon, and small intestines may all be found in it. Treatment. — When reducible, the hernia is held with difficulty by trusses, especially in large subjects. A broad belt with a pad fastened to it is sometimes more effectual. It is frequently irreduci- ble, however, and is prone to inflamma- tory manifestations. When it cannot be reduced, it is best to protect it by means of a cup-shaped pad held in position by a bandage or a belt. This variety of hernia is also liable to become obstructed, a complication occa- sionally leading to strangulation. There is local disturbance and sometimes pain; vomiting sets in and the other manifes- tations of strangulation already described present themselves. Taxis should be tried and, if care be taken to empty the hernial intestines of all gas by gentle pressure, often succeeds. If it should not, however, the proclivity of the hernia to rapidly become gan- grenous, owing to compression of its vas- cular supply, renders an immediate herniotomy advisable. When operation becomes necessary. Large umbilical hernia. the skin should be divided over the ori- fice, remembering that the sac is exceed- ingly thin and that it may readily be penetrated. Adhesive inflammation often causes the contents to be adherent, an- other complicating circumstance. To overcome the constriction without open- ing the peritoneum should be the first aim; if this is impossible, a couple of shallow incisions through the fibrous ring at its lower border from the inside of the sac will generally make it possible to reduce the strangulated loop. The 442 HERNIA. VENTRAL. adherent omentum should then be liber- ated, ligated, and removed, and its stump returned. After freshening the pillars of the ring and suturing, the wound should be closed and drained. Should the gut be gangrenous an artificial anus is the only resort. Ventral Hernia. — "Ventral" is a gen- eral term applied to hernise occurring in parts of the abdomen other than the um- bilicus, especially those following oper- ative procedures, such as laparotomy. It may also result from abscess of the ab- dominal wall, defective development, muscular rupture, etc. Strangulation is rarely witnessed, owing to the nature of the orifice. Its treatment is that recom- mended for umbilical hernia. The results of operation for the radi- cal cure of umbilical and ventral hernia have been more or less disappointing. [Dr. Bull and I have operated upon 34 eases of umbilical and ventral hernia; of these 15 were ventral, including -3 epi- gastric and 11 heniia following lapar- otomy; 4 following appendicitis opera- tions in which the wound had been left open. In the total number of cases of umbilical and ventral hernia there were 12 relapses out of 21 cases traced; 9 re- lapsed during the first year; 3 of the umbilical Avere strangulated, with 2 re- coveries. WiLLIAlI B. COLEY.] The large percentage of relapses oc- curring in umbilical hernia is explained by the fact that these cases are mostly very unfavorable for radical cure. They are stout women in middle age with a great abundance of fat and very little muscular tissue in the abdominal wall. Epigasteic Hernia. — This is a gen- eral term applied to forms of hernia oc- cupying the space between the end of the sternum and the umbilicus. These tumors are sometimes discerned with difficulty and are apt to cause symptoms usually referred to gastric disorders. In young persons suffering from gas- tric disorders a careful examination sometimes reveals the presence of small tumors, no larger than a hazel-nut, in the linea alba, between the ensiform ap- pendix and umbilicus, at the site of an inscriptio tendinse in the rectus. These hernial protrusions usually contain omen- tum, and, as the sac cannot readily be felt, the tumors may be mistaken for lipomata of the abdominal walls. They give rise to severe pains and vomiting. The radical operation for hernia causes a complete disappearance of the dis- turbances. Von Bergmann (Wiener med. Woch., No. 5, '91. Literature of '96-'97-'98. Especial attention called to hernia in the linea alba. These are often very small, varying in size from a pea to a walnut, usually above the navel, may be multiple, and occur generally in men from 20 to 50 years. All the author's twelve cases were among the working- classes. They are most apt to contain only subperitoneal fat, but may consist of omentum or intestine. The symptoms are the same in any case. These are very various. There may be no disturb- ance at all, or the symptoms may come on suddenly and be more severe. In the typical case there is colicky pain, increased by pressure, radiating toward the shoulder or giving the girdle-sensa- tion; there are generally recurring at- tacks of pain and vomiting. Kuttner (Mitteilungen aus der Grenzgebieten der Med. und Chir., vol. i, No. 5, '97). Epigastric hernia should include all hemiae which are found in the area bounded above by the xyphoid cartilage, below by the umbilicus, and on the sides by the cartilages of the ribs. They so commonly appear in the linea alba in comparison with other sites that they have been termed "hernia in the linea alba." In a series of 16,800 cases of all varieties of hernia examined by Berger there were 137 cases of epigastric hernia, some of the cases occurring alone, some in combination with other forms of her- nia. It is very exceptional to find these cases in subjects less than 18 years of age, and most of the subjects of such a HERNIA. RARE FORMS. 443 form of hernia are between 25 and 50. Astley Cooper, however, reported 2 con- genital eases, and some few cases have been reported as beginning in early childhood. The vast majority of cases are in males of the working class. As a rule, the onset is insidious. The patient complains for some time of stomach- symptoms before the hernia appears ex- ternally or when the hernia is so small as to escape detection without a careful examination. In not a few cases, how- ever, there has been a traumatism, fol- lowed by very acute local and general symptoms, and the tumor has appeared within a, few hours. Lothrop (Boston Med. and Surg. Jour., Feb. 25, '97). The size of the hernia and the conse- quent disability are of much interest, the herniffi ranging in size between that of an egg and a child's head. The weak- ness and discomfort caused by these her- niae are very much the same as in hernia following laparotomy. Observation of 1000 cases of lapa- rotomy done in the hospitals in Berlin, showing that nearly one-third of all the eases suffer from ventral hernia. In some cases the hernia does not develop for one or two years after the operation. Winter (La Semaine M6d., June 15, '95). In regard to the treatment of such cases, much depends on the age of the patient, as well as upon the character of the abdominal wall. As a rule, these patients are young adults with good abdominal muscles, little accumulation of fat, conditions the contrary of which is usually found in umbilical hernia and which so often contra-indicate operation. The results of operations for epigastric hernia are very satisfactory. The same is true of cases following appendicitis. Of four cases not one relapsed, though the hernise were of large size and adhe- sions were present. CsBcal Hernia. — This form-of hernia is far more frequent than is generally sup- posed. I have observed it 16 times in 531 operations. In a number of cases the caecum could be reduced, but the appendix could not, on account of adhe- sions to the sac. Csecal hernia occurs usually on the right side, but may be found on the left. I have operated upon one left inguinal hernia in which the sac contained a large, vermiform appendix. The patient was 10 years old. In the majority of cases, especially in young subjects, the hernia is congenital. Strangulated hernia of the csecum in any form is infrequent, the number of cases met with in a large series of 565 herniotomies amounting to only 1.59 per cent. Extreme rareness of uncomplicated cases of this form of strangulated hernia noted, two instances only being found in this same series. The very high rate of mortality (66.6 per cent.) was clearly due to the critical condition of the ma- jority of the patients at the time of operation. Bennett (Lancet, Feb. 1, '90). , Rare Forms of Hernia. — Diaphrag- matic Heenia. — This form may be con- genital or acquired. The congenital form is due to imperfect closure of the dia- phragm and the protrusion into the pleu- ral cavity of a portion of the abdominal contents. This occurs by the side of the ensiform cartilage, between the xiphoid and costal portions. A diagnosis of this condition is hardly obtainable. Case of diaphragmatic hernia in male child, 3 Vs years of age, showing the fol- lowing points of interest: 1. The phys- ical signs in this case were identical with those of empyema. 2. The frequent high temperatures, for which there was no ap- parent cause except constipation. Lynde (Archives of Pediatrics, Dec, '89). Literature of '96-'97-'98, Case of congenital diaphragmatic her- nia diagnosed during life. The patient was 14 months old. Percussion was dull on the left side of the chest and vesicu- lar murmur was absent; posteriorlj' on the left side interstitial gurgling could be heard at times. When the child was 444 HERNIA. EAEE FOESIS. inverted the lower part of the left chest became tympanitic and the note on per- cussion varied between tympanitic and dull, with variations in positions at dif- ferent times. In consequence of the de- velopment of vomiting, constipation, and collapse It was thought that some strangulation had possibly occurred and abdominal section was performed. All the intestines were found in the left chest, but were not strangulated. The child died. There was a semicircular de- ficiency in the posterior part of the left leaflet of the diaphragm 2 inches long. The spleen was in the left pleural cavity; the left lung was completely un- developed. The peritoneum was continu- ous with the pleura round the opening. Jeffreys Wood (Lancet, Apr. 16, '98). The acquired form may be due to rupt- ure of the diaphragm through violent effort, direct violence, or penetrating wounds. The penetration through the opening thus formed suddenly creates dyspnoea and asphyxia, besides other manifestations which the displacement of organs give rise to according to the site of the tear or laceration in the dia- phragm. Excessive thirst has been noted by Bryant as a prominent symptom. Case of diaphragmatic hernia in which the author performed laparotomy. Xearly the whole sigmoid flexure and the large omentum had disappeared through the diaphragm. All the efforts to eft'ect a replacement were useless, either through the stomach turning on its axis or the sigmoid flexure. The pa- tient died the day after the operation. G. Xaumann (Hygeia, Aug. 8, '88). Autopsy performed upon a man, aged 67 years, who had been for nineteen years subject to colic and dyspnoea, the first attack having followed a violent fit of vomiting. He died after an illness of five or six days, with vomiting and ob- stinate constipation. Through an open- ing in the diaphragm extending from the mediastinum five inches to the right, the caput coli, a loop of transverse and descending colon, and a mass of omen- tum had passed; the loop of colon was distended with gas and highly inflamed. The appendix vermiformis was seven inches long and one-fourth inch in di- ameter. Currier (Med. and Surg. Rep., Mar. 5, '92). Peopeeitoneal, or Inteestitial, Heenia. — There are three varieties of interstitial hernia classified according to the relative position of the sac: — • 1. In which the sac lies between the peritoneum and the transversalis fascia. This variety is very rare. A tumor is seldom present, and the condition is not often recognized until strangulation has occurred. 2. In which the sac lies between the external and internal oblique muscles. 3. In which the sac is external to the aponeurosis of the external oblique. In the last two varieties there is a well- marked tumor which is situated in the inguinal region, but seldom extends into the scrotum. While the mode of forma- tion in many cases is difficult to explain, in most eases the condition is associated and probably dependent upon unde- scended or partially descended testis. In the rare cases of this variety of hernia observed in women it has been associated with a hydrocele of the canal of Niick; the undescended testis or the hydrocele, furnishing an obstruction to the further progress of the hernia in the downward direction, causes it to enlarge upward, and, following the line of least resistance,, the sac may find its way to the situations already described. The conditions which may simulate this form of hernia are: a cold abscess from spinal or pelvic bone disease, or hydrocele of the cord. The only form of treatment to be recommended is opera- tive interference. LuMBAE Heenia. — This rare form of hernia emeTges in the region of Petit's triangle, after passing through the lum- bar fascia near the quadratus lumborum. HERNIA. RAEE FORMS. 445 and may result from strains, wounds, abscesses, or may appear spontaneously, especially in people of advanced age. It is easily reduced and retained by an ap- propriate belt. Record of 29 eases of lumbar hernia. The small triangular space bounded by the external oblique and latissimus dorsi muscles and the crest of the ilium (Petit's triangle), it is generally as- sumed, constitutes a relatively weak spot in the abdominal wall, and that her- nial protrusion may occur here, but that strangulation of the contained intestine is very unlikely to develop. Out of the 29 cases 16 developed spontaneously, or were attributed to strain, and all were in adults or elderly subjects. Males and females appear to be equally liable to lumbar hernia. Seven cases of appar- ently spontaneous origin were on the left side, 4 on the right. In 6 cases (about 20 per cent.) the hernia followed in the track of a previous abscess or sinus — 4 in males and 2 in females. In 5 cases the hernia was due to wound or other severe traumatism of the loin, and 2 were reported as congenital. A well-made ab- dominal belt is efficient in preventing protrusion. Hutchinson (Brit. Med. Jour., July 13, '89). Heenia into the FoEAMEisr OF Win- slow. — This variety, tbough very rare, is of special importance, because it fre- quently gives rise to intestinal obstruc- tion. It cannot be recognized without abdominal section; but treatment of the intestinal obstruction by enemata some- times succeeds in bringing about the reduction by causing distension of the gut and traction upon the engaged loop. In a case of hernia into the foramen of Winslow abdominal section was per- formed, and the nature of the trouble determined, although reduction could not be effected. Forty-eight hours later, after a large enema, the symptoms sub- sided and a rapid and complete convales- cence set in. A. Neve (Lancet, May 28, '92). IscHiATic Heenia. — This term is ap- phed to protrusions taking place through the lesser sciatic notch, those through the greater being called gluteal. It may occur on either side, and may be either congenital or acquired. It has been seen more often in females. Its contents may be bowel, ovary, or a diverticulum of the bladder. Incarceration of a portion of bowel along with an ovary has been ob- served in three cases. Ischiatic hernia is extremely rare (Garre). In all cases of perineal vagino-labial hernia the hernia issued from the pelvis, out of the perineum, and distended the labium majus. Three varieties dis- tinguished. In the "antei-ior" form the sac pro- trudes between the sphincter vaginae and the erector elitoridis. In the "median'' form it bulges between the sphincter va- ginas and the deep transversalis perinei. In the "posterior" form the hernia passes between the levator ani and the gluteus maximus. The abdominal orifice of the sac lies in front of or behind the lateral true ligament of the bladder. The best treatment for all forms of perineal hernia in women is a radical operation, which must be performed from the perineal aspect, the sac being exposed by an incision through the vulvar struct- ures. Winckel (Annales de Gynee. et d'Obstet., Aug., '90). Peeineal Heenia. — ■ In this form the protrusion occurs between the fibres of the levator ani in front of the rec- tum; it descends behind the bladder in men, and the vagina in women. It occurs oftener in the latter than in the former and often penetrates the labium majus, forming the labial, or pudendal, hernia. A true labial hernia also occurs, the sac descending between the ramus of the ischium and the vagina into the posterior portion of the labium. It may be mistaken for Bartholinian abscess and labial cyst, but the inflamma- tory manifestations of the former and the absence of gurgling in the latter gen- erally render a diagnosis easy. 446 HERNIA. RARE FORMS. HERPES. Winekel, who found 6 cases in 5600 patients examined by liim, reeommends a radical operation through the perineal tissues. Obtueatoe Heenia. — This is a rare variety of hernia, which protrudes through the obturator foramen between obturator externus and pectineus, push- ing before it the obturator fascia. The femoral artery and vein pass externally and in front of it, the adductor longus forming the opposite wall. The obtura- tor artery and vein may lie to the inner or outer side of the hernia, especially feature, in addition to the usual signs of strangulated femoral hernia. Taxis is sometimes successful, espe- cially if the thigh is flexed, adducted, and rotated inward. The muscles and tis- sues around the hernia are thus relaxed. If this fails, herniotomy should be per- formed, the nature of the vascular supply and the fact that the constriction is at the neck of the sac — which should be incised by cutting downward — being borne in mind. William B. Colby, New York. Labial hernia. near the neck: anatomical features which should be borne in mind when operative procedures are to be resorted to. It is seldom recognized and may be mistaken for femoral hernia. Its situation causes it to manifest itself in the majority of cases as an indefinite bulging or fullness of the tissues of the region, and careful palpation sometimes causes gurgling. It is usually met with in spare women past middle age and sub- sequent to the menopause. Men less fre- quently siiffer from this variety of hernia. It is rarely distinguished before strangu- lation occurs. Pain down the leg along the obturator nerve is a distinguishing HERPES.— Gr., ipnio, to creep. Definition. — Herpes simplex is an acute, non-contagious, benign disease of the skin, usually dependent upon a neu- ritis of the nerves sxipplying the part, and characterized by an eruption of vesicles in groups upon an infiamed, oedematous base. Herpes simplex may attack any part of the body-surface, but the malady shows a decided preference for two lo- calities. These parts are the facial and genital regions. Because of the usual distinct restrictions of the disease to one or the other of these sites, and the diversity in symptoms that is liable to HEEPES. SYMPTOMS. 447 be manifested, two varieties of the dis- order have been distinguished, and to eacli has been given a separate title. They are called herpes facialis and her- pes genitalis. While essentially the same in nature, the specific canses apt to pro- duce them, the dissimilarity of their manifestations, and the various diseases with which they are likely to be con- founded, make their individual descrip- tion a matter of necessity. Herpes simplex appears but rarely in other situations upon the body and still less likely is it to occirr in a generalized form. When such does happen, the term "herpes generalis" is applicable. [Our etiological and pathological knowledge of the afifection is still too limited to enable us to demonstrate with absolute certainty that there is always a preceding or accompanying neurosis, but evidence enough is at hand to war- rant our accepting this statement as the truth. The almost constant distribution of the lesions in the course of certain nerves points definitely to such a con- clusion. William Francis Robinson.] Symptoms. — Herpes facialis may oc- cur upon any part of the face or fore- head. Case of herpes affecting simultaneously the ophthalmic and the auriculo-tem- poral nerves. Vesicles appeared in the area supplied by the left frontal nerve, groups being present over the eyebrow, near the median line, close to the hair, and near the temple. The eyelids were reddened and swelled. Later, vesicles developed upon the left tympanic mem- brane. Bonnier (Jour, of Laryn., June, '93). Two instances of herpes ophthalmicus associated with paralysis of the ocular muscles observed. The first case oc- curred in a man aged 58 years, the third and fourth, sixth, and first divisions of the fifth nerves being involved. In the second case (a man of 79 years of age) there was complete ophthalmoplegia ex- terna, proptosis, and a glaucomatous condition of the eye, with hypaemia. The first case was benefited by iodide of potassium. Silcock (Clinical Jour., Aug. 8, '94). The Vermillion border of the lips, also of the nose, upper lip, cheeks, and auricles are favorite sites for its appear- ance. The mucous membranes of the mouth and throat are often implicated. So, too, the disorder may attack the cornea. Case of stubborn, recurrent, herpetic disease of the conjunctiva and cornea, in conjunction with menstrual disturb- ance of the menopause cited. The dis- ease took the form of a small loss of corneal tissue, with fatty, uneven edges, and resembled a phlyctenule in appear- ance. Its summit had undergone ulcer- ation. The eruption differed from that which is characteristic of herpetic dis- ease by its disposition and appearance. Stuelp (Archiv f. Ophth. [Grafe], B. 40, H. 2, '94). At the outset a slight tingling or burn- ing is felt in the part about to be at- tacked. Redness and swelling rapidly follow, and upon this oedematous base a cluster of tiny vesicles soon appears. Usually an areola surrounds the group. The groups vary in number from one to a half-dozen or more, and in size from the surface of a split pea to a silver twenty-five-cent piece. They are round, oval, or irregular in outline, and may be closely set or widely separated. The vesicles are from pin-head to a kernel of wheat or larger in size and number three to a dozen or more in each group. They are fairly firm to the touch and do not readily rupture. Most authors describe a preceding papular 'stage. This is exceedingly liard to demonstrate, and, if it does exist, is of very short duration. With care in the examination, fluid may be found in the lesions at the moment of their inception. At the outset each vesicle is filled with clear, transparent serum. This 448 HERPES. SYMPTOMS. gradually grows turbid, until by the end of the second or third day, if the lesion be not sooner ruptured, the liquid as- sumes a milky condition, and examina- tion under the microscope shows an abundance of pus-cells and degenerated epithelium. Where closely set the vesi- cles may coalesce, forming a flat-topped bleb. Unless interfered with, the vesicles run their course in from four to ten days, the process then being completed by the formation of a crust which des- iccates and falls, leaving a brownish, pigmented spot. This pigmentation gradually disappears without forming a scar or other relic of the disease. If the vesicle, as usually happens, is broken by picking, rubbing, or scratch- ing, an excoriation results, which, if it does not become infected, is shortly cov- ered with a crust, and the disease then runs its usual course and terminates in the ordinary way. Such crusts are dry and firmly attached. When the excori- ations become infected with pus-cocci or are treated with strong caustics, grave iilcers are apt to supervene and disfigur- ing scars remain. Hemorrhage into the vesicle (black herpes) and gangrene sometimes com- plicate the process. Subjective sensations are usually slight. The unsightliness of the dis- ease causes the patient more distress than does the pain of the disorder. The tickling, burning, or pricking sensations occurring at the outset may continue for a day or two and then subside, no further distress being experienced. Sometimes, though rarely, more or less itching is complained of, and even pain is occasionally felt. Herpes of the mouth and throat (canker spots) presents a somewhat dif- ferent appearance. Owing to the moist. warm condition of the parts the vesi- cles cannot develop as such. A round or oval patch, slightly elevated, and cov- ered with a whitish, sodden exudate, is first formed. These spots may be situ- ated upon the upper or under surface of the tongue, the border of the gums, the inner wall of the cheek, the palate, or the tonsil. Case of chronic recurrent herpes of the oral cavity seen in a man of 38, healthy until his eighteenth year, when, after an attack of typhoid fever, in 1874, the herpetic trouble began to show itself, — at first upon the lips and along the gums, later on the tongue. The eruption lasted from eight days to four weeks. In 1888 and 1889 for nearly a year the pa- tient was free from herpes. After this, however, the attacks recommenced with greater frequency, sometimes immedi- ately following one another. The patient complained of difficulty of breathing through the nose during the attacks. No general symptoms accompanied the at- tacks ; the pharynx and larynx remained free. Salivation was a marked symptom from time to time, and the mucous mem- brane of the cheeks was attacked. The immediate cause of the affection seemed to be some involvement of the trigeminus. Flatau (Deut. med. Woch., May 28, '91). The most frequent site of herpes of the larynx is upon the posterior face of the epiglottis, and in the neighborhood of the arytenoids. It is characterized anatomically by the evolution in these regions of herpetic vesicles surrounded by an inflammatory zone, and clinically by the symptoms peculiar to herpetic fever, and also by painful dysphonia, rawness of voice, oc- casionally aphonia, sometimes dyspnoea. Its invasion is abrupt, its course rapid, prognosis favorable, and cure complete. Relapses sometimes occur. Rarely it is accompanied by phenom- ena analogous to those of croup. Brin- dell (Rev. de Laryn., xvi, p. 233, '95). Herpes of the mouth, while not al- ways severe, usually occasions consider- able distress. HERPES. DIAGNOSIS. HERPES FACIALIS. 449 A condition that is known as "her- petic fever" is occasionally met with. The disease usually occurs in endemics and is characterized by languor, vomit- ing, and chilly sensations, followed by a rigor and then a sudden attack of fever. The fever may run as high as 104°; the tongue is moist and heavily coated; the throat is sore, and the glands of the neck enlarged. Eestlessness and delirium are exhibited at night. On the second day the vesicles appear and are usually confined to the face. Crocker speaks of defervescence being associated in some cases with the her- petic outbreak. The disease runs its course in about four days, terminating in recovery. The course of the disease and its oc- currence in endemics points to an infec- tious origin. Cases have been traced to sewer-gas and faulty hygiene. [Epidemics have been reported by Savage (Lancet, Jan. 20, '83) and Seaton (Clin. Soc. Trans., vol. xix, p. 26, '86). William Fbancis Robinson.] Diagnosis. — Herpes facialis is to be dis- tinguished from ECZEiiAby the larger size and greater stability of the vesicles, by their peculiar grouping, the insignificant sensations accompanying the disease, and the rapidity with which the disorder runs its course. There is no weeping, as in eczema, and no successive new forma- tion of vesicles upon the same sites. The resemblance of herpes, when the lesions have broken and crusts have formed, to IMPETIGO is sometimes marked. But in impetigo the crusts have been preceded by a single vesicle, bleb, or pustule. In- stead of a group of vesicles, the patches of disease are not distributed in the line of any cutaneous nerve, but are scattered irregularly over the surface, and typical lesions can usually be found upon the hands and also upon the trunk. There is often a history of contagion. Care must be exercised in not confounding herpetic lesions of the mouth with the mucous patches of syphilis. Many pa- tients, frightened by the knowledge of their exposure to syphilitic infection, point to their frequently recurring can- ker spots as indubitable proof that they possess the disease. More decisive evi- dence in the form of scars, alopecia, gummata, or the peculiar eruptions of syphilis must be searched for and found before confirmation of the subject's fears should be given. Veterans , of syphilis are sometimes subject to her- petic troubles of the mouth that give rise to much mental distress on the part of the patient, but which are not in any wise related to the precedent lues. Herpes occurs at all stages of pneu- monia, and is dependent rather upon the peculiar liability of the subject to herpes than upon the nature of the ease. Prog- nosis is better in eases in which the eruption occurs. Talamon (Rif. Med., Mar. 20, '95). Literature of '96-'97-'98. Buccal herpes must be differentiated from mucous patches. Buccal herpes is much more painful and much more liable to become fissured. It has from the out- set a marked milky tint, and long pre- sents in the centre of its polycyclic border a whitish circle, which is the last vestige of the broken-down or ruptured vesicle. The microcyclie contour has a positive value. The specific treatment is injuri- ous. Fournier (Revue Internat. de Med. et Chir., June 25, '96). Herpes simplex can be distinguished from herpes zoster by the bilateral dis- tribution of its lesions, the presence of fever, and the lack of nerve-pain. Herpes Facialis (fever-blisters). Etiology. — Herpes facialis is a com-, mon, though not necessary, accompani- ment of many fevers and of catarrhal 450 HERPES FACIALIS. PATHOLOGY. disorders of the nose, throat, bronchial passages, and lungs. The popular desig- nation "cold sore" is indicative of the frequency with which the complaint occurs in simple coryza. Typhoid and intermittent fevers frequently give rise to it. Herpes simplex is very apt to occur in pneumonia not only upon the face, but upon the genitals and at times in other localities upon the body. At one time it was believed to occur regu- larly at the crisis in all cases of sthenic pneumonia in which a favorable out- come was likely to occur. Such auspi- cious prognosis, however, can no longer be maintained. Disturbances of the digestive tract, especially in children, are prone to pro- duce herpes of the lips. Indigestion, gastritis, gastric ulcer, and enteritis in adults are frequently associated with this form of herpes. It is not unusual in malaria, but is said to be rare in re- lapsing fever. Herpes of the nose ami lips often co-exists with tonsillitis and bronchitis. Some persons are so extremely sus- ceptible to the disease that merely brushing the face or the lips with a feather will induce it. Many women are affected at each menstrual epoch with labial herpes. Literature of '96-'97-'98. Five cases of acute pyrexia occurring between the second and fifth days after confinement or abortion, in each of wliich the febrile attaclv terminated by an eru])- tion of facial (usually labial) herpes. In each case the attack was ushered in by rigors; the pyrexia was severe, rising to 103° to 104° F., and in each ease, after the appearance of the herpes, the pii- tients rapidly recovered. Attention called to the disquieting nature of these s^nnptoms and their liability to be con- founded with those of grave septic in- fection; when strict antiseptic precau- tions have been taken in the conduct of labor or abortion, and no local condition can be found to account for the subse- quent rigor or pyrexia, it may be well to remember that the explanation of these phenomena may sometimes be found in the occurrence of the herpetic disorder described. Lutaud (Jour, de M6d. de Paris, July 12, '96). Toothache as well as dental instru- mentation is khown to produce the trouble. Literature of '96-'97-'98. Herpes facialis may be due to irrita- tion of the trifacial nerve reflexed from some dental afi'ection. George Carpenter (Pediatrics, May 1, '96). Blows upon the head, exposure of the face to alternate hot and cold blasts, or the application of irritating medica- ments to the parts, are fruitful sources of the disorder. Many cases are thought to arise without appreciable cause, and are spoken of as idiopathic, but it is doubtful if such is ever strictly the truth. A careful analysis would, in all likelihood, reveal ' in each instance the existence of some irritating factor capable of producing the affection. Pathology. — Owing to the benign nature' of the disease, opportunities for studying its pathology are rare, and our knowledge is correspondingly lim- ited. [To Unna, of Hamburg, is due much that we know. His observations were Confined to the study of tissue taken from three living subjects affected with herpes genitalis, and one corpse dead of a febrile disease in which facial herpes was present. William Francis Eob- INSON.] Unna found that the process origi- nated in the upper layer of the rete mucosum and was a true coagulation- necrosis. The cells affected were much enlarged and the cell-contents were HEEPES FACIALIS. PROGNOSIS. TREATMENT. 451 greatly changed. The nucleus had dis- appeared and the protoplasm conld not be stained. This was due to the satura- tion of the cell by fibrinogenous sub- stance from the fluid surrounding the cell-body. The cell retained its normal shape and the prickles remained in- tact. Beneath the zone of necrotic tis- sue a layer of flattened and thinned prickle-cells was found that still re- tained its normal features and the cells their capacity for staining, thus indi- cating that the elevation of the whole epithelium ^yas a secondary, and not a primary, occurrence. Deeper down in the rete were cells in a necrotic condi- tion. In most of these the nucleus had disappeared, leaving only a cavity, while in some cell-substance had been com- pletely dissolved in the fluid of the blis- ter. The heads of many papillfe pro- jected into the cavity of the lesion and were entirely denuded of epithelium. It would appear, then, that the process consists of two distinct steps, the first consisting of a fibrinous infiammation of the upper priclde-eell layer, convert- ing it into a nuclear, degenerated, ne- crotic mass, forming later the roof-wall of the vesicle. The second, the loosen- ing of the epidermis as a whole, with the formation of a subepithelial blister, whose contents again undergo coagu- lation-necrosis. The blood-vessels and lymph-spaces underneath and about the lesion were found markedly dilated, and distinct, though not extensive, migration of leucocytes was evident. Prognosis. — The disease is a benign disorder running its course, if not irri- tated, in from four to twelve days. Xo scarring is produced. Pigmentation fol- lows the desiccation of the vesicles, but this soon disappears. The disease is ex- ceedingly prone to recur, — in many pa- tients with almost periodical regularity. Treatment. — The treatment of herpes of the face should be of the simplest kind. All irritation should be removed. No picking, scratching, or rubbing should be allowed. The smoker should be made to give up his pipe or cigar, and all forms of tobacco had best be inter- dicted. Strong acetic acid, if applied at the outset before the vesicles have formed, will often ciit short the attack or greatly lessen its severity. The action of the acid should be checked before whitening of the skin takes place. If the itching and burning are at all severe, lotions of dilute lead-water and opium, zinc oxide and lime-water, elderflower-water, cam- phor-water, or weak ammonia-water may be used freely. These should be followed by a simple dusting-powder, such as starch, boric acid and talc (1 to 8), stearate of zinc, or lycopodium. Painting the parts with flexible col- lodion after the vesicles have fully formed makes an admirable dressing. Ointjnents, as a rule, are not well borne. The Lassar paste (salicylic acid, gr. v; zinc oxide and talc, of each, drachma ij; vaselin, drachma iv) makes a good protective covering. Internal medication for the relief of the disease while in its course is useless. As a prophylactic, according to Duhr- ing, arsenic is of positive value, and will cure the tendency to the disorder. It should be given in full doses: ^/jo grain of arsenous acid four times a day, or Fowler's solution, 3 to 7 minims, after meals. Cold sponging of the body each day, especially of the spinal region, fol- lowed by vigorous friction, will help to control the tendency. Literature of '96-'97-'98. Herpes at the orifice of the external auditory canal cured by tonics and the 452 HEEPES GENITALIS. SYMPTOMS. DIAGNOSIS. local application of yellow oxide of mer- cury. L. S. Somers (Amer. Medico- Surg. Bull., Oct. 31, '96). Treatment of herpes of the cornea consists in weak duboisine and eserine; insufflation of powdered iodoform and cocaine, and the same in ointment once daily; occlusion; galvanocautery, if necessary; and, in infecting progressive ulcer, injections, under the conjunctiva, of antitoxin. Balezowski (Rec. d'Ophtal., June, '96). Herpes Genitalis. BesDJer has lately given the api^ella- tion "genitalis" to all forms of genital herpes, and the term is much to be pre- ferred to the older designations: "pro- genitalis" and "prffiputialis," neither of which were strictly accurate. Symptoms. — Burning and itching, with som_etimes pain, precede the ap- pearance of the vesicles. Usually there is but one group, but occasionally the number is greater. There are not apt to be as many vesicles in each cluster as is the case in herpes of the face. A reddened cedematous base with a single or at most two or three distinct vesicles upon it is not imcommon. Certain sites upon the genitals seem to be favored by the disease. These, in the order of their frequency in men, are the sulcus, the reflected mucous membrane of the pre- puce, the glans, the margin of the pre- puce, and the skin on the shaft. (F. B. Greenoiigh.) In women the sites of preference are the skin of the vulva, the inner border of the labia majora, any part of the labia minora, the prepuce, the clitoris, and the orifice of the urethra. When the lesions are situated upon the mu- cous membranes the vesicles rupture early and the patient first notices an ex- coriation, covered by a whitish deposit. Upon the integument of the vulva or penis the vesicles look like tiny droplets of water. They rapidly lose their clear shining appearance, however, owing to the increasing turbidity of the contents. Crusting follows, and if the disease is not irritated the process terminates by the falling of the scab in from one to two weeks. A pigmented spot remains. This eventually disappears. There is no scar. Literature of '96-'97-'98. In man the genital herpes is located upon the penis; in woman, either at the urethral orifice or upon the vulva. The base of the ulceration is yellow, but its principal characteristics is its micro- cyclic and polycyclic vesicle. A most important variety is that which, desic- cating from the centre to the periphery, assumes a papular aspect and resembles sometimes a chancre, sometimes a mu- cous patch. Herpes may arise suddenly or by successive eruptions. Its duration is variable, lasting from a few days to several weeks. Fournier (Revue Inter- nat. de Mgd. et Chir., June 25, '96). Itching is apt to be severe, especially in women. ISTeuralgic pain simulating that of zoster is sometimes felt. These cases should be regarded with suspicion, but it is not a wise measure to call every attack of this nature shingles. The lesions in the male are usually situated in the line of the dorsalis-penis nerve. When close set the vesicles may coalesce. Diagnosis. — The recognition of the disease does not usually present any great difficulty, but care is sometimes needed in arriving at correct conclu- sions. The mental distress of the pa- tient is generally out of all proportion to the severity of the disorder, and this, coupled with the ease with which the lesions may be confounded with the in- itial sclerosis of syphilis, makes the sub- ject a fruitful field for the quack and the unprincipled practitioner. Many a young man has had his life made bitter and has parted with his years of hard- HERPES GENITALIS. ETIOLOGY. 453 earned wealth because some such scoun- drel has pronounced the simple herpetic lesion exhibited a virulent chancre. If the truth might be known many of the wrecks behind the bars of our insane asylums could be traced to this cause. On the other hand, the ease with which syphilitic infection may take place at the site of the herpetic vesicle or excori- ation will make the careful practitioner exceedingly guarded in his statements to his patient. He is a physician of very limited observation indeed who has not seen an undoubted case of genital her- pes linger along, getting worse instead of better, until it had assumed the classi- cal featiTres of a chancre or chancroid, to be followed by the disastrous results of the one or the other. If there be a history of exposure to a probable source of infection, sufficient time to exclude the possibility of such infection must be insisted upon before a final answer be given. This, in the case of chancroid, need be but a few days. The pain, the intense inflamma- tion, the formation of a true ulcer, and the development of the single inguinal bubo will tell the story. If haste is necessary the autoinoculability of the secretion may be tried. If true chancre be expected, at least six weeks from the time of the exposure should be allowed to elapse before a definite decision can be rendered. _ The sluggishness of the lesion, the indura- tion, the double inguinal enlargements, and the characteristic eruption will dis- tinguish it. Literature of '96-'97-'98. Differential diagnosis must be made between genital herpes and eczema, or between it and chancre. The vesicles in eczema are microscopical in size and in- numerable, and disappear rapidly. The chancre is leas superficial than herpes; its borders are more irregular; its base is also irregular, and accompanied by some enlargement of the glands. By placing upon a, piece of glass some scrap- ings from a soft chancre, there are found elastic fibres which are not met with in herpes. Finally, inoculation with soft chancre shows a redness from its second day, and a vesicle upon the third, which is rapidly followed by ulceration. Eour- nier (Eevue Internat. de M6d. et Chir., June 25, '96). Etiology. — Herpes genitalis occurs in both sexes, but with relatively greater frequency in the male than in the female. In persons subject to the dis- order any irritation of the genital re- gions is likely to induce an attack. Ungratified sexual excitement, local uncleanliness, coitus, masturbation, fric- tion with the underclothing, passage in the male of a sound or pressure in the saddle on horseback or the bicycle are common and fruitful sources of the mis- chief. In some women it appears at each catamenial epoch, preceding, ac- companying, or following the period. It is frequent during pregnancy. Ve- nereal disorders, such as gonorrhoea and chancroid, as has been so well shown by Doyon, are apt to induce it. They are not, however, as he endeavors to show, its invariable precursors. Vaginitis and leucorrhoea are prone to give rise to the disease, the irritating discharges acting as the exciting factor. Fournier and Unna have shown that it is very common in prostitutes and lewd women. In women infected by their husbands with syphilis or gonorrhoea it is said to be in- frequent. From an experience of twenty-four years in the Hospital for Venereal Dis- eases in Copenhagen, the writer finds that 2.6 per cent, of prostitutes have herpes vulvaris. Out of 877 cases of herpes, 73.4 per cent, of the women were men- struating when examined, and many stated that they had the eruption only at the time of their period. It had no 454 HERPES GENITALIS. PROGNOSIS. TREATMENT. apparent connection with previous ve- nereal troubles, or with their practice of indulging in sexual intercourse during the flow. Vulvar herpes believed to be nearly always a menstrual exanthem, probably of trophic origin. The vesicles are most numerous immediately before the flow. They appeared in 70 per cent, of the eases on the labia majora. Bergh (Centralb. f. Gyniik., Feb. 8, '90). Herpes genitalis is a disease of early and middle adult life. It rarely occurs in infancy and seldom after fifty years of age. Like herpes of the face, it some- times appears to arise without appre- ciable cause. Disorders of digestion and constipation are named as exciting fac- tors, but it is doubtful if such be the case. A redundant prepuce is unquestion- ably an exciting element in men. Bala- nitis is sometimes regarded as a cause, but the probability is that it is due to the same derangements that induce the herpes. Prognosis. — Herpes genitalis is a dis- ease that recurs with exasperating fre- quency and occasionally makes life a burden to its victim. But, aside from the tormenting pruritus and the belief in its venereal origin, it is seldom that it gives rise to much that can be char- acterized as more than mere annoyance. The patient's fears need to be allayed and faulty sexual habits and hygiene cor- rected. The tendency of the trouble is toward rapid healing. Where ulceration results from the improper use of caus- tics the process may be much prolonged and phimosis with distinct narrowing of the prseputial orifice may result. Treatment. — Caustics should never be used in the treatment of herpes of the genital organs. Grave ulceration is liable to result and the more important factor of accurate diagnosis is almost sure to be clouded. The simplest antiseptic washes with absolute cleanliness are sufficient. Immersing ■ the parts, where possible, in a warm solution of boric acid, or bathing them with the same twice a day and dusting afterward with europhen or aristol, is all that is needed. Weak solutions of bichloride of mer- cury, zinc sulphate, or potassium per- manganate, may be used. Duhring speaks highly of the following for- mula: — ^ Zinci sulphatis, 9i-3j. Potass, sulphide, 91-3]. Spt. vini reetifieatus, 3j. Aquffi, f3vij. M. Sig.: Shake and apply frequently and freely. All sources of irritation should be re- moved. Borated cotton makes a good covering. For herpes puderidalis, an ointment of 30 grains of tannic acid to the ounce of cold cream used, the mixture to be ap- plied frequently during the day. Many cases seem to be of malarial origin and are benefited by quinine and Fowler's solution. Carstens (Phys. and Surg., Oct., '95). Literature of '96-'97-'98. The treatment of herpes is simple. Scratching must be avoided; absolute cleanliness and avoidance of all irrita- tion are imperatively demanded. In the beginning a little lint covered with vaselin is sufficient for genital herpes. Later on, talcum powder or bismuth subnitrate is useful. All measures fail during the acme of vulvar herpes. Cold cream and starch poultices quiet the pain. After the subsidence of this period, baths and inert powders are use- ful. Buccal herpes calls for nothing but emollient gargles. Fournier (Revue In- ternat. de Med. et Chir., June 25, '96) . In dressing the penis no bandage should be used. It interferes with the return-circulation and is liable to induce phimosis. Arsenic may be tried as a prophylactic, and cold sponging of the HERPES ZOSTER. SYMPTOMS. 455 body should be practiced daily. In per- sistent cases the use of the faradie cur- rent daily over the spine may be tried. In patients with a long foreskin cir- cumcision skould be advised. William Francis Eobinson, Chicago. HERPES ZOSTER (SHINGLES; ZONA). Definition. — Herpes zoster is an acute inflammatory disease of the skin, appear- ing in the course of certain cutaneous nerves, accompaiiied by severe nerve- pain, usually unilateral in the distribu- tion of its lesions and characterized by the occurrence of groups of firm, tense, globoid vesicles rising from an cedem- atous base. Symptoms. — The outbreak of the eruption is nearly always preceded by a severe nerve-pain in the neighborhood of the area about to be attacked. Occasion- ally it occurs at a considerable distance from the part. The onset of the pain is usually sudden. The patient retires at night in apparent good health and after resting well for a number of hours is suddenly awakened by a "stitch in the side." Or after a hearty meal he lies down for an after-dinner nap and rises at the end of the period with a feeling of general discomfort, quickly followed by fierce stabbing sensations in a given lo- cality. The pain is generally sharp and lancinating, but it may be dull, heavy, and boring. It is nearly always of suffi- cient severity to interfere with the pa- tient's usual vocations and may become almost intolerable. The rest at night is often broken and the patient then grows pallid from loss of sleep. There is usually no fever or preceding rigor. Sometimes there is slight chilliness, and there may have been malaise and gradu- ally growing indisposition for a number of days preceding the onset of the at- tack. In some rare instances the outbreak is not accompanied by any feelings of distress. This is more apt to be the case in children than in adults. The appetite for the most part remains good; but, owing to the insufferable nature of the pain, nausea and even anorexia may at times be incited. The functions of the different organs are, in general, conducted with their ordinary regularity. The attack of pain may make its ap- pearance days and even weeks before the eruption shows itself, l)ut usually the vesicles follow in the course of a few hours. A reddened or bluish-red patch of the size of a half-dollar silver piece or larger is first exhibited. This area rises to the height of two or three lines, is sharply defined, and is exceedingly ten- der to the touch. So painful is it that often the friction of the clothing can scarcely be borne. The discoloration deepens and there is a sensation of heat or burning in the patches. In a very short time the vesicles appear. The vesicles in herpes zoster when fully formed are unlike those seen in any other disease of the skin. They rise from the surface of the oedematous patch freely and distinctly, often having the appearance of being stuck on instead of forming an integral part of the tissues. They are tense, clear, and glistening, are oval or circular in outline, are al- ways in groups, and the roof-wall in each is so firm that they do not ordinarily rupture unless subjected to mechanical violence. At the outset the vesicles are filled with clear, translucent serum. This, in the course of a few days, grows cloudy in color and later becomes purulent. Haemorrhage sometimes discolors the 456 HERPES ZOSTEK. SYMPTOMS. contents of the lesions. The number of vesicles in each gronp varies from three or four to one or even two dozen. They are usually from a split pea to that of a coffee-bean in size, but occasionally when very numerous are not larger than a mustard-seed. When small the lesions are much more likely to break down. In most cases from three to a half dozen groups may be found, but this number may be less or it may be greatly in- creased. The clusters are generally found following the course of a certain cutaneous nerve; but, because of the overlapping of the filaments from differ- ent trunks, it is frequently difficult to determine the particular branch which is affected. The distribution is nearly always unilateral, but whe^e the disease is severe the limits of demarkation are not sharply drawn at the median line, and the disorder may trespass upon it to a marked extent. This is due to the extension of nerve-filaments from one side of the body to the other. Attention called to the great infre- quency with which herpes zoster affects two widely-separated regions. Case ob- served of a middle-aged man who pre- sented the lesions of the disease on the left side of the thorax, on the inner as- pect of the left arm, and on the left side of the forehead. Bradshaw (Lancet, Oct. 13, '94). literature of '96-'97-'98. Notwithstanding the common opinion as to the strict delimitation of the vesi- cles of zoster over a, determined nerve- territory, the writer finds in a large number of subjects vesicles disseminated over the entire tegumentary surface. These vesicles resemble those proper to zona, and, if their evolution is studied, it is found that they belong properly to the zoster, and are not pustules of self- inoculation. Jeanselme and Leredde (Gaz. Hebd. de Med. et de Chir., July 28, '98). In so-called double zoster the girdle, or zone, about the body is complete. This form of the disease is exceedingly rare and is very apt to be productive of great distress. The belief, however, in the fatality once accorded it has not been shown to be founded in fact. The pain is the chief symptom of an- noyance complained of. At times there may be more or less of itching and burn- ing sensations, but these are not apt to occasion marked distress. The pain usually persists throughout the course of the eruption and subsides as the ves- icles disappear, but it may endure for an indefinite period after all trace of the skin trouble has vanished. Weeks, months, and even years, with complete shattering of the nervous system, have been recorded of such continuance. Age has a decided influence upon the charac- ter of the pain. In children it is ordi- narily mild, while in the aged it is apt to be extreme in its severity. Case of a child suffering from reflex epileptic convulsions, which supervened upon an eruption of herpes zoster occur- ring in the distribution of the superior superficial branches of the cervical plexus, the left side of the head, neck, shoulder, and upper part of the thorax being affected. With the disappearance of the eruption the convulsions ceased. Byron {N. Y. Med. Jour., Jan. 10, '91). The pain is more decided when the head is attacked than in the regions of the trunk or limbs. In rare instances complete anaesthesia of the part follows or anffisthesia dolorosa may supervene. Motor as well as sensory disturbances exhibited in local paralyses may occur. Case of an old woman who, while suf- fering from a subacute attack of rheuma- atism, developed neuralgia of the right side of the neck and face with an erup- tion of herpes zoster. The eruption fol- lowed the course of the superficial cervi- cal plexus and the facial nerve. After a few days a complete Bell palsy occurred. HERPES ZOSTER. SYMPTO:\IS. 457 In the course of four months, under treatment, the palsy disappeared. H. A. Spencer (Lancet, June 9, '94). Case of herpes zoster with facial paralysis and another with sensory dis- turbances. The writer agrees, with Recklinghausen, that there is a primary Herpes zoster, with facial paralysis. {Eistein.) affection of vasomotor nerves, the vaso- dilators being irritated, and looks on the herpes as an intense angioneurotic dis- turbance which may be associated with disease! of the motor or sensory, spinal or cerebral, nerves. In most eases the disease results from causes acting on the body in general, though trauma and cold may assist. It is possible that infection or autointoxi- cation plays a part. Ebstein (Virchow's Arehiv, B. 139, H. 3, '95). Literature of '96-'97-'98. Typical case of herpes zoster, affecting the entire right side of the neck and face, corresponding with the lower region of the cervical plexus, observed in a man 75 years old. After ten days of acute suffering total paralysis of the right fa- cial nerve suddenly set in. The pain and the paralysis gradually diminished, and finally disappeared after from two to three weeks' treatment by the galvanic current. Olaf Frich (Norsk Mag. f. Lageordenskab., p. 1125, '96). Combination of herpes zoster and facial paralysis very rare. Ebstein was able to collate but eleven eases. The author has found seven others-, and adds the following of his own: a woman, aged 20 years, no nervous disease in family. Trouble began the day after sitting in a draught, with a drawing sen- sation in right side of face, slight tender- ness over right eyebrow, followed by pain radiating from neck to back of head and on right side. On the third day a total right-sided facial paralysis. Four days later a vesicular eruption on the lower half of the right ear and in the auditory canal, on the right half of the tongue, uvula, and palate. The paral- ysis was very marked, with complete reaction of degeneration. The tongue protruded straight; touch and taste un- impaired. Sensation of face intact. No tenderness at points of exit of the fifth and seventh nerves. No cerebral symp- toms. So far as the author knows, Herpes zoster, with facial paralysis. [ETistein.) this is the fourth case in which the paralysis preceded the herpes. The phe- nomena in this case may be explained as follows: The trigeminal branches were involved; the lingual herpes was caused by continuation of the inflammation 458 HERPES ZOSTER. SYMPTOMS. from the facial to the chorda tympani and affected only its trophic fibres. Eiehhorst (Centralb. f. innere Med., No. 18, '97). Loss of hair and teeth and atrophy of the muscles have been noticed (Strii- bing). The disease is usually benign and acute, running its course in from three to six weeks. Literature of '96-'97-'98. Zona may appear under three different conditions: First, toward the end of severe pulmonary tubercle, and it is then of no special interest; but in other cases it is a very early symptom, and may be looked upon as a premonitory sign. Cases cited of patients subject to herpes zoster, but who did not complain of any pulmonary affection. On examination of the lungs, however, early tuberculosis was discovered. In other cases, forming the third group, the signs of pulmonary tubercle may be discovered after a short interval, there being no physical indica- tion at the time of the eruption. Ron- her (Jour, de Med., Apr. 10, '97). Eesolution takes place bv absorption of the vesicular contents or a crust forms which desiccates and is then ex- foliated. Indelible scars are occasionally left at the sites of the vesicles. They have a punched-out appearance, as if a nail- head had been driven sharply into the skin and had left its impress upon it. These scars should never be mistaken for the relics of syphilis. The disease when attacking the region of the eye is aj)t to be unusually severe, and death has been known to follow. The eyesight is frequently endangered. In virulent types of zoster hsemor- rhage into the vesicles may take place, giving them a bluish or blackish appear- ance (zoster hfemorrhagicus). An abor- tive form of zoster, in which the pain appeared in typical manifestation, but without the development of vesicles, has been noticed. Coalescence of the vesicles often takes place. Where the blebs are opened dirty, grayish ulcers are apt to form. These ulcers are decidedly rebellious to treat- ment and invariably leave scars. All of the groups do not usually appear at the same time, but come out one after the other at intervals during the first week or ten days. They enlarge somewhat, but seldom unite. Eegional Zostee. — Herpes zoster may attack any part of the body, but it apparently exhibits a preference for cer- tain sites, and to its appearance in these localities certain names indicatiA^e of the region affected are given. Thus we have zoster capillitii, z. frontalis, etc. When the disease invades two adjoining regions more precise terms, such as zoster cervi- co-brachialis, z. intercosto-humeralis, and so on, are used. The general features of each are the same, but, owing to ana- tomical differences, some characteristics need special description. Zoster is not infrequently found at- tacking the various regions of the head. In the scalp (z. capillitii) the lesions are apt to be the seat of severe biuning sen- sations, the occipital region being most often the part affected. Over the fore- head (z. frontalis) disfiguring sears are likely to result. The branch of the supra-orbital nerve that passes upward is here the one that is usually involved. The ear (z. auricularis) is spmetimes at- tacked, and the cheeks, side of the nose, and chin are not vinusual sites. The dis- ease may appear in the mouth-cavity (z. biTCcalis), upon the inner wall of the cheek, and the gums. Zoster exhibits its greatest severity when the ej'e (z. ophthalmicus) is attacked. The first branch of the fifth nerve is then affected. The nasal filament of the same nerve is often implicated and the eruption ex- tends downward upon the nose and HERPES ZOSTER. SYMPTOMS. 459 cheek. The pain is severe. The con- junctiya is reddened and swelled, the cornea is inflamed, and iritis may follow, with marked disturbance of vision and oedema of the neighboring parts. In its severer forms disintegration of the eye- ball with loss of sight occurs and a re- siilting meningitis may lead to a fatal issue. Sympathetic involvement of the other eye may take place. While we must regard zoster of this region as a grave affection liable always to destroy the eye^ght and endanger life, yet instances are on record in which the attack, though serious, resulted most favorably. Case of bilateral zoster ophthalmicus occurring in a patient suflfering with chronic pneumonia and diffuse inter- stitial nephritis. The case was anom- alous in that the attack came on with- out pain and exhibited a variety of lesions. The eruption consisted of pus- tules, vesicles, and bullae occurring at the same time. By the end of the third day these lesions had broken down com- pletely, forming freely-diseharging ul- cers. The greater part of the face-region was affected. The disease ran its course in three weeks and ended in complete recovery. Robertson (London Lancet, July 7, '88). Zoster is more frequently encountered on the surface of the thorax (z. pector- alis) and the neighboring abdominal (z. abdominalis) parts than elsewhere on the body. The 'right side is more often affected than the left. In the thoracic region the intercostal nerves are at- tacked. The pain is marked and when occurring before the eruption appears is apt to be mistaken for pleurisy. The presence of fever is needed to establish the latter affection. In zoster of the thorax considerable interference wdth breathing is liable to be experienced, owing to the pain occasioned by move- ments of the chest-wall. Duhring notes that the pain here may simulate the dis- tress occasioned in angina pectoris. Be- cause of the peculiar distribution of the diseased areas in these parts in the form of a belt or girdle has arisen the com- mon designations of zoster as zona or cingulum. It is not unusual for the dis- ease to be preceded in this situation for some time before its eruption by its char- acteristic pain. The nerves affected in abdominal zoster come from the dorsal and lumbar portions of the cord. Two cases of thoracic herpes zoster in which a diffuse radialgia was observed. This is a painful sensation in the spinal region, both spontaneous and increased by pressure. It is localized along the chain of the spinal apophyses and a little on each side of these, and extended from the third dorsal to the second lumbar vertebra in the cases observed. In some eases zoster is a dermato-neurosis indica- tive of disturbances of nutrition of the nerve-elements in course of the evolution of an infectious malady. TerrS (Edin- burgh Med. Jour., Sept., '90). Herpes zoster braehialis involves the shoulder and upper arm to the elbow. It may extend down the forearm, and even as far as the finger-tips, attacking the palmar surface of the hand; but this is rare. The flexor surface of the arm is more often selected than is the ex- tensor. Case of herpes zoster occurring on the back of the thumb and on the skin cov- ering the earpo-metacarpal joint of the right hand, accompanied by hyperaes- thesia, pain, and paresis of the arm, oc- curring during an attack of measles. The symptoms were referred to the radial and circumflex nerves. Adenot (Revue de M6d., July, '91). In zoster femoralis the disease spreads over the buttock, thigh, and down the leg. It usually does not go below the knee and the feet are as seldom attacked as are the hands. Case of universal zoster. The sub- ject was a man, 30 years of age, who had suffered from two severe attacks of 460 HERPES ZOSTEE. DIAGNOSIS. ETIOLOGY. malaria. The first occurred at tlie age of twenty-seven and lasted for a number of months. At thirty he was afTected a second time with the disease. This was accompanied by severe neuralgic pain and burning sensations. Within a few days from the beginning of the fever the zoster appeared and was universal in its distribution. Even the conjunctiva and the mouth, nose, and anal cavities were invaded. Colombini (Commentaris Clinico delle Mai. Cut. e Genito-Urin., '93). ZosTEE Attpicus Gange^xosus ET Hysxeeicus. — Kaposi noted a peculiar form of recurring herpes in a number of cases reported by him to which he gave this name. Three of the subjects were women and one was a man. In all dis- tinct symptoms of hysteria were present. In each case the eruption consisted of vesicles and papules gathered in groups.- A central crust formed in each vesicle and aboiit it there developed a number of tiny pustules. A number of the lesions coalesced, and gangrene of the part followed. After separation of the slough and healing by granulation had taken place, keloid formed in many of the cicatrices. The period of develop- ment lasted for about eight days, when subsidence began to take place. Both sides of the body were afEected and in all but one case a number of recurrences took place. Diagnosis. — The recognition of herpes zoster does not usually present any great difficulty. The severity and peculiar character of the pain, the grouping of the large, firm vesicles upon an erythem- atous base, the lesions running their course without rupturing, and the com- mon limitation of the trouble to one side of the body and in the line of some cutaneous nerve are the distinctive feat- ures that differentiate the disease. At times heepes simplex assumes some of the severer features of zoster, or the zoster may be so mild that its mani- festations partake of the benign nature of the simple disease, in either of which cases some difficulty may be experienced in determining the true nature of the disorder. This, however, is but a matter of little moment so far as treatment or prognosis is concerned. It but empha- sizes the close relationship of the two affections. Eetsipelas begins with a marked rise in temperature, the area affected in- creases gradually by peripheral exten- sion, there is seldom any formation of vesicles, and the peculiar bluish hue of the disease is never seen in zoster. With eczema zoster need never be con- founded. The vesicles are wholly unlike. Those of eczema are small, thickly and irregularly scattered over the surface, and they rupture readily, while a con- tinuous flow of serum iollows their dis- solution. Three laws given by which to recog- nize skin diseases owning an origin in some disorder of the nervous system: 1. The disease will not occur in round patches, nor in oval ones, nor in streaks, but will be arranged according to the branching distribution of the filaments themselves; it will be panniculate or corymbiform. 2. There will be no power of infecting adjacent structures; the patches will not be serpiginous. 3. The diseases develop themselves fully in the first instance; the resul|s, when once declared, do not Increase. From the fact that when herpes zoster, if it occur a second time in a patient, never aflfects exactly the same area, the conclusion is drawn that the nerve is disorganized by the kind of neuritis which produces the original attack of zoster, and so is in- capable of being involved a second time. Hutchinson (Illus. Med. News, Jan. 26, '89). Etiology. — The surface-lesions in her- pes zoster are produced by an inflamma- tion of the nerves supplying the parts. This neuritis may occur at any point in HERPES ZOSTER. ETIOLOGY. 