HX00080276 'VcyjJ. AmcmmAhlmmms '.r'o Catalepsy ^O ^v Sofi?ctD§orfe Columbia ®nibers!itj> ^ COLLEGE OF PHYSICIANS • AND SURGEONS Reference Library Given by SAJOUS'S Analytical Cyclopaedia OF Practical Medicine BY CHARLES E. de M. SAJOUS M.D. AND ONE HUNDRED ASSOCIATE EDITORS iSSISTED BY CORRESPONDING EDITORS COLLABORATORS AND CORRESPONDENTS Illustrated witb €broino-CitDodrarb$ Engravings ana mm Second Revised Edition ■\70LtJ3xrE: I Philadelphia F. A. DAVIS COMPANY PUBLISHERS 1903 COPYRIGHT, 1902, 1903, BY F. A. DAVIS COMPANY. I Registered at Stationers' Hall. London, Eng.^ Philadelphia. Pa., U.S. A.: The Medical Bulletin Printing-house, 1914-16 Cherry Street. RESPECTFULLY DEDICATED TO THE AMERICAN MEDICAL PROFESSION AS AN expression of devotion. The Editor. Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/sajoussanalytic01sajo PREFACE. When, recently, the first issue of the Monthly Cyclopaedia of Practical Medicine, a journal published in connection with the present work, was placed before the profession, the changes which the Annual had undergone were described. Journals in pamphlet form being seldom preserved, it is deemed advisable to repeat in these pages the main reasons which have led to so im- portant a step. It was to adequately assist the general practitioner that the Annual OF THE Univeesal Medical SCIENCES was started. Just ten years ago the first series of five volumes appeared. What its life-history has been need hardly be told; that over five hundred thousand volumes have been distrib- uted in the United States alone, sufficiently indicates the generous reception accorded it, while the encouragement given the editor, especially by his col- leagues of the medical press, can but be recalled with emotion. The last ten years, however, have been prolific in changes on every side. The intense activity displayed in all departments of medicine, the multiplicity of divisions and subdivisions in medical nomenclature, the ever-increasing value of time and the stringency of available pecuniary resources have greatly modified the circumstances surrounding a physician's existence and his needs. Although the Annual had become a much appreciated work of reference for authors and teachers, the general practitioner, for whom it had been espe- cially created, failed to find in its columns the kind of assistance he required. Often disappointed because every disease, or subdivision of a disease, — pa- thology, treatment, etc., — could not be reviewed each year, owing to the fact that the subjects had not received the attention of writers, he condemned the work in toto, overlooking the origin of the omission. Again, he found the work too voluminous for current reading, — the very mass of progressive work appalled him! A careful analysis of the whole question revealed the underlying cause of trouble, — namely, that articles made up of heterogeneous excerpts fail to excite interest and, as a result, soon fatigue the intellect of the reader. Wlien- ever a new line of thought is introduced, the subject modified by the new point adduced must be recalled and former propositions tending to transform both the older and the newer conceptions of the subject must be simultane- ously considered and, as it were, digested. That the sum of intellectual labor required, if the progressive feature advanced is at all to prove profitable, must be arduous, is evident ; that such labor gradually engenders a disinclination to utilize the kind of literature involving it is a conclusion which deductive reasoning can but sustain. Briefly, the Annual had made for itself a place among writers, teachers, and investigators, but, for the reason given, it had not satisfactorily fulfilled its mission among family physicians, for whose benefit it had been especially planned. Overworked, overburdened, and often poorly paid, general practitioners, especially those exercising their calling in country-districts, share but little in the enjoyments of life. Harassed, ever anxious, their moments of respite are but opportunities for Nature, and, in enforcing her rights, she subdues functional activity to insure recuperation. In her way, therefore, she pre- pares their powers for the morrow and thereby contributes her share to their beneficent labors. But, we have seen, scientific progress also has its claims, and the sufferer is entitled to the resources of medicine, not as they were, but as they are. The duty of the medical editor, therefore, lies between Nature's requirements as regards the physician, and the claims of justice as regards suffering humanity. Both, it was thought, could be subserved by pre- senting even scientific literature in an attractive, entertaining, easily-under- stood form, with professional dignity as a constant guide. These general principles have formed the basis of a modified work, which is now placed before the profession. Instead of presenting the ex- cerpts from the year's literature arranged in order under a general head as before, each disease — including its subdivisions: "Etiology," "Pathology," "Treatment," etc. — is described in extenso, and the new features that the year has brought forth are inserted in their respective places in the text. In this manner the reader is saved all fatiguing study: he has before him what in the older work was left to his memory. The work, when completed, will present all the general diseases described in text-books on practical subjects — medicine, surgery, therapeutics, obstetrics, etc. — and, inserted in their logical order in the text, all the progressive features of value presented during the last decade. This will remove the cause of dissatisfaction caused by the absence of general subjects in the older work. If the year brings forth nothing new upon any particular disease, the latter will, at least, appear as it was when last studied, whether this be one, two, five, or twenty years before. The general arrangement adopted will make it possible to cover the entire field in six volumes. As may be seen in any medical dictionary, the siibjects treated in the first volume represent exactly one-sixth of the whck. While the general practitioner's needs will thus be adequately provided for, authors and teachers will not have to deplore the change. Instead of having at their disposal only the reviews of a single year, as before, they will have those of practical value published during the last ten years. The arti- cle of "Abdominal Injuries," for instance, contains one hundred and sixty article excerpts besides the general text; that on "Appendicitis," a still larger number. Being interpolated in the text and controversially arranged, the abstracts either sustain the views advanced or indicate fields as yet insuffi- ciently explored. This arrangement necessarily precludes chronological order; indeed, no attempt has been made to treat the various subjects historically, the aim being to give them an essentially practical form. So great an amount of matter from diiferent sources would seem to insure a degree of confusion tending greatly to increase the reader's labors. This is avoided by using large type for the general text — that is to say, the description of a disease — and small type for the excerpts from journals. Either may thus be read separately. If, for instance, the reader desires to merely review the general subject, he has but to read the text in large type; if he wishes to analyze or study a disease, operative procedure, drug, etc., in which he is particularly interested, he has but to include the small-type text in his perusal of the article. So complete a rearrangement of the entire text could hardly be success- fully carried into effect unless the editor could take part in the work of preparation. He therefore concluded that it would be best to have the ma- jority of the sections prepared under his immediate supervision and to submit them to the members of the associate staff for revision and correction. Each editor enjoying the privilege of erasing, changing, or adding anything he chose, the correctness of the views presented was thus insured, while the innovations could be satisfactorily carried into effect. How carefully the associate editors have fulfilled their share of the labor can be judged from the character of the several articles bearing their names. The sections which have been prepared in toto by associates are those on "Addison's Disease," "Angina Pectoris," "Astigmatism," "Actinomycosis," "Anthrax," "Acetonuria," "Albuminuria," "Alcohol," "Antipyrine," "Atropine," "Bella- donna," "Blepharitis," and "Bright's Disease." As may be seen, the members of the associate staff have again placed the editor under great obligation, and he wishes to express to them his deep gratitude. Drs. Witherstine and G. Archie Stockwell, of Philadelphia, and Dr. Arthur Turner, of Paris, have in other directions contributed to facilitate the editor's task and have placed him under many obligations. The unsigned articles have not been submitted to associates. The more important ones, such as "Acetanilid," "Animal Extracts," etc., were written by the editor, while the others were prepared under his immediate supervision. The editor also selected the abstracts for all the articles; any error of judg- ment on that score must, therefore, be ascribed to him alone. Only the ex- cerpts thought to convey practical information have been incorporated; but this feature of the work will be given further development. The classification adopted is, to a certain degree, a novel one, general sub- jects alone appearing in the list. In other words, individual symptomatic manifestations, such as asthenopia, aphonia, bradycardia, etc., have not been given separate sections, but have been considered under the diseases of which they form part. This has made it possible to save considerable space, which has been utilized for the elaboration of subjects that are scantily considered in text-books, notwithstanding their great practical importance. "Abdominal Injuries," for instance, so frequent since electric tramways, foot-ball games, and bicycling have come upon the scene, have been given over forty pages, while the various phases of "Alcoholism" — doubtless the greatest scourge of the human race — have been considered in an equally exhaustive manner. As to remedies, only those that are being generally utilized in a manner com- patible with scientific precision and in accordance with professional ethics have been incorporated. The list includes a few new agents which seem to merit further trial. Obsolete remedies have not been mentioned, the aim being to present those which constitute a modern physician's armamentarium. Again, only the diseases in which the remedies mentioned are of special value have been alluded to, along with what new points the recent literature may have afforded. To facilitate the use of the work, the subjects have been arranged in alphabetical order, the references being given in full at the end of each abstract. The index and reference list, which occupied so much room in the older work, could thu"; be dispensed with. The personal commentations contributed during the last ten years by the associate editors have been introduced when applicable, and many illustrious names — some of which recall departed friends, such as D. Hayes Agnew, Ben- jamin Ward Richardson, Dujardin-Beaumetz, J. Lewis Smith, Joseph O'Dwyer, and others — are thus perpetuated in the pages of the work. In the 1896 issue of the Annual the following statement was made: "The hard-worked practitioner is the protector of a correspondingly great number of human lives; to help him, therefore, in acquiring practical knowl- edge is to increase his fighting force, — i.e., to help him in the accomplishment of his duty — a higher one than any other allotted to man." These words can be repeated to-day; they represent the foundation of the new Annual and Analytical CTCLOPiEDiA of Phactical Medicine, which the editor respect- fully dedicates to the American Medical Profession as an expression of pro- found devotion. The Editor. 2043 Walnut Steeet. STAFF OF ASSOCIATE EDITORS. Ciis( Hevistd June 1, W03.) J. GEORGE ADAMI, JM.D., JIONTEEAL, P. Q. LEWIS H. ABLER, JI.D., PHILADELPHIA, PA. JAMES M. ANDERS, M.D., LL.D., PHILADELPHIA, PA. THOMAS G. ASHTOK, M.D., PHILADELPHIA, PA. A. D. BLACIvADER, M.D., MONTREAL, P. Q. E. D. BO^s^DURAXT, M.D., MOBILE, ALA. DAVID BOYAIRD, M.D., ^•EW TOP.K CITY. WILLIAM BROWXIKG, M.D., EEOOBXTJs", X. Y. WILLIAJM T. BULL, M.D., NEW TOBK CITY. CHARLES W. BURR, M.D., PHILADELPHIA, PA. HEXRY T. BYFORD, M.D., CHICAGO, ILL. HENRY W. CATTELL, M.D., PHILADELPHIA, PA. AYILLIAil B. COLEY, M.D., KEW YOP.K CITY. FLOYD M. CRAXDALL, M.D., NEW YORK CITl'. ANDREW F. CURRIER, M.D., NEW YORK CITY. ERNEST W. GUSHING, M.D., BOSTON, MASS. gwily:m g. da^t:s, m.d., PHILADELPHLA, PA. N. S. DA^aS, M.D., CHICAGO, ILL. AUGUSTUS A. ESHNER, M.D., PHILADELPHIA, PA. SIMON FLEXNER, M.D., PHILADELPHIA, PA. LEONARD FREEMAN, M.D., DENVER, COL. S. G. GANT, M.D., NEW YORK CITY. J. McFADDEN GASTON, M.D., ATLANTA, GA. J. McFADDEN GASTON, Jr., M.D., ATLANTA, GA. E. B. GLEASON, M.D., PHILADELPHIA, PA. EGBERT H. GRANDIN, M.D., NEW YORK CITY. J. P. CROZER GRIFFITH, M.D., PHILADELPHIA, PA. C. M. HAY, M.D., PHILADELPHIA, PA. (ix) STAFF OF ASSOCIATE EDITORS. FREDERICIK P. HENEY, M.D., PHILADELPHIA, PA. L. EMMETT HOLT, M.D., NEW TOEK CITY. EDWARD JACKSON, M.D., DENVER, COL. W. W. KEEN, M.D., PHILADELPHIA, PA. EDWARD L. KEYES. Jp.., il.D., NEW TOEK CITY. ELWOOD R. KIRBl^ M.D., PHILADELPHIA, PA. L. E. LA FETRA, j\I.D., NEW Y'OEK CITY. ERNEST LAPLACE, :\I.D., LL.D., PHILADELPHIA, PA. E. LEPINE, M.D., LYONS, FEANCE. F. LEVISON, M.D., COPENHAGEN, DENMAEK. A. LUTAUD, M.D., PARIS, FRANCE. G. FRANK LYDSTON, :M.D., CHICAGO, ILL. F. W. MARLOW, M.D., SYRACUSE, N. Y. SIMON JSIARX, M.D., NEW YORK CITY. ALEXANDER McPHEDRAN, il.D., TORONTO, ONT. E. E. MONTGOMERY, M.D., PHILADELPHIA, PA. HOLGER MYC4IND, JI.D., COPENHAGEN, DENIIAEK. W. p. NORTHRUP, M.D., NEW YORK CITY. RUPERT NORTON, M.D., WASHINGTON, D. C. H. OBERSTEINER, M.D., VIENNA, AUSTEIA. CHARLES A. OLIVER, M.D., PHILADELPHIA, PA. WILLIAM OSLER, M.D., BALTIMORE, MD. LE\ATS S. PILCHER, M.D., BROOKLY'N, N. Y. WILLIAM CAMPBELL POSEY, M.D., PHILADELPHIA, PA. W. B. PRITCHARD, M.D., NEW Y'OEK CITY. JAMES J. PUTNAM, M.D., BOSTON, MASS. B. ALEXANDER RANDALL, M.D., PHILADELPHIA, PA. CLARENCE C. RICE, M.D., NEW YORK CITY'. ALFRED RUBINO, M.D., NAPLES, ITALY'. REGINALD H. SAYRE, M.D., NEW YORK CITY. JACOB E. SCHADLE, M.D., ST. PAUL, MINN. JOHN B. SHOBER, M.D., PHILADELPHIA, PA. J. SOLIS-COHEN, M.D., PHILADELPHIA, PA. SOLOMON SOLIS-COHEN, M.D., PHILADELPHIA, PA. STAFF OF ASSOCIATE EDITORS. H. W. STELWAGON, M.D., PHILADELPHIA, PA. D. D. STEWART, M.D., PHILADELPHIA, PA. LE\\'IS A. STIMSON, M.D., NEW YORK CITY. J. EDWARD STUBBERT, M.D., LIBEETY, N. T. A. E. TAYLOR, M.D., SAN FKANCISCO, CAL. J. MADISON TAYLOR, M.D., PHILADELPHIA, PA. M. B. TINKER, M.D., PHILADELPHIA, PA. CHARLES S. TURNBULL, J\I.D., PHILADELPHIA, PA. HERMAN F. VICKERY, JI.D., BOSTON, MASS. F. E. WAXHAM, M.D., DENVER, COL. J. WILLIAM WHITE, M.D., PHILADELPHIA, PA. JAMES C. WILSON, M.D., PHILADELPHIA, PA. C. SUMNER WITHERSTINE, il.D., PHILADELPHIA, PA. ALFRED C. WOOD, M.D., PHILADELPHIA, PA. WALTER WYMAN, M.D., WASHINGTON, D. C. TABLE OF CONTENTS. (Volume I.) PAGE Abdomen, Contusions of 1 Abdomen, Injuries of 1 Abdomen, Wounds of 20 Abdominal Aorta, Aneurism of 329 Abortion 38 Abscess 60 Abscess, Acute 60 Abscess, Cold 65 Abscess, Tuberculous 65 Absinthium 67 Absinthium Poisoning 68 Acetanilid 68 Acetanilid Poisoning 70 Acetic Acid 74 Acetic- Acid Poisoning 75 Acetone, Excretion of 76 Acetone, Tests for 81 Aoetonuria 76 Aceto-ortho-toluide 85 Acetj'lene 86 Acetylene Poisoning 86 Acne 87 Acne Rosacea 96 Aconite 102 Aconite Poisoning 103 Aeonitine 107 Aconitine Poisoning 107 Acromegaly 108 Acromegaly, Thyroid Extract in 385 Actinomycosis 121 Actol 131 Addison's Disease 132 Addison's Disease, Suprarenal Extract in . 398 Adenitis 147 Adonis 160 Adonis Poisoning 161 Agalactia 161 Agaricin 164 Agraphia 435 Ainhum 165 Airol 166 Airol Poisoning 166 Alalia 434 PAQB Albumin, Tests for 178 Albuminuria 168 Alcohol 183 Alcohol Poisoning 185 Alcoholic Neuritis 193 Alcoholic Paralysis 193 Alcoholism 196 Alexia 437 Alkaloids 229 Aloes 231 Aloin 232 Alopecia 233 Alopecia Areata 240 Alum 249 Aluminium 250 Alumnol 251 Amenorrhoea 253 Amimia 435 Ammonia 260 Ammonia Poisoning 261 Ammonium 262 Ammonium-Chloride Poisoning 264 Amj'lene 267 Amylene-hydrate 268 Amylene-hydrate Poisoning 269 Amyliform 271 Amyl-valerianate 272 Ansemia 272 Anaemia, Bone-marrow in 409 Ansemia, Pernicious 279 Antemia, Pernicious, Bone-marrow in ... . 409 Analgen 294 Anesin 295 Aneurism 296 Angina Pectoris 342 Anhaloniura Lewinii 352 Animal Extracts 354 Anorexia Nervosa 416 Anthrax 419 Antipyrine 423 Antipyrine Poisoning 426 Aortic Aneurism 318 Aphasia 434 (xiii) TABLE OF CONTENTS. PAGE Aphemia 434 Aphrosia 434 Apiol 448 Apooynum Cannabinum 449 Apomorphine 451 Apomorpliine Poisoning 452 Appendicitis 455 Appendicitis: Relapsing Form 492 Apraxia 437 Argonin 495 Aristol 496 Arrested Growth, Thyroid Extract in ... . 363 Arsenic 501 Arsenic Poisoning 506 Arterio-venous Aneurism 339 Asthma 512 Astigmatism 526 Athetosis 532 Atropine 536 Atropine Poisoning 540 Auditory Blindness 435 Axillary Aneurism 328 Barium 547 Belladonna 548 Belladonna Poisoning 549 Benzoic Acid 556 Benzoin 558 Beriberi 559 Bismuth 571 Bismuth Poisoning 573 Blepharadenitis 576 Blepharitis 576 Bone-marrow 407 Boracic Acid 580 Borax 584 Boroformate 250 Borotannate 251 Borotartrate 251 Brachial Aneurism 329 Breast-pang 342 Brain Extract 415 Bright's Disease 586 Bromide of Ethyl 622 Bromides, Poisoning by 630 Bromine and Its Derivatives 622 Bromism 631 Bronchiectasis 633 Bronchitis 640 Buckthorn (Cascara) 654 Burns 654 Cajuput-oil 669 Calcium 670 PAGE Camphor ' 672 Cancer, Thyroid Extract in 390 Cannabis-Indica Poisoning 679 Cannabis Indica seu Sativa 677 Cantharides 682 Cantharides Poisoning 684 Carotid Aneurism 325 Cascara 654 Catalepsy 688 Chautard's Test for Acetone 82 Chlorosis, Bone-marrow in 409 Cirsoid Aneurism 337 Cold Abscess 65 Contusions of Abdomen 1 Contusions of Intestine 4 Contusions of Stomach 6 Cretinism, Thyroid Extract in 364 Cysts, Retention 576 Delirium Tremens 201 Epilepsy, Thyroid Extract in 375 Exophthalmic Goitre, Splenic Extract in. 404 Exophthalmic Goitre, Thymus Extract in. 392 Exophthalmic Goitre, Thyroid Extract in. 375 Fehr's Test for Acetone 82 Femoral Aneurism 333 Foot-drop (see also Neuritis, Multiple) . . 561 Goitre, Thymus Extract in 391 Goitre, Thyroid Extract in 377 Gunning's Test for Acetone S3 Gunshot Wounds of Abdomen 21, 35 Heller's Test for Albumin 179 Heynsius's Test for Albumin 179 Hindenlang's Test for Albumin 179 Hodgkin's Disease, Bone-marrow in 411 Iliac Aneurism 332 Injuries of Abdomen 1 Insanity, Thyroid Extract in 379 Intestines, Contusions of 4 Johnson's Test for Albumin 179 Keloid, Thyroid Extract in 375 Lactation, Thyroid Extract in 384 Laparotomy (see also Peritonitis; Stom- ach, Surgery of) 29, 481 Le Nobel's Test for Acetone 82 Legal's Test for Acetone 82 TABLE OF CONTENTS. XV PAGE Leprosy, Thyroid Extract in ... , 375 Leulcaemia, Bone-marrow in 410 Lieben's Iodoform Test for Acetone 83 Lungs, Actinomycosis of 124 Lupus, Tliyroid Extract in 374 Macewen's Method in Aneurism 312 Malarial Cachexia, Bone-marrow in 410 Malerba's Test for Acetone 84 Mania a Potu 207 McBurney's Operation 4S2 Mescal Button 352 Middle-Ear Disorders, Thyroid Extract in. 384 Millen's Test for Albumin 179 Muscular Atrophy, Thyroid Extract in . . 385 Myxoedema, Thyroid Extract in 382 Nephritis 586 Nerve Extract 415 Neurasthenia, Suprarenal Extract in ... . 401 Neuritis, Alcoholic 193 Nitroeyanide Test for Acetone 84 Obesity, Tliyroid Extract in 386 Orehitic, or Testicular, Extract 412 Organic Extracts 403 Osseous Deformities, Bone-marrow in. . . . 411 Ovarian Extract 405 Paralysis, Alcoholic 193 Paralysis of Diaphragm (see also Diph- theria, Complications) 5fil Penzoldt's Indigo Test for Acetone 84 Perchloride-of-Mercury Test for Albumin. 179 Pituitary Extract 402 Placenta, Retention of 41 Poikilocytosis (see also Stomacli, Car- cinoma) 284 Poisoning, Absinthium 68 Poisoning, Acetanilid 70 Poisoning, Acetic Acid 75 Poisoning, Acetylene 86 Poisoning, Aconite 103 Poisoning, Aconitine 107 Poisoning, Adonis 161 Poisoning, Airol 166 Poisoning, Alcohol 185 Poisoning, Ammonia 261 Poisoning, Ammonium Chloride 264 Poisoning, Amylene-hydrate 269 Poisoning, Antipyrine 426 Poisoning, Apomorphine 452 Poisoning, Arsenic 506 Poisoning, Atropine 540 ,, . . PAGE Poisoning, Belladonna 549 Poisoning, Bismuth 573 Poisoning, Bromides 630 Poisoning, Cannabis Indica 679 Poisoning, Cantharides 684 Popliteal Aneurism 335 Psoriasis, Thyroid Extract in 373 Quantitative Tests for Albumin 181 Reynold's Test for Acetone 83 Rhinoscleroma 99 Roberts's Test for Albumin 179 Rodent Ulcer (see also Camphor, and Tumors of Eyelids) 76 Splenectomy (see also Spleen) 17 Splenic Extract 403 Stenocardia 342 Stomach, Contusions of 6 Subclavian Aneurism 327 Suprarenal Extract 394 Syphilis, Thyroid E.xtract in 387 Syphilitic Alopecia 240 Tanret's Test for Albumin 179 Testicular Extract 412 Tests for Acetone 81 Tests for Albumin 178 Tetany, Thyroid Extract in 387 Thymus Gland, Extract of 391 Thyroid Gland, Extract of 354 Torticollis, Thyroid Extract in 388 Traumatic Aneurism 336 Tuberculous Abscess 65 Uterine Disorders, Thyroid Extract in. . . 388 Varicose Aneurism 329 Warm Abscess 60 Word-blindness (see also Vascular Dis- eases of Brain) 437 Word-deafness (see also Tumors of Brain; Vascular Diseases of Brain) .. . 436 Wounds of Abdomen Due to Military Firearms 35 Wounds of Abdomen, Non-penetrating. . . 20 Wounds of Abdomen, Penetrating 21 Wrist-drop (see also Lead Encephalop- athy; Mercurial Poisoning; Neuritis, Multiple) 561 Xanthoprotein Test for Albumin 180 Sajous's Analytical Cyclopaedia of Practical Medicine. ABDOMEN, INJURIES OF THE. Contusion. Symptoms. — The symptoms attend- ing a contusion of the abdomen, whether caused by blows, kicks, spent bullets, the passage of heavy bodies — such as ve- hicles — over the abdomen, etc., are not always such as to call attention to the seriousness of the lesion present. The gravest abdominal injuries may co-esist with practically no external or general indication of mischief, the patient walk- ing a long distance, perhaps, without ex- periencing anything more than slight local pain where the blow had been re- ceived. Case of traumatic rupture of the small intestine caused by a very slight blow which left no mark. Extensive peri- tonitis and free exudate were present six hours after the injury, although there was almost entire absence of symptoms apart from cessation of peristalsis and slight vomiting. J. J. Buchanan (An- nals of Surg., Nov., 1900). From observations of some twenty cases of visceral injury, following con- tusion of the abdomen, verified by opera- tion or autopsy, the most prominent were pain, tenderness, and muscular rigidity, and likewise the most reliable. The deep-seated, localized pain following injury, especially increased by pressure, and accompanying local or general mus- cular rigidity, is one of the most con- stant signs of intra-abdominal injury. 1—1 The association of these three symptoms is almost pathognomonic of abdominal irritation. Pain, however, is often pres- ent, with tenderness, in injuries limited to the abdominal wall; but in these in- stances muscular rigidity is generally absent. In the absence of subcutaneous pain localized tenderness with rigidity is strongly suggestive of visceral in- jury. Of the three symptoms, muscular rigidity is the most reliable, and some- times the only sign. In the absence of other diseased conditions spasm of one or more of the abdominal muscles fol- lowing the traumatism may be looked upon as Nature's effort to protect an injured organ from further irritation. Vomiting is a symptom often present, but not always an accompaniment of severe visceral injury. It is commonly present with involvement of the stomach and upper part of the intestinal tube, and with injuries resulting in severe shock. The signs of free fluid in the abdominal cavity are very suggestive. C4. E. Brewer (Annals of Surgery, Feb., 1903). The abdominal walls may be but slightly injured; but, again, the lesions may consist of extensive extravasations of blood between the layers, or sufficient laceration of the muscular and other tis- sues to give rise to more or less local sloughing. Such lesions of the abdom- inal wall, however, are not always ac- companied by injury of the abdominal organs. ABDOMEN. CONTUSION. SYMPTOMS. A trifling superficial injury of tire abdominal wall may be associated with serious internal lesions, owing to the re- sistance offered by the abdominal walls and the fragility of the abdominal or- gans. The external appearances, there- fore, should not be taken as a criterion. Narrow bodies, the action of which is exerted on a small area, reach more deeply by overcoming resistance of the abdominal parieties more easily than larger bodies. Resistance varies with the age, state of obesity, and state of relaxation or contraction of the muscles. The direction of the blow is of impor- tance. If perpendicular to the deeper structures, it is most harmful; when parallel, it tends to glide oiT; when obliqus, the force is modified. Demons (Brit. Med. Jour., Nov. 27, '97). Case of young man riding bicycle when he was struck in upper part of abdomen by end-pole of an express-cart coming in opposite direction. He was thrown from wheel, but recovered himself soon. Only symptom slight pain and tenderness at seat of injury. Three hours later general abdominal pain and tenderness, steadily increasing. Temperature rose quickly five hours after injury. Abdomen was opened: in first eight inches of small intestine drawn out of wound two rents encountered, the larger was complete and involved half-circumference of gut. Smaller one partial, involving peritoneal covering and part of muscular coat only. Beginning peritonitis present. No ex- travasation of intestinal contents. No evidence of hasmorrhage of importance. Five inches of intestine, including in it both rents, resected, and bowel sutured. Recovery complete on twenty-fourth day. Francis S. Watson (Boston Med. and Surg. Jour., Feb. 10, '98). A severe blow in the abdomen is likely to occasion either haemorrhage or per- foration. In haemorrhage the pulse grows softer, while with perforation and ex- travasation the pulse hardens. Turner (Lancet, May 5, 1900). In collapse or death from blows upon the epigastrium the solar plexus may be disregarded as a factor; the cause of collapse or death is the mechanical vio- lence exerted upon the heart-muscle or its nerve-mechanism. G. W. Crile (Phila. Med. Jour., Mar. 31, 1900). In the majority of cases, however, severe contusions of the abdominal wall, whether the deep organs are involved or not, are followed by agonizing pain in the region of the injury, restlessness, nausea or vomiting, marked prostration (indicated by a small, rapid, and irreg- ular pulse), pallor (sometimes attaining lividity), cold sweats, rigidity of the ab- dominal wall, meteorisni, anxiety, and fear of a fatal issue. Diffused rigidity of the abdominal wall in a case of contusion of this region, even in the absence of any other serious symptom, is a decided indication for im- mediate laparotomy, while the absence of contracture, whatever may be the ex- tent and gravity of the associated symp- toms, contra-indicates surgical interven- tion. Of 10 cases in which, owing to the presence of this symptom, laparotomy was performed, this treatment proved successful in 9. Of 17 cases of severe abdominal contusion in which no opera- tive treatment was applied in conse- quence of the absence of rigidity, all ended in recovery. Hartmann (Bull, et Mem. de la Soc. de Chir., Mar. 12, 1901). All these symptoms bear the imprint of a severe nervous commotion, and, if the extensive distribution of the sympa- thetic nervous system in the abdominal cavity is borne in mind, the fact will become evident that symptoms usually witnessed immediately after the receipt of the injury are due mainly to the in- fluence of the concussion upon the sym- pathetic supply. Sudden death has been known to follow a violent blow, espe- cially when received in the region of the solar plexus. The pain varies according to the loca- tion of the traumatism and the sensitive- ness of the patient. Very severe at first, it usually becomes less marked after a ABDOMEN. CONTUSION. SYMPTOMS. few hours. It is greatly influenced by shock, profound prostration reducing its intensity by reducing sensation. Great restlessness usually accompanies abdomi- nal pain after injuries, as well as during other diseases, such as appendicitis, when the suffering is due to a localized trouble. The pain may be radiated in various directions, — the shoulder, the umbilicus, the left axilla, the testicles, etc., — according to the site of the pri- mary lesion. Local tenderness is usually marked over the site of the traumatism. The vomiting varies greatly in inten- sity from mere nausea to the most vio- lent expulsive efforts, which are liable, by the strain upon the abdominal organs, to suddenly increase the extent of the lesions. The vomited matter sometimes contains blood, especially if the tapper portion of the digestive tract is involved in the injury. Constant and persistent vomiting tends to indicate a contusion accompanied by visceral lesions. In simple cases the vomiting is re- peated but two or three times. Wlien the intestine is ruptured the vomiting is persistent and intractable and liver-dull- ness is absent. Berndt (Deutsche Zeit. f. Chir., vol. xxxix, p. 516). The degree of shock depends upon the nature and extent of the injury and es- pecially upon the amount of blood lost. When the signs of collapse gradually become more marked, internal haemor- rhage from rupture of one or more of the visQera is to be feared. The pulse, usually rapid and weak at first, gradually becomes stronger and slower if a favorable reaction is about to take place. If, on the contrary, an unfavorable course is being taken and some complication is to occur, its rapid- ity and tension may become increased. Irregularity is not a favorable indication if it persists. The temperature is independent of the pulse, except when a favorable reaction is taking place, when it may return to the normal line after having gone be- yond or below it. The usual belief that a subnormal temperature always follows internal hemorrhage is fallacious; for it may also be raised. The temperature, therefore, is of no value as a guide. It is generally believed that sub-' normal temperature is always present when there is intraperitoneal haemor- rhage. Cases showing that there may be, on the contrary, a marked elevation of temperature. Eeynier and Quenu (See. de Chir., Dec, '95). Case in which there was an elevation of temperature of 3 V=° F. five hours after receipt of injury. Vautrin (La Med. Mod., Feb. 15, '96). In abdominal injuries due to blunt force the symptoms are referable to the abdominal wall and cavity, or both. Pain may be severe or slight. As an early symptom vomiting is constant, dis- tension may be slow or rapid, rigidity develops later, shock may or may not be present. The temperature and pulse, par- ticularly the latter, are considered of great importance. Opium, even in small doses, renders the diagnosis of such in- juries difficult, and should never be ad- ministered early. After an abdominal injury, if there is tenderness, accelera- tion of the pulse tending to increase ever so slightly, together with abdominal dis- tension and a rise in temperature, the diagnosis of a grave injury is made abso- lute. In most eases but a few hours of dose observation are required to estab- lish the diagnosis. In such eases explora- tory laparotomy should be performed at once unless the condition is so desperate that anesthesia means certain death. E. S. Fowler (N. Y. Med. Jour., Aug. 19, '99). Hfematemesis may assist in establish- ing the diagnosis of lesion in the stom- ach or the upper portion of the intestinal tract, while the presence of blood in the stools may do the same as regards lesions of the intestines as a whole, in- cluding the colon. But, in itself, this ABDOMEN. CONTUSION. DIAGNOSIS. symptom is, by no means, characteristic, since a violent strain may cause sudden engorgement of pharyngeal, gastric, rec- tal, or hsemorrhoidal vessels and then, several days after the accident, blood- rupture ensue. Even when present, streaks in vomited matter or stools are not always indicative of an alarming condition. Blood in the urine is a more reliable sign of lesion in the urinary tract, espe- cially the kidney and bladder. Anuria is also indicative of lesions in these or- gans; but, as shock frequently arrests the flow of urine, it is only valuable as a symptom after all symptoms of shock have passed. Haemorrhage into the orbits and from the ears are occasionally met with when the concussion has been very severe. This symptom does not necessarily in- dicate that the injury is an unusually dangerous one. A few hours after the accident the pain usually becomes reduced; the pa- tient may be more quiet and, perhaps, somnolent, although the pulse remains in its former condition. This period lasts between twelve and twenty-four hours. If at the end of this time there be no complication, a visceral lesion is probably not present. If, on the con- trary, the symptoms gradually increase in