461 the track of the nerve, in the ganglion through which the nerve passes, or in the central nervous system. The skin- manifestations, while of the greatest in- terest, are entirely secondary to the nerve-disturbances. They are the super- ficial indications of serious trouble deep within the body. Tuberculosis is a predisposing factor to herpes zoster. It may lead to herpes directly by implication of the intercostal nerves adjoining the diseased pleura, but, as a rule, there is some added de- termining cause, as intoxication by lead, alcohol, or uraemia, or some infection, as in one of the writer's cases in which the immediate cause was influenza. Huchard (Union M6d., No. 42, '94). Several cases in which an eruption of herpes zoster has followed some cause producing mental emotion or anger. Roche (Lancet, Oct. 13, '94). Literature of '56-'97-'98. Case of a woman, aged 25, from whom six teeth were extracted under gas. Six days afterward a marked herpes zoster appeared in the right axillary region and over the right mamma. George Fernet (Brit. Med. Jour., Jan. 30, '97). The list of causes known to be oper- able in the production of the disease is a long one. These different agents vary greatly in their nature, but their action is alike in that the irritation of each, operating upon the nerve, is sufficient to induce a true inflammation of its sub- stance. Climatic influences are most promi- nent. Epidemic herpes zostet considered an infectious neuropathy, prevailing epider- mically under the influence of climatic conditions not as yet understood. Weiss (Archiv f. Derm. u. Syph., H. 4, 5, '90). Sudden changes of temperature, ex- posure of the body when warm to a draft of cold air, a cold plunge into the water, lying out on the damp grass at night; getting overheated in close, hot cars, theatres, ball-rooms, or elsewhere, and then going suddenly into the cold, outer air; in short, any change whereby the surface-temperature of the body is rapidly lowered is capable of producing the disease. Next in order are injuries of the body. These may be slight or severe. Blows upon the head or over the spine, sur- gical operation, the prick of a thorn (Janin), the opening of an abscess, gun- shot wounds, or the pulling of a tooth have been followed by the disorder. Poisoning with sewer-gas will produce the disease. The use of the faradic or galvanic current may induce it. The in- ternal administration of arsenic (Neil- sen) is a well-known factor in its produc- tion. It has followed the ingestion of a large dose of Cayenne pepper (H. W. Blanc). Mental exhaustion, overwork, worry and sudden exertion may give rise to the malady. Undoubted instances of infection have occurred. One of the most remarkable was recorded by Walther and quoted by Duhring. [This case, given in "Text-book of Cutaneous Medicine," vol. ii, p. 485, de- serves further mention. A student was attacked by herpes zoster. He was re- moved from his room, which shortly afterward was occupied by another per- son. This person in a few days' time was taken with the same disorder. He, too, was transferred and the room leased to a third occupant, like the first, a stu- dent, who straightway developed a case of zoster. Numerous epidemics have been observed, the most notable among which are those recorded by Kaposi in Vienna in 1888, and by Weiss at Prague. The latter observer noted fifteen cases in less than two months. The nature of the epidemic, coupled with the season at which it occurred, led Weiss to regard the infectious agent as one peculiarly dependent upon climatic influences: a 46-2 HERPES ZOSTER. PATHOLOGY. supposition that coincides with our general knowledge of the disorder. William Feancis Robinson.] Nerve-lesion in herpes zoster is prob- ably due to some micro-organism. The disease considered infectious, like croup- ous pneumonia. Kaposi (Wiener med. Woch., Nos. 25, 26, '89). The disease may occur at any age and in either sex. It is most frequent in early spring or late autumn: seasons when marked changes in temperature are liable to take place. Zoster occurs in about 2 per cent, of the cutaneous diseases of children. It is most common between 4 and 6. Lee (Med. Press and Circular, June 27, '88). Herpes zoster is rare among children. Most children suffering from herpes zos- ter show digestive troubles. After the tenth year children suffering from zoster seem to be liable to neuralgic pains. The treatment is local and protective. Droixhe (Jour. d'Accouche., Nov. 30, '89). In a series of 235 cases of herpes zoster 45 per cent, were males; most cases oc- curred between the ages of 10 and 15. The greater proportion of cases occurred in the spring months. In most cases the sensitive fibres of the nerves alone were affected, but 2 cases of marked facial paralysis came under notice accompany- ing herpes zoster of the face or head. Herpes zoster cannot be shortened in duration or the eruption aborted. Irri- tation should be avoided and the vesicles should not be broken. Greenough (N. Y. Med. Jour., Oct. 19, '89). Pathology. — Barensprung demon- strated that the disease was primarily one of the ganglionic system, and this has been confirmed by numerous other investigators. Wyss examined a case dead of zoster facialis, and found the' ganglion of Gasser enlarged, soft, and deeply injected. The nerve between the brain and ganglion was surrounded by extravasated blood. It w-as healthy at its origin. The peripheral filaments were infiltrated with soft tissue. In a case in which the first branch of the trigeminus and the naso-ciliary branch were the nerves attacked found, at the necropsy, the interstitial tissue of the Gasserian ganglion infiltrated with inflammatory products and the ganglion- cells destroyed. The ciliary nerves were likewise found affected. Daniellsen found the intercostal nerve reddened and thickened and the neurilemma markedly infiltrated in a case of zoster of the trunk. Later studies have confirmed the state- ments of these older observers, but they have also added much to our knowledge. We now know that the ganglion is not alone the part that is first attacked, but that the inflammation may arise at any point in the continuity of the nerve- trunk in its peripheral termination, in the spinal cord, or within the brain. When the brain or spinal cord is the seat of the trouble, bilateral zoster is apt to follow. This is rare. In the case of zoster following blows' and injuries to the skin only the terminations of the nerves appear to be affected. The skin-lesions of zoster have re- ceived much attention. Biesiadecki and Haight were the flrst who made a careful study of the vesicle. They found that it began in the deeper layers of the rete and that the exudation forcing its way upward separated the rete-cells, forming elongated bands or threads. After reaching the horny layer the fluid — no longer able to make its way between the cells — lifted the epidermal layer bodily, thus forming the roof-wall. Eobinson's investigations led him to the discovery of a perineuritis of the cutaneous nerves exhibiting a small- celled infiltration of the neurilemma. Unna found that the vesicles in her- pes zoster had a structure distinctively their own, due to a peculiar form of HERPES ZOSTER. PATHOLOGY. PROGNOSIS. 463 epithelial degeneration to which he ap- plied the term "ballooning." In the proc- ess of colliqiiation that here takes place the cells increase greatly in size, becom- ing, in many instances, hollow spheres, and in others with one side drawn out, suggestive of a balloon. Other unique and Yarions forms are assumed. The protoplasmic contents are converted into a fibrinous opaque mass, the nucleus is divided into a number of daughter- bodies that do not wholly lose their nuclear character, and the prickles are lost, thus severing the union of the cells the one with the other. In this disor- ganized condition the cells separate and accumulate in the hollow of the vesicle. From the roof-wall of the lesion are seen hanging a number of compressed, cord-like, epithelial cells, forming a spe- cies of partition, thus dividing the cavity apparently into a series of compart- ments. But because of the indifferent connection possible in cells undergoing this form of degeneration there is no real division of the vesicle. The vesicle- contents, in addition to the degenerated epithelium and giant cells, consists of coagulated fibrin. Into the base of the vesicle can usually be seen projecting the denuded summits of the papillae. The , vesicle is situated well within the epithelial tissues. When the acme of vesicle-formation is reached marked emigration of leucocytes from, the neighboring vessels into the papillary body and the vesicle takes place. It seems, however, never suffi- cient to fill the cavity of the blister, crusting and desiccation taking place be- fore this condition is reached. What appears peculiarly striking is the relatively unimportant changes that take place in the epidermis around and beneath the vesicles. The blood-vessels and lymph-spaces are dilated for but a few lines only. The sweat-glands are not affected. The hair-follicles share in the process inasmuch as the prickle-cell layer dips downward toward their base. The cutis is affected in a slight degree only and that mainly in the infiltration of a few leucocytes. Pfeiifer was the first to call attention to some peculiar bodies in the vesicles of herpes zoster. [Pfeiffer (Jlonat. f. Prakt. Derm., p. 589, '87) regarded these bodies as organ- isms belonging to the protozoa and the probable cause of the disease. Hartzell (Jour. Cut. and Genito-Urin. Dis., Sept., '94) examined these same structure? carefully and came to the conclusion that they were not protozoa, but the prod- ucts of cell-degeneration, and had noth- ing to do with the origin of the disorder. T. C. Gilchrist (Johns Hopkins Hosp. Reports, vol. i, '96) made an exhaustive study of the subject, examining, in all, twenty cases. He found the bodies in sections of tissue taken from the skin in the erythematous stage of the disease as well as in the vesicles. In no case could he discover amoeboid movement. He describes them as bodies having a well-defined outline with granular eon- tents. They were found singly and in groups. In the vesicles they were gathered at the sides and bottom. Some large groups were found wliere no ves- icle-formation could be detected. The author thinks that the bodies are the nuclei of epithelial cells or eleidin gran- ules similar to those found in the mucous layer. William Fbancjs Robinson.] Prognosis. — Herpes zoster runs its course usually in from three to six weeks. Abortive types may end in ten days or less, while the severer forms may be much prolonged. The disease is rarely fatal, save when the ophthalmic region is attacked. A lethal issue is then pos- sible, and the eye may be sacrificed even if life be spared. Scarring is a not in- frequent sequel of zoster if the vesicles be broken. The cicatrices are gathered in clusters -typical of the grouping of 464 HERPES ZOSTER. TREATMENT. the disease, and each has an angular out- line with precipitous edges that gives to it a distinct and unmistakable individu- ality. Long continuance of the neural- gia may vex and weaken the nervous system until the subject becomes a com- plete physical and mental wreck. Such cases are, however, exceptional. Double or bilateral zoster is rare. We can ex- plain its occurrence upon the assump- tion of a neuritis within the central nerv- our system, or, at least, beginning there. Its increased severity is, no doubt, due to the greater involvement of nerve- trunks, but the gravity that once was supposed to attach to the trouble has been disproved. Herpes zoster recurs so seldom that one attack is believed to render the pa- tient immune. Treatment. — Herpes zoster is a self- limited disease, rarely endangering life and seldom recurring. Its treatment is, therefore, simple. The most urgent in- dication with which we have to contend is relief of the pain. This is sometimes nearly unbearable. The character of the distress is likened often by the patient to that of a red-hot iron drilling into the flesh. Sleep then is impossible, and the restlessness is extreme. The subject affected should be put to bed and absolute quiet enjoined. Free- dom from worry and care, coupled with complete physical relaxation, is essential to the best results to be obtained from treatment. The bowels should be moved freely. For this purpose a mild dose of calomel given at bed-time, followed by a brisk saline cathartic in the morning, answers well. To keep the bowels open a glass of warm Hunyadi water, or a Sedlitz powder may be given each day before breakfast. The diet should be light and easily digestible. Milk freely if the patient can tolerate it, broths, soups, soft-boiled eggs, oysters in season, fish, and chicken should constitute the list from which the articles of food for the patient's need may be selected. These patients often have very good appetites, and care should be exercised in not allowing overindul- gence, such a course usually being fol- lowed by marked aggravation of the pain. Internal medication has not as yet shown itself capable of shortening the course of the disease. But there are a number of drugs that markedly affect the pain and malfe the patient's condi- tion bearable. Chief among these is zinc phosphide. This may be given in doses of ^/eto V3 grain in tablet form every two or three hours until the pain is under control, when the dose may be reduced. It is sometimes more effectual when combined with the extract of nux vomica, Vg to V4 grain of the latter drug being used. Sodium salicylate and salicin in 10-grain doses every four hours, especially if there be any rheumatic taint, are often productive of much good. Antipyrine, phenacetin, and other drugs of the series relieve the pain, and it is thought have even shortened the course of the disease (Jennings). Arsenic is often used, but we should not forget that it is capable of producing the affection, and therefore likely to aggravate, instead of benefiting, the disorder. When em- ployed it should be used in full doses, V20 grain of arsenous acid in tablet form, or combined in a capsule with a small amount of iron, being given four times a day. Or 3 to 5 minims of Fowler's solu- tion in water after taking food may be used. Quinine in full doses is serviceable when malarial poisoning is the basis of the trouble. Camphor in small doses often repeated has been found to give the patient comfort. HERPES ZOSTER. TREATMENT. 4G5 Case of herpes zoster of unusual dis- tribution, occupying the auricular, lower maxillary, and cervical regions. The pain was very severe. Opiates had been used without relief. Camphor given in- ternally in 5-minim doses of spirit of camphor on sugar three times a day. There was a remarkable improvement almost immediately. Drinkwater {Brit. Med. Jour., Apr. 13, '95). If there be much nervousness, the bromides of sodium and potassium may be needed, but it is best to do without these drugs if possible. Tincture of aconite in drop-doses at intervals of two hours has proved serviceable. Sodium hyposulphite in 5-grain doses every three hours does good. It will be seen that the list of drugs employed is a long one, which being rightly interpreted means that no one of them is infallible, but that all will fail at times to produce the results expected. If we cannot control the pain by drugs given by the mouth we may resort to hypodermic injections. Ten minims of chloroform will usually be sufficient to check the pain. Cocaine may also be used, but it is best to avoid this drug, owing to the danger of inaugurating the habit. Morphine siilphate given sub- cutaneous in from ^7^- to ^/j-grain doses will always control the pain. It is well to combine this drug with the sulphate of atropine, using ^/loo to ^/^^ grain of the latter. External treatment should not be neglected. The vesicles should be pre- served intact if possible. Opening them will not shorten the course of the dis- ease or mitigate the distress in any par- ticular, and it nearly always results in the production of an obstinate ulcer that leaves an ugly scar. No picking or rub- bing of the lesions should be permitted, and all sources of irritation — such as harsh woolen underclothing — should be removed. Dressings that protect the lesions from the air should be employed. One of the best applications that can be used is alcohol. [This was well demonstrated by De- loir (Brit. Jour, of Derm., vol. iii, p. 269), and Duhring has called especial at- tention to it in his recent edition of "Cutaneous Medicine." William Fean- cis Robinson.] It should be used in full strength, 94 per cent., and at frequent intervals. Compresses of cotton or soft-linen stuff should be saturated with the alcohol and bound over the parts. To prevent evap- oration, these should be covered with some impermeable material, such as oil- silk or gutta-percha. This gives prompt relief to the burning and local distress, and affords the patient much comfort. Ointments and pastes can often be used to advantage. Lassar's paste (see Heetes Simplex) is useful. "When properly made it furnishes a good pro- tective dressing. It should be thickly applied and then thoroughly dusted over with a simple powder, such as talc or corn-starch. Anodyne remedies — such as opium, belladonna, or cocaine- may be added to it if needed. It is capable of relieving the cutaneous symp- toms, and under it the lesions dry up and heal without rupturing. Simple ointments may relieve the itching and burning, but their softening influence upon the epidermis renders the rupture of the vesicle more probable. Lime-water, black-wash, carron-oil, and lead-water washes may be found use- ful. They should be applied freely, the surface being kept constantly moist with gauze saturated with the agent chosen. Lotions of carbolic acid and camphor, ^/ 4, to ^A drachm of each to the ounce of alcohol, are valuable. The following substances in alcoholic or aqueous solu- tion are often found useful: Tannin, 30 to 60 grains to the ounce; menthol, 5 466 HERPES ZOSTER. TREATMENT. to 15 grains to the ounce; benzoin tinct- ure, 30 minims to tlie oiTnce; resorcin, 5 to 15 grains to the ounce. These should be applied freely to the affected parts and allowed to dry, after which a dusting-powder may be used with ad- vantage. Such may be made of zinc oxide, starch, boric acid, lycopodium, or talc. Anderson's dusting-powder — which is compounded of camphor, zinc oxide, and starch — is especially useful. Liquid thiol diluted with an equal part of water, or with twice the amount of ether, applied in herpes zoster with beneficial result. Stepp (Munch, med. Woch., Jan. 6, '91). In herpes zoster local sedatives to' the vesicles recommended when the case is typical. Thick bandage is applied over a dusting-powder composed of amylum, or amylum and opium, to reduce pain and keep the part dry; a layer of wad- ding is placed over these. In zoster haemorrhagica, or where the vesicles are elosely set, the affected parts must be carefully protected lest they be torn. With this object in view the fol- lowing ointments were prescribed: — B Boric acid, 75 grains. Glycerin, q. s. to make a solution. IJ Simple ointment, 5 ounces. Cocaine or extract of opium, 22 grains. In cases in which neuralgia is a com- plication Fowler's solution is invaluable. Kaposi (Med. Press and Circular, Jan. 16, '95). In herpes zoster treatment should al- ways be begun by the administration of a saline purge, preferably sulphate of soda. In dealing with the eruption the effected part must be kept absolutely di-y; the painful region should be covered with a layer of cotton-wool, sprinkled with the following powder: — B Starch-powder, 2 ounces. Oxide of zinc, 4 to 5 drachms. Powdered camphor, 15 to 45 grains. Crude opium powdered, 15 grains. For the neuralgia the following pills are given: — 1} Extract of stramonium. Extract of hyoscyamus, of each, %„ grain. Extract of belladonna, 'Aj grain. To make one pill. Four of these to be taken daily. If these pills do not relieve the pain, antipyrine must be given internally. A. Robin (Bull, de Th6r., Oct. 30, '95). Literature of '96-'97-'98. A dusting-powder composed of equal parts of subgallate of bismuth and talc is a useful application in herpes zoster; where this does not prove effective, an ointment containing 1 part of subnitrate of bismuth to 3 parts of cold cream will relieve the burning. For the neu- ralgia which so often accompanies or fol- lows it, quinine in large doses given two or three times a day, continued to the point of tolerance, is the best remedy. Careful nursing and management are important adjuncts to the treatment. Weber (N. Y. Med. Rec, July 9, '98). Where tenderness can be detected over the exit or in the course of a spinal nerve the wet cup may be tried. Not more than 1 ounce of blood should be abstracted. Or a blister may be applied. For this purpose cantharidal collodion answers an admirable purpose, and fre- quently gives marked relief. Paquelin cautery at a red heat used in the treatment of the neuralgia of zos- ter, cauterizing the skin over the origin of the nerves superficially, but not enough to produce scarring. Elliot (Jour, of Cut. and Genito-Urin. Dis., Sept., '88). Literature of '96-'97-'98. In nearly all cases of herpes zoster a tender spot may be found higher up over the nerve- trunk. At this point the ap- plication of a counter-irritant in the form usually of flying-blisters or tur- pentine recommended. Theodore Wil- kins (Med. Rec, Sept. 26, '96). Duhring speaks very highly of the use of the constant current in the treatment HIP-JOINT DISEASE. SYMPTOMS. 467 of zoster. Its iise wherever possible is to be commended. From five to ten cells of the ordinary zinc carbon battery should be used. The negative pole should be placed over the seat of the eruption and the positive grasped in the patient's hand; or, better still, be passed up and down the spinal column. The be- lief exists that if used early enough it will abort or greatly shorten the course of the disease. Certain it is that it will greatly subdue and soften the pains of the disorder. It is of the greatest value in the lingering pains that remain after the zoster has subsided. In such cases the current should be used two or three times daily, fifteen minutes being given to each application. WiLLiAii Francis Robinson, Chicago. HIP-JOINT DISEASE. Definition. — What is usually known as 'Tiip-joint disease" is a tuberculosis of the hip-joint; but tuberculosis, by no means, includes all the diseases which may affect the hip. The hip may be affected by tuberculosis, by syphilis, by rheumatism, and by a variety of acute infectious processes subsequent to the occurrence of some acute infectious dis- ease in other parts of the body, or may be the seat of a simple synovitis caused solely by trauma. A synovitis of the hip is usually associated with ostitis, but a synovitis may exist independent of ostitis and subside without the occurrence of any involvement of the bones. The hip-joint is also the seat of arthri- tis deformans and Charcot's disease, though the latter is rare; and occasion- ally loose bodies are found in it. Malig- nant tumors also may affect the hip. Functional affections of the joint are usually traumatic neuroses, but may be considered here. Symptoms. — The symptoms of inflam- mation in the hip vary somewhat, accord- ing to the character of the inflammation present. If the hip is the seat of an acute synovitis, pain will be felt in the hip itself, which will be intensified by movement of the joint or by pressure over the neck of the femur at a point between the great trochanter and the crest of the ilium. The position of the limb is very characteristic. The thigh is flexed upon the abdomen, abducted, the toes everted, and the entire limb rotated outward. This position allows the cap- sule to contain the largest amount of fluid, and, in consequence, is the position of ease which the joint naturally assumes when overdistended. In cases of this sort, also, there is usually a distinct his- tory of a traumatism immediately pre- ceding the occurrence of pain. These cases are also extremely sensitive to any sort of motion. In standing the patient bears all the weight of the body upon the sound side, and in consequence of the position of the affected thigh, the gluteo- femoral crease on this side is much less distinctly marked than on the well but- tock. In cases where the joint is the seat of an acute infection, following measles, scarlet-fever, or the like, the same train of symptoms will be present, though the progress of the disease will be much more rapid, while, combined with the local symptoms, will be found those of general systemic infection, and under these cir- cumstances disintegration of the joint may progress with remarkable activity. In syphilis of the hip, on the contrary, the disease may have been present for months without the occurrence of pain sufficient to attract the parents' atten- tion. It is only when a marked limp be- comes noticeable that medical advice is sought, and in some of these cases when marked deformity is present and joint- 468 HIP-JOINT DISEASE. SYMPTOMS. spasm is very pronounced, manipulation seems to give rise to but trifling incon- venience, and the parents at times are loath to believe that serious trouble ex- ists, because the child complains so very little. Fibrous ankylosis of the left hip-joint fol- lowing typhoid fever, relieved by brisement ford. In tuberciilosis of the hip the pain at the outset is not apt to be marked; but, should an abscess form in the femur or the disease progress until the cartilage becomes involved, the pain becomes most exquisite, children often crying severely from the jar occasioned by a person walk- ing on the floor, and so shaking the bed. In some of these cases there is a dis- tinct history of traumatism, and in others it seems impossible to find precisely when the disease began. Many of the cases which come to the surgeon with the history that the first symptoms were noted by the parents a few days previous, being evidently of very long standing. The inattention of the parents to the trifling limp which the child exhibits, and the fact that it did not at first com- plain of pain sufficiently to attract their attention, being responsible for this. Quite frequently these children complain of being stiff on rising in the morning, and exhibit a decided limp, but after having been at play for some hours they run in almost a natural manner, and so little is thought of it. In some cases this limp gets better and may almost disap- pear for a number of weeks, occasionally a couple of months, then reappear in a still more aggravated form, to subside once more, and again reappear. It is un- usual, however, for cases to pursue this course, and the majority grow progress- ively worse, and do not, unless treated, exhibit these periods of freedom from symptoms. Literature of '96-'97-'98. In hip-joint disease the first symptom in the majority of eases is a limp, and this is generally worse in the morning. It frequently disappears for a time, and then returns. The next most frequent symptom is pain, which may be either at the hip or the knee. By carefully con- trasting the motions of the two hip-joints it is not difficult to detect the restriction of the motions in the affected joint. In examination all rough handling of the joint, and particularly pounding on the heel, or similar methods of trying the eflfect of concussion on the joint depre- HIP-JOINT DISEASE. SYMPTOMS. 469 cated. De Eoy W. Hubbard (Pediatrics, Jan. 15, '96). The obturator nerve sends a little fila- ment to the inner side of the knee-joint as well as to the hip-joint, and to this fact is due the characteristic pain in the knee which usiially accompanies disease in the hip- joint, and which, in the great majority of cases, antedates the occur- rence of pain in the joint itself. The obturator nerve often joins the long saphenous, which accounts for the fact that pain in the big toe is very frequently noted before pain in the knee, which, however, seems to have escaped the atten- tion of a good many writers on this sub- ject. Quite frequently children will be brought for observation because they limp and because they have complained of pain in the big toe, which the mother had supposed was due to some defect of the shoe or stocking or an ingrowing nail. Examination in these cases will fre- quently reveal the presence of hip-joint disease. One of the first things which is present in inflammation of any joint is spasm of the muscles controlling the motions of that joint. In hip disease efforts have been made to draw inferences, on ac- count of the preponderance of spasm in a particular group of muscles, as to the location of the disease in the joint, but so farwithout having put us in a position to diagnosticate with exactness the loca- tion of the focus of inflammation from the presence of spasm in certain groups of muscles. Not infrequently there may be noted, in addition to the spasm of the muscles immediately controlling the joint, spasm of the calf -muscles, although attention has very seldom been drawn to this fact. It often will be seen quite pronounced in the early stages of the disease, when deformity is very slight and limitation of movement in the hip- joint but slightly marked. It will usu- ally be found in those cases where pain in the great toe has been noted instead of pain in the knee. Hand in hand with muscular spasm comes atrophy of the muscles afliected by the spasm, and this atrophy shows itself too promptly to be attributed wholly to disuse, and seems to be dependent on impaired nutrition. It is one of the earliest and most important signs in con- nection with joint spasm in the diagnosis of incipient and doubtful cases, being of vastly more importance than the occur- rence of pain; but usually it is not present until the disease has been in existence for some time. The position assumed by patients with disease in the hip-joint varies according to the progress which the disease has made. At the outset the almost invari- able rule is that the patient bears the weight of the body upon the sound leg, the toes of the affected side being turned slightly outward, the thigh being flexed, the leg everted and slightly abducted; the buttock on this side is decidedly flat- tened, and the gluteo-femoral crease lower down and more or less obliterated. On account of the abduction of the leg it seems longer than its fellow, but if accurate measurements be taken, with the limbs in the same relative position to the median line, this will be found to be an apparent, and not an actual, length- ening. As the disease advances this dis- tortion becomes more and more marked, until the thigh may be flexed almost to the point of striking the chest, and the leg everted and abducted to the limit of possible motion. If the capsule has been greatly distended with fluid, it may spon- taneously rupture, or some sudden move- ment may rupture it, and the leg may pass in a very short time from the posi- tion of extreme abduction and external 470 HIP-JOINT DISEASE. SYMPTOMS. rotation, to one of adduction and internal rotation. Quite frequently this change accompanying the rupture of the capsule is followed by marked relief from the pain of which the patient had previously complained. This position of adduction was formerly spoken of as the "third Appearance at the outset. (Say re.) stage" of hip-joint disease, that of marked flexion and eversion being called the "second stage," while the former position of slight flexion was denomi- nated the "first stage" of the disease. And for purposes of explanation, it pos- sibly may be well to retain these terms in some cases, though they do not repre- sent invariably the different stages in the progress of the disease, as we some- times find cases with marked adduction in the commencement of the disease, though in such cases we usually find the leg is rotated outward instead of being rotated inward, as it is when the thigh passes from the position of extreme ever- sion and abduction to that of adduction. Coincident with the change of posi- tion from abduction to adduction, there comes a change from apparent lengthen- ing to apparent shortening of the limb. If the disease has been in existence some time, there may be actual diminution in the length of the leg from absorption of bone, as well as the apparent shortening due to the adducted position in which the limb is held. Diagnosis. — The diagnosis in hip-joint disease should only be difficult in the early stages. If a child is brought, com- plaining of a limp, an obscure pain in the toe, calf, or knee, do not be satisfied with finding something in the toe, calf, or knee which may account for its limp and pain, because it may possibly have disease of the hip in addition to its other ailments; but strip it, and watch its posi- tion with great care, allowing it sufficient time to become composed and assume its natiiral attitude, as quite frequently, under the influence of excitement, slight disturbances of function may easily be masked. After noting any of the ab- normalities of attitude which have been just described, place the child upon its back upon a hard surface, — a table cov- ered with a shawl, for instance. It is important that the surface be not so thickly covered as to leave a yielding surface for the back to rest upon, as slight alterations in the position of the pelvis may then pass unobserved. With the normal child lying on its back, with its pelvis in such a position that a line HIP-JOIXT DISEASE. SYMPTOMS. 471 drawn from the centre of the sternum over the umbilicus throu.gh the symphy- sis pubis is at right angles to a line join- ing the two anterior superior spines of the ilia, the entire back should rest upon the table while the lower extremities are in a straight line with the trunk, and also rest upon the table. If there is any arching of the lumbar spine, raise both legs until the entire spine rests upon the table, and then lower the side which you contact with the table, and a slight arch- ing of the lumbar spine will result. This tilting of the pelvis does not necessarily mean the presence of hip-joint disease. It means a contraction of the ilio-psoas muscle, which may be caused by inflam- mation of the spine, by appendicitis, or by salpingitis; but the previous history of the last two affections would exclude them from consideration, while careful examination of the spine should clear up Eight hip- joint disease, showing position in which leg must be placed to make back lie flat on table. believe to be the sound one until the back of the leg rests upon the table. If the joint of that side be unaffected, there will be no change in the position of the tnmk and pelvis, and the spine will re- main in contact with the table. Xow lower the other leg gently to the table, and if there is invplvement of the hip, the psoas and iliacus or rectus femoris muscles will be sufBciently contracted to' tilt the pelvis before the leg comes in the diagnosis between disease of the hip and disease of the spine, though in some cases both exist simultaneously, and the mistake of recognizing only one is some- times made even by men of experience. In investigating the condition of the patellar reflex in hip disease the writer found an increase of the reflex on the affected side, as compared with the sound side, and, in proportion as there was ir- ritability of the joint with muscular spasm, so was there an increased patellar 472 HIP-JOINT DISEASE. SYMPTOMS. reflex. In the differential diagnosis be- tween hip disease and lumbar caries this symptom is of value, as in the latter dis- ease the reflexes are much less apt to be exaggerated and the reflexes on both sides are equal. Braekett (Boston Med. and Surg. Jour., Mar. 31, '92). Both legs lying fiat upon tlie table should then be moved to and fro, to ascertain, if possible, the presence or absence of muscular spasm. It is frequently advised that an anses- thetic be administered, in order that the condition of a diseased joint may be thor- such long standing that there should be no difficulty in reaching a diagnosis even by an inexperienced observer. The mode in which to determine mus- cular spasm in the early stages of the disease, at which time it is most impor- tant to arrive at a correct diagnosis, is, first, to thoroughly gain control of the patient, and cause it to allow complete muscular relaxation, as a child will, in many instances, voluntarily stiffen its muscles when first examined, and thus mask the presence of a slight involuntary Right hip-joint disease, showing tilting of pelvis. oughly investigated. As far as diagnosis is concerned, this is absolutely unneces- sary. The administration of the anses- thetic, by the removal of the sensitive- ness from the joint, removes the neces- sity which Nature feels for establishing the involuntary muscular protection which she gives all inflamed joints, and thus removes from the surgeon a most valuable means of diagnosis. If the rigidity of the joint is due to adhesions, and so persists after the anaesthetic has been administered, the case has been of spasm. The joints should then be moved through all normal ranges of motion, beginning with the sound side, and slight involuntary twitches taken into account. It is usually quite unnec- essary to manipulate the joint so vio- lently as to cause pain, in order to arrive at a correct diagnosis, and, in the major- ity of cases, pain will not be elicited unless very extensive movements are made, and unless the limitation of mo- tion which Xature puts to the joint is violently overcome. Pressure over the HIP-JOIXT DISEASE. SYMPTOMS. 473 hip-joint proper may at times give rise to pain; it very frequently does, but in many eases pain cannot be so elicited. The length of the two lower extremi- ties should now be noted, the distance from the anterior spine of the iliu.m to the internal malleolus being taken as the most reliable measure; and in this con- nection care must be exercised that both extremities occupy the same relative posi- tion to the trunk at the time the meas- ures are taken or they will be of no value, flexion and adduction causing much apparent shortening, while abduction causes apparent lengthening. The relation of the trochanters to Nelaton's line should be noted, by pass- ing a string from the anterior superior spine of the ilium to the tuberosity of the ischium. Xormally this line should just touch the upper border of the great trochanter. If the latter lies above it, the cause may be fracture of the neck of the femur, congenital dislocation of the hip on the dorsum of the iliiim, bend- ing of the neck of the femur, absorption of the head or neck of the femur, or ab- sorption of the upper part of the rim of the acetabulum, allowing the femur to glide upward; which cause is present in each ease must be determined by the sur- geon. Atrophy of the muscles occurs early in joint disease, and the circumference of each thigh should be noted, both at the upper portion and also at a point lower down, — say, four inches above the knee, — care being taken to measure the thighs at corresponding points, or the results will be useless. literature of '96-'97-'98. Atrophy of the limb coinciding with hypertrophy of the fold is one of the most important signs by which to recog- nize tuberculous osteo-arthritis before any other symptoms have appeared, while the absence of these trophic troubles is conclusive evidence of the non-existence of a tuberculous lesion of the eoxo-femoral articulation, even when it is indicated by other symptoms. Alexandroflf (Presse M6d., Dee. 9, '96). In noting muscular spasm care must be had not to mistake the flaccidity of a paralyzed muscle for the normal state, and suppose the healthy side to be the seat of muscular spasm by contact. The fact that the more relaxed thigh was the smaller ought to clear up any possibility of error, and it would seem that it hardly required mention save for the fact that such mistakes have occurred. The temperature and pulse should also be noted, any elevation of the former above normal being taken, in a doubtful case of every incipient disease, as con- clusive proof that disease is present, espe- cially if there is present in addition an accelerated pulse. The amount of elevation of tempera- ture is a fair index of the violence of the inflammatory process. Disease in the saceo-iliac joint should be diflferentiated from hip-joint disease primarily by the position which the patient assumes while standing, the body being sharply bent through the lumbar spine, away from the diseased side, in order to free the articulation from pressure. This position is typical of sacro-iliac disease, is not easy to de- scribe, but, once seen, cannot be mis- taken for anything else. Pressure of the two ilia toward each other gives rise to pain by compression of the diseased joint. Pain, in like manner, would be produced if pressure were made with the hands on the great trochanters, which might lead to doubt as to whether the disease were in the sacro-iliac or the hip- joint; but if the disease were in the hip- joint and the pain were caused by press- ure with the hands on both trochanters. 474 HIP-JOINT DISEASE. SYMPTOMS. pain would not be caused by pressing the ilia together with the hands behind the hip-joint, and the diagnosis would be cleared up in this manner. Direct press- ure over the sacro-iliac Joint also gives rise to pain, and rotation of the hip fails to produce muscular spasm. Congenital dislocation of the hip may be mistaken for hip-Joint disease, but the history is different: there is no history of traumatism, and there is usu- ally no history of pain. The disturbance of gait has been noticed from the first efforts at walking, which generally have been made long after the time at which children ordinarily commence to walk, and there is usually marked prominence of the buttock on the side of the dislo- cation, and while the child is recumbent the head of the bone can be caused to glide upon the dorsum of the ilium, while the great trochanter is felt to ap- proach and recede from the crest of the ilium. The oiily point in common with hip-Joint disease is the limp, which, how- ever, is different in its characteristics from the limp of hip disease, and the fact that the great trochanter is above Nek- ton's line. In hip disease the trochanter would only be above Nelaton's line in an advanced case, whose history would be absolutely different from that of con- genital dislocation of the hip. Confusion may arise at times in regard to FEACTUEES OF THE NECK OF THE FEMUE in small children where there is a history of traumatism, pain, and limping, but the diagnosis can usually be made by the fact that the disability and the pain immediately followed the trauma- tism, and the great trochanter was imme- diately found to be above Nelaton's line; the only confusion possible being in cases which do not come under observation for months after the occurrence of the symp- toms and where no history can be ob- tained. Such cases often present a picture of flexion and adduction ' which greatly resembles that of old hip-Joint disease with absorption of the head of the femur. In COXA VAEA, caused by the bending of the neck of the femur, the diagnosis is more obscure. In these cases, also, the great trochanter may be above Nelaton's line. The motion of the Joint may be limited, but careful investigation of the relation existing between the trochanter and the head of the femur, in combina- tion with the direction of the neck of the femur to the shaft, and differentia- tion between the limitation of motion produced by spasm of the muscles and that caused by abnormal relations of the neck of the femur, which cause the latter to strike the ilium, will clear up the diagnosis. The onset of coxa vara is insidious, pain, often felt chiefly in the knee, being the first symptom; then limping, with perhaps difficulty in kneeling and sitting. The pain is worst while the process is de- veloping, but, while pain usually de- creases, the joint-stiffness often increases progressively. Physical signs: Projec- tion of the trochanteric region with a depression between great trochanter and glutei; thigh-muscles usually atrophied; abduction of hip always limited, with tendency to adduction. Where the downward bending of the neck is com- bined with a backward displacement and rotation of the head the signs are more marked. The limb is then rotated out- ward and adducted, while internal ro- tation and often flexion are impossible. The trochanter is above Nfilaton's line in all cases. De Quervain (Sem. M6d., Jan. 29, '98). At times periostitis of the great tro- chanter may simulate quite closely hip disease, pressure over the trochanter giv- ing rise to acute pain. If the head of the femtir, however, be pressed into the ace- tabulum by one hand on the middle of HIP-JOINT DISEASE. SYMPTOMS. ETIOLOGY. 475 the thigh while the knee is abducted with the other, no pain is produced and the sensitive spot is thus located in the trochanter and not in the head of the femur. The occurrence of tumors of the femur and ilium should not be overlooked. These are almost always sarcomata, and can usually be difEerentiated from tuber- culosis or syphilis by the rapid enlarge- ment of bone usually following quite soon after a traumatism associated with pain, which is usually caused by pressure on nerve-trunks and does not resemble in its characteristics the night-crises of ordinary hip-joint disease. Muscular spasm is also usually wanting. The im- portance of a correct diagnosis' being reached very early in such cases cannot be overestimated, as it is only by prompt amputation that life can be saved. Case, aged 6 V2 years, in which there were a large abscess and symptoms of hip disease. The joint was incised, much pus was evacuated, and the capsular and round ligaments were found to have given way. The bone was only diseased to a small extent. The trouble mended slowly and then became stationary after four months. Sinuses had formed, which were opened. No necrosed bone found, but the inner portion of the upper third of the thigh was enlarged and there was an obscure sense of fluctuation. On firmly compressing the part a large mass of solid faecal matter was squeezed out. The mass, it is believed, was lying be- tween the vastus intemus and the ad- ductors, and had been there for several weeks. The explanation is that the pa- tient must have had an attack of typh- litis, and that there were perforation and pus leading through the obturator fora- men, thus forming a track for the sub- sequent passages of faeces. The patient made a complete recovery. Henry G. Eawdon (Liverpool Medico-Chir. Jour., July, '88). A point to be borne in mind in mak- ing a diagnosis of abscess in connection with a fluctuating swelling on the but- tock is the possibility of confounding one with an aneurism, as there is on record a case of gluteal aneurism that was opened with fatal result under the impression that it was an abscess. It is always best to confirm the diagnosis by an aspiratory needle. Etiology. — The ordinarily accepted type of "hip disease" or "morbus coxa- rius'' is a tuberculosis, which in the vast majority of instances begins in the bone, though it may, in exceptional instances, commence with synovial membrane. How the tubercle bacilli gain access to the bone is a matter which is still under discussion. It is probable that the bacilli are present in the circulation and that under the influence of a traumatism, not necessarily severe, a lowering of the resistance is produced in the neighbor- hood of the joint siif&cient to favor the local development of bacilli which have been present in the general system for a long time, but which had not increased on account of lack of suitable conditions. Hip-joint disease believed to be local tuberculous affection, due tq accidental inoculation and not to a constitutional or strumous condition. The irritation of the peripheral extremities of the nerves in or about the joint produces muscular spasm, which, in turn, distorts the joint by trauma, aided by the bacilli of tuber- culosis. Phelps (N. Y. Med. Jour., Aug. 31, '89). Tubercular material was injected by Miiller into the femoral artery of ani- mals with negative results. When in- jected into the crural artery from which the nutrient artery of the femur arises or into the nutrient artery itself, typical bone tuberculosis was set up. Tubercular matter from phthisical lungs injected into animals' joints sets up tuberculous joint-disease, while in- jection of inorganic matter not contain- 470 HIP-JOINT DISEASE. PATHOLOGY. ing tuberculous matter either into the joints or general condition does not cause tuberculosis. Schiiller rendered guinea-pigs and dogs tuberculous by inhaling solutions of tubercular material from diseased lungs and injected the same into the animals' lungs. The joints of these animals were then wrenched or bruised, which pro- duced a typical chronic tubercular syno- vitis in a great proportion of the cases, while healthy animals whose joints were similarly treated suffered from only a temporary sprain. The exanthemata are frequently fol- lowed by joint-tuberculosis — apparently on account of the lowering of the general vitality below the point where the tis- sues are capable of resisting the growth of the tubercle bacilli. Pathology. — In the early stages of hip- joint disease there is an hypersemia in the cancellous tissue about the epiphyses where the disease usually begins, in the centre of which a small gray tubercle appears. The capillaries in the Haversian canals become blocked up with bacilli. An hypersemia is kept up, the trabecules in the hypersemic area are absorbed, en- larged bone-spaces are formed, and fatty degeneration of the bone-cells occurs. The gray spot in the centre of the hyperasmic area increases in size, its centre begins to grow yellow; other sim- ilar spots occur and merge into each other; the centre breaks down and be- comes a semisolid cheesy mass and may turn into pus. The blood-vessels in the periphery of the inflamed area often become so blocked that the blood-supply is cut off, and necrosis of a larger or smaller part of the apophysis of the femur results. If all conditions are favorable, the focus may become absorbed or may become cal- cified, or else as the focus of disease increases in size it may grow toward the surface of the femur, open outside the joint-cavity, and the case may run a com- paratively short course with little or no destruction of the joint, or, as is more usual, it may break into the joint itself, setting up a purulent synovitis. The synovial membrane becomes in- flamed and thickened, the blood-vessels are engorged, an increased serous or sero- purulent effusion takes place, and the joint becomes filled with a gelatinous mass, the cartilage becomes eroded, and the bare ends of the bone come in con- tact. If the process becomes less violent, on the contrary, the granulations become firmer and not so pale and gradually give place to fibrous tissue, adhesions forming between the joint-surfaces, sear-tissue taking the place of the granulations, and contraction of the capsule limiting mo- tion on the joint. When the focus of disease is in the ilium, the area of inflammation may ad- vance toward the pelvis as well as toward the acetabulum, and in these cases the periosteum lining of the ilium on its inner side becomes much thickened. At times the entire bottom of the acetab- ulum may be absorbed and the head of the femur pass into the pelvis; at other times there is only a small hole through which pus passes to form an abscess which may burst into the bladder or rectum or burrow under the adductor tendons or out on the buttock. Even in this condition recovery is not impossible. The size of the acetabulum is often increased by the progress of erosion and also by the action of reflex muscular spasm in crowding the head of the femur against the upper rim of the acetabulum. Cases having been reported in which the head of the bone lay inside the pelvis in Comparison between tubercular and healthy hip-joints, showing absorption of the head and neck of the femur, rarefaction of the head, and absorption of the acetabulum. Normal side shows epiphysial cartilage below the head of the femur and cartilage in the acetabulum, where innominate bone has not yet ossified. Bandages and adhesive plasters shown on thigh of diseased side. (8a/yre.) HIP-JOINT DISEASE. PROGNOSIS. 47': spite of the limbs' having been kept par- allel by plaster of Paris, which had pre- vented the occurrence of deformity. The importance of this fact as bearing on the necessity of traction as well as fixation in the treatment of the disease should not be overlooked. The erosion of the upper part of the acetabulum accounts for part of the shortening in some cases of hip disease. Eetardation of growth may give actual shortening of the femur, and it is not unusual to find that the leg and foot of the affected side are also smaller than their fellows. If the disease progresses sinuses may burrow from the joint in all directions both inside and outside the pelvis, and later on amyloid changes in the liver and kidneys will be set up or a tubercular meningitis or a general tuberculosis may set in. Prognosis. — Prognosis in disease of the hip-joint varies very much, being largely determined by the amount of de- struction which has taken place before the case comes under observation, the amount of recuperative force possessed by the patient, and the intelligence of home co-operation — the last, perhaps, being the most essential element. Cases of syphilitic disease ought to give excellent results, if to local protec- tion of the joint be added thorough, per- sistent antisyphilitic treatment. Cases of acute traumatic synovitis, if seen at once, and given absolute and com- plete rest, almost always recover per- fectly. Cases of acute, infectious osteomyeli- tis demand prompt operation and re- moval of diseased foci. If this can be done before too much general systemic infection has taken place, prompt recov- ery usually follows. In tubercular cases, seen early, recov- ery, as a general thing, takes place. The time which a patient will have to wear a splint is very seldom under two years. If the patient is able to dispense with it inside of this time, it is remarkably fortunate, and the parent should not be led to anticipate such a result. The amount of shortening which may take place, and the amount of impairment of motion, cannot always be accurately de- termined beforehand, and it is very un- safe to make a definite prognosis. Cases may be seen at apparently the same time after the onset of the first sypmtoms, with apparently the same amount of dis- ease, be treated in precisely similar man- ner, and while one recovers with an ab- solutely-perfect joint at the end of two years, the other may drag on a tedious course of four, five, or six years, and at the end of that time recover with decided shortening and marked diminution of motion. The only difference in the two cases apparently having been the per- sonal equation of power to resist disease. What can be promised is that, if the patient's recuperative force is sufBcient to allow it to recover at all, it can re- cover with a leg parallel with its fellow, and not flexed upon the trunk. And the parents may be told that the length of time during which a splint will probably have to be employed will not be less than two years. Number of cases of hip disease ob- served which lasted a remarkably short time, though, when first seen, there was nothing to distinguish them from cases in which treatment had to be continued over years. Out of one hundred and fifty-six cases applying for treatment, thirteen made a rapid recovery and re- mained well. Eight of these seemed to have had a simple acute synovitis, but resembled true hip disease so closely that a diagnosis between the two was im- possible. In other cases there must have been an 478 HIP-JOINT DISEASE. TREATMENT. ostitis, the cases recovering with shorten- ing, thickening about the trochanter, and, in some cases, slightly-limited mo- tion. Lovett and Morse (Boston Med. and Surg. Jour., Aug. 18, '92). The question of abscess also comes into the prognosis, and parents are fre- quently anxious to know whether or not a child will have an abscess. In many cases there is felt at the time of first ex- amination a brawny, porky induration around the hip-joint, which is the fore- runner of an abscess, or the child may be found with an inflamed, sensitiye joint which absolutely precludes any possibil- ity of motion, and in such cases it is quite probable that an abscess will develop more or less speedily. In other cases, where the patient is seen early, and the brawny induration is as yet not present, no definite prognosis can be given, though the percentage of cases 'that de- velop abscesses when thorough treat- ment is carried out from an early stage of disease is decidedly small. Treatment. — The indications for treat- ment in disease of the hip-joint are, pri- marily, to give the joint physiological rest, and, secondarily, if the general con- dition of the patient demands special treatment, to counteract syphilis, rheu- matism, and so forth, to take such meas- ures as seem demanded. To obtain rest of a joint like the hip is not easy. The Thomas hip-splint en- deavors to secure it by fixing the trunk and lower extremity by means of an iron bar three-fourths of an inch by three- sixteenth of an inch and long enough to extend from the scapula to the lower third of the calf and fitted with cross- bars long enough to embrace three- fourths of the circumference of that part of the body where they are placed, namely: at the thorax, calf, and upper third of the thigh. The splint is padded with felt covered with leather and bent to fit the contour of the body in its de- formed position, and then bandaged firmly to it. In acute synovitis of the hip it is an excellent means of treatment, and in cases where no other form of treat- ment is practicable and capable of doing much good. The fixation which it gives the hip, however, does not counteract the reflex muscular spasm which in chronic joint-disease creates so much of the de- struction which is seen in cases left to Nature, and which is capable, in cases which have been simply prevented from having flexion but not treated with trac- tion, of causing perforation of the ace- tabulum. Traction in the proper line and of sufficient amoiTnt to relieve involuntary muscular spasm and so lessen intra- articular pressure is the best agent we possess for relieving pain in chronic joint-disease and should always be added to any apparatus that is employed for securing fixation, as the latter, unless thus supplemented, but partially fulfills its mission. Another objection to the Thomas splint is the method by which it straight- ens the deformity, which is effected by bending the splint backward by wrenches from time to time. If there is contrac- tion of the flexor muscles, this proceed- ing must result in crowding the head of the bone violently against the acetabu- lum, thus running the risk of re-exciting inflammation. In the majority of cases there is too much deformity when they first come under observation to permit the applica- tion of a splint. Such cases should be put to bed, a long padded side-splint, with a cross-bar at the bottom, should be firmly bandaged against the sound leg and the trunk as far as the axilla, and the body and leg thus secured may, if necessary, be fastened to the sides of the HIP-JOINT DISEASE. TREATMENT. 479 bed for the purpose of retaining them in position. It is sometimes found better to band- age the patient with Bradford's frame, a rectangle of iron gas-pipe somewhat longer and broader than the child, which has canyass stretched tightly across it except at the part where the hips lie, which is left open for a bed-pan. A long board shoiild be placed under the mat- tress, as the ordinary spring-mattress is too yielding to allow proper control of an inflamed joint. Adhesive-plaster straps, furnished with buckles at one • end, are next applied to the diseased limb, the buckles being just above the malleoli, and the plaster extending as high on the thigh as possible. Heavy extension diachylon plaster, spread on mole-skin, is best for this purpose, as the ordinary rubber plaster is irritating to many skins when worn for a long time, and is spread upon such thin cloth as to be incapable of enduring the strain nec- essary in many cases to afford relief. In applying the plaster it should be warmed but very little, and in many eases need not be warmed at all, but should be snugly bandaged to the skin, and well rubbed with the hand to secure coapta- tion of the plaster. This tight bandage may then be removed and replaced by one not so closely bound. Some prefer, in addition to the two side-straps of plaster, a spiral of plaster passing around the leg in both directions, which serves to hold the plaster more snugly in position. Properly-applied extension plasters should remain for several months without the necessity of change. To the buckles are now attached small leather straps, which are fastened to a cross-bar below the sole of the foot, from which cross-bar a stout cord extends over a pulley-wheel at the foot of the bed and supports a weight. The amount of weight will vary in different cases, and should be that which experience shows gives the greatest amount of relief in the particu.lar case, and may vary from two to fifteen pounds. The direction in which the traction is made should be de- termined by the deformity which is pres- ent in each particular case. A really efficient apparatus for hip disease must afford traction outward as well as downward, sO' that the mean force exerted shall be in an axis with the neck of the femur, and thus relieve from pressure all the articulating surfaces of the joint. It must afford immobility and allow of unlimited out-of-door exer- cise, as far as pain or danger to the dis- eased joint is concerned. Wallace Blan- chard (Chicago Med. Jour, and Exam., June, '89). When the body and sound leg are firmly bandaged to the side-splint and the back is flat upon the bed, the diseased limb will assume a position either of ab- duction or adduction, combined with flexion, and in this position, whatever it may be, the line of traction must be made, and it must be made sufficiently great to give the patient freedom from pain. If traction, so applied, fails to relieve pain, and the position is that of adduction, a second line of traction may be made by passing a well-padded band around the thigh, close to the groin, and making traction outward at right angles to the long axis of the femur, over a pulley fastened to the side of the bed. The leg must be supported in its ele- vated position by pillows or by two boards hinged at one end and supplied with a prop, so as to make an inclined plane which can be raised or depressed accord- ing to the needs of the patient. If there is great tenderness behind the trochanter, a blister may be applied with great benefit. In cases of ostitis of the trochanter with marked tenderness, relief can fre- 480 HIP-JOINT DISEASE. TREATMENT. quently be obtained by plunging the sharp point of PaqiieHn's cautery deep into the bone, the skin over the tro- chanter having been injected with a drop or two of a 4-per-cent. solution of co- caine. In exceptional cases there may be an effusion in the joint of so great extent as to make aspiration advisable, but this is unusual. If the synovitis be- comes purulent the joint must be incised and washed out with Thiersch or Labar- raque solution. The line of traction is this manner.. And in such cases, where faithful trial of this method of reducing the deformity fails to give results, the patient should be ansesthetized and the joint forcibly straightened. If, at this time, it is found that there is so much contraction of the rectus muscle or the adductors as to prevent reduction of the deformity, except at the expense of vio- lently crowding the head of the femur into the acetabulum, free section of the contractured tissues should be made be- Extension apparatus. to be changed little by little every few days, as the spasm of the muscles sub- sides, until the leg is gradually brought parallel to its fellow and flat in bed, without disturbing the position of the trunk and the sound leg. When the legs can be made parallel and rest on the bed without tilting the pelvis, a splint may be applied. In some cases the disease will have advanced so far at the time of first observation that adhesions will have formed -around the joint too strong to permit reduction of the deformity in fore reduction is attempted. The joint should then be immobilized either with a splint or with a plaster-of-Paris dress- ing extending from the ankle to the thorax, while weight-and-pulley traction is again resumed. If plaster of Paris is employed, it should be reinforced at the groin by a strip of iron to prevent crack- ling. When the deformity has been overcome and the joint is free from ac- tive inflammation, the patient may be allowed to rise when supplied with a suit- able apparatus. HIP-JOIXT DISEASE. TREATMENT. 481 The object of the hip-splints now in use is twofold: First, to enable the pa- tient to walk about easily without bear- ing weight upon the diseased joint, and, second, to prevent the joint from receiv- ing the traumatism consequent upon or- dinary motion. If the patient is very large and fat or the joint extremely sen- sitive, it will be found wise to vise a pair of crutches in addition to the hip-splint, as the joint in this manner will be better protected and the patient freed from the galling sometimes occasioned by the pressure of the perineal straps in very heavy and fat patients. In the great majority of cases the apparatus most suitable for protecting the joint consists of a pelvis-belt with a bar running down the outer side of the leg to a point a couple of inches below the sole of the foot, where it joins a cross-bar, to which are attached two straps which serve to fasten the instrument to the buckles on the adhesive plaster. By means of a rachet and key on the foot-piece which is attached to a notched bar sliding inside of the main bar, which is hollow, the splint may be made longer or shorter. Just above the knee a metal horseshoe- shaped collar holds the thigh in position. Two straps pass from the front of the pelvis-belt to the rear, between the legs, and serve to hold the pelvis-belt in posi- tion. The buckles to which these straps are attached should be near together in the front, to avoid pressure on the fem- oral vessels, and widely separated at the back in order that the pressure may come under the tuberosity of each ischium. An elastic strap runs from the middle of the back bar of the pelvis-belt to the side-rod to prevent the pelvis-belt from tipping up too far in the back. When applied the pelvis-belt is to be fastened sufficiently firm by the perineal straps to prevent it from rising higher than the anterior superior spines of the ilia, while the foot-piece is buckled to the exten- sion-straps, leaving two and a half to three inches between the sole of the foot and the top of the foot-piece. By means of the rachet and key extension is then made until the watient is comfortable. Sayre's long hip-splint. As the splint projects below the level of the foot, an extra sole and heel must be added to the shoe of the opposite side, which should usually be about four inches high, and the splint should be so regulated that, when the proper amount of traction is made, the patient being upright, the length of the splint and the 482 HIP-JOINT DISEASE. TREATMENT. length of the sound leg with the high shoe will be the same. The splint should be sufticiently long to prevent the patient from touching the foot to the floor, and, if the elevation on the oppo- site shoe is not high enough to compen- sate for this elongation, walking will be very uncomfortable. In the majority of cases a splint of this kind gives adequate protection and results in excellent cures. But if it is found that the parents do not fully understand the home management of the apparatus, or if the patient lives at a distance, so that it is seen at infre- quent intervals, it may be wise to add to the splint a thorax-belt, which is joined to the pelvis-belt by means of a rod continuous with that passing down the side of the leg. This form of splint prevents the occurrence of flexion after the patient is allowed to walk, which sometimes takes place with the other splint if improperly applied, but it has the disadvantage of limiting the motions of the patient very materially, and being much more cumbersome. With the pa- tients, however, who live at a distance, and where home eo-pperation is not in- telligent, it is wise to employ it. The mistake must not be made of placing a joint in the bar that runs from the foot to the thorax-belt, as this will render the apparatus worthless. In some cases, also, instead of the perineal bands, it may be better to use a ring, as suggested by Dr. A. M. Phelps, for the latter cannot be tampered with by careless attendants, and, if it is fitted to the limb with proper care and sufficiently well padded, can be used with a fair degree of comfort. In adult eases where dependence can be placed upon intelligent co-operation of the patient, the use of the short traction- splint and crutches may be advisable. In this form of splint the side-rod ter- minates at the knee-joint and is joined to a pair of hoop-shaped metal bars, which pass across the front of the femur and are supplied with two jaws on each side of the knee just above the condyles. Adhesive plasters are fastened to the thigh, terminating in broad, webbing bands, which are reversed over the jaws of the splint and fastened to buckles. By means of a rachet and key traction on the joint is made in the same manner as in the case of the long splint. Two cases of hip-joint disease cured with perfect motion, although in one case resection had been advised by an eminent surgeon as the only means of saving life. These eases were treated by traction without immobilization. The long, portable traction-splint was used, and the patients encouraged to walk as soon as it was securely applied. Trac- tion was continued at all times, the ap- paratus being worn at night as well as in the day-time. Locally, compound iodine ointment was applied daily, either in the groin or behind the trochanter of the affected side. Constitutional treat- ment was employed throughout the en- tire course of the disease, compound syrup of hypophosphites being given in summer and codliver-oil in winter. J. K. Young (Univ. Med. Mag., Aug., '93). Statistics of 407 cases of morbus coxarius treated between 1859 and 1889, exclusive of exsections. Of these there were, in the first stage, 118; sec- ond stage, 119; third stage, 82; not mentioned, 88. Total number of cases, 407. Results: cured, motion perfect, 71; cured, motion good, 142; cured, motion limited, 83; cured, ankylosed, 5; un- known, 78; under treatment, 14; aban- doned treatment, 3; discharged, 2. Died of exhaustion, 2; died of phthisis, 1; died of pneumonia, 1 ; died of tubercular meningitis, 5. Total deaths, 9. Total number of cases, 407. Above cases in which the writer knows the result and the kind of splint worn, excluding cases under treatment. Cures with perfect motion: long splint, 19, or 21.59 per cent.; short splint, 54, or 28.12 per cent. Total, 73. Cures with good motion: long splint, 34, or 38.63 per HIP-JOINT DISEASE. TREATMENT. 483 cent.; short splint, 86, or 44.79 per cent. Total, 120. Cures with limited motion: long splint, 29, or 32.95 per cent.; short splint, 49, or 25.52 per cent. Total, 78. Cures with ankylosis: long splint, 3, or 3.40 per cent.; short splint, 1, or 0.52 per cent. Total, 4. Deaths: long splint, 3, or 1.56 per cent.; short splint, 2, or 1.04 per cent. Total, 5. Treated with long splint, 88; treated with short splint, 192. Total number of cases, 280. require. Cases in which both hips were involved were treated in the wire cuirass. Traction was regarded as vital to proper success. L. A. Sayre (N. Y. Med. Jour., Apr. 30, '92). Series of cases of deformity following diseases of the hip and due to insufficient care during treatment observed. The ac- companying cuts illustrate some of these cases. L. H. Petit (Gaz. des H6p., Feb. - 16, '95). Deformities following hip-joint diseases due to insufficient care during treatment. (Petit. The mode of treatment had been rest in bed, with traction in the line of the deformity applied to the diseased leg, and occasionally traction in the axis of the neck of the femur, the sound side being bound to a long side-splint. Blisters were usually applied behind the trochan- ter major. When the deformity was re- duced the patient was allowed to go about with the short traction-splint and crutches, or the long traction-splint, with or without crutches, as the case might Literature of '96-'97-'98. The ambulatory treatment in an early stage is extremely unsatisfactory, recum- bency and complete rest giving better re- sults. A persistent high temperature, with no obvious cause in the early stages of hip- joint disease, indicates that the disease will run a rapid and destructive course, and is ominous of an unfavorable ter- mination. 