intensity, the likelihood of grave in- jury is very great. In the light of present knowledge, however, the practitioner should not de- lay active procedures until the patient's life becomes compromised by permitting the mechanical injury produced to start an infectious process, when the manner in which the injury was inflicted and the force applied tend to suggest serious in- ternal lesion. Diagnosis. — The diagnosis should pri- marily be based upon the history of the accident, the manner in which the in- jury occurred, the shape of the body, or bodies, by means of which the trauma- tism was inflicted, and the degree of per- cussive force applied, and, secondarily, upon the symptoms present. Lesions of the Intestinal Tract. — Va- rious theories have been advanced as to the manner in which rupture of the intestine is brought about, but experi- ments have shown that squeeziiig of the gut between the compressed abdominal wall and the vertebral column is the main mechanical factor brought into action. Crushing against the ilium is rarely produced. Another, although rare, cause of rupture is the presence, in the intestinal tract, of liquid or semi- liquid material, the sudden circum- scribed pressure exerted upon the gut causing it to burst, through overdisten- sion. The small intestine is the seat of lesion in 75 per cent, of the cases of rupture in the course of the intestinal canal. Hence the importance of care- fully ascertaining in each case the direc- tion from which the percussive force came, the intensity of that force, and the relative position of the organs between the site of pressure and the spinal column. The character of the force and th& mode of its application always appear to be of much value as a help to diag- nosis in most cases of intestinal injury, for it would seem that where the force is of diffused rather than of a local- ized character the injury is more likely to be extensive or even double. Thus, when a human being is run over, the wheel of a vehicle passing either over the abdomen or the back with the abdomen downward; when he falls from a height upon a plank or beam; is trodden on by a horse; or is crushed between two obtuse bodies, it is most probable that either a solid viscus has been lacerated or that some portion of the small intes- tine has been torn in one or more places. ABDOMEN. CONTUSION. DIAGNOSIS. Thomas Bryant (London Lancet, Dec. 7, '95). Seven cases of severe contusions of the abdomen, with intestinal perfora- tion. The seat of perforation is, in the majority of cases, in the small intestine, and successively in order of frequency come large intestine, stomach, and duo- denum. Physical signs are tympany in the epigastrium and an area of dullness in the lower portion of the bowel. Adolph Schmitt (Munch, med. Woch., July 12, '98). Case of a boy, aged 16 j'ears, who had been kicked in the abdomen by a horse, but who presented no sign of ex- ternal injury. There was vomiting im- mediately after the accident, and ex- amination showed that the abdominal walls moved in respiration, although not quite freely; no tenderness in any par- ticular spot on light pressure; dullness on percussion in the hypogastrium and flanks, in the latter situation changing with the position of the body. Urine was voided without difficulty. The pulse was 116, and the patient suffered from shock. He was put to bed at once, and an effort made to relieve the shock. Two days later his condition suddenly became much worse: he went into collapse and died a few hours later. The autopsy showed several pints of bloody fluid in the peritoneal cavity and a tear in the jejunum near its com- mencement, close to the spine, about one and one-half inches long, in the longitudinal axis of the bowel, at its free border. Livingston (Brit. Med. Jour., Mar. 1, 1902). Another factor of importance in es- tablishing a diagnosis is the size of the instrument causing the injury. Lesions of the digestive canal, for instance, are usually the result of violent and sudden percussion produced by a body over a limited surface of the abdominal wall. The predisposing factors are the pres- ence of solid, semisolid, or fluid matter in the hollow viseera; leanness of the individual, and intestinal adhesions. Any of the above accidental causes of injury being fulfilled, rupture of some portion of the gastro-intestinal tract is likelj', especially if there is loss of con- sciousness at the time of the accident, followed by collapse, severe pain, a rapid and weak pulse, vomiting, tympanites due to the escape of intestinal gas into the abdominal cavity, and tenderness and rigidity of the abdominal walls. Such a diagnosis is further strengthened by hasmatemesis or bloody stools, the former tending to indicate a lesion of the stom- ach. Death occurs in 96 per cent, of such cases if unoperated. Two signs which enable the physician to diagnose the occurrence of intestinal perforation before peritonitis has had time to manifest itself: first, distinctness of the murmurs of the heart and respi- ration during auscultation of the abdo- men, — due to the presence of intestinal gases in the peritoneal cavity. Second, change in the pulse^, which, at the moment of perforation, becomes accel- erated, to slacken some hours later, — due to the absorption of putrid gases acting as cardiac poison. Gluzinski (Sem. Med., Nov. 6, '95). A ruptured intestine is probably pres- ent, though this is not certain, when, after a diffuse injury to the abdomen or a severe local injury as the immediate i-esult of the accident^ there is little col- lapse, and where vomiting soon becomes a prominent and persistent symptom, with lasting local pain and great thirst, with or without abdominal enlargement. Nineteen cases of rupture of the intes- tine adduced confirm the truth of this statement. Bryant (London Lancet, Jan. 11, '96). After contusions and wounds of ab- domen contraction of the muscles of ab- dominal wall indicates certainly visceral lesions. Out of ten cases of serious con- tusion it was present seven times, and surgical intervention resulted in the dis- covery in each case of grave visceral lesions. M. Hartmann (Jour, des Prat., Oct. 29, '98). Two cases of rupture of colon. The indications for exploration are the nature 6 ABDOMEN. CONTUSION. DIAGNOSIS. and history of the injury, frequent and early vomiting, early development of rigidity of the abdominal walls, local ten- derness, and impairment of resonance in the right iliac region; the absence of definite signs of injury to the urinary bladder or solid viscera, combined with the evidence of serious injury, shock, pain, rising pulse, general pallor and per- spiration. The special signs — as cellular emphysema, localizing the injury to the uncovered portions of the duodenum and colon, or possibly free gas in the peri- toneal cavity — may be present. The presence of any of these signs with a rising pulse above 100 will form indica- tions for abdominal exploration. G. H. Makins (Annals of Surgery, Aug., '99). Lesions of the Stomach. — Blows seldom cause rupture of tlie stomach, the elas- ticity of the organ, even when contain- ing liquid or semiliquid material, being such as to cause it to escape injury under sudden impact or great pressure. It is also protected by the lower ribs, the liver, and the intestines. Nevertheless, this organ is occasionally involved in traumatism affecting other abdominal viscera. In the majority of cases the rent is found near the pyloric orifice, but the greater curvature may be the seat of the lesion, while the entire organ is occasionally torn from end to end. In the latter case, however, death ensues almost immediately in practically all cases. Pressure during lavage of the stomach may also cause laceration of the mucous membrane. Case of a man who died in coma after several washings of the stomach for opium poisoning. At the necropsy sev- eral rents of the mucosa were found. Conclusion that the presence of the fluid was the cause of the injury, by pressure. Key-Aberg (Deutsche med. Zeit., Apr. 28, '92). In the case of incomplete tears there may be hsematemesis and severe localized pain resembling that of gastric ulcer, — gnawing and burning in character. This is followed by localized inflammation with tendency to the formation of adhe- sions. Hsemorrhage between the coats of the stomach may also occur in incom- plete tears, a cyst-like pocket being formed. Violent pressure upon the stomach may cause it to be crushed against the spinal column, and the mucous surfaces be lacerated by interpressure of the an- terior and posterior walls of the organ. In such a case a marked lesion neces- sarily follows, giving rise to copious liEematemesis. Case of a boy who was caught between two freight-cars. Shock and vomiting of blood, but no external injury. Twelve hours after the accident the abdomen opened and a slight laceration in the spleen sutured. No other injury found. The autopsy showed two ruptures of the mucous membrane of the stomach, — one of the anterior wall about its middle and the other opposite to it in the posterior Avail, the mucous membrane alone being stripped from the muscular layers. J. H. Clayton (Brit. Med. Jour., Mar. 24, '94). The presence of rupture of the stom- ach can be ascertained by inflating the organ with hydrogen-gas through an elastic stomach-tube. If the organ be dilated by this procedure, penetration beyond the mucous coat is improbable. If the stomach cannot be distended, complete rupture has taken place, and tympanites, due to the presence of the gas in the cavity proper, will be recog- nized. Eupture of the stomach implicates the peritoneal coat in the majority of cases, the elasticity of the peritoneal invest- ment being less than that of the two internal coats: muscular and mucous. The contents of the stomach, or a por- tion of them, escape into the peritoneal cavity and cause severe suffering and shock, followed promptly by death or septic peritonitis. ABDOMEN. CONTUSION. DIAGNOSIS. Lesions of the Liver. — The liver, owing to its friable nature, its size, and its anatomical position, is the organ most frequently injured, because indirect con- cussion may cause a profound lesion. A fall from a great height into water may thus cause a gaping rent of the capsule and parenchyma and open a large num- ber of vessels. Severe and sudden blows of any kind, especially those involving much surface, over the abdominal wall may thus cause injury to this organ. Again, its softness, which may be in- creased by hypertrophy, causes it to yield readily to the crushing produced by carriage-wheels, ear-bumpers, etc. The severity of all the general symp- toms is usually increased. The pain, when the liver is seriously injured, is peculiar; it radiates from the right hypochondrium to the waist, the scro- biculus cordis, or the scapular region. The respiration is generally embar- rassed; there is marked shock. Examina- tion of the fseces may show the absence of bile, especially if the bile-duct is rupt- ured: an occasional complication. The dissemination of bile in the system causes itching and, after a time, jaundice. The escape of bile into the peritoneal cavity may not give rise to peritonitis, however, this fluid being aseptic. A serous exudate may result from the irri- tation caused by its presence, forming a composite fluid which may be retained in the peritoneal cavity a considerable time. Case in which, after severe contusion in the hepatic region, swelling, with considerable rise of temperature, super- vened. Incision in the median line. A cavity, from which about a quart of reddish fluid issued, found. Recovery. Lyonnet and Jaboulay (Lyon M6d., No. 10, '95). Case of rupture of the liver in which there was copious exudation into the abdominal cavity. Urine containing bile; stools ash-gray. Seven quarts of dark mahogany-colored fluid withdrawn, and found to contain much biliary pig- ment, especially biliverdin. Recovery. Eoux (Le Bull. M6d., Dec. 8, '95). A rent is probable after a severe injury if there is collapse, if the pulse becomes more rapid and small, if the patient shows signs of exsanguinity, if the area of liver-dullness on percussion is in- creased, and if pain radiating to the scapular region is complained of. Severe injury may exist, however, without these indications. Diagnosis of rupture of the liver is ren- dered difficult by the fact that the local symptoms do not arise till late, while the danger is greatest during the first twenty- four hours. Zeidler (Deutsche med. Woch., Sept. 13, '94). Case of a boy, aged 16, run over by a cart which had passed over his abdo- men. The boy walked a quarter of a mile to the hospital. Wlien admitted he was pale and in great pain, but his pulse was full; no external signs of injury. On the fifth day he had an action, ac- companied with severe abdominal pain, speedily followed by collapse and sudden death. Fissure three inches deep was found in the right lobe of his liver. Thomas Bryant (Lancet, Nov. 2, '95). Lesions of the Gall-lladder or Biliary Ducts.- — -Blows and other conditions capable of causing hepatic rents some- times implicate these organs in the le- sion. There may be severe pain in the right hypochondrium if a rupture exists, vomiting of food and bile, and icterus. The urine is usually dark-mahogany and the stools ash-gray in color. Tender- ness over the hepatic region is usually marked. The intensity of the symptoms depend to a degree upon the quantity of bile voided into the abdominal cavity; but, this secretion being aseptic, peri- tonitis only occurs as a complication when the peritoneum is itself implicated ABDOMEN. CONTUSION. DIAGNOSIS. in the traumatism, or when the lesion is at the junction of the biliary tract and the intestinal canal, the latter in that case acting as a source of infection. Case of a man \vhOj after a severe blow in the right hypochondrium from the shaft of a cart, showed all the symptoms of rupture in the biliary tract. Seven quarts of a dark-brown liquid, rich in biliary pigments, biliverdin, etc., with- drawn on the fourth day by paracentesis. Prompt recovery. Jules Eoux (Mar- seille-med., Aug. 25, '95). Case of rupture of the gall-bladder by contusion. Inflammation developed slowly and death resulted in three days. Post-mortem showed the patient had a large gall-bladder with numerous gall- stones. If an operation had been made early the chances would have been favor- able. McLaren (Journal Amer. Med. Assoc, July 9, '98). Lesions of the Spleen. — The causes of injury to this organ are the same as those of the liver. Eents, sanguineous infiltration, and partial crushing are the lesions most frequently observed. En- largement of this organ through a malarial cachexia renders it susceptible to lesions which traumatism would not give rise to were it in its normal state. In extensive lesions copioiis hsamor- rhage usually takes place and death rapidly follows. If the lesion present is less severe, however, and the hsemor- rhage be moderate, there is tendency to collapse, increasing pallor, and a feeling of suffocation. The latter symptom and severe radiating pain in the region of the spleen are generally present, besides the signs pecidiar to all abdominal in- juries. If the patient survives suffi- ciently long the immediate effects of the traumatism, peritonitis or abscess and other complications frequently result. Severe local pain generally continues for some time, and chills are not infrequent. Percussion shows the organ to be more or less enlarged. Case of young man who fell from his horse and was struck on left side of thorax low down in the axillary line by animal's hind hoof. Brought to hospital in state of shock. Patient complained of considerable pain over the left side of the lower ribs, rather toward the back. In- fusion of 1200 centimetres of sterile salt solution given. Next day symptoms of internal injury were apparent. Opera- tion. The peritoneum purplish in color, bulged forward, and peritoneal cavity completely filled with blood-clots and fluid blood. Kupture of spleen found. Spleen removed, together with blood- clots in peritoneal cavity. At this stage of operation patient was in a moribund condition. Vein in arm was opened, and saline infusion of 2000 centimetres given. Recovery uneventful. Charles McBumey (Med. Record, Apr. 23, '98). Four successful cases of splenectomy for rupture without external wound. Di- agnosis of ruptured spleen is arrived at from (1) the locality of the injury; (2) the evidence of internal haemorrhage, and (3) the large fixed dullness in the left flank. Ballance (Practitioner, Apr., '98). In diagnosis of rupture of the spleen vomiting is a most important guide; in simple contusion of the alimentary tract it seldom, if ever, occurs. After injury, the patient may be able to walk or drive for half an hour or even more. Then there is a feeling of acute pain in the splenic region, and a sense of extreme weakness. On examining the body the splenic region is tender, dull on percussion, and rigid. There is pain on deep inspiration, the breathing is short and jerky, and a fracture of the ribs may be suspected. Pain spreads over the ab- domen; abdominal distension and rigid- Itj' become apparent, especially in the upper left quadrant of the abdomen. Symptoms of hemorrhage now develop rapidly, pallor, extreme anxiety, thirst, small frequent pulse, and vesical tenes- mus. Trendelenburg (Deut. med. Woch., Oct. 5, '99). Enlargement and disease of the spleen greatly predispose to rupture. Haemor- rhage is the most constant symptom, though this may be caused by rupture of ABDOMEN. CONTUSION. DIAGNOSIS. the mesentery or liver. More charac- teristic and less constant is pain in the region of the spleen and of more impor- tance is dullness of the percussion-note extending over the left upper abdominal and left lumbar regions. When let alone a rupture of the spleen is almost always fatal from haBmorrhage. Lewerenz (Ar- chiv f. klin. Chir., B. 60, H. 4, 1900). Lesions of the Kidmeys. — The kidney is firmly held in place by its attachments, while its consistence is such as to pre- clude elasticity. Hence, a blow or undue pressure may cause rupture. All the causes of injury that may take part in the production of lesions elsewhere may also induce renal lesions, which may con- sist of contusion, rupture, or laceration. Thirty-six cases of renal lesions of traumatic origin. An abundant liEemor- rhage may take place without any rupt- ure from tearing of the vascular net- work surrounding the organ, and which sometimes becomes engorged. Guter- bock (La Semaine Med., July 3, '95). Haematuria is valuable only as show- ing the fact of rupture of the kidney, but not as a symptom by which to de- cide on operating. It is not the visible loss of blood by the bladder, but the easily overlooked, but far more danger- ous, bleeding into the perinephric tissues, or into the peritoneal cavity, that should receive the chief attention. W. W. Keen (Annals of Surg., Aug., '96). Injury of the kidney and parenchyma- tous nephritis. Case of a boy, aged 7, who was run over by a coal-cart, the wheels of which passed over the right leg and the right lumbar region. On ca- theterization immediately after the acci- dent, 2 ounces of normal urine with- drawn. No pain. Two hours later he passed 12 ounces of bloody urine. Ex- amination made thereafter showed hajma- turia. The blood from the body gave indications of leucocytosis. The condi- tion of the kidney gradually improved with rest in bed, and six weeks after the injury the patient discharged as recov- ered. J. Yarrow- fN. Y. Med. .Jour., .Jan. 6, 1900). Besides the symptoms common to severe abdominal traumatism there may be increased pain in the lumbar region with radiations in the direction of the pubis and rigidity of the muscles. Dull- ness on percussion is sometimes elicited. Anuria may also occur, but this is not a characteristic sign. Hsematuria is an important indication of renal laceration, howeyer, although it may not present itself at once; it may be followed by the appearance of pus. The catheter should be used in these. Eetraction of the testicles is also said to occur (Kayer). The ureter is very rarely involved; when it is, the symptoms are not modified. Enlargement of the lumbar and hypo- chondriac regions is present in the ma- jority of severe cases, but may supervene late in the history of the case. Thanks to the compensatory work of the uninjured kidney, the mortality of renal lesions is not so marked as when other abdominal organs are injured. Statistics of 120 cases, showing 53 re- coveries and 67 deaths: a mortality of 53.7 per cent. Eeckzy (Wiener klin. Woeh., Nov. 8, '88). Even severe wounds have been known to heal. If large renal vessels are torn, marked lividity occurs, the patient rapidly becoming exsanguine. Death may thus follow very soon. Involve- ment of the peritoneum in the injury is promptly followed by peritonitis, the signs of this affection appearing a few hours after the receipt of the injury. Sepsis is not an infrequent complication in unoperated cases. Statistics of 118 cases published since 1878, 50 of which were fatal. In M of these the fatal result was due to primary, continuous, and secondary haemorrhages combined with shock, while suppuration, including peritonitis, caused death in 16 cases. W. W. Keen (Annals of Surg., Aug., '96). Case of boy run over by heavy wagon. 10 ABDOMEN. CONTUSION. PROGNOSIS. resulting in fi-acture of right lower ribs; symptoms of internal lisemorrhage pointed to right kidney. When abdo- men was opened, spleen had been com- pletely severed from remainder of organ and forced to right side of abdomen. Eight kidney was so badly crushed that it had to be removed. Remnant of spleen removed. Boy died in twenty- four hours. At autopsy it was found that left kidney had been torn completely through. Robert Abbe (Med. Record, Apr. 23, '98). Injuries to the ureter in addition to the general symptoms of shock, which may subside within a few hours, are characterized by the appearance of little blood in the urine and perhaps only an occasional clot. If no lesion of an ab- dominal organ accompanies rupture of the ureter, no very great symptoms will be manifested. Transient hcematuria should not be overlooked, especially with persistent pain in the side. C. L. Scudder (Boston Med. and Surg. Jour., May 2, 1901). Prognosis. — Death almost invariably attended rupture of the intestinal tract prior to the introduction of exploratory abdominal section, and prompt resort to active surgical procedues, when neces- sary, is indicated. Chavasse has collected thirty-six cases of kicks in the abdomen by horses, thirty-five of which died. A man who has been kicked in the abdomen by a horse has one chance out of three of dying. More than one-half of personal cases saved, thanks to intervention, although it is true that some eases were opened which might have recovered spontaneously. The laparotomy did no harm. Intervention should be practiced when there are sharp, local pains and rapid elevation of temperature. Kir- misson (La France Med., No. 14, '95). Three hundred and seven cases of con- tusions of the abdomen, from the kick of a horse, treated without operation, found in literature; 215 recovered and 92 died. Of 36 cases in which operation was practiced, 26 died and 12 recovered, and in only 3 of these could operation have been considered as imperatively necessary. As soon as a patient is kicked in the abdomen by a horse, he should be taken to a hospital, a careful history of the accident taken down, and the pa- tient treated expectantly. He should be placed in bed, heat applied, pain relieved, and should be given no food; evei-y half- hour the temperature and respiration should be recorded, with a note of the general condition and the local symp- toms. The moment that peritoneal reac- tion or general infection is evident the abdomen should be opened. Seven cases personally witnessed in which recovery occurred without operation. Nimier (Arch, de M6d. et de Pharm. Mil., Mar., '98). Where abdominal contents are rupt- iired 96 per cent, of cases die. Early operation favored. John T. Rogers (Jour. Amer. Med. Assoc, July 9, '98). As to the liver, as late as 1864 wounds of this organ were considered as practi- cally hopeless in every instance. "While a very small proportion of these cases recover without surgical interference, as is shown by the scars occasionally found in the hepatic parenchyma, the fact re- mains that an exploratory laparotomy, permitting the surgeon to quickly arrest the loss of blood in case of hemorrhage and to rid the peritoneal cavity of ac- cumulated extraneous fluids, has greatly reduced the mortality. The prognosis becomes much more unfavorable when peritonitis has set in, but a fatal issue may sometimes be averted, even in ad- vanced cases of this complication, by surgical intervention. Case in a girl, aged 9, who, four days after receiving a kick, came under treat- ment, with well-marked peritonitis. On the fifty-second day abdominal section; adhesions found everywhere. Neverthe- less almost steady recovery. A year afterward the child seen and in perfect health. Greiffenhagen (St. Petersburg med. Woch., Apr. 25, '92). The same remarks apply to rupture of the gall-bladder. ABDOMEN. CONTUSION. PROGNOSIS. 11 Case of rupture of the gall-bladder due to a blow upon the abdomen. Three weeks after the accident laparotomy was performed with the removal of three quarts of brownish fluid contain- ing numerous blood-clots. Convalescence slow, but complete. Thomas (Deutsche med. Woch., July 14, '92). Slight contusions of spleen heal read- ily, but rents and tears of any impor- tance are frequently followed by fatal hsemorrhage. Abscesses occasionally complicate convalescence. Case of V-para of 31 in sixth month of pregnancy. Drunken man had trod- den on the left side of her abdomen; on following day there were signs of inter- nal haemorrhage. Laparotomy disclosed rupture of spleen as source of bleeding. Spleen extirpated and the woman made excellent recovery and was spontaneously delivered of a healthy child at full term. Tabulated eight reported cases of re- moval of spleen for injury, five recoveries. Savor (Centralb. f. Gyn., 1305, '98). The great majority of cases of rupture of the kidney that recover are those in which the initial lesion had been com- paratively slight. In the graver cases, in which there is copious hsemorrhage into the perinephric tissues or into the peritoneal cavity, of which the growing exsanguinity of the patient is an indi- cation, the prognosis depends upon the speed with which adequate surgical pro- cedures are instituted. Occasionally, however, the blood is held in check by the renal capsule. The prognosis depends greatly, there- fore, upon the patient's ability to stand operative procedures suitable to estab- lish a positive diagnosis and bring the lesion that may at any moment destroy life within the immediate reach of art's highest powers. When serious injury is rendered probable by the nature of the accident, and the symptoms present also indicate a serious lesion, an explo- ratory incision, if the patient is not past relief, a careful examination of the or- gans involved, arrest of haemorrhage, closure of the disrupted tissues, or cleans- ing of the abdominal cavity may save him even when his condition appears almost hopeless. Again, the prognosis is influenced by the time elapsing between the accident and the institution of surgical proced- ures. The sooner they are resorted to, all things considered, the greater the chances of success. No case can be considered as hopeless imless a subnormal temperature, cold and cyanosed extremities, and other signs indicate that the end is near. A case may be considered as inoperable when there is profound collapse, the tongue being cold, the extremities cya- nosed with an imperceptible pulse, and a temperature ranging from 96° to 97° F. Editorial (La Med. Mod., Feb. 15, '96). A case of penetrating gunshot wound of the abdomen in which, nearly ten weeks afterward, the bullet, weighing 20 grammes, was extracted. The intestines were not opened, the entire fistulous tract being dissected out. He recovered in six weeks. The bullet had a steel casing, and its deformity showed that it had already struck once and had then been deflected. Calcareous particles and bits of clothing were found in the ab- dominal fistula. M. Hassler (Jour, de Med. de Bordeaux, Feb. 3, 1901). Even when performed late in the his- tory of the case, the operative measures sometimes prove successful. Case in which blow on abdomen caused rupture of pancreas followed by rapid formation of larger pancreatic cyst simu- lating closely an abdominal aneurism. Four week's after injury cyst evacu- ated through the abdominal incision and drained. Critical condition of pa- tient contra-indicated attempt to suture wound in pancreas. On third day fol- lowing operation subphrenic abscess was evacuated through a bronchus and pa- tient rapidly recovered. There was pro- 13 ABDOMEN. CONTUSION. TREATMENT. fuse discharge of pancreatic fluid from abdominal wound. The cyst contracted to small sinus, Avhich healed on seventy- seventh day after operation. Patient fifteen months after injury was well and showed no functional disturbance of any alimentary process. H. W. Gushing (Jour. Amer. Med. Assoc., Mar. 7, '98). The early recognition of a rupture of the bladder greatly influences the prog- nosis. About 60 per cent, of the most unpromising lesion, intraperitoneal lac- eration, are saved by prompt surgical measures. The remaining 40 per cent, are imsuccessful mainly on account of delay in resorting to abdominal section. A successful result has, nevertheless, followed laparotomy as much as fifty- four hours after the rupture. Keviews of the literature of 32 cases collected, 22 of which are intra- and 10 extra- peritoneal. Of the intraperi- toneal cases 10 recovered. Of the extra- peritoneal ones 7 recovered. Sehlanger (Archiv f. klin. Chir., B. 43, ■92). As a result of surgical intervention, the mortality from traumatic rupture of the bladder has, during the past fifteen years, been reduced fi-om 90 to about 54 per cent. Of 18 eases of extraperitoneal rupture treated by operation, 10 ended in recovei-y and 8 in death. Of 34 patients in whom the peritoneal covering of the bladder had been involved in the injury, 14 recovered after operation and 20 died. Sieur (Archives Gen. de M6d., Feb., Mar., '94). Treatment. — Shock. — Shock or col- lapse, though itnreliable as a sign of severe injury to the abdominal viscera, is, nevertheless, an alarming condition, especially if the temperature is subnor- mal and the breath is shallow, and it should at once receive attention. The patient is placed in bed with the head low, and a free supply of pure air in- sured, supplemented with oxygen if prac- ticable. Hot-water bottles are placed around him and he is covered with blankets previously warmed, if possible, or wrung out of hot water. Two main elements have to be borne in mind in this class of cases: (1) that the state of shock is due to a direct com- motion of the sympathetic system with probable inhibition of the heart's action, and (2) the possibility of an internal lesion which may involve death by ex- sanguination or the outpour into the peritoneal cavity of gastric or intestinal fluids. While the first condition calls for stimulants adapted to sustain the flagging heart and restore the action of the vasomotor, the agents employed should not be administered by the mouth, since, in ease of rupture of the stomach, the duodenum, or jejunum, a portion, at least, of the fluid may be added to those that may have found their way into the peritoneal cavity. Eectal and subcutaneous injections should, therefore, be resorted to. If no remedy be at hand, subcuta- neous injections of 1 drachm of whisky or brandy may be employed, and re- peated every five or six minutes until reaction occurs. A turpentine stupe or a fresh mustard poultice (not plaster) over the xiphoid cartilage, and a rectal injection composed of a tablespoonful of turpentine, a raw egg, and a teacup- ful of warm water, sometimes act with surprising rapidity. Hypodermic injec- tions of ether, or, better still, tincture of digitalis with V120 grain of atropine, repeated in fifteen minutes, are nec- essary to sustain cardiac action. After the second dose the digitalis may be injected alone several times more. These measures are greatly assisted by galvanic stimulation of the phrenic nerve, the negative pole, moistened in a solution of chloride of ammonium, being applied to the neck in the depression immediately in front of the sterno-mas- ABDOMEN. CONTUSION. TREATMENT. 