484 HIP-JOIXT DISEASE. TREATMENT. Under recumbency and fixation the temperature becomes, if not quite nor- mal, at least constant. R. L. Swan (Med. Press and Circular, May 12, '96). The treatment of abscesses occurring in tuberculous joints, is one which has been very widely discussed, and in re- gard to which there have been many dif- ferent opinions. The prevailing trouble with many surgeons is that they fail to regard the abscess as an incident in the career of a tubercular joint, and treat it as a thing by itself, neglecting the bone-inflammation which was the orig- inal starting-point of the abscess. If it ■fl'ere possible to locate the focus or foci of disease and to remove all foci without doing great damage to surrounding healthy parts, the logical treatment of all tubercular inflammation would be the radical excision of all tubercular foci as soon as detected. This proceeding, in- deed, became quite fashionable some years ago abroad, but experience has shown that better results are obtained by older and more conservative methods. If we cannot absolutely eradicate all tubercular foci, the chances of securing a good result are better by leaving them alone, provided they remain incapsulated and are not subjecting the patient to gen- eral systemic infection. Under rest and compression, good hygienic surround- ings, and forced feeding many collections of tubercular matter disappear. If they come to the surface it is the best plan in many cases to disinfect the skin with great thoroughness, apply a sterilized dressing, and allow them to open spon- taneously; wash the cavity thoroughly with peroxide of hydrogen or chlorinated soda (Labarraque's solution). Abscesses treated in this way rarely give rise to any disturbance and usually close in a few months. In the tubercular hip-joint disease eai-ly and complete excision strongly recommended. Arthur E. Barker (Brit. Med. Jour., Jan. 19, '89). Tubercular abscesses in the course of hip- joint disease to be treated on true surgical principles: free incision, thor- ough curetting of the walls of the abscess-cavity while the wound is being flushed with plain boiled sterile water, and complete closure of the wound in the skin without drainage. "W. J. Taylor (Annals of Surg., July, '95). literature of '96-'97-'98. Treatment of hip- joint disease is fix- ation and traction. Excision of abscesses should be performed when they enlarge rapidly, are associated with great pain, are burrowing and producing pressure upon other important structures, or are attended with marked sepsis. When an abscess appears upon the sur- face as a, tumefaction merely, with no other evidence that it is an abscess than that it is associated with hip-joint dis- ease, to excise and subject the patient to further danger of pyogenic infection would be anything but good treatment. S. L. McCurdy (Med. and Surg. Reporter, Feb. 8, '96). If there has been a mixed infection grafted on top of the original tubercular focus, immediate operation with free in- cision of the abscess, complete removal of all debris, and thorough drainage should be employed. As a usual thing, the abscess has originated in the bone, and in the cavity will be found very fre- quently some crumbs of dead bone, al- though occasionally they are not present, while not infrequently, in cases opened at an advanced stage, the abscess seems to have been shut off from the Original bone-focus, which has healed up after extruding its carious bone. Many cases , pass on to abscess quite promptly, and, indeed, it sometimes seems as if those cases which suppurated early and ran an acute course got well in shorter time than those which were accompanied with less pain and less suppuration. The oc- HIP-JOIXT DISEASE. TEEATMENT. 485 currence of abscess does not necessarily mean a less favorable result, and it is not imusiial to see cases of double hip dis- ease, one side having been the seat of an abscess and the, other having been free from suppuration, in which the motion is better on the side where suppuration took place. If great destruction of the head of the femur or the acetabulum are present when the ease first comes under observa- tion, or if, in spite of protection and good hygienic surroundings, the case does not do well and disintegration of the joint is progressing, the question of excision pre- sents itself. And here again the difficult problem is when to operate and when not. The great majority of cases, seen in the early stages and properly treated, never reach the point of operation, ex- cept in the class of acute infectious osteo- myelitis. And, again, there are other cases which come to the surgeon, with grave hectic symptoms, a hip full of bur- rowing sinuses, and a mass of dead bone inclosed in a thick involucmm, which have no chance for life except by the prompt removal of all diseased tissue and proper drainage. [Number of cases of resections of the hip recovered with very good motion. One has almost perfect motion ; can run, dance, skate, and walk many miles with- out the slightest fatigue, although more than 3 inches of his femur and much of his acetabulum were removed; yet he has only 'U inch shortening of the limb. Lewis A. Sayke, Assoc. Ed., Annual, '90.] » Ultimate results in 66 cases of hip- joint excisions (by cure is meant that all sinuses have closed, and there is no symp- tom of trouble about the hip; by re- lieved, that sinuses are open) : There were 32 children discharged cured, 25 died, 3 discharged relieved, 2 discharged not improved, and 4 in the hospital. Of the cause of death, 14 died from amyloid degeneration, 1 from amyloid de- generation and peritonitis, 2 from gen- eral tuberculosis, 1 from acute nephritis, 1 from septicaemia, 1 from heart-failure, 1 from coma (uraemic), 3 from menin- gitis, and 1 from exhavistion. Of the patients discharged cured, the present condition of 23 is absolutely known: 1 is well 18 years after dis- charge; 1 well 11 years after discharge; 2 well 9 years after discharge; 1 well 7 years after discharge; 2 well 6 years after discharge; 1 well 5 years after dis- charge; 1 well 4 years after discharge; 1 well 3 years after discharge; 4 well 2 years after discharge; 9 well 1 year after discharge. Poor (N. Y. Med. Jour., Apr. 23, '92). Preparation of a hip-joint on which the writer had performed resection some years before. It demonstrated that the end of the femur had made a good mov- able joint in the acetabulum. Not a bad functional result obtained in one hun- dred and fifty hip-joint resections. Sehede (Deutsche med.-Zeit., May 22, '93). Between these two extremes we find a third class, in which the surgeon at times is in doubt whether the continued use of a splint for a longer period of years is better, or whether a free removal of the head of the bone, scraping of the acetabulum, and removal of all tuber- cular tissue may not, in the end, give a better result. Such cases must be de- cided by each man on his own experience. In case operation is decided upon, if the patient has a large abscess and is very much exhausted, it is usually better to open the abscess freely and wash it out at one sitting, and in a few days, when the patient has rallied from the removal of retained pus, to complete the clearing away of dead bone, except in cases presenting many old sinuses, where it sometimes is best to unite these by an incision. The best method of reaching the joint is by an inci- sion starting midway between the an- terior superior spine of the ilium and 486 HIP-JOINT DISEASE. TREATMENT. the greater trochanter, and, passing over the great trochanter, down the thigh along its outer aspect. This incision should pass completely through the peri- osteum and extend to a point below the lesser trochanter. By means of a curved bistoury the periosteum should now be divided at right angles to the original cut and, by means of a periosteal ele- vator, peeled up from the femur. At the digital fossa it will be necessary to resort to the knife to divide the muscles in- serted there. At all other points the periosteum can be peeled ofE by the peri- osteal elevator. The femur should be sawed just above the lesser trochanter, and the head removed from the socket by means of a pair of lion forceps, or may be dislocated from the acetabulum prior to sawing, at the pleasure of the operator. If there are evidences of disease farther down the shaft of the femur the peri- osteum must be split lower and the femur sawed in two lower down. The acetab- ulum should then be explored, and, if any foci of disease exist, they should be carefully removed with a sharp spoon. If the acetabulum is perforated, the opening must be enlarged so that no shoulder of bone shall cause pus to ac- cumulate in the pelvis. Sometimes it is necessary to " drain such intrapelvic abscesses through the sciatic notch in- stead of the acetabulum. If any sinuses exist, they should be carefully cleaned and all tubercular tissue removed as far as possible. The wound should then be thoroughly packed from the bottom with iodoform gauze and the patient placed in a wire cuirass. The wire cuirass con- sists of a wire frame-work extending from the head to the heels, with a pair of movable foot-pieces, which allow the legs to be lengthened or shortened. The sound leg and the trunk are firmly band- aged in position by a roller bandage. Turns of the bandage also pass over cotton pads in the groin and around the handles of the cuirass and serve to give counter-traction. The diseased limb is then fastened to the foot-board of the cuirass by means of adhesive pieces ex- tending to the thigh, as for the applica- tion of a hip-splint, and the foot-board is then drawn down until both legs are of the same length, the bandages just mentioned as passing between the legs keeping the trunk from slipping down. The patient can be dressed in his cuirass, which is cut away under the buttock for this purpose, with much less pain than in any other manner, and can have the benefit of out-door life from the time of operation, being transported in a wheeled carriage. Simple method presented by which re- cumbency, with any advantage, can be obtained without the counter-balancing evils which attend it when used in the general way by confining a patient to bed. A light carriage with wicker-work sides, rubber tires, and well-tempered springs is made of a length suitable for the patient, allowing for at least three years' growth; and it is surprising how a child will grow on such a carriage in the fresh air and sunlight. Cut illus- trates carriage as used by the author. W. W. Bremner (Med. Rec, Aug. 3, '95). If a cuirass cannot be had a double Thomas hip-splint will answer the pur- pose if combined with traction by weight and pulley. The wound should be dressed as frequently as may be neces- sary to keep it clean, the packing gradu- ally being rfimoved as new bone regener- ates from the inner surface of the peri- osteum, and in some cases Nature will form an artificial Joint almost as perfect as its fellow, although this is not to be expected, and a certain amount of short- ening and more or less disability usually result. Cases of double hip disease must be HIP-JOINT DISEASE. HOMATROPINE. 487 treated by rest in bed or by the use of the cuirass, as it is not possible to apply an apparatus which will allow them to walk in a convenient manner and still protect the joint. In exceptional cases ampiitation at the hip-joint may be a necessity to save life, but this is most uncommon, recovery with a most excellent joint on which the patient walks well having been reported by Dr. J. C. Spencer after the removal of nine inches of femur. In certain cases of malignant growths or tubercular invasions, which are not amenable to ordinary operative inter- ference, the removal of the lower ex- his index-finger and readily reached and compressed the common iliac artery. Entire absence of bleeding was readily maintained throughout the amputation which followed. The field of operation was free from bandage or appliances of any kind. The author recommends the procedure on account of its simplicity, its certainty, its aseptic character, and because it can be applied to cases which require that the deeper tissues should be severed at an unusually high level. In performing the amputations, it was found that this method of controlling the ar- tery has the advantage that all the smaller arteries in the stump can be readily identified and ligatured, it being only necessary to lift the finger for a fraction of a second and so allow a mi- Light carriage for cases in which recumbency is unavoidable. (Bremner. tremity, together with the ilium, at one operation recommended, disarticulating at the symphysis pubis and the sacro- iliac junction. Jaboulay (Lyon Med., Apr. 15, '94) . literature of '96-'97-'98. Three consecutive successful amputa- tions at the hip-joint, in which the fol- lowing procedure was adopted. In the first place, as much blood as could be safely returned to the body from the limb to be amputated, by means of posi- tion or elastic bandage, was so returned. Then an incision was made through the abdominal wall about 1 Va inches inter- nal to the anterior spine of the ilium. Through this incision an assistant passed nute quantity of blood to escape. Charles McBurney (Annals of Surg., May, '97). If amputation is done, Fernaux Jor- dan's method should be employed. Eeginald H. Satee, New York. HODGKIN'S DISEASE. See Lym- phatic System, Diseases of. HOMATROPINE.— When atropine or hyoscj'amine is heated with baryta- water, the alkaloid is resolved into tro- pine (an artificial alkaloid) and tropic 488 HOMATEOPINE. THERAPEUTICS. acid. Tropine, mandelic acid, and dilute hydrochloric acid are then mixed, and a prolonged, gentle heat is applied; when the mixture is evaporated homatropine crystallizes out in- deliquescent, color- less, regular, prismatic crystals. Homat- ropine is freely soluble in alcohol, ether, chloroform, and oil; more slowly in water. Its salts with hydrochloric, hy- drobromic, and sulphuric acids are white and crystallize well. In therapeutic prac- tice homatropine hydrobromate is most generally used. It occurs in small, white, lustrous, non-hygroscopic crystals, and is soluble in 10 parts of water. The solu- tion is quite permanent. For internal use homatropine may be taken in doses of V120 to Veo grain. Physiological Action. — The physiolog- ical action of homatropine closely re- sembles that of atropine. It dilates the pupil very rapidly and energetically, but the efffect passes ofE in 36 to 48 hours. The mydriasis of atropine lasts for 10 to 14 days, and that of hyoscyamine for 8 to 9 days. Eepeated instillations of homatropine solution (1 per cent.) causes a lowering of the pulse-rate, which is, however, only temporary. Slight hyper- seniia of the conjunctiva almost invari- ably follows its use. Instillations of strong solutions (4 to 5 per cent.) induce a burning sensation on the conjunctiva, and, if in large amount, its bitter taste becomes perceptible, but without the dryness of the pharynx which follows the use of atropine. The action of homat- ropine on the circulation also differs from that of atropine in that the former lessens the pulse-rate and diminishes the arterial pressure. Unlike atropine, again, it does not, as atropine often does, superindxice cutaneous eruptions. Poisoning by Homatropine. — No fatal eases of poisoning have been reported from the medicinal use of this remedy. and no toxic symptoms beyond a slight drowsiness. This, no doubt, results from the fact that the use of homatropine is almost exclusively by instillation in oph- thalmology. De Schweinitz and Hare, in experiments on frogs, have found that this drug in large doses first alters the respiration to the Cheyne-Stokes rhythm, then arrests it wholly; this is succeeded by a tetanic condition; and after that by a paralysis — leaving, however, the pe- ripheral nerves and muscles untouched. The heart-movement is retarded and the pulse-rate diminished. Death occurs from respiratory paralysis. Literature of '96-'97-'98. An undoubted instance of poisoning following the instillation of 1 drop of a 0.2-per-eent. solution of homatropine. C. A. Oliver (Amer. Jour. Med. Sci., Nov., '96). Treatment of Poisoning ty Homatro- pine. — The treatment of poisoning by this remedy is similar to that of atropine poisoning. The stomach, by emetics and the stomach-tube, is to be evacuated. Tannin and animal charcoal are then ad- ministered and emetics again given, fol- lowed by castor-oil. Artificial respira- tion, heat, stimulants, and hypodermics of strychnine are useful to support the respirations. Morphine may be given carefully as a physiological antidote. Therapeutics. — Homatropine is almost exclusively us^d by ophthalmologists to dilate the pupils and paralyze the muscle of accommodation for the purpose of cor- recting anomalies of refraction in healthy eyes. For this purpose it is used in solu- tion (4 grains to the ounce of distilled water), which is dropped into the eye every five or ten minutes until sufficient dilatation is obtained. For therapeutic uses;in ophthalmology, atropine is gener- ally used, although for incipient cataract HOMATEOPINE. HYDRACETIN. 489 Eisley prefers liomatropine, especially where there is discomfort without in- creased ocular tension. Homatropine is not a reliable cyelo- plegic in young subjects. Hansell (Amer. Jour. Ophth., Xo. 3, vol. xii). literature of '96-'97-'98. Homatropine valuable as a cyeloplegic. Drug to be applied at the upper border of the cornea, the patient looking strongly do^vn^vard. A solution of 2 to 5 per cent, is used, four to six instilla- tions being sufiSeient. The refraction should be determined within two hours of the last. Homatropine is not as reliable as other mydriatics when used by the patient at home. Homatropine is a better drug than atropine for use in eases where complete rest of the accommodation is needed; be- cause of its action being much shorter the eye returns to its normal accommo- dative power without passing through a long period of ciliary muscular weakness. The great advantage of homatropine is the brevity of its action. Toxic symptoms from homatropine are almost unknown. Homatropine is dangerous in eases where the ' tendency to glaucoma exists, as are all other mydriatics, but it is less dangerous than these. Homatropine does not produce con- junctival irritation. Jackson (Jour. Amer. Med. Assoc, Xov. 21, '96). As complete cyeloplegia secured from 6 instillations of a 2-per-cent. solution of homatropine at o-minute intervals as from a 1-per-cent. solution of atropine used 3 times daily for 2 days. F. Mayo (Med. News, June, '96). Homatropine has been used against the night-sweats of phthisis, but other remedies are preferable. C. SUMNEE WiTHBESTINE, Philadelphia. HUTCHINSON'S TEETH. See Syph- ilis. HYDRACETIN. — This substance — known also as pyrodin (not to be con- founded with pyridine), acetyl-phenyl- hydrozin, phenyl-acetyl-hydrazin, and phenacethydrazin — is produced by the reaction of phenylhydrazin with acetic anhydride. It occurs in hexagonal prisms or tablets of a silky lustre, with- out taste or odor. It is freely soluble in alcohol and chloroform and in 50 parts of water. Physiological Action and Dose. — Wild has found that this substance is without effect on the voluntary muscles, while upon the heart-muscles in large amounts it acts as a depressant and lowers blood- pressure by a direct action on the vaso- motor centre, and not by any action on the blood-vessel wall. It acts as a de- pressant upon the spinal cord, and lower- ing reflex action by its direct effects, and not by acting upon the nerve-trunks. It is a powerful antipyretic, analgesic, and antiparasitic, but an uncertain and dan- gerous one. The dose of hydracetin should not exceed V2 to 3 grains per diem, in divided doses. Poisoning by Hydracetin. — Given in repeated doses, hydracetin has a cumu- lative effect, and produces jaundice due to commencing haemoglobinsemia, with malaria, weakness, and a kind of angina. Less than 4 grains has produced cyano- sis of the face and extremities, coldness of the latter, reduction of the tempera- ture to 95° F., profuse sweats, accelera- tion and then retardation of the pulse, and an almost complete disappearance of the pulse and respiration. The urine becomes intensely dark red in color, and contains methEemoglobin, urobilin, and masses of amorphous, reddish-brown granules. The red corpuscles become discolored and show little tendency to form rouleaux. It is a powerfvil blood- poison, its distinctive action on the red 490 HYDEACETIN. HYDRASTIS. corpuscles being analogous to that of chlorate of potassium, pyrogallol, etc. Grave anaemia results, even from external use of this drug. Treatment of Poisoning iy Hydracetin. — Acute poisoning calls for the use of cardiac and respirative stimulants, heat, respiration, and evacuation of the stom- ach. Chronic poisoning has been suc- cessfully treated by the free use of milk, followed by ferruginous and other tonic remedies. Therapeutics. — Hydracetin has been used internally in rheumatic and other fevers, locomotor ataxia, and neuralgias. In a 10-per-cent. ointment it has been used in psoriasis. The iise of this remedy is attended with so much danger, and requires the exercise of such great caution, that its employment is strongly advised against, since it possesses no advantage over other remedies already in use. Further experi- ment with this drug should be aban- doned. C. SUMNEE WiTHEESTINE, Philadelphia. HYDRAEGYRTJM. See Syphilis. HYDRARTHROSIS. See Joints. HYDRASTIS.— Hydrastis, U. S. P., is the rhizome and rootlets of Hydrastis Canadensis, or golden seal. It is a small, perennial herb found in rich, moist woodlands throughout the United States, mostly in the northern and western por- tions. The dried herb has little odor and a peculiar, bitter taste. Hydrastis contains two principal alkaloids, hydras- tine and berberine; a third alkaloid, xanthopuccine, is found in very small quantity. Although berberine is found in greater amount than hydrastine, the latter is the characteristic alkaloid. Ber- berine is found in numerous other plants (Berheris vulgaris et al.). Hydrastine crystallizes in white, four- sided rhombic prisms; it also occurs in an amorphous form. When pure it is almost tasteless, being very sparingly soluble in water, but freely soluble in alcohol, ether, chloroform, and benzin (benzole). It forms salts with the acid, which are acid and bitter. Hydrastine is an artificial alkaloid produced from hydrastine by a process of oxidation. It also forms salts, one of which is ofEicial, the hydrochlorate (hy- drastininse hydrochloras, U. S. P.); this salt is soluble in water. Berberine crystallizes in yellow needles which have a bitter taste. It is soluble in hot water and alcohol, but insoluble in ether. Preparations and Doses. — Extract of hydrastis, fluid, V2 to 2 drachms. Glycerite of hydrastis. Tincture of hydrastis, ^/g to 1 drachm. Hydrastine hydrochlorate, ^/j, to ^/j grain (maximum dose, 2 grains per diem in divided doses). Berberine, ^/j to 15 grains. Physiological Action. — Hydrastis, like other bitters, promotes the secretion of the saliva and gastric juice, and thereby increases the appetite and digestive power. It also increases the secretions of the intestinal glands and of the liver. On the nervous system hydrastis has effects similar to those of quinine, but less marked. Porak's experiments dem- onstrate that hydrastine is a heart- poison, acting on the vasomotor system centrally. It is, therefore, uncertain and dangerous. Its derivative hydras- tine has no action on the heart, and but feeble action on the blood-pressure. It appears to act directly upon the capil- laries, its vasoconstrictive power being greater and more permanent than that of HYDRASTIS. THERAPEUTICS. 491 either hydrastine or ergot. Its action on the uterus is slight. Hydrastine, intravenously injected in the proportion of ^/a, grain for every 2 pounds of body-weight, produces con- stant diminution in the volume of kid- neys. In doses of V20 to '/go grain for every 2 pounds of body- weight the blood- pressure increases; the pulse is also in- creased by small doses. Large amounts diminish both pressure and the frequency of the cardiac beat and increase the sys- tolic contraction of the heart. Hydras- tine, in small quantities, diminishes the caliber of the blood-vessels. The accel- eration of pulse is attributed to excita- tion of the accelerator nerves of the heart; the subsequent slowing to stimu- lation of extracardiac centres of the pneumogastric nerves. Hydrastine stimu- lates spinal centres, followed by clonic and tetanic convulsions, and finally paralysis. The drug has a certain cumu- lative action, and is eliminated by the kidney particularly. No traces of it were found in the Dile. Marfori (Gaz. M6d. de Paris, June 7, '90). Poisoning by Hydrastis. — In poison- ous doses hydrastis may cause convul- sions, followed by paralysis, according to the quantity of the alkaloids present. Hydrastine is more convulsive in its efieets than berberine. When injected into the jugular vein, hydrastine causes a primary fall of arterial pressure, suc- ceeded by a decided rise, and the studies of Cerna have shown that it is an active poison, producing spinal convulsions, fol- lowed by paralysis (Hare). Ko fatal cases of poisoning by this drug have been reported. Hydrastine is poisonous to both cold- and warm- blooded animals; hydrastine destroys the irritability of the muscular tissue ; very large quantities produce loss of the functional activity of the efferent or sensory nerve-fibres, and also cause ansesthesia, when locally applied; in small amounts, it increases reflex activity by stimulating the spinal cord; later in the poisoning, by large quantities, hy- drastine diminishes reflex action by stimulating, at first, Setschenow's centre in the medulla oblongata, and afterward abolishes it by paralyzing the spinal cord; the paralysis produced by the drug is due to an action upon the mus- cles, the motor nerves, and spinal cord; the convulsions of hydrastine are of spinal origin; hydrastine destroys the electro-excitability of the cardiac muscle ; the alkaloid, in small doses, produces a primary frequency in the pulse-rate, due, probably, to a stimulating action on the cardiac motor ganglia; in moderate and poisonous amounts it diminishes the number and increases the size of the car- diac beats by an action upon the intra- cardiac ganglia and the heart-muscle itself; hydrastine lowers arterial press- ure by a direct action on the heart, and also through a paralyzing influence ex- ercised upon the centric vasomotor sys- tem; the drug produces at first an in- crease and afterward a, decrease in the number of the respiratory movements; hydrastine kills by failure of the respira- tion; the alka.loid lowers bodily tem- perature, the drug increases peristalsis; in hydrastine poisoning the salivary and the biliary secretions are largely in- creased, especially the latter; hydras- tine, locally applied, produces at first contraction of the pupil, afterward dila- tation of the same. David Cerna (Therap. Gaz., May, '91). Therapeutics. — Hydrastis is indicated whenever the tone of a mucous mem- brane is lowered in hsemorrhagic condi- tions and in malaria. Cataeehal Disoedees. — ^We find it beneficial, as a rule, in subacute or chronic catarrhal troubles: in chronic gastro-intestinal catarrh, in catarrh of the duodenum and gall-ducts with sub- actite jaundice, in catarrh of the uterus and vagina with leucorrhoea, in catarrh of the bladder and urethra, chronic nasal catarrh, etc. Not only does hydrastis possess de- cided tonic action, but it is also useful in all chronic, subacute, or catarrhal in- flammations of those organs lined with 492 HYDRASTIS. THERAPEUTICS. mucous membrane. W. C. Quiney (Chicago Med. Times, Nov. '91). Inhalations of a solution of the ex- tract 1 part, in salt water (3 parts), used with decided satisfaction in simple and tubercular bronchitis. Judson Palmer (Med. Age, Xo. 3, '91). Literature of '96-'97-'98. Good results obtained from use of fluid extract of hydrastis, in doses of 20 or 30 drops four times a day, in tuberculous subjects. The drug is superior to all others for phthisical cough. Sanger (Re- vue Inter, de M6d. ; Revue Med., Jan. 5, The conditions resulting from, or due to, the above are relieved by hydrastis: atonic dyspepsia, constipation due to de- ficient secretion, and spermatorrhoea. Malaeia. — Hydrastis is an excellent remedy in the treatment of intermittent and in chronic malarial poisoning, when cinchona preparations cannot be ob- tained. H^MOHHHAGE. — In the haemorrhage of puberty and the menopause in haemor- rhage associated with lesions of the ap- pendages, and in the uterine congestion of dysmenorrhcea, hydrastine hydro- chlorate, in doses of 1 V2 grains per diem (in divided doses), will be found effi- cient. The fluid extract, in daily doses of 100 to 150 drops, given in divided doses, will arrest the hasmorrhages occur- ring during pregnancy and the puer- perium. Administered to 97 cases of uterine hsemorrhage from various causes, with complete or partial success in 47 of them. Recommended for preventing flooding of any kind. Haeh (Proceedings Riga So- ciety Med. Practitioners, '87). Twenty minims of the fluid extract four times daily used for menorrhagia in a ca,se of uterine flbroids. The bleeding was completely arrested, and in three months' time the patient menstruated regularly. J. M. Fuchs (Med. Press and Circular, Jan. 25, '88). The di-ug is of especial value in haemor- rhages of the menopause, when there is no organic change in uterine tissues. In cases of myoma the results were unsatisfactory. The tincture of hydras- tine produced good effects in cases of atonic dyspepsia and general debility, commonly met with in women who have suffered from menorrhagia. Local use as important as internal administration; it has given excellent results in chronic endometritis, cervical erosions, and con- gestive states of the uterine cervix. It may be applied as a cervical dressing on the vaginal tampon, or added to the water used for the hot douche. H. M. •Jones (Med. Press and Circular, June 25, '90). Hydrastine is a heart-poison, acting on the vasomotor system centrally. It is an uncertain and dangerous remedy. Its derivative, hydrastinine, has no action on the heart, and its action on the blood- pre'ssure is feeble. Its vasoconstrictive power is much greater and more perma- nent than that of either hydrastine or ergot. Its action on the uterus is very slight. When a vigorous contraction of the uterus is desired, ergot is to be se- lected. In the hfemorrhages of puberty and the menopause, in those accompany- ing lesions of the appendages, and in the uterine congestion of dysmenorrhcea hydrastinine is preferable. In the case of uterine fibroids and endometritis its action is only palliative. It is best to give frequent doses, continued for many days in succession. Its administration should be begun before the commence- ment of the expected menorrhagia. Porak (Bull, de la Soc. de Med. Prat., Mar. 15, '92). Hydrastinine given in eighty-six cases of uterine hfemorrhage, the form em- ployed being V,-grain pills, 1 of which was ordered three times a day. The treatment was well borne, but patients frequently complained of painful uterine contractions. The most constant and re- markable effects were observed in haemor- rhage due to retro-uterine heematocele, an immediate arrest of haemorrhage be- ing obtained in all the five cases of this character. In functional menorrhagia considerable success was obtained; here HYDRASTIS. THERAPEUTICS. 493 2 pills daily were ordered a day or two before the expected period, 3 being taken as soon as it commenced and continued until its cessation. In liaemorrhage after abortion hydrastinine was usually effica- cious, as also in cases due to lesions of the appendages. It was of far less bene- fit in hsemorrhage due to chronic endo- metritis, to commencing abortion, and to uterine fibromata, though in all these classes of eases it sometimes proved use- ful. With hsemorrhages due to malig- nant disease no effect at all could be traced. Kallmorgen (Lancet, June 16, '94). In obstetrical cases liydrastis is dan- gerous neither to the mother nor the child. It exercises a curative and prophylactic haemostatic action on the uterus during pregnancy and at the time of accouchement. The fluid extract recommended in the haemorrhages during pregnancy and during the puerperal period, in amounts of from 100 to 150 drops per diem, divided into five doses; as an immediate curative agent in hsem- orrhage during accouchement, given to the extent of from 150 to 200 drops, in three or four divided doses; at the be- ginning of labor-pains in cases of pla- centa praevia; during dilatation, and in other cases; and, finally, as prophylac- tic measure against the frequent uterine hsemorrhages occurring at delivery or post-partum in cases of hydramnion, uterine inertia, and excessive develop- ment of the foetus and its membranes, or as the result of a profound ansemia of the patient or of the predisposition to flooding persisting from previous labors. Bossi (Nouveller Arch. d'Obstet. et de Gynfic, '91). Hydrastine has no influence upon the physiological loss of blood during and immediately after labor; it has no influ- ence upon the evolution of the uterus; it lessens the frequence and intensity of the pains, especially in multiparse; it does not arrest puerperal hsemorrhage; and it exerts no influence upon the ex- pulsion of clots from the uterus. Luigi Borde (Bull, delle Scienze Mediche, Dec, ;92). Hydrastinine is distinctly more power- ful than ergot; the arrest of hsemorrhage is prompt. The alkaloid is a powerful ecbolic. H. C. Wood (University Med. Mag., Aug., '94). Fluid extract of hydrastis, 20 to 30 drops, repeated several times daily, recommended in cases of haemoptysis. Koeniger (Ther. Monats., No. 11, '88). Drug found useless in the hsemoptysis of phthisis. Krannhals (Proceedings Riga Society Med. Practitioners, '87). Hydrastis found of service in the treat- ment of the night-sweats of a lai'ge num- ber of cases of hsemoptysis. The dose employed was 30 minims of the fluid ex- tract. Cruse (Cincinnati Lancet-Clinic, Ocl. 3, '91). Ten-drop doses of hydrastis Canadensis given in water every two or three hours is a sovereign preventive of epistaxis. Kohn (Med. Record, June 9, '94). Literature of '96-'97-'98. In tuberculous hsemorrhages hydrastis is the best pulmonary hsemostatic. Hsemorrhages of dysentery have been completely suppressed with this drug after all other measures had failed. Attention particularly called to the favorable and almost invariable effect that hydrastis exercises on hasmorrhoids, whether internal or external. Strangu- lated or irreducible hsemorrhoids are re- duced with greatest facility. As an oxytocic, it is not so rapid in its action as quinine. It is the preferable remedy in the haemorrhages of flbromyomasj and is the best means of combating the hsemor- rhages of pregnancy at any stage, pro- vided it is taken at sufficiently prolonged intervals — that is, 20 drops every three hours, or four times a day. Mariani (In- dgpendance'Mgd., Apr. 17, '98). The rationale of the hsemostatic influ- ence of hydrastis has been explained above; hence, when uterine contraction is desired, ergot is to be preferred, as hydrastis does not act on the muscular fibre of the organs, but on the vasocon- strictors. Woman seen in the fourth month of pregnancy in whom abortion took place 494 HYDRASTIS. HYDROCEPHALUS. on the third day of treatment with 100 drops of the tincture dailj', given for severe cervical catarrh. Von Styrk (Pro- ceedings Riga Society Med. Practitioners, '87). An aqueous extract of hydrastis Cana- densis, taken even in large quantity, produces no toxic efifect in warm- blooded animals. It produces always a reduction of the blood-pressure without any preliminary increase. It always pro- duces in rabbits contractions of the uter- ine body and horns. Under the influ- ence of hydrastis Canadensis the uterine contractions are most intense in cases of advanced pregnancy or soon after de- livery, while the most feeble contractions occur in a virgin uterus after its use. Large quantities of this extract may pro- duce premature delivery in the second half of pregnancy. Givopiszew (Bull. Gen. de Th6r., Nov. 8, '88). Small doses of hydrastine — '/m to ^/-.^ grain per 2 '/, pounds' weight of the ani- mal — are sufficient to bring on uterine contraction. The action upon the uterus is different from that of ergot, in that it is of central origin. K. Serdzew ("Das Pharmakologische Verhaltniss des Hy- drastins zum Blutgefassystem und zum Uterus," '90). Power of hydrastine to cause uterine contraction denied. P. Baunim (Ther. Monats., No. 12, '91). Abortion can be produced — not only at term, but also in the middle of con- ception — in rabbits, mice, and dogs by the use of hydrastine. P. Archangelski (Meditzinskoje Obozrenije, p. 52, '91). Topical Application. — In stomatitis and follicular pharyngitis the glycerite of hydrastis or the fluid extract will prove an active remedial agent. Fluid extract of hydrastis Canadensis used as topical application in pharyn- gitis, with or without enlarged tonsils, with favorable results. A. Felsenburg (Wiener med. Blatter, Nov. 29, '88). Literature of '96-'97-'98. In pruritus of the genitalia supposi- tories containing codeine or opium and hyoscyamus at night will often give the patient relief. H. Robb (Ther. Gaz., Sept. 15, '96). Unhealthy and sloughing sores, old ulcers, sloughing cancerous growths, and chancroids are favorably influenced when dressings of hydrastis are employed. C. SUMNEE "VVlTHERSTINE, Philadelphia. HYDKOCELE. See Testicles. HYDKOCEPHALTJS. Definition. — Hydrocephalus means an accumulation of serous fluid within the cranial cavity. The condition is fre- quently spoken of as dropsy of the brain, or as "water on the brain," and may occur as an acute or chronic affection. The location of the fluid varies, but is more frequently found within the cere- bral ventricles than outside the brain or between its membranes. Varieties. — The term "internal hydro- cephalus" is applied expressly to chronic hydrocephalus usually congenital in origin, and when the word hydrocephalus is used without qualification it is this variety of the disease which is univer- sally meant. Hydrocephalus may be primary, or secondary to some other dis- ease. Acute hydrocephalus is nearly always secondary to basilar meningitis, while chronic hydrocephalus is more fre- quently primary, and very often eon- genital; it also often develops after birth without any apparent antecedent cause. Hydrocephalus has also frequently been classified as congenital and acquired; but since many of the cases, apparently be- ginning after birth, really owe their origin to the same obscure causes which determine the congenital cases, it would seem better to regard the condition as acute or chronic, and as primary or sec- ondary. ACUTE HYDROCEPHALUS. SYMPTOMS. 495 I. Acute Hydrocephalus. Definition. — Acute hydrocephalus means an effusion into the ventricles or within the membranes of tire brain, as the result of an inflammation of the pia mater usiTally, either simple or tuber- cular, or it may result from other inter- cranial or systemic organic disease. Symptoms. — The symptoms of acute hydrocephalus necessarily depend for their mode of development on the cause producing the effusion, and, as menin- gitis of some grade is the most frequent cause, the signs of this disease very often precede and accoiapany those dependent upon the intracranial effusion. In other eases arising from gradual mechanical obstructions to the return venous circu- lation, the onset of symptoms indicative of ventricular dropsy may be most diffi- cult to determine; so that, especially if other serious illness — such as summer diarrhoea of infancy or one of the spe- cific fevers — complicate the case, the diagnosis may be conjectural or even im- possible. In such cases the meningeal affection sometimes runs a subacute course and gradually subsides, leaving an effusion which may, in rare cases, be absorbed again, but which more usually tends either to remain stationary or to slowly increase in amount until the char- acteristic physiognomy of the hydro- cephalic head is developed, and more or less permanent injury to the brain re- sults, although such patients may sur- vive for years in fair health. Commonly, however, the signs of acute hydrocephalus appear during the course of one or other of the conditions to be referred to under etiology. When the primary disease is acute non-tubercular basal meningitis, the child stricken with this disease is apt to be fretful; irritable, restless, and sleepless, for from a few davs to a week or two. Headache is another early symptom, and is usually combined with intolerance of. a bright light, while the face is flushed and the anterior fontanelle pulsates strongly. At this early period there may also be stra- bismus of irregular degree. Vomiting is frequently an early symptom, and may be an extremely marked one. The tem- perature is that of moderate fever, but in severe cases there may be hyperpy- rexia during the first two or three days or even longer. The pulse is in some cases distinctly slow and rather full, but in others much accelerated in rate and small in volume, or these conditions of the -pulse may vary or alternate. The respiration is often shallow and irreg- ular, and, after actual ventricular effu- sion has occurred in sufficient amount to cause compression of the brain, Cheyne- Stokes respiration is frequently noted, especially in the later stages of the dis- ease. According to the severity of the cause producing the effusion coma de- velops slowly or suddenly, with twitch- ings and rigidity of a limb, or of all the limbs. This tremor and stiffness of the muscles may include the neck and spinal muscles, and twitching movements of the facial muscles or of the head are very com- mon. In the rapidly-fatal cases the coma deepens, the pulse and respiration pro- gressively fail. The face is void of ex- pression, the eyes present marked con- traction of the pupils, with occasional irregular movements of the ocular mus- cles, convulsions may occur and be re- peated many times, and the little patient dies from failure of the respiration and of the heart's action. In some of these severe cases, inflam- matory in nature, there is often a marked remission of all symptoms, including the regaining of consciousness, a lessening of the spastic condition of the muscles, and a decided improvement of the gen- 496 ACUTE HYDROCEPHALUS. SYMPTOMS. eral condition. This change for the better is too often a deceptive one, and is followed by a return of the same grave symptoms noted above preceding death. In cases of simple non-tubercular basilar meningitis the improvement may be real and the patient slowly recover, and after some months the recovery may be a per- fect one. It is more common, however, that some permanent mental or physical defect is left as the result of the effusion, and such patients are a long time in re- covering from the very marked emacia- tion which always is present and in some cases is extreme. The course of the disease may be ex- tremely variable, and the duration from a few days to many months. In such cases the characteristic hydrocephalic head may develop, and the case very much resemble one of chronic hydro- cephalus. This variability in this dis- ease we must assume to be directly de- pendent upon the grade and extent of the primary inflammation, which in certain cases runs a subacute or almost chronic course which may finally end in more or less perfect recovery. Even in the most favorable case, when effusion has taken place into the ventricles, it is extremely rare that this effusion wholly disappears. The clinical and post-mor- tem evidence is strongly in favor of the view that when effusion once occurs it is, at best, only permanently limited in the favorable cases, the brain gradually accustoming itself to the changed con- ditions, while the majority of the cases show a tendency toward progressive in- crease of the ventricular accumulation. When tubercular meningitis is the primary condition, the same prodromal symptoms are usually noticed as have been above noted as ushering in non- tubercular meningitis. At times the on- set is very acute, but it is more apt to be gradual, with slowly-rising temperature, which does not commonly run so high as the temperature-curve of typhoid fever, nor does it often exhibit the very marked remittency usually observed in that dis- ease. Irregularity of the pulse, some changes in the respiration-rhythm, re- traction of the abdomen, irregularly- contracted pupils, slow and irregular lateral movements of the eyeballs and unilateral or bilateral flushing of the face, the taclie meningique, gradually de- velop. A violent convulsion, followed by hemiplegia with involvement of the face, may be the next symptom, and it may or may not be preceded by twitch- ings of the facial and orbital muscles. In many cases amaurosis, ptosis, strabis- mus, or facial paralysis alone may be noticed after a convulsion. Drowsiness may be present from the beginning of the illness, but coma comes on early or late, according to the severity of the case, and the clinical picture is one of coma slowly ending in death. The symptoms attending the course of other conditions producing acute hydro- cephalus, and non-inflammatory in na- ture, naturally depend upon the nature of the obstruction to the venous circula- tion and the manner of its occurrence. In cases arising from enlargement of the bronchial glands the cerebral effusion may accumulate very slowly and be un- suspected until the case is far advanced, when prominence of the fontanelles with absence of pulsation, some increase in the size of the cranium, coupled with gradual on-coming stupor, tremors, con- vulsive seizures, or some form of paraly- sis may direct attention to the cerebral condition. The clinical course of these cases, which are fortunately of rare oc- currence, is extremely variable, and the same may be- said of the symptoms pre- sented before actual dropsy of the ven- ACUTE HYDROCEPHALUS. ETIOLOGY. 497 tricles occurs, and evidences of intracere- bral pressure become manifest, so that such forms of the disease, while they may develop acutely, approach very closely and often nm into chronic hydro- cephalus. In all cases of acute hydro- cephalus the changes in the shape and size of the skull may be very slight, and if the disease occurs after the ossification of the cranial bones, such changes can- not be detected by measurements. Etiology. — Any cause which operates by obstructing the venous circulation within the cranial cavity may cause an acute effusion of serum into the ven- tricles or elsewhere within the skull. Thus, intracranial tumors, enlarged bronchial glands, retropharyngeal ab- scess, and intracranial heemorrhage are all causes of more or less acute hydro- cephalus. Literature of '96-'97-'98. Adult internal hydrocephalus, apart from acute meningitis, is almost always due to subtentorial tumor, and is, indeed, a very common consequence of such a tumor. The tumor causes the hydro- cephalus by (o) compressing the veins of Galen, (6) compressing the outlet from the lateral ventricles, or (c) compressing both. William Gordon (Lancet, Jan. 9, '97). The same is true of certain diseases fi'hich cause, at times, enlargement of the bronchial glands, and thus, by press- ure on the vense innominate, obstruct the venous circulation of the brain, re- sulting in passive congestion and effu- sion of serum from the engorged blood- vessels. Acute hydrocephalus has also been frequently noted in connection with exhausting diseases, like severe cases of scarlet fever, typhoid fever, and prolonged diarrhoea of children, espe- cially that occurring in summer. Literature of '96-'97-'98. Two cases, in children, of very marked hydrocephalus, with convulsions, spas- modic rigidity of limbs, exaggerated knee-jerks, and total blindness. Gastro- intestinal disturbance was in each case the starting-point of the affection. Mar- fan (Sem. Med., Aug 21, '96). In the latter class of cases the effusion is partly the result of the actual wasting of the brain, which favors passive con- gestion of the organ, and is also due, in part, to the great weakness of the circu- lation, which is a special feature of pro- tracted cases of infantile summer diar- rhcEa. Syphilitic meningitis may also be accompanied by an acute effusion into the ventricles, and in all of these cases a careful study of the family history, and a very critical examination of the pa- tient, should be made so as to discover, if possible, other evidences of the exist- ence of syphilis. Finally, certain writers have reported cases of so-called essential dropsy of the brain, in which there could be found no anatomical lesion to explain the eff'usion. Ko case of acute effusion within the cranium should, however, be put into the last category, tmless a careful and complete post-mortem fails utterly to reveal a pathological lesion, and the diagnosis of acute essential dropsy during life is certainly a wholly impossible one. Practically acute inter- cranial effusion of serum is more fre- quently seen as the resiilt of tubercular or simple leptomeningitis than from the other conditions .above enumerated. (Acute hydrocephalus and tubercular meningitis are often used as synonymous terms, but, in view of the many other conditions which occasionally give rise to the former, it would be well to discon- tinue such use of these terms as mislead- ing to students.) Occasionally intracerebral hsemoT- 498 ACUTE HYDROCEPHALUS. PATHOLOGY. rhage may result in the formation of a cystic accumulation of serum within the membranes of the brain or between them and the skull itself. Pachymeningitis may also cause a localized collection of serum. In such cases of localized cystic collections there is very apt to be marked pressiTre thereby of the subjacent convo- lutions. The amount of fluid present in any case of acute hydrocephalus is very small in comparison with the very large amount usually present in chronic hydro- cephalus, and very rarely exceeds four or five ounces. When acute hydrocephalus arises from inflammatory disease of the membranes of the brain, the meningitis is commonly basilar. This is particularly true of the simple and tubercular menin- gitis of children, while cases occurring in adult life frequently involve the mem- branes over the convexity of the brain as well. Leptomeningitis as a cause of acute ventricular efEusion is most fre- quent before the end of the sixth year, and more often arises in subjects debili- tated by previous disease, or by poor hygienic and social conditions. Pathology. — Post-mortem examina- tion of the brain in acute hydrocephalus of inflammatory origin reveals usually a basilar leptomeningitis, which may be simple, tubercular, infective, or syphi- litic in origin, with an excess of, fluid in the ventricles, causing a marked dilata- tion of them, while the substance of the hemispheres presents appearances due largely to the increased intracranial pressure. This intracranial tension often partly expels the blood from the vessels, especially during the last hours of life; so that at the post-mortem the brain - substance may look antemic, especially over the vertex and throughoiTt the sub- stance of the hemispheres. In cases of simple leptomeningitis the naked-eye appearances of the pia at the base of the brain will rarely present marked evi- dences of the intense hypersmia existing during life. The ventricles are dis- tended with a slightly-opaque or turbid serum, while the choroid plexus is over- distended with blood, which may also be extravasated in punctiform patches in their immediate vicinity. The micro- scope shows extravasation of leucocytes along the lines of the blood-vessels and distending the perivascular sheaths, and also reveals minute capillary haemor- rhages, pus-cells, and in some cases com- pound granule-cells, depending largely upon the duration of the disease. The cerebral substance in some cases may contain areas of softening, but the rule is to find no such lesions, and, with the exception of changes in shape from pressure, the convolutions may be nor- mal. When tuberculosis is present it is usu- ally also at the base in children, but may involve large areas of the pia mater in older subjects, and in adults the vertex is not infrequently the site of the tuber- culous deposit. The characteristic post- mortem appearance is the tubercle, and the location in which this is most com- monly found is in the pia overlying the crura cerebri, the optic, olfactory, and the point of exit of the third nerve, and also in the membrane as it extends over the corpora quadrigemini. The pia is much thickened, is covered by a grayish- white exudate, and the tubercles show as whitish-gray bodies imbedded in the membrane. In size the tubercles vary from exceedingly-minute bodies, hardly discernible macroscopically, to that of the head of a pin or even somewhat larger. The ventricles are distended with a turbid albuminous fluid, and there is thickening and softening of the epen- dyma. The microscope confirms the diagnosis and reveals the existence of ACUTE HYDROCEPHALUS. DIAGNOSIS. PEOGNOSIS. TREATMENT. 499 numerous obstructions of the smaller arterioles from tubercular deposit, or an obliterating endarteritis. Giant cells may be seen in the perivascular spaces or in the cerebral substance, while the bacillus tuberculosis is seen along the lines of the vessels and in and arovind the areas of the tubercular deposits. In all cases the bronchial glands should also be examined, since they are frequently a most important factor in the production of the ventricular effusion. Diagnosis. — The diagnosis of acute hydrocephalus is not difficult when it occurs as the result of meningitis. In such cases the prolonged coma, the irreg- ular movements of the muscular system, with the respiratory rhythm, are all sug- gestions of the increased intracranial tension due to the ventricular effusion. The subacute eases are, perhaps, the most difficult of recognition, and the condition of the brain may remain un- suspected until the graver symptoms ap- pear. The cases arising rather abruptly from the pressure of intracranial growths or from enlarged bronchial glands also present many difficulties in the way of early diagnosis, but the appearance of grave signs of cerebral disturbance, the discovery in certain cases of other evi- dences of tuberculosis, or of retropharyn- geal abscess causing embarrassment to the cerebral circulation, the exclusion of traumatism, the ophthalmoscopical ex- amination, and a careful study of the his- tory of the illness will often aid in mak- ing up an opinion. The very fatal case? which occur in large cities, especially during the course of the diarrhoeal dis- eases of infants and young children, pre- sent few difficulties in their recognition, because the brain-symptoms develop so early and progress so rapidly toward death. In these cases the tendency toward a marked, but most deceptive, re- mission of symptoms should be borne in mind. In all cases of acute hydroceph- alus the general wasting of the body is a prominent feature. In cases of long duration the emaciation may become extreme, and contractions occur in the limbs which may be more or less perma- nent should recovery take place. The characteristic hydrocephalic aspect is rarely seen in acute hydrocephalus, un- less the case should drift into the chronic condition, cases of which are only rarely seen. Cases arising frgm meningeal hemorrhage usually become chronic, the fluid being encysted between the mem- branes of the brain. Prognosis. — The prognosis of acute hydrocephalus is always bad. The dis- ease ends usually in death, or in perma- nent mental or physical defects, in the cases which escape death. Probably the syphilitic form is the most hopeful when the condition is suspected early enough to get the patient promptly under the influence of speciflc remedies. The cases arising from enterocolitis, or any of the acute fevers or other exhausting disease, offer little hope as to recovery, although occasionally a patient will recover. The tuberculous cases are absolutely hopeless, although Jacobi and others have testified to the recovery of two or three cases. Subacute basilar meningitis may cause ventricular effusion and subside, leaving the effusion, which may remain station- ary in amount or even lessen in amount so that the symptoms of its presence dis- appear; but usually the tendency is for it to increase, and finally, after months or years, the clinical pictiTre of chronic hydrocephalus is produced, should the patient have been a young child, thus admitting of the expansion of the cra- nium. Treatment. — The treatment of acute hydrocephalus is very often that of the 500 ACUTE HYDROCEPHALUS. CHRONIC HYDROCEPHALUS. VARIETIES. primary disease to which the ventricular effusion is only secondary. Sometimes, from the very rapid progress of the ease toward a fatal end, treatment can be of little avail. In the majority of cases it is almost hopeless, but in all cases every effort should be made, for occasionally the recovery of one of these cases from a seemingly-hopeless condition will amply repay the untiring care which they all demand. When the initial symptoms of menin- geal irritation appear, should the patient be seen at that early period, absolute rest in a darkened room, prompt vesication behind the ears with cantharidal collo- dion, in children, and regular doses of calomel in great amount should be in- stituted. If necessary, opium should be given to control the restlessness, prefer- ably combined with chloral, and these should be continued in suitable doses so long as the twitchings and spastic muscular condition continue. Irrigation of the bowels should be practiced where there is enterocolitis as the cause. In all cases every part and organ of the body should be very carefully exam- ined so as to exclude complicating con- ditions and establish the diagnosis. The initial treatment is of the greatest im- portance, for after the effusion has oc- curred there is less hope of doing good. When the patient is a sthenic subject and the arterial tension high, leeches or wet cups to the mastoid regions may be employed. After these measures the spinal ice-bag should be used in the cases with high temperature; and they should be avoided in those with low-tempera- ture range, as collapse has been induced in such patients in my own experience. The bromides and chloral will usually be demanded to mitigate the tendency toward convulsions, while they both tend to lessen cerebral hvpertemia. Chloral may be used as a rectal injection in cases where the stomach is non-retentive. In some cases the warm bath is desirable and helps to calm the muscular system. The diet should be carefully regulated and stimulants should not be given un- less demanded by the condition of the pulse. In the later stages signs of col- lapse should be watched for, and that condition anticipated, when possible, by the prompt administration of a rapidly- acting stimulant, such as ammonia. Should the patient recover from the acute stage of the disease, diuretics, in- cluding the acetate and iodide of potas- sium, should be employed, with tonics, massage, and electricity, in order to in- crease the nourishment and activity of the muscles. Although the percentage of recoveries is exceedingly small, it is large enough to warrant the utmost zeal in the treatment of these distressing cases. II. Chronic Hydrocephalus. Definition. — Chronic hydrocephalus means a progressive accumulation of serum within the ventricles of the brain, or in rare cases external to the brain and between its membranes, or between them and the skull itself; or in all of these situations. It is characterized by en- largement of the head, an almost pathog- nomonic facies, and by a progressive tendency toward death; often from grad- ual failure of the vital powers, or from intercurrent disease, or more rarely from rupture of the head. Varieties. — The term internal hydro- cephalus is used to denote the cases in which the effusion is ventricular, while external hydrocephalus is used to denote the cases in which the effusion is external to the brain. The former class of cases is by far the most numerous, and is meant when the word hydrocephalus is used alone. The disease may also be CHROXIC HYDEOCEPHALL'S. SYMPTOMS. 501 primary or secondary. Many of the cases are congenital, but in the majority of instances it is first noticed some weelis after birth. Symptoms. — The symptoms of chronic internal hydrocephalus and the external variety of the same disease are similar and differ only in degree. External hydrocephalus is extremely rare, and is secondary, in the vast majority of the cases reported, to meningeal haemor- rhage and to pachymeningitis. It is also found in cerebral atrophy, probably as a compensating lesion, and also has been found in eases of congenital cerebral malformations. The amount of fluid found is very small in comparison with that found in internal hydrocephalus, but some cases have been reported in which the head was decidedly enlarged and the sutures separated. Internal hydrocephalus, which is the ordinary variety met with in practice, presents as its chief symptom an en- largement of the head. In some cases this enlargement is very great, as in a case reported by Steiner, which exhib- ited a cranixim 32 '■'/^ inches in circum- ference at the eighth month. The normal circumference of the head at one year is given by Holt as from 18 to 19 inches. The increase in size of the head is usually in all directions, and the su- tures in marked eases are widely sepa- rated, while the cranial bones are ex- panded and thinned out until sometimes they have a parchment-like sensation to the touch. The fontanelles are very large and bulging; the veins of the scalp are engorged; fluctiTation of the head is quite common, and it may also be trans- lucent to light. The scalp is stretched and thin and exhibits very little hair. On the other hand, internal hydro- cephalus may exist with no perceptible enlargement of the head and with per- fect, and even premature, ossification of the cranial bones. Primary cases of in- ternal hydrocephalus are most often con- genital, but in most cases the condition is only recognized after some weeks sub- sequent to birth; but in other cases the condition develops rapidly in, utero, and puncture of the head may be necessary to effect delivery. In the largest class of cases nothing is noticed until several weeks have elapsed after birth, when the abnormal size of the cranium attracts attention. The child is also noticed to have difficulty to support or move the head, or is incapable of supporting it at all. Soon drowsiness and apathy are apparent in the infant, and it sinks into a condition of hebetude with all the senses less acute than normal. There is apt, at this time, to be either undue flac- cidity or stiffness of the extremities. The latter condition is more common and the thumbs are adducted with the fingers tightly closed. The pupils are usually contracted, but at times irregular or dilated. There is marked general ema- ciation. Convulsions may occur and be repeated, and slow rolling of the eyeballs laterally or more or less strabismus may be features of the case. Literature of '96-'97-'98. Case of a male aged 22 years at time of death. Had "water in the head" when a year old, but was supposed to have re- covered from this, though the head re- mained large. He grew up a bright, in- telligent child till his seventh year, when the head-symptoms recurred and rapidly developed. Very soon he became blind, and ti few years afterward his speech also -was lost, though hearing remained unaffected till death. During the course of the disease he was subject to infre- quent ahd very slight convulsions. At death the skull was completely ossi- fied, the face infantile in size and ap- pearance, and the teeth decayed. The body and the limbs were shrunk 502 CHROXIC HYDROCEPHALUS. ETIOLOGY. to the skeleton, and of board-like rigid- ity. Only the shoulder and fingers of the right side were movable, voluntary movement being accompanied with trem- ors. For fifteen years he had been nursed in the arms like an infant, con- stantly whining and crj'ing out. Death was preceded by coma of about four hours' duration. John Lindsay (Brit. Med. Jour., May 9, '96). Idiopathic internal hydrocephalus in the adult consists in an ependymitis giv- ing rise to a serous effusion into the ven- tricles of the brain. The causes, so far as known, are injury to the head, mental overstrain, alcoholism, disease of the middle ear, and acute infectious diseases. The affection may be either acute or chronic. The chronic cases present symp- toms so closely resembling tumor that they are usually diagnosed as such. The general symptoms are headaclie, vomit- ing, fever, stupor, delirium, optic neu- ritis, and convulsions. The local symp- toms are usually paralysis of the cranial nerves, especially exophthalmos, pain and rigidity in the neck and extremities, and hyperesthesia. The acute form may, after a course of some weeks, end in either complete recovery or death, or be- come chronic. The chronic form may pursue a varied course, with remissions and acute exacerbations, continuing for years, and ending finally in recovery or in death. Martin Prince (Jour. Nerv. and Mental Dis., Aug., '97). The rapidity of the enlargement dif- fers very much in different eases, and the clinical history depends largely upon this fact. In cases in which the increase of fluid is very slow the brain seems to aecomhiodate itself to the pressure, and the symptoms of intracerebral pressure may be very few or almost entirely lack- ing until the case is far advanced. When chronic hydrocephalus is secondary, and arises after ossification of the cranial bones is firmly established, the symptoms of increased cerebral tension are earlier and more markedly seen, although the amount of fluid in the ventricles is rela- tively very small in comparison to the primary cases. A well-developed case of internal hydrocephalus presents quite a striking and characteristic appearance. The face is small and overshadowed by the enlarged cranium, the forehead is prominent and bulging, the eyes are directed down and formed so that the white of the eye is always more or less uncovered by the upper lids, the child is often restless, and there is frequently twitching of the extremities; a short, sharp cry is often given, and, taken in connection with the emaciated body, the picture presented is almost pathogno- monic of the disease. The head is often rather flat behind, with bulging sides and greatly-rounded frontal regions. Etiology. — Chronic hydrocephalus arises often, especially the congenital cases, without any demonstrable lesion of the brain. In many cases it is due to meningitis, or to other organic disease of the brain, such as tumor. Some au- thorities attribute a large proportion of the cases to syphilis, which certainly does appear often in the family histories. Observations made upon 18 cases of hydrocephalus. Of these, 3 had well- marked symptoms or signs of congenital syphilis. Among the remaining 15, 13 '/, per cent, presented signs of enlarged liver and spleen, and which the writer believes were cases of hereditary syphilis, the result of an attenuated virus. It was noted that the apparently-healthy mothers of hydrocephalic children aborted more frequently than mothers who had borne healthy children. H. Eisner (Jahrbuch. f. Kinderheilk., B. 43, H. 4). Distinction must be drawn between congenital and post-partum hydroceph- alus. In the former only two spaces are found filled with fluid. Hydroceph- alus attributed to an obstruction to the flow of the eerebro-spinal fluid. The post-partum form generally arises in the first half-year of life, following various infectious diseases, such as syphilis, tuberculosis, and also rickets. Treatmeni, CHRONIC HYDROCEPHALUS. PATHOLOGY. 503 is useless; puncture brings about a tem- porary Improvement and sometimes causes improvement in symptoms due to brain-pressure; but the fluid collects again and the children die from maras- mus due to great loss of albumin. Pott (Med. Press and Circular, Nov. 13, '95). Other authors ascribe the congenital defect to rickets, but this connection is not by any means clearly proved, for much confusion has arisen from the fact that, clinically, rickets and hydroceph- alus have frequently been confounded, but they are sometimes associated. Pri- mary hydrocephalus has also been caus- atively referred to tuberculosis, but there is lack of positive evidence. The influ- ence of heredity is probably an important factor; often two or more children in the same family have been afEected. Extreme overwork and worry in the mother is, I believe, an important factor in determining the occurrence of pri- mary hydrocephalus. It must be ad- mitted, however, that we are still in the dark regarding the essential causative factor of primary hydrocephalus. In some cases of secondary hydrocephalus the cause can be clearly traced to an an- tecedent mild attack of basilar menin- gitis, or to a basal tumor, or to some mechanical cause producing venous stasis in the vessels supplying the ventricles. Two cases of hydrocephalus, associated with complete absence of communication between the fourth ventricle and the sub- arachnoid space. The ventricle in the first case was closed behind by a dense fibroid membrane between three and four millimetres thick; in the second by a close adhesion. O'Carroll (Dublin Jour. Med. Sci., Oct. 1, '94). Literature of '96-'97-'98. The most frequent causes of obstruc- tion in cases of chronic hydrocephalus are simple fibrous closure of the foramen of Magendie, adhesion of the surfaces of the tonsils of the cerebellum to each other and to the mai-gin of the fourth ventricle, and the presence of cysts be- tween the arachnoid and pia, at the pos- terior inferior aspect of the cerebellum. A. Bruce and H. J. Stiles (Scottish Med. and Surg. Jour., Mar., '98). Pathology. — The lesions found post- mortem are caused by the enormous dila- tation of the ventricular cavities in which the effusion usually accumulates. Thus in very marked cases all the walls of the ventricles are extremely thin, the septum lucidum is obliterated, and sometimes the brain-substance forms a mere envel- ope for a large central cavity formed by the gradual expansion of the ventricles. In more extreme cases nearly all of the brain-substance may have disappeared through the effect of the great pressure, and the brain resembles a cystic tumor, with only the basal ganglion and cere- bellum and portions of the temporo- sphenoidal remaining, as in a case of Peterson's, referred to by Holt. The fluid found in cases of chronic hydro- cephalus is slightly alkaline, translucent, specific gravity about 1005, and contains a trace of albumin and sometimes sugar. It also contains traces of alkaline chlo- rides and phosphates. The fluid in cases arising from meningitis is usually more turbid and contains a larger percentage of albumin. The quantity of fluid varies from a few ounces, in secondary cases, to six pints or more in primary cases. literature of '96-'97-'98. Hydrocephalic fluid is sterile and faintly alkaline and of a specific gravity varying from 1005 to 1010, having no toxic action upon animals. The propor- tion of albumin remains constant (about 0.25 per cent.), despite repeated punct- ures. Glucose has never been found, nor has peptone, urea, mercury, or potas- sium iodide. Salts are present in small quantity. It has the same chemical com- position as physiological cerebro-spinal fluid, and consequently is not an exudate 504 CHRONIC HYDROCEPHALUS. PROGNOSIS. DIAGNOSIS. or transudate, but a true secretion. Con- cetti (Wiener klin. Woch., No. 42, S. 934, '97). The brain-substance is anfemic, often there is no line of demarkation between the gray and white matter, and the effects of pressure are evident in bad cases, which show, under the micro- scope, marked degeneration of the nerve- elements. In lesser grades of effusion the microscopical changes may be scarcely noticeable. The ependyma may be normal in appearance, but is often found thickened, infiltrated with leu- cocytes, and granular to the naked eye. In some cases it has undergone degen- erative changes. In most cases some changes are found in the ependyma, and it is probable that these lesions are often directly responsible for the effusion itself, and that they result from an ante- cedent attack of ependymitis, simple or specific in character, and often occurring in foetal life. The bones of the cranium are more or less widely separated, sometimes to the extent of three inches. More rarely pre- mature ossification has occurred, and in these cases the head is not enlarged. The cranial bones are remarkably thinned, and may be almost as thin as paper. Spina bifida is quite freqitently associ- ated with hydrocephalus, and, less fre- quently, some form of meningocele or encephalocele complicates the case. Prognosis. — Complete recovery is prac- tically unknown. In the most favorable cases the enlargement of the head spon- taneously ceases after some years, and the patient may live for many years, but with no diminution in the size of the cranium. Mental defects are common in such cases. The majority of cases pro- gress more or less rapidly to a fatal end. The rapid cases die within the first year, and it is very uncommon for a case of marked infantile hydrocephalus to live over the sixth year of life. Death usu- ally results from marasmus, intercurrent disease, or from convulsions ending in coma from which the patient cannot be roused. Very rarely rupture of the head is a cause of death. Diagnosis. — The diagnosis is usually an easy one. Chronic hydrocephalus must be distinguished from rickets and hypertrophy of the brain. No error is liable to occur in the very marked eases, but when the effusion is of moderate amount the diagnosis may demand care- ful examination. From hypertrophy of the brain hydrocephalus is separated by its more rapid development, the greater enlargement of the head, the fluctuation which is often present, the universal character of the expansion of the cra- nium, which is more marked at the vertex in hypertrophy of the brain, and by the almost pathognomonic facies of hydrocephalus, inckiding the oblique direction of the eyes, with failure of the upper lid to completely cover the eyeball. To the touch hydrocephalus is softer and more compressible than hypertrophy. Literature of '96-'97-'98. Diagnosis of idiopatliic internal hj-dro- cephalus in the adult: great stress laid upon the variation in the intensity of the symptoms from day to day. These remissions and intermissions in the chronic cases must be largely relied upon to distinguish them from cases of brain- tumor. Martin Prince (Jour. Nerv. and Mental Dis., Aug., '97). From rickets chronic hydrocephalus is distinguished by the rounded head, which in rickets is sqitare or angular and often marked by nodules; also by palpa- tion and the other signs of the hydro- cephalic head above noted. In rickets, also, there will usually be other evi- CHROXIC HYDROCEPHALUS. TREATMENT. 505 dences of the disease in other parts of the body. Cases of chronic external hydroceph- ahis may present more difficulties in diagnosis, but they are of very rare oc- currence, and careful examination will usually separate them from the cases under consideration. Treatment. — The treatment of chronic hydrocephalus by internal remedies only rarely results in any benefit. Probably the best diuretic and alteratiye in these cases is the iodide of potassium, which should be given a trial in eases where it is not especially contra-indicated. In all cases of hydrocephalus congeni- tal syphilis should be looked for, and, if found, antisyphilitie treatment should be adopted energetically and as early as possible. Heller (Deutsche med. Woch., June 30, '92). Literature of '96-'97-'98. Case of child, 7 mouths old, suffering from chronic hydrocephalus. The head was enlarged, the fontanelles were wide open and bulging, and the veins of the face and scalp were dilated. The child was treated with potassium iodide inter- nally (2 or 3 grains daily), and in five months all signs of chronic hydroceph- alus had disappeared. J. Heller (Deut. med. Woeh., Xo. 5, '98). Surgically, compression of the skull by adhesive plaster applied in strips has been tried, and cases of marked improve- ment have been reported as resulting from this treatment. The treatment much in vogue is a combination of press- ure with adhesive strips covering in the entire vault and sides of the cranium, combined with occasional aspiration of moderate amounts of fluid, followed by the reapplication of the adhesive plaster. The effects of the pressure must be care- fully watched and the strips loosened or removed should dangerous symptoms appear. If syphilis is suspected mer- curial inunctions to the head should be practiced. Other modes of treatment are: inci- sion with drainage, puncture by the trocar, blisters, and lumbar puncture. When any operative interference is con- sidered, the preference of the writer is for repeated aspiration with strapping of the head. Five cases of hydrocephalus treated by puncture, in one only with success. Karnitzky (Brit. Med. Jour., Oct. 31, '91). Even when the fluid is allowed to flow out slowly, in order to avoid a too-sud- den evacuation, the death of the patient, often within twenty-four hours, is not prevented. Picqu6 (Le Bull. M6d., Oct. 28, '94). Three punctures made in a 4-month- old baby and over 2 pints of fluid re- moved. There was slight temporary im- provement, then Cheyne-Stokes respira- tion and death. Rachitis considered as an important factor in the etiology of the disease, and rachitic changes in the blood-vessels, particularly the veins, may cause stasis and transudation. With- drawal of the fluid by means of several punctures, taking away small quanti- ties, is preferable to removal of a large amount of fluid at one puncture. Isoher- nomor-Sadernowski (Archives of Pedi- atrics, July, '94). Ten ounces of fluid removed, with the aspirator, from the head of a child 2 years old, Avith satisfactory result, the fontanelles closing and the child becom- ing able to walk. Tordoff (Brit. Med. Jour., Apr. 18, '91). The point at which it is best to tre- phine for the purpose of reaching the lateral ventricles is two and a half centi- metres above and three centimetres be- hind the external auditory meatus. Moussous (Jour, de Med. de Bordeaux, July 26, '91). Case of a colored child, now 6 years old, operated on successfully for hydro- cephalus in infancy. Convulsions and other pressure symptoms had b^en pres- ent; aspiration was repeatedly done, with only temporaiy benefit, and an in- 506 CHRONIC HYDROCEPHALUS. TREATMENT. eision was made through the fontanelle, with result stated. Vinke (Weekly Med. Rev., Feb. 28, '91). Case of a boy, aged 3 years, hydro- cephalic from the age of 9 months; his intellect was unaffected, but he suffered from sleeplessness and pain. During anaesthesia a trocar was thrust through "the anterior and outer corner" of the anterior fontanelle, downward and in- ward; on reaching the ventricle, a jet of clear, serous fluid spouted out. Drainage was made by means of a collared cannula, which, however, was pushed out in about a week's time by the healing process. Recovery took place without a bad symptom. Illingworth (Brit. Med. Jour., Apr. 4, '91). Case of a child, 25 months of age, blind, deaf, and idiotic. Five centimetres above the external auditory meatus a, large opening, four centimetres in di- ameter, was made. A small opening was accidently made in the dura mater by the perforator, from which a large quan- tity of cerebro-spinal fluid escaped. The skin was then sutured, a drain being em- ployed to favor the exit of the fluid. The pulsations of the brain increased as the fluid drained away. Four months after the operation the child began to walk, but is still blind. Phocas (Revue Men. des Ural, de I'Enfanoe, Feb., '92). Of six cases, all tapped more than once, four improved and two almost recovered. The operation, if performed aseptically and the fluid drawn off slowly with the head well depressed, is not attended with the danger usually ascribed to it; im- provement usually follows the operation; and if done sufficiently early there is some prospect of the child's becoming a useful member of society. Hern (Brit. Med. Jour., Nov. 11, '93). Puncture of the skull favored in the treatment of hydrocephalus. The ad- vantages are: 1. Cessation of convul- sions. 2. Quieting of the restless, scream- ing patient. 3. Good influence on bodily development. 4. Improvement or saving of the physical functions. 5. Restoration of sight when lost. The disadvantages are: 1. Formation of an hsematoma; very rare, and usually avoidable. 2. In- fectious meningitis; avoidable by asep- sis. 3. Meningitis through pressure; gangrene; occurs also without puncture, and is avoidable by drawing off small quantities at a time. 4. Collapse; never occurs in dangerous degree under favor- able conditions. Wyss (Corres. f. Schwei- zer Aerzte, Apr. 15, '93). Trephining and tapping the lateral ventricles are indicated for distension due to chronic hydrocephalus, with moderate distension of the ventricles, without en- largement of the head; but if there is great distension of the ventricles with enlargement of the head, the operation would lead to fatal result. Frank (An- nals of Surg., Apr., '94). Puncture regarded as not a dangerous procedure if carried out under antiseptic precautions, and if the fluid be evacuated in small quantities at intervals of sev- eral weeks. The employment of perma- nent drainage Is more dangerous than evacuation of the fluid by puncture or even aspiration. Puncture is indicated in those cases in which, in a previously healthy child, symptoms of hydrocephalus rapidly de- velop; if a progressive enlargement of the head be distinctly noticeable; if marked bodily or mental impairment he threatened. Raczyski (Oesterr-ungar. Centralb. f. d. Med. Wissen., No. 20, '95). Paracentesis of the spinal canal substi- tuted for trephining of the skull in 3 cases of hydrocephalus. The needle of a Pravaz syringe being introduced between the third and fourth lumbar vertebrae; in all, the pressure symptoms were re- lieved as the fluid escaped, and in one, a child of 2 years with acute hydroceph- alus, the beneflt seemed to be perma- nent. Quincke (Inter, klin. Rundschau, May 3, '91). Quincke's statements in regard to the comparative ease and safety of puncture and drainage of the spinal canal in hy- drocephalus conflrmed. In cases of high pressure a. small fountain of cerebro- spinal fluid flows from the cannula. The quantities of fluid drawn off vary be- tween 1 and 3 ounces. The pulse is at first arhythmic, but soon becomes steady again. It should be performed only under chloroform narcosis. Operated in twenty-two cases forty-one times, without HYDROCHLORIC ACID. POISONING. .507 harm. Von Ziemssen (Centralb. f. d. Gesammte Therap., July, '93). Every effort should be used to increase the nutrition of the patient by codliver- oil, tonics, massage, and careful feeding, in the hope that the effusion may become self-limited and permit of life's being continued with more or less impairment of the mental and physical health. Charles jM. Hay, Philadelphia. HYDROCHLORIC ACID.— Hydro- chloric acid is a clear, colorless, pun- gent, fuming liquid having a strong acid odor and taste. It is miscible in all pro- portions with alcohol and water. It is incompatible with the alkalies and their carbonates, and with the salts of lime, lead, and silver. Preparations and Doses. — Hydrochlo- ric acid, 5 to 10 minims (diluted). Hydrochloric acid, dilute (10 per cent, acid), 10 to 30 minims. Physiological Action. — In common with other mineral acids, hydrochloric acid in its pure form is a decided caustic and escharotic. Its great affinity for water and its combination with the alka- line bases cause it to attack the living tissues energetically and induce destruc- tive changes. Its caustic action is not as powerful or far-reaching as that of sul- phuric or phosphoric acid. When in- gested in a diluted form and in medic- inal doses, its first action is to augment the salivary secretion. It is a general law that acids applied topically check the production of acid secretions from glands, while they increase the flow of alkaline secretions. Besides acting in this manner, the acid also acts through the cerebro-spinal nerves supplying the gland (Kinger). On reaching the stom- ach the acid combines with the alkaline bases present there and forms salts (hy- drochlorates), which are usually soluble and somewhat irritating. Hydrochloric acid is normally present (0.3 per cent.) as an ingredient of the gastric juice; it aids the pepsin to digest and render sol- uble the albuminous and albuminoid food-principles, converting them into peptones. It also aids in the transfor- mation of pepsinogen into pepsin. Hydrochloric acid has a very high dif- fusive power and passes readily through animal membranes. Any portion of in- gested acid which escapes union with the alkaline bases in the stomach diffuses rapidly into the blood and there forms salts with the bases of that fluid, setting free the weaker acids; this decreases the alkalinity of the blood and increases the acidity of the urine. Poisoning by Hydrochloric Acid. — Hydrochloric acid is an irritant and cor- rosive poison. When taken in a concen- trated form it destroys the mucous mem- brane of the mouth, epiglottis, oesopha- gus, and stomach, and violent gastro- enteritis attended with very alarming symptoms ensues. Pain is present throughout the digestive tract; vomiting of coffee-ground matter, blood, or even portions of the mucous membrane is asso- ciated with feeble pulse and clammy skin. Death occurs from collapse. Es- chars are formed externally, and, al- though the acid leaves a yellow stain on clothing, it does not stain the skin. If the case is seen very early, the character- istic odor of the acid may be detected in the breath, and whitish pungent vapor may be seen issuing from the mouth. In acute poisoning with the mineral acids renal changes are constant. K. N. Vinogradoff (Trans. Third Gen. Meeting Russian Med. Men at St. Petersburg, No. 2, p. 38, '89). Conclusions based on observations on eases of poisoning with hydrochloric acid: (1) it produces severe gastritis, 508 HYDEOCHLOEIC ACID. POISONING. THEEAPEUTICS. with embryonic proliferation and exten- sive cellular necrobiosis; (2) there is great danger of penetration of the caus- tic liquid into the respiratory passages during efforts at vomiting; and (3) such efforts, therefore, should be prevented, if possible, by washing out the stomach. LetuUe and Vaquez (Archives de Phys., Nos. 1, 2, '89). Fatal case of poisoning by hydrochloric acid obsei-ved. Patient took about an ounce of the drug by mistake, and the usual corrosive symptoms followed. Death ensued on the ninety-fourth day. P. J. Duncan (Lancet, Apr. 12, '90). Literature of '96-'97-'98. Case of poisoning by hydrochloric acid in a woman, who drank 1 tablespoonful of pure muriatic acid. Besides burning and pain in the stomach, vomiting, diar- rhoea, and cramps in the lower extremi- ties, there were observed: (fl) Absolute loss of tendinous reflexes on the first day of poisoning; this symptom disappeared on the second day; consciousness was complete. (6) Entire absence of injury of mucous membrane of the mouth, (c) Albuminuria, the sediments of the urine containing numerous hyaline and granu- lar casts and purulent corpuscles, (d) One day's fever 102° F. on the sixth day of the disease, without any apparent cause. Lande (N. Y. Med. Jour., June, '97). Treatment of Poisoning ly Hydrochlo- ric Acid. — In these cases the use of the stomach-pump or stomach-tube is con- tra-indicated. The chemical antidotes are the alkalies and their carbonates, magnesia, lime (wall-scrapings, if noth- ing better), and soap-suds. The admin- istration of albumin, eggs, milk, oils, etc., will act mechanically to protect and soothe the corroded tissues. Opium by mouth or by hjypodermic injection is use- ful to relieve the pain and irritation. To counteract the great depression which these cases present, intravenous injec- tions of ammonia may be made and nu- trient and stimulant cnemata given. If undiluted acid has been swallowed there is but little hope that the above reme- dies, or any other, will save the patient. Therapeutics.^ — Hydrochloric acid is seldom used as a caustic, though its serv- ices may be marked for that purpose in sloughing gums of mercurial stomatitis, mucous patches, etc., if nothing better is at hand. Literature of '96-'97-'98. For cauterizing enlarged tonsils hydro- chloric acid applied by a, long capillary tube to the excretory ducts of the ton- sils, three in each gland, at a sitting twice a week recommended. This is painless and produces no inflammation or swelling. Five or six applications are sufficient for moderately-enlarged tonsils. Kendal (Ann. of Ophthal. and Otol., '9G). Eight cases of sinuses eading to ne- crosed bone treated by the local use of hydrochloric acid. The acid employed was in the concentrated form, employed twice a week, the number of minims de- pending upon the individual case and the amount of bone exposed. The con- clusions were as follow: 1. No evil effects have resulted from its use. 2. The use of the acid in its concentrated form is preferable. 3. When the area of necrosis is extensive operative methods are advised. 4. Its action is limited to the necrosed area, whereas curetting may remove both diseased and healthy bone. 5. By the disintegration of the dead bone the neAvlj'-formed tissue has a better op- portunity for its more rapid develop- ment. Waterman (N. Y. Med. Jour., Aug. 8, '96). Intehkal Administration. — The pure acid is never used internally, ex- cept when largely diluted. It is not stable, but must be kept in dark bottles, well stopped and in a cool place. The dihtte acid may be given in beef-juice, in lemonade, or in syrup of lemon. When combined with the bitters, its efficiency is increased as a stomachic. In appro- priate cases it may be combined with HYDROCHLORIC ACID. THERAPEUTICS. 509 pepsin to increase the efficiency of the latter. It is most useful in gastric dis- orders and diseases consequent upon impaired digestion and assimilation. Gasteic Disoeders. — In atonic dys- pepsia, dilute hydrochloric acid may be given alone or combined with some prep- aration of pepsin, immediately after meals. Thus given, it is also useful when there is a deficiency of acid in the gastric juice, as in gastric cancer, a con- dition often made manifest by alkaline eructations. In excessive acid formation, acid eruc- tations, pyrosis, heart-burn, and ulcer- ative stomatitis it should be adminis- tered tefore meals. If the use of this remedy be too long continued the im- provement which at first follows its use lessens and then ceases, and a train of symptoms arises which require an oppo- site plan of treatment: a catarrhal in- flammation of the gastro-intestinal tract is induced, which is accompanied with diarrhoea, and perhaps wasting. Weak solution of hydrochloric acid by internal administration recommended as remedy for nausea and vomiting. S. Al- kiewlcz (Nowiny Lakarske, Feb., '92). Hydrochloric acid is capable of exercis- ing a double action upon the digestion: an enpeptic action and an antiseptic ac- tion. As an enpeptic, it should be em- ployed in all cases in which the digestive power is diminished and the amount of gastric juice is lessened. The following is the method of administration: — R Hydrochloric acid, 15 minims. Distilled water, 8 fluidounces. M. Sig. : A wineglassful toward the end of each meal and one-half hour after. Or R Hydrochloric acid, 45 minims. Distilled water, 9 '/, fluidounces. M. Sig.: A tablespoonful in half a glass of warm or cold water at the end of each meal. The centra-indications to the employ- ment of this drug are: all forms of hy- peracidity and dyspepsias accompanied by hypersesthesia. The treatment should , riot be continued for more than three weeks or a month, to be resumed, if nec- essary, after a remission of fifteen days. As an antiseptic it has produced good re- sults in cases of fermentation with pyro- sis due to the formation of organic acids, in dilatation of the stomach, etc. It should be given in these cases two or three hours after the meal. Huchard (Jour, des Praticiens; Ther. Gaz., Aug., '95). Pevees. — The treatment of fevers by hydrochloric acid is an old and favorite one. The use of the acid increases the secretion of the salivary glands and of the mucous membranes of the mouth, relieving the dryness of the tongue and fauces; it makes good the deficiency of acid in the gastric juice, which deficiency is a characteristic of most febrile affec- tions. In typhoid fever, alone, or, better, combined with pepsin, it restrains the diarrhoea, increases the digestive powers, relieves the dryness of the mouth and tongue and aids in preventing the accu- mulation and production of sordes. In scarlet fever and other eruptive fevers it relieves adynamia by improving diges- tion and assimilation. Phthisis. — Associated with this dis- ease there is usually a deficiency of the normal acid of the stomach and of the pepsin. Hydrochloric acid is useful in these cases, especially when the adminis- tration is stayed occasionally for a short time and then resumed. Ueinaey Disoedees. — When uric acid is present in the urine in excessive amounts as a result of faulty digestion and assimilation, the use of hydrochloric acid will cause a disappearance of the uric acid by improving the digestion. Cutaneous Disoedees. — In all skin affections which are symptomatic of im- paired digestion and assimilation, the 510 HYDROCYANIC ACID. POISONING. internal use of this acid is followed by good results. This explains the value of the remedy in certain cases of lepra, im- petigo, acne, erythema nodosum, urti- caria, etc. In very weak solutions it is a useful topical remedy against urticaria, profuse sweating, and torpid skin; for this purpose a general bath may be pre- pared (V2 to 1 ounce to the gallon of water). PoisoxiNG BT Alkalies. — Hydro- chloric acid diluted may be used as an antidote in cases of poisoning by the alkalies, but sulphuric acid, properly diluted, is preferable, as the salts formed by the former are usually soluble and somewhat irritating. C. Sumner Witheestine, Philadelphia. HYDROCYANIC ACID. — Hydrocy- anic acid, also known as cyanhydrie or prussic acid, hydrogen cyanide, and for- monitrile, is official in a 2-per-cent. solu- tion (acidum hydrocyanicum dilutum, TJ. S. P.), which is a colorless liquid, hav- ing the odor and taste of bitter almonds. Dilute hydrocyanic acid is prone to de- compose, becoming more or less brown in color, rendering it imfit for medicinal use; it should therefore be kept in a dark, cork-stopped bottle, and dispensed with a pipette, rather than by pouring it. The metallic salts are generally incompatible; also the red acid of mercury and the sul- phides; chlorine-water and all oxidizing agents change this acid into formalic acid. Dose.— Acidum hydrocyanicum dilu- tum (2 per cent.), 1 to 15 minims. Physiological Action.— Applied to the mucous membrane or the abraded skin, hydrocyanic acid rapidly diffuses into the blood. In medicinal doses it has a calmative effect. In larger doses it may cause nausea, faintness. giddiness, a feeble pulse, and great muscular weak- ness. Owing to its great diffusibility, its absorption is very rapid. It acts prin- cipally on the respiratory centre and the heart, and is eliminated very rapidly (one-half to one hour). If a larger quan- tity is taken it exercises a paralyzing eifect upon every part of the body; the respiration, heart, brain, nervous system, and all the vital parts are paralyzed at once. Poisoning by Hydrocyanic Acid. — Prussic, or hydrocyanic, acid is one of the most rapid and violent poisons known. A single whiff of the pure acid will kill; it is therefore very unsafe to handle. When a large toxic dose is taken, death may occur in from two to five min- utes. The usual symptoms are as follow: Sudden and complete insensibility, the eyes protrude with a glistening stare, the pupils are dilated and unaffected by light, the skin is cold and clammy, the extremities are relaxed and cold, the res- piration is slow and convulsive, pulse feeble or imperceptible, and involuntary evacuations of urine, faeces, and semen. The odor on the body, the wide-staring eye, the clenched teeth covered with froth, and the livid cyanosed face are the diagnostic signs (Hare). Series of experiments performed con- sisting in injecting amygdalin and emul- sion into the veins, so that on coming together they would form hydrocyanic acid. The changes which took place con- sisted in a slowing and final arrest of the respiratory movements, followed several minutes afterward by stoppage of the heart. These same results are reached even when artificial respiration is kept up from the first. Thirty minims of a 1 to 400 solution of hydrocyanic acid in- jected into the jugular vein of a dog weighing 38 pounds is sufficient to pro- duce death by the methods named above. "When the drug is given hypodermically to the frog the same phenomena occur, preceded by a complete loss of reflex ac- HYDROCYAXIC ACID. THERAPEUTICS. HYDROGEN DIOXIDE. 511 tivity. Grehant (La Semaine M6d., Sept. 25, '89). Absorption of hydrocyanic acid in the eye produces death from respiratory fail- ure in from two to three minutes, by the passage of the poison into the blood. Grehant {Brit. Med. Jour., Mar. 2, '91). Literature of '96-'97-'98. Results of forty-three observations upon various animals: Hydrocyanic acid stands foremost among agents likely to prove of antidotal value in chloro- form poisoning. The best way to apply it is undoubtedly by means of a graduated drop-tube on the back of the tongue. The exact dose in the dog and cat averages about one minim of Scheele's acid for every seven, or eight pounds of live body-weight. The object must be to give just enough acid to produce the preliminary excitant effect upon the respiratory centre. Frederick Hobday (Lancet, Jan. 1, '98). Treatment of Poisoning iij Hydro- cyanic Acid. — In poisoning by hydro- cyanic acid the most useful remedies are cold affusion to the head and spine; am- monia by inhalation, by mouth, and by intravenous injection; artificial respira- tion, atropine, and heart-stimitlants. If seen 'early, evacuation of the stomach by emetics or irrigation may be useful, the addition of peroxide of hydrogen to the irrigating fluid being capable of trans- forming any prussic acid present into oxamide, which is relatively harmless. Therapeutics. — Hydrocyanic acid is used principally to allay pain and spasms when taken internally. When applied externally it allays itching. Spasmodic Disoedees. — Hydrocyanic acid is useful in functional disorders of the pneumogastric nerve. In various forms of nervous vomiting, the vomiting of pregnancy, the reflex vomiting of phthisis, and that which accompanies some cerebral diseases, Bartholow sug- gests the following mixture: — I^ Acidi hydrocyan. dil., 1 drachm. Aquse laurocerasi, 2 ounces. M. Sig.: A teaspoonful every two to four hours. Xervous cough is often promptly re- lieved by 2 or 3 drops of dilute hydro- cyanic acid in a teaspoonful of wild- cherry syrup. Gasteic Disoedees. — Nervous gas- tralgia is quickly cured by this remedy. Nervous and irritative dyspepsia and enteralgia are promptly relieved. Cutaneous Disoedees. — Prussic acid afl'ords relief in many skin affections in which itching is a characteristic symp- tom. Fox suggests the following for- mula in pruritus, lichen, and in the syphilodermata : — I^ Hydrargyri bichloridi, 1 grain. Acidi hydrocyanici dil., 1 drachm. Emulsi amygdalae, 6 ounces. M. Sig. : Apply externally. C. Sumnee Witheestine, Philadelphia. HYDROGEN DIOXIDE. — Hydrogen dioxide, peroxide; peroxide of hydrogen; or oxygenated water in a pure, undiluted state, is a syrupy liquid of unstable com- position. It readily decomposes into oxygen and water. It is rarely met with in its pure state. For medicinal and surgical uses a di- luted solution is official; it deteriorates by exposure to heat, sunlight, or pro- longed shaking. It is, however, the most stable solution that has been prepared. Preparation and Dose. — Aqua hydro- genii dioxidi (3 per cent, or 10 vol.j U. S. P.), 30 to 120 minims. Physiological Action. — The official solution has a slightly acid taste, owing to the presence of a small amount of acid added as a preservative. Taken into the 512 HYDROGEN DIOXIDE. THERAPEUTICS. mouth it foams and produces a slight pungent, stinging sensation. Its proper- ties are those of an antiseptic, deodorant, >and styptic. Its effects are produced by the liberation of oxygen and by conse- quent oxidation. Taken internally, hy- drogen dioxide is not poisonous. The possibility suggested that the per- oxide contains impurities of an irritating nature, these impurities being the salts and acids used in the production of the remedy in question, and which in them- selves must be poisonous. Blackader (Boston Med. and Surg. Jour., May 19, '92). At ordinary temperatures and with ordinary agitation hydrogen dioxide is practically decomposed in eight weeks. Pressure exerts no restraining influence in this change. Boroglycerin, added in proportion of 1 per cent., retards decom- position, but does not prevent it. Ex- temporaneous preparation of hydrogen dioxide as required is recommended. Squibb (Ephemeris, Jan., '94). While taking hydrogen peroxide 10 out of 18 patients noticed that their urine was increased in quantity. D. M. Gam- mann (Med. Record, Nov. 2, '89). Therapeutics. — Hydrogen is an active destroyer of false membranes, pus, and pathogenic germs. It is sometimes used as a diagnostic means for the detection of pus, since contact with pus causes a foaming and frothing imtil all traces of pus have disappeared. It is also used in dressing wounds, etc. Hydrogen peroxide especially recom- mended internally in diabetes, phthisis, pertussis, syphilis, and angina pectoris. In diabetes it may be combined with co- deine in the following prescription: — IJ Codeine, 3 grains. Alcohol (sp. gr., 830), 2 ounces. Solution of hydrogen peroxide (10- volume strength), 2 ounces. Aq. destil., 12 ounces. M. Sig. : One-half fluidounce twice daily, in a wineglass of Avater. In pertussis 10 to 60 minims of ozonic ether in dilute r.Icohol is given in water, four times a day. The ozonic ether is pre- pared by agitating a 30-volume solution of the peroxide with anhydrous ether (equal volumes). B. W. Richardson (Lancet, Mar. 28, Apr. 4, '91). Diphtheria. — Hydrogen dioxide is one of the most valuable applications for the destruction and removal of false membrane, and this without danger of poison or of irritation. On contact with the false membrane an active efferves- cence ensues, and the membrane comes away in pieces or shreds. It is best ap- plied in spray form, using a rubber or glass-tipped atomizer on account of the oxidizing influence upon metal spray- tubes. It may also be applied by means of a swab or a glass syringe. Hydrogen peroxide in a number of cases of diphtheria produced appearances which might have been mistaken for the original disease, but which readily dis- appeared on withdrawing the peroxide. The disease had not only not been bene- fited, but had been prolonged by the use of the drug. Jacobi (Boston Med. and Surg. Jour., May 19, '92). Fifteen-volume solution of peroxide of hydrogen used in the form of a spray in the mouth and nose in diphtheria with- out any bad results. It seemed for a time to lessen the membrane, but the latter quickly returned. Buckingham (Boston Med. and Surg. Jour., May 19, '92). Case in flhieh, thirty-six hours after using the peroxide of hydrogen in Aveak solution as a spray and gargle, a whitish veil appeared in the mouth, and then beginning ulceration and a pseudomem- brane over these ulcerated spots. The peroxide was stopped and the patient recovered. Caille (Boston Med. and Surg. Jour., May 19, '92). A reliable solution of peroxide of hy- drogen is an efficient and safe germicide. By its oxidizing power it rapidly decom- poses pus, diphtheritic membranes, and other pathological decayed products. It is an excellent deodorizer and a non- irritating, cleansing agent for foul wounds, abscesses, etc. It is a valuable HYDROGEN DIOXIDE. THERAPEUTICS. 513 diagnostic agent in determining the pres- ence of pus, and by its use in operations the danger of wounding important structures can be lessened. E. Stuver (Ther. Gaz., Mar., '92). PuKULENT Affections. — The appli- cation of hydrogen dioxide to pus-secret- ing surfaces and cavities is followed by the most satisfactory effects. Whenever this agent meets pus, active efEervescence ensues, germs and pus are disintegrated, and the part is rendered aseptic without any fear of poison. For this purpose its use is quite extensive. Abscess-cavities, unhealthy suppurating surfaces, chan- croids, chancres, bed-sores, gangrenous wounds, ulcers, necrosis, cancerous wounds, etc., are all amenable to the beneficial action of this agent. Diluted with 4 to 8 parts of water it may be used with good results as an injection for gonorrhoea and leucorrhoea. Suppura- tion in post-operative wounds is checked and healing promoted by spraying the parts with hydrogen dioxide before ap- plying the dressings. Hydrogen peroxide has proved most successful in the treatment of tubercular abscesses and sores of all kinds. It is superior to anything employed in keep- ing drainage-tubes and deep cavities clean and sweet. T. S. K. Morton (Med. News, Dec. 28, '89). Peroxide of hydrogen is successfully used in abscess of the brain, and in many other cases where suppuration is the chief feature. In affections of the eye, nose, and urethra its use may be pre- ceded by cocaine or ether to prevent smarting. In old sinuses its employ- ment to be followed with balsam of Peru, which encourages granulation. Diph- theritic membranes are easily removed by it. Wherever there is pus peroxide of hydrogen should be used. The sub- stance should not come in contact with metals, nor with the hair, as it bleaches the latter. A solution kept tightly corked in a cool place remains active for many months. R. T. Morris (Med. News, Dec. 28, '89). Hydrogen peroxide is not an un- stable preparation if kept in a dark and cool place. It is an excellent antiseptic and disinfectant, and espe- cially valuable in herpes progenitalis, soft chancres, and gonorrhoea. This lat- ter disease is cured by the remedy, in injections, in from eight to twenty-four hours. Manassein (St. Louis Med. and Surg. Jour., Jan., '90). Hydrogen peroxide found of great use in fungous ulcers and cold abscesses, possessing, in the proportion of 1 to 100, an energetic disinfecting power. A solu tion in nutritive substance of 1 to 352 not only impedes the development, but after some daj's kills the spores of the bacillus of Charbon. Its action is stronger against the Charbon bacilli than is the bichloride of mercury. N. Pane (Annali dell' Istituto d'Igiene Sperimentale dell' Universita di Roma, '90). In 40 cases in which hydrogen perox- ide was used as good results were pro- duced as by the bichloride of mercury, and in some cases better. Buck (Times and Register, Jan. 3, '91). It may be used in cases where a com- plete opening of a fistula or abscess is impossible. Here irrigation with the per- oxide has an excellent action. It, then, an antiseptic bandage be applied, healing takes place very rapidly. If, in cachectic patients, the granulations are weak and slow in growth, one may alternate with injections of equal parts of ether and balsam of Peru. This procedure is of great value in suppurating cavities with indurated edges. Where the drug is in- jected into cavities, one must see that there is free exit for the gas which quickly forms. Graff (Med. Neuigkeiten fur prak. Aerzte, No. 2, '92). Peroxide of hydrogen valued in the treatment of exposed wounds, on the ground that it forestalls suppuration and promotes cicatrization. Application of a 15- volume solution to the nasal mem- brane and the mucous membrane of the cervix uteri recommended to remove ad- herent mucous for the purpose of medi- cation. C. M. Fenn (Ther. Gaz., Mar., '92). 514 HYDROGEN DIOXIDE. HYDRONEPHROSIS. Literature of '9G-'97-'98. Menthoxol, camphoroxol, and naph- thoxol consist of a 3-per-cent. solution of peroxide of hydrogen, to which a quan- tity of alcohol and 1 per cent, of menthol, or 1 per cent, of camphor, or 2 per cent, of naphthol, respectively, have been added. They destroy the spores of an- thrax within three hours and in a lO-per- cent. solution within six hours. These preparations were used in about two hun- dred cases of phlegmon, abscess, ulcers, and granulating wounds, sterilized gauze wetted with a 10-per-cent. solution being applied to the part with the usual cotton- wool dressing above it. The dressings were renewed, as a rule, every second day. As soon as the compound came into contact with the secretion of the wounds there was a considerable development of gas. In phlegmonous cases the necrosed tissue very soon came away, the secre- tion diminished, and healthy granula- tions appeared. Ulcers of the legs healed better under these dressings than under any other treatment. The three com- pounds did not show any difference in their action. They have an agreeable odor, and are therefore very useful in foetid sores or abscesses. No undesirable effect has hitherto been observed. Wagner (Deutsche med. Woch.; Lancet, Jan. 1, '98). AuEAL DisoEDBES. — The suppuration of middle-ear disease is lessened and the odor removed by the use of hydrogen dioxide. Impacted eer^imen may be dis- integrated by instilling a few drops of tlie solution into the ear. Violent effer- vescence ensues, the cerumen is disin- tegrated, and removal by warm water and syringe rendered easy. Used with success in 22 cases of sup- puration of the middle ear. In ozsena and rhinitis it is used in 10-per-cent. strength. F. W. Frankhauser (Times and Register, Aug. 15, '91). Insect-bites. — The application of tliis remedy counteracts the pain and poison of the bites and stings of insects, bees, wasps, and hornets. C. SUMNEE WiTHEESTINE, Philadelphia. HYDRONEPHROSIS.— Gr. §8up, water, and ve^pog, a liidney. Definition. — A collection of urine in the pelvis and calyces of the kidney due to obstruction. Varieties.- — In addition to the usual or more or less typical form, two subvarie- ties are distinguishable: (a) the inter- mittent and (b) hydronephrosis para- plegica. In the latter type paraplegia develops as a complication, and beyond the mention of this fact it scarcely de- serves a separate clinical description. Symptoms. — The clinical symptoms are somewhat dependent upon the cause and stage of development of the hydro- nephrosis. When, as generally happens, the condition is unilateral, it often es- capes notice, since the symptoms are slight or even wanting, until a tumor is discoverable. The ureter on the opposite side may become obstructed, followed by uremic manifestations, the latter occur- rence first inviting attention to the con- dition. In the bilateral form, the ursemic symptoms are apt to supervene easily. The flow of the urinary fluid may be noticeably diminished, though subject to variations. The patient may complain of frequent and acute pains that shoot about the affected loin-space and down- ward toward the thigh. Abnormal sen- sations of weight and a dragging dis- comfort, at times amounting to a dull^ aching pain, are quite common. The latter symptom, particularly in large hydronephrotic tumors, may be continu- ous and distressing; less frequently the cyst is painless. The tumor may cause obstinate constipation from pressure of the colon; or it may, if moderate in size. HYDRONEPHROSIS. SYMPTOMS. 515 provoke diarrhoea, from the pressure- irritation. Eesulting from the same cause are flatulency and irregular bowel- action. Among gastric symptoms, ano- rexia is the most common, while nausea and vomiting are sometimes associated. Hsematuria may be present, but is rare and usually occurs with attacks of pain. Slight albuminuria may be present. The urine is of low specific gravity; the urea is diminished, and the phosphates are greatly reduced in most instances. Eenal easts are absent, as a rule, unless chronic nephritis co-exists as a complication. In all except the earliest stages there is easily detectable a swelling in the region of the affected kidney. It in- creases in size in a slow and gradual man- ner, and there is great dilatation of the pelvis of the kidney. Visible bulging usually occurs in the hypochondriac and lumbar regions. On palpation, a rounded, firm, more or less elastic and sometimes fluctuating tumor is detected. The enlargement may be slightly tender. I would advise energetically that when the tumor is of moderate size it is most readily felt when the abdominal position is employed, ex- amining bimanually. Percussion elicits dullness over the mass, except in cases in which the colon overlies it, when the note is tympanitic: a characteristic sign of renal tumors. Moderate enlargements generally do not descend during inspira- tion, though exceptions to this rule rarely occur. Inteeiiittent Foem (Landau). In this variety decided variations in the size of the tumors Occur: i.e., coincident with a more or less sudden increase in the quantity of urine passed (polyuria) the tumor quickly diminishes. On the other hand, the enlargement gradually in- creases from retention as the flow of urine decreases. The principal cause of hydronephrosis is a movable kidney, and hence the affection occurs mostly in women that have borne children. Ac- cording to Albarran, the polyuria which commonly follows the attacks of pain in movable kidney is due to excessive uri- nary secretion, and not to a flow of urine which has previously been retained in the pelvis of the kidney. He reports a number of cases in which an operation for movable kidney, in patients suffering from intermittent hydronephrosis, was performed by himself, and total absence of dilatation of the pelvis of the kidney was noted. Preceding and accompanying the poly- uria in these cases are colicky pains, and haematuria is not uncommon. For ob- vious reasons, the tumor in intermittent hydronephrosis displays considerable mo- bility. The general features consist merely of a certain loss of flesh and strength incident to the associated worry and anxiety. The filling of the nephry- drotic cyst, the enlargement, and the pain of subsequent discharge, with marked diminution of the tumor, recur with variable frequency. Among the causes that are apt to produce a kinking of the ureter, and thus excite an attack, are violent physical exertion; jarring or jolting, as in riding or driving; or acute gastro-intestinal derangement, and strong mental emotions. The duration of the attacks varies from several hours to a day, though the cyst may continue to increase in size for several days after the pain has disappeared. During the intervals, and even while the greatly in- creased flow of urine is present, the pa- tient feels tolerably comfortable. The occurrence of chills, fevers and sweats, rapid pulse, nausea and vomiting, and abdominal distension is indicative of suppuration, and the appearance of the common sequel — pyonephrosis. This is 516 HYDEONEPHROSIS. SYMPTOMS. DIAGNOSIS. ETIOLOGY. confirmed by the cloudy iirine, revealing pus, following both discharge and aspira- tion. Chronic nephritis may supervene, as shown by the lower specific gravity and the presence of albumin and casts in the urine. The arterial tension will then Fig. 1. — Urinary organs of a. newborn child, showing mechanical obstruction. (Bland Sulton.) be increased, as a rule. Among other sequelffi may be mentioned acute febrile or chronic afebrile urasmia, the latter having been mentioned above. Differential Diagnosis, — {a) Pyone- phrosis may be eliminated in the absence of an abundance of pus-cells in the as- pirated fluid and of the general symp- toms of suppuration. EcHiNOCOCcus Cyst. — In this dis- order there is a history of close associa- tion vsdth dogs; the size of the tumor constant and slowly increasing; urea is not demonstrable in aspirated fluid. In fluid removed by puncture the echino- coccus-hooklets, shreds of membrane, and sodium chloride are found. A mov- able kidney is not detectable. The urine is constant in amount. Eecurrences do not occur. Additionally, hydronephrosis must be distinguished by exclusion from ovarian cyst, cystic hidney, and tumors of the spleen, liver, and gall-Hadder. It is some- times necessary to detect the tympanitic band, to evacuate the colon by the intro- duction of air, and this, coupled with a chemical examination of the fluid ob- tained on exploratory puncture, will suf- fice in most cases. With reference to ovarian cyst, it is to be recollected that a slight amount of urea is sometimes ' found. Etiology. — The principal factor in the production of dilatation of the pelvis of the kidney is chronic or prolonged ob- struction, caused by occlusion of the ureter, either congenital or acquired. Probably from 20 to 35 per cent, of the cases are congenital (Roberts). The former cases are due to obstruction in- duced by a defective development or malformation of the ureter of one or both sides, usually the latter. An instance of hydronephrosis, occur- ring in a, young man, in which there seems to be a congenital factor of causa- tion. The tumor apparently followed a fall, but when the patient was but a day or two old the father had had occa- sion to call the attention of the physician to the enormous size of his abdomen, and HYDRONEPHROSIS. ETIOLOGY. 517 this had nevei- entirely disappeared. The tumor at the present time was of enor- mous size, filling up the whole right side of the abdomen, the hypogastrium, and a part of the left iliac fossa. Lannois (Lyon M6d., Xov. 30, '90). Literature of '96-'97-'98. In many cases hydronephrosis develops during intra-uterine life. The specimen illustrated in Fig. 1 was obtained from an infant which survived its birth a few days. Only one kidney was present. Dissection clearly indicated that me- chanical obstruction of some kind inter- fered with the flow of urine through the vesical orifice of the ureter. In Fig. 2 is shown an example of narrow ureter, acting as cause. Bland Sutton {Clin. Jour., July, '97). There may be atresia, a yalve-like formation, or an acute (oblique) inser- tion of the ureter into the kidney. literature of '9G-'97-'98. Apart from hydronephrosis caused by renal calculi, the most common form of obstruction capable of determining hy- dronephrosis is a valve-like projection which occludes the upper end of the pelvis of the kidney or one of its divi- sions. Fenger (Ann. of Surg., June, '96). Excessive dilatation has occasioned more or less mechanical difficulty during labor. The causes, both predisposing and exciting, of the acquired cases are varied, and may be conveniently grouped in tabular form as follows: 1. Sex, women being more often subject to hydronephrosis than men, especially those having borne children. 2. Age; apart from the congenital cases, hydro- nephrosis is most common in middle and advanced life. 3. Impacted calculi in the ureter or renal pelvis. 4. Disease of the ureteral walls, as inflammatory thick- ening and cicatrical stenosis from iilcers. 5. Flexion and twisting of the ureter, as from movable kidney. The usual cause for intermittent hy- dronephrosis is a floating kidney which, when displaced, causes a, kink in the ureter, thus arresting the evacuation of urine until the organ slips back into place again. Most of these cases of in- termittent hydronephrosis eventually be- come permanent, owing to inflammatory changes which often result in bands of adhesions, thus fastening the kidney in its displaced position. Terrier and Bau- Fig. 2. — Large intermitting hydronephrosis due to an inadequate ureter. {Bland Sut- ton.) douin (Revue de Chir., Sept., Oct., Dec, '91). Simple hydronephrosis considered as due, in many instances, to an inherited tendency, often associated with more or less malposition or mobility of the kid- ney. Cramer (Centralb. f. Chir., Nov. 24, '94). Hydronephrosis produced in the dog, four out of eight times, simply by sep- arating the kidney from its attachments. Tuffier (La Semaine M«d., Dec. 1, '93). 6. Pressure upon the ureter from 518 HYDRONEPHROSIS. ETIOLOGY. PATHOLOGY. without, as by tumors and constricting bands (pelvic adhesions). The gravid and retrodisplaced uterus, uterine and ovarian neoplasms, and similar condi- tions causing compression or traction and obliteration of the lumen of the ureter, are found in this class. Case of cancer of the uterus which caused complete obliteration of the left ureter and almost complete obliteration of the right. The ureter was moderately and the pelvis enormously dilated, the latter forming a, large pocket; the kid- ney itself appeared to be but slightly involved. On the left side, where there was complete obstruction of the ureter, there was almost no hydronephrosis. Frumussaine (Bull, de la Soc. Anat., No. 10, '93). Case of inguinal hernia where the hernial sac contained a knuckle of pro- lapsed ureter, marked hydronephrosis re- sulting as a consequence. P. Reichel (Centralb. f. Chir., Aug. 13, '92). Case of intermittent hydronephrosis depending upon an acute bending of the ureter in its upper portion. Braun (Wiener med. Woch., July 19, '90). Aberrant renal vessels considered as a cause of hydronephrosis, as seen in four cases. In two of these veins and in the other two arterial branches were the aberrant vessels. N. Pitt (Brit. Med. Jour., Apr. 21, '94). Hydronephrotic kidney in which the obstructive cause was a small branch of the renal artery, which crossed the ureter a short distance from the insertion of the latter into the pelvis, causing an angle in the course of the ureter and produc- ing obstruction. Coats (Glasgow Med. Jour., May, '94). 7. Diseases and tumors of the blad- der that involve the ureteral orifices, particularly carcinoma, or that cause re- tention, as prostatic enlargement. 8. Urethral structure. Case of double hydronephrosis due to obstruction of the ureters at point of entrance into the bladder by the thick- ening and infiltration of the bladder- walls from vaginal and uterine cancer. Street (So. Med. Rec, Mar., '90). Case in which the cause of hydrone- phrosis was a fibrous perivesical thick- ening at the point where the ureter en- ters the trigone. Martin (Montreal Med. Jour., Feb., '94). Traumatic hydronephrosis may be due (1) to serious injury, with rupture and consecutive stricture of the ureter; (2) to an extravasation of blood about the kidney and ureter; (3) to a blood-clot obstructing the ureter; (4) to displace- ment, by the traumatism, of a calculus, which lodges in the ureter; (5) to dis- placement of the kidney and closure of the ureter. P. Wagner (Schmidt's Jahr- bucher, Apr., '94). Pathology. — The cyst caused by a dilatation of the pelvis of the kidney, often assuming the shape of the latter, may become very large, containing as much as several gallons of fluid. The external appearance of the walls may be lobulated, particularly in medium-sized sacs; the interior, however, shows only partial septa projecting from the walls into the cavity of the sac, as a rule. Ac- cording to the site of the obstruction one or both ureters may also be dilated, and if, as is usual, one kidney is involved, its fellow is often hypertrophied. Marked enlargements cause displacement of the adjacent abdominal organs. Atrophy of the renal tissues results and is proportionate to the size of the tumor or dilatation. Accumulated liquid causes flattening and atrophy of the papillse and gradually of the tubules and glomeruli, and in extreme cases rem- nants only of the renal structure remain in the walls of the hydronephrotic cyst. In the renal parenchyma (medullary and cortical) there is a growth of connective tissue, a chronic nephritis with degener- ation and atrophy of the renal cells. The mucous membranes lining the pelvis and calyces first become thinned, and later thickened, by the growth of con- nective tissue, thus forming a dense sac- wall. HYDRONEPHROSIS. TREATMENT. HYOSCYAMUS. 319 If hydronephrosis is ~ complete, — that is, if the urethral outlet is wholly im- pervious, — only a moderate dilatation of the kidney occurs, since atrophy of the nephritic tissue, under such circum- stances, speedily ensues, thus putting an end to the secreting process. If, how- ever, the hydronephrosis is incomplete, great dilatation eventually takes place, since in the latter condition hypertro- phy rather than atrophy of the paren- chyma is the rule. Albarran and Legueu (La Semaiue M6d., Apr. 30, '92). The fluid contained in the sac is usually a clear, thin, yellowish, watery urine. Its composition, however, varies. The specific gravity is low, and the re- action is often slightly alkaline. Traces of albumin, urea, and uric acid are found, although in long-standing cases the lat- ter two ingredients may be absent. Tur- bidity may be observed, owed to admixt- ure with pus, blood, or epithelium, but only in instances in which previous in- flammatory conditions — as a calculous pyelitis — or local complications — as hsemorrhage, suppurative inflammation, and the like — have existed. Prognosis. — In unilateral hydrone- phrosis, the more common variety, the prognosis is guardedly favorable, on ac- count of the establishment of compensa- tory function on the part of the un- affected kidney, and this is particularly true if the case be one of movable kidney. The bilateral affection is always grave, having about the same outlook as chronic pyonephrosis. Among danger- ous accidents and complications may be mentioned uraemia, rupture of the sac, and infection of the cyst by pus-organ- isms. Eecoyery may ensue in rare in- stances in which a spontaneous discharge of the fluid occurs. Treatment. — The congenital form, when bilateral, is not amenable to treat- ment. It is rarely feasible to force the fluid out by manipulation of the tumor. This method tends to remove the occlu- sion, when caused by a slight' twist or kink in the iireter. In unilateral hydro- nephrosis, carefully tapping the cyst may be practiced, thus overcoming the me- chanical discomfort. Operative interfer- ence, with a view to removing the special obstructive cause, is also to be encour- aged and advised in suitable cases. Double lumbar nephrotomy performed at the twenty-second hour after birth for congenital hydronephrosis. The child, several weeks after the operation, was still living and passing all his urine through the lumbar fistulse. Henry Morris (Lancet, Jan. 27, '94). In acquired hydronephrosis sympto- matic treatment only is required in moderate enlargements, though some- times gentle massage over the sa!c, prop- erly directed and cautiously applied (to avoid rupture), may cause a reduction in the size of the cyst. In the majority of instances surgical measures only are of use. Eepeated aspiration of the sac has in a few reported cases accomplished a cure. Surgical measures also embrace nephrotomy and drainage, nephror- rhaphy (particularly when caused by movable kidney), and nephrectomy. Nephrectomy advocated for hydrone- phrosis. J. Bland Sutton (The Clin. Jour., Nov. 15, '93). In no cases in which the symptoms are mild should surgical procedures be un- dertaken, as in some instances of the in- termittent variety. James M. Andees, Philadelphia. HYDEOPERICARDIUM. See Peei- CAKDiuM, Diseases of. HYDROPHOBIA. See Babies. HYOSCYAMUS AND HYOSCINE.— Hyoscyamus (U. S. P.) is the leaves and flowering tops of Hyoscyamus niger, or 520 HYOSCYAMUS. PHYSIOLOGICAL ACTION. henbane, which is indigenous to the United States. The plant is an annual and belongs to the family of Solanacce. The fresh herb has a rank, heavy, sicken- ing, unpleasant odor, which disappears on drying. The plant contains hyos- cyamine, an active principle (alkaloid), which occurs as white, silky crystals, and also in an amorphous form, as a brown, syrupy liquid. From the latter Laden- burg derived a new hyoscyamine. He found that hyoscine, hyoscyamine, and atropine were isomeric, having the same formula, and each being separable into tropic acid and tropine, or pseudotropine. Both hyoscyamine and hyoscine form salts with the acids. Preparation and Doses. — Hyoscyamus, 5 to 15 grains. Extract of hyoscyamus, 1 to 3 grains. Extract of hyoscyamus, fluid, 3 to 10 minims. Tincture of hyoscyamus, 10 to 60 min- ims. Hydrobromate of hyoscine, ^/joo to Vioo grain. Hydrobromate of hyoscyamine, ^/^^o to Veo grain. Sulphate of hyoscyamine, ^/g^ to ^/gj grain. Physiological Action. — Its action on man is analogous to that of belladonna and stramonium, though milder. Chil- dren can be given a larger dose than adults. Hyoscyamine, according to Gnauck and other observers, resembles atropine in its action upon the vagus and heart-muscle, though its effects are less marked and prolonged. It seems also to exercise an inhibitory influence upon the vasomotors, especially those of the abdominal vessels. It is an active soporific. Hyoscyamine is a serviceable hypnotic, liaving most of the advantages of its rivals and none of their disadvantages. It is entirely harmless in doses which are still sufficiently strong to be effect- ive. G. Lemoine (Gaz. M6d. de Paris, July 14, '88). Hyoscine is eliminated as such from the system; it retards respiration, slows the pulse, dilates the pupils, diminishes salivary secretion and perspiration, but has no apparent action on the cord or motor area of the brain. Kobert and Sohrt and Konrad and Schleussner (Munch, med. Wooh., p. 365, '89). Study of the physiological action of hyoscine hydrochlorate upon cold- and warm- blooded animals. Upon the first, minute doses (less than ^/„ grain) slow the action of the heart by stimulating the peripheral cardio-inhibitory appa- ratus. Larger doses accelerate cardiac action, increase muscular contractility, irritability of spinal cord, and conduct- ing power of motor nerves; they also slightly depress the excitability of pe- ripheral sensory nerves. Still larger doses intensify these symptoms, lowering reflex action. Toxic amounts produce diastolic arrest of heart, loss of reflexes and of function of both sensory and motor nerves, and finally cerebral paraly- sis. On warm-blood animals, as dogs and rabbits, hyoscine at first diminishes and afterward increases the cardiac beats by a primary stimulation and a secondary paralysis of the peripheral cardio-inhibi- tory apparatus. Subsequently the drug diminishes the pulse by depressing the excitomotor apparatuses of the heart. The pressure is increased through stimu- lation of spinal and vasomotor centres; it is later depressed, owing to exhaustion of cardiac muscle. It retards respiration, diminishes secretion of saliva, depresses irritability of motor area of cerebral cor- tex, and lowers pathic sensibility. It causes prolonged dilatation of pupil, due to stimulation of sympathetic nerve. The drug has no action on peripheral or visceral temperature, nor does it acceler- ate the process of deoxidation of the blood. Its action would seem to resemble that of atropine, but it differs from this in that it depresses cerebral irritability. K. L. Pavloff .(London Med. Recorder, May 20, '90). Clinical effects of hyoscine resemble in HYOSCYAMUS. PHYSIOLOGICAL ACTION. 531 every way those of atropine. Gordon Sharp (Practitioner, Jan., '94). Treatment of Hyoscyamus Poisoning. — If seen early enough, emetics or warm drinks should be administered, followed by the use of the stomach-tube. Tannin and charcoal may be used if a stomach- tube is not at hand and absorption has not taken place. Among the antidotes advised are coffee, alcohol, pilocarpine (^/g to ^/i grain), muscarine nitrate (^/ao to y^s grain), morphine sulphate (Vs to V2 grain), or eserine (V200 to Veo grain). The violent action of the drug should be restrained by the use of the foregoing antidotes given by hypodermic injection, in moderate doses, and re- peated at intervals, as indicated by the condition of the patient and the urgency of the symptoms. Case observed in which ^/„ grain of hyoscyamine produced thirst, a burning sensation in the throat, numbness, and loss of power. W. S. Thomson (Brit. Med. Jour., Aug. 25, '88). Excessive dryness of the throat, pros- tration, and insomnia lasting through the whole night found after the inges- tion of ^/m grain of hyoscyamine. J. A. West (Brit. Med. Jour., Sept. 22, '88). The writer's personal experience with the 'Aoo grain of hyoscine, followed, in two hours, by another dose of the same size recounted: Soon after the second dose, poisonous symptoms, consisting of extreme dryness of the mouth, muscular tremors, accelerated respirations, imper- fect vision, mild delirium, and visual de- lusions, were present. There was also an intense desire to urinate, though the at- tempt was unsuccessful. The urine passed next morning was opaque and of a peculiar odor. All the eflfects of the drug had passed off in thirty-six hours, with the exception of sensitiveness of the eyes. W. A. Carey (Univ. Med. Mag., Apr., '89). Case of poisoning Avith ^/,5 grain of the hydrobromate of hyoscine in a very large man, weighing not less than 200 pounds. He was at the time in an irritable and susceptible condition, and the drug was given for sleeplessness, which had re- sisted other hypnotics. In five minutes after the injection dryness of the mouth and throat were noticed, attended with a constant desire, but at the same time an inability, to swallow. In a few min- utes his speech became thick and was accompanied by complete paralysis of the soft palate and upper lip, the latter being limp and immovable over the up- per teeth, and gave the already much- impaired voice a muffled sound. The pupils at this time were noticed to be slightly dilated. S. W. Morton (Therap. Gaz., Feb., '89). Hydrochloride of hyoscine has pro- duced erythema of the face lasting an hour or two. Magnan and S. Lwoflf (Jour, des Soc. Scientifiques de la France et de I'Etranger, July 24, '89). Case reported in which the administra- tion of '/120 grain of hyoscine hydrobro- mate to a patient with clironie intestinal nephritis and obscure brain-symptoms was followed by toxic symptoms. W. A, Edwards (Univ. Med. Mag., June, '89). Case of poisoning by 6 drachms of the tincture of hyoscyamus observed, marked by symptoms very similar to those of belladonna poisoning. The respiration was, however, entirely unaffected. A. H. Dodd (Brit. Med. Jour., Sept. 21, '89). Literature of '96-'97-'98. Case of severe form of cystitis impli- cating both eyes and extending to the choroid and retina. Adhesions had al- ready formed when the case came under observation. The inflammation lasted four months. Atropine, homatropine and cocaine, and atropine alternating with eserine were used with little or no effect. One grain of the hydrobromate of hy- oscine was made up to a 1-per-cent. so- lution in water. Two drops of this solu- tion were put into one eye, and as the patient felt no pain she put 2 drops into the other eye as well. Five minutes afterward she complained of giddiness and a feeling of lightness in the head; she staggered, and had to be assisted to bed. Then great dryness of the mouth and throat with thirst super- vened. The giddiness increased, gradu- 522 HYOSCYAMUS. THERAPEUTICS. ally the senses became confused, and the power of speech was lost. Complete mus- cular relaxation became pronounced and she became rapidly unconscious. The breathing was slow and occasionally deep sighing. The face was flushed, the pulse full and regular. This unconscious stage lasted for about four hours, and was succeeded by a period of semiconsciousness. At times the patient seemed to have perfectly re- covered; at other times she was quite delirious. She talked incessantly, was occasionally irritable, although, on the whole, it took the form of a pleasant delirium. After about two hours of this delirium she became gradually calmer, and then dropped off into a sound and seemingly natural sleep, which lasted for about an hour and a half. When she awoke she remarked that she had not slept so well for a long time. She had no remem- brance of the events of the night further than being assisted to bed. There were no evil after-effects. The adhesions have stretched slightly. R. A. Morton (Brit. Med. Jour., Feb. 8, '96). Therapeutics. — The chief use of hyos- cyamus is as a sedatiTe to the nervous system. Spasmodic conditions, vesical pain and irritation, pertussis, and nerv- ous coughs are relieved by preparations of hyoseyamus. In insanity hyoscine hydrobromate is given to allay acute or chronic maniacal excitement (by mouth, Vioo grain to Vso grain; by injection, ^/loo to Vao grain). It is indicated in general paresis, melancholia, epileptic insanity, or quiet forms of mental aber- ration. In spermatorrhoea and nocturnal emissions hyoscine is of great value. Hyoscine found more active than hy- oscyamine. It appeared useless in chorea, athetosis, and whooping-cough, and to have but a weak hypnotic action in tabes. Its effects were' most prompt in paralysis agitans and in senile and al- coholic tremor, but its influence is not lasting. It always produces a sense of fatigue, and flashes of light, dizziness, dryness of the throat, dilatation of the pupil, and delirium are apt to occur. Buddee (Deutselie med. Woch., May 17, '88). For the tumultuous heart's action of Graves's disease application of ice to the prsecordium recommended, and, for a general sedative, hyoscine hydrobromate. Taylor (Med. News, Dec. 16, 23, '93). Several hundred hypodermic injections of a 2-per-cent. solution of the hydro- chlorate of hyoscine given, and conclu- sion reached that for states of excitement and exaltation occurring in any psychosis whatever the drug surpasses all others. Its action is prompt and more certain than that of morphine, chloral, and paral- dehyde. It is not a true hypnotic, since when given in acute mania it leaves the patient always awake, though it ap- pears to make him exceedingly sleepy. J. Sagl6 (Wiener med. Woch., June 2, '88). Several hundred injections used in dif- ferent mental disorders, and in condi- tions of excitement of a chronic form hyoscine is at times useful in doses of '/i!5 to '/oo grain, but it must not be given continuously for more than two to three days. In acute curable psychoses it is to be avoided as long as other remedies have any effect; and, if exhaustion of the strength is feared, the drug should be given at long intervals only. In af- fections of the heart it is never to be used. E. Konrad (Centralb. f. Nerven- heilk., etc., Sept. 15, '88). The hydrochlorate of hyoscine, given hypodermically in doses of ^/j26 to V4« grain, is very useful in maniacal fury, paralytic excitability, and the extreme restlessness of the melancholic. It was also successful in insomnia when chloral and morphine had failed. Fischer (Lan- cet, June 30, '88). Three thousand single doses of hyos- cine given internally to 88 patients with different varieties of mental disease. In 82.2 per cent, the hypnotic effect was very satisfactory. Never any ill effects seen, except occasional dryness of the mouth and thirst. The first dose should be V,o5 to Voo grain, to be later increased as habituation occurs. Kny (Milnch. med. Woch., No. 13, '88). Hypodermic injections of the muriate HYOSCYAMUS. THERAPEUTICS. 