13 toid mnscle, and the positive over the epigastrium. These means are sometimes inefficient and hypodermoclysis should be per- formed. If a fatal issue seems inevitable, saline transfusion is indicated. When the case is not very urgent, and the operator can act with deliberation, hypodermoclysis should be performed. When the symptoms are alarming and life is about to ebb, saline transfusion is indicated. T. L. Rhoads {Ther. Gaz., Oct. 15, '97). Administration cf morphine indicated in cases of great shock after injury. Use of drug should not be continued, one or two hypodermics usually being sufficient. McBurney (Med. Record, Apr. 23, '08). Eeaction. — As soon as reaction oc- curs in these cases another danger threatens the patient, that of hsemor- rhage, which the state of collapse has so far prevented to a degree, unless an extensive injury have caused overwhelm- ing exsanguination. In this event, how- ever, the patient's recovery from the preliminary shock would hardly have taken place. Hence the necessity of closely watching the suSerer. After a severe abdominal injuiy the patient passes through a stage of col- lapse, through a stage when the diag- nosis remains uncertain, through a period when the signs of hfemorrhage show themselves, and through a period of slow complications. Van Verts (Arch. G6n. de Med., Jan., '97). Cases of prolonged collapse sometimes turn out to be trivial, while a short period of it may be the prelude to the most grave complications. The former cases are, unfortunately, rare, and pro- found shock of any duration should be looked upon with suspicion. This is especially the case when a second period of shock is passed through — the "relaps- ing collapse" of Bryant — indicative of a secondary haemorrhage or the giving way or separation of some damaged tissues. That cases, clearly showing by their history and the active symptoms a grave injury, should be submitted to surgical measures as early as possible will hardly be gainsaid in the light of our present knowledge. An equally positive conclu- sion, based on every means of diagnosis available, will alone warrant the asser- tion that no serious injury is present; but if, on the other hand, doubt exists, abdominal section will alone insure the patient adequate protection. If nothing be found, no harm will have been done if precepts governing aseptic surgery have been closely followed; if a rent in the liver, an intestinal tear or rupture, a serious hemorrhage be discovered and , adequately dealt with, the patient will have received the benefit of all our art's resources. Hyperesthesia of abdomen after injury is indication for operation. An increase in respirations to twenty-eight or thirty per minute makes indication absolute. Cold extremities also significant. Le Dentu (Le Progres Med., Oct. 27, '97). In abdominal injuries when there is pain without cessation and nausea, it is best to operate. J. B. Murphy (Jour. Amer. Med. Assoc, July 9, '98). The seat of rupture being located, the nature of the injury will deter- mine the procedure to follow, linear enterorrhaphy being indicated in longi- tudinal ruptures, and circular enteror- rhaphy in complete ruptures, a Murphy button being employed. These proced- ures are now generally preferred to an artificial anws. It is sometimes impos- sible to adequately adjust the edges of the wound, owing to the condition of the margin, and an omental graft must be used to cover the contused area so as to avoid a secondary perforation. Considerable extravasation of fseces, 14 ABDOMEN. CONTUSION. TREATMENT. bloody and other liquid or semiliquid ma- terial may have occurred into the peri- toneal cavity. All chances for further contamination of the intestinal tract having thus been removed by closure of the rupture, the peritoneal cavity should be carefully cleansed by flushing with warm, sterilized water, a soft aseptic sponge being employed to gently mop all the surfaces that may, in any way, hav€ come in contact with the infectious fluids. The cavity is then closed and free drainage insured. Satisfactory results are obtained even in cases in which very great injury and ample opportunity for infection of all wounds have markedly compromised the issue. Case in a young man who, some time previously, had been severely wounded in the abdomen by a wagon-pole. The intestines were much contused and very dirty. In some places the serous and muscular coats were torn through. The intestines and peritoneal cavity were carefully cleansed with a solution of iodine terchloride (1 to 1000) and the wounds united. The patient recovered without fever. Langenbuch (Deutsche med. Woch., Apr. 28, '92). The after-treatment should be based upon the necessity of insuring rest for the intestinal tract for a few days. This may be- carried out by administering ■opiates. The patient's strength should be sustained, however, by means of nutrient, but small and frequently ad- ministered, enemata. Under all circumstances, an abdomi- nal injury should cause the patient to be watched several days. After an uncom- plicated injury he should remain in bed and be placed on a milk diet for a few days. Anodyne applications over the abdomen and a little morphine, inter- nally, if there is pain, is all that is usu- ally required in these cases. In the less fortunate the procedure to be adapted varies according to the organ involved. Intestines. — The probability of a rupt- ure having been recognized, the abdo- men should be opened by an incision through the linea alba, and any haemor- rhage quickly arrested. The next step is to locate the visceral injury. Of im- portance in this connection is the fact that in the majority of cases the rupt- ure is due to compression against the spinal column. The spot over the abdo- men upon which the blow carried being considered as the one end of an imagi- nary line and the centre of the vertebral column as the other end, the probabili- ties are that the rupture will be found near the linear axis. In dogs with intestinal perforation there is constriction of the intestine above and below the point of injury, and swelling of the intestinal loop at the point of lesion. Lesions are always superposed in the direction of the spine; so that by going from injured portion of wall toward the spine the wounded loops are always found. Fgvrier and Adam (Revue Int. de Med. et de Chir., Oct. 25, '94). Four eases of abdominal sections for severe injuries without external wounds. One should make a careful exploration of viscera before closing parietal incision. Three of the cases reported terminated fatally and at the autopsy it was dis- covered in two cases that a wound of the intestinal tract had been overlooked. A. M. Shield (Practitioner, Nov., '98). Again, if the rupture cannot be read- ily found, hydrogen may be insufflated into the rectum, as advised by Senn, and the spot from which the gas escapes will indicate the location of the rupture, — approximately, in the case of the small intestine, and accurately below the ileo- csecal valve. Disorders, or lesions other than those sought after, are misleading conditions that should be borne in mind. ABDOMEN. CONTUSION. TREATMENT. 15 Lesions of the jejunum are sometimes difBcult to locate. Ruptui'e of the jejunum. The patient was struck by the back rail of a barrow, across the upper part of the abdomen; severe pain, but not fainting. He was able to push the barrow a little further and to walk about a mile. No wound nor any bruising evident over the abdomen; very little tenderness, and breathing not markedly thoracic. Tem- perature, 97° F. ; pulse, 80 and weak. On the day follo\^■ing peritonitis present, and laparotomy performed by Mr. Cheyne. At the upper part of the cavity, behind the liver and stomach, the peritonitis was most acute, and a rent was found in the upper end of the jejunum. Patient returned to bed very much collapsed and died nine hours after the operation. C. J, Hood (Brit. Med. Jour., Apr. 5, '90). Stomach. — Wlien the sjaiiptoms of complete tear are recognized, the pres- ence of the organ's contents in the abdominal cavity render an immediate laparotomy imperative. The incision should include the tissues between the xiphoid cartilage and the umbilicus. If the tear cannot be quickly found, repe- tition of the inflation with hydrogen-gas will help to locate it. As soon as located any bleeding vessel should be ligated, and the stomach evacuated and cleansed through the adventitious opening of any substance that may have remained in it. If the wound be a lacerated one, it may be necessary to pare its edges. This be- ing done, the tear is closed, the mucous membrane being united with a contin- uous or interrupted suture, cut short, and the muscular and serous coats by the continuous Lembert suture. Closure of the laceration having removed all danger of further extravasation into the peritoneal cavity, the latter must be flushed with warm, sterilized water and mopped out with a soft sponge. The cavity is then closed and a drain left if the peritoneal surfaces have been ex- posed to contamination for some time. Experiments in cats in which large openings in the stomach we successfully closed by means of an omental plug. The surrounding mucous membrane always prolapsed freely and the piece of omen- tum, already fixed to the serous coat close to the seat of excision, was sewn around the wound, the omental tissue being fixed to the serosa. A process of omentum was then sewn over the whole, this being necessary in the case of cats, owing to the thinness of the omentum. The transplantation not only succeeded, but the omental tissue gradually as- sumed the character of gastric mucous membrane. Well-formed glands devel- oped. Enderlen (Deut. Zeit. f. Chir., Apr., 1900). Liver. — Especially when the history of the case seems to indicate the possibility of a lesion of this organ is careful watch- ing imperatively demanded, owing to the violent lijemorrhages which they in- volve. Either this complication or peri- tonitis having been recognized, the ab- domen should be opened at once in the middle line. The abdominal wound should be large enough, if possible, for the surgeon to see the liver, but in every case he ought to make a careful explora- tion with his finger, especially directing his attention to the convex and posterior surfaces of the organ. When a rupture is fotind, the wound may either be cauterized, plugged, or sutured. Paquelin's cautery can hardly arrest haemorrhage from large vessels in deep wounds of the liver; here the suture may be used. The blood-pressure in the liver-vessels is low; hence arrest of hEEmorrhage can surely be obtained by the tampon. The wound in the liver can also be better observed where the tampon is used. Three personal cases in which the measures were successful. Weidler (Deutsche med. Woch., Sept. 13, '94). Where the wound is a large one the 16 ABDOMEN. CONTUSION. TREATMENT. combination of sutures, mattress-sutures, and tamponade may be necessary; but, as a rule, the tampon should be used only in cases where sutures have failed to check the haemorrhage. Of the three methods the thermocautery is of least value; it will check only moderate parenchymatous haemorrhage, is of no value in extensive wounds, and is apt to be followed by secondary hsemor- rhage. Schlatter (Annals of Surg., Apr., '97). A jet of steam to control haemorrhage from the contused liver or omentum, first recommended by Sneguirefl, has antiseptic as well as hsemostatic virtues. When the tampon is employed, the sur- rounding peritoneal cavitj' should be shut off by a feAv sutures. Doyen (Le Progres M6d., Oct. 30, '97). Plugging with antiseptic or aseptic gauze seems to give the best results, one end of the gauze being left out at the angle of the abdominal wound. The plug should be removed not earlier than the forty-eighth hour, lest there should be a recurrence of the haemorrhage, and not later than the fourth day, lest a bil- iary fistula should be formed. When the bleeding is very severe sponges mounted on holders appear to produce more satis- factory pressure than simple plugging, which is, perhaps, better reserved for slighter injuries. Hot-water irrigation may be of advantage in these cases. A ligature should be applied to any large vessel which is seen to have been torn. Sutures are particularly useful when the laceration extends deeply into the sub- stance of the liver, since by their means the edges of the wound may be brought lightly together and the bleeding can be controlled. Drainage of the pelvic pouch, by an opening just above the pubis, serves best to give free passage to subsequent discharges. The capsule should be included in the stitches. The prognosis is very unfavorable when peri- tonitis has occurred, but something may still be done to prevent the fatal issue by opening and afterward draining the abdominal cavity. Two cases of rupture of the right lobe in a woman of 21 years struck by a train. Rent found in the under surface of the liver, 2 V: inches long, and I Vs inches deep; also several small rents in the spleen. Wound closed. Rapid recovery. Case of a man, 44 years old, caught be- tween two cars. Rent in the under sur- face of the liver. Haemorrhage was checked by pressure with gauze, and the abdominal wound closed. Rapid and good recovery. H. B. Delatour (Med. News, Eeb. 17, 1900). Ruptured liver in a man of 25 upon whom a case of glass, weighing half a ton, fell. Collapse, pain, and tenderness in the upper part of the abdomen, and increased liver-dullness. Almost pulse- less within three and one-half hours. Intravenous injection of saline solution given, and the abdomen opened. Found full of blood, and across the under sur- face of the liver was a laceration ex- tending from the gall-bladder to the posterior part. The laceration was packed with iodoform gauze, and the wound was approximated. The patient remained pulseless nearly thirty hours, but gradually recovered. Thomas Car- wardine (Lancet, May 12, 1900). Spleen. — After a simple contusion the spleen soon returns to its normal condi- tion without further trouble, and a few days in bed, coupled with strapping of the side to limit motion, usually suffice. When, however, there is laceration of the parenchyma the convalescence is slow, abscesses following in quick succession. After a time these cease and recovery is uninterrupted. Sjanptomatic treatment, revulsion over the organ, and tonics may shorten the duration of such cases. When the symptoms do indicate that essanguination of the patient is taking place, death will most probably follow, although the haemorrhage is not as copi- ous as it can be in tears of the liver, the ABDOMEN. CONTUSION. TREATMENT. 17 splenic capsule being more elastic than that of the latter organ. Eemoval of the organ should be resorted to. The ab- dominal wall is opened by means of an incision through the left semilunar line and the peritoneum is freely opened. The hand being introduced into the cavity, all adhesions are torn up and the organ is brought to view. The vessels entering the hilum are then clamped and the organ is removed. The stump is ligated and, after sponging out the abdominal cavity, the wound is closed. Results of splenectomy for rupture. Study of seven cases suggests following conclusions: 1. A marked leueocytosis follows removal of the spleen. It follows immediately after removal, and continues gradually to decline ; lasts six months or more. 2. The various forms of leucocytes are increased in number in various pro- portions, and do not bear the same ratio to each other as in normal blood. 3. The ansemia produced by the accident is very slowly recovered from after the re- moval of the spleen. 4. In a certain number of cases (three out of seven) the removal of the organ is followed at an interval of from ten days to three weeks by a train of symptoms characterized by pyrexia, wasting, extreme weakness, an- semia, frequent pulse, pallor, thirst, and headache, Avhieh last for a varying period and are slowly recovered from. 5. The external lymphatic glands undergo en- largement and in some cases a marked hypertrophy. George Heaton (Brit. Med. Jour., Aug. 19, '99). Kidney. — The majority of mild cases of perirenal extravasations of blood and urine recover as the result of rest and expectant treatment. The patient should be kept in bed and his diet limited to liquids, the best of which is milk; this beverage requires, besides, the least physiological labor from the in- jured organ. The nourishment of the patient may further be sustained by rectal injections of beef-tea, and these should entirely be resorted to if there is vomiting, the latter tending greatly to encourage haemorrhage. When the latter occurs in the direction of the bladder, there is likely to be accumulation of blood-clots, which, if small, will readily pass out with the urine. Frequently, however, the clots are large and cause retention of urine and marked tenesmus. A large catheter should therefore be in- troduced and kept in situ when the heematuria is marked, and the bladder occasionally washed out with a weak boric-acid solution. Median urethrot- omy to remove clots and relieve reten- tion sometimes becomes necessary in these cases. When the symptoms do not improve under these measures, an incis- ion should be made, exposing the seat of injur}', the extravasation removed, and the parts restored, by appropriate meas- ures/ to their normal conformation. There is great danger in delaying operation in these cases; the decompo- sition of the clots and the cystitis which is excited by their presence, as well as the frequent catheterization needed, ex- pose the patient to all the dangers of suppuration of the wounded kidney, and also to the risk of infection. Henry Morris (Clin. Jour., Aug. 1, '94). The dangers of rupture of the kidney are mainly hemorrhage and sepsis. When, therefore, the symptoms are such as to indicate marked haemorrhage or sepsis, and especially if a tumor form quickly in the lumbar region, an explora- tory operation should at once be done. If severe laceration be present, or the kidney's functions be practically com- promised, or the hemorrhage be such as to require ligation of the renal vessels, kimbar nephrectomy should immedi- ately be performed, primary nephrec- tomy being safer than secondary re- moval of the organ. Eleven cases of kidney traumatisms, with eight recoveries and three deaths. 18 ABDOMEN. CONTUSION. TEEATMENT. expectant treatment having been em- ployed. Wagner (Deutsche Zeit. f. Chir., B. 34, p. 98, '93). Five cases of primary nephrectomy with one death, a mortality of 20 per cent.; and thirteen cases of secondary nephrectomy with five deaths, a mor- tality of 38.5 per cent., showing that secondary nephrectomy is nearly twice as fatal as primary. As to the route of the operation; of three cases of abdominal nephrectomy, one died, a mortality of 33.3 per cent.; and fourteen of lumbar nephrectomy, of vphich four died, a mortality of 28.6 per cent. W. W. Keen (Annals of Surg., Aug., '96). Bladder. — When a patient presents the history of a severe abdominal con- tusion or crushing, followed by inability to micturate, the catheter should at once be used. Most important signs of vesical rupt- ure: a peculiar pain felt at the time of the injury; chilling of the surface of the body, which persists for some time: an urgent desire to micturate, which the patient cannot satisfy; the absence of any vesical swelling above and behind the pubes, and also the absence or the presence, but in verj' small quantity, of urine in the bladder. Catheterizing, though valuable, ought not to be prac- ticed except with very gieat caution. Sieur (Arch. Gen. de Med., Feb., Mar., '94). The presence of htematuria will indi- cate a lesion in the urinary tract, kidney, or bladder. If the urine withdrawn is observed to be well mixed with blood and, instead of red, it appear brown and smoky, the lesion is probably one of the kidney. If, on the contrary, the urine be bright red, the probability is that the bladder has been torn. In the latter condition the diagnosis may also be as- sisted by the quantity of fluid passed at a given time. If, when the catheter is introduced and after a history marked with shock, no urine is obtained, the chances are that not only the bladder has been ruptured, but that the laceration. is extensive, the opening having allowed the vesical fluids to escape into the ab- dominal cavity. A free flow, on the con- trary, would tend to show that the tear, if any exist, is small. Of course, the invagination of the intestines into the- vesical opening, or a valve-shaped lacer- ation, may cause the same favorable signs to exist, thus misleading the diag- nostician. Very small lesions may be- present, sufficient to allow the urine to escape, drop by drop, into the surround- ing parts. Detection of them is very difficult, the subsequent complications- alone showing the presence of extrava- sated fluids. The presence of any tear, except very" small ones, may also be ascertained by injecting a weak boric-acid solution into the organ, through the catheter. If a. rupture be present, the bladder will not fill and rise above the pubis. Filtered air may be used for the same purpose, but it is less satisfactory, owing to the- danger of secondary collapse. Case in which diagnosis was estab- lished by inflating the bladder with air forced in by two or three compressions- of the rubber ball of an ether-freezing microtome. The amount of air to be introduced need only be very small, and only moderate pressure is required for the inflation. The introduction of air through the- rent into the abdominal cavity, even in small quantity, v.as attended by a pro- found disturbance in the patient's gen- eral condition, which passed off on open- ing the abdomen and allowing the free- air to escape. The method should not be applied till the patient is on the operat- ing-table, so that, should the collapse threaten life, the abdomen could be opened at once. W. J. Walsham (Univ. Med. Jour., July, '95). The urine may have passed into the prevesical connective tissue outside the- ABDOMEN. CONTUSION. TREATMENT. 19 peritoneiTm, or the vesico-rectal or ves- ico-uterine space, owing to a rupture in these locations. This constitutes the extraperitoneal lesion. Cellulitis and sloughing rapidly ensue without subse- quent involvement of any organ in the neighborhood of the lesion, the vagina, the rectum, etc., the patient dying from septicfemia. Two eases of unconiplieated intraperi- toneal rupture of the bladder. Death probably due to the absorption of the urine by the peritoneum and to its con- tinuous accumulation in the blood. In both cases the rupture was situated on the posterior wall. There were no signs of acute peritonitis in either case. The patients lived probably five and three days, respectively^ after the accident. Joseph Coats (Brit. Med. .Jour., .July 21, '94). To ascertain whether a tear be extra- peritoneal or not, a measured quantity of a weak boric-acid solution is injected through the catheter. If the full amount is not recovered, the chances are that the rupture is extraperitoneal. In investigating a suspected case of rupture the greatest care should be taken to keep the bladder aseptic: so that, in case there is a rent, germs cannot spread into the tissues, and especially into the peritoneal cavity. In making the test also of injecting fluids in measured amounts, and then observing whether the same amount is voided, care should be taken not to distend the bladder more than very moderately, lest a partial rupt- ure be converted into a complete one. H. Aue (Deutsche Zeit. f. Chir., p. 351, '92). Eupture into the peritoneal cavity, the intraperitoneal form of lesion, is less urgent as far as symptoms go. One, and even two, days may elapse before active symptoms appear; but, when they do, rapid progress toward a fatal issue from general peritonitis is the rule. Uncomplicated contusion of the blad- der readily yields to a few days' rest, the application of ice, and general symp- tomatic treatment. When, however, there is cause for suspecting a rupture from the nature of the accident or the violence of the blow, the catheter should at once be introduced. The presence of blood renders operative interference im- perative. After the rectum has been distended with a rectal bag an incision three inches long is made in the middle line of the hypogastrium, beginning half an inch below the upper edge of the pubes, as in suprapubic lithotomy. It is best to first open the prevesical space, when it can be determined whether the rupture is extraperitoneal, and, if so, the necessary treatment to be carried out. If the rupture is found intraperitoneal, the abdominal incision is carried upward and the peritoneal cavity is opened, when the rent is located and properly disposed of. John B. Deaver (Univ. Med. Mag., July, '96). The peritoneum is then carefully rolled up, along with the prevesical fat. The bladder being thus exposed, search for the rupture is the next step. The rent is usually found along the poste- rior surface vertically down from the urachus; frequently an extravasation of blood and urine indicates the spot. Occasionally, however, considerable diffi- culty is experienced, and opening of the organ is necessary so as to permit the introduction of the finger, and thus allow of exploration of its inner surface. The rupture may be extraperitoneal or intraperitoneal. If an intraperitoneal laceration is found, the incision should be extended upward, the peritoneal cav- ity opened, and the cystic wound closed with fine silk by means of Lembert sutures, one-eighth of an inch apart, including only the peritoneal and mus- cular coats. The mucoits membrane of the bladder should be respected. Impor- tant, in this connection, is the neces- 20 ABDOMEN. WOUNDS. sity of ascertaining that the sutures will hold; this may be done by distending the bladder with a lukewarm milk or an alkaline solution. Of the 28 cases recorded by various operators, 11 recovered and 17 died. Of the 11 that recovered, in only 1 was peritonitis present at the time of opera- tion, while, conversely, of the 17 that died, in 8, and probably in 9, peritonitis had already set in. The causes of death in the 8 cases in which there \^as no peritonitis at the time of operation were : in 5, shock or hsemorrliage or the two combined, and in 3 peritonitis, the peri- tonitis in 2 out of the 3 being due to leakage of the rent or giving way of a suture. In no fewer than 4 out of the 28 cases was the bladder found, at the post-mortem examination, to leak. The importance of testing the competency of the bladder by injecting milk or other bland and easily detectable fluid could not, therefore, be too strongly urged. W. J. Walsham (Univ. Med. Jour., July, '95). The abdominal cavity is then carefully irrigated and closed, leaving a drain if there is any possibility that fluids will accumulate in any of the surrounding tissues. Wounds. Wounds of the abdomen may be non- penetrating, when the abdominal walls alone are injured, and penetrating, when the peritoneum is included in the lesion, irrespective of the instrument (pistol, knife, etc.) with which the lesion is pro- duced. Non-penetrating Wounds. Non-penetrating wounds are usually due to pointed cutting or blunt instru- ments. The lesions caused by a pointed in- strument, involving the skin and muscles only, are usually very slight. With due aseptic precautions careful exploration of the wound with the finger may be re- sorted to if the visceral examination do not suffice. Probes had better not be used, lest the wound be transformed into a penetrating one. Lesions caused by cutting instruments (knives, swords, etc.) vary in importance according to their depth and length. When the muscles are cut, the support for the abdominal organs is compro-. mised, and ventral hernia may follow, unless great care be taken when the wound is closed. Lesions caused by blunt bodies (such as shot, glancing bullets, and fragments of shells, etc.) are usually attended by symptoms of contusions corresponding in intensity with the force of the blow. Severe laceration of the abdominal tis- sues may thus be caused and death occur from intestinal lesions. The hfemorrhage attending these vari- ous kinds of wounds is usually slight. There is considerable ecchymosis, but this soon disappears. Occasionally shots or bullets become imbedded in the ab- dominal tissues. Treatment. — After carefully arresting bleeding, cleansing, and disinfecting the wound, the tissues are united. In deep incised wounds the prevention of ventral hernia should be borne in mind, and the cut muscular tissues brought accurately together by means of catgut sutures. This being done, silk sutures are also introdiTced and brought out to the sur- face, thus including the muscles and skin. Capillary drains are alone to be used, if drainage is at all necessary, larger drains affording opportunity for the formation of a ventral hernia. The abdomen should be supported by means of a bandage applied over the dressing and the patient kept in bed until com- plete repair of the wound has taken place; from two to five weeks, as a rule. The bandage should be carried long after recovery, and the patient be warned of ABDOJIEN. I'KNETKATING WOUNDS. SYMPTOJIS. 21 the danger he might incur by violent movement or strain. Penetrating Wounds. The softness of the tissues of the abdominal parietes causes them to be easily penetrated, and the organs within the cavity are all vulnerable for the same reason. The interstices between them occasionally allow the harmless passage of a weapon or bullet, but such cases are extremely rare, only nine such cases having been recorded during the Ee- bellion. The missile may graze the peritoneum and barely miss it along with the deeper organs. Unfortunately wounds causing laceration of one or more of the abdom- inal viscera are the most frequent, and their fatality is proverbial unless a timely diagnosis allow of prompt protective measures. As is the case in contusions, the di- rection from which the missile or stab comes is of great importance. A bullet arriving from the side and striking near the linea alba would probably create a button-hole wound or bury itself in the abdominal walls. A bullet coming from the front, on the contrary, would most probably perforate the organs in its axial line of flight. If the bullet has passed through the body an imaginary line between the entrance and exit will probably indicate the organs injured, including, of course, the peritoneum. Here again, however, the spinal column may cause deviation when the initial velocity of the bullet is small, and a deceptive line of injury furnished. To positively determine the course of a bullet is difficult in many cases. In stab wounds the opening is fre- quently of a sufficient size to permit pro- lapse of the omentum: an evident proof that the abdominal cavity has been penetrated. This rarely occurs in bullet wovmds unless a large projectile, or a bullet coming from either side of victim, have caused comparatively large solution of continuity of the tissues. Prolapse of the omentum is most frequently ob- served in lesions of the left side. Coils of the small intestines are also frequently prolapsed and, in rare cases, the stomach, the liver, or the spleen have appeared between the lips of the wound. Symptoms. — As is the case after con- tusion, penetrating wounds of the ab- domen may give rise to no symptoms capable of affording any reliable clue to the extent of the internal injuries. Pro- found shock may be present and no serious lesion exist. Case of a man brought into one of the surgical wards with an external wound. He was lifted to bed absolutely helpless and a serious gunshot wound of the abdomen suspected from gravity of symptoms. The bullet found in the leg of his drawers. The patient was unable to get out of bed for hours. A. B. Miles (Southern Surg, and Gynec. Trans., vol. vi, p. 183, "94). Severely injured individuals may, on the contrary, present no acute symptoms and, perhaps, walk or ride a considerable distance before showing noticeable evi- dence of their condition. Case of 15-year old boy who sustained penetrating wound of the abdomen, with protrusion of more than a foot of intes- tine, by being horned by a bull. There was total absence of shock, although the accident occurred si.x hours before the boy came under observation, and the pa- tient was brought in a country-cart over five miles of very hard road. George Bidie (Brit. Med. Jour., Sept. 24, '98). Profuse hfemorrhage alone gives rise to symptoms denoting a grave lesion: rapidly progressive exsanguination or acute anfemia; nausea or vomiting; weak, rapid, and sometimes irregular pulse; dilated pupils; cold sweats; yawning, 22 ABDOMEN. PENETRATING WOUNDS. DIAGNOSIS. ending in convulsions and coma. Shock is likely to be progressive in these cases. Fatal cases of marked laceration of liver and bowel in which there was neither shock, haemorrhage, nor high pulse. W. L. Robinson (Jour. Amer. Med. Assoc, Dec. 15, '94). If the shock is progressive it means internal haemorrhage. When a patient is first seen he may be profoundly shocked and not be much disturbed, but, if he continues to become more shocked, it means hsemorrhage. Shock at the time of injury does not mean haemor- rhage, but later on it does. L. McLane Tiffany (Pacific Record of Med. and Surg., Feb. 15, '96). The only symptoms that are present in practically all cases are pallor and vomiting: the accompaniments of any severe blow on the abdomen, and there- fore of no value whatever as differential signs. The temperature is of no assist- ance in these cases. Cases showing that with normal tem- perature a fatal injury (without opera- tion) may be present, while, after oper- ation, a subnormal temperature may be expected; 95° F. has been recorded. L. M. Tiffany (Amer. Jour. Med. Sci., May, '96). Diagnosis. — On general principles dangerous complications are to be ex- pected when marked shock, nausea, vomiting, hiccough, anxiety, intense thirst (indicating a probable involve- ment of the peritoneum), and insomnia are present. Besides these indications there are others peculiar to each organ which greatly assist in establishing at least an approximately certain diagnosis. The absence of liver-dullness is of less significance than is usually believed, but the disappearance of liver-dullness is of more value. The most important symp- toms in personal cases were tension of the abdominal muscles, local meteorisms, and dullness in the region of the wound. The general symptoms were those of peritonitis. Petersen (Miincliener raed. Woch., Apr. 9, 1901). Intestines. — According to Senn, bul- lets striking the abdomen antero-posteri- orly rarely cause more than four per- forations, while oblique or transverse shots are likely to produce a much larger number of lesions: from fourteen to sixteen. On general principles, however, a penetrating wound may always be con- sidered as having caused a lesion of the intestines. The most important symptom is the escape of intestinal gases and more or less fluid substances through the wound. The mere presence of emphysema around the wound is of no value, however, since air is generally forced into the wound by the bullet. Some years ago Senn recommended the insufflation of hydrogen-gas to ascer- tain the presence of intestinal perfora- tion. Having introduced it into the rectum, he ascertained whether it es- caped into the peritoneal cavity and thus passed out through the parietal opening. The method was found unreliable, how- ever, and has been pretty generally dis- carded. Case in wliieh the absence of intestinal pei'foration was established by ether in- flation of the intestines. The bowels were inflated with ether, which escaped from the mouth. The peritoneal cavity was opened, and the ball was found to have passed above the liver, injuring the diaphragm, and burying itself in the tissues behind. The blood-clots were removed and the abdomen closed. The inflation of the intestines caused a sense of fullness, but no other discomfort. The patient made an uneventful recovery. E. M. Sutton (Jour. Amer. Med. Assoc, Dec. 30, '99). Free hajmorrhage from the wound tends to indicate an intestinal lesion; if the stools also contain blood the diag- nosis may be considered as certain. In small wounds of the bowel the mucous membrane pouts out and closes the orifice; as soon as peristalsis occurs ABDOMEN. PENETRATING WOUNDS. DIAGNOSIS. 23 it is drawn in, and there may be an escape of a small fseeal mass. A large amount of fseeal matter may thus be extruded through a small opening. Klemm (Deutsche Zeit. f. Chir., B. ,33, H. 2, 3, '92). In wounds of the intestines of very short extent (the most frequently met with) the mucous membrane makes a hernia between the lips of the wound, obstructing and thus preventing the flow of the faecal matter, and in conse- quence avoiding the onset of peritonitis. The gas would pass through the wound, facilitating at once the passage of these materials. Tobias Nunez (Brit. Med. Jour., Oct. 9, '97). Probes have been discarded in pene- trating wounds, owing to the irregular course followed by the bullet in many cases and the danger of creating a false passage. Digital exploration of small wounds furnish but little information, while in bullet wounds there is danger of pushing into the peritoneal cavity what foreign substances may happen to be present. The majority of surgeons now favor enlargement by an incision at least two inches in length, intersecting the bullet or incised wound. Layer after layer of tissue is carefully dissected on each side of the track, the walls of which, in gun- shot wounds, are usually darker than the normal tissues, owing to contact with the lead or powder-products of combustion. Using the grooved director to divide the tissues and the haemostatic forceps to grasp any bleeding vessel, the perito- neum is finally reached, when the cer- tainty that a penetrating wound is present or not may be established. If practiced with strict aseptic precautions, this procedure does not expose the pa- tient. Study of fifty-six cases showing that proof of penetration through peritoneum should be sought by enlargement and careful investigation of original wound. Penetration having been found, imme- diate enlargement of the wound shouli be made. C. L. Seudder (Boston Med. and Surg. Jour., July 25, '95). Stomach. — Hajmatemesis is a frequent symptom of penetrating wound of this organ and a much more valuable one than in contusion, since, in the latter, a slight laceration of the mucous mem- brane may produce it. The blood may be pure, but in the majority of instances it is mixed with partially-digested ali- mentary semiliquid material. If the wound is sufficiently large to allow the contents to escape through it the nature of the injury is, of course, clear, but an important complication is to be appre- hended: extravasation into the perito- neal cavity capable of causing peritonitis. If this is circumscribed, adhesions are formed and the patient recovers. Fre- quently, however, general peritonitis follows, ending in death. Hence the importance of an early recognition of extravasation. Besides hasmatemesis and the presence of gastric fluids, there are usually present in such injuries the marked symptoms witnessed in cases of contusion: rapidly progressive anaemia, pallor, fluttering pulse, etc. Liver. — A wound of the liver gives rise to all the symptoms observed when a contusion has caused laceration of the organ. Intermittent pain, radiating in various directions, especially toward the shoulder, if the convex portion of the organ is torn, and in the direction of the waist, if the concave or inferior portion of the organ is the seat of injury. There is marked pallor, superficial itching, and, later on, jaundice. The stools may be clay-colored, thus indicating the absence of bile. The hfemorrhage varies in these cases according to the cause of the lesion; one 24 ABDOMEN. PENETRATING WOUNDS. DIAGNOSIS. caused by a bullet is prone to be accom- panied by considerable and frequently fatal bleeding. Stab wounds, when the weapon is not large, do not give rise to considerable hsemorrhage. A copious flow of blood from a wound in the hepatic region indicates that the liver is involved. The flow of bile through the wound is a valuable sign, but it is seldom that this secretion can be obtained alone, blood being usually mixed with it. Spleen. — In cases in which the spleen is wounded the diagnosis can easily be es- tablished by the location of the external opening and the direction of the track. Perforating gunshot v> ound of the kidney. (M. E. Richardson.) (Annals of Surgery.) As is the case in contusion, there is marked local pain and profuse bleeding, which, if the organ is greatly lacerated, may soon prove fatal. This is apt to occur after gunshot wounds at close range, the organ under such circum- stances becoming pulpified. Puncture wounds are less likely to produce fatal hsemorrhage. Kidneys. — The symptoms frequently accompanying wounds of the abdominal organs, extreme pallor, weak pulse, cold extremities, nausea, and vomiting are apt to be most marked when, besides the organ itself, the peritoneum has been pierced. A wound of the kidney gives rise to severe pain in the majority of cases, but this symptom may be absent. As in cases of laceration, the pain radiates in various directions, especially in the di- rection of the external genital organs. The testicle of the corresponding side, besides being the seat of considerable suffering, is frequently raised by spas- modic contractions of the scrotum. At first a small quantity of bloody urine may be passed, but this is often followed by vesical tenesmus and com- plete retention, due to the presence of clots in the bladder. Much information is sometimes ob- tained by a close examination of the wound of exit. If the track of the bullet be antero-posterior and the missile have entered from the front and penetrated the kidney, the exit wound will be found in the lumbar region. It is frequently found in this situation to contain urine, a positive indication that the organ or its annex, the ureter, has been wounded. If the wound of entrance be in the back, its location over the site of the kid- ney may suggest a lesion of the latter; but the urine test will only be of value if the projectile only penetrate the kidney without perforating it. If it penetrate the organ, the extravasation will take place into the peritoneal cavity. The same will be the case if the missile enter from the front without going through the organ. Bullets buried in the renal parenchyma either become encysted or cause abscesses, and pass out through the ureters or into the adjoining parts. Case of gunshot wound of the kidney made evident by the appearance of urine saturating the dressing in the lumbar region. The amount of urine on the dressing gradually decreased, and after about six weeks the sinus had closed. William F. Barry (Med. Record, Mar. 24, 1900). ABDOMEN. PENETRATING WOUNDS. PROGNOSIS. Bladder. — The symptoms vary accord- ing to the location of the wound. A perforation between the symphysis and the peritonenm above does not give rise to general symptoms; whereas shock, pallor, weak pnlse, vomiting, etc., may be much marked when the peritoneum is involved in the injury. In all cases, however, severe pain is experienced at the site of the lesion and radiating to the thighs and testicles. The passage of urine soon becomes very difficult and spasmodic. It may be voided, drop by drop, for a long while, notwithstanding the efforts of the pa- tient, then suddenly gush out for a few moments and again flow slowly. This symptom may be due to accumulation of clots or to spasm of the urethra. If the catheter is passed, hsematuria be- comes evident when the bladder has been penetrated: a characteristic sign. As in the case of rupture due to contusion, infiltration may take place through the wound into the neighboring tissues; any obstacle to the free passage of urine greatly encourages this. Hence the necessity, in all bladder lesions, of keeping the organ as free as possible by the frequent use of the catheter. Prognosis. — The statistics so far pub- lished differ so widely that it is difficult to reach a definite conclusion. It is cer- tain, however, that gimshot wounds are more frequently fatal than stab wounds, but that stab wounds, in which the peri- toneum is penetrated, are fully as fatal as gunshot wounds.'' Intraperitoneal wounds of the bladder are uniformly fatal, while extraperito- neal wounds gave a mortality of only 15 per cent. Gunshot wounds of the kidney are attended with a death-rate of 44 per cent. In gunshot wounds of the liver the mortality is 26.8 per cent. Wounds of the spleen are difficult to diagnose; mortality 65 per cent. Wounds of spinal cord in the lumbar region result fatally. Mortality of wounds of the pelvic bones also very high. Seliger (Prager med. Woch., '92). Statistics collected by various writers, showing the mortality to range from 65.6 per cent, to 70.67 per cent. Shock is one of the chief causes of these re- sults. Conner (Jour. Amer. Med. Assoc., Sept. 16, '93). Immediate operation is the best and wisest course to pursue in perforated, punctui'ed, and gunshot wounds of the abdomen. This is the rule which is fol- lowed in the University of Munich. Seven gunshot wounds treated with a mortality of 58 per cent., and 22 stab wounds, with a mortality of 18.1 per cent. Series of 30 eases treated by con- servative methods between 1870 and 1890, the mortality having been 46.6 per cent. Paul Ziegler (Miinch. med. Woch., Mar. 8, '98). In 253 cases of gunshot injuries of the abdomen the total mortality was about 52 per cent.; in 28 of the 133 fatal cases unsecured perforations or haemorrhage was found; peritonitis at the operation was found in 11 of the cases that recov- ered, showing that about 5 per cent, of such cases recover even if this dangerous complication is present. H. H. Grant (Jour. Amer. Med. Assoc, Mar. 17, 1900). The kind of weapon inflicting the in- jury plays an important role in this con- nection. A triple-edged bayonet is more likely to produce a serious laceration than a fiat blade. Again, wounds caused by small weapons, such as a Mobert rifle, for instance, would hardly produce le- sions to be compared to the old Enfield or Minie rifles, which sometimes caused a large portion of an organ to protrude through a wound of exit the size of an apple. Portions of the solid viscera are some- times cut off or shot off, leaving a gap- ing tear, which greatly compromises the issue. Again, as is often the case with the liver, the bullet, or any foreign ma- terial dragged in by the latter, may lead 26 ABDOMEN. PENETRATING WOUNDS. PROGNOSIS. to complications which greatly reduce the chances of recovery. An important factor is the time elaps- ing between the receipt of the injury and that at which competent treatment is applied in mild cases. This is espe- cially true as regards the early utiliza- tion of surgical measures when these become necessary. The sooner these are instituted, the more favorable the prog- nosis, especially during the first ten hours. Statistics of 154 laparotomies for gun- shot wounds: Operation five hours after traumatism; mortality, 52.7 per cent. Operation ten hours after traumatism; mortality, 74 per cent. Operation twenty hours after traumatism; mortality, 73.9 per cent. Operation after twenty hours after traumatism; mortality, 78.2 per cent. Haemorrhage kills early, if at all. Edouard Adler (Jour, de Med. et de Chir. Prat., Sept. 25, '92). Intestines. — The prognosis depends greatly upon the nature of the lesions. Stab wounds opening the intestine lengthwise, if small, often heal of their own accord; transverse wounds are more serious, while complete section of the bowel is a very dangerous complication. Gunshot wounds show a great fatality. Prior to the introduction of antiseptic surgery the mortality exceeded 90 per cent.; since then, the mortality has been decreased to 43 per cent, in cases oper- ated during the first twelve hours. When all surgeons will handle the intestines with gentleness, operate quickly, and otherwise reduce the chances of shock, it is probable that the prognosis will be greatly improved. Perforations of the descending colon and sigmoid flexure are seldom fatal; those of the transverse colon give a worse prognosis, by the for- mation of fistulas, adhesions, and abnor- mal communications. Again, diathetic conditions may compromise recovery. Notwithstanding great injury and other conditions greatly reducing th>'' chances of recovery, recoveries are occa- sionally obtained. The omentum., although it does not contain unstriped or striped muscular tissue, has power of mobility, and applies itself over lesions that may occur in the cavity of the peritoneum. Thanks to the omentum, aseptic surgical wounds of the ureter, bile-duets, etc., can be left to heal without sutures, since it practically walls in the wound. Millan (Gaz. des Hop., July 1, '99). Case of abdominal injury caused by the horn of rhinoceros in which a por- tion of several knuckles of gut pro- truded through the opening, two inches above Poupart's ligament. The gut was cleansed and returned and the parietal peritoneum, skin, and superficial fascia then closed by different sets of sutures. In eleven days was up and around. E. W. Waters (Brit. Med. Jour., Nov. 3, 1900). Stomach. — Uncomplicated wounds of this organ frequently yield without trouble when the bullet, blade, or other instrument causing the perforation is small, especially if the stomach was empty at the time the injury was in- flicted. The mucous membrane bulges out and forms a plug which obturates the hole until reparative processes have sealed the aperture on the peritoneal side. Complicated cases, in which the lesions are extensive, soon reach a fatal issue if deprived of timely surgical inter- vention. An individual shot when the stomach is distended with food will have a better chance to recover if subjected to an oper- ation and the peritoneal cavity washed out. The probability is that during efforts at vomiting part of the contents of stomach will be extruded through per- forations into peritoneal cavity. R. B. Hall (Cincinnati Lancet-Clinic, May 7, '98). Liver. — The prognosis of wounds of the liver depends mainly upon the com- ABDOMEN. PENETRATING WOUNDS. PROGNOSIS. 27 plications. If the patient does not die from liEemorrhage soon after the receipt of the injury, he is still exposed to the results of extravasation into the peri- toneal cavity, the presence in the liver ■of a foreign body, — the bullet and what material it may have forced into the wounds, — etc. Peritonitis, hepatitis, and •abscess are, therefore, dangers to be taken into consideration. Hepatitis and -abscess are much less to be feared, how- ■ever, from stab wounds, no foreign body being left behind, unless, as in dueling, the sword-point strike the spinal column, •causing the blade to break. In such an event, however, the hfemorrhage woxild probably prove mortal very rapidly. As to mortality, the statistics of Edler, Mayer, and others show it to average .about 50 per cent., including the cases •attended by complications. Records of 272 cases of wounds and injuries of the liver. Cases divided into those due to direct and those due to in- direct violence. Direct injuries, 164 cases, with 58 deaths, — a mortality of 35,3 per cent.; indirect, 108 cases, with 92 deaths, — a mortality of 85.2 per cent. The for- mer class again divided into two groups, of 54 punctured or incised wounds, 24, or 44 per cent., proved fatal, while of 110 gunshot wounds only 34, or 30 per cent., were mortal. Of the 272 cases, 150, or 50.5 per cent., died. These figures cor- respond very closely with the tables of Edler, which showed a mortality of 39.1 per cent, after shot wounds and 55 per cent, of all cases. Homer Gage and R. Lorini (Boston Med. and Surg. Jour., Apr. 28, '92). Spleen. — Slight punctured wounds of the spleen are not mortal unless compli- ■cated with laceration of a large artery. They are sometimes followed by ab- scesses which heal after a prolonged period in the great majority of cases. Severe punctured wounds are dangerous in proportion, but if the primary hem- orrhage is not such as to cause an early fatal issue, the chances of recovery are about those of slight wounds. Gunshot wounds are much more seri- ous as a result of rupture of the spleen taking place itnder the concussion, when the bullet is large and its velocity is great. Fatal haemorrhage quickly en- sues. Eupture of the spleen may also occur during convalescence. Case of wound in the right hypochon- driac region from which the spleen was protruding. Wound had been exposed to soiled clothing and a septic process feared. The entire spleen was removed. Recovery followed and in two weeks the wound had completelj' healed. 0. St. John Moses (Lancet, Jan. 27, 1900). During the War of the Eebellion the proportion of deaths was 93 per cent. In civil life, however, the weapons used are, as a rule, less powerful, and it is probable that the mortality, especially since antiseptic surgerj' has been gener- ally utilized, is much smaller. The predi- lection of this organ for abscess greatly darkens the prospects of recovery. Kidnetjs. — Complications are also to be feared in lesions of this organ, namely: peritonitis, nephritis, and secondary hsem- orrhage. Again, the position of the kid- ney makes it probable that other organs are also injured in the majority of cases. The direction from which the bullet or stab came, the length of the penetrating blade, etc., are important factors when the nature of the injury is to be deter- mined. Bladder. — Gunshot wounds of the bladder are always serious as far as com- plications are concerned, rectal, vaginal, perineal, and scrotal fistulse being very frequent. As to the mortality of penetrating wounds of the bladder, it is not so great as in lesions of any of the other ab- dominal organs. Stab wounds are more frequently mortal than imcomplicated 28 ABDOMEN. PENETRATING WOUNDS. TREATMENT. bullet wounds, the proportions being 29 per cent, in the former and 17 per cent, in the latter. When, however, osseous lesions are also present, penetration or fracture of the pelvis, etc., the mortality reaches 29 per cent. Case in which a crow-bar entered the right thigh in front and emerged below the right shoulder posteriorly about an inch and a half below the angle of the right scapula. Notwithstanding tox- Eemia, hepatic rupture, and the presence of septic fluid in the thorax, patient sur- vived the injury three weeks. A. C. Miller (Edinburgh Med. Jour., Oct., '99). Treatment. — The preliminary meas- ures indicated in the treatment of com- plicated contusions of the abdomen are also applicable in that of penetrating wounds of that cavity. Protrusion of portions of the intestines, the mesentery, and the omentum through the external wound is an early complication met with in many cases of penetrating wound. If the protruding mass be intestinal and in good condition it should at once be re- turned into the abdomen. An easy way of accomplishing this (recommended by Levis) is to raise the middle of the patient's' body by means of a pillow, the hands, etc., while he is lying on his back. The anterior portion of the pelvis is thus separated to an abnormal degree from the anterior portion of the thorax, and the increased room in the abdominal cavity thus obtained causes the intes- tines to spread out, as it were, and, their weight causing traction upon the pro- truding loop, the latter quickly slips in. At times accumulation of gas or fsecal matter checks its inward progress; the gas can easily be let out by inserting a clean hypodermic needle into the pro- jecting bowel; the faecal matter can also be reduced in quantity by drawing out an additional portion of the gut — thus increasing the size of the loop — and gently pressing small portions of the contents into the unprolapsed bowel, thus diminishing the tension of the pro- truded mass. It is sometimes necessary to enlarge the abdominal wound. If the projecting mass be greatly inflamed the latter procedure is unavoidable. If it be gangrenous it had better be incised and the formation of a faecal fistula per- mitted. An omental protrusion, if healthy, can be immediately returned, but if greatly inflamed or gangrenous it should be transfixed near the abdominal wall and tied with a double ligature; then excised. The stump is then secured in the deeper portion of the wound with ligatures and adhesive strips. Punctured wounds of the abdomen are frequently recovered from spontaneously, owing to the absence of serious visceral lesions. The same statement may be made as regards bullet wounds, but with less emphasis. That laparotomy should be performed in every case is a view that wide-spread clinical testimony does not sustain; but that a wound of sufficient importance to cause anxiety be enlarged down to the peritoneum to allow of a careful examination and adequate pro- cedures, if need be, and that laparotomy proper should be reserved for lesions which, from the nature of the symptoms, tend toward a fatal issue, is in keeping with the teachings of the most advanced, but safe, surgery. The wound of entrance should be en- larged, and, if the missile has entered the abdomen, a section is called for. Operation is proper soon after the in- jury, before the peritoneal membrane has become infected or much blood lost. Tiffany (Amer. Jour. Med. Sci., May, ■96). Hypersesthesia of the abdomen is an indication for operation. An increase in the respirations to twenty-eight or thirty ABDOMEN. PENETKATIXG WOUXUS.. XKEAT.ME.NT. 29 per minute is an absolute indication for operating. Cold extremities are also significant. Le Dentu (Le ProgrSs Med., Oct. 27, '97). When surgical measures become nec- essary, including enlargement of the wound, the patient should be placed un- der an anaasthetic. The rectum should be emptied by copious injections con- taining a tablespoonful of glycerin to the pint. A subcutaneous injection of morphine (V^ grain) is recommended by many surgeons. If, however, there is a tendency to shock without much pain, this agent had better be withheld. Rec- tal injections of whisky and warm water, 2 ounces of the former and 4 of the latter, is useful to sustain cardiac action. It may be repeated in an hour if evi- dences of impending shock are still present. If, after a careful examination of the enlarged wound, it is found that the peritoneum is not involved, the exposed tissues are carefully cleansed and the wound is closed, deep sutures being used to hold the tissues in accurate apposi- tion. As already stated, the possibility of ventral hernia should be borne in mind: the patient should be kept in bed for some time and a bandage be worn until all local weakness has disappeared. If, after a stab wound, the parietal peritoneum alone is foimd incised or penetrated and there is no evidence that the organs behind have suffered injury, the tissiies must be cleansed with great care and the peritoneal flaps brought to- gether, the serous surfaces being kept in contact. A continuous catgut suture is used for the peritoneitm; the muscles and skin are then united and the wound is closed. The measures already out- lined to prevent ventral hernia are also indicated for the deeper wound. When laparotomy becomes necessary the incision should be made in a spot affording the operator the greatest op- portunity for a wide field of action, and should be sufficiently long. When performed for the arrest of dangerous haemorrhage, a long median incision will enable the surgeon to reach any organ with ease: an important factor, for the missile or blade inflicting the injury may have traversed harmlessly between sev- eral coils of intestine and have caused a rent in the organ most remote from the point of entrance. Again, the incision should be free, so as to make it possible to easily reach all parts of the abdomen to allow of a thorough removal of all extravasations which might otherwise ultimately cause complications. Case ending fatally through the fact that a too limited parietal incision had been made. A longer incision would have permitted more extensive irrigation and prevented peritonitis, which devel- oped in the upper portion of the abdo- men. Dubujadoux (Archives de Med. et de Pharm. Militaires, Aug., '95). In most cases of perforating wound when operation is decided on it is a good plan to make the incision through the point of entrance, and, when necessary, to apply silk-thread retractors. Charred tissue must be excised, and the part injured secured with fingers or forceps and drawn out, surrounded by gauze or sponges, and dealt with by suture or ex- cision as the case requires. When flush- ing is employed for the removal of foreign matter or extravasated fluid, some clean water left within the cavity often has a very beneficial effect. In hepatic injury often the chief difficulty is haemorrhage. This, however, can be stopped by pressure with or A\ithout per- chloride of iron or suture. Wounds of the intestine can be treated expeditiously by the aid of some sort of contrivance; but, of all the mechanical instruments introduced. Murphy's button is the best. J. Ward Cousins (Brit. Med. Jour., Oct. 21, '99). 30 ABDOMEN. PENETRATING WOUNDS. TREATMENT. One of the important elements of suc- cess in the treatment of gunshot and stab wounds of the stomach is time. Unnecessary time lost in finding and suturing the visceral wounds is a source of immediate danger to life which should be eliminated as far as possible by means which enable the surgeon to fig. 1. — Suturing of posterior wound through anterior. Purse-string catgut suture in place. (W. Senn.) (British Medical Journal, Nov. 8, 1902.) make a quick and correct diagnosis, and by resorting to a method of suturing which closes the wound safely and se- curely with the least possible delay, and which leaves it in a condition most favorable for speedy definite healing. It is well known that small penetrating wounds of the .stomach often heal with- out operative intervention. By contrac- tion and relative displacement of the different muscular layers of the thick wall of the stomach the tubular wound is contracted and obstructed sufficiently to prevent leakage until the canal on the peritoneal side becomes hermetically sealed by firm plastic adhesions which prevent extravasation during the time required for the repair of the visceral wound. If in lai-ger wounds of the stomach the same degree of occlusion can be accomplished by the simplest mechanical means, then such a pro- cedure should take the place of the more time-consuming methods of suturing now in general use. This can be ac- complished with the purse-string suture. In gunshot injuries the defect in the stomach-wall is circular and the wound- margins contused; hence the deep su- tures could at best furnish a barrier to the escape of stomach-contents only for a short time, as their hold in the necrosed tissues would be imperfect and only of brief duration. In short, round wounds the circular suture is the one whicli will bring and hold together in permanent uninterrupted contact the serous surfaces in the most efficient manner. In the treatment of gunshot wounds of the stomach the principal object of suturing should be to close the perforation in such a way as to guard securely against extravasation, and at the same time approximate and hold in apposition a maximum surface of intact healthy peritoneum. This is accomplished by making a cone of the injured part of the stomach, with the apex corresponding with the wound di- rected toward the lumen of the organ. The purse-string suture, applied in a manner that will be described in the ex- perimental part of this paper, will main- tain this cone until the healing of the visceral wound has advanced sufficiently to render further mechanical support superfluous. The cone on the mucous side of the stomach acts in the manner of a valve, which in itself is an effective Eig. 2. — Purse-string silk suture in place. (N. Senn.) (British .Medical Journal, Nov. ,S, 1902.) barrier against the escape of stomach- contents, while the circular suture con- stitutes almost an absolute safeguard against leakage, and brings in contact the serous surfaces in the interior of the cone. For wounds of the posterior wall of the stomach the author recom- mends a purse-string suture of heavy ABDOMEN. PENETRATING WOUNDS. TREATMENT. 31 durable eatgut to be applied through the anterior wound. The anterior wound is closed with a purse-string su- ture of silk of medium size applied to the base of the cone on the serous side. It is desirable that the circular suture should cause no necrosis of the included tissues. By using an absorbable suture in closing the posterior wound in the interior of the stomach this object is Fig. 3. — Showing result of purse-string silk suture closing anterior wound in stomach- wall. (N. Senn.) (British MediOiil Journal, Nov. 8, 1302.) gained, as only a small part of the thickness of the stomach-wall is sub- jected to pressure, and the tension caused by the ligature is gradually lessened by softening of its material, and is entirely removed by the absorp- tion and digestion of the ligature in less than three weeks. The wound of the posterior wall of the stomach is found and made acces- sible by inserting through the anterior wound a grasping forceps with which the posterior wall is seized at a point where, from the course of the bullet, the second wound is supposed to be located. Through a wound large enough to admit the index finger the greater part of the posterior wall of the stom- ach can be made accessible to sight and touch, and the perforation can be lo- cated and closed with the purse-string suture in a few moments. In doubtful cases inflation of the stomach should invariably be practiced for the detec- tion of a second and possibly a third perforation. The experiments demonstrated the safety of the circular suture in the treatment of gunshot and other pene- trating wounds of the stomach. All • of the animals operated upon in this manner recovered, and the repair of the injuries as shown by the specimens are ideal. The absence of adhesions over the posterior wound and their constant jiresenee over the anterior wound indi- cate that the presence of the silk liga- ture and the needle punctures were the causes of the circumscribed plastic peritonitis which produced them. In none of the specimens could any indica- tions be found of necrosis of any of the inverted tissues, and included in part by the circular suture. In the course of three weeks the con- tinuity of the mucosa at the seat of the injury was completely restored. The result of these experiments has. convinced the author that the circular suture compares favorably with the- methods of suturing in general use, and besides has the great advantages over them in the ease of its application and the saving of much valuable time. Suturing of the posterior wound by partial eversion of the stomach through the anterior obviates unnecessary hand- Fig. 4. — Showing in-igation of bursa omentalis- through the opening in the posterior wall of the stomach. (N. Senn.) (liritiBh Jledical Journal, Not. 8, 1902.) ling of the organ and the necessity of interfering with the vascular supply in- cident to exposure of the posterior wound, as is done by the methods now generally practiced. If extravasation into the retroga.strio space has taken place, flushing through the posterior- 32 ABDOMEN. PENETRATING WOUNDS. TREATMENT. wound and a vertical slit in the gastro- colic ligament and gauze drainage through the latter are invariably in- dicated. N. Senu (Brit. Med. Jour., Nov. 8, 1902). The stomach and the transverse colon are best brought to view by an incision in the linea alba. In the case of the stomach hernia of the mucous membrane will facilitate recognition of the lesion. The ascending colon requires lateral in- cision on the right side, and the descend- ing on the left. These also should be sufficiently long to facilitate the search for the injury or injuries that may be present in the organ itself and beyond. The incision may be such as to inter- sect the wound of entrance. This is de- sirable at all times, the aim being, of course, to always avoid unnecessary solu- tions of continuity. Sitch an incision can fortunately be made in many of the cases in which the haemorrhage is not formidable. Hcemorrhage. — When the abdominal cavity is opened and the haemorrhage, which is usually more venous than arte- rial, is marked, the blood rapidly accu- mulates in the most depressed portion of the cavity from an invisible source. To mop out the blood with sponges is gen- erally recommended; but such a proced- ure does not cause the htemorrhage to cease, — the first desideratum. In these formidable cases an assistant should at once introduce his hand throiigh the wound — hence the advisability of a long incision — and compress the abdominal aorta below the diaphragm. This proced- ure immediately checks the flow. Care- fully cleansed and disinfected sponges having been made ready in the mean- time, the blood present is quickly, but not roughly, sponged out. When this is finished the source of haBmorrhage is sought after. If any difficulty is experi- enced, the digital pressure upon the aorta may, for an instant, be decreased, and a sudden gush will point to at least the direction from which the blood comes. The necessary steps are then taken to arrest the flow, and the abdominal aortJi is released as soon as possible, — not sud- denly, but by a gradual reduction of pressure. The measures to be adapted in arrest- ing hjemorrhage vary according to the organ involved. Gunshot wounds of the liver are frequently stellate, and rents, radiating from the bullet-track in vari- ous directions, greatly increase the bleed- ing surface, the parenchyma in this organ taking part to a great degree in the emission of blood. To force resilient sponges into thes€ tears is to increase their depth. If the wound be not very extensive, it may be sutured with catgut or cauterized with the actual cautery. If the wound is extensive it had better be packed with long strips of iodoform gauze, one end of which is brought out of the external wound. Five cases of wounds of liver: two by fire-arms and three by a cutting instru- ment. Two great dangers are hsemoi-- rhage and infection. Immediately after accident, if there is indication of inter- nal hsemorrhage, exploratory laparotomy should be performed. For control of haemorrhage tampon may be utilized in grave cases, where work must be done quickly. Suture is method of election. Statistics show, out of 50 cases of oper- ative interference in hepatic wounds, 36 resulted in a cure and 14 ended fatally. L. Walton (Araer. Medico-Surg. Bull., Jan. 10, '98). The spleen is next in order as to pro- fuseness of hsemorrhage. The same pro- cedures may be adopted as for the liver, but the introduction of iodoform strips is to be preferred. If these means fail, splenectomy is the only measure left. ABDOMEN. PENETRATING WOUNDS. TREATMENT. 