523 of hyoscine used in 90 eases of insanity. The effect of the drug does not appear so soon in paralytics as in maniacal pa- tients. It has no influence on pulse or respiration. The dose employed was '/so grain, and no bad results were at any time seen, excepting vomiting in one in- stance. Kraus {Orvosi Hetilap, No. 16, '88). Hyoscine found most reliable as a brain-sedative, especially valuable in de- lirium tremens. Bruce (Amer. Jour, of the Med. Sciences, Oct., '88). The writer's experience has been en- tirely unfavorable with hyoscine both as a sedative and as an hypnotic. John J. Weaver (Lancet, Nov. 2, '89). When hyoscine is given in small doses it does not act as an hypnotic, but as an excitant to cerebral action. There seems to be no disposition to form the habit. It is a safe remedy in ^/^- to Vib- grain doses, repeated, if necessary, in two hours. This dose, however, is an unsafe one if the hyoscine be pure. E. B. Pot- ter (Buffalo Med. and Surg. Jour., Sept., '89). Hyoscyamine, from V120 to Vso grain, found to be a safer, more certain, and more efficient hypnotic in acute mania than hyoscine in similar doses. Lemoine (Le Bull. Med., p. 1008, '89). Hyoscine never fails to act as a prompt and powerful sedative in cases of mental excitement, and no bad after-effects fol- low. Walter S. Coleman and J. Taylor (Lancet, Oct. 12, '89). In asylum practice hyoscine has largely supplanted morphine in the treat- ment of acute mania, the violence of acute melancholia and of general paresis, and as an hypnotic in general. It is remarkable for the absence of untoward after-effects. Hyoscine is most service- able in cases of cerebral disease requiring an anodyne. After the administration of small doses of hyoscine in suitable cases the sleep produced is quiet and re- freshing, and the system remains free from the after-headache, nausea, hebe- tude, and constipation that follow in the wake of opium and other narcotics. Administration of hyoscine of value in cases of senile trembling, paralysis agi- tans, and fibrillary agitation. In cases of chorea, and of various spasmodic affec- tions of the nervous and respiratory systems, hyoscine may be given hypo- derniically, in doses of from '/300 to '/ion grain. Roberts Bartholow (Med. News, Dec. 12, '91). Chloride of hyoscine to be given in doses of Vol to V22 grain. In various forms of chronic psychoses, in whicli other narcotics had proved themselves of no value, the drug was continued as long as six months, with but slight in- terruption, and gave, as a rule, eight hours' rest. In 25 per cent, of the cases, however, it could not be used, either on account of the dryness of the mouth, be- cause the patients became accustomed to its use, or because an exciting instead of a quieting effect was produced. Oringe (Hospitalstidende, vol. ix. No. 16, '91). Hyoscine believed to be most valuable as a- mental alterative in nervous dis- orders, in which it must be given in small, and, if necessary, repeated doses. Hyoscine, however, must not be used in- discriminately, as its abuse will do more harm than good. It was found of no value in mental depression. The author uses the drug in doses of from 'Aoo to 'Ago grain, increasing it cautiously up to Vw grain. He advises a sterilized solu- tion, with 5 grains of borij acid to the ounce, and recommends as antidotes, in eases of poisoning by it, pilocarpine and caffeine. Lionel Weatherly (Jour, of Mental Science, July, '91). Tried in five cases of hystero-epilepsy, and it was found that it would abort an incipient attack and one already devel- oped, a dose of Voi grain usually being sufficient. Tolerance was not estab- lished. Bela Nagy (Pester Medisinisch- chirurgische Presse, Nos. 8, 9, '94). Literature of '96-'97-'98. Hyoscine employed in a case of angina pectoris believed to be of neurotic origin, with excellent results. Ostwick (Med. Eec, May, '97). Hyoscyamus has anodyne powers and has been used in griping pains and neu- ralgias, and is often added to purgative pills to lessen the griping effect. It has 524 HYOSCYAMUS. HYPEROPIA. been used with success in strangulated hernia, its effects — anodyne and anti- spasmodic — serving advantageously to overcome the constricting ring in mild cases. Case of strangulated inguinal hernia in which reduction could only be accom- plished after the patient had taken, dosimetrically, 30 granules of hyoscya- mine and the same number of granules of sulphate of atropine, followed by 45 grains of chloral-hydrate in 1 ounce of the syrup of morphine. Lemarig (Jour, of Med. and Dosimetric Therap., Apr., '91). Left crural hernia reduced, after taxis had failed, by means of belladonna oint- ment and ice to the tumor and the in- ternal administration, frequently re- peated, of hyoseyamine and strychnine. Berruyer (Jour, of Med. and Dosimetric Therap., Apr., '91). C. Sumner Witherstinb, Philadelphia. HYPEEMETROPIA. See Htpbb- OPIA. HYPEROPIA, OR HYPERMETRO- PIA. — From Gr., hyisp, over, and q-^/, sight, was proposed by Helmholtz. Later Bonders introduced the root ^etoov, measure, into the word, changing it to "hypermetropia" to make it correspond with other terms introduced by him as ametropia and emmetropia. The term is often replaced by the abbreviation H. Definition. — That error of refraction in which the principal focus of the diop- tric media lies behind the retina. Eays parallel when they enter the eye tend to focus behind the retina and are inter- cepted before they come to a focus: the eyeball is too short from before back- watd. Symptoms.— If the hyperopia is of very high degree the eyeball is usually small in all directions, appears deep set, and noticeably fails to fill the orbit. The pupil is small from contraction of its sphincter, associated with excessive exer- tion of the accommodation. Through a similar association there may be con- vergent squint, either constant or occur- ring when the attempt is made to see near objects clearly. When the power of accommodation has been lost, as by age or the use of atropine, vision is imperfect at all dis- tances. With sufHcient accommodation clear vision is possible by excessive exer- tion of the ciliary muscle. This causes headache, most frequently frontal, some- times occipital. Strain of the accommo- dation also causes chronic or recurring conjunctivitis, redness or inflammation of the lid-margins, styes, etc. The use of accommodation to correct the hyper- opia leaves less for the focusing of near objects. Hence presbyopia appears early, requiring the use of convex lenses for near work before the age of 45. In high degrees continuous near-seeing may be impossible even from childhood, or ob- jects may be held very close to the eye to make up for imperfect focusing by en- larged retinal images. In old age the convex lenses needed are stronger than would be required for failure of accom- modation alone. The eye-strain may lead to inflammation of the choroid, optic nerve, or retina. The defect tends to give a distaste for reading and other occupations requiring near vision. Literature of '96-'97-'98. Fact insisted upon that all are born hypermetropic, and that later on we be- come myopic. In hypermetropia there are variations in degree under the influence of the power of accommodation, which have the effect of increasing the manifest hyper- metropia as the years go by; others, again, by reason of anatomical changes in the eye, lead to diminution in the amount of hypermetropia. HYPEROPIA. HYPERTROPHY OF THE HEART. 525 This diminution of the hypermetropic condition is owed to a great law by vir- tue of whicli during infancy and youth nearly all eyes are subject to an increase in refraction. This phenomenon results in producing in the one class of eases a reduction in the amount of hyperme- tropia, and in others causing the appear- ance of emmetropia, and even of myopia, and even, occasionally, a progressive in- crease in the degree of the latter. G. Martin (Recueil d'Ophtal., No. 8, '96). Extreme hypermetropia is prejudicial to speech. In youth the effort made to see distinctly at a short distance creates difficulty in finding the right word, and this difficulty persists during the whole life. De Haas (Annales d'Ocul., Tome xvii, p. 56, '97). Etiology. — Hyperopia may be due to flattening of the cornea or crystalline lens, making the focus of the eye unusu- ally long: hyperopia of curvature. More commonly it is due to the antero-pos- terior axis of the eyeball being shorter than the normal standard: axial hyper- opia. It may also be caused by the absence of the crystalline lens, as from injury or extraction for cataract: apha- kial hyperopia. Hyperopia is usually congenital. Nearly all eyes are hyper- opic at birth, and 70 per cent, continue so throughout life. It tends to increase after the age of forty years through the continued growth of the crystalline lens. Varieties. — Hyperopia that cannot be corrected by the accommodation the eye possesses is called absolute H. That which is still corrected by accommoda- tion in spite of efforts to relax the ciliary muscle is called latent H. That which can be revealed without use of a mydri- atic (cycloplegic) is called manifest H. That which can be either corrected or revealed is called facultative H. Diagnosis. — "V^Tien distant vision re- mains equally good or is rendered clearer by convex lenses hj'peropia is present. and the strongest convex lens that allows clear distant vision comes nearest to measuring the hyperopia. The slightest hyperopia is rendered manifest by test- ing both eyes together, beginning with convex lenses that are too strong and making them weaker until distant vision is clear. To find its full amount it is often necessary in young persons to em- ploy a mydriatic (cycloplegic). With a convex lens before it the hy- peropic eye can see clearly beyond the focal distance of the lens; and by scias- copy the point of reversal is found be- yond the principal focus of the lens. Treatment. — Hyperopia requires cor- rection by a convex lens. Usually one strong enough to correct all of it is best. The lenses should be worn constantly if there is convergent squint, headache, or inflammation of the eye or its append- ages. If symptoms only arise after use of the eyes for near work, wearing of the correcting lenses at such times may be enough. Diminishing the amount of near work required of the eyes may give relief. Persons who are hyperopic but suffer no inconvenience from the hyper- opia require no treatment for it. Hyper- opia co-exists with astigmatism in the majority of cases; and the very careful measurement and correction of both errors of refraction may be necessary to render the glasses at all satisfactory. Edward Jacksox, Denver. HYPERTROPHY OF THE HEART. Definition. — Increase in the thickness of the walls of the heart. The process maj' be general, affecting the entire organ. More often it is confined to, or predominant in, one side of the heart. The left ventricle is rather more often affected than the right. The amount of 526 HYPERTROPHY OF THE HEART. SYMPTOMS. muscular tissue in the auricles is scanty even when under the influence of hyper- trophic changes. Varieties. — Simple hypertrophy is as- sociated with a normal size of the cardiac cavities. Eccentric hypertrophy implies enlargement of the cavities as well as thickening of their walls. Concentric hypertrophy — thickened walls encroach- ing on the cavities — is seldom, if ever, met with. (It is said to occur as a con- genital condition. ■ Its existence in any particular case should not be affirmed until by prolonged soaking in water all rigor mortis has softened.) Symptoms. • — It is astonishing how little subjective disturbance may be present, even when the hypertrophy is pronounced. To be sure, the enlarge- ment is an attempt on the part of nature, as we shall see under Etiology, to avert symptoms; yet we wonder how the bulk and strength of the organ can fail, as they often do, to attract its owner's attention. There may 'be cardiac dis- comfort, throbbing or heaviness, espe- cially when lying on the left side, but seldom any pain. Sometimes there are signs of cerebral hyperaemia: vertigo, tinnitus aurium, flashes of light, head- ache, and disturbed sleep. In a general way, it is fair to say that the more promi- nent the subjective symptoms are in any patient, the more likely it is that he has something more than pure hyper- troph}'-: either a merging of the hyper- trophy into dilatation or else some neu- rotic disturbance. Objectively, we notice the pulse, the chest-wall, the epigastriiim, and the heart itself. The pulse is regular and of good strength. It is usually not rapid, except in exophthalmic goitre. Irregu- larity and intermittence suggest failing compensation. The wall of the artery may be normal, but in many instances it is rather stiff or presents the uneven ridges of calcification. It is said that in hypertrophy of the right auricle there may be such a regurgitation through the tricuspid valves (even if competent) be- fore they completely close as to cause a venous pulsation in the root of the neck. This must be a rare phenomenon. In- spection shows a forcible, extended, and dislocated cardiac impulse. This may be. powerful enough to render the thorax of a young subject asymmetrical, so that the lower part of the sternum and the ribs adjoining it on the left bulge for- ward. If the left ventricle is mainly affected, the apex is lower than normal and displaced to the left; if the right ventricle, the apex is displaced still more to the left, but it is not lowered. En- largement of the right ventricle is evi- denced also by pulsation in the epigas- trium and in some cases at the right edge of the sternum. Universal hypertrophy, as seen in some cases of aortic regurgita- tion, lowers the apex to the seventh or eighth intercostal space and displaces it to the nipple-line, while the whole body jars under its powerful efforts like a small tug-boat with a large engine. Upon palpation the apex seems blunter than normal, and its impulse is slow and powerful, contrasting with the rather spiteful tap of dilatation. Sometimes the action of the auricles can be detected by the lightly-opposed hand. Percussion demonstrates an increased area of dull- ness, extending a trifle higher than normal, or even iip to the second space, but exceeding the normal limits mainly in a lateral direction, one or two fingers' breadths to the right of the sternum, and as far as the nipple or the anterior axillary line on the left. Inasmuch as aortic regurgitation is sometimes asso- ciated with dilatation of the aorta, we may in this disease get dullness in the HYPERTROPHY OF THE HEART. DIAGNOSIS. ETIOLOGY. 527 second right interspace at the right edge of the sternum. The first sound at the apex is dull and loud. It has a booming quality, contrast- ing with the Talyular snap of hyper- trophy. A redu.plieation of the first sound at the apex (gallop-rhythm) is ominous of beginning cardiac debility. At the base the first sound is not heard so distinctly as in dilatation, while the second sound is loud and clear, with strong accentuation of that valve (aortic or pulmonary) which corresponds to the obstruction that the hypertrophy is trying to overcome. For instance, in chronic nephritis the aortic second sound is accented, and, in right-sided hyper- trophy, the pulmonic. In the presence of valvular lesions it need not be said that the murmurs caused by them more or less modify or replace the physiolog- ical sounds. Differential Diagnosis. — Nervous pal- pitation does not give the sensation of strength in the cardiac impulse, although if long continued it merges into hyper- trophy. The sounds are more valvular and have a certain "irritable" character. Dilatation has a feeble impulse, com- ing against the chest with a weak slap. The first sound at the apex has less mus- cular quality than in health, while in hypertrophy the difference is the other way. In other organs we notice signs of failing compensation. There are dull- ness and moist rales at the base of the lungs or even hydrothorax. The liver is enlarged. Dependent parts are oedem- atous. The urine is scanty, high-col- ored, with an excess of urates and more or less albumin. Care must be taken not to mistake a displaced heart for an enlarged one, whether the change in position be due to thoracic tumor, pleural effusion, or pressure through the diaphragm. Again, the retraction of the lung because of chronic phthisis or failure to expand after pleurisy may expose a normal heart in an abnormal way. On the other hand, emphysema may mask actual hyper- trophy. In a complicated case under my care a left-sided pneumothorax, limited by adhesions, acted similarly. The area of dullness in pericardial effusion is triangular, with the base downward. That of a generally-hyper- trophied heart is ovoid. Moreover, the feeble impulse and distant heart-sounds would at once exclude hypertrophy. It is advisable in every case to estab- lish the cause of the hypertrophy. When this can be done it confirms the diag- nosis, — besides having a possible influ- ence upon treatment. Etiology. — -Hypertrophy results from increased demands upon the circulation. An essential condition for its develop- ment is a fair degree of cardiac and sys- temic nutrition. A patient far advanced in phthisis cannot develop hypertrophy, nor will greatly-occluded coronary arter- ies siipply to the myocardium the req- uisite material for new growth. The causes of hypertrophy may be enumer- ated as follows: 1. Obstruction to the general circulation, as occasioned by coarctation of the aorta, hypoplasia of that vessel, or compression of it by de- formed chest-walls or tumors. Considerable stress laid upon defective and incomplete development of the thorax in the etiology of pseudohyper- trophies of adolescence. The deformity is characteristic, and consists in an elongation of the thorax, with constric- tion of the antero-posterior diameter. The heart is forced downward and the apex is sometimes felt as low down as the fifth intercostal space, giving the illusion of a true hypertrophy. The prseoordial shock is unusually energetic. Huchard (La Semaine Med., Nov. 3, '94). [The presence of the apex in the fifth 528 HYPERTKOPHY OF THE HEAET. ETIOLOGY. intercostal space in adolescents not con- sidered abnormal. E. N. Whittieb and H. F. ViCKEEY, Assoc. Eds., Annual, '96.] Aneurism might be expected to cause hypertrophy, but it seldom does, unless associated with aortic regurgitation. Atheroma of the aorta is set down as productive of hypertrophy. It embar- rasses the heart because it increases the friction of the blood-current and dimin- ishes the elasticity of the artery. Con- versely hypertrophy tends to produce atheroma by maintaining a high arterial pressure; so that the two conditions are apt to co-exist. Other things which in- crease the labors of the left ventricle and enlarge it are arteriosclerosis, acute and chronic nephritis, and, to a certain extent, pregnancy. The connection between kidney and cardiac hypertrophy is attributable to primary toxicity of the blood. Dominicis (Wiener med. Woch., Nov. 17 to Dec. 1, '94). In connection with the chronic granu- lar kidney we have hypertrophy of the muscle and of the fibrous tissue belong- ing to the whole arterial system con- nected with the left side of the heart and of the muscles of the heart itself. Dick- inson (Lancet, July 20, Aug. 3, '95). 2. A second class of the causes of hypertrophy includes those conditions which obstruct the lesser or pulmonary circulation, viz.: tumors, excessive pleu- ral effusion, emphysema, chronic inter- stitial pneumonia, and some cases of phthisis. Orth states that some cases of chronic bronchitis exhibit a degree of hypertrophy of the right ventricle not accounted for by the amount of emphy- sema present. 3. Valvular lesions are sure to cause hypertrophy unless the pa- tient is too feeble, or unless he is over- whelmed by the shock of their sudden development, as, for example, when a cusp of the aortic valves is torn off by violent exertion. More will be said about the valves under Pathology. Chronic adhesive pericarditis causes hypertrophy, particularly when, besides the oblitera- tion of the pericardial space, there is adhesion of the outer surface of the peri- cardium to the pleura. Interstitial myo- carditis is another cause. 4. Long-con- tinued and severe muscular exertion — as exemplified in blacksmiths, iron- molders, coal-miners, and longshoremen — may endanger the heart; also pro- longed or habitual mental excitement or worry, to some extent. 5. Somewhat allied to the preceding causes are exoph- thalmic goitre and excess in tea, cofiEee, tobacco, alcohol, and venery. Sometimes more than one cause operate in a single person. Laborious occupations affect much more severely the free drinkers than the total abstainers. Brewery- workmen illustrate this; although it may be that the effect of beer is due not merely to the alcohol it contains, but also to the large amount of liquid and to the carbohydrates dissolved in it, which would, in an excessive drinker, tend to keep the arteries at rather high tension. In embryonic life, and for a time after birth, the heart grows by increase in size and by division of the muscle-cells. Later, the growth of the heart depends essentially upon the enlargement of the muscle-cells alone. In hypertrophy of the heart, produced by artificial lesions of the aortic valves, true dilatation of the left ventricle always precedes the hypertrophy. Hypertrophy may develop even when the general nutrition of the body is very unfavorable, and in hyper- trophy the increase of the weight of the heart and of the transverse diameter of the muscle-cells is proportional. Tangl (Virchow's Archiv, June, '89). Heart-hypertrophy follows any condi- tion or set of conditions increasing the amount of work done bv tlie heart. The HYPERTROPHY OF THE HEART. ETIOLOGY. 539 causes of heart-hypertrophy may be di- vided into two broad classes: (1) causes Ijdng in lesions of the heart itself, inter- fering with proper function; (2) causes outside the heart. The first class is subdivided into (a) lesions of the valves, and (6) lesions of the heart-wall. Of 105 eases of heart- hypertrophy valvular lesions were pres- ent in 13. Of lesions affecting the heart- wall there were found myocarditis, tuberculosis, and aneurism. In some cases of localized myocarditis there is a, compensatory hypertrophy of other por- tions of the same wall. An aneurism of the hfeart-wall may throw out of function so large an area of muscle that the re- mainder must hypertrophy to make up for the portion lost. Again, an aneurism may be so situated in the heart-wall that the function of one or more of the valves may be interfered with. The second class of causes of heart- hypertrophy may be subdivided into (a) causes acting directly and interfering mechanically with the contraction of the heart, and (6) causes acting by increas- ing the general arterial blood-pressure. Cases of the first class resolve themselves into pericardial adhesions. There were 8 examples of this lesion, and of these 4 were tuberculous. In 7 out ' of 8 eases there were hyper- trophy and dilatation of the right ven- tricle, — in most cases extreme, — and in 5 cases uniform dilatation of the whole heart. Of the causes acting by increasing the general arterial blood-pressure, some offer mechanical obstruction to the blood- flow in territorial areas, others to the blood-flow in the whole general arterial system. To the former class belong (a) nephritis, and (6) pressure of tumors and the like upon vascular trunks. There were 14 cases of left-ventricle hypertrophy associated with nephritis without arteriosclerosis. This number included only 1 case of acute nephritis. Causes producing mechanical obstruc- tion to the blood-flow in the whole ar- terial system include' (a) the action of drugs and poisons (as alcohol, digitalis, and tobacco); (6) excessive work; (c) hydrajmic plethora (including general arterial hypoplasia) ; {d) cardio-nervous influences; (e) arteriosclerosis. Arteriosclerosis Avas found to be by far the most common cause of left-ventricle hypertrophy. It is the most frequent of all causes of heart-hypertrophy due to conditions lying outside the heart, oc- curring in subjects over thirty years of age. Of the 105 cases of heart-hyper- trophy from all causes, there are 62 cases dependent upon arteriosclerosis. Of these 62 cases, 38 had well-marked chronic dift'use nephritis, 17 slight chronic diffuse nephritis, 3 subacute nephritis, 1 acute glomerulonephritis, and 3 normal kidneys. Aneurism of the aorta occurred in 4 cases. In 20 cases there were valvular lesions. In most of these hearts the coronary arteries were dilated, thickened, and tortuous, and the seat of recent or chronic endarteritis. W. T. Howard (Johns Hopkins Hosp. Reports, vol. iii, Nos. 4, 5, 6, '93). Hypertrophy is never primary, and dilatation always precedes hypertrophy in a, hard-working heart, whether the in- creased labor be due to resistance from within or from without or to nervous stimulation and augmented action. J. G. Adami (Montreal Med. Jour., May, '95). Statistics showing the proportion in which the various causes manifested themselves in 360 cases. Cardiac hyper- trophy, due to some cause or other, was found to exist in no less than 105 cases. Of these arterial sclerosis was found to be the cause in 59 per cent.; chronic nephri- tis in 13.4 per cent.; valvular lesions in 12.4 per cent.; adhesions of the peri- cardium in 7.6 per cent.; excessive mus- cular work in 3.8 per cent.; tumors in 1.9 per cent.; aneurisms in 0.95 per cent.; hjemie plethora in 0.95 per cent. More than 50 per cent, of the cases of cardiac hypertrophy in general hospital work were due to arterial disease. La- fleur (Montreal Med. Jour., May, '95). The principal causes of cardiac hyper- trophy other than disease of the valves and of the myocardium and adherent pericardium are as follow: 1. Organic changes in the arterial system, including obolescenee of the capillaries and also congenital narrowing of the arteries. 2. the overfllling of the circulation. 3. The 630 HYPERTROPHY OF THE HEART. PATHOLOGY. circulation in the blood of either foreign substances or an excess of substances which are found normally in small quan- tities. 4. Causes that act in a manner still unknown on the general or cardiac nervous system. The diffuse form of ar- teriosclerosis is rightly considered as, in many respects, the most important; the changes are wide-spread, affecting the whole arterial system to a greater or less extent. James Stewart (Montreal Med. Jour,, Apr., '95). Pathology. — The muscular fibres of an hypertrophied heart are increased in size somewhat, but mainly increased in in thickness. The auricles are never yery thick. The left in health is about ^/s inch and may become ^/ ^ inch when hypertrophied. The right auricle is still thinner, and shows its tendency to hy- pertrophy by changes in its auricular appendix rather than in the rest of its cavity. Before measuring the walls, rigor mortis should be relaxed, as already advised, by soaking in water. Mere in- spection may prove deceptive as to the existence or not of hypertrophy in cases of eccentric hypertrophy, because the Fig. 1. — Excentric hypertrophy, due to adhesive pericarditis. number. Macroscopically, the cut sur- face is red and firm. The extent of the hypertrophy can be determined by the size of the organ, the thickness of its walls, and its weight. A normal heart should be of about the same biilk as the closed fist of the subject. The wall of ■the normal left ventricle is about ^/g inch in thickness, and of the right V4 inch, or a little less. The left ventricle seldom attains the thickness of 1 inch; the right may reach ^/^ inch, and it has been re- ported as being even more than an inch walls may look relatively thin and yet be absolutely hypertrophied. Weighing is a valuable procedure. The normal heart weighs 8 or 9 ounces. In disease the organ may weigh 1 pound or 1 ^/j poitnds, and exceptionally 3 pounds, i.e., as much as the liver ! ^Description of cuts : Fig. 1. Ex- centric hypertrophy as a result of chronic adhesive pericarditis in a man aged 26 years. Weight of heart with pericardium, 1328 grammes (44 ounces). Valves competent. Wall of left ventricle 2 V. centimetres thick ; of HYPERTROPHY OF THE HEART. PROGNOSIS. TREATMENT. 531 right ventricle 5 millimetres. Patient of Dr. F. C. Shattuck, at one time under the care of the writer. Specimen due to the courtesy of Dr. J. H. Wright. Fig. 2. Boy aged 6 years, in the writer's wards with exeentrie hypertrophy due to mitral regurgitation. The black line indicates the extent of cardiac dullness. Two attempts to obtain a radiograph were unsuccessful. Herman F. Vick- ERY.] Of course, the immediate effect of any of the causes of hypertrophy is manifest in the corresponding portion of the heart, and not in the whole organ. Aortic stenosis and regurgitation en- large the left ventricle. In time, how- ever, stasis is produced in ihe pulmonary circulation, and the right ventricle also hypertrophies. Valvular lesions, whether regurgitant or obstructive, cause an ap- propriate part of the heart to hyper- trophy, and then, sooner or later, more or less directly (with one exception) en- tails increased labor upon all the other portions of the heart. The exception is mitral stenosis, which affects the left auricle, the right ventricle, and the right auricle, and then tends to cause stasis in the general venous return, with con- sequent obstruction to the outflow of blood from the left ventricle and aorta into the arterial capillaries; but this ob- struction to the expulsive efforts of the left ventricle does not result in hyper- trophy of that portion of the heart, be- cause so little blood is admitted into it through the stenosed mitral valve. The greatest hypertrophy occurs in aortic regurgitation {cor hovinum). There is first eccentric hypertrophy of the left ventricle. When this reaches sufBcient size, there arises relative insufficiency of the mitral valves, and thereupon hyper- trophy of the left auricle and the right side of the heart. The inevitable result of hypertrophy is eventual debility and failure. By the time of death dilatation may far surpass hypertrophy; or the hypertrophied mus- cle may be more or less changed by fatty degeneration. In some cases the muscu- lar condition is apparently so good that the pathologist surmises failure of the nervous mechanism to be the terminal factor in the case. Prognosis. — As just stated, the condi- tion must terminate unfavorably. So long, however, as the hypertrophy com- pensates for the obstacle which rises to it, or grows proportionally with any aug- mentation of that obstacle, the patient Fig. 2. — Exeentrie hypertrophy due to mitral regurgitation. may feel perfectly well. Even during this time of perfect compensation he may, however, suffer from cerebral hsemor- rhage or (if the hypertrophy affects the right ventricle) pulmonary hsemorrhage. Escaping these dangers, he may do well for years, but finally dies, either from dilatation or fatty degeneration or the failure of innervation already mentioned. Treatment. — The care of a patient with hypertrophy demands that we should allow nothing to aggravate the condition, and should in every way pos- sible promote the nutrition of the myo- cardium. The etiology must be con- 533 HYPERTROPHY OF THE HEART. TREATMENT. sidered. Tobacco and alcohol must be forbidden and excitement and worry averted. Simple, nutritious food should be taken regularly in moderate quantity. It would be better to permit lunches than the ingestion of a large amount at one time. Moderate and habitual exer- cise is beneficial. The exact amount and character may be determined partly by the experience of the patient: dyspnoea and palpitation are not to be caused by it. If there is discomfort and throbbing in the left chest, bromides may be useful, or a drop or two of tincture of aconite, or veratrum viride, thrice daily. In a stout patient an occasional saline purge may be useful. Treatment for hypertrophy itself is out of place, and the restriction to low diet or the, use of aconite is sometimes danger- ous. We have really to consider not the treatment of hypertrophy, but the treat- ment suggested by the hypertrophy. It may be necessary to diminish the volume and improve the quality of the blood by appropriate diet, hygiene, and tonics. It may be desirable, also, to diminish the resistance of the arterio-capillary net- work by aperients, eliminants of various kinds, and by relaxants of the arterioles and capillaries, such as nitroglycerin and the nitrites. By these means the work thrown upon the heart is reduced, and, if necessary, the heart may also be strengthened by strychnine and digitalis. Broadbent (Lancet, Mar. 21, '91). Blood-letting at times, of life-saving usefulness, when the right side of the heart becomes engorged and overdis- tended by increased obstruction to the flow of blood through the lungs or left side of the heart, — a condition not rarely observed in intense bronchitis, especially when complicating emphysema, pulmo- nary oedema, and incompetence or steno- sis of the mitral orifice are present. J. E. Atkinson (Maryland Med. Jour., Dee. 29, '94). In arterial tension, opium and iodides are followed by a rebound when taken for weeks or months. This can be pre vented by giving short courses of sodium salicylate to carry off accumulated uric acid, the cause of increased arterial ten- sion. A. Haig (Therap. Gaz., Sept. 16, '95). Mercury is valuable far beyond its sup- posed alterative action. Its special bene- fit is exercised in dilated and hyper- trophied heart. To give digitalis a fair chance, preliminary doses of mercury are absolutely necessary. William Murray (Lancet, Sept. 28, '95). Engorgement of the portal system is almost always present in heart disease. Mercurial purges given in long-continued small doses are of the greatest impor- tance in these cases: V» grain or even '/loo grain of corrosive sublimate with tincture of the chloride of iron will effect revolution by aiding true heart-tonics. Adonidin, cactus, convallaria, or other? of newer remedies are of no real value. Satisfaction in real heart trouble is only obtained with nitroglycerin, strophan- thus, and digitalis. Horatio C. Wood (Cleveland Med. Gaz., Aug., '95). The treatment of cardiac hypertrophy is much the same in all cases, regardless of cause. Walsh and Page are in accord as to the great value of aconite — 1 drop every two hours until its effects are manifest. Page deprecates digitalis, recommended by Walsh and Osier as a cardiac stimulant, when valvular trouble is present, broken compensation being the signal for its use. The latter authors are also in accord regarding the value of blood-letting. Osier emphasizing the fact that with signs of dilatation — as indi- cated by gallop-rhythm, urgent dyspnoea, and slight lividity — venesection is, in niany cases, the only means by whicli the life of the patient may be saved; 20 to 30 ounces of blood should be ab- stracted without delay. Striimpell prac- tically advises the same remedies as Osier. When compensation has been es- tablished, Striimpell recommends baths ranging from 90° to 93° F., which are well borne by the patients and exercise a peculiarly beneficial and invigorating Influence upon the heart. F. W. Camp- bell (Montreal Med. Jour., June, '95). The following method of treating cases of dilatation and hypertropliy I'esulting HYPNOTISM. INDUCING HYPNOSIS. from overexertion advised: In marked cases rest in bed. Stimulants, such as brandy, wine, ether, etc., tend to irritate the organ. Digitalis is very useful in many eases. The use of strophanthus preparations and the ordinary medical cardiac stimulants in addition to digi- talis may be employed. Calomel affords great service after the other cardiac remedies fail. Narcotics and hypnotics are to be used with great care. Ice-bags are of doubtful value. Blood-letting is to be recommended. The use of aerated beverages is to be avoided. Hermann Eieder {Deutsche Archiv. f. klin. Med., B. 55, p. 8, '95). A daily cool bath, with rubbing, is a good tonic. Hot baths and Turkish baths are unfavorable or dangerous. Heeman F. Vickehy, Boston. HYPNOTISM. Definition. — Hypnotism is a subjective psychical condition, composed of hypno- sis, a pseudosleep-like state, in which the subject's natural susceptibility to sug- gestions is increased, and usually a post- hypnotic period of varying lengths, dur- ing which certain acts, suggested by the hypnotist while the subject was in a state of hypnosis, are performed. [According to Moll, " A person in an hypnotic state is called an hypnotic, or subject. A hypnotist is a man who hypnotizes for scientific purposes. A hypnotizer is a, man who makes hyp- notism a profession." J. T. Eskridge.] A post-hypnotic suggestion is a sug- gestion made during the period of hyp- nosis for the patient to follow out after the stage of hypnosis has passed away, and the subject has returned to appar- ently normal consciousness. It is prob- able that, during the time in which post- hypnotic suggestions are actually being followed out, the subject is in a state of partial hj'pnosis. Inducing Hypnosis. — There are sev- eral methods by which hypnotic sleep may be induced. When these have been divided into two classes they have been termed the physical and psychical. [The latter I prefer to call the sug- gestive method, and is the one that 1 usually employ except for very nervous, self-conscious, or hysterical subjects. I shall only briefly refer to some of the physical methods of inducing hypnosis, and then describe in greater detail the one I commonly employ, as I found it attended with least nervous strain to the subject hypnotized. J. T. Eskridge.] It is well for the patients to avoid, during the induction of hypnosis, as well as during the hypnotic state, everything that tends to excite or increase their nervous tension. Hypnosis may be in- duced by requesting the patient to fix his eyes intently on some bright object — such as a button or a lighted candle held a short distance from the eyes, a little to one side and nearly on a level with the top of the head — until the eyes close from fatigue, when the hypnotic condition may be completed by the hyp- notist making passes with his hands from above downward. The hands need not be in actual contact with the patient, but the operator should stand in front of his subject and the stroking should be from the upper portion of the face downward as low as the hips or knees. Braid often resorted to the above method. Staring at a spot on the ceiling or at revolving mirrors has been success- fully employed to induce hypnosis. The eyes must be held in an uncomfortable and strained position. The best position for this is looking iipward and slightly to one side. [Professor Charcot employed at times, especially for the hysterical, a sudden flash of an electric spark, the noise of a loud-sounding gong, or a stern command to go to sleep. He also modified the Braid method by placing pieces of glass close to the bridge of the nose. This 534 HYPNOTISM. INDUCING HYPNOSIS. procedure causes strong convergence of the eyes and quickly produces sleep, but it often throws the hysterical subject into a cataleptic condition. He induced hypnosis in some by pressure on an "hypnogenic" or "hysterogenic" zone, such as an ovary or the top of the head. It is said that if a powerful magnet is brought near some hysterical subjects it will cause sleep. J. T. Eskridge.] After an hysterical person has been hypnotized a few times her staring in- tently at her own image in a mirror may cause hypnosis, the patient remaining in a cataleptic condition. Some employ a species of fascination by requesting the subject to look the hypnotist fixedly in the eyes until suggested movements are made or spoken commands are per- formed. The effect of the fascination is apparently increased if the subject grasps the hands of the operator while each stares in the other's eyes. If the hypnotist presses on one or both ears of the subject or firmly holds the eyelids closed and exerts gentle pressure on the eyeballs, through the closed lids, hypno- sis may result, especially if the person operated upon is endeavoring to concen- trate his mind intensely on some subject. literature of '96-'97-'98. To successfully effect hypnosis some co-operation on the part of the patient is necessary. This may be essentially passive, but it is the inability to resist that constitutes the neurotic stigma. A. A. Eshner (Phila. Polyclinic, Dec. 11, '97). [The first person whom I ever hyp- notized I did so without intending or thinking of hypnotism at the time. The subject unintentionally and involun- tarily went into a profound state of hyp- nosis. J. T. Eskridge.] Eealizing the dangers that may result from practicing hypnotism by the phys- ical method (although, as is readily seen, no method is purely phj'sical) and the unpleasant medico-legal questions that might arise against the hypnotist in the employment of this method, I have adopted almost exclusively the follow- ing: I first explain to the patient that hypnosis, as I endeavor to induce it, is nothing more than a condition into which the person voluntarily places him- self by allowing his mind to follow my suggestions to the exclusion of every other thought. That I have not and never shall have any power to put him to sleep without his consent and desire. That after I get him to sleep I can make suggestions which he will carry out in his normal or wakened state without thought or vohmtary ejffort on his part, and by this means I shall, to a great ex- tent, be able to keep his mind off himself or his ailments. After the patient has comprehended what I desire, he is placed in a comfortable posture, either sitting or reclining, preferably the former, when I request him to close his eyes and think of sleep as I suggest the phenomena to him, telling him that the whole matter is in his hands and I have nothing to do with his sleeping except as I suggest its phenomena which he must try to realize that he is experiencing. I endeavor in every case to free the patient's mind of any thought of the mysterious. I now request him to think of sleep, of his going to sleep, and repeat two or three times: "Your eyelids are getting heavy; you begin to feel drowsy; your head feels full and heavy; you experience an increased sense of drowsiness and a stronger in- clination to sleep; your eyelids are get- ting heavier; you are feeling more and more drowsy; your arms begin to feel numb, sleepy, heavy, and powerless; a sleepy sensation is passing over your entire body and legs; my voice seems far- ther and farther off; now it appears to be far away, and to come from a great HYPXOTISil. SUSCEPTIBLE SUBJECTS. 535 distance; your eyelids are now decidedly heavy, and you are going into a deep and soothing sleep; now you are asleep and cannot waken until I tell you to do so; you cannot open your eyes." If the patient does not succeed in opening his eyes on my requesting him to do so, but at the same time positively assuring him that he cannot open them, I begin to make the necessary therapeutic sugges- tions in regard to his ailment. A combination of two or more of the different methods of inducing hypnosis is often desirable and may be necessary to hypnotize the very nervous, the ap- prehensive, the self-conscioiis, and the h3'sterieal. I have not employed any but the suggestive method for a number of years, although I have freqiiently failed by this means in hypnotizing subjects that I am sure could have been put into an hypnotic state by the use of other methods. Many of these, I am equally sure, would have been benefited by thera- peutic suggestions made while they were in a condition of hypnosis. [I hesitate to use any means that may be employed to deprive a person of con- sciousness against his will. I have never hypnotized a woman except in the pres- ence of a third party, and for a number of years I have refused to hypnotize any- one unless a third party was present. After I have hypnotized a woman I al- ways suggest that she will never come to my ofEce alone. J. T. Eskridge.] Awaking the Subject from Hypnosis. — The patient should never be awakened suddenly or in a state of agitation. One of the simplest methods is to suggest to the patients that they are gradually awaking and that within twenty or thirty seconds they will be wide awake with eyes open and feeling first rate, etc. One may suggest that the subject will grad- ually awake and then blow gently on the face. The eyelids may be raised and the patient called by name. Susceptible Subjects. — All persons are not equally susceptible to hypnotic in- fluences and some apparently cannot be liypnotized at all. A number partially yield to hypnotism, but to an insufficient degree to make them follow out sugges- tions. When hypnosis is attempted by the operator suggesting to his subject the natural phenomena of sleep, those that are ordinarily termed hysterical and those that are intensely self-con- scious are not easily hypnotized. On the other hand, when the physical, or Char- cot, method of inducing hypnosis is em- ployed, the hysterical, provided they are not at the time greatly agitated by their own thoughts and apprehensions, are readily hypnotized. The somnambu- lists, or sleep-walkers, yield most readily of all subjects that I have encountered. Those trained to unquestioning and im- plicit obedience, such as sailors and sol- diers, make excellent subjects, as a rule. [I have found that the Latin races are more easily hypnotized than the inhabi- tants of the northern portions of con- tinental Europe, or the Englishman, Scotchman, Irishman, or American. J. T. ESKEIDGE.] Too great a desire or an overanxiety to be hypnotized, amounting to a fear lest one may fail, not infrequently prevents one from yielding to hypnotic influ- ences. Those that can concentrate their thoughts on suggestions to the extent of subjectively realizing that what the hyp- notist is saying is really taking place are readily hypnotized. Disturbed attention from any cause greatly interferes with hypnosis. As a rule, the laborer and the chronic hospital invalid will yield more readily than the mentally active. It is a mistake to conclude because a person is hypnotizable that his mental power and attainments are poor, for many who are mentally strong are easily hypnotized after they have determined to yield to 536 HYPNOTISM. SUSCEPTIBLE SUBJECTS. the hypnotic influence. Anything that interferes with the physical comfort of the siibject or disturbs his thoughts will render him more difficult to hypnotize than when he is pleasantly affected by his snrroiindings. On the other hand, soothing influences, mental or physical, favor hypnosis. An imcomfortable posi- tion of the body of the subject, a room that is overheated or too cold, a strong, light, an attack of indigestion, pain, an overloaded stomach, the stimulating eifects of alcohol, coffee, tea^ or the nerv- ous effects of a strong cigar increase the difficulties in inducing hypnosis. Like- wise mental agitation, emotional excite- ment, worry, apprehension, pre-occupa- tion of the mind, and self-consciousness have a similar influence. Hypnosis is favored by bodily comfort, twilight, a darkened room, music, the presence of fragrant flowers, and freedom from all influences that tend to prevent the mind from following a suggested train of thought. A fair amount of intelligence seems to be necessary for the induction of hypnosis. It is impossible to hypno- tize the lowest grade of idiots. It is extremely difficult to induce hypnosis in the insane. [After repeated efforts in trying to hypnotize a number of insane persons I have not a single success to record. Voisin claims to succeed in hypnotizing the insane. J. T. Eskridgb.] Some are hypnotizable at one time and not at another. Some persons may not yield to hypnotism at the first attempt, but do so after repeated trials. A num- ber, especially the hysterical, cannot be put to sleep by the suggestive method, but will rapidly go into a cataleptic state on employing the means usually used by Charcot and his followers. Some experi- menters succeed in hypnotizing 80 or 90 per cent, of their subjects, while others cannot claim success in nearly so great a proportion; so that much depends upon ■the experience, the methods, the pa- tience, and the individuality of the hyp- notist. Sex. — Personally I have succeeded in inducing hypnosis in a greater proportion of male subjects than of female. Lie- bault and others have been able to hyp- notize a larger proportion of their female subjects, although the difference is not great in favor of the susceptibility of the latter. The hysterical are often hypno- tizable by the Charcot ■ method, while they will rarely yield when the suggestive one alone is employed. [I have not used the former method for a number of years, and this may account for my failure in inducing hyp- nosis in the extremely nervous and hys- terical. J. T. ESKBIDGE.J Cases of failure are probably due to conscious or unconscious resistance on the part of the patient, or to inability to fix the attention. Hysterical subjects are more difficult to hypnotize than others, while the insane usually cannot be hyp- notized. A. Liebault (Le Sommeil Pro- voqu6, p. 310, '89). Age. — Persons from about the sixth or seventh to the twentieth year make the best subjects for hypnotism. It is usually extremely difficult to hypnotize a child under four years of age. Middle- aged and elderly persons often readily yield to hypnotism, but, as a rule, they do not exhibit such a susceptibility as is generally found between the years of seven and twenty. Clijiate. — Eesidents of warm and tropical climates are said to be more eas- ily hypnotized than inhabitants of colder countries. I have had no experience with the former except after they have immigrated to Colorado. Among our foreign population here the French and Italian are the most susceptible. In estimating the proportion of per- sons who are hypnotizable many modify- HYPXOTISJI. HYPNOSIS: ITS DEGREES AND VARIATIONS. 537 ing circumstances have to be taken into consideration. JSTot the least of these is the personal influence of the hypnotist. Some may be hypnotized by one person and not by another of equal experience. He who succeeds in getting his subject en rapport with himself will usually be able to induce the hypnotic state. It is, in the employment of hypnotism as a therapeutic agent, as it is in the use of other aids to effect a cure, the per- sonal equation of the hypnotist that plays a part of no small importance. As a general rule, it may be stated that the oftener a person has been hypnotized the more easily subsequent hypnoses will be effected. In very nervous, self-con- scious, and hysterical subjects, when only the suggestive method to induce hypno- sis is employed, it often happens that the first attempt at hypnosis nearly succeeds, and that at every subsequent effort of the operator the faihire is more and more pronounced, until finally no approach to hypnosis can be obtained. It is probably best not to rely entirely upon the sug- gestive method in inducing hypnosis in this class of subjects. [In those cases in which I have suc- ceeded at the first sitting in getting the patient thoroughly hypnotized, never have I failed of complete success in a subsequent attempt at hypnosis, pro- vided the subject was in a good condi- tion. It is a curious experience with me, it may not be new to others, that dipsomaniacs, during the time the in- tense desire for alcohol has been upon them, have not completely yielded to the influence of hypnotism nor have followed suggestions made at these times, not- withstanding I had often succeeded in completely hypnotizing them between their periodic drinking-bouts. J. T. EsK- KIDGE.] As TO Whether a Person Can be Hypnotized Withottt His Knowl- edge OE Consent oe Against His Desire. — If the suggestive method only is employed in inducing hypnosis we are justified in af&rming that a person can- not be hypnotized without his consent and voluntary co-operation. When one or a combination of the so-called phys- ical methods is used in inducing hypno- sis the subject may not only be hypno- tized without his consent or desire, but against his wish in the matter. [Pertinent to this subject Bjornstrom says: "It certainly is true that a con- scious and willing co-operation promotes sleep, but a number of cases are on record where the sleep appears unex- pectedly, ' unconsciously, and against one's will." J. T. Eskhidge.] Hypnosis : its Degrees and Variations. — A clean-cut and terse description of hypnosis is very difficult, as the condition varies in different subjects, being modi- fied to some extent by the normal tem- perament of the subject, his mental and physical condition at the time, the depth to which the hypnosis is carried, and the method employed to induce it. The or- dinary subject, when hypnotized by the suggestive method, especially if every precaution is taken to soothe the patient and prevent his becoming nervous and excited, sits or lies as one in a quiet and peaceful sleep, — the somnambulistic state. Temperature, pulse, and respiration vary little from the normal; the face is usu- ally slightly flushed; the voluntary mus- cles are relaxed and the head and lim^bs assume the positions forced by gravity. If the siibject is nervous, apprehensive, or excited, and one of the so-called phys- ical methods is employed to hypnotize the patient, the limbs may become rigid —the cataleptic state — or he may go into a profound and stuporous sleep, — the lethargic state. The latter condition is not produced primarily by startling the patient, by means of striking a loud- sounding gong, by the sudden flash of an electric spark, or by a stern command to 538 HYPNOTISM. PHYSICAL EFFECTS. sleep, such as will cause the cataleptic state suddenly to develop; biit is pro- duced by staring, or by pressure upon the eyeballs effected by means of the fingers held gently against the upper eyelids. Charcot recognized three stages, viz.: (1) the cataleptic; (2) the lethargic; (3) the somnambulistic. I shall not take up space here in describing the cataleptic (see Cata- lepsy) and the lethargic conditions. The somnambulistic state is the most interesting, both for psychological and therapeutic purposes. It is induced most typically by the suggestive method of effecting hypnosis, although it may be caused by any method that affects the imagination, especially by staring. It may be brought about secondarily from the cataleptic or lethargic condition by the operator gently pressing or rubbing the subject's head. The insensibility to pain found in the somnambule is usually the result of the suggestion that the patient cannot feel pain, although it sometimes occurs without any voluntary suggestion on the part of the operator. There is no increase of muscular irri- tability, similar to what is found in the lethargic state. If the hypnosis is slight the muscular tone is nearly normal, but if it is deep the muscles are relaxed; yet slight muscular contraction can be caused in some cases by exciting the cutaneous nerves over the muscles. The special senses and memory are sharpened during hypnosis. [Many claim that the mental facul- ties generally are improved while the subject is in a somnambulistic state, but my observations have led me to believe that this apparent improvement can be accounted for by the heightened state of activity of the special senses. J. T. EsK- BIDGE.] For the most part the somnambule is largely deprived of his normal sponta- neity, although he does often exhibit some power of reasoning, and performs certain acts that meet with his approval, and refuses to do other things because he seems to realize that they are unneces- sary or improper. On the whole, the dis- criminating power of the somnambule is usually far below normal, and it can often be almost, if not completely, de- stroyed by repeated suggestions for this purpose, provided that the suggestions are made with discretion and the subject is positively given to understand that the thing suggested for him to do is right and proper for him under the circum- stances. Physical Effects of Hypnotism. — The cataleptic and the lethargic stages do not interest us here. Nearly all, if, indeed, not all, the altered conditions found in the organs of locomotion in hypnosis, in- duced by the suggestive method, are due to suggestion. If no suggestions are made the subject sits or lies as if asleep, and the limbs fall from force of gravity. If one succeeds in hypnotizing an ex- tremely hysterical person by the suggest- ive method, and she be allowed to go into a cataleptic or lethargic state, then she may exhibit the phenomena common to these conditions. (See article on Cata- lepsy.) By timely suggestions the hysterical can be prevented from exhibit- ing any cataleptic phenomena. Nearly all the general and special sen- sory functions seem to be sharpened in a person while in a state of hypnosis, and those that are not affected by the hyp- notic state may be increased by the proper suggestions. It is remarkable how acute the hearing often becomes. The subject at times will be able to tell what figures or letters have been written by some one in a distant portion of the room, while the other occupants can scarcely hear the motions of the pencil. HYPNOTISM. PSYCHICAL MANIFESTATIONS. 539 [I have never found one who has been ahle to read in this manner what has been written if several words or a few lines are written in small letters. I have repeatedly satisfied myself that hearing, vision, taste, and smell are increased, es- pecially if the suggestion is made that they will be. J. T. Eskeidgb.] Temperature and pressure sensations are increased by suggestion. Power to feel pain may be present unless the sug- gestion is made that it will be absent, although I have found it absent when no voluntary suggestion has been made. Persons soon become fatigued on put- ting them to severe tests to determine the capacity of their sensory functions. I have seen patients become exhausted, manifest great nervousness, begin to sigh, the face to flush, and profuse per- spiration to appear after undergoing an examination of their physical or mental powers. Literature of '96-'97-'98. In cases in which a patient, on being subjected to hypnotic influence, shows convulsive tremors, all hypnotic sugges- tion should immediately cease, and the subject should be wakened and advised to rest in the recumbent posture; a small amount of some gentle stimulant should also be administered. G. de Clive- Lowe (Austral. Med. Gaz., Dec. 20, '97). Psychical Manifestations in Hypno- tism. — Of all the phenomena of hypno- tism that of memory is the most pro- nounced and the most easily studied. The memory, as in the sleep-walker, or natural somnambule, is acute during hypnosis, not only for occurrences dur- ing previous hypnoses, but generally, both for the waking and sleeping states. Some persons affected with natural som- nambulism remember during the som- nambulistic state only what occurred during previous states of this condition and nothing of their normal states. [So far as I have investigated, all persons in an artificial somnambulistic state retain a memory of all occurrences during previous hypnoses, a partial, and sometimes an accurate, memory of things that took place during their nor- mal states. Most cases of hypnotism that I have carefully studied, unless I have made a suggestion to the contrary, have been able during their normal states to recall a few things that have been said to them during hypnosis, and as time elapses, they have, by effort, re- called much that has occurred while they were in an hypnotic state. J. T. Esk- eidgb.] A suggestion during hypnosis to the effect that they will remember nothing that has taken place during this period causes memory to be a perfect blank after they are awakened. In like manner, if the suggestion is made during hypnosis that they will remember everything on awakening, the result will be as sug- gested. After the suggestion has once been made during hypnosis that nothing will be remembered on being awakened, nothing will be remembered after sub- sequent hypnoses until after the effect of this suggestion has been destroyed by a contrary one. [I admit that memory is totally a blank or very imperfect in the waking state for what has occurred during hyp- nosis, but I have met with, as stated above, cases in which the subject could recall a few things that took place dur- ing the hypnosis if no suggestion had ever been made that nothing would be remembered. I, therefore, cannot agree with those who contend that all memory for occurrences of the hypnotic period is abolished in every case after the pa- tient has been awakened. J. T. Esk- eidgb.] "While memory during the state of hypnosis is iTsually so acute and so accu- rate for all previous hypnoses, yet the hypnotist has it in his power, by simply suggesting to this effect, to prevent the subject in one hypnosis remembering 540 HYPNOTISM. DANGERS OF. anything that has occurred during all previoiis hypnotic states. This has an important medico-legal value, and might prevent criminal acts of the unscrupulous to go undetected. Another characteristic of the memory in hypnotism is the power unconsciously to remember things weeks, months, or probably years after they have been sug- gested, yet at no time during the period between the time when the suggestion was made and the moment at which the act suggested was carried out is the person able to recall the faintest idea of this latent memory; neither is he con- scious that a suggestion has been made. During a subsequent hypnosis, after the carrying out of a post-hypnotic sugges- tion, the person is able to describe every detail in relation to the suggestion and its execiTtion, but " during the waking state nothing of it is remembered. [I have a patient, a noted sleep-walker of this city, whom I have for a period of years hypnotized once every two or three months. During hypnosis I suggest to her that she will come to my office two or three months hence, on such a day and at such an hour and bring a friend with her. She has failed to appear at the appointed time only twice. On each of these two occasions she called me up by telephone at the time appointed for her to come, almost to the minute, tell- ing me that she could not get anyone to come with her. I had previously sug- gested that she should never come to my office alone. Her friends have re- peatedly asked her between these periods when she was going to visit me. Her reply has invariably been: "I don't know; when I am wanted, I suppose." J. T. ESKBIDQE.] The power of a person in an hypnotic condition to recite passages that they had simply casually read a long time be- fore is often wonderful. While memory is usually very acute in this condition, I have found a few persons in whom it seemed poor. All prolonged trials of memory during hypnosis are very fa- tiguing. Diagnosis of Hypnosis. — It is not always possible to detect feigning. The relaxed and expressionless condition of the face, most typically seen before the hypnotist begins with his suggestions, the falling of the limbs and head by the force of gravity; the slow, labored, and jerky movements executed in carrying out suggestions are hard to simulate. A person feigning usually overdoes his part. Dangers of Hypnotism. — So far as my reading goes there has been only one death recorded as occurring from the direct effects of the excitement incident to intense mental strain of a person in hypnosis. [An account of the death and autopsy may be found in the Journal of the American Medical Association (Oct. 27, '94). The unfortunate subject was a neurotic female, who, after being hyp- notized, was subjected to intense mental strain and requested to exercise clair- voyance while hypnotized. Her answers were not remarkable, considering the in- formation given her by the operator, a non-medical man, but the strain proved too great and she collapsed and died in a few minutes. J. T. Eskbidqe.] Kearly all are agreed that the indis- criminate use of hypnotism or the em- ployment of it by persons ignorant of the possible bad effects that may result from it, is highly reprehensible and should be forbidden by law. Much de- pends upon the methods employed to induce hypnosis. Eepeated hypnosis, unless the greatest precaution is used, may result in weakening the ego of the subject. It does not seem to me justi- fiable to hypnotize for experimental pur- poses alone. [He who resorts to hypnotism is deal- ing with a potent agent, and he should use it as carefully as he would a deadly HYPNOTISM. DANGERS OF. THERAPEUTICS. 541 poison. No one would think of giving large doses of morphine or strychnine simply to study the physiological effects of these agents upon man. If these remedies are given for their therapeutic effects, then the resulting phenomena should be studied and recorded. J. T. ESKBIDGE.] When it is necessary to employ hypno- tism for the relief of some conditions, then it is justifiable, in my opinion, for the observer to study the physical and psychical effects. The hypnotized should never be subjected to prolonged physical or mental strain. Persons should not be kept in an hypnotic condition for days at a time. When the suggestive method of inducing -hypnosis is employed, the same subject should not be too repeatedly hypnotized over a long period, and every precaution should be used, by suggestion and otherwise, to prevent any ill efEeets. It seems to me that hypnotism is only justifiable for therapeutic purposes in a limited number of cases. Hypnotism regarded in the light of a physical force, as real as the currents of electricity and as potent for good in the relief of disease. Luys (Jour, de M6d., Feb. 28; Mar. 7, 13, 20, '92). The cases in which hypnotism should be used are very few. Charcot (Berliner klin. Woch., June 3, '89). Hypnotism is either useless or has only a temporary value in cases of slight func- tional disturbances, and in many pa- tients it has an injurious action. Ziems- sen (Miinch. med. Woch., Aug. 10, '89). Hypnotism is often followed by in- jurious after-effects, such as nervousness, and even convulsions. Mendel (Berliner klin. Woch., June 3, '89) ; Lombroso (Le Bull. M6d., July 21, '89). Hypnotism is apt to produce evil effects on the organism, and it especially favors and develops tendencies to hys- teria. Germain S6e (Ther. Gaz., Apr. 15, '90). Literature of '96-'97-'98. Hypnotism is a pernicious practice, in that it lessens one's power of resistance, and so degrades the patient both mor- ally and intellectually. William James Morton (N. Y. Med. Jour., Mar. 13, '97). There is no doubt that the methods employed by Charcot and his followers — such as tiring the subject by gazing at bright objects held in such a position as to strain the eye-mtiscles, the sudden flashing of an electric spark before highly-hysterical subjects, frightening a nervous person by striking a loud-sound- ing gong hidden near her, or stamping the floor with the foot, and in a loud and commanding voice bidding the person go to sleep — may result in great nervous and mental strain, often throwing the sub- ject into an hystero-epileptic condition. Convulsions and insanity have followed such procedures. As. to whether some persons may pos- sibly be hypnotized against their will, it is my opinion that these are mainly ac- cidental cases and could rarely be used for the purpose of crime. ISTo one can be hypnotized against his will if only the suggestive method of inducing hypnosis is employed. It is probable that after repeated hypnotic siiggestions a person might be forced to commit a criminal act against his will or desire. [A. Stodart Walker has recently de- tailed such a case, and says that he has met with more than a dozen experiences. J. T. ESKRIDGE.] Therapeutics. — Pebcautions Neces- SAET. — As it is diflicult to hypnotize the highly nervous and intensely self-con- scious by the suggestive method, it is well to refrain from hypnotizing these sub- jects when it is possible to help them as much by other methods. When it seems imperative to induce hypnosis in them the suggestive method, combined with staring, pressure on the head, or stroking of the body should be resorted to. In all classes of subjects hypnosis should not be induced more frequently than seems 542 HYPNOTISM. THERAPEUTICS. absolutely necessary. To prevent resort- ing to hypnotism too often it is well at each seance to suggest that the impres- sions will be lasting, and repeated hypno- tizations will not be needed or desired by the subject. The latter should be cautioned against depending entirely upon the help of another, but encouraged to assert his will and become independ- ent. Such suggestions should be re- peated in a firm voice two or three times while the patient is in a deep hypnosis. Unpleasant or exciting suggestions should be avoided during hypnosis as much as possible, and if we are forced to use any such, their effects should be counteracted by the proper suggestions before the subject is allowed to awaken. It is better, as a rule, to suggest that the patient will remember nothing of what has been said during the seance. We should never allow ourselves to use sug- gestions to satisfy a morbid curiosity, neither should we inquire into the pri- vate affairs of the patient. The subject should always be told before being al- lowed to awaken that nothing biit good can result from the hypnosis, that noth- ing but proper suggestions can be fol- lowed, and that he will feel better, less nervous, and refreshed on awakening. It is safer never to hypnotize a person, espe- cially a female, except in the presence of a third party. The suggestion should be made during each hypnosis that no one shall ever be able to hypnotize the sub- ject against his will, and not even then except in the presence of a third person. If any delusions have been suggested during the hypnosis they should be de- stroyed before the person is allowed to awaken. The awakening should be done in a soothing manner. It is well for most persons, if not absolutely necessary for all, to be aroused slowly, by being told that they are gradually awakening, and will be wide awake in a certain number of seconds, feeling quite well, without mental or physical depression. The value of hypnotism in each indi- vidual case depends upon whether the mental impression made by the hypnotist upon the subject in the state of hypnosis is capable of removing and taking the place of another mental impression of which the subject is possessed. I believe that the therapeutic influences of hypno- tism are due to suggestions which are made sufficiently strong to become more or less permanent mental impressions. The mind of every normal person is in a more or less receptive condition, the de- gree depending largely upon the presence or absence of disturbing influences. We are constantly, when in contact with others, making and receiving impres- sions. It is not necessary for us to be hypnotized to be swayed to some extent by the influence of .others. [Tuke's work is replete with examples of this fact. Probably the reason why a person in a state of hypnotism is more susceptible to suggestions than in his waking or normal condition is due to the fact that the mind is freed from all influences at the time save those of the hypnotist. J. T. Eskridge.] We should not expect too much of hypnotism. At best it permits only of making suggestions more effective for good or bad than can be done upon one in his waking state. [Elsewhere I have said: "It seems to me that much injustice has been done hypnotism as a therapeutic agent by the extravagant claims made for it by some conscientious physicians. Whether it has or should have a place in therapeu- tics we must decide after giving it a fair trial. So many of the results alleged to have been obtained by hypnotism seem so exaggerated that one is led either to doubt the honesty of the hyp- notist or suspect that his judgment has HYPNOTISM. THERAPEUTICS. 