33 Sometimes a portion of the organ pro- jects through the wound; removal of the protruding portion should be practiced after passing a ligature around the mass. Case of prolapse of spleen through a perforating wound of the abdomen of three weeks' standing. Spleen at first considered to be the liver, though on the left side, on account of the size, shape, and color of the organ. Attempts to reduce it failed. It slowly contracted, becoming, within a month, less, by half, in size, and contracted very firm adhe- sions to the skin, the peritoneal cavity, meanwhile, being completely shut off. As there had been a compound fracture of the tenth rib, with subsequent necro- sis of the broken ends of the bone, a sinus remained, leading from the pro- lapsed organ to the bone; and here the adhesions were very vascular. The pleura had escaped uninjured. Splenec- tomy. Uneventful recovery. E. Harold Brown (Brit. Med. Jour., Jan. 16, '97). The walls of the stomach and intes- tines may also give rise to marked liEem- orrhage notwithstanding their compara- tive thinness. The number of vessels coursing through them, however, is very great. In these cases it is best to hem the margins of the wounds with tine silk. The bladder may be treated in the same way. The mesentery sometimes bleeds pro- fusely when perforated. The mesenteric vessels should be ligated eti masse with fine silk. Hemorrhage of the kidney is arrested in the majority of cases by iodoform- gauze package. If this should prove in- effectual the organ must be exposed and the vessels tied if possible. If not, nephrotomy or nephrectomy should be resorted to. The latter operation does away with the chances of complication attending the former, while the kidney of the other side assumes the function of both. Case in which the patient, a boy of 8 years, was shot by his brother with a small Elobert pistol, the bullet entering just above the os pubis and passing down toward the right. Considerable urine extruded from the wound, and 03dema of the scrotum and penis ap- peared. Incisions allowed the escape of considerable urine and the bullet was also extruded. The patient rapidily re- covered. B. Bayerl (Miinehener med. Woeh., May 7, 1901). Perforation. ■ — To detect the presence of a perforation and its location, Senn's hydrogen test, already mentioned, may be employed. Senn's method of hydrogen-gas insuf- flation, however admissible in recent eases, should be used with great caution after the lapse of a few hours. The dis- tension and motion of the intestines caused by the insufflation might rupture inflammatory adhesions, burst open in- testinal wounds that had nearly healed, and make a peritonitis general which had become circumscribed. McGraw (Trans. Amer. Surg. Assoc, vol. vii, '89). The fact that the intestines are, at times, perforated in twenty spots by a bullet suggests the considerable degree of care that should be given to this part of the procedure, which is carried out in the following way: The perforation nearest the rectum having been detected, the portion of intestine perforated is gently brought into full view. An as- sistant causes the gas in the portion of gut below the laceration to escape through the latter by slight pressure. This being done, the next step is to ascertain whether there is another perfo- ration above. A fresh, perfectly aseptic glass tube is placed at the end of the insufflating tube and introduced into the wound with the tip directed away from the rectum. The assistant now being directed to compress the intestine below the perforation, a small amount of gas 3-1 ABDOMEN. PENETRATING WOUNDS. TREATMENT. blown above the latter will inflate the upper segment if there is no opening, or indicate the location of the perforation if there is one. As soon as the latter is detected, the tube is withdrawn, the neighboring intestine on each side of the first perforation is disinfected, and the opening is closed. This procedure is renewed until all perforations have been found and closed. This plan renders un- necessary the renioval of the intestines from the abdominal cavity during any part of the operation, the source of com- plications in many cases, and of death by aggravated shock in others, and is now recommended by the majority of Amer- ican surgeons. There is great ground for the objec- tion to Senn's method, made by many surgeons, as regards its use for purposes of diagnosis prior to laparotomy, but, in the detection of perforations after the abdomen has been opened, it is of value, and may be used, at times, to great advantage. The manner of closing the wound is that indicated for lacerations following blows. The stomach and intestinal per- forations being treated in the same way, the margins of the wound are turned inward and the serous surfaces are imited by a continuoiTS, fine-silk Lembert suture or by interrupted sutures, including the serous and muscular coats and the sub- mucosa. These are cut short and left in, being eventually discharged per anum. At times the tissues around a perfo- ration are sufficiently contused to render an omental graft necessary. Entereetomy is sometimes required, and not infrequently exsections of the intestine are necessary. In that ease the intervening portion, if it is not too long, had better be resected, thus avoiding a double operation in the continuity of the gut. Case with six intestinal perforations and wound in bladder 4 centimetres long. Resection of 62 centimetres of small intestine. Slight cystitis; recov- ery uneventful. Eieder (Le Bull. M6d., Jan. 3, '95). After the active measures described have been carried out the extravasation of the contents of the stomach or intes- tines may make it necessary to flush the peritoneal cavity. Warm, sterilized water should be used, but care should be taken not to handle the intestines roughly. By turning the patient on his side the fluid is poured out. The abdominal cavity is then dried with large sponges wrung out of warm, sterilized water. Chilling of the viscera shottld be carefully avoided, and the parts should be exposed to the air as short a time as possible. Case of stab wound illustrating the value of salt solution. Within the abdo- men, where only salt solution was used, no inflammation or trouble followed; A\hereas at the abdominal wound, where bichloride, etc., were used, suppuration took place. P. R. Bolton (Med. Record, July 31, '97). Case in which coeliotomy for gunshot wounds disclosed fourteen perforations of the small intestine. Closed with con- tinuous and Lembert suture. Abdom- inal cavity flushed with saline solution, drained with gauze; recovery. George Sherrill (Med. Record, Oct. 7, '99). Drainage is sometimes necessary, espe- cially for wounds of the solid viscera, such as the liver, spleen, kidneys, etc., in which active measures were not re- sorted to early. In abdominal surgery the weight of evidence stands in favor of dispensing with drainage whenever it is possible. Method of closing abdominal wound layer by layer has greatest number of advocates, and materials mostly used for sutures are catgut, chromieized cat- gut, silk-worm gut, and silver wire. Causes of post-operative wound-infection fire unnecessary manifestations of wound, ABDOMEN. WOUNDS DUE TO illLITARY ARMS. 35 rough retraction of its edges and pro- longed pressure with metal retractors, imperfect hsemostases, strangulation of large bits of tissue by ligatures, and un- due tension of the sutures. A. C. Hef- fenger (Med. Record, Dee. 17, '98). Case of attempted suicide in which the intestine was wounded with a pair of scissors. The intestinal wounds were closed with silk, mostly by interrupted sutures, and a gauze drain was carried out of the median end of the wound and the walls of the abdomen closed. Recovery. Deiters (Miinch. med. Woch., Sept. 4, 1900). To summarize: we will say that imme- diate exploration of the abdominal cavity is indicated as soon as it is suspected to have been penetrated or in any way in- jured by a traumatism. The injury to its contents must then be repaired under strict aseptic precautions. The value of salt-solution flushing is emphasized by the results of practical experience. ShoiUd no lesion be found, the mere exploration should result in no serious After-treatment. — Food should be withheld for thirty-six hours, but a little water and brandy, in teaspoonful doses, may be allowed, especially if there is any degree of shock. In that case it is advisable also to use stimulants by the rectum or subcutaneously. Kutritive enemata of beef-tea and milk are neces- sary to sustain the patient's powers. In three cases that recovered one had 16 wounds of the small intestine; one, 14, and another, 10, and it would seem almost impossible to imagine that re- covery could have taken place in these cases without operation. The after- treatment is regarded as all-important. During the first twenty-four hours only cracked ice was allowed and stimulants. On the second day the patients were fed with chicken-broth at intervals of two to four hours. Rectal feeding with pre- digested foods and alcohol was practiced. A. B. Miles (Annals of Surg., Dec, '93). The bowels should be kept freely movable. Large doses of Epsom salts sometimes serve to thwart the danger of peritonitis, without compromising the intestinal wounds, by removing all nox- ious material that may have accumu- lated in the bowel. Liquid food may be permitted by the evening of the second day, and soft, easily digested food after a week, rectal alimentation being continued until then. The sutures can be removed on the ninth day. The closure of the external wound must be complete before the pa- tient can be allowed to leave his bed, and the danger of a ventral hernia should be counteracted by means of an abdominal supporter. Hypodermic injections of strychnine, ^/go to V30 grain, three times a da)', ac- cording to indications, will prove most effectual in maintaining the strength of the patient and toning the muscular wall of the intestine. Wounds Due to Military Fire-arms. [See supra, Peneteating "Wounds, for details.] During the Franco-Prussian War Ger- man soldiers were frequently found suf- fering from wounds of so frightful a nature that the French were accused of using explosive bullets contrary to the International Convention to that effect. Wounded limbs showed lesions of so de- structive a character that the hole made was a magma of muscle, tendon, bone, blood, etc. Dead subjects were found with their heads completely shattered, the brains being scattered on all sides. The good faith of the French was soon demonstrated, however, experiments hav- ing shown that their rifle, the Chasse- pot, was capable, when fired at close quarters, of creating unusual lesions on account of the initial velocity and the greater rotation of the bullet. This was 36 ABDOMEN. WOUNDS DUE TO MILITARY ARMS. attributed mainly to the reduced diam- eter of the bore, 11 millimetres, and to the increased quantity of powder used. In 1886 France adopted 8 millimetres as the calibre of her military arm, and the other nations soon followed her ex- ample. The United States Government adopted two calibres, one of 7.62 mil- limetres for the army, and one of 6 mil- limetres for the navy. Contrary to all expectations, the effects noted in recent wars, the war between Chili and Peru, in which a 7.6-millimetre calibre was used; that between China and Japan, in which a 7.9-millimetre was used on the Japanese side, and the more recent Chitral expeditions and Abyssinian cam- paigns, in which 7.9-millim-etre and 6.5- millimetre arms, respectively, were em- ployed, were less destructive than the larger calibres, while the wounds caused by them healed with greater rapidity than those following lesion due to the action of larger balls. During the Chil- ian War there were instances where men completely perforated through the chest would suffer from slight shock, a slight hasmoptysis, and soon be out. This radical difference between the •destructive power of large and small cali- bres, or, rather, between the destructive ■effects of an arm such as the Chassepot (11 millimetres) and the modern rifle (6 to 8 millimetres), is mainly attributed to the fact that lead was formerly em- ployed in the manufacture of bullets; whereas, at present, in order to avoid destruction of the bullet during its prog- ress through the barrel, resulting from the great increase of the powder-charge, and with the view of reducing the weight carried by the soldier, owing to the in- troduction of repeating arms, the bullet itself is either made of some hard metal, or it is covered with some such substance as nickel, steel, German silver, etc. These physical features, added to the smaller diameter of the projectile, the much greater velocity with which it travels, its more or less pointed tip, causes it to penetrate soft tissues as would a long, thin blade, separating- rather than destroying them. There- fore perforations in a muscle are clean- cut; at times their walls are even col- lapsed; as a rule, the channel is about the size of the bullet; large blood-vessels are severed and bleed until the heart ceases to beat, etc. Experiments on dead bodies seemed to show that very different effects were to be expected as soon as any resistance was offered to the passage of the bullet. When the skull was struck even at long range (1100 metres, Kocher), for in- stance, the brain was completely disor- ganized and the skull was fractured in all directions, while at short range ex- plosion of the head might be said to have taken place. But experiments on dead bodies are now known to furnish but little accurate information as regards the effect of projectiles, the living tissues being affected differently. At short range destructive effects on soft and hard tissues are produced, but these do not vary from those by older weapons at equal distances. Accepting only as evidence that fur- nished by the use of small-calibre bullets on the living, it may be said that the arms now furnished to armies do not give rise to injuries such as those met with in civil life, when weapons of vari- ous kinds, imparting to bullets a much smaller velocity, are used. It is evident, judging by the practical evidence at present at our disposal, that military gunshot wounds cannot be con- sidered absolutely as belonging to the category reviewed in this article. But it is only a question of degree as to the ABDOMEN. WOUNDS DUE TO MILITARY ARMS. 37 injuries inflicted, and the military sur- geon, by exercising his usual powers of discernment, will find a larger number of curable cases, whenever the severe haemorrhages frequently attending the use of these new weapons will not have caused death soon after the receipt of the injury. Wounds of the thorax and abdomen divide themselves into penetrating and perforating. It must not be forgotten that a slight haemoptysis may accom- pany the first type, from the mere im- pact of the blow. In all wounds the probe is always eontra-indieated. As to the prognosis of chest wounds, sta- tistics are very pessimistic, for, unless the cases die within the first two or three hours or are killed by meddlesome surgery, they recover in a vast majoritj' of cases. It is certain that here a masterly inactivity should characterize the operator. In dealing with lodged balls the author cannot do better than quote Abernethy, who, in speaking to his students, said that when Sir Ralph Abercrombie, who had received a bullet in the thigh, was placed under the sur- geon's care, "they groped and they groped and they groped, and Sir Ralph died." It must be remembered that per- forating wounds of the abdomen do not in many cases enter through the ab- dominal wall. Many have entered via the pelvis or the chest. In wounds above the umbilicus, probably, there are 3 per cent. Avhich penetrate without per- forating. The direction of the bullet has importance, the antero-posterior being better than the oblique, and these, in turn, being more favorable than the flank-to-flank type. Prognosis is based properly upon the statistics of many eases. These in general show that un- operated cases give a 55-per-cent. mor- tality. In patients operated upon dur- ing the first 4 hours, there is but 1.5 per cent. ; in 4 to 8 hours, 44 per cent. ; in 9 to 12 hours, 63 per cent. ; after 12 hours, 70 per cent. The speaker emphasizes the importance of early diagnosis. Faecal extravasation usually does not occur until after the fourth hour. This is due partly to the in- testinal paresis resulting from the im- pact. The treatment is to cover the wound and not handle it too much. Infusion of very free type and equally generous drainage, particularly in civil practice, are both indicated. Injuries of the posterior cavity call for posterior drainage. Seeking the ball is contra- indicated; unless, indeed, it comes into view without efl'ort, it should be let alone. (William L. Rodman.) Many men are led astray by the old and erroneous teaching that the circuit- ous route in the abdomen is an utter impossibility. It may chance that a spent bullet striking the skull may be deflected by the bone, but no bullet can be turned aside by the soft viscera. Another point is that the shape of the abdomen is constantly changing. It is by no means difficult to place an athlete in such a position of strain that the anterior abdominal wall is in contact with the backbone. This, no doubt, explains the anomalous conditions where bullets have traversed the abdomen without injuring the viscera. (Mc- Graw.) Army surgeons are averse to early operations on the field. The fact that officers who had lain in the open for twenty-four hours with no care save a protective dressing, with absolutely no food or drink, have recovered, is in- structive ; it may very likely be that such absence of eating or drinking is a desideratum. (Grant.) The importance of venesection in in- cipient pneumonia following bullet wounds should not be overlooked. Shock is entirely distinct from bfemor- rhage. (Roberts.) All-important treatment in the case of chest wounds is absolute costal im- mobilization. The manner of accom- plishing this is to put on a cast of either plaster of Paris or rubber plaster, extending from the umbilicus to and over the shoulders. (Ochsner.) The prognosis depends very materially on whether the viscera are full or empty. If empty, the same forces whicli when full extrude food close the wound. The value of aseptic food has been al- together overestimated, for the alimen- tary canal contains about every known 38 ABDOMEN. pus-producing organism. It is tlie in- jury to the mucous membrane which kills the patient. (Laplace.) In controlling the haemorrhage from chest \Younds a most valuable method was that of cording three extremities for fifteen minutes, then passing on to the fourth, alternating in this way for several hours. It serves the same pur- pose as venesection, but preserves the blood. The author has heard from a great many of his old students, who have been operating in the Philippines and Cuba, and gave their reports to him in detail. They agreed thai on the bat- tlefield operations cannot be done be- cause of the absence of two essentials: fire and water. The value of morphine, pushed to its limit, which constitutes a so-called opium splint and which makes the patient comfortable, is prob- ably a very important factor in saving lives. (Dawbarn.) Proc. Amer. Med. Assoc. (N. Y. Med. Jour., June 14, 1902). Our recent campaign has but verified the teachings just outlined. Eknest Laplace, Philadelphia. ABDOMINAI ANEURISM. See Aneukisji. ABORTION. Definition. — Abortion is a term used to denote the expulsion of the product of conception, aliye or dead, during the first six months of pregnancy; or, more exactly, the expulsion of a product of pregnancy which has not yet attained the period of viability, thus including cases where the foetus may perish dur- ing the sixth month of pregnancy and be delivered a month or so later. A number of authorities, especially American and English, only apply the term "abortion" to expulsion of the ovum during the first three months, while "immature delivery" and "miscar- riage" are applied to expulsion of the product of conception from the end of the third month to that of the seventh, — i.e., from the formation of the pla- centa to the time the child becomes viable. When the expulsion takes place between the period of viability and the normal term of pregnancy, it is called "premature delivery." Frequency. — It is difficult to ascer- tain the frequency of abortion (1) be- cause during the first two months of pregnancy it often occurs without being detected; (2) because, when known and even when occurring at a late date, it is frequently allowed to go without treat- ment. The statistics obtained in maternities give a proportion of one abortion to three normal pregnancies; but such a proportion cannot be accepted as a rule, lying-in hospitals receiving only women in an advanced state of pregnancy. It is generally admitted that spontaneous abortion occurs most frequently during the first three months of pregnancy. Viability. — Until recently the f CBtus was clinically looked upon as viable only after the seventh month; but more care- ful treatment — above all, the use of the incubator and of artificial feeding by means of the stomach-tube — has caused children born during the sixth month to be looked upon, clinically, as well as legally, as viable. A very young fcetus may breathe after delivery. This occurred in three cases in the fifteenth, fifteenth, and nineteenth Aveeks respectively. In the first of these there were sis respiratory movements be- fore and five after severing the cord, the foetus living one hour. In the second case the foetus lived an hour and a half and breathed five times. The third foetus lived but half an hour and breathed eight times. The autopsy showed air in the stomach, but the lungs were empty. Glockner (Cent. f. Gyn., No. 1, '90). In performing an autopsy upon a M'oman who is supposed to have at- ABORTION. SYMPTOMS. 39 tempted abortion search should be made for the embryo or pieces of it, or for the placenta. If the uterus is empty, the thickness of its walls must be meas- ured, and the insertion of the placenta sought, as this can be recognized up to the tenth day after the expulsion of the embryo. This is possible even later, if the uterus is kept in 90 per cent, alcohol. The examination of the ovaries is of only relative importance, as no positive signs exist there. Stains of meconium, if found, will prove the abor- tion. If an instrument has been used to cause abortion, traces of the damage done by it will be seen. This is espe- cially true when the uterus has been perforated. Brouardel (Jour, des Pra- ticiens, .Jan. 12, 1901). Symptoms. — Abortion is divided as to its symptomatology by the majority of obstetricians into four classes: — 1. Abortion occurring during the first month. 2. Abortion occurring during the sec- ond month. 3. Abortion occurring between ' the beginning of the third month and the end of the fourth month. •i. Abortion occurring during the fifth and sixth months. After the third montli the abortion presents very distinct clinical characters. Abortion in general is ustially pre- ceded by dysmenorrhceal pains, extend- ing as far as the loins, and a sensation of bearing down in the pelvis, or con- tractions of the uterus with or without haemorrhage. When the death of the foetus precedes the abortion, the uterus ceases to in- crease in size, and all reflex symptoms caused by pregnancy disappear. Abortion During the First Month. — This usually gives rise to symptoms simulating those of retarded menstrua- tion. Slight pains in the back in the region of the uterus are complained of; the symptoms, in this particular, resem- ble those of normal labor, but are very much less marked. Blood, blood-clots, and flakes of the mucous membrane of the uterus are gradually expelled during several days. The ovum is expelled en- tire, but it is so small that it is rarely discovered. Abortion During the Second Month. — Inasmuch as the uterus has decidedly increased in size as compared to the flrst month, the contractions and pains are proportionately stronger. The embryo is usually expelled inclosed in the un- broken membranes. Sometimes, how- ever, the latter are ruptured. The embryo and membranes may be detached from the uterus in two ways: (a) By hemorrhage between the mem- branes and the uterus, followed by uter- ine contraction. (6) By contraction of the uterus, fol- lowed by hsemorrhage. In the latter case the abortion is more prolonged, the mem- branes being detached biit slowly from the uterus. If the embryo be still living, the abor- tion lasts longer, and the haemorrhage is greater. If the embryo be dead, the whole is usually expelled like a foreign body, and without rupture of the mem- branes. Examination of the uterus will show that it is increased in volume, and situ- ated lower down in the pelvis than nor- mally. The cervix is dilated, softened, and filled with blood-clots. The dilata- tion is more marked in multiparse than in primiparffi. The cervix, though dilated, does not become effaced; and the embryo con- tained in the unruptured membranes may pass through the cervix and be ex- pelled. If the membranes are ruptured, however, the embryo passes by itself, the very thin umbilical cord breaks, and the cervix closes. The membranes are, in 40 ABORTION. SYMPTOMS. this latter case, expelled later on. The membranes are ruptured about once in every two cases. Abortion from the Beginning of the Third to the End of the Fourth Month. — • This occurs nearly always in two stages, the first consisting in the expulsion of the foetus, and the second in the expul- sion of the membranes and placenta. The cervix in this form of abortion tends to diminish in length. The uter- ine contractions act more powerfully than in the previous forms of abortion. Under their influence the membranes are ruptured and the fretus is expelled. The placenta may still be adherent; the cervix then closes again, and the placenta and membranes are expelled later on. Hgemorrhage is likely to ac- company the delivery of the placenta and membranes, especially when the former is only partly detached. Under these circumstances each uterine con- traction is accompanied by htemorrhage. The placenta may be already detached when the foetus is expelled; in such a case it is likely to be expelled imme- diately after the latter, before the cervix closes, but part of the decidua may re- main in the uterus after delivery of the placenta. This occurs most frequently when the foetus is dead. Statistics show that retention of the placenta occurs most frequently during this period. At three months the placental form is well established, and the uterine contents behave much as they do at full term, with these differences: the placenta is less firmly put together and is more firmly united to the uterus. There is danger, therefore, of masses of placenta being retained, even though much may be expelled. Ayers (N. Y. Med. Record, Sept. 28, '95). Abortion During the Fifth and Sixth Months. — The foetus and placenta are al- most always expelled separately. Uterine contraction is more marked; the cervix tends to become more efEaced and to dilate. Delivery of the placenta usually fol- lows delivery of the foetus rapidly, and the tendency to hsemorrhage is less marked than in the previous forms of abortion. Of 501 cases of abortion analyzed by Varnier and Brion, the foetus, or em- bryo, and the placenta were expelled separately in 453, and together in 48 cases. When the delivery occurred in two stages, the time found to elapse between the expulsion of the fcetus and that of the placenta was as follows: 120 eases, within 15 minutes; 81 cases, from 15 to 30 minutes; 78 cases, from 30 to 60 minutes; 83 cases, from 1 to 4 hours. In 275 cases treated in the last two years of those eases terminating natu- rally expulsion of the whole ovum oc- curred in hospital in 145 cases. The remaining 39 were admitted with the placenta partially or entirely retained. Complete expulsion occurred after a period varying from a few hours to three days as a maximum. During this time rigorous antiseptic precautions were ob- served (douches, etc.). All these cases terminated favorably with two excep- tions: one patient was septic on ad- mission, and died of septicaemia; the other case died of pulmonary tubercu- losis. Maygrier (L'Obstetrique, July, '97). Whenever the placenta and membranes are not expelled within four hours after the expulsion of the fcetus, or embryo, there is retention of the membranes and placenta. Abortion may take place suddenly, or resemble, in that particular, the irregular periodicity of normal labor, with more or less hsemorrhage. It may, indeed, last several days, owing to weakness of the uterine contractions or adhesions to the Development of the ovum (Caseaux, Hunter, Erdl, &c ) Fiqures 3 and b The ovum during the second and fourth week Fiqure c Seclion of the uterus ' reduced I showinq thei thickened mucous membrane which is fofurnish the decidua vera. FiqurEsdand,dTheo«um attheendofthesixlh week ABORTION. PATHOLOGY. COMPLICATIONS. 