543 been -warped by enthusiasm." J. T. ESKRIDGE.] I have never seen a case in which a fixed habit of years' duration has been broken up by one or two hypnotic treat- ments, althoiigh many claim such a de- gree of success. In these cases my expe- rience leads me to believe that repeated hypnotic suggestions extending over prolonged periods are necessary, and that even then the treatment will rarely be successful for periods of years. There will come times in the feelings of the alcohol or morphine Tiabitue when the impulse to indulge is overpowering. Further, it must be remembered that scarcely any habit can be broken up by hypnotic suggestions unless the patient is desirous of getting rid of such a habit and fully co-operates with the hypnotist. The desire of the subject in his waking state and the influence of the suggestion made by the operator during hypnosis are both necessary in enabling a person to overcome such a habit as the morphine or alcohol, and even then they often fail, owing probably to the weakness of the will of the habitue when the temptation is at its strongest. Analgesia. — Some contend that pain- ansesthesia does not occur spontaneously in hypnosis, but is the result of sugges- tion. Bjomstrom seems to take it for granted that it is almost universal even without suggestion. My personal expe- rience is that in numerous cases anal- gesia does not occur irrespective of sug- gestion, and in a few it is not complete after repeated suggestions to this effect have been made. Were it not that we possess better and more reliable anesthetics in chloroform and ether, hypnotisfii would to-day be extensively employed in surgery. It is only when the administration of an anaesthetic would be likely to be attended with danger that there is any excuse to resort to hypnotism in surgical cases. Hypnotism recommended for opera- tions in the mouth, as the patient is able to swallow the blood, and thus escapes the danger of its falling into the respira- tory passages. Forel (La Semaine M6d., Aug. 14, '89). Case of a patient who, under the in- fluence of hypnotism, was operated upon with the most satisfactory results. It was a case of osteomyelitis in the upper third of the humerus, and required a painful surgical operation. Three days before the operation the patient was hypnotized six times, and was very well under control by the proper time. Ed- ward L. Wood (Med. Rec, Jan. 4, '90). Hypnotism is of great value in chil- dren, and also in dental operations. In operations of some gravity, however, the fear of the patient outweighs any other influence, and hypnotism does not suc- ceed. Osgood (Internat. Dental Jour., June, '93). For the Eelief of Labor-pains. — Hypnotism has been employed by a number for this purpose. It is a very uncertain agent in these cases unless the subject has been hypnotized before labor begins. This often requires considerable time and patience, and a few inhalations of chloroform answer the purpose much better. After employing hypnosis on thirteen patients in labor, the conclusion reached that hypnotism is an uncertain and in- elKcient anaesthetic, and produces a de- cided diminution in the force of the uterine contractions. Auvard and Secheyron (Archives de Tocologie, Nos. 1, 2, 3, '88). Organic Disease. — I have employed hypnotism in the treatment of organic diseases only in a few instances, and then on the earnest solicitation of the patients or their friends. Nothing further was expected in the treatment of these cases by hypnotic suggestion than the relief of certain symptoms, such as pain and de- spondency and the improvement of the 644 HYPNOTISM. THERAPEUTICS. organic functions. In some instances despondency has been replaced by hope, pain assuaged, if it was not acute; sleep induced, the bowels regulated, and appe- tite and digestion improved. I must con- fess that I haye seen very few cases of organic disease in which more was ac- complished by hypnotic suggestion than could have been attained by other and less troublesome means. [I have met Avith one case of cervical pachymeningitis of several years' dura- tion in which pain and sleeplessness have been relieved for a period of nearly three years, although the patient was hypno- tized only six or seven times. J. T. EsK- EIDGB.] The presence of the physician who inspires his patient with confidence and hope is a constant suggestion that health will be restored. Out of 29 cases of organic disease of the nervous system, treated by hypnotic suggestion, only one cure was obtained, and that was doubtful. Pain and other symptoms may, however, be relieved. Van Eeeterghem and Eedeu (Clin, de psycho - therapie suggestive. Compte rendu des rSsultats obtenus pendant la premiere p6riode bisannuelle, 92 pp., gr. 8, '89). Case of tabes dorsalis treated by daily hypnotism for about three weeks. In ad- dition to local anaesthesia and partial loss of sight, there were severe pains in the chest and back, obstinate constipa- tion, inability to walk more than half a mile, loss of appetite, insomnia, and great mental depression. The patient was hypnotized, and suggestions were made as to the bowels, digestion, sleep, and pains, the parts at the same time being gently rubbed. The following day the bowels were moved naturally for the first time in three months. After three Aveeks of treatment the patient's habits had greatly improved. The relief con- tinued until the time of writing the re- port (about four months), although the disease probably progressed. Tuckey (Lancet, Aug. 24, '89). Case of a man suffering with an ad- vanced stage of disseminated sclerosis of the cord was so benefited as to be en- abled to leave the hospital. The diagno- sis was verified, as the patient returned within a year and died of tuberculosis. Fontain and Sigaud (Lancet, Aug. 24, '89). Hypnotism and suggestion are useless in organic cerebral and spinal disease. Danillo (St. Louis Med. and Surg. Jour., June, '89). Case of infantile hemiplegia observed, in which improvement \\as produced after hypnotization for three months. The author believes that every person capable of displaying functional nerve- disturbance may be successfully hyp- notized, and his experience led him to consider hypnotic treatment for organic lesions unsuccessful. J. H. Whitham (Brit. Med. Jour., Feb. 28, '91). Functional Disohders. — Gastro-in- testinal disorders of a functional char- acter may be temporarily and in some instances apparently permanently im- proved by hypnotic suggestion. At the suggestion of the operator the appetite increases and digestion improves. [I have not undertaken to treat many of these cases by suggestion, and those that I have were mostly inmates of the County Hospital. The improvement in moat instances was only temporary. When the loss of appetite and impaired digestion depended upon functional nerv- ous states the effect of treatment was better. J. T. Eskkidge.] It is easy by suggestion to cause the bowels to move at will, and often they will move at regularly suggested periods for days subsequently; but repeated sug- gestion from time to time is necessary to prevent a return to a constijMted habit. Hypnotism is of little value in breaking up a costive habit except in those cases in which the habit is of short duration and due simply to a neglect to obey the calls of nature. All the functional disorders of the nervoiis system do not improve by hyp- notic suggestion. I have never sue- HYPNOTISM. THERAPEUTICS. 545 eeeded in improving the condition of a typical hysterical subject by means of hypnotism, mainly from the fact that I have refrained from using any method to induce hypnosis in this class beyond the suggestive method, and none have become thoroughly hypnotized. Many experimenters — among whom may be mentioned Van Eeeterghem, Eeden, Bidon, Stembo, Sperling, Bernheim, Danillo, Moll, Striibing, Mendel, Briand, Eingier, and others — report success in the treatment of a number of their cases of hysteria by means of hypnotic sug- gestion. "What method they employed to hypnotize this class of their patients is not stated. Danillo acknowledges that most of his cases have relapsed after they had been helped or cured. Those cases of hysteria in which the symptoms are many and quickly chang- ing are less amenable to treatment than those cases in which there is some single severe symptom. Sperling (Deut. med. Woch., Oct. 31, '89). In 40 cases of severe hysteria and other neuroses, 9 were completely cured and nearly all improved. In 164 slighter neuroses, 47 were cured, 37 markedly im- proved, and 39 slightly improved. Van Reeterghem and Eeden (Clinique de psycho - therapie suggestive. Compte rendu des rSsultats obtenua pendant la premiere pfiriode bisannuelle, 92 pp., gr. 8, '89). Of three hundred cases observed more than one-third were hysterical. The author had good results in almost all from the use of hypnotism. It is indi- cated (1) in the spasmodic attacks of grave hysteria and the paralyses follow- ing; (2) in monosymptomatic hysteria; (3) in ordinary hysteria; (4) in hyster- ical insanity. Bgrillon (Wiener klin. Woch., No. 4, '92). Two severe cases of imaginary disease reported cured by suggestion. Both cases occurred in women: one of these imagined that she had paralysis of the legs, through paternal inheritance, and for nine years was actually confined to bed and chair, from a supposed inability to walk. After so long a period of im- aginary suffering, one single suggestion w as sufficient to effect a cure. The other patient imagined that she had u. ta]]e-\\orm, and was cured when she was made to expel the imaginary animal. William 6. De Wees (Kans. City Med. Index, Feb., '91). My personal attempts favorably to in- fluence epilepsy have been a failure, and this is in accord with the experience of others. I have had no experience in the treatment of chorea or paralysis agitans by hypnotism. Some report good re- sults, but I suspect that the effect is temporary. Literature of '96-'97-'98. Functional neuroses of all kinds are favorably influenced by suggestion. The nervous disorders of writers and artisans yield in a short time, epilepsy and paralysis agitans excepted. Mental dis- eases are not at all, or but very little, influenced by suggestion. Alcoholism is. Suggestion can be used in various dis- eases for which one can find no adequate cause, as in insomnia and a great many pains. By producing local anaesthesia of the skin, one can do minor operations. Neurasthenic conditions in the sexual sphere are markedly benefited by sug- gestion. Louis Lichtschein (Med. Rec, May 2, '96). I have seen a few cases of stammering greatly benefited by suggestion, but they have all relapsed. Insomnia yields quite readily to hypnotic suggestion if the sub- ject is easily hypnotized. Eepeated hyp- noses are necessary for the relief of sleeplessness, and relapses are common. I have never seen any permanent benefit result to the neurasthenic. They are difficult subjects to hypnotize and the hypnosis is rarely profound. Neuralgia of a mild form and headache may be re- lieved in good subjects, but no perma- nent results are obtained without the removal of the causes. I have tried in -35 546 HYPXOTISM. THERAPEUTICS. vain to relieve severe odontalgia and trigeminal neiiralgia. Others claim great success. In neuralgia the writer affirms that he has effected a permanent cure in about 10 per cent, of the eases treated by hyp- notic suggestion. W. C. Delano East- lake (Med. and Surg. Reporter, Sept. 5, '91). Hypnotic suggestion practiced nearly fifteen hundred times, usually with very marked success. In various functional nervous disturbances, hysteria, insomnia, neuralgia, headaches, and in morbid mental states bordering on insanity de- cided benefit has followed its use. Frederick H. Gerrish (Boston Med. and Surg. Jour., July 21, '92). Case of mydriasis cured by hypnotism. It was unilateral and disappeared after seven ' sittings. Three months later the other eye presented the same condition and was cured in the same way. Booth (Amer. Med. Surg. Bull., Nov. 1, '95). Literature of '96-'97-'98. Hypnotic suggestion acts upon specific cases of either pain or disability which depend upon morbidly persistent organic memories of pain or disability. Mary Putnam Jacobi (N. Y. Med. Jour., Apr. 9, '98). Insanity. — I have never succeeded in hypnotizing an insane person. Voisin, of Parisj professes to have hypnotized about 10 per cent., and asserts that good results have followed in some instances. Vicious Habits in Childhood and YoiTTH. — A few years ago I had had no experience in the treatment of these cases. During the past three years I have hypnotized several of these subjects. The apparent permanent benefit in nearly all, except in those in which brain- power was very deficient, has been en- couraging. Habits of lying, stealing, and masturbation have been broken up. I have repeatedly hypnotized all these subjects. [C. L. Tuckey reports success in the treatment of such a subject with a bad heredity. J. T. Eskridge.] Case of sexual perversion cured by suggestion. Schrenck-Notzing (Jour, of the Amer. Med. Assoc, June 21, '90). Hypnotism advocated as a means of correction and education for the vicious and depraved, especially the young. Twenty-two cases tried: 4 failures, 8 improvements, and 10 cures. Lifibault (Revue de I'Hypnotisme, Jan., '89). Hypnotism may be of inestimable serv- ice in the moral education of backward children. Brunnberg (L'Hypnotisme, jugS par les Specialistes, '93). Hypnotism is a powerful therapeutic agent in the treatment of onanism, sper- matorrhffia, and various forms of im- potence. Persistent erotic dreams ban- ished in a single lady of 20 by this means after the sixth seance. Victor v. Gyurkovechky (Wiener med. Presse, Xo. 47, '92). Four hundred and twenty-two cases treated by hypnotism with good results, the best effects being observed in dis- eases accompanied by pain. Treatment regarded as of great value in correcting vicious habits in children. Henry Hulst (Med. Rec, Mar. 4, '93). The Alcohol and Deug Habit. — Although persons belonging to these classes ordinarily afEord fair results, yet there are many discouragements and failures in their treatment by hypnotic suggestion. The subjects of these habits, except possibly the cocaine habitue, who is generally too nervous to become thor- oughly hypnotized, are usually easily hypnotized, and for a prolonged period at first find little difficulty in following suggestions. One of the essential con- ditions for these subjects to be benefited by the treatment is for them to have a strong desire to break off their vicious habits. Suggestions made contrary to their desires have little or no efl'ect. The dipsomaniac is least influenced by hyp- notism. In one instance of this class, however, I have apparently succeeded in HYPNOTISM. HYSTERIA. VARIETIES. 547 getting rid of the inordinate desire for alcohol. [Formerly, this patient was one of the worst dipsomaniacs that I have en- countered. After treating him for .nearly two years, an~d succeeding in lessening his bouts from ten or twelve to three or four a year, I then adopted the plan of suggesting to him that when he wanted alcohol he would ask his wife for it and drink at home. At the same time I suggested that he would drink nothing but beer and would not want more than one or two glasses of this, as he would feel nauseated, and would vomit. He now asks his wife for beer once or twice a month, takes one or two glasses, be- comes very sick, but does not vomit. Subsequently the patient went to a saloon and began to drink, but he began to vomit and became so sick that he had his wife telephoned for to take him home. In a number of cases I have succeeded in making the Iwhitucs vomit every time that they have taken alcohol in any form. J. T. EsKKiDGE.] I have been able in a number of in- stances to remove slight functional men- strual disorders in subjects that were easily hypnotized. Case of monoplegia of the left leg, with amenorrhoea lasting one year, cured by suggestion. Regnault (Le Bull. Med., July 23, '93). I have had no experience in treating nocturnal enuresis by suggestion. Others report success with these cases. J. T. ESKRIDGE, Denver. HYPOSPADIAS. See Urethra, Dis- eases OF. HYSTEEIA. — Gr., I'aTfpa, the womb. Definition. — Hysteria is supposed to be a fimctional psychoneurosis due to a morbid condition of the cerebral, spinal, and sympathetic nerve-apparatus, but apparently involving primarily the cerebral cortex, and is characterized by mental, motor, sensory, vasomotor, and visceral disorders. Varieties. — A sharp distinction must be made between hysterical manifesta- tions and the disease known as hysteria. The fact is that all human beings and many of the lower animals may at some time, under peculiarly-trying circum- stances, exhibit some of the manifesta- tions commonly observed in hysterical subjects. A failure to draw a line of de- markation between hysteria and the acci- dental manifestation of the symptoms of the disease accounts for much of the dif- ferences of opinion in regard to the fre- quency of the morbid process. Some authors, and not a few neurological spe- cialists, seem to regard hysteria as a com- paratively frequent disease. My experi- ence has taught me that the more care- fully one studies his cases and the more patiently and thoroughly he examines into each symptom and analyzes it, the less frequently he meets with genuine cases of hysteria. A person sustains an organic lesion of some portion of the body, and during the progress of the dis- ease manifests many hysterical symp- toms, but after recovery from the organic disease there are no more hysterical 5}'mptoms. This is not hysteria, but the symptoms of it are the epiphenomena which have been added to the symptoms of the organic lesion. I have come to limit hysteria to those persons who, hav- ing a predisposition to the disease, de- velop its symptoms. Such a predisposi- tion is more commonly inherited, but it may be acquired. For hysteria to be- come a disease the symptoms must be more or less continuous, usually remit- tent in character and frequently attended by parox3'sms. Excluding all those cases in which hysterical manifestations are but the epiphenomena of other morbid 548 HYSTERIA. SYMPTOMS AXD DIAGNOSIS. processes, I have found true hysteria very infrequent in the adult and still less common during childhood. Symptoms and Diagnosis. — Multiplic- ity and variability characterize the symp- toms of hysteria. There is not an organ of the body the functions of which may not be deranged in this disease. The symptoms may be as numerous as those that may arise from the perverted func- tions of every organ of the body. Fort- unately no one ease presents even the majority of the symptoms of hysteria. There are, however, certain classes of symptoms which characterize the dis- ease, both during the paroxysmal and interparoxysmal stages, although only one or many of these are present. Hysterical children often only mani- fest the mildest symptoms of the disease, unless subjected to some severe physical or psychical influence. They may re- main emotional, oversensitive, depressed, show lack of the ordinary self-control, and yet manifest no distinctive stigmata of the disease for years. Indeed, the dis- ease may never become developed in them, but by proper education and fort- luiate circumstances they seem to over- come, to a great extent, their natural tendencies to become hysterical. Many adults go through life burdened by the psychical soil of hysteria, but never de- velop the disease in a typical manner because they have never been subjected to causes sufficiently strong to overcome their power of resistance. For convenience of study the symp- toms of hysteria may be divided into two classes: (1) the interparoxysmal, which are more or less continuous and consti- tute the stigmata of the disease; and (2) the paroxysmal. The interparoxysmal symptoms may be studied under the fol- lowing headings: Psychical, sensory, motor, and vasomotor. Psychical Symptoms. — These vary with the individual temperament of the patient, and are always present to a greater or less degree in every hysterical subject. Such a person seems defective in will-power, although Sachs observes that the will is more misdirected than weakened. The impulses of inclination are followed regardless of thought or reason. There is an increased impres- sionability and suggestibility; so that conscious impressions are more numer- ous than in health and suggest to the patient all kinds of fancies, whims, ca- prices, and perverted actions. In the worst cases self-control is lost, and, in all, it is impaired. The patient is irri- table, unduly sensitive, and is annoyed by trifles. Self-consciousness is in- creased, trifles are magnified, the patient becomes emotional, and is easily elated or depressed, laughing and crying alter- nately without any apparent cause for either. The tendency to become dis- couraged and despondent is almost as great in some cases of hysteria as it is in melancholia. Some are painfully conscious of the action of every organ in the body. Every subjective sensation suggests the idea of a dreaded disease of this or that organ. Let an idea be sug- gested to the patient, especially if it re- lates to some physical or mental disabil- ity, and the thing suggested will likely follow. Thus we may often account for the presence of pain, paralysis, contract- ure, spasm, disturbance in sensation, and for various visceral derangements, espe- cially of the heart, stomach, and kidneys. A multiplicity and variability of various kinds of subjective sensations are char- acteristic of hysteria, such as are rarely ever due directly to organic disease. We must remember, however, and too great stress cannot be laid on this fact, that we mav encounter organic lesion of the HYSTERIA. SYMPTOMS AXD DIAGNOSIS. 549 nervous system and hysteria associated in the same person, and that in many such cases the pronounced symptoms of the latter will obscure the less obtrusive evidences of the former, sinless a careful search is made for them. Sexsoey Syjiptoms. — Sensation may be abolished, increased, or perverted in various Avays. The special senses are commonly affected v^hen general sensa- tion is involved. The general sensory disturbances may be classed as anaesthe- sia, hypersesthesia, and parassthesia. The special senses, except tactile sense, vsrill be considered in a separate section. Ancesthesia, next to hyperffisthesia, in some form is the most common sensory disturbance in hysteria. Few, if any, will indorse Gendrin's claim that in every case of hysteria, from the begin- ning to the termination of the malady, general or partial aneesthesia exists. [On examining 400 eases of hysteria Briquet found some form of anaesthesia in 240. J. T. Eskbidge.] The anaesthesia may be complete for all forms of sensation, it may affect one or more of the sensations, or there may be a simple lessening of cutaneous sen- sibility. It may extend over the entire body (extremely rare); it may involve one side of the bodj^, hemiansesthesia (the most common form); the whole cu- taneous surface may be anaesthetic ex- cept a few isolated areas; one or two limbs may be anesthetic, the trunk escaping; sensation may be lost in an arm from the finger-tips to the elbow or to a point just below it (glove-anssthe- sia); one leg may be similarly affected as high as the knee (stocking anaesthesia); or various anaesthetic spots or zones may be found in different portions of the body. Loss of tactile and pain senses is common. It is rare to find heat-sense alone absent. The power of localization is frequently lost when tactile sense is disturbed. Muscular, joint, and press- ure sensations are infrequently entirely lost, except in those cases in which all forms of sensation are abolished. It is extremely rare that some response can- not be obtained by the application of a wire brush attached to a faradic battery. Analgesia of all tissues, skin, bone, mus- cle, and nerve, is sometimes found. Tac- tile auEesthesia of the skin and mucous membranes is not uncommon in hemi- anaesthesia and total anaesthesia, al- though in these cases sensation is often partially or almost completely preserved around the anus, over the labia, to a less extent over the nipples, and immediately around the mouth and eyes. In hemi- anesthesia the special senses of the cor- responding side are often affected. [According to Briquet, hemianesthesia is much more frequent on the left side than on the right, the proportion being seven to two. J. T. Eskbidgk.] The following are the most important diagnostic features of anesthesia of hysterical origin: — 1. In hemianesthesia the loss of sen- sation is often profound, extending from the crown of the head to the sole of the foot. 3. The reflex action of the skin over the anesthetic area is normal, or nearly so. 3. The pupils dilate when the skin of the neck on the anesthetic side is irri- tated. 4. The fingers of the anesthetic hand can still be used, without the aid of sight, in the performance of fine and dextrous movements. 0. When the arm or leg is affected the anesthesia may cease abruptly at the shoulder or hip, or at the elbow or knee. 6. The ovarian tenderness is often greater on the anesthetic side. The 550 HYSTERIA. SYMPTOMS AXD DIAGNOSIS. other tender spots on the affected side nsually persist, notwithstanding that analgesia over all other portions of this side is profound. 7. The loss of sensation may extend up to, or just beyond, the middle line in front, but may not reach the median line on the back. 8. The anaesthesia may come on sud- denly as from traumatism; it may de- velop or increase after an hysterical par- oxysm; it may increase during the exam- ination or at the menstrual period; it is often changeable from day to day, and may be transferred from one side to the other. 9. The anaesthetic area ends abruptly. (The same thing is found in some cases of syringomyelia.) 10. In hemi anaesthesia there is fre- quently a condition of "crossed ambly- opia," the affected eye being on the side on which sensation is lost. Tlyperwsihesia and hyperalgesia, to a greater or less extent, are probably pres- ent in nearly every ease of hysteria. The rarest form is in those cases in which there is an increased cutaneous sensibil- ity over nearly the entire body. The next rarest form is unilateral hyperses- thesia. Commonly in cases of almost general bilateral or unilateral hyperses- thesia there are small areas of ansesthesia. The most common form of hysterical hyperajsthesia and hyperalgesia is that in which sensitive areas or points are found in variou.s portions of the body. These have been termed "hysterogenic zones," because pressure over these points will often excite a convulsion or may cause it to stop if the pressure is made after it has developed. The sensitive points are usually found over the ovarian region, usually the left; in the left hypo- chondriac region; over the lower portion of the ribs; over the breasts, more com- monly the left; the upper front portion of chest; on top of the head; on each side of the spinal column, and sometimes over various portions of the spine. Fre- quently numerous superficial sensitive points may be found over the abdomen, or the entire abdomen may be acutely sensitive to superficial pressure. In some cases the skin over the entire spinal col- umn may be so acutely sensitive that the slightest touch causes the patient to cry out with pain. Spontaneous pain is often complained of in the intercostal spaces, over the heart, and over the entire spine, including the coccygeal region. In some cases the pain radiates up the cervical region of the spine over the back of the head. This symptom is very com- mon in traumatic hysteria. The organs of special senses do not escape. Head- ache is a common and very distressing symptom in hysteria. The vertex is the most frequent seat of the pain, although it may be located in any other portion of the head, especially in the occipital, suboccipital, the temporal, or frontal re- gion. Painful joints and neuralgic p^ins in various portions of the body are com- mon in hysteria. Hysterical arthropathy has sometimes led to unnecessary amputation. Intense pain and even swelling, and a light form of genuine arthritis, may be present. The excessive tenderness of the skin is an excellent diagnostic point. Anaes- thesia is of great use in clearing up an obscure case. Those cases recover best in which no local treatment is adopted. Charcot (Jour, de M6d. et de Chir. Prat., July 10, '91). The following are diagnostic points in hysterical hypersesthesia: — 1. The areas of increased sensitive- ness are often ill defined, changeable, and may be bordered by areas of anaes- thesia. 2. In hemianffisthesia the deep-seated HYSTERIA. SYMPTOMS AXD DIAGNOSIS. 551 tenderness, or hysterogenic points, are most marked on the side corresponding to that on which sensation is lost. 3. When the pain or tenderness are superficial, deep and steady pressure, es- pecially over the spine or abdomen, may give a sense of relief, after the excite- ment caused by the contact of the hand has passed away. 4. The painful joints may show no local changes, nor any other evidences of organic disease, and the patient is very averse to the slightest movement of the afPeeted joint. 5. The presence of other stigmata of hysteria. ParcBsthesia. — Numbness is a common form of disturbed sensation in hysteria. This is often attended with "pins and needles" sensation. The skin may tingle or burn, or there may be a sensation of pricking. Some complain of a feeling likened to worms or other insects crawl- ing under the skin. Others are troubled with a sensation as though water were being poured down the back, or allowed to drip drop by drop on the spine. The scalp and the brain are frequently the seat of all kinds of si^bjective sensations. Each organ of the special senses may ap- parently be the seat of perverted sensa- tions, peculiar to the function of that particular organ. Parsesthesia may affect only one side of the tongue if it is uni- lateral in character. The only diagnostic point to be gained by a study of parsesthesia of hysterical origin is that organic disease never gives rise to such a variable multitude of symp- toms, especially of the character of those above mentioned. The Special Sense-organs. — The eyes may be affected in various ways. They may be the seat of neuralgic pains. They may be so acutely sensitive that the pa- tient is apparently unable to have her room lighted without having her eyes covered. HyperEesthesia of the retinse is frequ.ently increased by the attending physician allowing the patient to remain in a darkened room. A careful study of the vision, color-perception, the fields, and the action of the irises should be made in every case of hysteria. Total blindness of one or both eyes is exceed- ingly rare. The loss of sight comes on suddenly after a fit or a mental or phys- ical shock.' While the patient does not consciously see, and acts accordingly, yet by the proper tests it can be demon- strated that vision exists. Great care is required in distinguishing these cases from those of feigned loss of vision. literature of '96-'97-'98. Three cases in which complete loss of vision in one or both eyes occurred with- out the presence of fundus changes or lesions of the optic nerve or brain, as far as could be detected, to account for it. Restoration of function occurred in all the oases. Alvin A. Hubbell (N. Y. Med. Jour., July 17, '97). "Crossed amblyopia" is more common than amaurosis. In this condition in hysteria the vision is very slight and the fields are narrowed in the eye correspond- ing to the ansesthetic side of the body. In the opposite eye vision is lessened and the fields are impaired. The fields for perception may be lessened in three dif- ferent ways: There may be bilateral homonymous hemianopsia (the blind fields on the right or left half of each eye, etc.); a central blindness (central scotoma); or a concentric narrowing of all the fields (the most common defect). Bilateral homonymous hemianopsia in hysteria is exceedingly rare, and the ma- jority of careful observers have never seen a case. A sufficient number, how- ever, has been reported, by most excel- 552 HYSTERIA. SYMPTOMS AND DIAGNOSIS. lent investigators, to demonstrate the possibility of its occurrence from func- tional cerebral disturbance. As found in hysteria, it has features which distin- guish it from the cases that have an or- ganic origin. It comes on suddenly, is usually transient, it involves the half of each field corresponding to the anass- thetic side of the body, with both con- junctivae aneesthetic, and the other halves of the visual fields are greatly nar- rowed. The cases of hysteria presenting central scotoma show no changes in the retinje. Concentric narrowing of the visual fields is frequent in hysteria, and this may take place to so great an extent that only extreme central vision remains. "Hemiopia" may accompany ophthal- mic migraine of hysterical origin, but in these cases it is always transitory, as is the migraine, and appears to be due to a temporary exaggeration of the concen- tric narrowing of the visual field. Gilles de la Tourette (Annales d'Oculo., Oct., '91). Color-perception is often greatly changed from the normal in hysteria. There may be a complete loss of color- perception, — achromatopsia; or there may be simply a disturbance of this, — dyschromatopsia. In the former condi- tion everything has a grayish appear- ance, with an inability to distinguish one color from another. Dyschroma- topsia is the more common defect. The normal color-fields from without inward are as follow: Blue, yellow, red, green, and violet. Thus, blue is the largest and violet the smallest. In hysteria red and blue may change places, so that red occu- pies the largest field. In narrowing of the color-fields the colors at first disap- pear in the order of their normal posi- tion, those occupying the smallest fields being obliterated, or "squeezed out of the centre" first. Violet is the first to disappear, then green, but red remains, and is said to be the most persistent color in hysteria. The color-fields are diminished in the order of their normal extent, and they may be lost in the same order: violet first, then green, red, yellow, and blue. Gowers ("Diseases of Nervous System," second ed., vol. ii, p. 994). The fields, both for objects and colors, may remain entirely normal in hysteria. Some of the following changes, so far as the field of vision is concerned, are likely to be present in cases of hysteria: (ffl) Simple contraction of the color-fields, with unaffected form-fields. (6) Contrac- tion of both form- and color- fields, the green field being relatively more con- tracted than the others, (c) Partial or complete reversal of the normal sequence in which the colors are appreciated, most commonly that variety in which the red field is greatest in extent. Under these circumstances the color-fields may be normal in extent, sometimes even wider than is normal, or there may be an asso- ciated contraction of all the color-fields, (d) Unusual obscurations of portions of the visual field, — for example, in the form of an hemianopsia, or greater con- traction of the fields on one side than on the other, the greater contraction usually being found on the same side with the anaesthesia. J. K. Mitchell and de Schweinitz (Jour, of Nervous and Mental Dis., Jan., '94). Monocular diplopia is not peculiar to this disease, as it occurs from organic disease of the brain. Hippus, or contrac- tion and dilation of the pupils irrespect- ive of light, has little diagnostic signifi- cance, as it is found in various depressed conditions of the nervous system. It should be borne in mind that the pupil- lary reflex is normal in hysteria, even in the eases of blindness or hemianopsia. Like the eye, the other organs of special sense are usually affected on the anes- thetic side. HYSTERIA. SYMPTOMS AXD DIAGNOSIS. 553 Literature of '96-'97-'98. Possible disturbances of the ocular muscles that may occur in hysteria are: (1) disassoeiation of the movements of the eyes; (2) paralyses, which may affect individual muscles or associated groups of muscles; (3) contractures, which maj' affect individual muscles (spastic squint), associated groups of muscles (conjugate deviation), or both internal recti (convergent squint) ; (4) strabismus concomitans; (5) nystagmus; (6) conditions of paralysis or contracture of the muscles of accommodation; (7) conditions of paralysis or contracture of the muscles of the lids (blepharospasm, nictitatio, ptosis pseudoparalytiea, etc.). Kunn (Wiener klin. Eund., Xos. 22, 23, 25, '97). Points in the diagnosis of hysterical ej'e affections: — 1. If vision is lost or greatly lessened the patient acts as though she does not consciously see, yet hy the proper tests it may be demonstrated that she does see. 2. In "crossed amblyopia" the worst eye is on the side corresponding to that on which the ansesthesia is situated, with or without paralysis or contracture, but the face is not paralyzed. 3. In homonymous hemianopsia both cornea are anaesthetic. 4. In dyschromatopsia blue may dis- appear before red. 5. In achromatopsia everything ap- pears gray. 6. The presence of other stigmata of hysteria. Hearing in some cases becomes so acutely sensitive that the patients are annoyed by ordinary sounds and by con- versation. Unilateral deafness may oc- cur alone, but it is oftener in association with affection of the other organs of special sense of the same side, which cor- responds to the anassthetic side. The deafness may be transferred to the oppo- site ear, with the transference of the an- ffisthesia to the opposite side of the body. The auditory canal and tympanum are anaesthetic. The loss of hearing is not always complete. The auditory nerve loses its normal irritability to electrical stimulation. Lloyd is in error in con- cluding that because the tuning-fork in hysteria can be heard better by aerial conduction than by bone-conduction it is a proof that the loss of hearing is psychical. [The fact is that we can normally hear the vibrations of a tuning-fork through the air better and longer than we can through the bones of the head (Rinnfi). J. T. ESKEIDGE.] The transference of the deafness from one side to the other by suggestion, the absence of evidence of ear disease, and the presence of other stigmata of hys- teria are important aids in the diagnosis. Smell and taste may be increased, les- sened, or abolished on the side corre- sponding to the ansesthetic side of the body. Motor Symptoms. — Paralysis in some forms is not infrequent in hysteria. Probably the most common form is pa- ralysis of the adductors of the vocal cords, producing aphonia. The paralysis may affect a few or many muscles. It may take the form of a monoplegia, hemi- plegia, a paraplegia, or there may be almost a total paralysis, except of the face-muscles. It is often associated with contracture and ansesthesia. In many cases contracture is absent. When the paralysis takes the form of hemiplegia there may be hemiansesthesia, affecting all the special senses on the paralyzed side. In some cases of hemiplegia the anjesthesia is segmental in character. In monoplegia, if anesthesia is present, it affects the entire paralyzed part or its distal portions. The same rule holds good in paraplegia. In hemiplegia the 654 HYSTERIA. SYMPTOMS AND DIAGNOSIS. arm is usually affected to a less extent than the leg. The face is probably never paralyzed in hysteria as it is in hemi- plegia from organic brain disease. Case of hysterical facial paralysis ob- served in a girl of 9 V2 years. There was no other paralysis, excepting of the tongue, and no sensory disturbances. Deseroizilles (Le Bull. Med., Jan. 7, '91). Ptosis of hysterical origin occurs occa- sionallj', but it is not due to paralysis of the levator muscle. Paralysis may affect the tongue, pharynx, larynx, and oesophagus. Lloyd adds: "And even the anus"; but Gowers states that incon- tinence of urine or fseces never occurs. The paralyzed leg, when the hysterical patient js able to walk, is dragged as a heavy and almost useless limb. The pa- ralysis is excited by trauma, a fit, or by some emotional disturbance. Aphonia of hysterical origin usually comes on suddenly and spontaneously, so far as we are able to judge. The usual exciting cause is some emotion or a ca- tarrhal condition of the larynx. The patient is able to whisper if the tongue is not involved, but when it is paralyzed voluntary articulation is lost. Such pa- tients are often able to sing, and may talk aloud in their sleep, or while under the influence of an anaesthetic, yet be unable to utter a distinct articulate sound voluntarily. Power in the limbs is rarely absolutely lost. The patient may be able to move the limbs in bed, but as soon as the erect posture is assumed the legs may give way at the knees. If the patient is able to walk the gait is shufHing, the steps short, but the front portion of the foot does not drop as in paralysis of organic origin. On testing the strength of the weak- ened muscles in hysteria the extensor muscles contract more than in health, and this gives to voluntary muscular movements the appearance of the pa- tient's intentionally resisting the force of flexor contraction. If the patient is requested to grasp the dynamometer with all her power the muscles on the back of the arm can be seen to contract, causing an irregular and jerky move- ment of the hand. The nutrition of the muscles is well maintained considering that the muscles are not used. Electrical reaction is prac- tically normal. In all cases in which the reactions of degeneration are found pres- ent there is some organic change in the nervous system to account for the phe- nomena. Gowers states that muscular irritability is normal in one-half the cases, but that it is slightly increased in cases in which spinal tenderness is pres- ent. In this condition the knee-jerks are excessive, and on tapping the patellar tendon the trunk-muscles contract and the patient experiences a sharp pain in the lower portion of the back. These phenomena I have seen especially well marked in cases of traumatic hysteria. The knee-jerks may be lessened, but they are rarely ever entirely absent. In those gases in which they seem to be absent they may be elicited if the precaution is taken to see that the flexor muscles of the knees are not contracted. True ankle-clonus is rare in hysteria except in cases in which the heel is drawn up by chronic contracture of the calf-muscles. Spurious ankle-clonus is not infrequent. On first pressing the foot upward there may be one or more slight, irregular movements of the foot; they cease, and in a few seconds begin again, but can be prevented by firm and continuous press- ure of the foot upward. True ankle-clonus is exceedingly rare in hysteria, but it does occur. I have been able to obtain it during the convul- sion and in some cases of contracture of the calf-muscles. HYSTERIA. SYJIPTOMS AND DIAGNOSIS. 555 The plantar reflexes are often slight or entirely absent in hysteria. The other superficial reflexes may be present or ab- sent on the paralyzed side. No bed- sores form even in the bedridden cases. Contracture frequently occurs in con- nection with paralysis of hysterical ori- gin, but it may develop independently of it. The causes are usually those that give rise to paralysis. It may last min- utes, hours, months, and in some cases even many years. The degree of con- tracture gradually increases after its beginning, although the condition de- veloped suddenly. The nutrition of the muscles is not materially interfered with except in those cases in which the con- tracture is extreme and of prolonged duration. The opposing muscles of the contracted group are tense, so that the affected joints are held as in a vice (Lloyd). Sensation is often lost in the skin over the affected muscles or in the distal portions of the limb. In cases of contracture of the arm, leg, and face of tlie same side, there may be a condition of hemiansesthesia of the affected side, the face being turned toward the anses- thetic, paralytic, and contractured limbs. The ansesthesia in these cases usually in- volves the entire side of the body from the sole of the foot to the crown of the head. The special senses of the same side do not escape. Of the limbs, the arms are more frequently the seat of con- tracture than the legs. One or both arms may be affected. The hand, the hand and wrist, or the entire arm may be in- volved. The contracture in the arm is flexor in character. The finger-nails may be buried in the palms of the hand, or the fingers may be flexed at the meta- earpo-phalangeal joints and extended at the other joints, as in tetany. This is the only exception from the rule of flexor contracture in the hands and arms in hysteria. The flexor contracture of the hand is not lessened by forcibly flex- ing the wrist, as is the case of contracture from organic trouble. In the legs, whether one or both are affected, the contracture is extensor in character, ex- cept that the toes are flexed. The heels are often pulled upward to such a de- gree by the calf-muscles that the dorsum of the foot is on a line with the front of the tibia. The feet are rigidly extended at the ankles, and the legs at the knees and hips. Contracture is said to involve one side of the face in some cases. I have never seen a case with hysterical contracture of all the muscles of one side of the face. Temporary contracture of the eye-muscles, producing strabismus, I have met with in a few eases. Con- tracture of the tongue-muscles occurs. The muscles of one side of the neck may be so affected as to produce a condition of torticollis. Contracture of the obieu- laris palpebrarum muscles may produce a pseudoptosis. This may be unilateral or bilateral. Sometimes the diaphragm is affected. In some cases a part of a muscle may be the seat of contracture, giving rise to the appearance of a tumor. Such pseudotumors have been observed in the calf, pectoralis major, and abdom- inal muscles. Two forms of hysterical contracture exist, as follows: — 1. One concerns single parts and limited groups of muscles, and may last for years without organic change in muscles, joints, or interstitial tissues. In this form also sudden cessation of con- tracture is possible. 2. A form which attacks in succession one limb after another until nearly all voluntary muscles, including those of the trunk, may be affected. These never get well abruptly, and in them muscles, joints, and areolar tissue undergo serious organic changes. In the first form the muscle-reflexes and me- 556 HYSTERIA. SYMPTOMS AND DIAGNOSIS. chanical and electrical reactions are but little changed, %\hile in the generalized form late in the disease the reflexes are diminished or lost and the quantitative electrical reactions are decreased. It is only in this form, after years of life in bed, that changes in the cord are to be expected, and whether these are inde- pendent accidents or secondary products of the hysterical condition is not defi- nitely known. S. Weir Mitchell (Revue de Chir., Aug. 24, '95). Ataxia. — Ataxia in hysteria is pro- nounced in some cases. It is usually greater than what is observed from or- ganic disease, and the movements that the patient makes to maintain the up- right posture are greatly exaggerated. Astasia-abasia, occasionally observed in hysterical subjects, is an inability to stand or walk, although the limbs are strong and can be moved freely in all directions while the patient is sitting or reclining. Choreoid movements of the hands, arms, or of different groups of muscles are often seen, especially in chil- dren or young adults. One shoulder is suddenly drawn up or the head is jerked to one side, backward, or forward. Some- times the movements are shock-like in character. I have witnessed one case of hj'steria in the male in which, on the patient's attempting to stand or walk, he would spin around like a top until he fell. Ehythmic or oscillatory movements of the head, trunk, or limbs sometimes occur in hysteria. Tremor. — The tremor often seen in hysterical cases closely simulates that caused by poisoning from lead, arsenic, mercury, etc. Lloyd is probably right in the belief that the tremor in its early stage, due to these poisons, is partly hysterical in its nature. The tremor of hysteria may be rapid, 8 to 12 per second; medium, 5 V2 to 7 V2; slow, 4 to 5 per second. The majority of cases of tremor of hysterical origin cease during repose if the patient is not watched, and all, even those that are continuous during repose, are increased in extent by muscular effort, although the rhythm does not change. On account of the influence of exertion on hysterical tremor the latter has sometimes been mistaken for the in- tentional tremor of disseminated scle- rosis. Hysterical tremor is more common in men, and may resemble every kind of tremor associated with organic disease. If the tremor appear after a fit, it is of special importance in determining hys- teria. When the tremor diminishes, it may be increased by pressure on the hysterogenic points. Charcot (Le Pro- gres M6d., Sept. 6, '90). Tremor in hysteria may develop very insidiously or suddenly, under the in- fluence of fright or moral shock, and still more frequently after a convulsive at- tack. It may begin with a true attack of trembling. In order to distinguish hysterical trembling from the trembling in Graves's disease, it needs the evidence of other symptoms of either affection. Dutil (Nouvelle Iconographie de la Sal- pftriere, Jan., Feb., '90). Hysterical tremors may be detected by certain common traits. These are of three types: the hystero-emotional trem- ors, arising from fright, emotion, etc.; the hystero-toxic tremors; and a, purely , hysterical tremor, consecutive to hyster- ical attacks. Their evolution is often characteristic, coming on after a shock and attended with headache and intel- lectual troubles. The tremors may vary in character, and are not infrequently of an anomalovis type. Oddo (Marseille- m6d., Oct. 15, '91). The hysterical patient will often touch an object, as a nail driven into the wall, without much difficulty, but after the finger has remained a few seconds in con- tact with the object the arm becomes affected with an irregular, jerky tremor, differing from the tremor of multiple sclerosis, in which great effort is fre- quently required in bringing the finger HYSTERIA. SYMPTOMS AXD DIAGNOSIS. 557 in contact with a small object, biit the tremor ceases as soon as this has been accomplished. (Buzzard.) Diagnostic Points ajioxg the MoTOB Phenomena of Hysteria. — 1. In aphonia, etherization and faradization of the throat will cause the patient to ■ speak. Talking during sleep may occur, and singing is possible in many cases. The aphonia may have come on suddenly after emotional disturbance of trauma- tism. Paralysis of the vocal cords is al- ways bilateral in hysteria; unilateral pa- ralysis is due to organic disease. The aphonia disappears suddenly. 3.- In hemiplegia the face is not par- alyzed, although it is often ansesthetic on the side corresponding to that of the hemiplegia. 3. The leg is dragged or shuffled, the foot is not swung outward in bringing it forward, and the toes do not catch on the ground or floor as is the case in hemi- plegia from organic brain disease. 4. The nutrition and electrical irrita- bility of the muscles are well preserved. 5. The deep reflexes may be normal, and the plantar absent on both sides. If the knee-jerks are increased, the differ- ence between the two sides is not great. Absence of the plantar on one side rarely occurs in hysteria. 6. On testing the strength of the flexor muscles there is abnormal contrac- tion of the extensor muscles of the joint. 7. The flexor contracture of the hand is not lessened by forcibly flexing the wrist as occurs in organic disease. 8. Ptosis of hysteria is not due to pa- ralysis of the levator, but to spasm of the orbicularis, and the spasm is increased on requesting the patient to look up. If double, the head is thrown backward on trying to look upward. If the head is held by some one both orbieulares con- tract (Gowers). 9. The ataxic gait is exaggerated be- yond that of organic disease, and has the same psychical character as the muscular movements of the hysterical convulsion. 10. Astasia-abasia, inability to stand or walk, is always presumptive evidence of hysteria. 11. The tremor usually ceases during repose if the patient thinks that she is not watched, but it sometimes continues while the patient is sitting or lying. Vol- untary motion increases the tremor. If the patient is requested to touch with the index finger of one hand a small object, little difficulty is experienced in doing this, but after the finger has been in con- tact with the object a short time, irreg- ular jerky movements of the arm begin, differing from the tremor of dissemi- nated sclerosis, in- which great effort is frequently required in bringing the finger in contact with the object, but, this accomplished, the tremor ceases im- mediately (Buzzard). 12. It is probably safe to say that par- alytic incontinence of urine and fseces never occurs, and the presence of incon- tinence of either should always arouse suspicion of organic disease. ViSCEEAL AND VaSOMOTOE DiSTUEB- ANCES. — In many cases of hysteria these symptoms become quite pronounced, and some of them may persist for a long time, and become troublesome, or even dangerous to life. The pharynx may become so irritable that deglutition is difficult or almost impossible on account of spasm of the pharyngeal muscles re- sulting from the presence of food. Be- sides the globus hystericus, spasm of the larynx may take place and greatly em- barrass respiration. Literature of '96-'97-'98. Functional dysphagia occurs more fre- quently in women than in men, but it is 558 HYSTERIA. SYMPTOMS AND DIAGNOSIS. not uncommon in the latter, and may appear in children. There may be pain, or a sense of con- striction, or a feeling of a foreign body in the gullet often at about the cricoid cartilage, or even higher. The condition may be associated with glohtis hystericun or other evidence of hysteria, or the dys- phagia may be the only symptom. Where there is evident spasm of the gullet, this comes on in advance of the act of swal- lowing. A. Coolidge (N. Y. Med. Jour., Aug. 28, '97). Indigestion in some form is common in hjfsteria, but that form which inter- ests VIS most in this connection is that in which the stomach and bowels become greatly distended with gas. Peristaltic movements of the bowels may be greatly lessened and in some eases apparently reversed. A section of the bowel may become greatly distended and form a phantom tumor of the abdomen. Literature of '96-'97-'98. Patient, male, aged 19 years, after a period of overwork, suffered so greatly from difficulty in breathing and palpi- tation of the heart, that he was obliged to remain eight weeks in bed. Later the curious symptom developed that with each inspiration the stomach filled with air, emptying again on expiration. The chemical and motor conditions of the or- gan remained normal and there was no sign of pyloric stenosis. Herz (Med. News, Jan. 1, '98). Constipation may be so troublesome ,that neither brisk purgatives nor ene- mata have much effect. Vomiting often proves annoying and sometimes danger- ous. It may occur almost immediately after the food is swallowed, apparently before it has reached the stomach (oesoph- agismus). In some cases after the food has lain in the stomach for some time considerable gastric pain and distress are complained of and the food is vom- ited. In such cases, especially when the subject is a young girl, as is often the case, the symptoms of gastric ulcer are closely simulated and may cause some apprehension. Pure hysterical vomiting is unattended by nausea, and the patient does not show signs of exhaustion from the act. It occurs fifteen minutes to an hour or more after eating, and the whole contents of the stomach are apparently ejected; but probably this is rarely so, as the patient may show comparatively little emaciation, although vomiting may persist for weeks. The emesis may be purely mental, or it may be partially vol- untary, for ;f)urposes best known to the patient. It is well known that malin- gerers may become quite expert at vomit- ing at will. It is sometimes difficult or almost impossible to deterniine how much the vomiting is due to psychical in- fluence and how much to pure voluntary effort. In some instances the vomiting may be so persistent as to endanger the life of the patient by starvation, but this is extremely rare. Hysterical anorexia may be so great that the patient is un- able to take sufficient food to maintain life. In those cases in which persistent refusal to take food is kept up for weeks or months and yet the patient does not greatly emaciate, it becomes evident that deception is being attempted. Irregular and rapid heart-action is common in hysteria and is often a source of apprehension and distress to the pa- tient. The pulse-rate may be 100 or 140 per minitte, or even more. The patient often becomes faint on the slightest ex- ertion, such as made in turning in bed or sitting up. Dyspnoea and pseudo- anginal attacks may occur from a little extra physical effort, or from emotion, especially fright. Frequent co-existence of hysteria and cardiac affections noted more frequent in men than in women, especially in those suffering from mitral stenosis, HYSTERIA. SYMPTOMS AXD DIAGNOSIS. 559 either alone or complicated with insuffi- ciency. Hysterical praecordial pain, hysterical dyspnoea, and hysterical apo- plexy should be carefully differentiated from similar symptoms due to cardiac disease. Giraudeau (Le Semaine M6d. June 26, '95). Eapid respiration, from 40 to 80 per minute, may be of hysterical origin. In these cases the pulse-rate may not be cor- respondingly accelerated. An annoying hysterical congh is not an infrequent symptom in young girls. I have never witnessed a persistent and continuous rise of temperature, 3° or 4° F. above normal, in hysteria, but cases presenting this symptom have been reported by competent observers. Intermittent rise of temperature is not uncommon. A dif- ference in the axillary temperatures of several degrees has been observed. We should always be on our guard in cases of supposed hysterical fever and en- deavor to detect any deception that may be attempted. Eetention of urine is not an infrequent symptom in some female subjects. Incontinence from hysteria never oc- curs. It may be that those cases of in- continence that have been reported were either the incontinence of retention or the incontinence that sometimes occurs in healthy persons from a weakened con- dition of the vesicular sphincter as a re- sult of allowing th& bladder to become overdistended for several hours. Abun- dant secretion of light-colored urine of low specific gravity is common after any emotional excitement. Anuria may oc- cur. Complete suppression may last for ten days, without the ordinary symp- toms of ursemic intoxication. Gowers ("Diseases of Nervous System," second ed.). Many vasomotor disturbances — sucli as local dilatation or constriction of the blood-vessels of the skin, flushing; uni- lateral sweating, especially of the head and neck; swelling of the hands or feet or of the joints — may occur in hysteria. Case of ecchymotie spots and pemphi- goid eruptions of hysterical origin. The ecchymoses appeared after a convulsive attack, and have persisted during two years. Raymond (La Semaine Med., Dec. 31, '90). Attention called to an oedema with bluish discoloration, which at times oc- curs in hysterical subjects. The affec- tion resembles, in some respects, Ray- naud's disease, but is not symmetrical, like the latter, and does not lead to gan- grene, as Reynaud's disease does. Char- cot (Jour, de M6d. de Paris, Feb. 22, '91). Paroxysmal Stjiptoms. — The con- vulsion is the most prominent symptom of hysteria, and, while it does not occur in the majority of cases of this disease, it is the one symptom first thought of by many, especially among the laity, when the term hysteria is mentioned. The hysterical convulsion of the classical type, first described by Charcot, and fur- ther elaborated and illustrated by his industrious pupil, Eicher, is of very in- frequent occurrence in this country. Here the paroxysms assume numerous atypical and abortive types. There are great similarities and dissimilarities be- tween the hysterical and the epileptic convulsion. Prodromal symptoms are often absent, or if present are not recog- nizable in epilepsy. In hysteria they almost invariably occur, and are usually so pronounced as to be observed not only by the physician, but by the patient and attendant. They often begin several days before' the convulsion takes place in pronounced cases of hysteria. In the lighter forms of this disease, especially in those cases in which the paroxysm is caused by temporary physical exhaustion or emotional shock, the prodromal period does not extend over more than a few hours at most, and frequently it is appa- rently limited to a few minutes. After the exhaustion and excitement caused by 560 HYSTERIA. SYMPTOMS AND DIAGNOSIS. attendance upon a ball, in wliicli the patient has danced until the early morn- ing hours, the emotional disturbance fol- lowing a lover's quarrel, a sharp disagree- ment with an intimate friend, or the receipt of sad news, the subject becomes excessively nervous, impatient, irritable, and breaks out into fits of apparently causeless laughter or crying. The emo- tional disturbance and loss of self-con- trol increase, and soon an hysterical con- vulsion, immediately preceded by an aura, supervenes. In the majority of cases of hysteria the prodromal symptoms extend over a period of two or three days. The psy- chical phenomena are the mor6 promi- nent. The mood of the patient changes; she is depressed, peevish, irritable, nerv- ous, and unable to pursue her ordinary routine duties. She often becomes less sociable, keeps to herself, seems to be absorbed in her own thoughts, and may show evidences of being suspicious or the subject of hallucinations or delu- sions. Personal habits change; from being neat and tidy, she neglects her person and her dress. In some instances there is great increase of motor activity and there may be maniacal tendencies; in others, the patient is mute, broods, and becomes melancholic. The appetite is capricious, lessened, or lost; the tongue is coated, the digestion poor, there may be nausea and vomiting, and the bowels are often constipated. Sometimes deg- lutition is difficult on account of spas- modic action of the throat-muscles, and in some cases there may be spasm of the oesophagus or of the larynx. The stig- mata of hysteria, especially relating to the sensory and motor phenomena, may develop or increase at this time. The convulsion is immediately pre- ceded by an aura, most commonly from the ovary; next from the throat, the globus; from the head, the clavus; or from any "hysterogenic zone." In the child the paroxysm may consist of a maniacal outbreak, with hallucinations or delusions; it may take the form of violent motional disturbance, inappro- priately termed chorea major, attended with delirium and a tendency to break furniture; or it may be an epileptoid convulsion. Hysteria may be present in ver}- young children. The simplest form shows itself by exhibitions of anger without sufficient cause and crying. A more accentuated form manifests itself by the child's stif- fening out its limbs, the face becoming violet and turgescent, with trembling of the whole body. Chamnier (Med. Press and Circular, Dee. 9, '91). It is rare even in adults in this coun- try to have the classical convulsion di- vided more or less distinctly into four stages. The first stage is known as epi- leptoid; the second, the period of grand movements; the third, period of passion- ate attitudes; the fourth, the period of delirium. In the hysterical convulsions that I have witnessed the first and second periods have been fairly well «iarked, but the third stages has been entirely absent, and only occasionally has the fourth period been present. Literature of '96-'97-'98. There are three periods in a complete hysterical attack. 1. The preconvulsive period, in which the aura — mental, sensory, or ovarian — occurs. 2. The convulsive period, consisting of the tonic and the clonic spasms. 3. The post-convulsive period, of which the most striking feature is the delirium identical with the mental state which characterizes one or the other of the dif- ferent varieties of hynosis. In the first period consciousness and memory are always preserved, and injury which might" occur during the second HYSTERIA. SYMPTOMS AND DIAGNOSIS. 5G1 period may be prevented by precaution- ary measures. In the second period consciousness and memory are usually abolished, and the patient has no knowledge of the convul- sions. In the third period consciousness is usually preserved. He has knowledge of his movements, and yet when the attack is terminated he is ignorant of what he has said and done during this third stage. Any one of the three periods may exist alone. A. Pitres {Eevue Neurol., Sept. 15, '96). [The following is rather typical of hysterical convulsions as I have observed, them. An hysterical female at 22 years, after presenting many of the prodromal symptoms for two or three days, com- plained of a sudden choking sensation in the throat, which she said was rising and choking her. She fell, or, rather, sank, to the floor, without hurting her- self. The whole body and limbs became rigid and she shook all over as one with a severe chill. The legs and feet were extended, the arms flexed at the elbows, and the fingers were firmly flexed over the thumbs. The pupils were slightly dilated, but equal in size and responded fairly well to light. The eyeballs were rolled in different directions under the closed lids, but on raising the upper lids the balls turned upward and inward. The face did not change in color percep- tibly, although the breathing stopped for at least 30 or 40 seconds. At the end of about a minute clonic, convulsive movements began in the arms; the legs ^veTe flexed and extended at the knees and hips a number of times, and the head ■^^•as turned from side to side in a rhythmical manner. During the period of clonic movements, which lasted about eight minutes, the pupils and color of the face remained normal and the tongue was not bitten. The patient did not soil Tier clothes nor froth at the mouth. After the clonic convulsive movements ceased the patient lay as if exhausted. A pin-prick was scarcely recognized, and consciousness seemed greatly blunted, but on pressing over the left ovary the convulsive movements recommenced, and these were followed this time by opis- thotonos, rolling of the body from side to side, and various exaggerated move- ments. In watching this case the psychical character of the movements was well marked, and the movements seemed almost voluntary. They were different from the reflex, forcible, shock-like movements of epilepsy. There was a rhythm in the movements which is never observed in the convulsive stage of true epilepsy. J. T. Eskridge.] There is, however, in many of the graver cases of epilepsy, especially in children and young adults, periods of maniacal excitement and hysteroid-like movements, which follow true epileptic convulsions. These may occur a few minutes, hours, or a day or so, after one or several epileptic fits. I have a ease of epilepsy, in a girl 15 years old, under my care at present, in which maniacal outbreaks take place the first or second day after a series of convulsions. They have never followed a single convulsion in this patient. There are many abortive and atypical types of an hysterical convulsion. A condition of ecstasy, somnambulism, catalepsy, trance, or lethargy may follow or even take the place of the convulsion. Charcot called attention to the fact that mental symptoms may take the place of ■ the convulsive seizure. We may have no convulsion, but a condition of alternat- ing consciousness, the abnormal state of consciousness apparently entirely replac- ing the convulsive seizure. I have one such case under my care at present. It is important to bear in mind that firm pressure over "hysterogenic zones," especially over the sensitive ovarian re- gion (?), will bring on a convulsion or may arrest it if the pressure is made dur- ing its progress. I have been able on two or three occasions to arrest an hys- terical convulsion by forcibly pulling 563 HYSTERIA. DIFFERENTIAL DIAGNOSIS. and flexing one of the great toes. Many of the stigmata of hysteria, such as an- aesthesia, contracture, and paralysis de- velop or increase soon after hysterical convulsions. Limited space will not permit me fur- ther to discuss the paroxysmal stage of hysteria, although I have left many in- teresting points untouched. Some points in the diagnosis of hys- terical convulsions: — 1. The immediate cause of the con- vulsion is often some mental shock or physical exhaustion. 2. The patient sinks rather than falls to the floor, and rarely injures herself in sinking. 3. Pupils equal and rarely normal in size and respond to light. It must be borne in mind that strong and continued muscular movements will cause the pu- pils to dilate and will prevent their re- sponding quickly to light. Literature of '96-'97-'98. Attention called to the absence of the pupil-reflex in attacks of hysteria. Ob- servations were made in the clinic of Professor Krafft-Ebing, who confirmed the diagnosis and the fact of the absent reflex. The latter was also confirmed by the ophthalmologist Bernheim. The ob- servations were made by having the lids held apart, the eye being illuminated by a hand-lamp and the cornea protected by salt-solution. Thus the eyes could be observed for many minutes. The pupils were ■wide open and motionless for as much as twenty seconds. J. P. Karplus (Wiener med. Woch., No. 52, '96). 4. The color of the face remains prac- tically normal. There may be a slight venous congestion of the face if the breathing ceases several seconds beyond the interval observed in health. This is in marked contrast to the changes ob- served in the color of the face in severe eases of epileptic convulsions. 5. The tongue is not bitten, unless it is injured in the fall; but this is rare. There is rarely blood and froth oozing from the mouth, and the clothes are not soiled by the discharge of faeces or urine. 6. Consciousness in some cases seems to be fairly preserved, usually it is blunted, and probably is never as pro- foundly lost as in case of epilepsy. 