41 uterus or retention in the cervix of the masses to be expelled. (Kokitansky, Schlilein.) Sudden or rapid abortion is frequent during the first two months; when the expulsion takes place after the third month it generally presents the charac- ters of normal delivery. Pathology. — Abortion comprises a period of uterine dilatation, the expul- sion of the ovum, and involution of the uterus; when delay occurs in any one of these three stages the abortion is protracted. The most frequent cause is failure of the os and cervix to dilate, resulting from a rigid condition of the tissues following laceration or previous inflammation. The internal os may be closed and the external os and cervix dilated, or the external os may be closed while the internal is dilated. The mus- cular wall of the lower portion of the ut«rus is thinned in abortion, so as to give a lower segment, which is as well marked in the aborting uteriTS as in the uterus in labor at full term. The peri- toneum over this part of the uterus be- comes loosened, as the result of the ex- pansion of the museiilar wall; and the deeidua over the same area is also sepa- rated from the same cause. (Berry Hart.) Complications. Eetention of the Secundines. — This is the most frequent complication of abortion, spontaneous or criminal, and may present either of the following characters: The placenta is non-adher- ent, but remains within the uterine cavity until finally expelled, either en- tire, or in pieces. As infection easily occurs in such a case, great attention should be paid to the temperature. The placenta remains completely adherent. When this is the case the placenta is expelled only some days later, as late even as thirty days after delivery of the fcetus. [According to some autliors, the pla- centa may be absorbed and no expul- sion occur. This opinion cannot any longer be admitted. When the placenta remains for years in the uterine cavity without producing alarming symptoms it is likely to become transformed into a mole. A. LuTAUD.] The placenta is partly adherent and partly non-adherent. This is the most dangerous condition, as it is the most liable to be accompanied by hasmorrhage or septicsemia. Great care should be taken in such a case not to pull on the placenta, lest more haemorrhage be pro- duced by further detachment. An entire placenta in the uterus is not dangerous, but fragments rapidly give rise to grave sj'mptoms. Bureau (Jour, de Med., Apr. 3, '92). Tetanus after abortion. The latter occurred during the third month. The uterus was properly cleared, but on the ninth day the temperature rose, then fell after an injection of collargolin. Trismus was observed on the next day, followed by tetanus, which grew worse till the fifteenth day. Numerous in- jections of Behring's tetanus antitoxin were administered, and recovery fol- lowed. Osterloh (Monats. f. Geb. u. Gyniik., Aug., 1902). HEMORRHAGE. — Haemorrhage may oc- cur during the detachment of the ovum itself, during the detachment of the pla- centa immediately after delivery of the foetus, or during detachment of the pla- centa, the latter occurring several days after delivery of the fcetus. The blood may be normal and be at once expelled from the genital organs; or it may form a half-coagulated mass within the vagina. Masses of fibrin in the blood should be diagnosed from the ovum itself, for which they may be mis- taken. The symptoms are those of all forms 42 ABORTION. COMPLICATIONS. ETIOLOGY. of hsemorrhage. When profuse there is a weak pulse, pallor, disturbances of hearing and sight, and vertigo. The danger from the hsmorrhage is not so great as the general symptoms would often indicate; still, any serious loss might diminish resistance to infec- tion. Cases of haemorrhage before miscar- riage, indicating the advisability of rap- idly bringing the abortion to an end when the loss of blood is serious. Martin (N. Y. Med, Jour., Feb., '92); Blood (Chicago Med. Times, Aug., '92) ; Hirst (Amer. Gyn. Jour., Feb., '92). Inversion of the Uterus. — Inver- sion of the uterus is occasionally ob- served as a complication. The uterine wall should be handled with care when efforts at reduction are made, pressure with finger-tips being avoided. But 1 case of inversion of uterus met with in 190,000 labors at Rotunda Hos- pital; 250,000 births were recorded in Vienna without a ease. Case of patient who had three living children, but dur- ing fifteen months preceding entrance into hospital she had miscarried four times between third and fourth month. On fifth day following last miscarriage she flowed freely, with sudden pain in abdomen, attended with collapse. She remained in bed six weeks. Two days after getting vip she felt that something came down and endeavored to keep it back with a cloth. Examination detected inversion of uterus. The mucous mem- brane of uterus showed no tendency to become dry and skin-like. Several days later uterus menstruated, which lasted four days. Under ether, reduction was accomplished only by making free in- cisions into the cervix and longitudinal incisions over uterine mucous membrane at region of internal os, in addition to continued pressure kept up on neck of swelling and over its surface. Patient subsequently became pregnant and was delivered at term without trouble. A. W. W. Lea (Med. Chronicle, vol. viii. No. 3, p. 177, '98). Septicemia. — Septicsemia frequently accompanies excessive haemorrhage. It may be revealed by foetidity of the lochia. The latter symptom is not in- variably present, however, as no odor may be noticed, notwithstanding active septicaemia. Chill and high temperature may be considered as the positive signs of infection. Case in which abortion was followed by septic endometritis, salpingitis, gen- eral peritonitis, and an abscess of each ovary. Dorsett (Weekly Med. Review, Feb. 14, '91). Tetanus, etc. — Tetanus and other nervous disorders may follow abortion. Case of tetanus following abortion at the fourth month. Brownlee (New Eng- land Med. Monthly, Nov., '91). Case of hemiplegia following abortion. The cervix had been dilated with tam- pons to remove an adherent portion of the placenta. Fenwick (American Jour, of Obst., Apr., '91). Case in which, twelve days after a supposed artificially produced abortion, a 30-year-old woman suffered from trismus and tetanus, the convulsions being se- vere and frequent. Successful treatment by means of antitoxin. Ch. F. Withing- ton (Boston Med. and Surg. Jour., vol. cxxxiv. No. 3, '96). Etiology. — The causes of abortion may be due to disorders affecting the father, the mother, or the fcetus itself. Analysis of a large number of cases of abortion occurring in the author's prac- tice gives the following conclusions: Habitual abortion gives 18.6 per cent, of the whole. Uterine diseases cause 50 per cent, of the abortions. Reflex causes, either simple or complicated, exist in 21.5 per cent. Syphilis affecting the foetus, retroflexion, salpingitis, and rheumatism, each 7.1 per cent. There were 78.5 per cent, that subsequently bore children, and 21.5 remained sterile. Of these, 14.3 per cent, have Incurable uterine affec- tions or are past child-bearing, and 7.2 are healthy, but sterile. Leith Napier (Satellite of the Annual, Feb., '89). Paternal Causes. — Abortion may be due to the following paternal influences: ABORTION. ETIOLOGY. 43 Advanced age; lowered vitalitj', due to overwork or excesses, especially venereal; to syphilis and tuberculosis; and to nox- ious influences, such as lead poisoning and alcoholism. Three cases of frequent abortions, due to lead poisoning from service-pipes, ■which ceased when the cause was re- moved. Swan (Brit. Med. Jour., Feb. 16, 'S9). Case of a 37-year-old X^TII-para, who has aborted in the last sixteen preg- nancies at between the fourth and the seventh months, after her husband be- came a house-painter, and soon after de- veloped lead colic, followed by paralj'tic symptoms. She seemed free from any of the symptoms from which her husband suffered, and had not been subject to either tubercle, syphilis, or alcoholism. Before her husband had become a painter she had given birth to two healthy chil- dren. Daniel (Journal d'Aecouehement, May 17, '96). Maternal Causes. — Similar causes to those mentioned for the father act in the mother, and with more certainty if both parents are affected by them. In addition the following noxious influences are to be noted: Tobacco (women employed in tobacco manufac- tories), carbon disulphide (women em- ployed in India-rubber works), and car- bonic oxide. To this latter agent is due the frequency of abortion in cooks, whose profession causes them to breath this deleterious gas during a portion of the day. Bad hygienic surroiindings, especially insuiEcient food, frequently promote abortion, while overfeeding and obesity (Stoltz) may also act as etiological fac- tors. Among local causes fibromyomata of the uterus and deviations (especially re- troversion) are the most frequent causes. Congestion of the uterus is a more im- portant factor than retrofle.xion. Leith Napier (Brit. Med. Jour., Dec. 20, '90). The predisposition to miscarriage in certain women is due to retroversion. Excellent results obtained from the use of pessaries when a miscarriage seemed imminent. Henry Coe (Int. Jour, of Surg., May, '92). Two causes of successive abortions merit, in particular, the attention of the obstetrician: (1) uterine affections, and retroversion in particular; (2) syphilis. Schuhl (Nouv. Arch. d'Obst. et de Gyn., Feb., '92). Analysis of 235 cases with reference to the causes. Syphilis is the most impor- tant cause, and accounts for 27 per cent, of the eases; retroflexion of the uterus is accountable for IS per cent.; chronic metritis and endometritis, 10 to 15 per cent. ; uterine fibroids, 4.7 per cent. ; ab- normal conditions of the placenta, 4 per cent.: anteflexion of the uterus, 3.5 to 6 per cent. ; molar pregnancy, 1 per cent. ; Bright's disease and lateral deviations of tne uterus, 0.5 per cent. Romlield (Cent, f. Gyn., No. 39. '95) . Distinct local uterine conditions in otherwise healthy women: 1. Hi-devel- oped uterus: the muscular coat does not readily soften, yet remains very irri- table. Rare. 2. Displacements, especially flexions. Spur at the angle of flexion hypertrophies interferes with uterine de- velopment. 3. Congestion of the body and cervix, due to idiosyncrasies. Endo- metritis. Charpentier (Ann. de Gyn. et d'Obstet., May, '97). Lacerations of the cervix, especially those of some depth, are a frequent cause of abortion. A primipara can usually give some cause for an abortion, such as a misstep or a fall, but in those who have previously borne children, where there is a fissure extending as high as the internal os that will admit the tip of the index finger, or the integrity of the lower uterine segments is lost, predisposition to abortion is undoubted. E. W. Rogers (Montreal Jled. Jour., April. 1902). Extensive laceration of the cervix, the foetus in such a case not being sustained from below. (Olshausen, Schwartz.) Old peritoneal lesions of the adnexa, especially ovarian cysts, come next in order as local etiological factors. 44 ABORTION. ETIOLOGY. Genital Excesses. — These act espe- cially by mechanical means. Yonng married women frequently abort five or six weeks after conception, on this ae- eoimt, while abortion is frequent among prostitutes for the same reason. (Parent Duchatelet.) Acute oe chronic general diseases, acting either by excess of temperature and changes in the composition of the blood or by alterations in the placenta. Typhoid Fever. — Abortion occurs in about two-thirds of the cases of typhoid fever, and is more apt to take place dur- ing the earlier than the later months of pregnancy. Enteric fever materially influences the course of gestation, since abortion occurs in something like two-thirds of the cases. Thus, Sacquin collected 310 cases, and found abortion in 199; while Martinet found 66 abortions in 109 cases. W. For- dyce (Brit. Med. Jour., Feb. 19, '98). The most prominent feature is uter- ine haemorrhage, which is often the first symptom of impending abortion. The use of ergot is to be avoided in cases of pregnancy occurring in conjunction with typhoid fever. Other remedies, such as cold baths or even quinine, may be safely used. The history and treatment of the typhoid state proper remain unaffected by the co-existing pregnancy. Pneumonia. — During the first months of pregnancy abortion occurs in more than one-third of the eases of pneu- monia, but this complication occurs with increasing frequency the more advanced the pregnancy. Taking a general aver- age of cases of abortion occurring during pneumonia, an estimate placing it at two-thirds of the cases is probably cor- rect. The foetus itself may suffer from pneumonic infection, and die soon after birth from pulmonary, meningeal, endo- cardial, or other lesions. Statistics of 213 cases of pneumonia during pregnancy: In 118 cases the preg- nancy was interrupted, there being 42 abortions and 76 premature deliveries. Death of the mother occurred in 75 cases among the 213 : a mortality of 35 per cent. The mortality of the mother is greater in premature deliveries than in abortion. S. Flatte (These de Paris, '92). Influenza. — It is probable that the marked nervous phenomena play a lead- ing part in the production of abortion. The vasomotors bear the brunt of the toxic effects in the majority of cases, and the secondary results of vasomotor dis- turbance in the uterus, which is richly supplied with vessels, are obvious. Report of a number of abortions or premature deliveries resulting from in- fluenza. Trossat (Lyon Med., Mar. 11, '90). Doubt whether abortion and premature labor in influenza depend upon mechan- ical irritation from coughing and hyper- iemia, with local congestion. It is very probable that in such cases the cause is infection from the uterine mucosa. Case of abortion occurring during influenza in a girl 19 years old; phlegmasia alba dolens developed three days after con- finement, followed on the fifteenth day by pyaemie abscesses in the sternal region. Labadie-Lagrave (La Med. Mod., Feb. 25, '92). Measles. — This disease seldom occurs during pregnancy. According to some authorities measles and pregnancy have but little reciprocal influence. Of eleven cases collected by Klotz, however, nine were attended by premature delivery. The influence of measles is but slight during the first months of pregnancy, and increases in gravity with the age of the pregnancy, the occurrence of this disease in childbed being generally fatal. Besides the danger of puerperal haem- orrhage, pneumonia is a frequent and formidable complication. Scarlet Fever. ■ — This disease rarely ABORTION. ETIOLOGY. 45 complicates pregnancy, although it is comparatively frequent in the puerperal state. The period of invasion being fre- quently absent, it is probable, however, that it remains unrecognized, and that a larger proportion of cases of premature birth and abortion are caused by it than is generally supposed. In some cases the stage of incubation is prolonged to such a degree that the scarlet fever contracted during pregnancy is recognized only after delivery by the sudden develop- ment of the eruption over the entire body. Of 8 pregnant women suffering from scarlet fever, 6 who were from 4 to 6 months with child recovered with- oiit accident, 1 aborted at 3 months, and 1 had a premature delivery at 7 months (Legendre). The cases are generally characterized by high fever, emesis, marked congestion of the face, and sud- den appearance of the eruption, which occasionally assumes a livid color. Small-pox. — This disease manifests a preference for women in whom the preg- nancy is not far advanced, but proves much more dangerous when it occurs near the parturient state. It attacks pregnant women oftener than any other disease. The probability of abortion varies with the intensity of the process present. Varioloid causes abortion in about one-tenth of the cases attacked (Mayer). Discreet variola causes abor- tion in about one-half the cases, while in confluent variola and hemorrhagic variola abortion nearly always occurs, especially if the pregnancy be advanced. The foetus may be expelled during either one of the stages: invasion, erup- tion, or suppuration. It may present characteristic variolous cicatrices: Occa- sionally the child remains unaffected; it may also suffer from the disease before or soon after birth, the mother remain- ing immune. Among 72 cases of small-pox in preg- nant women, 31 miscarriages and 20 deaths. Sangregorio (Med, Standard, May, '88). Abortion occurring during variola is usually attended with more than the ordinary amount of hseraorrhage. Gas- parini (Gaz. Med. Lombarda, No. 18, '92; I'Union Med., July 5, '92). Several serious cases occurring during convalescence after small-pox. The grave symptoms are due to the retention of the fffitus, which has died during the acute stage of small-po.\, and which is frequently only expelled during or after convalescence. Arnaud (Gaz. des Hop., July 28, '92). Cholera. — Women are the most sus- ceptible to this disease ditring the later period of pregnancy. Abortion almost always occurs, even in comparatively slight attacks, and the prognosis for mother and child is most unfavorable. The abortion has been ascribed to uter- ine contractions, to acute hsmorrhagic endometritis, and to disturbance of the foetal circulation caused by the thicken- ing of the blood. It is probable that these three factors are present simulta- neousl)', in addition to placental granu- lar degeneration, which cause the death of the foetus. Icterus. — This disorder rarely presents itself ditring pregnancy. It may occur in three forms: — (a) Simple catarrhal icterus, in which abortion frequently, though not always, occurs; (b) icterus gravis, in which abor- tion always occurs, and is almost invari- ably fatal; and (c) the epidemic icterus, peculiar to pregnant women, which causes abortion in the great majority of cases. Icterus presents a peculiar feature that renders it important in connection with pregnancy: i.e., its tendency to either precede or accompany the fatal patho- logical changes attending yellow atrophy of the liver. Pregnancy exerts a perni- 46 ABORTION. ETIOLOGY. cious influence upon the course of even simple icterus, owing probably to the obstruction afforded not only to hepatic circulatory functions, but also those of the kidneys. This would tend to cause reabsorption of the biliary acids and to produce yellow atrophy. Fatal icterus during pregnancy is also due occasion- ally to the lesions attending phosphorus poisoning. Malaria does not frequently compli- cate pregnancy, but causes abortion in about one-half of the cases attacked. Pregnancy seems occasionally to cause a relapse in women apparently cured of malarial fevers. On the other hand, parturition suspends periodical parox- ysms, in a large proportion of the cases, for two or three weeks. The malarial paroxysms occurring during pregnancy are characterized by irregularity, and the foetal movements may be suspended while the paroxysm lasts. Quinine may safely be given even in large doses, which best control the febrile phenomena. The ease is different in habitual abortion Action of quinine on pregnant women. In 49 pregnancies quinine was used in 47, tlie patients suffering more or less severely from malarial fever. Of these, 47 cases terminated at the usual period by the birth of a child, and 2 aborted. In these 2 cases it is extremely probable that the high fever from which they suffered was instrumental in producing abortion. Medicinal doses of quinine are poM'erless to induce abortion. The drug may be safely given in therapeutic doses during pregnancy. 0. Frederici (La Clinica Ostetrica, April, 1902). Chorea rarely occurs as a complica- tion, and especially affects primiparse. It causes abortion in about one-half of the serious cases, and the exhaustion consequent upon the violent muscular movements occasionally proves fatal to the mother. The child, when parturition is approaching, may not be lost with the mother, but it is frequently affected with chorea. In a small proportion of cases of chorea paroxysms cease at the beginning of parturition. Syphilis. — Whether contracted at the beginning or during the course of preg- nancy, syphilis gives rise to very marked and widely spread initial symptoms, while the subsequent symptoms are mild. When syphilis is contracted previous to conception, abortions occur repeat- edly; but, as with time the date of the infection becomes more remote, the abortions occur at a later date in the course of the pregnancy, until premature delivery may occur, and finally delivery at term. When conception and infection occur simultaneously, abortion is almost con- stant if no treatment be given; if imme- diate treatment be instituted the chances of abortion are somewhat reduced. When infection occurs after concep- tion has taken place, the nearer the two dates of conception and infection are to each other, the more will abortion be likely to occur. A thorough mercurial treatment should be inaugurated as soon as the presence of syphilis is known. Diabetes. — This disease may compli- cate pregnancy either on account of its presence before conception, or it may occur during pregnancy only. Abortion occurs in about one-third of the cases, one-fourth of these ending fatally, gen- erally by collapse. The child, though viable, usually perishes. This complica- tion presents itself almost invariably in multiparffi. Disease of the Heart. — The influence of cardiac disease upon pregnancy varies with the character and seat of the affec- tion that may be present. Generally speaking, however, abortion and prema- ABORTION. ETIOLOGY. PROGNOSIS. 47 ture delivery are frequently observed: i.e., in about two eases out of every five of heart trouble. While acute pericarditis seems to bear practically no influence iipon the normal course of the gestation, chronic peri- carditis is a pernicious accompaniment of pregnancy, owing to the insufficient compensation afforded by the heart itself for pre-existing valvular lesions to satisfy the increased demand upon that organ. Acute endocarditis assumes increased dangers during pregnancy through a marked tendency to assume an ulcerative process^ which generally ends fatally. Mitral lesions, especially mitral steno- sis and insufficiency, are considered by Germain See and Porak as the cardiac disorders most likely to cause death of the patient. If slight, however, or en- tirely compensated for, the parturition may occur without trouble. Intense passive pulmonary congestion, oedema, ascites, and metrorrhagia are to be feared in all such cases. Aortic insuffi- ciency or stenosis is generally most marked in advanced pregnancy on ac- count of increased arterial tension, but these untoward symptoms frequently disappear after parturition. Pulmonary Diseases. — In the great majority of instances pregnancy hastens the development of phthisis, and pre- cipitates its progress. In women predis- posed to phthisis the probabilities as to the occurrence of this disease are thus increased by marriage. Although they sometimes escape it during the first preg- nancy, the likelihood that the disease will show itself in future pregnancies is nevertheless great. Abortion or pre- mature delivery is frequent in these cases, and the viability of the child is proportionate to the condition of the mother. Every effort should be made to thoroughly nourish such eases, overfeed- ing, milk, etc., forming the basis of the measures to be instituted. Chronic pleurisy, empyema, and em- physema are liable to produce dilatation of the heart and thus render it inca- pable of compensating for the increased arterial tension of the parturient state. These conditions, however, are more dangerous to the mother than to the child; indeed, abortion under such cir- cumstances sometimes saves the patient's life. TRAUMATisii. — Brutal treatment of pregnant women, falls, etc., are well- known causes. The farther removed from the genital organs is any trauma- tism the less likelihood is there of abor- tion being produced. Even small oper- ations — the opening of an abscess, the extraction of teeth, etc. — have caused abortion. Case of abortion caused by the extrac- tion of a tooth thirteen days before. Labor Avas immediately preceded by severe haemorrhage from the dental al- veolus. Poyntz (Indian Med. Record, Feb., '91). Abortion may be due to too frequent pregnancies. Among other well-known causes may be cited long Journeys or short joitrneys too frequently repeated; excessive walking, climbing, riding, or other physical exercise; falls, moral shocks, etc. Causes Due to the Fcetus or Mem- branes. — Degeneration of the villosities of the chorion, hydramnion, and vicious insertion of the placenta are the main causes of abortion due to abnormalities of the foetus and the secundines. Prognosis. — The embryo, or foetiis, al- ways perishes; the prognosis, therefore, only applies to the mother. Cases of spontaneous uncomplicated abortion al- most always recover with proper care. The cause of the abortion, the date of the pregnancy, the degree of antisepsis ABORTION. PROGNOSIS. DIAGNOSIS. employed, or the previous cleanliness observed by the patient all bear influence upon the final issue of the case. In Pinard's service the mortality of abortions was 0.81 per cent.; of abortions having begun outside the service, 37.5 per cent. At Bellevue Hospital no case of death has occurred since it has become customary in that institution to empty the uterus in every case of incomplete abortion. Out of 926 cases noted by Hirst there were 13 deaths: a mortality of 1.4 per cent. As to the mortality of the product of conception, out of 434 cases in Pinard's service, the foetus was born alive in 221, dead and macerated in 199, and died during delivery in 14 cases. In abortion due to syphilis the foetus is almost always dead and macerated; in abortion due to vicious insertion of the placenta, almost always alive; in albu- minuria in about equal proportions. Involution of the uterus is usually more rapid than after normal delivery, on account of the lesser size of the uterus. Incomplete delivery may be a cause of imperfect involution. Patients should be kept in bed ten days. Metri- tis is likely to be the sequel of abortion -when the patient is allowed to leave her bed too soon. The influence of perfect involution on future pregnancies is marked. A woman may lose immense quanti- ties of blood in a threatened abortion, appear moribund from exsanguination, and yet rally and go on to full term under appropriate measures. Diagnosis. — Pain, haemorrhage, dila- tation of the cervix, and descent of the ovum are the characteristic features of abortion which easily distinguish it from other disorders. Dtsmenorehcea may be mistaken for -impending miscarriage. In this disorder the cervix is closed and firm and the pain precedes hsemorrhage. In abortion, on the contrary, the cervix is open and soft and the hemorrhage usually precedes the pains. Ohganic lesions of the cervix — such as tumors, etc. — sometimes give rise to hsemorrhages; but the history of the case and a careful local examination will generally establish the nature of the condition present. A soft polypus may, however, resemble a small ovum, and increase the diiBculty. Hepatic colic and nephritic colic sometimes simulate labor-pains, but the absence of hsemorrhage from the vagina, and the intensity of the suffering, soon establish the identity of these diseases. Threatened abortion being the condi- tion present, the next point is to ascer- tain whether the abortion is inevitable. Abortion is inevitable (1) when the membranes are ruptured, (2) when the foetus is dead, or (3) when any foetal part is already engaged in the cervix (Auvard). So long as symptoms of these three conditions are not present, abor- tion may not occur. When symptoms, such as hsemorrhage, have occurred, it is often difficult to determine whether abortion has really taken place, and, if so, whether it is incomplete or complete. Uterine explo- ration may then become necessary. During the first weeks of pregnancy the embryo may be so small as not to be easily found, and a positive diagnosis may not be established until, by subse- quent events, continuation of pregnancy or involution of the uterus takes place. When the foetus is dead it may remain in the uterus and the latter be thought, by the attending physician, to be empty. In some cases, even after hsemorrhages and the expulsion of portions of the secundines have taken place, the inter- ABORTION. DIAGNOSIS. TREATMENT. 49 ruption of pregnancy has only been apparent. Tubal abortion may simulate common abortion. The ovum is not invariably expelled from the o-stimn of the tube and discharged into the uterus. Case in which a complete decidua was dis- charged, the ovum being subsequently e.xpelled. The diagnosis was supported by the detection of a thickening of the right cornu. Skutsch (Centralb. f. Gyn., No. 25, '97). Spurious abortion. A class of cases in which a mimicry of early pregnancy and of abortion occurs quite different in its characters from the condition known as "spurious pregnancy." They are not associated with hysteria, and the usual functional disturbances of pregnancy are not exaggerated. They differ from pseudocyesis in the existence of definite changes in the uterus, and from preg- nancy, either topic or ectopic, in the essential point of the absence of an ovum, a mimic abortion: in the occur- rence of a period of amenorrhoea with enlargement of the uterus and forma- tion within it of a body, the detachment and expulsion of which is followed by a return to menstrual regularity and the former condition of general health. The body expelled is not an ovimi, but is formed entirely from menstrual struct- ures. Three cases recorded. A membrane having the essential characters of the decidua of pregnancy. Diagnosis impossible until after the dis- charge of the cast. T. W. Eden (Lon- don Lancet, Sept. 25, '97). Tubal abortion and operation. A low mortality follows removal of a gravid tube in early pregnancy, when there are s^inptoms of internal haemorrhage. On the other hand, a good number of diffuse intraperitoneal haemorrhages do not kill, but end in the formation of an hae- matocele. Prognosis is very uncertain, and any case may end fatally. An ex- ploratory incision through the vagina is advised, preparations being made, in any case, for abdominal section. The escape of blood-clot and broken-down tissue when Douglas's pouch is opened con- firms the diagnosis of tubal abortion. The uterus and tubes can then be e.x- 1- plored with the finger. If the tube is found ruptured, abdominal section is required; if there is simple and com- plete tubal abortion into the peritoneal cavity, Douglas's pouch should be drained. When the expulsion is incom- plete, or there is a tubal mole, the ovum being retained in the tube, abdominal section and removal of the tube are in- dicated. Spinelli (Archivio Ital. di Ginec, .June, 1901). Treatment. Theeatened Abortion. — Absolute mental and physical rest is imperatively demanded. The patient should be kept in bed, with her hips slightly elevated, and be given only light and cool food. To arrest the uterine contractions tincture of opium, 12 drops every two hours, may be given by the mouth; or extract of opium, 1 grain in a supposi- tory, every three hours. If the pain is severe, morphia, ^/^ grain, and atropia, Vso grain, should be administered hypo- dermically. Laudanum enemata, 25 drops to ^/„ pint of water, are also ef- fective. If an idiosyncrasy preclude the use of opium, chloral-hydrate, 10 grains, and bromide of potassium, 20 grains, every two hours, then every three hours, may be used instead. A good method is to administer opium, one-half of the dose under the form of laudanum enemata and the other half as subcutaneous injections of morphine (Eibemont). Constipation from the ef- fect of the opium is to be avoided. The fluid extract of viburnum pruni- f olium, ^/s to 1 drachm every three hours or 10 drops every half-hour, with chloral hydrate, 8 grains, is valuable to arrest titerine contractions when opium cannot be used on account of its constipating tendency. The tincture of viburnum prunifolium is useful in cases where the membranes have been ruptured and the liquor 50 ABORTION. TREATMENT. amnii discharged, but where there are still hopes of preventing a miscarriage. It should not be given, however, when the fcetus is dead, when a miscarriage has actually commenced, or when there is any reason why it is not best that birth should be delayed. Auvard (Bos- ton Med. and Surg. Jour., Mar. 22, '88). Viburnum paralyzes both the centres of voluntary motion and the reflex func- tions of the spinal cord without impair- ing sensation or consciousness, and it is consequently destined to become an ap- proved remedy in all diseases character- ized by increased excitability of the motor centres. The solid extract of the drug is recommended, in doses of from 5 to 10 grains, and the fluid extract in doses of from V: drachm to V2 ounce. R. L. Payne (Med. News, Apr. 2, '92). Inevitable Abortion. — When abor- tion cannot be avoided, all the foregoing measures are contra-indicated. During the first two months but little treatment is necessary other than rest in bed. If no untoward symptoms appear, such as marked haemorrhage, rise of tem- perature, etc., expectant measures are sufficient, at least for some days. During the third month the ovum may be expelled entire,^ — i.e., without rupture of the membranes. In this case no active measure is required beyond, perhaps, an antiseptic douche, — a creolin 2-per-cent. solution of a weak carbolic- acid one, — employed twice daily. When, in the course of the third month the sac ruptures and the liquor amnii escapes, the sudden reduction of the pressure exerted by the ovum upon the intra-uterine surfaces causes free hemorrhages from the utero-placental vessels. HamorrJiage. — The treatment of the ha?morrhage at this period is that for the subsequent one. The patient being placed in the Sims position, all clots are removed and the vagina is packed with iodoform gauze or cotton-wool. If the bleeding persist, vaginal douches of hot alum solution, 1 ounce to the pint, are administered. The packing is then re- newed, and 3 drachms of the fluid ex- tract of ergot are injected into the rectum. If the bleeding is alarming, the uterine canal may be packed with small pledgets of iodoform cotton or gauze. Whenever abortion takes place none of the tissues should be left in the uterus. 1. At 4 weeks best to keep down hsemorrhage and to wait for nature to act; if interference necessary, deeidua to be removed, using the curette. 