7. The muscula.r movements are psy- chical in character, i.e., they seem often to be purposive in their nature, and lack much of that pure reflex act observed in epilepsy. In hysteria rhythm or fre- quency of the movements is maintained, but the force varies; in epilepsy the fre- quency lessens, but the force of the mus- cular contraction is kept up until the convulsive movements cease. 8. The hj'sterical convulsion is usu- ally much longer than the epileptic. They may last from ten or fifteen min- utes to an hour or more. 9. Pressure over a sensitive ovary or other "hysterogenic zones'" will some- times arrest the convulsion. 10. Co-ordinated and exaggerated muscular movements, apart from the rhythmical clonic convulsive movements, especially marked if restraint is at- tempted, form a large part of the convul- sion. Differential Diagnosis. — At the end of each heading, sensory symptoms, the spe.- cial sense-organs, motor symptoms, and paroxysmal symptoms, or hysterical con- vulsions, will be found a summary of the principal diagnostic points of each group of phenomena. It is unnecessary to re- peat them here. In the vast majority of instances the diagnosis of hysteria is comparatively easy if one is. familiar with all the ear- marlcs of the disease. Much precision and certainty is lost to that physician who regards hysteria as a protean dis- HYSTERIA. DIFFERENTIAL DIAGNOSIS. 563 ease, without certain constant and char- acteristic symptoms. While it is true that on superficial observation the symp- toms of hysteria at times may appear to mimic those of nearly every organic lesion of the nervous system, viscera, and joints, yet, by a careful study of it, espe- cially of the stigmata, their onset, course, and duration, it will be discovered that hysteria is a definite and distinct disease with its own laws and clean-cut symp- toms, and that the mimicry is but so in appearance. It must never be lost sight of that hysteria and organic disease may be associated. The two diseases may exist in the same person at the same time. Indeed, in one who is -strongly predis- posed to hysteria the development of or- ganic disease will give rise to hysteria. In such cases it is important to bear in mind that the pronounced and more ob- trusive symptoms of hysteria may, and frequently do, overshadow, if they do not entirely obscure, the indistinct symptoms of organic disease. A failure to recog- nize this fact is, I am quite confident, to blame for many mistakes, and not a few blunders that I have encountered in the practice of some excellent physicians. The first duty of the physician on meeting with a case that seems to be hys- terical in character is to determine, if possible, by repeated, thorough, and sys- tematic examinations whether or not there is any organic lesion present. The presence of a multitude of symptoms, all pointing to hysteria, are not sufficient to rest a diagnosis upon, if there is one symptom that positively indicates an or- ganic lesion. Cortical Lesions op the Bhain. — Paralysis and anaesthesia of the distal portion of a limb from a. cortical lesioii should never cause any difficulty in the diagnosis from hysteria, unless the pa- tient is also the subject of the latter dis- ease; yet I have seen cases in which this mistake has been made, in one instance, too, by a neurologist of no mean ability. In the first place, there is absence of the stigmata of hj^steria. The paralysis and anaesthesia begin gradually, and the latter is rarely ever profound or exten- sive. If the lesion is irritative and at- tended by contracture, muscular wasting will occur. The spasm is at first limited and Jacksonian in character. The deep refiexes of the affected limb are excess- ively increased, while those of the other limbs may remain normal or nearly so. Soon other symptoms of organic lesion, especially choked disks and evidences of intracranial pressure, develop. The re- verse of all these symptoms obtains in hysteria. In the event that the patient were hysterical the presence of the posi- tive symptoms of a focal lesion of the brain would make the diagnosis clear. Ceeebellab Tumor. — Most of the cases of tumor of the brain that have been mistaken for hysteria have been located below the tentorium. I have one such case under my care at present. This patient was treated eighteen months for neurasthenia and hysteria. It is fair to state that she comes of hysterical stock, and has the most prominent of the stig- mata, even to the paroxysmal symptoms. A careful history, which revealed the fact that certain symptoms pointing to organic disease began gradually eighteen months ago and has since slowly, but steadily, increased, together with uni- lateral facial paralysis and double choked disks, make the diagnosis easy. Hemianesthesia from Brain-le- sion. — This is extremely rare unless as- sociated with some motor disturbance. The deep reflexes, especially the knee- jerk, are increased to greater extent than is found in hysteria; hemianopsia will likely be present and the special senses 564 HYSTERIA. DIFFERENTIAL DIAGNOSIS. on the hemianaesthetic side are less afEected. In hysteria there is probably "crossed amblyopia." The hemianes- thesia that occurs in alcoholism and in some cases of metallic poisoning, espe- cially from lead, is evidently hysterical in its natnre. Hemiplegia. — The paralysis of one side of the face; the state of the reflexes, — the deep excessive and the superficial slight, or abolished, on the paralyzed side; the absence of "crossed amblyopia"; or profound affection of the special senses would exclude hysteria as the cause. Hemianopsia. — If due to organic brain-lesion in the occipital lobe this may be the only symptom, except, perhaps, pain in the head. It is not changeable and persists for a long time, if not for life. In hysteria it is transient, change- able, the other fields are narrowed, the conjtmctivse of both eyes are anaesthetic, the color-fields are probably reversed, and other stigmata of hysteria are pres- ent. Paraplegia. — If due to myelitis affecting the lumbar region, paralysis of the anal and vesical sphincters, the loss of the reflexes, muscular wasting, bed- sores, and the reactions of degeneration would stamp the nature of the trouble. If the cervical or dorsal cord or the lat- eral columns were the seat of the lesion the exaggerated reflexes with true ankle- clonus and other evidences of organic disease would serve to determine the character of the trouble. In poliomye- litis the muscular wasting, loss of re- flexes, and the reactions of degeneration would exclude hysteria as the cause of the paralysis. Syringomyelia has many symptoms in common with hysteria, but the muscular wasting, often the weak- ness of the sphincters, the changes in the reflexes, and the absence of the stigmata of hysteria would be sufficient on which to base a diagnosis. Multiple neuritis presents organic changes, as shown by reflexes, wasting, and the reaction of de- generation. Disseminated Sclerosis. — Buzzard says: "Multiple sclerosis, like hysteria, is common in women at puberty; a his- tory of some moral shock often precedes both; there are few cases of multiple sclerosis in which there are not hyster- ical symptoms added; and many symp- toms of the former have long been looked upon as hysterical." The same writer states that the plantar reflexes are usu- ally well marked in multiple sclerosis, and feeble or absent in hysteria. Paraly- sis is usually sudden in its onset, and more complete and flaccid in the latter than in the former. When blindness occurs in one eye, it is generally com- plete at first and comes on suddenly in hysteria, whereas in multiple sclerosis absolute blindness in one eye is rare. In the latter the acuity of vision lessens gradually with contraction of the visual fields, until the eye is almost useless; then vision improves in this eye and fails in its fellow. Atrophy of the optic nerve and nystagmus occur in multiple scle- rosis, but are probably never of hysterical origin. The tremor of multiple sclerosis may be simulated by an irregular tremor occurring on voluntary movement in hysteria, but in the latter the excursions are usually less; there are a tardiness of the initial muscular effort and a con- traction of the antagonistic muscles. Gowers lays considerable stress upon the diagnostic importance of the presence of the last symptom. The hysterical pa- tient affected with tremor will often touch a small object with the index fin- ger without much difficulty, but after the finger has remained a few seconds in contact with the object the arm be- comes affected with an irregular or jerky HYSTERIA. DIFFERENTIAL DIAGNOSIS. ETIOLOGY. 565 tremor, differing from the tremor of dis- seminated sclerosis, in which great effort is frequently reqiiired in bringing the finger in contact with an object, but as soon as this has been acepmplished the tremor ceases. Cases of ceeebhal syphilis fre- quently present hysterical symptoms. If the symptoms are typical of the latter, and there is no positive evidence of or- ganic intracranial lesion, the true nature of the malady can only be suspected from the history of infection or from the evi- dences of syphilis in other portions of the body. Feigning. — In most cases of hysteria that I have met there has been an exag- geration of some symptoms, and in not a few some have been intentionally or unintentionally feigned. It is a com- paratively easy matter to distinguish be- tween a case of simple feigning and hys- teria. Given a case of traumatic hysteria with the stigmata of the disease well marked, it is not always an easy matter to say just to what extent intentional feigning enters into the symptoms. Insanity.- — It is a mistake to class sjTnptoms of monomania, such as claus- trophobia, mysophobia, etc., among those of hysteria. Neurasthenia. — Theoretically, the difference between hysteria and neuras- thenia is well marked. The former is a disease with its stigmata and paroxysmal symptoms, all or any of which may come on or end suddenly; the latter is an ex- hausted state of the nervous system, hav- ing a gradual beginning and ending, and unattended by stigmata or paroxysmal symptoms. Practically, however, hys- teria is a psychoneurosis, and neuras- thenia, while it begins as a neurosis, frequently becomes a neuropsychosis. Nerve-exhaustion in a person who is pre- disposed to hysteria may cause the devel- opment of the typical symptoms of the latter disease. In cases in which hysteria and neurasthenia are associated a careful study of the manner in which individual symptoms have developed will iisually enable one to determine which is the pri- mary malady. Epileptic Convulsion. — There will, as a rule, be little difficulty in distin- guishing between an epileptic and an hysterical convulsion, especially if the physician is fortunate enough to witness the seizure. If this is impossible the presence of an educated nurse, especially trained for this purpose, is absolutely necessary for information on which to base a diagnosis. Points in the diag- nosis will be found in this article in con- nection with the description of the hys- terical convulsion. Almost the reverse of these conditions obtain in an epileptic fit. Feigning. — It is not infrequently nec- essary to differentiate between an hyster- ical and a feigned convulsion. This is not difficult unless the malingerer is familiar with the stigmata and paroxys- mal symptoms of hysteria. The latter, like dementia, is a most difficult condi- tion for the ignorant to feign. If the malingerer should be a physician or a clever trained nurse the differential diag- nosis might be most difficult, and some- times, perhaps, impossible. Etiology. — Can a person who is not the subject of a vitiated inheritance de- velop hysteria on being subjected, for a prolonged period, to some of the well- known causes of hysteria? Or, to put it differently, is the only predisposing cause to hysteria heredity? Such a con- clusion has been reached by some alien- ists in regard to the predisposition to in- sanity. So few are born with a nervous system free from hereditary taint of some kind that it is very difficult to 566 HYSTERIA. ETIOLOGY. answer the query here propounded. Per- sonally, I can see no reason why such exciting causes of hysteria as trauma, toxEemia, shock, and certain chronic dis- eases may not so exhaust and disarrange the nervous apparatus that it will be- come almost, if not quite, as weak and unstable as that which may be inherited from an unhealthy ancestry. Probably the predisposition to hysteria when ac- quired is less typical than when in- herited. Heredity. — Herman B. Sheffield is almost alone in attributing slight influ- ence to heredity in the causation of hys- teria. It does seem, especially to those who have given the subject of heredity much careful study and who have ob- served the offspring of unhealthy ances- try, that it is impossible to belittle the direct and indirect influences of heredity as a predisposing cause of hysteria. It is probable that the children of hysterical parents would not themselves become hysterical could they be excluded from all the trying ordeals of life. Such chil- dren, however, have weakened, irritable, and unstable nervous organizations, and even the little home annoyances, from which no one is free, are often sufficient to give rise to an attack of hysteria. Briquet found in a study of 351 hyster- ical subjects that a neurotic element ex- isted in about 25 per cent, of the rela- tives, and in healthy, non-hysterical women it was traced in only 2 ^/g per cent. As a rule, the earlier in life that hj'^steria develops, the greater the neu- rotic element in the relatives. Any in- fluence in the ancestry that vitiates the nervous organization may lead to a de- generative taint in the children. Insan- ity, epilepsy, alcoholism, syphilis, injur- ies to the head, etc., in the parents, may indirectly predispose the children to hysteria. Fully-developed hysteria, of course, is never inherited, but a predis- position to it, a soil favorable for its de- velopment, well marked or slight, is prob- ably almost universal in children of hys- terical parents, and commonly exists in those who are born with weakened nerv- ous organizations. While most women and many men have nervous organiza- tions favorable for the development of hysteria if they are subjected to exciting causes sufficiently strong, yet they re- tain ample resisting power to cope with all the ordinary trials of life to enable them to prevent manifesting the disease. I have met many strong men who ad- mitted that they felt hysterical, although I could detect no symptoms of the dis- ease. Attention called to the comparative frequency with which hysterical symp- toms are superimposed upon cases of or- ganic disease of the nervous system. In these cases there is often a neuropathic ancestry, which may be considered the predisposing, as the disease itself is the determining, cause of the neurosis. C. H. Hughes (Jour. Amer. Med. Assoc, Sept. 17, '92). Literature of '96-'97-'98. Direct heredity is frequent in hysteria, and, according to Briquet, half the hys- terical mothers give birth to hysterical children. Liability to convulsions is one of the nervous manifestations most fre- quently transmitted to offspring (Fgrg). Silvio Ciarrocca (Gior. Inter, dellc Seienze Med.; Can. Pract., July, '98). Age. — Hysteria is most common be- tween the tenth and twentieth years of life. In nearly one-half the cases the disease first manifests itself during the second decade of life. The disease rarely begins after the fortieth year and is in- frequent before the seventh. Of the 92 cases reported in America occurring be- fore the fifteenth year, one child was 1 ^/o years old; one 2 years; three 3 years; and four 4 years. HYSTERIA. ETIOLOGY. 567 Two epidemics of hysteria observed in jSIoseow. One occurred in a school for girls (aged 10 to 13), as many as 18 out of 21 being consecutively attacked. The other case was observed in a lace-factory where a number of young girls, aged from 19 to 26, were engaged. Shataloff (Wratsch, No. 9, '91). literature of '96-'97-'98. Hysterical angina occurs more fre- quently in women under forty, tends to periodicity, to become nocturnal, and the attacks are induced by violent emotion. H. T. Patrick (N. Y. Med. Jour., Feb. 22, '96). Hysteria exists in children at all ages. Eight of the eighteen eases observed were below four years of age, and as many of them were boys as girls. It is as frequent in children as in adults. M. Terrien (Archives de Neurol., p. 299, Oct., '97). During childhood the discrepancy be- tween the sexes in regard to the relative frequency of the disease is less marked than later in life. Of the 92 cases occur- ring in children, analyzed by Sheffield, 61 were found in the female and 31 in the male, a proportion of two to one in favor of the female. In adults the dis- ease is ten or fifteen times more frequent in the female than in the male. Twenty-two eases of male hysteria seen in the course of four years in a ward of thirty-eight beds. Most of these patients were robust, vigorous men, quite able to follow their occupations. Bitot (Jour, de M6d. et de Chir. Prat., Jan. 10, '91). In the male hysteria usually presents itself in one of the milder forms, and such manifestations as the contractions, the vomiting, and the hystero-epilepsy rarely occur. N. P. Dandridge (Boston Med. and Surg. Jour., Sept. 19, '95). Eace. — Hysteria is found among all races; even the savage does not escape altogether, but to a much greater extent than the civilized. The negro in Amer- ica is frequently the subject of the dis- ease. The Jews, especially the Eussian ■Tews, in proportion to their limited pop- ulation, give the largest number of cases. Among the Latin races of our popula- tion is found more hysteria relatively than is met with in the native-born. The disease is apparently more frequent in the mild and warmer climates than in the cold. Altitude. — Persons who are exceed- ingly nervous, impressionable, and pre- disposed to hysteria are probably more likely to develop the disease on coming to a high altitude than at sea-level. Like chorea, hysteria is probably most fre- quent during spring and fall. The con- ditions inseparable from civilization, es- pecially worry, overwork, and excitement favor the development of hysteria. We meet with cases of habit- or imitation- hysteria just as we see eases of "habit- chorea." Defective education and vicious home-influences, especially as seen with hysterical mothers and oversympathetic friends, are potent causes of hysteria among weakly children and emotional young women. Tkauma. — The influence of trauma- tism in the causation of hysteria has re- ceived a great deal of attention from the neurologists during the past fifteen years, . and, I think, deservedly so. The cases have formed a group by themselves, and have received the names: "traumatic neurosis," "traumatic psychoneiirosis," and "traumatic neurasthenia." They are apparently cases of pure hysteria, and the name "traumatic hysteria," proposed by James Hendrie Lloyd, is probably the best we have. Cases of hysteria from traumatism are frequently the subjects of litigation. It may occur in its most persistent form from apparently slight injuries, and is often found in persons who have no claims for damages. Hys- teria from traumatism often persists for 568 HYSTERIA. ETIOLOGY. years, and sometimes for life. The par- oxysmal symptoms are frequently well marked, and those that may persist for an indefinite time are spinal hyperes- thesia, hemiansesthesia, local paralysis, tremor, contraction of the yisual fields, headache, nervousness, and exhaustion. These cases may be distinguished from feigned disease by the presence of the stigmata of hysteria. Tra^imatic hys- teria is by no means limited to the female sex. Various neuroses may originate from accidents of all kinds, and frequently in consequence of very slight traumatisms in which the psychical element is the main factor. In most cases the phenom- ena can readily be placed under the head of hysteria. Very frequently hysteria is mixed with neurasthenic symptoms, or the latter alone present. Dubois (Corres. f. Schweizer Aerzte, Sept. 15, '91). Toxemia. — Alcohol, morphine, co- caine, lead, arsenic, sulphide of carbon, and aiitoinfection may give rise to hys- teria. Most of these poisons may caufee organic changes in nervous structure, and the cases may present symptoms of hysteria and of organic disease at the same time. They may, however, result in hysteria when no recognizable organic changes have taken place. The motor and sensory paralysis of hysteria may be dependent upon struct- ural alterations in the nerve-centres. Th. Leber (Deutsche med. Woch., Aug. 18, '92). Of 60 cases of hysteria in men, al- cohol was the exciting cause in 18. Al- coholic hysteria is similar in all points to hysteria from other causes. Hysterical attacks are especially likely to be brought on by a fresh drinking- bout in the subjects of chronic alcohol- ism, in whom also traumatic hysteria is especially liable to occur. Similar mani- festations of hysteria are also met with after chloroform narcosis and in subjects of the morphine habit. Liihrmann (Ar- chiv. de Neurol., Nov., '95). Depressing or irritating mental and moral influences are potent factors in the causation of hysteria. To religious ex- citement may be attributed a number of cases of the disease. Whatever lessens vigor, exhausts, or depresses, may give rise to hysteria in the predisposed. Among causes thus acting may be placed diabetes, syphilis, typhoid fever, influ- enza, chlorosis and anaemia, etc. Sexual excesses, masturbation, and imgratified sexual desire are depressing in character and tend, in persons hysterically predis- posed, to act as exciting causes of the disease. Hysteria occasioned by malaria modi- fies the symptoms of the latter and con- stitutes a form of malarial attack of per- nicious appearance which is important to recognize. Bidon (La M6d. Mod., Mar. 2, '95). Disease of the Genehative Organs. — There is no doubt that many of the lighter and irritating affections of these organs, both in the male and female, in- crease the nervous condition of the suf- ferers; and, if they are not the direct exciting causes of attacks of hysteria, they increase the liability to them and exaggerate the symptoms when the dis- ease is present. It seems true, also, that the depressing effects of prolonged at- tacks of hysteria increase the tendency to the development of disease of the gen- erative organs. Operative interference on the generative organs, especially in the hysterical female, should only be undertaken when the local condition jus- tifies it. Ovaries should not be removed in the hope that the psychical effects of the operation will cure the hysteria. There are grave causes of hysteria which arise from irritation of the ovary. In such difficult forms of ovarian his- tology, where every plan of treatment is of no avail and threaten the existence of the patient, oophorectomy is indicated. HYSTERIA. ETIOLOGY. PATHOLOGY. 56a Spannocchi (Deutsche med.-Zeit., Feb. 27, '90). In both hysteria and hystero-epilepsy it Js necessary to distinguish carefully those eases in which the symptoms are clearly referable to the reproductive or- gans. These, and these alone, should be operated upon, nor should oophorectomy be performed on these cases until every other means of relief has been exhausted. Before operation physical examination may or may not disclose abnormal con- ditions of the pelvic organs. The opera- tion rests upon rational rather than physical signs. Operatioii usually discloses ovaries in a more or less sclerotic condition, and often Avith cystic degeneration. Ad- hesions are found in some cases, but not in all. The uterus is sometimes smaller than normal, and sometimes, but not al- ways, its position is not normal. Dudley P. Allen (Western Reserve Med. Jour., Dec, '95). Organic Disease in Geneeal and OF THE NeHTOUS StSTEM ESPECIALLY. — As is well Imown, there may be an association of organic and functional dis- ease at the same time, or a person who is predisposed to hysteria may develop or- ganic disease, and this, in turn, may cause the manifestation of hysterical symptoms. We have then, as S. Weir Jlitchell has so graphically expressed it, "the symptoms of real disease painted on an hysterical background." The fact that the seat of the organic lesion often determines the location and the char- acter of the hysterical symptoms not in- frequently misleads the physician, and may cause him to err in diagnosis if he is not on his guard. AVe often meet with tuberculosis and hysteria in the same subject. A catarrhal condition of the larynx may cause hysterical aphonia, dyspnoea, or even spasm of the larynx. An inflamed joint in a person predis- posed to hysteria may lead to the devel- opment of hysterical symptoms, such as contracture and paralysis of the limb. It is not uncommon for a case of tumor of the brain to present many of the most pronounced symptoms of hysteria. I have at present a patient under my care who has been treated for a period of eighteen months for hysteria and alleged uterine and gastro-intestinal disorders. She has been subjected to several oper- ations by certain orificial surgeons. Be- sides her hysterical symptoms, she has double-choked disk, blindness, intense headache, vomiting, cerebellar tituba- tion, and paralysis of one side of the face. A careful examination, and the recogni- tion of the symptoms of organic disease would have prevented the error in diag- nosis and saved the patient unnecessary annoyance and pain, and her friends needless expense. I have seen a few eases of tubercular meningitis in the adult in which the early symptoms were of an hysterical character. Suggestion, while probably not a di- rect exciting cause of hysteria, yet is capable, when the disease is present, of exaggerating the symptoms, and possibly may, in persons who are very nervous and hysterically inclined, be the influ- ence sufficient for its development. Ee- peated medical examinations, while the physician makes from time to time dili- gent inquiries for certain associated symptoms, soon lead hysterical subjects to assume the lacking phenomena in their own cases; so that what was at first a slight hysterical disturbance becomes in time fully-developed hysteria. I have observed the effect of suggestion on hos- pital patients who were not at the time the subjects of examination, but intently watching the investigation of other pa- tients in the same ward. Pathology. — So far as we know, hys- teria has no anatomical basis. In the absence of any demonstrable change in 570 HYSTERIA. PROGNOSIS. TREATMENT. the central nervous system its pathology must remain theoretical and speculative. As the clinical phenomena of this dis- ease are observed there seems to be a faulty interpretation or misinterpreta- tion of afferent impressions, a morbidly- emotional state, with disturbed will and reason; hence all the efferent impulses, both conscious and subconscious, are per- verted or allowed to run at a tangent. The morbid process is probably a dis- turbed condition of the cerebral cortex, affecting the neurons, their processes, and the protoplasmic material, giving rise to perverted function of the highest nerve-centres and leading secondarily to derangement of the normal or harmoni- ous action of the lower centres and of the sympathetic nervous system. Prognosis. — The disease is rarely dan- gerous to the life of the patient, yet it must be borne in mind that a person may become so exhausted that death takes place in spite of the efforts made to improve nutrition. Gowers mentions one case of death from spasm of the larynx. The prognosis of severe hysteria in childhood is not as good as some writers seem inclined to believe. Chil- dren so afflicted not infrequently become chronic hysterical subjects as they grow to years of maturity. The mental de- velopment is often deficient in such chil- dren. The lighter forms of hysteria, both in children and adults, usually re- cover comparatively rapidly if judicious treatment is instituted. The inherited nervous or hysterical temperaments, and sometimes the acquired predisposition, also continue through life. The natural tendency of all cases of hysteria is to ch Tonicity. In nearly all the milder cases, and in the vast majority of the severer ones, the symptoms, including the stigmata and the paroxysms, disap- pear entirely under favorable circum- stances, but relapses are common if the patients are subsequently subjected to trying ordeals. Cases which show evi- dences of beginning mental degeneration are practically hopeless. Traumatic hys- teria may last for years, or even a life- time. Spontaneous cure rarely occurs in the male, although hysteria in the male subject is usiially curable. It seems to be the experiences of most physicians that hysteria in the female, associated with chronic pelvic troubles, is very ob- stinate, and often rebellious to treat- ment. Paralysis, contracture, or anses- thesia may persist for a long time and finally disappear rapidly or even sud- denly. Literature of '96-'97-'98. A fatal termination may sometimes re- sult from the different effects of hysteria, and death may be due to spasm of the glottis so severe as to require trache- otomy. Sudden death may occur after hysterical vomiting, — in one such case no lesion of any kind being found on post-mortem examination. Fournier and Sollier (Jour, de M6d., Aug. 25, '96). Treatment. — Phevbntion is of great importance. If more attention were paid to it during childhood and early youth there would be fewer cases of hysteria, both in children and adults. Vitiated states of the nervous system in parents and their ancestors may give to the ofE- spring weak, irritable, and unstable nerv- ous organization. The associations and environments of such children, fre- quently consisting of hysterical manifes- tations in the parents or other relatives, undue parental anxiety and sympathy, lack of self-control, vicious habits and methods of education, may suggest trains of thoughts and actions to the children that will sooner or later lead to the de- velopment of hysteria in them. When practicable, oversympathetic and over- HYSTERIA. TREATMENT. 571 anxious parents should delegate the early ediication and care of their children to suitable nurses or attendants. Separa- tion of the children from such parents and other relatives is followed by good results if tutors and companions are se- ' lected with Judgment, so that the train- ing is in the right direction. "While the mental training, which is the more im- portant, should be carefully looked after and continued for years, the physical should not be neglected. Open-air life and "exercise should be insisted upon as much as possible; cool or cold baths ought to be given night and morning, followed by brisk rubbing of the skin by means of a coarse towel; the diet should be nutritious and easy of digestion, and most of the sweetmeats excluded; regu- lar and systematic habits as to eating, sleeping, exercise, and study should be rigorously maintained; and any disorder of the health should be corrected as soon as possible. Developed Htsteeia. — As isolation is of the utmost importance in the treat- ment of hysteria, considerable judgment and skill are necessary in selecting those who are to form' the companions of hys- terical subjects. The nu.rse should be faithful, educated, and well trained, and have good sense, tact, patience, gentle- ness, firmness, and diligence in her work. The patient is often compelled to be alone with her nurse for months, and if the latter is tactless and irritating the best-directed efforts of the most skillful physician will be defeated. The phy- sician should be firm, but gentle, and the possessor of considerable personal mag- netism. Unless the physician can in- spire the confidence and respect of his patient he should not xmdertake the treatment of a severe case of hysteria. The rest-cure of Weir Mitchell has many advantages in the treatment of hysteria. It gives an opportunity to separate the patient from parents and sympathetic relatives and friends; it enables the physician to carry out to the letter, without interference, special plans of treatment; and it affords an oppor- tunity to inspire the patient with hope by the proper siiggestions, without the latter's being constantly counteracted by "Job's comforters." The rest-cure is not necessary for all cases of hysteria, but there are few that will not improve much more rapidly by isolation from relatives and friends than they will at home. Forced feeding, massage, and faradiza- tion are important aids in the treatment. Milk is one of the best articles of diet. It should be deprived of most of its cream at first. This may constitute the only article of diet in the rest-cure cases for two or more ■vireeks. Food should be given the patient every two hours while she is awake. Massage and electricity .may be employed daily or on alternate days. In hysteria the rain-shower and the jet are usually efficacious, Dana (Di- etetic Gaz., Dec, '91). Strong galvanic currents (20 to 60 milliampSres ; electrodes, 6 by 12 centi- metres) to the hack and ovarian region used with almost uniformly good results in hysteria. Hirehf elder (Med. Stand- ard, Aug., '91). Literature of '96-'97-'98. Neurasthenic patients who are also hysterical often derive great' benefit by static electricity or by franklinization. Most, but not all, hysterical patients whose condition is proved by static elec- tricity show an intolerance, varying in degree, toward the high-frequency cur- rents, and especially toward autoconduc- tion in the electric cage. Faradization, which is, as a rule, indicated as alone serving to produce an effect upon certain local hysterical troubles, especially those of sensibility in one organ or a limited 573 HYSTERIA. TREATMENT. region, is often powerless, while static electricity, which acts in a general man- ner, may give more rapid and more eflectual results. Apostoli and Planet (Annales d'Electro., May 15, '98). The moral treatment is of great im- portance and requires tact and skill on the part of the physician and nurse. In some cases hypnotism may be resorted to so that suggestions may be more effect- ive; but, as a rule, this should be avoided, and is, in the vast majority of cases, un- necessary. Eepeated assurances on the part of the physicians may inspire the hopes of the patient; especially is this true if the nurse has the tact and good judgment to increase the patient's con- fidence in her physician. As a rule, it is best to get along with as little medicine as possible. It is a mistake absolutely to prescribe the bro- mides in hysteria, as some have done. Sodium bromide in 10-grain doses after each meal, diluted vrith half-glass of water, is often effective in relieving rest- lessness and sleeplessness. It should be employed only for such special purposes. Its indiscriminate use in these cases can- not be too strongly condemned. Such tonics as reduced or lactated iron, ar- senic, valerianate of zinc, extract of sum- bul, etc., may be given as occasion re- quires. I have never employed oil of turpentine, recommended by Gowers to be pushed to the point of strangury. The special symptoms often require relief. Aphonia is sometimes relievable by the faradic current applied to the throat externally. "Weir Mitchell has tried it with success in some cases, teach- ing the patient to endeavor to speak only after fully inflating the lungs. Paralysis sometimes disappears suddenly. Usually after applying massage or electricity the patient may be induced to move a group of muscles, and if this is commented on favorably the voluntary movements may be increased after each treatment. Con- tracture is best treated by gentle meas- ures, such as rubbing the parts and grad- ually extending the limbs a little from time to time. Sometimes it is necessary to etherize the patient and forcibly ex- tend the limbs, or even perform tenot- omy. Anorexia and vomiting are best overcome by absolute rest in bed, judi- cious feeding, and firmness in the man- agement of the patient. If the food con- tinues to be ejected the nasal tube may be employed with good effect. The' sen- sory disturbances may be treated with the faradic brush, small and repeated blisters, and suggestion. Eetention of urine should not be relieved by the cath- eter until all other means have been ex- hausted. One of the most effective methods that I have employed is the application of ice to the abdomen or a cold douche to the spine. Suggestion sometimes is sufficient to enable the pa- tient to empty her bladder. An hysterical convulsion may often be arrested by the sudden and unex- pected application of ice to the spine or abdomen, or by placing the patient in a tub and pouring a bucket of cold water over the head and body. A prompt emetic will usually arrest a fit. The best for this purpose is ^/^o grain of apomo- phine given hypodermically. Inhalation of nitrite of amyl will often cause the convidsion to cease. H. A. Hare has recommended holding the patient's nos- trils closed for 30 or 40 seconds. Press- ure over the sensitive ovary does not always succeed. I have been able on two occasions to cause a sudden cessation of the convulsion by grasping the patient's great toes with each of my hands and firmly extending and flexing them. In the treatment of hysterical convvil- sions. all attendants who are not needed should be banished from the room. The ICHTHYOL. PHYSIOLOGICAL ACTION. 573 first thing to be done is to put pressure upon any hysterogenic zone. Suggestion may be eflfective, but it often fails. A constant current, rapidly reversed, is also beneficial. In some cases the wearing of colored glasses, varying the color with the subject, has a distinct effect. Pitres (Pittsburgh Med. Review, May, '91). J. T. ESKEIDGE, Denver. I ICHTHYOL. — Ichthyol (ammonium ichthyol-sulphonate) is a distillation product prepared from a bituminous mineral, foimd in the Tyrol, which is rich in fossilized remains of fish and sea- animals, whence the name "ichthyol" {ixdvg, fish). By dry distillation of this bituminous mineral a crude volatile oil is obtained which, at a temperature of 212° r., is treated with an excess of con- centrated sulphuric acid, forming ich- thyol-sulphonic acid. This latter sub- stance unites with the alkaline bases (am- monia, soda, lithia, etc.) and forms ich- thyol-salts, of which the principal ones are ammonium ichthyol-sulphonate (or ichthyol-ammonium) and sodium ich- thyol-sulphonate (or ichthyol-sodium), the former being always understood when the term ichthyol is used alone. These substances are rich in sulphur (about 15 per cent.), which is combined partly with oxygen, partly with carbon, in a condi- tion similar to that in mereaptans and organic sulphides (Baumann). Ichthyol has a reddish-brown color and a bitumin- ous taste and odor. The sodium salt is semisolid (the consistency of a solid ex- tract), and the ammonium-salt is a thick, brown liquid of the consistency of syrup. Ichthyol is readily soluble in water and in a mixture of equal parts of alcohol and ether; it mixes well with lanolin, vaselin, glycerin, fats, and oils, and with collodion and traumaticin. Preparation and Dose. — Ammonium ichthyol-sulphonate, 3 to 20 minims. Lithium ichthyol-sulphonate, 3 to 10 grains. Sodium ichthyol-sulphonate, 3 to 10 grains. Zinc ichthyol-sulphonate. Hydrargyrum ichthyol-sulphonate. Physiological Action. — Ichthyol has antiphlogistic, anodyne, alterative, anti- pruritic, antiseptic, and astringent prop- erties. Its peculiar virtues are largely ascribed to the large amount of sulphur it contains. When administered internally, al- though having a peculiar odor, it excites no nausea. In medicinal doses it is be- lieved that it retards the disintegration of albuminoid substances and favors their formation and assimilation (Zuel- zer, Charles). In larger doses it increases peristalsis and has a laxative action on the bowels. Helmers has found that a third of the sulphur contained in the drug is eliminated by the urine, while the remaining elements pass out in the faeces. He also finds that the sulphur of the ichthyol takes at least seven days to be completely removed from the or- ganism; hence he concludes that ich- thyol is not simply passed through with the food-excretions, but is first absorbed into the system and then again secreted. When applied locally, it acts as a re- ducing agent (abstracts oxygen from the tissues) and exerts a peculiar contractile effect upon the vascular tissiies; hence the application of ichthyol is followed by a diminution of heat, a reduction of 574 ICHTHYOL. THERAPEUTICS. swelling, a paling of the tissues, and a relief of pain (Unna). Moreover, the drug undoubtedly inhibits bacterial de- velopment, as proved by the experiments of Fessler and Klein. Injected subcutaneously, ichthyol lowers the rectal temperature for about an hour (Dujardin-Beaumetz). Therapeutics. — Ichthyol is not only peculiar in its origin, but in that it pos- sesses so many widely-different thera- peutic properties. We would naturally infer that its use would be indicated in a large variety of ailments and disorders. This we find to be true. Although not a panacea, it has established itself as one of the most valuable therapeutic aids at our command. Ichthyol can be used pure or dissolved in any of the usual solvents. It can be administered internally in substance, in pill, capsule, or watery solu- tion (adding some essential oil to cover the taste). It can be used externally, or topically, in spray, by inhalation or gargle, in oint- ment, in suppository or on tampons, in water or oily solutions, or as a varnish (dissolved in collodion or in traumati- cin). Ichthyol, when given by the mouth, may he increased to 15 grains a day. Locally, it may he mixed with lanolin, zinc ointment, or glycerin, varying in strength from 5 to 50 per cent. For a regenerative action, the weak ointments are better; for a resolvent action, as in gout, rheumatism, and neuralgias, the strong ones are recommended. T. Crans- toun Charles (Lancet, Sept. 26, '91). To produce an impermeable layer of ichthyol, which can be easily and quickly removed -without irritating the skin, the writer uses the following: Ichthyol, 40 parts (by weight); starch, 40 parts; concentrated solution of albumin, 1 to 1 Va parts; water, enough to make 100 parts. The constituents must be mixed in definite order: the starch must be moistened with the water, the ichthyol then rubbed well in, and, finally, the albumin must be added. The concentra- tion may be regulated by the thickness of the layer, the first application being wiped off with a moist cloth, so as to have the finest possible coating. An ichthyol - carbolic - acid varnish having the same properties can be made in a similar way, with the omission of the albumin. The formula is: Ichthyol, 25 parts; carbolic acid, 2.5 parts; starch, 50 parts; water, 22.5 parts. The ich- thyol and carbolic acid are dissolved in the; water with gentle heat, and the starch then added. The first prepara- tion, "vernic sum ichthyoli," is recom- mended in acne when the skin is irri- table, in rosacea seborrhoeica and in rosa- cea simplex, in "ulerythema centrifu- gum," in intertrigo, "tubercular'' eczema, seborrhoeica eczema, and erysipelas. Unna (Brit. Jour, of Derm., Apr., '91). When applied externally, previous washing (except when contra-indicated, as in eczema) of the afflicted parts each time', with soap and warm water, and gentle drying are advised. After the painting, inunction, or embrocation, it is best to cover the parts with carded cot- ton or flannel, and apply over all rubber cloth or rubber tissue, to prevent evap- oration, repeating the process night and morning. To avoid staining the clothes, ichthyol may be applied pure and then dusted with French chalk to form a crust, the usual dressings being afterward ap- plied. The odor of ichthyol may be dis- guised, if desired, by the addition of a small quantity of vanillin or cumarin or of the oils of citronella, eucalyptus, or turpentine. The remedy can be administered by subcutaneous injection in weak, watery solutions (1 to 3 per cent.), but if not freshly prepared the solution must be previously sterilized by boiling for a short time before using. For the hypo- dermic injection of exudates and tumors, ICHTHYOL. THERAPEUTICS. 575 solutions as strong as 50 per cent, have been employed. The stains upon the clothing and bed- linen^ soiled during the application of iehthyol, may be removed by boiling in soap and water, or by washing with soft soap, if attended to at once. Eheumatism. — Iehthyol is useful in all forms of rheumatism. Its application in these cases is followed by a prompt relief or cessation of the pain, and a diminution of the swelling, redness, and febrile action. Dressings kept constantly moist with a watery solution (10 to 20 per cent.) of iehthyol have proved of great value in acute arthritis, muscular rheumatism, lumbago, sciatica, and gout. If an ointment be preferred the fol- lowing may be used: — IJ Iehthyol, 2 to 4 drachms. Oil of citronella, 15 to 30 drops. Lard, vaselin, or lanolin, 1 ounce. — M. In acute cases this may be gently rubbed over the affected parts and a piece of linen (lintine) spread with the above applied. This is to be covered with cotton and bandaged tirmly. In subacute or chronic cases the- ointment is best riTbbed in well before applying the cotton and bandage. Iehthyol in olive-oil (1 to 3) may be used in the same way. The effect of these applications, especially in subacute and chronic cases, may be heightened by giving ichthyol- sodium (2 to 6 grains) internally, two hours after meals, either alone or com- bined with an equal quantity of sodium salicylate. Forty-eight cases treated with sulph- ichthyol of soda in doses increasing up to 20 grains a day. It has a peculiarly favorable influence on the general condi- tion. Its action was especially good in rheumatism. Lorenz (Berl. kiln. Woch., July 16, '88). After several days the stomach can tolerate V^ to 1 V^ drachms of iehthyol. Therapeutic action is largely due to the 15 per cent, of sulphur which it contains. F. Vigier (La Semaine Mfid., Feb. IS, '91). Iehthyol recommended hypodermically, as it possesses, under these circumstances, analgesic properties. Particularly is it of value in cases of neuralgic pains asso- ciated with inflammatory processes which have caused exudations. Damines (Th6se de la Faeultg de Paris, '92). Peritonitis. — In peritonitis iehthyol is best applied pure, with a brush, over the whole abdomen. The abdomen is covered by cotton, and that again by rubber tissue or thin rubber cloth to prevent evaporation. Pain, tenderness, tympanites, and fever subside under this treatment. Phthisis. — Scarpa treated a series of 150 cases of tuberculosis with iehthyol, giving 20 to 200 drops daily of a watery solution of the pure drug (1 to 2) with the following results: 23 deaths; 17 ap- parently cured; 50 notably improved; 32 some improvement; 28 not improved. The beneficial action of the remedy was manifested first in the relief of the cough, expectoration, and dyspnoea, and later by an improvement in the general condition. Iehthyol recommended in pulmonary tuberculosis. It is cheaper than creasote, and in many cases is better borne. The Avriter has used it during the past two years in more than 100 cases with good results; particular attention called to the remarkable effect it has on nutrition. He prescribes a mixture of equal parts by weight of iehthyol and Avater, and di- rects 4 drops to be taken t. d., before meals if it can be borne; if not, after meals. A little black coffee helps to cover the taste. The dose must be gradu- ally increased by a drop daily, until 40 drops are taken at once; it should al- ways be taken flcll diluted with water. The full dose must be continued for a long time. Cohn (Lancet, i, 1521, '94). 576 ICHTHYOL. THERAPEUTICS. Literature of '96-'97-'98. In the treatment of pulmonary tuber- culosis, dry catarrh, purulent catarrh, bronchial dilatation with fcetid expecto- ration, acute bronchitis, best eflects ob- tained from employment of ichthyol. In numerous cases of tuberculosis the use of guaiaeol or creasote was alternated with that of ichthyol for several months with excellent results. It was employed in capsules containing 4 grains each and covered \\ith a coating which enabled the capsule to pass through the stomach into the intestine without becoming dis- solved. From 4 to 8 capsules a day were taken at meal-times. In two-thirds of the cases there was an increase in A-\eight. M. le Tanneur {Gaz. des Hopi- taux; Revue Med., Jan. 5, '98). GYNiECOLOGICAL DISORDERS. In these disorders ichthyol has been tised on account of its anodyne properties, its resolvent and absorptive action, and its kolyseptic powers. It has been found useful in removing periuterine and pel- Tic exudates, in the treatment of chronic metritis, inflammatory condition of the tubes and ovaries, erosion of the cervix uteri, leucorrhoea, and pruritus of the genitals. The remedy is used internally in pills (1 V2 grains), at first 3 daily, later 6. Locally, a mixture of ichthyol, 1 ■drachm, and glycerin, 2 ^/^ ounces, may be applied on cotton tampons. The rem- edy may also be rubbed in over the abdo- men in ointment with lanolin (equal parts), or combined with soft soap (1 to 8). Suppositories containing 1 to 4 grains of ichthyol may be administered •pw vaginum. Ulcerations and erosions may be painted with pure ichthyol. For leucorrhoea lavage with a watery solu- tion (5 to 10 per cent.) or a 5-grain siip- pository may be used night and morning, preceded by a copious hot-water irriga- tion. Ichthyol found of considerable value as an analgesic and resolvent in parametri- tis, perimetritis, aflfections of the ovaries and tubes, cervical erosions, and pruritus vulvae. It is used locally in the form of a 10-per-cent. glycerin solution of the sulphichthyolate of ammonium, applied on tampons and internally as a pill. The disagreeable odor of this drug can be masked by the addition of cumarin. Freund (Lancet, May 24, '90). Ichthyol is superior to the nitrate of silver, creolin, and carbolic acid in the treatment of various inflammatory dis- orders of the female genitalia. The best preparation for injections is a 10-per- cent, solution of the drug in glycerin. Richard Bloeh (Jour, de M6d. de Paris, May 10, '91). Ichthyol is recommended as a resolvent in chronic affections of the ovaries, tubes, cellular tissue of pelvis, and even in hematocele. A glycerole of ichthyol mixed with boric acid, 10 to 100, is em- ployed. A tampon saturated with the mixture is placed in the vagina, and may be kept there for three days. Ed. Egasse (Bull. G6n. de Ther., July 30, '91). One hundred and fifty cases of women suffering from various affections, 142 be- ing of the genital organs, treated by ichthyol. Tampons saturated with glyc- erole of ichthyol (10 per cent.) were used, and the drug was administered in- ternally at the same time in pills of 1 'A grains, from 1 to 6 daily being taken. The disagreeable odor may be disguised by a 1- or 2-per-cent. essence of citron- ella or esence of eucalyptus. Of 22 cases of inflammation of the uterus there were 12 cures, 9 were improved, 2 failures; of 120 cases of periuterine inflammation, 59 recoveries, improvement in 56, 5 fail- ures; 2 cases of fissure of the breast, rapid cure; 6 cases of inoperable cancer, considerable diminution of the fostid se- cretion. E. Hermann (Inaugural Dis- sertation, '92). The pure drug found most satisfactory and reliable in congested states of female pelvic organs. Storer (Boston Med. and Surg. Jour., Aug. 2, '94). Fifty-per-cent. dilution with glycerin is the best congested states of the female pelvic organs. A. D. Sinclair (Boston Med. and Surg. Jour., Feb. 8, '94). Ichthyol, owing to its analgesic, anti- septic, antiphlogistic, and resolvent ac- ICHTHYOL. THERAPEUTICS. 577 tion, may render real service in gynse- eology if its employment is judiciously associated with other therapeutic meas- ures, according to the indications. Lorain (Jour, de Med. de Paris, Mar. 28). Genito - Ueixaet Disoedees. — In acute cystitis the lower part of the abdo- men may he painted with ichthyol, pure or in a 30-per-cent. ointment, to relieve the pain. The bladder may then be irri- gated five or six times daily with a warm (86° P.), aqueous solution (2 per cent., increasing to 5 per cent.). In chronic cystitis a warm 1-per-cent. solution may be used once daily. Gonorrhoea is amenable to urethral in- jections of a watery solution (1 to 3 per cent.) of ichthyol. ISTeisser states that a 1-per-cent. solution will destroy gono- cocci. Ichthyol regarded best-known remedy for genito-urinary affections of blennor- rhagie origin. The writer used it in 1 10 cases, 80 of which were men affected with blennorrhagia in various stages, and 30 were women showing inflamma- tion of all parts of the genital apparatus. The men were given urethral injections of an aqueous solution (1 to 4 per cent.), while tampons, soaked in 10-per-cent. glycerole of ichthyol, were introduced into the vagina of the female patients. The results were brilliant. Only 7 of the men were not cured, though im- proved, the rest leaving hospital entirely recovered after a treatment of from fif- teen to thirty days. The women were cured without exception. P. Colombini (Commentario Clin, delle Mai. Cut. e Genito-Urin., Nos. 5, 7, '93). Use of ichthyol strongly advised in acute urethritis, a 2-per-cent. aqueous solution being injected from five to six times daily, gradually increasing the strength to 5 per cent. As the patient improves, the number of injections are diminished to one in the morning and one in the evening. In acute cystitis the writer applies 30-per-cent. ichthyol oint- ment to allay pain, and after the acute period employs irrigation, injecting about one quart of a Vs-per-cent. aque- ous solution of ichthyol twice a day for a few days and then once a day. In chronic cystitis he injects, once daily, a 1-per-cent. solution of ichthyol. Villetti (lleport of Inst. of. Exp. Pharm. of the Eoyal Univ. of Rome, '94) . Ichthyol employed with success in the blennorrhagic urethritis of women. E. Coltman, Jr. (Univ. iled. Jour., Mar., '94). Ichthyol in hot solutions, for urethral use (0.5 to 2 per cent.), is very valuable in acute urethritis, especially in those cases where the mucous membrane is very sensitive. In subacute urethritis, where the lesions are circumscribed, local applications (with the aid of the endoscope) render great service. Ich- thyol suppositories, in the majority of cases, cause the inflammatory symptoms to disappear in the course of a prostatitis. In chronic urethritis, with infiltration, ichthyol by itself is inefficacious, but as- sociated with the mechanical treatment, or alternating with it, it appears to be of great benefit. Administered internally, it does not have any beneficial effect on nephritis or pyelitis. H. Lohnstein (Therap. Monats., Apr., '94). In cases of primary and secondary ca- tarrh of the bladder the writer washes out the viscus with 'A- to I-per-cent. solutions of ichthyol. By this means pain was relieved, micro-organisms were destroyed, and ammoniacal fermentation prevented. Colosanti (Eiforma Medica, Jan. 12, '94). In prostatitis the injection of a small syringeful of a 10-per-cent. solution by the rectum three or four times daily re- lieves the pain and causes a marked re- duction in the size of the swelled gland. Cutaneous Disoedees. — Ichthyol is especially useful in skin affections asso- ciated with atony and induration of the deeper layers of the skin and in which pain or inflammation exists. In acne Unna advises the use of a 50- per-cent. watery solution of ichthyol, well rubbed in on retiring, and washed off with warm soap-water in the morning; durinsr the day a weak solution of hi- 578 ICHTHYOL. THERAPEUTICS. chloride of mercury is used. In addition to the external use of the remedy, Unna advises the internal use of it, in doses of from 8 to 30 grains daily. In rosacea, with tendency toward eczema, mild applications are used ex- ternally; in forms tending toward acne the remedy may be applied freely. In nervous eczema ichthyol should be used internally and externally. For erythema multiforme and lichen urticatus Unna advises external applications of pure ichthyol or of strong solutions. In in- tertrigo a 10-per-cent. salve or watery solution is beneficial; in eczema margin- atum, the same is advised, with the addi- tion of from 2 to 10 per cent, of salicylic acid. Ichthyol is also used with advan- tage in the chronic stages of keloid and lupus. In the latter Unna recommends the following: — ]^ Bichloride of mercury, 1 to 4 parts. Sodium ichthyol-sulphonate, 5 to 10 parts. Distilled water, enough to make 100 parts.— M. . Ichthyol is of decided benefit in both acute and chronic urticaria, and also in chronic alcoholism, in which the tremor rapidly disappeared, the appetite re- turned, and sleep became normal and un- disturbed. The depression and chronic gastric catarrh were likewise greatly diminished by the drug. Good results were also observed in chronic rheuma- tism, administered internally and with local applications. In arthritis defor- mans the pain was greatly lessened. Nils Gadde (Therap. Monats., Mar., '90). Ichthyol given internally is an effect- ual remedy for certain forms of urticaria caused by errors of diet. Lanz (Rev. Med., Oct. 21, '94). The efficacy of ichthyol is not in- creased by the addition of lanolin, but is materially augmented by rubbing. H. A. Hare (Boston Jled. and Surg. Jour., Oct. 15, '94). Following paste recommended in ec- zema of the female genitals: — 1} Ichthyol, 1 'A to 2 parts. Powdered starch. Flowers of zinc, of each, 12 parts. Vaselin, 25 parts. Von Sehlen (Monats. f. Prakt. Derm., July, '94). Literature of '96-'97-'98. Itching, which is so often found in con- nection with eczematous conditions of the anal and genital regions, can be greatly relieved by the use of an ich- thyol wash ranging in strength from 1 to 2 drachms to the ounce of water. Cantrell (Phila. Poly., Apr. 4, '96). The variola ichthyol is an ointment composed of 10 parts of ichthyol to GO of fat and 20 Sanoli's olive-oil, chloro- form, or glycerin. The ointment should be rubbed in three times a day as soon as the papules become visible. Cassenko (Brit. Med. Jour., June, '97). In erysipelas ichthyol has proved of great value. It reduces the congestion, tension, swelling, and pain, and appears to limit the extension of the disease. The thickness of the skin determines, in a measure, the strength of the application to be used. The surface is carefully washed and dried, and a salve (30 to 50 per cent.) made with lanolin or vaselin gently rubbed in. For use on the lower extremities Unna advises the following: Ichthyol and ether, of each, 1 part; col- lodion, 2 parts. Another formula is ich- thyol, 2 parts, with ether and glycerin, of each, 1 part. Instead of the fore- going, a watery solution (1 to 3) may be applied two or three times daily. In erysipelas, experience with a 30- to 50-per-cent. ichthyol ointment has con- firmed the value of the remedy. Spread on rags and used to cover the affected area and extend a little beyond, this ointment cured 4 eases of facial erysipe- las in two or three days and 5 other cases in five or six days. ICHTHYOL. THERAPEUTICS. 579 In burns and frost-bites good results obtained with ichthyol. The internal use of ichthyol as a reeonstitutive and tonic is of great value in anaemic dys- peptic subjects suffering from eczema. Kopp (Miinch. med. Woch., Aug. 27, Sept. 3, '89). In erysipelas the affected parts to be painted morning and evening with col- lodion, to which ichthyol has been added in the strength of 10 per cent., the appli- cation being made so as to cover the healthy skin for an extent of three centi- metres around the affected patch; the application is always made from healthy to diseased skin. In eighty oases in which the author has used this method it has not failed once. When the varnish comes away the skin is left in a healthy condition. Victor Cebrian (El Siglo Med., Dec. 17, '93). The ichthyol preparations (ammonium and sodium) in weak solution in a short time destroy the pyogenic and erysipelas streptococci. Ichthyol is used with success in the suppuration from these cocci. The staphylococcus aureus and albus, the bacillus pyocyaneus, the bacillus of typhoid, ozsena, and anthrax, and the spirillum of Asiatic cholera show more or less resistance to ichthyol. The diphtheria bacillus in fresh colonies is easily destroyed by weak ichthyol so- lutions, while mature ones are acted upon with difliculty. Ichthyol has rendered good service in the treatment of typhus and ozsena. It is recommended that it should be preserved only in substance or in a, 50-per-cent. solution; weaker solu- tions may be culture-mediums for micro- organisms, as the staphylococcus aureus. Weak solutions should be sterilized by heat. Rudolf Abel (Centralb. f. Bak. u. Parasitenk., No. 13, '93). In burns of the first and second de- grees strong applications are made and a subsidence of pain and congestion fol- lows. Pure ichthyol painted on, or the use of an ointment composed of equal parts of ichthyol, zinc oxide, and vaselin, produces a happy effect. In burns of the first degree is used a mixture of 5 parts of zinc oxide, 10 parts of carbonated magnesium, and from 1 to 2 parts of ichthyol. In burns of the sec- ond degree the following composition employed: 5 parts of zinc oxide; 10 of prepared chalk; 10 of starch; 10 of lin- seed-oil; 10 of lime-water; and from 1 to 3 of ichthyol. This material is ap- plied once daily. When there is a great deal of inflammation in the burn these two preparations can be used at the same time, the burn being first dusted with the powder, and the paste being laid on over this. Leistikow (Semaine M6d., xv, p. 487, '95). In frost-bite Lange recommends the use of ichthyol in olive-oil (3 to 20) used as a paint; Heuss advises ichthyol in camphorated oil (1 to 4), rubbed in once or twice daily, and covered with cotton. In chilblains (pernio) the use of an ointment of ichthyol (10 to 30 per cent.) or of equal parts of ichthyol and turpen- tine is attended with good results. Unna advises the use of a mixture of ichthyol, 5 parts; chloroform, 2 parts; and petro- latum, 3 parts, to make an ointment. If the skin is broken the chloroform is omitted and zinc ointment replaces the petrolatum with advantage. In furunculosis solutions or ointments (10 to 50 per cent.) are equally efficient, the inflammatory symptoms tisually sub- side, and, if applied sufficiently early, ichthyol will abort the boils. "With the external treatment it is well to give cal- cium sulphide in ^/4-grain doses every two or three hours for twelve hours, and then three or four times a day as sug- gested by C. J. E. McLean. In prurigo and pruritus the applica- tion of ichthyol in a 5- to 10-per-cent. watery solution, after washing with warm water and soap, has given excellent results. Lange advises a mixture of ich- thyol, 2 parts, in absolute alcohol and ether, each, 9 parts; to be used as a paint or by inunction. WorxDS AND Ix.TUBiES. — Inciscd and 580 ICHTHYOL. THERAPEUIICS. post-operative wounds dressed with pure ichthyol heal by first intention. Cracked nipples heal well under a 20-per-cent. ointment, but it must be wiped off before nursing. Fissure of the anus and other anal lesions do well under the use of pure ichthyol applied by means of a camel's hair pencil morning and evening and after defecation. Ichthyol considered as the most valu- able drug in the treatment of anal fis- sure. A brush is impregnated with the pure drug, and thus introduced into the anus, and the contraction of the sphinc- ter-muscle forces it into all the folds of the mucous membrane. This treatment is assisted when necessary with cas- tor-oil. Van der Milligen (Jlonats. f. Prakt. Derm., '95). Literature of '96-'97-'98. Venomous insect-stings should be treated by the application of pure ich- thyol, or a mixture of equal parts of ich- thyol and lanolin. If, when the surgeon first calls, swelling already exists, ich- thyol is applied, sheet India rubber is laid over this, and an ice-bag placed on the India-rubber tissue. Administration internally in such a case of 10-drop doses of a mixture of equal parts of ichthyol and spirit of ether advised. Ottinger (N. Amer. Pract., Feb., '97). Sprains and painful injuries about the joints do well under ichthyol; it should be well rubbed in, on the surface of the injured parts, covered with cotton, and a bandage firmly applied. Miscellaneous Disorders. — The painfulness of parotitis subsides rapidly when the parts are anointed with ich- thyol-lanolin (1 to 2 per cent.) and cov- ered with cotton. In many cases undi- luted ichthyol is indicated. (Lange.) It is an efficient remedy in almost all affections of the mucous tract. Ichthyol found especially applicable in catarrh of the mucous membranes. In the rapid growth of children, when ' scrofulosis is localized in the nose, with ozaena, ichthyol, locally and internally, acts much more quickly and certainly than codliver-oil. Von Hoffmann and Lange (Therap. Monats., May, '89). Sulphichthyolate employed in a case of chronic nephritis of eight months' standing. Fifteen grains a day caused abundant diuresis and a reduction of the albuminuria. Blittersdorf (N. Y. Med. Jour., Oct. 19, '89). Inhalations by means of an atomizer of a cold 2-per-cent. solution of ichthyol repeated twice daily, and not too deeply inspired, have given excellent results in acute laryngitis. No ill effects have fol- lowed. Cieglewiez (N. Y. Med. Jour., vol. Ixxvii, p. 826). Two-per-cent. solution of ichthyol rec- ommended as a gargle in anginas of al- most every kind, except the follicular variety. The mouth and throat are to be carefully gargled, and a portion of the solution then swallowed. L. Herz (Wiener med. Woch., No. 2, '93). Ichthyol ointment, 2 ^U- to 10-per-cent. solution, advocated in the treatment of scrofulous blepharitis. Luciani (Ann. di Ottal., xxiv). Literature of '96-'97-'98. Ten- to I5-per-cent. ointment of ich- thyol in lanolin is very efficacious in ciliai-y blepharitis. Germani (Gazz. degli Osped., June 20, '96). Ichthyol in pills {'A to 3 grains in twenty-four hours, rapidly increasing the dose to 10 or 15 grains in the day) is one of the most valuable remedies in whooping-cough. Maestro (Med. Week., iv, '96). In a case of acute idiopathic oedema of the epiglottis in a man of 41, a spray of ichthyol, '/., per cent, in ice-water every fifteen minutes, with ice externally, gave rapid relief. W. P. Meyjes (Jour. Laryn., Ehinol., and Otol., Mar., '97). C. Sumner Witherstine, Philadelphia. ICTERUS. See Jaundice. IDIOCY. See Insanity. INDICAXUEIA. SYMPTOMS. ETIOLOGY. 581 INDICANURIA. Definition. — Indican, in small quanti- ties, is a nsual constituent of the urine; under certain circumstances, however, the amount is so large as to merit the designation of indicanuria. Symptoms. — jSTormal urine contains ver}' small quantities of indican; about 0.004.5 to 0.0195 gramme are excreted in twenty-four hours; different animals secrete much more, horses about twenty times as much. Urine containing much indican is dark colored, brown to black; in rare cases indigo is deposited as a blue powder. The presence of indican in excess in the urine is demonstrated by different tests. 1. Heller's Test. — By the addition of nitric acid a blue-violet ring is formed on the point of contact of acid and urine. 2. Jaffe's Test. — Equal volumes of urine and hydrochloric acid are mixed in a test-tube; a few drops of a solution of sodium hypochlorite are added and the mixture is shaken. The blue color of indigo will then appear. Stokvis pro- poses to add some drops of chloroform, in which the indigo dissolves. [Richardson (Med. Xews, '99) proposes to substitute a solution of hydrogen di- oxide to the solution of hypochlorite of *' soda, contending that the reaction takes place more rapidly and that the color is more distinct. F. Levison.] Senator modified Jaffe's test in the following manner: Ten to 15 centime- tres of urine are mixed with an equal quantity of concentrated hydrochloric acid; 3 to 5 cubic centimetres of chloro- form and 1 drop of saturated solution of chlorinated lime are added and the mixt- ure is shaken. The chloroform is col- ored blue when indican is present in excess. Obermayer's Test. — The urine is pre- cipitated by the addition of a solution of acetate of lead; the filtrate is treated by the addition of concentrated hydrochlo- ric acid and a few drops of a 2 to 4 per 1000 solution of perchloride of iron; the mixture is shaken with chloroform. Quantitative tests have been indicated by Jaffe and Salkowski, advantage being taken of the bleaching powers of hypo- chloride of calcium, a standard red solu- tion of this salt being used to effect the complete decoloration of the indigo. Etiology. — By the decomposition of proteids indol is formed, which is ab- sorbed in the intestine and oxidized in the blood, forming indoxyl. When ex- creted in the urine it is combined with sulphuric acid and excreted as indoxyl- snlphiTric potassium-indican. This salt may be isolated as rhomboid, white crys- tals, which are soluble in water and hot alcohol, hardly soluble in cdld alcohol, and not at all in ether; by heating it with hydrochloric acid it is divided into sul- phuric acid and indoxyl, which in pres- ence of oxidizing substances gives in- digo. By fermentation of urine contain- ing much indican, indigo is also formed. In some cases indigo-red also is formed by heating the urine with nitric acid. Eosenbach (Berl. 