2. At 6 to 8 weeks chorion causes most trouble; finger or curette used and strip of iodo- form gauze introduced to fundus. 3. At 10 to 12 weeks fcetus comes first; other tissues apt to need artificial removal; finger best; gauze as before; small doses of ergot for twenty-four hours. Edward Ayers (Medical Record, Sept. 28, '95). When fragments of placenta or other adnexa are left in the uterus they rapidly give rise to foul discharge, which may be followed by grave septic symptoms. The patient should at once be placed in the Sims position and be given an anaes- thetic, if necessary. The endometrium is then thoroughly cleansed and curetted, then washed out with hot 1 to 5000 corrosive-sublimate solution. No ergot should be administered until the uterus is thoroughly emptied. The external genitals are then carefully cleansed and a compress of carbolized cotton is applied over the vulva. Lysol, in 1-per-cent. solution, is highly recommended for in- jections in infectious cases. When with closed os haemorrhage is profuse, we must no longer speak of "threatened," but of "beginning," abor- tion. In cases like this, especially if the OS enlarges, we cannot possibly reckon on saving the embryo, although this may unexpectedly occur in rare instances. The third stage is that of complete abor- ABORTION. TREATMENT. 51 tion; persistent bleeding usually denotes retention of bits of membrane, and the proof of retention is usually found in the patency of the os to one finger. Ex- amination of the ovum is necessary to determine the likelihood of the persist- ency of portions within the uterus. In this waj', if we find that the integrity of the expelled ovum has not suffered, we need have no fear of retention. If the ovum is incomplete, and htemorrhage continues from the uterus, we have every warrant for emptying the uterus with the curette. If the os uteri closes, we may feel sure that the remains of decidua must be slight. With every evidence of expelled ovum and closed os, persistent bleeding can be due only to atony of the uterus. Lantos {Monats. f. Geburts. u. Gynak., May, '99). If haste imperative, the cervix is di- lated and a lateral incision is made in the cervix. The uteriis is then emptied with a blunt, rounded, fenestrated curette, followed by swabbing. The uterus is thus emptied without haemor- rhage. The pain is very slight and no anaesthetic is required. The incision in the cervix is at once sutured. This method is prompt, sure, and safe. Dolfiris (Semaine Mgd., Sept. 5, 1900). The best method to adopt to incur little risk for the patient: No inter- ference is necessary in ordinary cases except in eases of severe anaemia pro- duced by a profuse haemorrhage or by long-continued slighter bleeding, when portions of the ovum are retained, and in cases which have become septic. The most rational method of arresting hsemorrhage is to remove the ovum com- pletely. If this has left the body of the uterus, and is retained partially or totally in the cervix or vagina, a spec- ulum should be introduced, and, if the finger cannot easily complete the re- moval, ovum forceps may be used. When the ovum is still in the body of the uterus, one or two fingers should be introduced, and — while counter-pressure is exercised by the other hand from the abdominal wall — the sac separated completely from the uterine wall. Once it has been separated, it can usually be removed by combined action of the internal finger and expression from witliout. The whole process can be made more easy if one seizes the an- terior lip of the cervix with vulsellum forceps (double-toothed), and admin- isters an anaesthetic. The operator must not be disturbed by the haemor- rhage, but must rely on the fact that this will cease on completion of the abortion. If the cervix is not permeable for the finger, thorough plugging of the uterus, cervix, and vagina with sterile iodoform gauze is then indicated. The cervix is brought into view with a Sims speculum by means of a uterine catheter or sound, and the size of the uterus by bimanual examination, and not by the sound. The vagina is to be thor- oughly irrigated, cleansed, and dried, and then the strips of gauze introduced with smooth ovum forceps. All one's efl'orts should be directed toward keep- ing the ovum intact. At times it may be necessarj' to substitute a sound for the forceps in packing the uterus. If the ovum is not cast out after twenty- four hours, the plugging is to be re- moved, the passage again thoroughly disinfected, and a second packing under- taken. Sellheim (Mtinchener med. Woch., March 11, 1902). Delayed Aboetion. — When this oc- curs prolonged expectant treatment exposes the pati-ent to dangerous heem- orrhage and septicEemia; hence early active measures are indicated. If the adnexa are not expelled in twenty-four hours, injections of hot carbolized water into the uterus, between its walls and the ovum, every three hours, using a Bozeman catheter, may be employed; or, if the haemorrhage is controlled and the OS is sufficiently patent, the finger may be introduced, then hooked, and the uterine contents evacuated. If the os is not dilated, a piece of iodo- form gauze or an iodoform bougie can be inserted; in from twelve to twenty- four hours the finger can generally be introduced and the adnexa removed. If this is difficult, a blunt curette may be 52 ABORTION. TREATMENT. employed instead of the finger, prefer- ably Thomas's large model. Sims's sharp curette is also highly recommended. If used with due care it is an excellent in- strument. "When intervention is necessary, in- stead of the curette I simply use my finger, which is a marvelous instrument for one possessed of intelligence, while the curette is a blind instrument which I only use when there is htemorrhage or infection." For intra-uterine injections a solution of permanganate of potassium recommended. Tarnier (L'Union Med. du Can., Nov., '97). To use the finger as a curette is, in most cases, unsatisfactory, even when one hand is used for pressing the fundus down. The finger is often arrested at the internal os or does not reach the uppermost part of the cavity, and, at all events, it can only be used to separate the ovum from the uterus, and cannot remove the deoidua vera. Henry J. Gar- rigues (Med. News, Nov. 6, '97). Condition indispensable and invariable for the efficient and thorough use of the curette after abortion, — namely: that the uterine canal should be sufficiently dilated to permit the index finger to explore the uterine cavity to the fundus, in order not only to determine the quan- tity and location of the retained secun- dines, but also to enable the operator to be perfectly sure that the cavity has been entirely emptied when the operation is completed. An empty uterus after abortion almost always contracts, and all hsemorrhage from its cavity ceases. A failure to con- tract at that time is an exception. If a hot sterilized or carbolized intra-uterine douche is used after emptying an abort- ing uterus, prompt contraction and cessa- tion of bleeding takes place. Only in women very much exhausted from haem- orrhage might it be advisable to pack the empty uterus after abortion with iodoform gauze, or, better, sterilized gauze, in order to save her even the few drops of blood which would ooze away during the first day or two, until she has rallied. Paul F. Mund& (Med. News, Nov. 27, '97). Case in which patient had been curetted on two occasions to remove remains of incomplete abortion. At second opera- tion, failing to remove all placental tis- sue with curette, uterine cavity was plugged, and, after forty-eight hours, finger introduced and remaining portions removed. Severe haemorrhage led to ex- tirpation of uterus. On microscopical examination, material removed by curette proved presence of muscular tissue. Conclusion that placenta in this case must have been abnormally adherent, and uterine wall abnormally soft, and that the finger is a better instrument than curette in imperfect abortion. Duhrssen (Berl. Med. Soc, May, '98). This treatment, if applied sufficiently early, causes a reduction of temperature. Within an hour or two a chill may indicate slight absorption of infectious elements through the vessels laid open during the operation; but rapid improve- ment usually follows. When the curette is used the softened condition of the uterine tissue should be borne in mind; death from perfora- tion has been reported. (Alberti, Long, Many accidents have been attributed to the curette. Eecamier reported three cases from perforation of the uterus by his curette; Dumarquay two; Chamber- lain had a case of hysterical tetanus; Peaslee, a death from collapse; Thomas, a narrow escape from the same cause; and Parker, a case of peritonitis. But in these cases it was not the Sims sharp curette. It should, of course, be handled with ordinary common-sense in order not to cut too deeply and, perhaps, per- forate the uterine wall. Personally used in a large number of cases without acci- dent. Goldberg (Buffalo Med. Jour., Aug., '97). In 99 cases (out of 275) requiring operative interference, 55 were treated by digital exploration and removal of fragments, and 44 eases were treated by curetting. In this series of eases 6 deaths occurred. In 2 cases, at the autopsy, a perforation was found at the fundus ABORTION. TREATMENT. 53 uteri, with peritonitis. Both cases were already infected before reaching the hos- pital. In 1 curettage had been carefully performed; in the other the uterus had merely been packed with gauze. The third fatal result was due to suppurative salpingitis, operated upon after leaving the hospital. The 3 remaining deaths were due to infection, the patients arriving at the hospital with grave sep- tic symptoms. Maygrier (L'Obstfitrique, July, '97). Antiseptic douches are important to remove what detritus may remain behind a 3-per-cent. carbolic-acid solution from the endometrium after curetting. Packing of the itterine cavity with iodoform gauze after curetting is not a safe procedure; it has caused peritonitis. The too copious use of corrosive-sub- limate solution for injection has caused death. If the cervix will not yield to simple measures, Hegar's, Ellinger's, or Barnes's dilator may be used. New method of treating incomplete abortion: With Bozeman's intra-uterine douche, a hot creolin solution is allowed to flow, always watching to see that the return-cuiTent remains free. All loose clots and debris are removed by the dull curette. The cavity is again washed, until nothing remains but the firm de- cidual tissue (which clings to the uterine wall) and the creolin solution returns white. Finally the uterus is packed from the fundus to the external os with iodoform gauze. The first gauze is with- drawn, thereby wiping out the cavity, and a second piece is firmly placed so as to stop all haemorrhage. No opiate is allowed. As a result of this procedure the inert uterus is stimulated to contract. The blood, unable to escape, distends the cavity and flows in between the decidua and the uterine wall, dislodging the former. Finally, the internal os dilates, the gauze is expelled, and all the uterine cavity with it. Another creolin intra- uterine douche is then given, and, if en- dometritis exist, the gentle use of the sharp curette and a gauze drain com- plete the work. Contraction and invo- lution of the uterus go on rapidly. Three illustrative cases. Anna M. Stuart (N. Y. Med. Jour., Sept. 6, '96). In curetting after incomplete abortion tliree following points insisted on: 1. Be- fore introducing the curette a sound should be used and the length it pene- trates marked on curette. 2. A specu lum should always be used. 3. Iodoform (or, preferably, xeroform) gauze should be introduced into the uterine cavity after curetting in haemorrhage, or the gauze should be packed well in to excite uterine contraction and left there for twenty-four hours; in infection it is in- ti'odueed loosely to act as a drain into vagina, into which a plug of cotton- wool is placed to absorb discharge. Beuttner (Rev. Med. de la Suisse Rom., Jan. 20, '98). The following procedure recommended in incomplete abortion: Under chloro- form cervical canal is dilated with, first, index finger and then middle finger. Uterus is fixed with hand acting through abdominal wall. Then, with two fingers or one, interior of uterus is thoroughly scraped. To evacuate uterus it is some- times sufficient to make traction on pla- cental fragments \'\ith fingers or with one finger hooked. Usually it is neces- sary to employ uterine expression, done by placing two fingers in posterior vagi- nal fornix and pressing them forward, while with other hand placed on hypo- gastriura pressure is made on anterior fundus uteri. Uterine cavity is then washed out, and mixture of glycerin and creasote applied. Only when there is any haemorrhage and the uterus docs not re- tract properly it is necessary to plug utero-vaginal canal with iodcform gauze. P. Budin (Progres Med., Sept. 17, '98). Treatment of abortion based upon 100 cases met with in four years. Vaginal plug usually quite useless. If removal of the ovum is indicated, the manual method is always preferable. Expression fatigues the patient very little, and is indicated when the os has a diameter of about four centimetres, and when the ovum is, in great part, detached and in the cervical canal. In 15 cases this plan was followed, and in 12 the ovum was 64 ABORTION. TREATMENT. thus deliveredj but in 3 only pieces came away, and the rest had to be removed by the finger. If expression fail, two fingers are to be introduced into the uterus, and the ovum or parts of it at once taken away. In abortion, just as in labor, everything should be removed at once. The finger is generally to be preferred to the curette. The use of all kinds of ovum forceps condemned. Ninety-nine women recovered fully. Drejer (Norsk Mag. for Laegevidensk., No. 3, Mar., '99) . Expectant treatment, antisepsis being the only measure resorted to, is preferred by some (Varnier and Pinard), active procedures being only resorted to in cases of serious hjemorrhage or infection. Study of 4333 cases in Tauffer's clinic tending to demonstrate that even re- tained membranes should only be re- moved when decided indications are present. Velits (Int. klin. Rund., Mar. 8, '91). In cases of retention of the placenta after abortion the practice of Tarnier is as follows: 1. Antiseptic preliminary injections either of permanganate of potash, 1 to 2000, or of carbolic-acid water, 20 to 1000, with iodoform or salol dressings to the vulva. 2. In case there is danger of infection through putrefac- tion of the placenta, recourse should be had to digital and antiseptic curettage after dilatation. 3. When the physician is called after septicasmia has become generalized, or when the symptoms of infection are very pronounced, it be- comes necessary, considering the immi- nence of the danger, to resort to curet- tage of the uterine cavity, using, at the same time, all antiseptic precautions. Quinine, in large doses, has recently been recommended. The expectant treatment of abortion is to be preferred. Packing of the uterus and vagina recommended. Of 292 cases observed only 1 ended fatally. This pa- tient was already infected and suffer- ing from high fever. Curetting and local treatment wei-e unsuccessful. It is best to leave, as long as possible, the expulsion of the ovum to the natural forces, which in many cases of abortion are better able to do it than our hands and instruments. When some special danger exists for the mother, however, or when the termination of the abor- tion may easily be accomplished, inter- ference is permissible. The fear of packing, which until re- cently was prevalent, has disappeared, for, with due precaution, it is Avithout danger. There is not so much danger of infection with it as with manual and instrumental procedures. P. Miiller (Volkmann's Samml. Klin. Vort., No. 153, Apr., '96). Case of sevei'e post-partum infection in which, notwithstanding active measures, the patient seemed to be becoming mori- bund. Twenty ounces of sterilized saline solution injected into the cellular tissue at first. Improvement of the symptoms followed at once. The injections were continued twice daily for six days. Diu- resis and a fall in the pulse-rate were marked throughout, the intestinal irri- tation stopped, and the temperatui'e be- came normal. The patient made a per- fect recovery. Ostermayer (Centralb. f. Gynak., Mar. 12, '99). Electricity may be used as a substitute for the curette in incomplete abortion. For the immediate removal of retained secundines the faradic current is em- ployed, but, for the removal of these after retention for some time, the gal- vanic is preferable. Case in which the galvanic current was used very successfully, the strength being 60 milliamperes, and the appli- cation continued for eight minutes and repeated three times. The positive pole was introduced into the uterus, the selec- tion being made because of the local effect, since this pole promotes coagula- tion, and is haemostatic: a fourth reason is added as probable, but not proved, — its antiseptic powers. H. D. Fry (Amer. Jour, of Obst., vol. xxi, p. 593). Injections of cold water successfully used in retention of the placenta, in a woman who had expelled a foetus of six ABORTION. HABITUAL. 55 months. Immediately after the lavage the uterus contracted and the placenta was also expelled. John Morton (Indian Med. Record, Dec, '91). Two hundred and seven cases per- sonally treated vpith curette. Sequelte were met with in only 34.4 per cent, compared with 92.4 in those in which it was not employed. In the former, the menses were regularly re-established in 60 per cent., pregnancy to term supervened in 53 per cent., abortion re- curred in only 13 per cent., and sterility prevailed in 32.3 per cent. "^^Iien the curette was not used and fingers were, regular menstruation in 39.4 per cent., pregnancy to term also in 39.4, repeated abortion in 47.3, and sterility in 25.1. The cases were all treated upon the same general principles, and the curette was only employed in the presence of the strongest indications. Schaeflfer (Deutsche Praxis, Nos. 1-3 and 5-8, 1901). Streptococcic serum in the septicaemia of abortion has been used with apparent success. Exhaustion from Hemorrhage. — This condition maj' be treated by rectal injections of 1 or 2 quarts of cool saline solution, or careful injection of hot (120° F.) saline solution into the femoral artery (middle of Poupart's ligament), using a larg€ hypodermic needle con- nected with a Davidson syringe. Sub- cutaneous and rectal saline injections may be given simultaneously, if need be. Hypodermic injections of Veo grain of strychnine enhance the action of injec- tions. Habitual Abortion. — Etiology. — • Habitual abortion may be due to either constitutional or local causes. Of the former the principal are syphilis, lead poisoning, tobacco poisoning, and heart disease. The local causes are divided into four groups: Malformations of the uterus, displacements of the uterus, active con- gestion of the uterus and especially of the cervix, and diseases of the cervix or body of the uterus. Malformations. — In these cases the uterus has preserved some of the char- acters of the infantile uterus, the body being disproportionately small or the cervix disproportionately large. Disten- sion of the uterus by the growing ovum causes severe attacks of uterine colic and sympathetic disturbances, which com- mence during the second month, and usually lead to abortion about the third or fourth month. These cases are not common, because fecundation is rare in the malformed uterus. Displacements. — Flexions are of more importance in this connection than either versions or prolapse. In ante- or retro- flexions there is a thickening of the uterine tissue at the angle of flexion, which interferes seriously with the prog- ress of pregnane}', and leads to repeated abortion at the third or fourth month. Congestions. — In the case of women who habitually lose freely at the monthly periods it is not uncommon to find that during pregnancy they have a periodic loss of blood, accompanied by pain, es- pecially during the latter months. In plethoric women these haemorrhages during pregnancy are beneficial, and should not be arrested. Diseases of the Uterus. — Endometritis, new growths of the body of the uterus, and extensive erosion of the cervix usu- ally lead to abortion. (Charpentier.) Treatment. — The causes should be sought after and any existing affection removed, if possible. Syphilis especially requires prolonged and curative treat- ment. In congestion of the uterus Carpentier recommends wet cupping of the loins to relieve the engorgement, and thus enable the uterus to retain the ovum. Any special irritability of the genital organs that may exist should be 56 ABORTION. HABITUAL. TREATMENT. treated by rest in bed for some days at the menstrual period during pregnancy. Viburnum prunifolium, ^/j to 1 drachm of the iluid extract twice daily, or asafoetida, 1 grain in pill three times daily, as soon as pregnancy is suspected, and gradually increased, are frequently recommended. Chlorate of potassium, 15 to 30 grains daily, is valuable in this connection, but is more likely to disturb the stomach. A large number of drugs possess more or less marked powers as abortifacients and hence should be avoided during pregnancy. Quinine, cantharides, pilo- carpine, strychnine, erigeron, elaterium, jalap, podophyllin, aloes, senna, scam- mony, and violent purgatives in general, especially those likely to cause engorge- ment of the hsemorrhoidal vessels, are the most pernicious agents in this par- ticiilar that are in general use as reme- dies for other conditions. Although quinine appears to have but little oxytocic action in some, in others it excites uterine contractions, especially in delicate, nervous, and anaemic women; it should not be given in large doses un- less with some narcotic that will act as sedative upon the uterus. (Coromilas.) To replace quinine, when indicated for malaria, phenocoll, which, while efficient for malaria, has no action on the uterus ; 22 grains divided in four cachets given five, four, three, and two hours before febrile paroxysm. Titone (Brit. Med. Jour., Mar. 23, '9.5). Cases of so-called habitual abortion, which so commonly depends on a dis- eased state of the endometrium, may be overcome by a two minutes' steaming at 212° F., followed, for six or eight days, with applications of tincture of iodine. Results in ten cases: In five the fever disappeared speedily by crisis, in two lysis occurred, and in three there was no notable fever to begin with. The occur- rence of lysis indicates infection of a moderate grade. In almost all cases the odor ceased at once or became so slight as to be hardly noticeable. Pincus (N. Y. Med. Jour., Mar. 20, '97). In cases in which women who are usually regular pass over a period, as well as in habitual abortion, exhibition of 5 to 8 grains of aeetanilid, repeated in one, two, or four hours as necessary, advocated. In cases of ovarian irrita- tion, where there seems to be tendency to separation of ovum at what would have been a menstrual period, more or less regular use of viburnum prunifolium and potassium bromide, with aeetanilid at time of each periodic disturbance, recommended. In emergency cases aee- tanilid 10 to 15 grains, repeated at short intervals, should be given, but in every instance individual susceptibility should be considered. Harnsberger (Jour. Amer. Med. Assoc, Oct. 22, '98). Twenty-one cases of abortion and premature labor, with death of the em- bryo or foetus. These were treated by prolonged rest in bed, and by the ad- ministration of iodide of potassium and iron throughout the entire pregnancy. The avithor's cases may be divided into three classes: one, syphilitic, in which the sj'philis was old or hereditary; the second class, in which the kidneys were very deficient in action and the patient was threatened with nephritis; and the third class, in which the patient was constantly absorbing necrotic material from a chronic endometritis. He be- lieves that the treatment acts by pre- venting the rupture of vessels in the placenta. Stress is also laid upon the chronic anaemia present in these cases, for which the author uses iron. Lomer (Zeits. f. Geb. u. Gj'nilk., Bd. xlvi, H. 2, 1901). Potassium chlorate recommended in habitual abortion. As soon as the pa- tient i.s pregnant 3-grain doses of potas- sium chlorate are given. This is con- tinued during the entire period of gesta- tion, decreasing the daily dose of the drug in the last weeks to 2'/= grains. No untoward effect has been observed, either on the mother or the child, from this treatment. The pregnancy was brought to normal completion in a num- ber of women who previously had noth- ABORTION. MISSED. 57 ing but miscarriages. S. Remy (Semaine Medicale, xxii, No. 39, 1902). Missed Aboetion. — The embryo sometimes dies as a result of the con- ditions giving rise to abortion, and re- mains in the iiterine cavity, — the so- called "missed abortion." The active symptoms of miscarriage may be pres- ent; or the patient may only ascertain by the cessation of all foetal motion that it is no longer living. The foetus may entirely disappear, or become trans- formed into a shrunken remnant. They are most frequently expelled within six months, but sometimes remain in the uterus as long as eleven months. The usual symptoms of premature delivery are gone through. In its altered con- dition, the product is variously termed "fleshy mole," "blighted ovum," or "apoplectic ovum." The occurrence of this complication is comparatively rare. It may repeatedly occur in the same woman. Case of missed abortion in which the embryo perished during the second month of pregnancy, and was retained until the tenth month. I. Kobro (Norsli Mag. f. Lag., 4 R., X 12, S. 1110. '9.5). The first factor is the death of the foetus; this is followed by shrinking of the chorionic sac and blood-extravasa- tion among the villi. As a result, nu- merous small, rounded protrusions are to be seen when the interior of the sac is examined, — the so-called "subehorionic hffimatomata," "tuberous subehorionic hsematomata," or the "tuberculous ova" of Granville. They are considered by some observers as malignant. When the fcetal circulation ceases, the ve.ssels of the placenta are rapidly ob- literated. The foetal epithelium covering the chorion and its villi degenerate, and the maternal blood between the villi forms clots, which are altered into dense laminated fibrin. The decidual cells then multiply and invade the fibrin, which they gradually replace, filling the inter- villous space with layers and bands of decidual tissue. At the same time they disintegrate the foetal epithelium, which comes to be represented by scattered heaps and row.s of nuclei, and finally dis- appears. The amnion remains almost unaltered, but adheres closely to the chorion, and the united membranes are thrown into folds and convolutions, cov- ering the rounded lobes of altered pla- cental tissue. The foetal portion of the placenta does not grow after the death of the foetus, though the maternal por- tion containing the decidual cells re- mains active. It is therefore improbable that malignant new growths can arise from foetal placental elements. W. E. Fothergill (Brit. Med. Jour., Mar. 20, '97). The fleshy mole is undoubtedly a form of the process known as "abortion," but the obstetrician should remember that the pathological changes which produce it may occur at very diilerent stages of pregnancy. The precise time at which the arrest of normal pregnancy occurs cannot always be determined by exami- nation of a fleshy mole. Neumann (Monats. f. Geburt. u. Gyn., Feb., '97). In tuberose fleshy mole abortion is pro- duced in the following manner: There is an undue blocking of the serotinal si- nuses in the large-celled layer, leading to a slow engorgement of the intervil- lous circulation. This will bulge out the chorio-basal septa, and, as these tack down the chorion at definite points, the amnion and chorion will bulge up between. This produces the tuberose swellings. The embryo dies as the re- sult of this interference with the cir- culation, and its death is "secondarj'." The placenta becomes a thrombosed mass and is retained a certain time before expulsion. The primary link in the chain of events is the excessive clotting in the serotinal sinuses from a cause as yet unknown. D. Berry Hart (.Jour, of Obstet. and Gynsec. Brit. Em- pire, May, 1902). The first symptom is usually a bloody discharge, which is frequently taken for the return of menstruation. The uterus 58 ABORTION. INDUCED. is found to be enlarged according, of course, to the size of the foetus, and the internal os generally permits of the introduction of a finger-tip. The pres- ence of the ovum, or foetus, may there- fore be ascertained in a proportion of cases, but when this is impossible the diagnosis is established with difficulty. The discharges generally become very foetid, however, and suggest, by the char- acter of the odor emitted, the nature of the body present. Treatment. — Bemoval of the dead foetus is the only course to be pursued. The means are precisely those for the removal of the placenta just described, the strictest antisepsis being observed. Induced Aboetion". — It is seldom necessary to induce abortion during the earlier months of pregnancy, as the dis- orders occasionally rendering this step obligatory are frequently amenable to other measures. The most important conditions that may necessitate this step are incoercible vomiting, heart disease threatening life, and serious hydramnios. Many drugs — such as saffron, tansy, wormwood, cinnamon, horehound, etc. — generally considered as capable of provoking expulsion of the foetus, are practically without effect, while more powerful agents — such as rue {Ruta graveoUns), savin, red cedar. Arbor vitce, and yew — are only active when giving rise simultaneously to dangerous general symptoms. In women predisposed to abortion, however, all these drugs, be- sides others previously mentioned, are capable of exciting expulsive contrac- tions of the uterus. The means for the purpose are, briefly, catheterization of the uterus, injections between the uttrus and ovum, mechan- ical dilatation of the cervix, the vaginal tampon or douche, and electricity. It is important to bear in mind, in this connection, that a physician should never perform abortion without one or more consultants. A new method of producing abortion: A curved silver catheter, 2 millimetres in diameter, is passed to the fundus uteri. A syringe, with a capacity of about 4 grammes, is attached to the catheter, and by it 3 grammes of tinct- ure of iodine are injected into the uterine cavity. The catheter is now removed, and a tampon placed against the cervix to prevent the iodine from coming in contact with the vagina. This method is uniformly successful and quite free from danger. The abortion occurs within two or three days. The iodine penetrates and destroys the em- bryo, while its antiseptic properties are a safeguard against sepsis. Oelschliiger (Edinburgh Med. .Jour.; from Centralb. f. Gynilk., No. 27, 1901). The electric current is a safe means when artificial abortion is necessary. The patient is placed on a table or gynfecological chair, the external geni- tals and the vagina are washed with a solution of formalin or lysol and soap, the cervix exposed by a speculum, and the canal cleansed by means of pledgets of cotton saturated in a 2-per-cent. solution of lysol. Apostoli's bipolar electrode is then introduced in such a manner that the platinum end of the second attachment is seen around the external os. A constant current is ap- plied and gradually increased from 50 to 73 and even 100 milliamperes, for ■ fifteen minutes. At the end of this time the electrode is removed and the cervix and vaginal portion of the uterus swabbed with a 2-per-eent. solution of lysol. Three applications are usually sviflSeient to insure success. M. M. Mironoff (Phila. Med. Jour.; from Jour. Akouscherstwa i Zshenskick Boleznei, No. 12, 1901). Criminal Abortion. — In all civilized countries most severe punishment is inflicted upon criminal abortionists; in most of them the penalties are increased if the crime is committed by professional persons, such as medical men, midwives, ABORTION. INDUCED. 