'klin. Woch., '89 and "90). Indicanuria is ordinarily dependent on decomposition of the intestinal con- tents consequent upon constipation or occlusion of the intestinal tract, espe- cially of the small intestine, while occlu- sion of the large intestine does not cause it. In the conditions of hunger the albu- minous secretions of the bowels are de- composed and form indol; newly-born infants do not produce indol, because their intestines do not contain bacteria. [Gehlig (Jahrbiich f. Kinderh., '97) found that nurslings in good health only present traces of indican in the urine. When digestive troubles occur the quan- 582 INDICANURIA. ETIOLOGY. tity of indican is augmented. F. Levi- SON.] Infants nourished with sterilized cows' milk show, at times, small amounts of indican in the urine, even if the digestion is normal. In case of digestive derange- ment indican is almost always present, the amount increasing with the intensity of the derangement. In older children with normal digestion the presence of small amounts of indican in the urine is the usual condition, as well as in adults. This excretion is increased after the in- gestion of food rich in nitrogenous mat- ters, particularly meat and eggs. No re- lation between tuberculous disease and increased elimination of indican could be determined. Gehlig (Jahrbileh f. Kin- derh. und physische Erziehung, Aug. 6, '94). ' Indicanuria regarded as of real im- portance in children. It exists in normal urine, but in such small quantity that indicanuria may be regarded as patho- logical, especially in children in whose food there is less nitrogen than in that of adults. Indican being a derivative of indol, indicanuria is particularly met with in cases in which there is a, hyper- production of indol, as in acute and chronic affections of the digestive tract and in certain acute diseases, such as typhoid fever, pneumonia, severe chorea, etc. It is constant in tuberculosis, with which it is in direct relation. Djouritch (Revue Men. des Mai. de I'Enfance, Feb., "94) . Indican is fo^ind in cases of decompo- sition of pus, as in putrid empyema, putrid suppurations, etc.; it has also been observed in different diseases, es- pecially of the stomach and the bowels, carcinoma of the stomach, gastric ulcer, acute and chronic gastric catarrh, chol- era nostras and Asiatica, peritonitis, etc. [Simon (Amer. Jour. Med. Sei., '95) states that a relation exists between in- dican and the acidity of the gastric juice in the sense that a subnormal amount of free hj'drochloric acid calls forth an increased degree of intestinal putrefac- tion, and, therefore, an increased forma- tion of indol. F. Levison.] The constant elimination of five milo- grammes of indican in adults, or even less in children, is pathological. The ex- cess depends upon the increased putre- faction of albumins or deficient altered activity of the bile and pancreatic se- cretions. In such case flatulence occurs, and the whole conditon may be bene- fited by change of diet. In other cases there is continuous cause of indican with or without flatulence, uninfluenced by diet. Herter and Smith (N. Y. Med. Jour., June 22 to July 20, incl., '95). Presence of indol and indican almost constant in the liver affected with vari- ous lesions, much less frequently in the kidneys, spleen, lungs, and heart. The greater frequency of their presence in the liver is explained by the fact that this organ, being on the route of the supra- hepatic portal circulation, is one of the store-houses of the indol developed in the intestines. F. Villard (Marseille-mfid., June 15, '95). In a series of experiments the quantity of indican in the urine, under a purely albuminous diet, was enormously in- creased in patients vi'ith affections of the spleen and in dogs whose spleens had been removed. This would tend to indi- cate that the spleen has the function of checking the processes or eliminating the products of albuminous decomposition in the intestine. Mazzetti (Wiener med. Woch., Aug. 1, '91). Indican found in the urine of typhoid and other forms of fever and in faecal toxaemia. Churton (Lancet, Aug. i.4, '89). There is no causal relation between indicanuria and suppuration, and the increase of the latter is of no value in revealing a hidden abscess. Beckmann (St. Petersburger med. Woch., July 28, '94). Literature of '96-'97-'98. The Introduction of large numbers of colon bacilli into the intestines increases the indican and the ethereal sulphates of the urine. The introduction of large numbers of the proteus vulgaris may in- crease the ethereal sulphates, but not per- ceptibly. The introduction of the lactic- acid bacillus may reduce markedly the INFANTILE MYXCEDEMA. SYMPTOMS. 583 indican and ethereal sulphates. Herter (Brit. Med. Jour., Dee. 25, '97). Indican has been recognized as a symp- tom of tuberculosis. [Fehm found by a comparative exam- ination of 15 tuberculous and 14 non- tuberculous children (Corres. f. Schweizer Aerzte, '93) indicanuria in tuberculous children in a proportion of 61 per cent, and in the non-tuberculous in a propor- tion of 40 per cent. F. Levison.] In the urine of healthy children and those suffering from simple dyspepsia indican was very rarely found. In grave forms of diarrhoea it was almost invari- ably found; but when the diarrhoea was mild it appeared less often and in smaller quantities. In tuberculosis it was always present. The author believes it due to the decomposition of milk-albumin. Hochsinger (Wiener med. Woch., Apr. 18, '91). Indicanuria cannot be considered as of significance in the ^ diagnosis of tubercu- losis in children. Giarre (Lo Sperimen- tale, p. 98, '93). The indican reaction is more positively connected with anomalies of digestion, especially in mixed feedings, than with tuberculosis, the principal malady; con- sequently indican has no other diagnos- tic importance than that of indicating the degree of decomposition of albumi- noid substances in the intestines. Be- tween indicanuria and tuberculosis there is no relation of sufficient constancy to give value to Hochsinger's sign that in- dicanuria is a sign of tuberculosis in childhood. Cima (Trans. Internat. Cong, of Eome, '94). It must, nevertheless, be borne in mind that ingestion of large quantities of nitrogenous food is apt to lead to indi- canuria even if no derangement of the digestion be present. In different diseases of the nervous system, especially after epileptic fits, an abnormal quantity of indican has been noticed in the urine. Indican found in the urine of patients suffering from mental diseases; nothing characteristic established except that the quantity was twice as great in the acute as in the chronic foi-ms. Bondurant (Amer. Medico-Surg. Bull., Feb. 15, '94). In chronic cystitis indican may be de- composed in the bladder and indigo de-. Ijosited from the urine as a blue powder. [Ord (Berl. klin. Woch., '78) found a, calculus, consisting chiefly of indigo, in the pelvis of a patient who died from a sarcoma of the kidney. F. Levison.] P. Levison, Copenhagen. INFANTILE MYXCEDEMA (CRE- TINISM). Definition. — Cretinism is a chronic disease of nutrition due to loss of, or im- pairment of, function of the thyroid gland, and appears at any time between birth and puberty; after puberty it is known as myxoedema. It causes retar- dation of development in the sensory, motor, and trophic nervous systems, leading to a retention of an infantile state, and to an extraordinary dispro- portion between the different parts of the body — ^the brain, bones, skin, mu- cous membranes, and generative organs suffering most. Literature of '96-'97-'98. Symptoms of cretinism are to be ex- plained as the result of the myxoedema- tous process in the undeveloped tissues of an infant. A scientific application of the principles of heredity by such methods as have been used in such sub- jects as deaf-mutism, idiocy, and other nervous diseases will demonstrate similar relations and yield similar results in cretinism. William B. Noyes (N. Y. Med. Jour., Mar. 14, '96). Symptoms. — These depend to a greater or less extent on the length of time the disease has lasted, and the age at which the affection has developed, but mainly on the degree of involvement of 584 INFANTILE MYXCEDKMA. SYMPTOMS. the functions of the thyroid gland. Girls are more often affected than boys, though the difference in proportion is not very large, but the symptoms, aside from the sexual organs, are in both sexes the same, and are characteristic in every prononunced case. The disease may vary much in intensity, but even in the less marked cases diagnosis is seldom difficult, when all the symptoms of ab- normal development are carefully sought and studied. Cretinism differs from most other diseases in that it is to be recognized by signs rather than by symp- toms; the most prominent alterations concern the surface of the body, and are thus readily visible; so that the over- sight of a case by a physician familiar with the disease is nearly impossible. When the disease has commenced at birth or very early in infancy, it is sel- dom recognized before the child is six months old, although it has been diag- nosed as early as the sixth week. It may, however, develop in utero. After the -sixth month the symptoms begin to be- come prominent; it is noticed that the child does not grow as rapidly as it should, that it is not as bright mentally as is usual, that its tongue is too large for its mouth, and lolls out between the teeth. The tongue may be so large as to impede respiration when the child lies on the back, and pieces of the tongue have even been excised through mistaken diagnosis. On further examination it is seen that the skin all over the body instead of be- ing soft, and of normal color, is thick, swelled, dry, and scaly. Nowhere, or only to the slightest degree, does it pit on pressure; it lacks the glistening waxy look of cedema due to renal disease. In a very exceptional case reported by Euh- rah, the cfidema was not general, but affected certain parts alone of the body. The desquamation may be furfu- raceous, like that of measles, or it may more closely resemble that of scarlet fever. The hair is apt to be thin and coarse, and in older children may be lacking in parts where it is always found under normal conditions, as in the ax- illae and on the pubes. Even in infants it will be noticed that the eyebrows and eyelashes are very scant, and perhaps al- together lacking. Thick hair has been noticed in some cases, but this is certainly exceptional. The face has a false look of old age, and sometimes has a distinct toad-like aspect. The eyelids are puffy and swelled, leaving but a narrow slit through which the eyes can be seen. The nose is depressed between the eyes, and the alae nasi are thick, thus making it seem still more flat, from the external width of the nostrils. The ears also suf- fer from the same thickening, and stand out from the head. The lower lip, partly due to the lolling tongue, is everted and swelled. The teeth, if there are any, are irregular, ragged, and decayed; the second teeth often do not appear at all, or are much delayed in coming through, and are then, like the first, diseased, and of abnormal shape and size, although there is nothing distinctively character- istic in their form. The abdomen is swelled, and there is often an umbilical hernia, though this is seldom of large size. The back is arched and there may be more or less curvature of the spine. The limbs are short and stunted; so that the thick skin lies in folds on the arms and legs and on the face (forehead) as well. The hands and feet are unde- veloped, pudg3', and look like those of a pachyderm; fingers and toes are immo- bile, with a tendency to stand apart, as a result of the morbid condition of the skin. The nails are short, brittle, often INFANTILE MYXCEDEMA. SYMPTOMS. 585 striated, either longitudinally or ver- tically; they lack the normal glossy ap- pearance. The child is distinctly pale, although there may be some suffusion of the cheeks. The fontanelles remain patent long beyond the normal term. All the muscles of the body are weak; the child cannot support itself, and the overlarge head droops forward, so that the chin may rest on the chest. Goitre, which is common in the endemic form, is only occasionally seen in the sporadic cases, though usually the thyroid gland cannot be palpated. In the supraclav- icular regions large masses of fat are sometimes seen, which with the thick, wrinkled skin may form a sort of collar; so that the head seems to be supported, as artiticially done in high cervical caries, with a Thomas collar. The mental condition of the child is as ill developed as the physical; the patient is apathetic, sits about with apparently no interest in any person, not even recog- nizing his parents or objects aboiit'him. If the child attempts to walk, the move- ments are slow; there is more or less in- eo-ordination, owing to the general paresis of the muscles; but there is no paralysis; the deep reflexes are present but commonly weak. The face is im- mobile, there is dullness of expression and action; the child makes no attempts to walk, talk, read or write, and does not answer questions readily. The child exhibits no desires except, perhaps, for food, and manifests its hun- ger or thirst by inarticulate cries. There is often a distaste for meat, but the ap- petite may be voracious. Constipation is usually present. Abnormal sensations are not common, and there is usually retardation in the sense of pain; head- ache is not complained of. The cretin is usually good tempered and does not cry. The child has to be fed with a spoon and almost altogether with fluid or semifluid food, for the mucous mem- branes from the mouth to the rectum are apt to be swelled; these undergo changes similar to those of the skin. Memory is deficient, and speech is slow, thick, and hoarse. Although idiots, their idiocy is not such as one sees in cerebellar sclerosis: they have no tics, no epileptoid movements; they do not make faces; do not grit their teeth, and do not masturbate. Infants and yoimg children, as in so many other afEections, often suffer from convulsions, but these are in no way pathognomonic. There is no sweating, and no secretion from the sebaceous glands, but there is constant drooling from the wide-open mouth, and there is a secretion of tears. Their temperature is invariably subnor- mal, and they are always auEemic. They suffer from cold and are subject to sores and ulcers, which do not heal readily. The genital organs are also involved, and show signs of lack of development; the testes and ovaries are small and atro- phied. Girls may, however, menstruate, and this profusely, and there is occasion- ally a tendency to severe haemorrhage from the uterus, or in both sexes from the nose and gums. The heart, lungs, liver, spleen, and other abdominal organs do not appear to be involved; the kid- neys act naturally, though the amount of urine passed, and the percentage of urea and uric acid excreted, may be a little less than normal; a trace of albumin and hyaline casts have been noted in some eases, but these are not persistent and point to no radical organic alterations in the kidneys, but the brain, skin, mu- cous membranes and bones are invariably affected, usually all of them in about equal degree, though in many cases the body is apparently more diseased than the brain, at any rate as far as can be 5SG INFANTILE MYXCEDEMA. SYMPTOMS. DIAGNOSIS. judged from a study of the mental facul- ties. Literature of '96-'97-'98. [Combe (Revue M6d. de la Suisse Romande, Anno xvii, Nos. 2 to 6) divides myxcedema in children into three classes, which may be easily recognized by spe- cial grouping of the symptoms noted above : — 1. Congenital myxcedema with com- plete nanism and absolute idiocy. 2. (a) Precocious infantile myxcedema with incomplete nanism and imbecility, the child showing some rays of intelli- gence. (6) Late infantile myxcedema: merely a backward child, neither idiot nor imbecile, but the intelligence merely less developed than in other children of same age. 3. Abortive {"fruste") myxcedema, where there is nanism, swelling of in- teguments, cyanosis, and coldness of limbs, but mobility is preserved, intelli- gence is almost normal, and there is very slight cachexia. The same author says further on: "Whether from a clinical point of view or a pathological one these two diseases (myxcedematous idiocy and congenital myxcedema) ought to be united, the one resembling myxoedematous troubles in the formed subject — myxcedema of the adult; the other representing the same symptoms in the as-yet-undeveloped or- ganism of the child — congenital or in- fantile myxcedema." In this statement we fully concur. He does not draw any real distinction between cretinism and myxcedema, but divides cretins, in respect to their in- telligence, into the following three or- ders, beginning with the lowest order — the pure idiot: — 1. Cretins. 2. Micretins. 3. Cre- tinoid state. 1. The cretin proper is I'homme-plante (Eoesch) ; his sense of smell and taste is but little developed, and the sense of touch is much diminished; such cretins are apt to die young of epilepsy or car- diac weakness, but may live to be 70 or 80 years old. They lead a purely vegetative life. 2. Micretins are on the intellectual level of a chimpanzee, because the ani- mal can do all that a micretin can. He is "I'homme-animal." (Roesch.) 3. The cretinoid state is simply char- acterized by a retardation of intelligence, by a certain difficulty in comprehension, by a heaviness of mind; it corresponds to the abortive type of atrophic myxce- dema. Such classification may be helpful up to a certain point, but the classes cannot be kept rigidly distinct, the border-line between either too being invisible. William Osler.] As in any other disease three orders may be recognized: (1) the very severe, (3) the less severe, and (3) the aborted, so to speak; they should not be sepa- rated, but shall all be classed under one main head and recognized as belonging to one entity. In no one case of cretin- ism shall we find all the possible symp- toms present, and no two cases will ex- actly resemble one another; but from the symptoms present we can. say whether the case is a severe one or not. [If the two classifications are carefully studied it will be seen that there is no essential difference between them; a pa- tient with congenital myxcedema is a cretin; the micretin is described by the condition of precocious infantile myxce- dema, and the cretinoid state is that of abortive, or "fruste," myxcedema. Will- iam Osler.] Differential Diagnosis. — Cretinism must be distinguished from achondro- plasia: i.e., foetal or congenital rickets, idiocy,' and infantilism or dwarfism; also lipomatosis universaliSj and hydrsemic ansemia. [Koplik (N. Y. Med. Jour., vol. Ixvi, No. 10), following the lead of Horsley and Barlow, believes that ''sporadic cre- tinism or infantile or congenital myxce- dema should now also include those con- genital cases fon.ierly reported as con- genital rickets." William Osler and Rupert Norton.] INFAXTILE MYXCEDEMA. DIAGNOSIS. 587 ACHONDEOPLASIA, CHONDEODTSTEO- PHIA FCETALIS, Or FCETAL RICKETS, pre- sents certain similarities to cretinism (Osier, Trans. Congress Amer. Phys. and Surgs., vol. iv, p. 190, '97). Although children suffering from this condition are dwarfs, yet they do not show any myxcedematous change of the skin; the long bones are very short, but the articu- lations are enormous, due to an hyper- trophy of the cartilaginous ends of the bones. Mentally the patients are not de- generates. KiCKETS. — • From ordinary rickets there can be little or no difficulty in dis- tinguishing cretinism; in the former we find no thickening of the skin, which is moist, not dry as in infantile myxoedema. We also have the beading of the ribs, the enlarged epiphyses, and the prominent bosses on the skull, none of which are seen in cretinism. But it is the condi- tion of the skin and facial aspect which make cretinism absolutely characteristic. Idiocy. — Children suffering from idiocy, when not due to disturbance of the thyroid function, do not suffer, as a rule, from retardation of physical growth. Their heads are apt to be smaller, much smaller than those of cre- tins, except in cases of hydrocephaly, and the fontanelles and sutures have usually closed prematurely. Here, again, the lack of any alteration in the skin would be almost enough to distinguish the two diseases at first sight. But from the type known as the Mongol idiot the marks of distinction are not so readily recognized. [The Mongol type of idiot resembles the cretin more closely than any other. Telford Smith, in speaking of this form, says: "Idiots belonging to the so-called Mongol type are those who most nearly resemble the cretin, both in physical aspect and in mental character. In idiots of this type we get the stunted growth, the dull, heavy expression, with open mouth and thick lips; the slow, deliberate movement, and hoarse, gut- tural, and monosyllabic speech; the mental apathy, and lack of spontaneity; the sluggish circulation, and sensitive- ness to cold. A thickened condition of subcutaneous tissue is often found, with dull cutaneous sensibility. The skin is coarse and drj', the hair short and thin. First and second dentition are delayed. As far as palpation enables one to judge, the thyroid gland is subnormal in size. Pseudolipomata I have not found." He has tried the effect of thyroid extract with some benefit, but there is not the same remarkable change as in the cre- tins. I cannot altogether concur with Dr. Telford Smith's statement as to the slow, deliberate movements and mental apathy of Mongolian idiots. It was a form in which Dr. Kerlin, of Elwyn, was particularly interested, and with him I had many opportunities of seeing cases. They rather impressed me as vivacious, often very sprightly and mis- chievous. In no instance was there any condition of the subcutaneous tissues suggestive of myxoedema. William OSLEE.] To distinguish infantilism from cre- tinism is in many instances extremely difficult, and there is much confusion in the papers on this subject. literature of '96-'97-'98. [Brissaud (Nouvelle Icon, de la Sal- pgtriere, Anno x, No. 4, pp. 240-262) believes that infantilism is nothing more nor less than myxcedematous idiocy, and that the differences in degree of in- fantilism result from two conditions di- versely associated: (1) the intensity of the atrophic thyroid lesion; (2) the age at which the suppression of the thyroid function produced arrest of development. He says "many cases of infantilism should better be called cases of 'anangio- plasia'; they have nothing to do with disturbances of the thyroid. Such are the cases first described by Lorain; they are not cases of arrest of development, but rather arrest of growth as a partial result of premature epiphyseal ossifica- 588 INFANTILE MYXCEDEMA. ETIOLOGY. tion; there is nothing infantile about them, except the figure; these are cases of small adults." Or in other words in- fantilism is a "morphological syndrome characterized by the preservation in the adult of the exterior form of infancy with the non-appearance of the secondary sexual characters" (Osier, Trans. Con- gress Amer. Phys. and Surgs., vol. iv, '97). There are many cases reported (Wunderlich, Brit. Med. Jour., ii, 1420, '97; Dukes, Brit. Med. Jour., i, 618, '98; and others) where the symptoms of cre- tinism or myxoedema are almost alto- gether lacking, and where the evidences of infantilism exist, but which improve markedly under thyroid treatment, thus showing that they should be classed as cases of cretinism, and not infantilism. It is such cases as these which have led to the confusion on the subject; but in future the differential diagnosis will be made readily if in no other way than by the effects of thyroid treatment; for undoubtedly a condition of infantilism does exist, non-dependent on the condi- tion of the thyroid gland. William OSLEK.] Lipomatosis universalis is a form of partial idiocy, with enormous fat accu- mulation; growth is not stunted, and the condition of the skin is quite dif- ferent from that of cretinism. In hydrsemic anaemia there is a swelled condition of the eyelids, face, and lips; sometimes of the extremities ; but rarely of other parts of the body. The tempera- ture is normal; the bony system is per- fect; there is no macroglossia, no altera- tion in hair or skin, no oblitei'ation of bridge or nose; no mental defect. Kop- lik (N. Y. Med. Jour., vol. Ixvi, No. 10). Etiology. — All forms of cretinism de- pend on absence or atrophy of the thy- roid gland^ or upon some disturbances of its function. But we are as yet in igno- rance as to those causes which produce atrophy, or as to what the exact func- tions of the gland are. Xon-existence of the gland as a congenital affection has been demonstrated in a few cases of cre- tinism. Sporadic cretinism may occur, as far as we yet know, in any land; cases have been reported all over Europe and in this country. Literature of '96-'97-'98. Clinical summary of 60 eases observed in the United States by various au- thors: — Sex: Males, 24; females, 36. Age: Under two years, 6; from two to five years, 12; five to ten years, 12; ten to fifteen years, 10; fifteen to twenty years, 7; twenty to thirty, 3; thirty to forty, 4; over forty years, 4. Nationality: American, white, 12; col- ored, 1 ; Polish, 2 ; French, 1 ; German , 5; Swede, 1; Hebrew, 1; Norwegian, 1; Irish, 7; English, I; Swiss, 2; Bohe- mian, 1; nationality not given, 23. Locality: There is no region in the country in which the disease is endemic, nor does it appear to be more prevalent in those districts, as in Michigan and parts of Ontario, Avhere goitre is com- mon. Condition of the thyroid gland: Goitre was present in 7; gland stated to be normal in 12; gland small in 2; gland not to be felt in 16; no note in 20. William Osier. (Amer. Jour. Med. Sci., Oct., '97). Thp endemic form probably occurs only in mountainous regions, and usually in the valleys between the mountains; it is endemic in parts of Switzerland, Italy, France, India, South America, Central America, and Mexico. In the United States and Canada this form is unknown, and it is never seen in low- lying countries or on the sea-coast. Goitre is prevalent where endemic cre- tinism occurs, and the two affections bear a definite, though unknown, relation to each other. Baillarger says: "Endemic cretinism never exists without endemic goitre." In localities where goitre among human beings exists, it is also found to be prevalent among animals, especially among miiles, but also among dogs and goats. INFANTILE MYXCEDEMA. ETIOLOGY. 589 Literature of '96-'97-'98. [The idea has long existed that the drinfiing-water in these mountainous re- gions was the cause of both goitre and endemic cretinism, and that they were due to either chemical or physical prop- erties of the water, but Combe (Revue Mgd. de la Suisse Komande, Anno xvii, Xos. 2 to 6) thinks that experiments have proved that the maladies cannot be attributed to either of these proper- ties, but that the cause is a living micro- organism. He says that "goitre, and consequently cretinism, is an infectious disease, caused by a microbe, and that the microbe produces an hypertrophy of the thyroid, as others produce an hy- pertrophy of the spleen, kidneys, etc." He thinks that it is not always due to the drinking-water, but that the microbe may be "air-borne." Virchow also thinks air a possible means of infection. He and Kabuteau believe that goitre is the result of the feeble action of a, noxious principle, and cretinism that of a strong and prolonged action. Bouchardat and Bircher think that goitre is the first stage of cretinism. Air-infection might account for the epi- demic which occurred in Somersetshire, England, in 1847; no cases are to be found there now. Combe gives an in- teresting account of an epidemic of goitre which occurred in Lausanne; and his study of these cases leads him to be- lieve that not only is air an important factor in the causation of the disease, but that the aflfection is also contagious. Mendel (Deutsche med. Woeh., p. 101, '95) suggests that the function of the thyroid is to secrete a substance which, when present, prevents the formation of or neutralizes, if formed, certain toxic substances. If the thyroid material be wanting, these hypothetical toxins ac- cumulate and excite the symptoms al- ready named. Paterson (Lancet, ii, 849, '97) expresses his views in the following manner: "The first theory is that the gland secretes some substance which is essential to the healthy and harmonious working of the central and peripheral nervous systemi?. By the want of this substance the nerv- ous mechanism is deprived of a some- thing which regulates the formation and deposition of mucin products, so essential a feature of both ^diseases (sporadic cre- tinism and myxoedema), the mucin be- ing thus deposited in the superficial and finer meshes of the corium, impairing motility and impeding nervous influ- ences, afferent as well as efi'erent. The second theory is that the thyroid gland excretes from the blood some materials formed in the body-metabolism, which by tlieir retention cause a form of tox- semia, affecting principally the cerebral centres and the nervous mechanism con- cerned in mucin metabolism.'' Combe (Revue M^d. de la Suisse Romande, Anno xvii, Nos. 2 to 6) sets forth a new view. He says: "Not alone the material antitoxins, but also the toxins, pass through the placenta. The child, as a result, would run a risk of being continually intoxicated, not only by its own toxins, but by those of its mother, if he did not possess a powerful anti- toxic gland. "^^Tiat is the object of the thymus if not to accomplish this im- portant task? The thymus is a powerful antitoxic gland, and a .gland antitoxic for albuminoid toxins, like the thyroid, since cases of myxoedema have been treated and cured with the thymus given in sandwich. Now, the cretin, whether he has a goitre or an atrophied thyroid, is born with a non-atrophic thymus. It is thus the active principle of the thymus which supplies the absent thyroid antitoxin, but as the thymus atrophies, as its active principle dimin- ishes, poisoning manifests itself, and as a consequence cretinism develops. If the child is born a cretin it is probable that atrophy attacked the thymus as well as the thja'oid: a fact which it is necessary to verify. This hypothesis is all the more probable, as Marie observed a case of congenital myxcedema in which the thymus was hypertrophied." From this he concludes that "the thyroid is an antitoxic gland whose function is to de- stroy, or modify, either by rendering innocuous or useful, some toxic sub- stances resulting from the digestion of certain albuminoid bodies.'' Moussu (Comptes-Rendus Hebdom. des Stances de la Soc. de Biologie, 2. S., 590 INFANTILE MYXOEDEMA. ETIOLOGY. vol. iv, No. 2, '97) and Brissaud (La Presse M6d., vol. i, No. 1, '98), on tlie other hand, do not believe that all the conditions seen in cretinism are due to the thyroid alone, but are also largely dependent on the parathyroid glands. Moussu draws deductions from experi- mental evidences, which, he believes, prove that the two glands have two distinct functions — the suppression of the thyroid causing only chronic disturb- ances, that of the parathyroid provoking acute accidents; that death almost al- ways follows extirpation of the latter, '\\hile disease alone is the result of ex- tirpation of the thyroid. The parathy- roids hypertrophy after removal of the thyroid. Brissaud from clinical evidence alone draws similar inference with regard to the difference of function of the two glands. He says "without doubt neither the structure nor the functions are the same, but it appears evident that very early in life they may replace each other ("qu'elles se confondent a I'origine") ; and if, at a given moment, they are specialized so as to fill two absolutely- different roles, and possibly antagonistic ones, the simplest may, in a measure, take the place of the more complex and highly developed; in short, to take up both rOles, should it so happen. The human thyroid gland, if this is the case, would represent a perfected parathyroid with delicate epithelium ("perfectionnde a (pithcUvm fragile"), but still preserv- ing among its new elements the old parathyroid epithelium, more worn ("fruste"), more resistant, and more durable. . . In any ease, however, it seems to me incontestable that the thyroid myxoedema, to speak accurately, is that form Avhich is not complicated by intellectual apathy, and that para- thyroid myxtEdemais that form which, resulting from a total alteration of the glandular structure, expresses itself not only by the characteristic infiltration, but by the arrest of development in the cretinoid idiot, or by the brutishness of cachexia strumipriva." Magnus Levy (Verhandlungen des Congresses f. innere iled., Wiesbaden, '07) believes that cretinism in all its various forms depends on a perverted function of the thyroid, whether that be an increased or a lessened one. In four cases which he studied he found a dim- inution in the consumption of oxygen and formation of carbon dioxide, whereas in Graves's disease it has been more than once proved that there is a marked increase in the consumption of oxygen and the formation of carbon dioxide. Bircher (Trans. Congress Amer. Phys. and Surgs., vol. iv, p. 203, '97) stands alone with his theory of the non-de- pendence of cretinism on the thyroid gland, but the accumulating evidence is so strongly opposed to such an idea that his proppsition demands more confirma- tory evidence than he has brought for- ward to substantiate it. Such are a few of the theories which have been suggested to explain the con- ditions found in cretinism, but, except for the microbie theory of Combe, they do not explain the ultimate cause of the atrophy or degeneration of the gland. WiLLTAM OSLER and RUPEBT NORTON.] In this disease as in all obscure ones we find numerous causes given as pos- sible factors, but none of them seem to play an important part; alcohol, syphilis, and tuberculosis have been considered in this relation, but no definite connection can be traced between them and cretin- ism. It has been suggested that cretin- ism may follow "alcoholic conceptions." Various nervous diseases in the families of both father and mother, or in the parents themselves, have been looked to as producing the cretinoid state, but no proof can be shown to confirm this theory. Cretinism may, however, follow as a very rare result some of the infec- tious fevers; for example, typhoid, scar- let fever, pneumonia, and whooping- cough; also an injury. Myxoedema in adults has followed erysipelas and acute rheumatism. Women who have once given birth to a cretin are likely to give birth to more if they become pregnant but this may be prevented in some in- stances by placing the mother under thy- INFANTILE MYXCEDEMA. ETIOLOGY. 591 roid treatment during her pregnancy. And, again, women who have lived in healthy countries and given birth to healthy children may give birth to cre- tins if they remove to a place where cre- tin.ism is endemic; bnt may, again, give birth to healthy children, if they return to a healthy locality. [It has been suggested that as cre- tinism is more common in the female sex than in the male, that the thyroidal con- gestions caused by menstruation, preg- nancy, and lactation may play a part in bringing about degenerative altera- tions of the gland. Cretinism does oc- cur among the negroes of the United States, but is rare. "In cretins 25 per cent, have no thyroid gland, or it is re- placed by connective tissue; in the re- maining 75 per cent, the function is suppressed as a result of degeneracy of the gland, and in these cases, according to Kocher, there is oftenest a colloid goitre" (Combe, Eevue M6d. de la Suisse Eomande, Anno xvii, Nos. 2 to 6). Goitre is more common in females than in males, and cretinism, with or without goitre, is more common in females. Griesinger has pointed out that, where cretinism is endemic, besides cretins, mieretins, and the goitrous, one finds also a quantity of imbeciles, deaf-mutes, stut- terers, dwarfs, and degenerates. The French Commission came to the conclu- sion that goitrous parents engender cre- tins in a much larger proportion com- parativelj' than non-goitrous parents. WiLIJAM OsLER and Etjpekt Norto.n.] literature of '96-'97-'98. Sound and strong parents who have lived far from regions in which cretinism is endemic and had there begotten nor- mal children, after moving into a dis- trict of cretinism have begotten one or more cretins. In some of these cases the parents, either father, mother, or both, became victims of goitre, but with- out a trace of cretinism. Moreover, after such parents have returned to their former place of residence, they again begot healthy children. In some cases normal children were begotten in the cretin districts by parents to whom cretins Mere also born. The same influences which lead to goitre are a cause of cretinism. When- ever goitre or cretinism appears in chil- dren, one or the other of the parents will be found to have goitre. The discom- forts caused by goitre, no matter how intense they may be, never lead directly to cretinism, not even in the slightest degree, but cretinism arises only and solely, when, by degeneration of the thy- roid gland through goitre, or equally well by means of some other injury of the gland, its function is destroyed or seri- ously impaired. Inherited and, at the same time, congenital cretinism is de- rived from the mother alone; while in- herited cretinism, which appears only after a lapse of months, or years, is de- rived from the father alone. Inherited and congenital cretinism is an exception. The so-called inherited cretinism, as a, rule, is congenital ; that is, acquired during foetal life. The injury of the thy- roid gland and the pathologico-anatom- ical substratum are the same as in cre- tinism, which develops later. But the injurious material is absorbed by the mother from without, and by her is transferred to the thyroid gland of the fcetus. The overruling factor, then, is always the influence of the land upon which the mother lives. So long as the child is in embryo, its tissues, the pro- vision and nourishment, as well as the disposal of waste-products, are cared for through the maternal blood. If, there- fore, the thyroid gland of the child does not develop, or becomes atrophied through disease, the gland of the mother acts perfectly, both for herself and the child; so that the body of the child, at the moment of birth, will not show anv more cretinic degeneration than that of the mother herself. If the latter have only a goitre in a thyroid gland in a, normal portion of which the functions are still satisfactory, the child, at birth, will be plump and well-shaped. It is only when the child, independently of the mother, begins to nourish its own nervous system and with it the thyroid gland, that, as in acquired cretinism, the disturbance begins gradually to appear. 592 INFANTILE MYXCEDEMA. PATHOLOGY. Koeher (Paris Correspondent Boston Med. and Surg. Jour., June 24, '97). There is still one point to be con- sidered with regard to the etiology of this disease, and that is the part played by "iodothyrin," or "thyro-iodine," as it was first known. In 1895 Baumann (Hoppe- Seyler, Zeitschrift f. physiol. Chemie, '95) demonstrated the existence of free iodine in the normal thyroid gland. It exists there in very minute amount, and there is less in the glands of children than in adults, and less in diseased glands (goitres) than in healthy ones. He later extracted the body "iodothy- rin," which he believes to be the active principle of the gland; but it is doubtful whether this is the pure active principle; and, even were the cretinoid condition due to lack of formation of iodothyrin in the human body, we would still be in ig- norance as to the primary cause of dis- ease of the gland. Therapeutic use of iodothyrin has shown that both cases of myxcEdema and parenchymatous goitres do improve under its administration; and that in sufficient doses it will pre- vent the development of the well-known symptoms, which occur in dogs, from which the thyroid gland has been experi- mentally removed. Pathology. — Whether all the patho- logical findings in sporadic and endemic cretinism are identical is a question still sub judice, but the later studies seem to show that there is no essential difference between them, and that the earlier- drawn distinctions are not sufficient to separate them. Virchow was the first to state that the brachycephalic skull was typical of the endemic cretin, and was due to a premature S3fnthesis of the os basilare, and the sphenoid, posticus, and anticus. This produces flattening of the bones at the root of the nose, and gives the peculiar expression to the cretin. His deductions were drawn from a single case, and it has since been shown that the brachycephalic type of head is not characteristic, but that the skull may be flattened, round, or pointed (platy-, tropho-, or oxy- cephalic). It thus ap- pears that no type of skull is typical of cretinism. Another distinction has been made be- tween endemic and sporadic cretinism, and that is that in the former the fon- tanelles close early, in the latter may re- main open for a long time; but the sig- nificance of this difference is not yet ap- preciated or understood. The most in- teresting abnormal conditions seen in this disease pertain to the thyroid gland, the long bones, and the skin. Literature of '96-'97-'98. [The changes occurring in the thyroid have been most carefully and thoroughly studied by de Coulon (Virehow's Arehiv, '97) and Barker (Trans. Congress Amer. Phys. and Surgs., vol. iv, pp. 196-199, '97), and their findings correspond in all essentials. The alterations found may be summarized as follows: "That, in ad- dition to the evidence afforded by the size of the gland and the marked in- crease of connective tissue in it, the cellular and nuclear changes are atro- phic and degenerative in nature, there can be but little doubt. The nuclear changes especially are those which are now generally recognized as character- istic of degenerative processes. They correspond in many respects to some of the lesions described by Oertel in human diphtheria, and by Flexner in experi- mental poisoning of animals with diph- theria toxins. Schmaus and Albrecht believe such nuclear appearances to be evidences of degeneration'' (Osier, Trans. Congress Amer. Phys. and Surgs., vol. iv, p. 190, '97).] It appears that goitrous manifesta- tions are far commoner in endemic than in sporadic cretinism, but goitre has been noted in several instances of the latter IXFAXTILE MYXCEDEMA. PATHOLOGY. 593 type of disease, and in all probability the presence or absence of goitre cannot be considered as a radical difference in the two affections. Cretinism has a decided relation to goitre in this sense, — that the same fac- tors that produce goitre produce cre- tinism. Cretinism may be present, how- ever, in persons who not only have no goitre, but in whom all traces of a thy- roid gland are absent. It appears, then, that cretinism bears a close relation to the abolition of function of the thyroid gland. The causes of endemic cretinism must be the same as those of endemic goitre. It is probable that this is infec- tious in nature and dependent upon some factor contained in the drinking- water. Theodore Kocher (Deut. Zejt. f. Chir., B. 34, '92). Literature of '96-'97-'98. [Hofmeister (Fortschritte ruf dem Gebiete der Eoentgen-strahlen, B. 1, H. 1, '97), studying a ease of cretinism with the Roentgen rays, shows that the altera- tions in the long bones in this condi- tion are identical with those alterations produced in animals where the thyroid has been removed; such changes have been noted by him in guinea-pigs, and by Eiselsberg's experimenting with sheep, goats, and pigs. They both found that, if the thyroid be removed early, the bones grow slowly in length, and the epiphysial plates remain present for a long while. Hofmeister calls the result- ing condition, after Kaufmann, "chon- drodystrophia thyreopriva." In this condition the epiphyses remain carti- laginous long beyond the normal term. The rays show that, although the bones are otherwise normal in form, they are very small, and what appears most evi- dent is lack of bony ends. In all the long bones only the diaphysis is to be seen — the epiphysis is either not present or there are only a few small nuclei of bone to be made out. The patellse, al- though they could be felt, were not seen with the rays. In concluding his paper he states that "between sporadic and endemic cretinism no absolute dif- ferences exist which in an individual case make a differential diagnosis pos- sible." Dolega (Verhandlungen des Congresses f. innere Med., Wiesbaden, '97) speaks of the autopsy of a cretin, aged 28 years, whose skeleton throughout showed the embryonal cartilaginous epiphysis and synchondrosis. Microscopical examina- tion of the bones showed conditions which resembled foetal rickets, but did not appear identical. Langhans (Virchow's Archiv, B. 149, H. 1, '97) in an interesting paper, says: "Up to the present time no premature ossification of cartilage has been demon- strated in any cretin. The bones first represented by cartilage grow very slowly in length, and the epiphyses remain fiat, ossification precedes very slowly, the centres of ossification in the epiphysis appear very late, and the epiphysial plates remain a long time over the normal period. Remains of these even up to 45 years of age may still be demon- strated. . . . Periosteal growth is not markedly disturbed. . . . An abnor- mal thickness of the bones, such as Klebs describes, I have not been able to confirm. William Oslee.] In cretinism all autopsies agree in certain changes occurring in the histo- logical development of bone quite dis- tinct from changes occurring in rachitis, syphilis, or osteomalacia. In the long bones the typical and almost geometrical arrangement of the rows of cells, always found where hyaline cartilage is ossify- ing, becomes completely disordered. The rows of cells become irregular, the cap- sules swell up, and many of the cartilage- cells within shrink or disappear. The ground-substance itself may become liquefied in places, and all ossification which arises normally in such cartilage is checked, and growth in a longitudinal direction stops. The most marked change is at the junction of the epiphyses and shaft. In some of the autopsies fibrous connective tissue seems to appear around the epiphyses, forming soft, white de- posits. Ossification of bone from mem- brane, and especially from the perios- teum, is exaggerated, and the bonea may become abnormally thick. William 594 INFANTILE MYXCEDEMA. PATHOLOGY. B. Noyes (N. Y. Med. Jour.,, Mar. 14, '96). As a result of the above-mentioned facts it is now shown to be impossible to separate cretinism from operative cachexia thyreopriva, as Bircher has done. Therefore we may conclude from our present knowledge that they are identical and that the former is, as Kocher first sharply and clearly stated, very probably caused by a lessened func- tion of the thyroid during the foetal period as a result of toxic influences, either by becoming atrophic or entirely degenerating, or possibly by the forma- tion of non-functioning struma-islets {"Struinahnoten") and the remaining portions of the gland being caused to disappear by pressure. . . . We should consider the development of the cretin in the following light: That cre- tins in foetal condition develop normally, that only after birth does the absence of the normal thyroid make itself felt, and that the first signs of cretinism appear at the fourth or fifth month after birth, and in the course of the next years of in- fancy make themselves more and more evident." From the examination of three speci- mens of thyroid gland from adult cre- tins, nothing especially abnormal is found in gross appearances of texture. Microscopically, is noticed a deficiency of gland-tissue and excess of connective tissue, and adventitia of the arteries thickened. In one of the less altered glands there were small foci filled with leucocytes. The most perfect alveoli are small and have only a single layer of epithelium; the others show less and less epithelium, some showing none and being filled with leucocytes or colloid masses, or cellular dihris. There was never wanting some gland-tissue capable of performing its function. This lends strong support to the theory of the de- pendence of cretinism upon disordered function of the thyroid. A. Hanan (Brit. Med. and Surg. Jour., Oct. 4, '90). As regards the alterations occurring in the skin, there is no such general agreement. The important question of the deposition of mucin is undeter- mined; the number of cases investigated thus far has been insufficient to settle this point, as the findings have differed. Literature of '96-'97-'98. [Virchow does not consider mucin as a constant and specific product of skin which has undergone myxoedematous changes; and Unna found no mucin in two cases studied by him. A number of studies of the skin in- myxoedema have been reported, but as yet there are none on this tissue in cretinism. Since the two diseases seem to be now recognized as identical, we may accept the altera- tions found in myxcedema as character- istic also of cretinism. Barclay Ness (Glasgow Med. Jour., Aug., '97) describes the condition of the skin in myxoedema, from the study of one case with autopsy, as follows: "The skin from the back of the hand was ex- amined, and it was found that there was an abnormal proliferation of cells in the eorium, especially along the courses of the capillary vessels. With regard to the sudoriparous glands, these were not atrophied, but their epithelium was much swelled, indicating a condition which might possibly have interfered with their function, and thus explained the dry condition of the skin.'' Beck (Monat. f. prakt. Derm., B. 29, No. 12, June 15, '97), in reporting his findings in the skin in a case of myx- oedema, reviews all the work done on this subject, and his paper is the most exhaustive one that has as yet been published. He draws the following con- clusions: "Regressive and progressive changes both play a part alongside each other. The regressive changes were noted in the epidermis and the different tissue-elements of the cutis; the latter were limited to the collagen and the smooth muscle-fibres of the cutis. In the epidermis the regressive changes present themselves as a 'sterile' con- dition, a necrosis and a degeneration of the protoplasm of the epithelial cells; IXFAXTILE MYXCEDEMA. PATHOLOGY. 595 in the cutis these changes are marked by a fibrillation of the collagen bundle and the formation of koUastin. The pro- gressive changes consist of s^n increase in the collagenous tissue in the middle, and a multiplication of the smooth mus- cle-fibres in the middle and lower layers of the cutis. A special place must be reserved for the changes in the fat-tissue, which, as it appears, not only increases in amount, but also undergoes a chemical change of the fat-globules." Langhans (Virchow's Archiv, B. 149, H. 1, '97) found marked fatty degenera- tion of the muscles; it was generally distributed throughout the body, and the fat-globules were everywhere small. He says this condition is very rare and differs from that found, for instance, where it attacks the heart; then the distribution is not so general, and there is variation in the size of the fat-glob- ules. He contends that in cretins this may result from the low temperature and imperfect oxidation; but toxic in- fluences and the ansemic condition may also play a part. In reporting a case of cretinism with autopsy Friend (Med. News, Dec. 4, '97) states that study of the pituitary body, thymus gland, suprarenal capsules, as well as of other tissues throughout the body, merely showed an excess of fibroid growth in all; and that the marrow was red in all the bones. Ness (Glasgow Med. Jour., Aug., '97) in his case, found extreme thickening of the capsule of the kidneys, with fibroid degeneration of the glomeruli; the latter appeared to have been primarily affected, and the capsule secondarily in places. (Although albuminuria and casts are found in the urine in a small number of cases, yet so far as we know there is no characteristic lesion of the kidneys in these cases, nor does the kidney seem in any manner to be seriously affected.) Eed marrow in the bones (Friend) is unusual. "The marrow instead of being red is yellow (fat-marrow), which ex- plains the ansemic condition of cretinoids. Cnly at the extreme ends of the bones near the cartilage is red marrow found" (Langhans). William Oslee and Ru- PEET NOETON.] There seems to be a general agree- ment among observers that the blood shows a condition of secondary anaemia; but there is considerable variation in the findings. Blood studied in a case of congenital myxoedema treated with thyroid. The diameter of the red corpuscles before the treatment began was 3.13 microns; afterward it was 7.5 microns. At the same time the appearance of nucleated red corpuscles was observed, which dis- appeared under treatment. It would appear as though the persistence of the foetal state of the blood coincided with the tardy development of the body. Lebreton and Vaquez (La France M6d. et Paris M6d., Jan. 18, '95). literature of '96-'9r-'98. [Koplik (N. Y. Med. Jour., vol. Ixvi, No. 10) says: "It is an interesting fact that in this ease, early in the disease, the haemoglobin was greater than later on, though the infant was immediately placed upon thyroids." This would seem to point to the fact that the ansemia of cretinism develops as the disease pro- gresses, and is not present at the initial stage of the disease. Vaquez (Le ProgrSs M6d., Mar. 20, '97) found "merely a condition of an- semia, with presence of nucleated red cells; there appeared to be augmenta- tion of the globular diameter" (first noted by Kroepelin) ; he did not find any leucocytosis, but there was an in- crease of the large mononuclears rela- tively to the number of polynuclears, after treatment with thyroid. PoUaci (La Eeforma Med., vol. ix, Oct., '97), who has studied the blood in cretinism more carefully than any other observer, draws the following con- clusions: 1. The blood of these two myxoedematous cretins presented the physio-histological characteristics of a common simple secondary anaemia; in different degree a single characteristic distinguished this oligsemic condition from similar conditions of oligsemia met with in other diseases — that was the presence of megalocytes. 2. Digestive leucocytosis had no special character- 596 INFANTILE MYXQEDEMA. PROGNOSIS. TREATMENT. istics which distinguished it from ali- mentary leucoeytosis studied in other diseases. Foerster (Deut. med. Woch., Nos. 12, 13, 16, '97) does not mention the pres- ence of megalocytes, but says that "there is generally a slight diminution of the reds, with deficiency of haemoglobin; as regards the whites they may or may not be increased, probably generally not. With reference to the different forms of white cells, there are not sufficient studies to express any definite opinion, as the findings have varied." William OsLEE and Rupekt Norton.] On other pathological conditions ex- isting in cretinism not enough is known to report definitely, but a few of them, may be mentioned. Curvature of the spine occurs in some cases, though not in any large percentage. Some observers have noted hypertrophy of the pituitary body after thyroidectomy on animals; but nothing can be stated as to the mean- ing or importance of this fact. Excess of cement in the heart, which was first described by Ord, was not found by ISTess (Glasgow Med. Jour., Aug., '97) in his case. literature of '96-'97-'98. [Langhans (Virchow's Archiv, B. 149, H. 1, '97) found" exactly the same con- dition of the ovaries as Hofmeister did in his experiments with guinea-pigs: i.e., a marked degeneration as shown by the presence of numerous small cysts. The testicles, according to this author, were neither macro- nor micro- scopically normal; they were small and contained but few spermatozoa. Maflfeo, Niepoe, and Stahl have described this same atrophic condition of the testicles. The "muscle-spindles" have been most ex- haustively studied by Langhans (Vir- chow's Archiv, B. 149, H. 1, '97), but, as he says, they have been previously so little studied that the changes he found in them in cretins cannot be definitely stated to be characteristic; yet the alterations in them from the normal were so marked that he believes they are one of the stigmata of this dis- ease; the changes seem to consist of an exfoliation of the lamellae of the spindle, with a deposition of mucinoid granules in the spindles, and an increase of con- nective tissue running through them. William Osler and Rupert Norton.] Of other pathological conditions found in cretinism we know little or nothing. Prognosis. — This has entirely changed since the introduction of the thyroid treatment; previous to this discovery little could be done to improve the cre- tinoid condition. To-day the outlook for cretins, more especially the sporadic cases, is bright; as regards the endemic cretins we cannot entertain such a hope- ful view, though the chances of their improvement are much greater than they were. Cretinism is never of itself a fatal disease. Treatment. — The use of the thyroid gland in one form or another has revolu- tionized the treatment of cretinism. Be- fore this discovery we could do but little to improve the condition of patients suf- fering from this disease; pilocarpine seemed to be of some service through its action as a sudorific, and a mild winter climate also helped in slight degree to keep the patients from going down hill as fast as they otherwise might. In the thyroid gland there seems to have been fotind a specific, and no other remedy appears necessary with which to treat the disease. The remedy, though a specific, is not all-powerful, since the permanency of its action depends on its constant use. Even with its use we can- not promise a cure in any given case, for unless treatment be continued indefi- nitely a relapse will surely occur. The treatment seems to be of more avail in sporadic than in endemic cretinism; but this is not an established fact, and it seems probable that if treatment is begun as early as possible in cases of INFANTILE MYXCEDEMA. TREATMENT. 597 endemic cretinism we may hope for the same good resiilts as are seeu in children with sporadic cretinism. But to attain this mothers with goitre or those who have given birth to cretins or other de- generates should take the thyroid treat- ment during pregnancy. One satisfac- tory result of treatment is "that one thing appears to be proved by our obser- vations, which corresponds to the findings of other observers, and which is not only theoretically interesting and practically important, but also consoling for the pa- tient, and that is that under no condi- tions will the disease (which has been treated with thyroid, and then treatment stopped) develop again in its primary in- tensity." (Poerster, Deut. med. Woch., Nos. 12, 13, and 16, '97.) The later in life the condition of cre- tinism develops, the greater is the prob- ability of almost perfect mental recovery under treatment, since mental degener- acy is uever so prominent in adults as in children; the adult does not become an idiot as the child does from cretin- ism; whereas if the condition has de- veloped early in life and been left un- treated, the chance of normal mental development is seriously diminished. In both instances the return to a normal physical state is almost certain, as the body-symptoms react sooner to treat- ment, and they are the first to recur if treatment is interrupted. The increase in height and the im- provement in the condition of the skin under thyroid treatment are the two features which make the prognosis so favorable. Children show a most as- tonishing rapidity of growth during the first months or a year of treatment — a gain of eight inches in a year has been seen and in a number of cases the in- crease was an inch or more a month for several consecutive months. After hav- ing thus attained a nearly normal stat- ure, growth proceeds gradually, as in healthy children. Literature of '96-'97-'98. Case of a child who presented a typ- ically cretinoid appearance when first seen in February, 1896, then 5 years old. Mentally deficient. Given one 5-grain tabloid of thyroid extract (Burroughs, Wellcome & Co.) daily, which raised the temperature to 102° F.; dose reduced to one-half. Gradual improvement. Weight fell at first to twenty pounds, and then slowly increased, the cretinoid aspect disappeared, and the intelligence steadily improved. Continued to take smaller quantities of the extract, and has de- .veloped into a, healthy child, weighing thirty-seven pounds, and measuring thirty-seven and one-half inches in height. No thyroid gland could be de- tected on palpation. W. Carr (Brit. Med. Jour., Nov. 13, '97). Probably cretins never develop phys- ically so as to become the equals of nor- mal children of their own age, but they are no longer dwarfs. This development of stature is the single permanent gain of treatment, since there is relapse of all the other features of cretinism if treat- ment is not persisted in. The change of the myxoedematous state of the skin is as remarkable as that of growth; the wrinkles disappear, also the oedema, and from being harsh, dry, and scaly, it be- comes soft, moist, and smooth. The hair also shows great improvement, it grows normally where it had been lacking be- fore, and becomes fine and thick, sup- planting the coarse, thin hair character- istic of cretinism. It is the brain, however, which, as the more delicate organ, suffers most in this condition; it responds more slowly than the body to the effects of treatment, and seldom if ever recovers a normal tone. Children who have suffered from cretin- ism are not so intelligent, as a rule, 598 INFANTILE MYXCEDEMA. TREATMENT. as other healthy children. As Koplik (jST. Y. Med. Jour., vol. Ixvi, No. 10) says: "Though the thyroid treatment rescues these unfortunates from a state of per- petual idiocy, it does not restore fully the psychical state, which has become dwarfed for a greater or less period be- fore the therapy was initiated. Though bright, the children are not the equals of children of normal condition of their own age, but are very slow in appropri- ating ideas and in perfecting their speech-vocabulary." However, there are exceptions to this rule, and where the degree of cretinism is not marked, where the body seems to be more affected than the brain, children may be quite as in- telligent and bright as those unaffected. There are a few cases reported where, though the physical symptoms were very much ameliorated, yet there was almost no improvement in the mental condition. [Such cases have been reported by d'Andrea and Pieraeeini. It is probable that in such instances there is a bad neurotic family history, or that the children themselves, before the onset of cretinism, have suffered from some neu- rosis (for example, convulsions, epilepsy, etc.). William Osler and Rupert Norton.] Effect of thyroid treatment is: In- creased metabolism, shown by (1) eleva- tion of temperature; (2) increased ap- petite, with more complete absorption of nitrogenous foods; (3) loss of weight, with nitrogen excreted in excess of that taken in the food; (4) growth of skele- ton in the very young; (5) marked im- provements in body-nutrition generally; (G) increased activity of mucous mem- branes, skin, and kidneys. The rheu- matic symptoms and the anaemia are not only not relieved, but are most fre- quently aggravated. G. N. Crary (St. Louis Med. and Surg. Jour., July, '95). Literature of '96-'97-'98. [Increase of ansemia and aggravation of rheumatic symptoms observed in case of goitre complicated with rheumatism in which thyroid tablets were given. The tablets were discontinued and salic- ylates and iron substituted with good effect. C. S. WiTHERSTiNE, Assoc. Ed. Annual, '96.] Without treatment cretins may live to an advanced old age, even to 70 or 80 years, though death is more common be- tween the second and third decade or be- fore 35. They are liable to very slight ailments, and usxially die of some inter- current affection, since cretinism seldom of itself causes death. We know of no difference as regards prognosis whether the child has a goitre, or shows atrophy or absence of the thyroid gland. In some cases even the goitre itself may be cured. Combe (Eevue Med. de la Suisse Eomande, Anno xvii, Nos. 2 to 6) says: "Goitres may be cured by thyroid treat- ment; the younger the patient, the more efficacious is the treatment. Cystic goitres are not amenable, nor old colloid ones where there is mxich new growth of connective tissue, with a colloid de- generation of the vascular walls and in- terstitial tissiie." The remedy is a powerful one, and, where used carelessly, a dangerous one; patients have been killed by injudicious use of the thyroid gland. Literature of '96-'97-'98. [Anders (Jour. Amer. Med. Assoc.,. July 10, '97) says: "There can be no question that the evidences of cardiac disturbance constitute a really serious defect, and perhaps the only one in the thyroid treatment." He goes on to say,, however, that "the relation of mere al- buminuria or actual nephritis to myx- cedema is not definitely known. On the other hand, it should be pointed out that the symptoms of Bright's disease have been observed to appear after the ac- complishment of a cure by thyroid feed- ing, in cases which no urinary phenom- ena had been present during the course of myxedema." This is certainly a very INFANTILE MYXCEDEMA. TREATMENT. 599 rare occurrence and not one to be con- sidered in the use of the drug. Telford Smith (Lancet, vol. ii, 853, '97) has lately drawn attention to one of the disturbances resulting from this treat- ment which should be watched for: "1 have found that during thyroid treat- ment this rapid growth of the skeleton leads to a softened condition of the bones, resulting in a yielding and bend- ing of those which have to bear weight; and as cretins under treatment become much more active and inclined to run about this tendency has to be guarded against. The bending takes place most markedly in the tibia and fibula, the in- creased size of the ends of these bones at the ankle and knee being very notice- able.'' William Osler and Rupebt Norton.] The use of thyroid extract is only per- missible when the patient can be kept constantly under observation, because of the severe and sometimes dangerous symptoms which it produces. Zarubin (Archiv f. Dermat. u. Syph., B. 37, H. 3, '96). Case of cretinism in a girl, 14 years of age, in which the thyroid-gland treat- ment was instituted and followed by a very slow improvement mentally and a much more marked one physically. After undergoing the treatment at ir- regular periods during about nineteen months, her temperature suddenly rose to 104° F., her pulse to 160, and respira- tion became so short and thick that it was only with difficulty they could be counted. At this time she was taking 6 grains of thyroid extract daily. Medica- tion was immediately stopped, but her condition remained the same, with one remission of temperature and pulse-rate, during two days, when, on January 22d, at 1 o'clock in the afternoon, she died. S. H. Friend (Med. News, Dec. 4, '97). Caution must be exerted in the use of thyroid medication, for, while it is all powerful for good in suitable cases, it is not without ill effect in poorly-selected cases or in overdoses. It is best to be- gin with 5-grain doses daily and increase gradually to 15 grains daily in divided doses. A rise of temperature to one de- gree above normal, an increase of the pulse-rate of more than twenty beats per minute, or any gastro-intestinal dis- turbance indicates that the dose is too large and must be reduced. F. A. Dodge (Northwestern Lancet, Oct. 15, '98). Many methods have been suggested and tried for administering the thyroid gland, but the best and only practical one is by the mouth. The gland may be used raw or cooked, or prepared with glycerin as an extract, or in powder, tab- let, or pill form. The surest and safest form is the tablet as prepared by one or other of the large wholesale drug firms (Parke, Davis & Co.; Frazer, Armour, and others). These tablets are not all of equal strength; so that in treating a case it is better to use but one make than to change from one to another. The dose varies from ^/j grain once or twice a day in infants, up to 5 grains t. i. d. in adults, till all symptoms of cretinism have dis- appeared; the drug may then either be omitted entirely for from three to six weeks, when symptoms of cretinism al- most always recur, and treatment must be resumed, or doses of 5 grains every week or ten days may be persistently taken, and thus all evidences of return- ing cretinism be avoided. It is, perhaps, better after the first period of treatment has been successfully carried out to omit all treatment till some of the old symp- toms again appear, and then to note care- fully just how much thyroid is required to extinguish these; in this manner it is easier to estimate just the dose required from time to time to stave away any sign of the disease. In some instances the tablets seem to lose their effect, and it is then well to try those of another make for a time; the first will, if resorted to again later, often- times be found to have the same good effects as when first tried, but the organ- ism seems to get dulled to them, and not 600 INFANTILE MYXCEDEMA. TREATMENT. to respond so quickly after prolonged administration, just as is often seen in the use of digitalis in cardiac disease. The dosage must be regulated by the effects either advantageous or the re- verse; where no bad symptoms are noted the drug may be pushed, but on the slightest evidence of any or some of the conditions to be immediately mentioned the drug should be stopped entirely for awhile, till all its bad constitutional effects have passed off. The remedy may give rise to headache, syncope, and vertigo; to tachycardia, dyspnoea, suffusion of face and profound perspiration; to rise in temperature of two or more degrees (slight rise is a good sign, as the patient's temperature is al- most invariably from one to two degrees subnormal); to nausea, vomiting, gastro- intestinal pains and profuse diarrhoea; to rheumatic pains, tremor, and general weakness; to itching, urticaria, ery- thema, and eczema; to glycosuria or al- buminuria. Many of these effects are doubtless due to contaminations of the active principle of the drug, but at pres- ent these noxious bodies cannot be sep- arated, and therefore extreme care must be taken in the use of the drug. Most of the bad symptoms will pass off when the drug is stopped, and require no further treatment, but if the prostration that may occur is severe, suitable remedies to counteract this condition should be ac- tively employed. [Marie (La Presse Mgd., Oct. 9, '97) notes a curious symptom caused by thyroid treatment, namely: excessive thirst; the thirst was so great that the treatment had to be stopped; on the other hand, however. Briquet (La Presse M6d., Oct. 9, '97) relates a ease where treatment cured the excessive thirst which had existed previously. But such a symptom is anomalous whether before or after treatment, and therefore of but slight significance. William Osler and RUPEKT NOBTON.] (See also Thykoib Extract in Ani- mal Extracts, volume i.) The treatment, as far as we can now see, must be continued on and off through life. William Osler, Baltimore. Rupert Norton, Washington.