59 and druggists. Notwithstanding this, criminal abortion is extremely frequent, principally in large cities. It is generally between the second and fifth month of pregnancy that abortion is artificially produced. Criminal abortion is performed by means of drugs and by local and sur- gical intervention. A large number of drugs were, until recently, thought to possess active ecbolic properties, but a more elaborate study of the question has shown that no drug has a special action upon the uterus for expelling the prod- uct of conception. Criminal abortion is sometimes brought on by using lead. Four cases in whielr it was definitely determined that lead was taken for this purpose, and in which a diagnosis was made by discovering a blue line on the gums. Fourteen similar instances known of, some of which were personally seen, others having occurred in the practices of colleagues. As a rule, the diagnosis in these cases was at first acute gastri- tis, renal colic, tubal inflammation, and similar conditions. In many cases the patients misrepresented matters abso- lutely, and there was not the least sug- gestion in their story of the actual cause of their condition. Schwarzwaeller (Berliner klin. Woeh., Feb. 18, 1901). The only fact to be admitted in a medico-legal point of view is that some drugs may cause abortion in predisposed women, but more by the general dis- turbance of the system than by any spe- cific action on the womb. The strong cathartics (scammony, jalap, etc.), given in large doses, may be classed in this category. Caustic acids are also active in the same sense. Examination of 72 women on whom criminal abortion had been performed. In 1 case death resulted from nervous shock. In 5 other cases, during or shortly after the injection, faintness, dizziness, and vomiting occurred, lasting several hours and disappearing without leaving any trace. In nine-tenths of the cases there was no special disturbance. Abor- tion usually resulted in the course of a day, sometimes in six or eight hours. In only 4 of 5 cases was fever present or the patients obliged to remain in bed for several days. In 25 cases, however, there Mas evident endometritis, which propor- tion would show some relation to the operation. It was strange that no septic troubles arose, as no special care was taken either of the syringe or the solu- tion used. Vibert (Jour, de M6d., Feb. 26, '93). Case of criminal abortion by the use of a tupelo tent in which the latter had been forced through the uterine walls. The tent was found lying transversely in Douglas's cul-de-sac. Supravaginal hys- terectomy performed, on account of the septic condition of the pelvic cavity. The perforation, beginning at the inter- nal OS, extended obliquely upward and the tent had been forced through the serous coat Just below the left horn of the uterus. W. Easterly Ashton (Med. Bull., July, '97). Opinion recorded as to liability of person who consents to have abortion performed upon her: The judge, when summing up in the Collins trial, decided that "the woman who submits herself to an unlawful operation is guilty of felony just as much as the agent she employs." Editorial (Ga. Jour, of Med. and Surg., Sept., '98). Death may ensue without the produc- tion of traumatism, during the intra- uterine use of instruments, probably through the intermediary of the sympa- thetic system. Case of sudden death during attempted abortion while introducing the nozzle of a syringe into the os uteii. Judicial in- quiry. No uterine abnormality found, although the cervix was soft and patu- lous. Death seemed to be due simply to syncope from a stimulus arising in the uterus. It was a phenomenon of inhibi- tion. Syncope has been observed after passage of the sound. De la Touche (Sem. GyniSc., June 23, '96). 60 ABORTION. In performing an autopsy upon a woman who is supposed to have at- tempted abortion search should be made for the embryo or pieces of it, or for the placenta. If the uterus is empty, the thickness of its walls must be measured, and the insertion of the placenta sought, as this can be recognized up to the tenth day after the expulsion of the embryo. This is possible even later, if the uterus is kept in 90-per-cent. alcohol. The ex- amination of the ovaries is of only rel- ative importance, as no positive signs exist there. Stains of meconium, if found, will prove the abortion. If an instrument has been used to cause abor- tion, traces of the damage done by it will be seen. This is especially true when the uterus has been perforated. Brouardel (Jour, des Praticiens, .Jan. 12, 1901). Six hundred and ninety-eight cases of abortion witnessed, supposed to be spon- taneous. Four of the women died: that is, 0.57 per cent. During the same period forty-four cases of criminal abortion were treated: the mortality was 56.8 per cent.: that is, only nine- teen women recovered. In the presence of a complete or incomplete abortion, due unmistakably to mechanical meas- ures, or even when such abortive meas- ures are suspected, and in absence of any complication, early evacuation fif the uterus is required. If septic acci- dents have already developed, evacua- tion is still more urgent, and general measures are also indicated. Maygrier {L'Obstetrique,'July 4, 1902). A. LUTAUD, Paris. ABSCESS. — Lat., ahscessus, from ah- scedere, to depart. Definition. — A collection of pus in an adventitious cavity, the result of an acute, circumscribed inflammation due to infection with pus-forming microbes. Varieties. — An abscess may be acute, or ivarm, when due to pus-microbes only: staphylococci, streptococci, and others; chronic, or cold, when due to a specific microbe, especially that of tuberculosis. Abscesses have been classified accord- ing to: — 1. Etiology. — Atheromatous, embolic, fsecal (stercoraceous), lymphatic, meta- static, miliary, ossifluent, puerperal, pyse- mic; residual symptomatic, or congest- ive; tropical, tubercular (strumous, or scrofulous), etc. 2. Pathology. — Acute, or warm; cana- licular; caseous; chronic, or cold; critical, difl:use, gangrenous (anthrax), ligneous, perforating, phlegmonous, etc. 3. Location [Organ or Tissue In- volved). — Alveolar (gum, jaw, teeth), of antrum, of axilla, bone (subperiosteal), brain (cerebral, cerebellar), bursal, cor- neal (hypopyon), deep, dorsal, follicular, hepatic, of hip-joint, iliac, ischio-rectal, lacunar, lumbar, mammary (milk; weid, or weed; breast), marginal, mediastinal, meningeal (extradural, subdural), of middle ear, of neck, nephritic and perinephritic, of nose, of palate, palmar, of pancreas, pectoral (empyema), peri- typhlitic, popliteal, of prostate, psoas, rectal, retropharyngeal, of skin (furun- culosis), of scalp, of space of Eetzius (preperitoneal cavity); spinal, or verte- bral; of spleen, superficial, thecal, ure- thral and periurethal, vulvo-vaginal (Bartholinian), etc. All the above ^•arieties will be considered under their respective anatomical heads. Acute, or Warm. Symptoms, — An abscess may either be superficial or deep. When it is super- ficial the local symptoms predominate; when it is deep the general symptoms are generally the most marked. The pain, due to compression of the nerves by the disturbed tissues, varies in degree with the density of the parts involved, the local supply of sensitive nerves, and the tension produced by the inflammatory products. In superficial abscess the pain is generally localized in ABSCESS. ACUTE. SYMPTOMS. ETIOLOGY. 61 the centre of the swelling, and is sharp and lancinating; in deep abscess it is more diffuse and dull. Eedness is due to engorgement of the local blood-supply, and the swelling to the inordinate distension of the ves- sels and the secondary escape of blood- plasma, colorless corpuscles, etc., into surrounding tissues. It may become very great in regions such as the lids, the lips, etc., in which the cellular tissue is lax. As the purulent foci run together and form a single cavity, the centre of the tumefaction becomes soft, and darker in color, and the abscess is said to be "pointing." (Edematous infiltration in superficial abscess denotes the presence of pus; in deep abscess subcellular oedematous in- filtration is an important sign of deep suppuration. Local heat, throbbing, and tension are mechanical results of the causes of tu- mefaction tending to decrease as the formation of pus progresses. Plyperpyrexia is in relation with the location of the abscess, the ease with which the pus-microbes can enter the circulation, and the amount of pus and necrotic tissues present. In superficial abscess there is but little rise of tempera- ture, but in deep abscesses it sometimes reaches 104° P. (40° C.) at the time the wall of granulation tissue is established. A remission of about one degree each morning usually takes place. When the pus has found an issue, or has become completely surrounded by the limiting membrane, the intensity of the fever is usually reduced. In a superficial abscess, if a chill oc- cur, it is usually very slight, and appears between the fourth and the eighth day. It indicates the formation of pus. In a deep abscess a chill generally occurs, last- ing from a few moments to half an hour. Eluetuation is generally obtained when the purulent focus has been formed. A sharp localized pain, on pressure over the apex of the swelling, obtained at this time supports the likelihood that pus is present, but fluctuatipn is liafcle to be a misleading symptom. Interference with motion or the normal functions of a part is sometimes produced through the proximity of the abscess. Etiology. — Inflammation due to trau- matisms and lesions of all kinds, espe- cially the introduction of foreign bodies under the epidermis, are the usual causes of abscess. While blows do not appar- ently produce superficial lesions in the majority of cases, the fact remains that an invisible abrasion may be present and serve as a channel for the introduction of the pyogenic organism. The cutaneous glands, through weakened local resist- ance, may also become the transmitting media. Any cause removing the epithe- lial layer of the mucous membrane may also form the primary etiological factor of an abscess in the membrane or in the submucous connective tissue. Abscesses also arise in connection with the various septic fevers. Suppuration can occur in man with- out the presence of bacteria. Both in animals and in man suppuration may be due to the irritation of chem- icals. Investigators have shown that suppuration is only a certain stage of inflammation, not a separate qualita- tive form of inflammation. The serous formation of blebs and buUse becomes purulent without the presence of bac- teria. Karl Kreibich (Wiener klin. Woch., June 13, 1901). Case of subcutaneous abscesses due to the gonococcus in a child 2 years of age. The little patient sufl'ered from typhoid fever, and a few days after ad- mission to the hospital developed an acute anterior urethritis, which was proven to be gonorrhoeal in nature. 62 ABSCESS. ACUTE. PATHOLOGY. DIFFERENTIAL DIAGNOSIS. The source of infection could not be established. Seven and ten days later, respectively, areas of induration ap- peared to the left and right of the anus. Both were found to contain pus in which gonococci were present. Gershel (Med. Record, Feb. 7, 1903). Pathology. — While several varieties of micro-organisms are found in the pus of an acute abscess, staphylococci and streptococci are by far those most fre- quently observed, the former being usu- ally found in circumscribed abscess and the latter in diffuse ones. The first step in the process is increased rapidity of the flow of blood in the part, the vessels be- coming engorged and dilated. This is succeeded by slowing of the current and passage through the vascular walls and into the surrounding tissues of colorless corpuscles (leucocytes), a few red cor- puscles, and blood-plasma, the latter of which become coagulated and finally softened. One or several cavities are thus formed; but, if the cavities are multiple, the barriers usually soften and a single focus is established. The pus is composed of the corpuscles which perish in the cavity thus formed, the broken- down remains of tissue, and the plasma. At a distance from the location of the abscess the circidation is normal, but, as the diseased area is approached, the slow- ing of the blood-current becomes gradu- ally more evident, until a zone of living leucocytes is met, forming a protective barrier around the abscess-cavity. The surrounding parts also become permeated with new vessels, and a zone of granula- tion tissue (the pyogenic membrane of older writers) is formed. The spread of the suppuration being thus checked, the pus is forced to the surface because it finds the least resistance in that direc- tion; but, if an aponeurosis or fascia interfere, it burrows until an exit is found. The role of the white corpuscles (leu- cocytes) has been interpreted in various ways; Cohnheim considered them as ele- ments of repair; others have attributed to them the role of scavengers. The prevailing theory at present, however, is that of Metschnikoff, who considers them able to attack and destroy invading or- ganisms. The process is termed by him phagocytosis, the cells being called pha- gocytes (^aj^6),to eat, and ?£i;to$, a cell). The dead leucocytes in pus must be looked upon as the cells that have been brought up rapidly to interfere with the spread or diffusion of the products of the micro-organisms; a large number of these cells coming in contact with the poison in a concentrated form may suc- cumb to its action; but before doing so they are able to deal with a certain quan- tity of the poisonous material, breaking it down and rendering it inert. Other cells are constantly being brought up to assist these, until, at length, the bacteria are completely hemmed in. They live for a short time on the dead tissues; but, being localized by the barrier of leuco- cytes, they ultimately die, either from inanition or because they are poisoned by their own products. It is found very frequently on opening an abscess that no organisms can be seen, those that were originally present appearing to haA'e undergone degenerative changes and to have been taken up by the phagocytes, or devouring cells. (Sims Woodhead.) Differential Diagnosis. — Fluctuation onh' indicating the presence of fluid, the presence of this sign without the other symptoms mentioned should inspire great circumspection, especially if surgical measures are to be resorted to. Aneueism is the most dangerous con- dition to fear. Its less acute history, and the thrill and its-expansile pulsation, can ABSCESS. ACUTE. PROGNOSIS. TREATMENT. 63 only exist in close proximity to a large vessel. Certain semisolid growths may sim- ulate an abscess. When the possibility of an aneurism has been eliminated, a fine trocar or exploring needle, if carefully used, will determine the diagnosis. Prognosis. — This depends upon the general health of the patient. In the robust a suppurative process usually reaches the stage of resolution without giving rise to complications. In individ- uals weakened by disease, hereditary or acquired, an abscess may be protracted and exhaustive, and diffusion is more likely to occur if resisting tissues inter- fere with the superficial evacuation of the pus. Deep abscesses are especially prone to become protracted through this cause, the resistance of muscular apo- neuroses, etc., forcing the pus into the cellular interstices. Fistulous tracts, or large suppurative areas, are thus created, and the patient may succumb to blood poisoning or asthenia. Treatment. — General Measures. — Best and elevation of the afEected region, if possible; salines, if purgation is neces- sary. Easily assimilable food, but not low diet; avoidance of stimulating bev- erages, alcohol, coffee, etc. Internal Remedies. — If the case is seen early the suppuration can sometimes be arrested by the use of one of the follow- ing agents, supplemented by one of the local applications: Tincture of aconite, 1 to 3 drops every hour, closely watching the patient's pulse; tincture of veratrum viride, 1 drop every hour until the pidse becomes slower, the skin moist, and slight nausea is experienced. Calcium sulphide (sulphurated lime), Vio grain every hour; or 3^ Sulphate of quinine, 1 grain. Ext. of nux vomica, ^/^ grain. For one pill; to be taken every three hours. External Bemedies. — The surface is carefully cleansed with antiseptic soap and sprayed with a 2-per-cent. carbolic- acid solution, or with hydrogen peroxide, every two hours, the atomizer being used for ten minutes at each sitting. (Ver- neuil.) Compresses dipped in hot 1 to 4000 corrosive-sublimate solution are very effective. If the abscess is located upon an ex- tremity, a 1 to 4000 corrosive-sublimate solution may be employed in the form of a bath for the limb, the latter being left in the solution several hours at a time. A solution of nitrate of silver (30 grains to the ounce) may be applied frequently with a camel's-hair pencil. Tincture of iodine may be applied in the same manner every three hours. When the surface becomes very tender, belladonna ointment may be rubbed in every two hours. In abscesses characterized by very severe pain a 10-per-cent. solution of cocaine may be introduced by cataphore- sis, the anode sponge of a galvanic bat- tery being applied to the part. The sittings should last five minutes, and be repeated every three hours, the current not exceeding 5 milliamperes. During the intervals warm fomentations — with borated, camphorated, or pure water — are of great value. Pads of gauze wrung out of hot borie- acid solution (an ounce to a quart of water), applied as hot as the patient can bear them, and well covered with oiled silk to keep in the heat and moisture, are the best; wherever applicable, as with the hands or feet, the inflamed part should preferably be submerged every hour for a period of five to ten minutes 64 ABSCESS. ACUTE. TREATMENT. in the hot, boric solution itself. James Stuart (N. Y. Med. Jour., Jan. 16, '97). Surgical Measures. — li suppuration cannot be avoided, the abscess should be opened as soon as an adequate quantity of pus has formed to constitute an ab- scess sufficient in size to be recognized by the surgeon as such (Senn), or as soon as the presence of pus has been deter- mined by tlie exploring needle or syringe. If a local anffisthetic is necessary, one of the following may be used: Twenty drops of a 1- to 5-per-cent. solution of cocaine introduced subcutaneously near the abscess; ether sprayed over the seat of the abscess until local numbness is experienced; chloride-of-methyl or chlo- ride-of-ethyl vapor. The latter is espe- cially efficacious; the parts turn white when ready, — generally in about two minutes. Seltzer water spurted over the surface may be used to advantage when none of the other agents can be obtained. To open an ordinary abscess a single small incision suffices; but, if it is large, several small incisions should be made to render perfect evacuation of its con- tents possible by drainage. If the ab- .scess is superficial, the skin alone should be cut, but if it is deep seated the skin and fascia should be incised and the grooved director, or the points of a pair of forceps, used to reach the pus, the opening being kept patent with forceps. The cavity is then thoroughly emptied and syringed out with 1 to 4000 corro- sive-sublimate solution until the fluid comes out perfectly clear. Pressure with the fingers is to be avoided. The in- cision and its siTrroundings are then care- fully washed with the same solution, and an aseptic drainage-tube inserted. The wound is dusted with iodoform or der- matol, and an antiseptic dressing is applied, exerting slight pressure with bandage. If the abscess is deep, the drainage-tube should be shortened daily; if it is superficial, the drainage-tube can be withdrawn the second or third day. Thirty-two eases of abscess treated by the Otis method: The skin about the affected area is scrubbed with green soap and washed with sulphuric ether and then with bichloride (1 to 1000). A narrow bistoury is then inserted into the abscess-cavity, and the contents gently, but thoroughly, squeezed out; the cavity is irrigated with bichloride (1 to 1000) and immediately filled to moderate dis- tension with warm iodoform ointment (10-per-cent. iodoform and vaselin), care being taken not to use a sufficient de- gree of heat to liberate free iodine. An ordinary glass gonorrhcEal syringe is used, the plunger being removed, and the barrel warmed in the flame of an aleo- hol-lamp and filled with ointment by means of a spatula. On finishing the injection, at the instant of withdrawing the syringe from the wound, a compress wet with cold, bichloride solution is applied, which instantly solidifies the ointment at the orifice, preventing the escape of that into the abscess-cavity. A large compress of sterilized gauze is then applied by means of a firm spica. The patient is told to return in four days, when, if all is well, the dressing is reapplied; but, if any evidence of inflam- matory action is found the wound is thoroughly irrigated and cleansed and the injection repeated. It is simple and safe; the patient is not prevented from going about. It leaves no scar. Edwin M. Hasbrouck (N. Y. Med. Jour., June 13, '96). To postpone active measures until the last moment should be relegated to the past. Best to incise it. Break down all the divisions between the loculi with the flngers, then rub the walls gently and thoroughly with gauze until the last swab shows no trace of pus or debris. When dressing, distension of the cavity with irrigating fluid should be avoided. Plugging favors the accumulation of ABSCESS. COLD, OR TUBERCULOUS. SYMPTOMS. PATHOLOGY. 65 blood or serum. In many eases primary union may be obtained by stitching the abscess. If any fluid accumulates, it should be allowed to escape as soon as possible. Pus will not flow upward. Neve (Indian Med. Jour., Aug. 16, '99). To prevent stitch abscesses cleanse the skin in the usual way with soap and water, and rub into the skin of the operative field hydrated lanolin- oleate of mercury (20 per cent.). A piece of lint smeared with the ointment covers the skin until the second inunc- tion, twelve hours later; the lint is then reapplied until the time of operation, when the superfluous ointment is rubbed off with sterile gauze. A. E. Maylard (Annals of Surgery, .Jan., 1902). Cold, or Tuberculous. Symptoms. — These abscesses fre- quently attain a large size, and last for months without their presence being de- tected. Besides failing general health, the symptoms of the causative trouble are the only prominent ones. The spine, the hips, the genito-urinary tract, and the lymphatic glands are the organs most prone to tuberculous disorders giv- ing rise to cold abscesses. They some- times appear several months and even years after the beginning of the primary No pain is experienced, as a rule; cold abscesses are not even tender to the touch. There is no redness until the ab- scess is about to break, the focus of the liquid mass being otherwise too deeply seated. Slight hyperpyrexia is usually present. There is no local heat; hence the name "cold" is given this form of abscess by the Germans, to differentiate it from the "warm" abscess. The above symptoms are usually fol- lowed by the sudden appearance of a swelling. Though generally soft, it may be hard, and suggest a tumor in the vicinity of the spinal column (Pott's dis- 1- ease), above or below Poupart's ligament, after burrowing along the psoas muscle (psoas abscess), on the inner aspect of the thigh, or in the lumbar region (lumbar abscess), etc. In the neck cold abscesses are usually due to disease of the neigh- boring cervical lymphatic glands. The skin either remains normal or gradually becomes thinned and softened until an external opening is formed. Fluctuation, usually detected with ease, is sometimes hidden by a thick investing layer of lymph, which gives the mass a peculiar tension, suggesting a lipoma or some other hard growth. Aneurisms sometimes convey the sensa- tion produced by a cold abscess: a fact to be borne in mind when operative pro- cedures are under consideration. Pathology. — A cold abscess can al- ways be traced to a specific inflammatory process, and almost invariably to one of a tubercular nature. Where the conflu- ent masses in the centre of a nodule begin to break down, there is formed a collection of material surrounded by tuberculous tissue. This material be- comes infiltrated with leucocytes, and thus is produced a cavity containing fluid fatty material, fragments of cells, and leucocytes, around which there is granulation tissue filled with tubercles. In this way a tuberculous abscess is formed. (Cheyne.) It seems at times to be quite a matter of accident whether the abscess breaks into the joint or finds its way by a more circuitous route into the surrounding connective tissue. As the tuberculous masses spread, caseation takes place at different points in the wall, and the masses are discharged into the cavity of the abscess; but the spread of the abscess is effected generally by what is termed 'Tiurrowing of pus." This burrowing occurs in various direc- tions, and large collections of pus, alto- 66 ABSCESS. COLD. DIAGNOSIS. PROGNOSIS. TREATMENT. getlier out of proportion to the original lesion, are formed, and are known as cold abscesses. (Warren.) What has been called a chronic ab- scess is very often no abscess at all. In tubercular processes the product of tissue-proliferation undergoes coagula- tion-necrosis, and disintegrates into a granular mass, which, when mixed with a sufficient quantity of serum, forms an emulsion that microscopically resembles pus, but under the microscope shows none of the histological elements which are found in true pus. An abscess can only be called such if it contain pus. A true chronic abscess can originate in a tiibercular, actinomycotic, or syphilitic lesion, when the granulation tissue is secondarily infected by the localization of pus-microbes, which convert the em- bryonal cells into pus-corpuscles. (Senn.) Differential Diagnosis. — The concom- itant disorder usually makes a diagno- sis easy in a case of cold abscess; but occasionally the swelling is the only in- dication of ill health, and it is important to determine, under such circumstances, the nature of the pus. The macroscop- ical appearances of "laudable" pus and of "sanious" pus are frequently so simi- lar that a de visu diagnosis is not Justi- fied. Bacteriological examination of the contents of such abscesses will show con- clusively whether they are true pus-con- taining abscesses or whether or not they are pseudo-abscesses. If cultivations are made of their contents, piis-microbes will grow upon proper nutrient media if it be a true abscess, while, from the con- tents of a pseudo-abscess only the mi- crobes of the primary infection can be cultivated. The information obtained by the discovery of the essential cause can be confirmed by inoculation experi- ments. (Senn.) Prognosis. — The walls of cold ab- scesses are usually tense and tough, and are lined with cheesy tuberculous ma- terial. They do not tend to collapse, as is the case with acute abscesses, and for that reason are healed with difficulty. When, however, the seat of the original trouble can be reached and successfully treated, the fluid in the parts of the ab- scess-tract is absorbed, and the caseous matter undergoes calcification. This fortrinate issue of the case is seldom met with, however, and the abscess usually continues, the primary etiological factor acting as a drain for the diseased area. The prognosis, therefore, depends upon the result obtained in the treatment of the latter. Treatment. — It is a well-known clin- ical fact that, when such a cold or tuber- ciilous abscess opens spontaneously, or is- incised in a careless way, profuse sup- puration and hectic fever follow, with only too often a speedy fatal result from septic infection. Unless the surround- ings of the patient admit of carrying out the antiseptic treatment to its full and perfect extent, a chronic abscess should not be evacuated by incision. It should be aspirated. When an incision can be made, it should be free, and the cavity should be thoroughly curetted, cleansed, disinfected, and iodoformized, then su- tured, drained, and treated as a recent wound. On general principles, necrosed or de- tached bone should be looked for in all cases. Strict antiseptic precautions are imperative to avoid mixed infection (bacilli of tuberculosis and pyogenic cocci). Preliminary precautions should be taken to meet violent hcemorrhage due to vascular erosion. When there is local inflammation and spontaneous opening of the abscess is probable, there should be a free incision, a thorough scraping of its walls with ABSCESS. ABSINTHIUM. 67 Volkmann's curette to transform the suppurating surfaces into bleeding ones. The cavity is then cleansed with a 5- per-cent. solution of carbolic acid, a long drain is applied, and the wound is stitched as far as the drain. An anti- septic dressing is then applied. (Volk- mann, Trelat, Pozzi.) After opening the abscess the cavity may be washed out with peroxide of hydrogen in 10-per-cent. solution or packed with iodoform gauze. Eemoval of the limiting sac is then performed by decortication, the steps being: free incision, the sac detached with finger or spatula and removed, and the cavity closed immediately. (Lannelongue.) Peroxide of hydrogen is a prophylac- tic and curative medicament in the treatment of suppurative skin lesions so common in infants. A twelve-volume solution is ample as a skin-wash twice daily. This rapidly cures superficial lesions. Abscesses must obviously be evacuated before the peroxide solution is used. Cochart (Jour, de Med. de Paris, April 21, 1901). The removal of the limiting sac is facilitated by filling the wound with paraffin; the mass can then be removed as if it were a lipoma. (Cazin.) A psoas abscess should be opened in the loin and groin when possible. In the loin the incision should be made through the external and internal ob- lique, transversalis, and lumbar fascia, along the outer edge of the erector spinse to the edge of the quadratiis lumborum. The latter muscle and the transversalis fascia are divided on a level with the tip of the second or third lumbar trans- verse process, avoiding the lumbar ar- teries. The sheath and the psoas are then perforated with the finger or a trocar. A counter-opening is then made below Poupart's ligament to form a tunnel, into which a large-size drainage- tube is inserted. This is replaced, later on, by a tube at each end to obtain oblit- eration, beginning from the centre of the canal. If one incision is preferred the loin shoi^ld be selected. Aspiration and Injections. — AVhen no local inflammation indicates that the abscess is soon to open, the fluid may be withdrawn with a large aspirator; a 5-per-cent. solution of carbolic acid is injected and then aspirated. This pro- cedure is renewed until the solution withdrawn is perfectly clear. A Lister bandage is then applied, insiiring slight pressure. Five days later the treatment is renewed. About five sittings are re- quired. (Boeckel.) Injection fluids: Iodoform, 1 part; ether, 5 parts; distilled water, 5 parts. Injection not to be renewed while iodo- form is being excreted in the urine. (Mosetig-Moorhof, Verneuil.) Less painful is a mixture of 1 part of iodoform to 10 of glycerin (Billroth) or of olive-oil (Brims). Intoxication may be prevented by sterilizing the iodoform and excipient (except ether) by heating at 212° F. separately. (Tillmann.) Boric acid, a 4-per-cent. solution, may be used as above (Menard), or naphthol and camphor, 1 part each. About thirty sittings are usually required. The lesion being a tuberculous one, the general system should be treated ac- cordingly. Nutritious food, including a free supply of milk and eggs, pure air, sunlight, and sea-air, if possible, are in- dicated, as well as tonics and alteratives (codliver-oil and hypophosphites, iodine, iodides, arsenic, quinine, strychnine, etc.). Q guMNER WiTHERSTINE, Philadelphia. ABSINTHIUM (WORMWOOD) .—Ab- sinthium (the Artemisa absinthium of 68 ABSINTHIUM. ACEXANILID. Linne) is a fruit-bearing plant growing in the northern latitudes of Europe, Asia, and Africa, and naturalized in North America. It grows in dry ground and is often found along roadsides. The leaves and tops are utilized in pharmacy, and contain a volatile oil and other con- stituents, — absinthol, absinthin, etc. The preparations usiially employed are an infusion and the powdered leaves. Dose. — Volatile oil, 1 to 2 minims; in- fusion, 1 to 2 drachms; powdered leaves, 20 to 40 grains. Physiological Action. — Absinthium especially affects the central nervous system, and there is a striking resem- blance between its toxic effects and a paroxysm of idiopathic epilepsy, — namely, twitching of the muscles of the face and ears, followed by clonic and tetanic spasms of the muscles of the trunk and extremities, with salivation, cries, involuntary emission of urine, and finally a period of unconsciousness. A cordial — "absinthe" — is extensively used in France as a supposed stomachic tonic and as an intoxicating agent. It surpasses in perniciousness any beverage known, and contributes markedly to the deterioration of that country's popula- tion. Absinthe Poisoning^. — As already stated, a poisonous dose of absinthe gives rise to symptoms simulating an attack of epilepsy. In a fatal case there is abolishment of the reflexes, anuria, and finally arrest of respiration and of car- diac action. Autopsy of case in which death had followed the ingestion of one and a half pints of pure absinthe. The liver con- tained 0.21 of 1 per cent, of aleoliol, the blood 0.33 of 1 per cent., and the brain 0.44 of 1 per cent. The epithelium of the stomach and that of tlie kidneys were desquamated. The mucous mem- brane of the stomach and the renal blood-vessels were very much congested. The stomach presented evidence of haem- orrhage in the larger curvature. Symp- toms attributed more especially to alco- hol, the characteristic effect of absinthe being the production of epileptiform coma. Pauly and Bonne (Gaz. Hebd. de Med. et de Chir., May 13, '97). Absinthe is not only an epileptogenic poison, but also a stupefying principle, which would add its action to that of alcohol. Lepine (Gaz. Hebd. de Med. et de Chir., May 13, '97). Treatment of Poisoning. — Lavage of the stomach should at once be resorted to even if the respiration, the cardiac action, and the reflexes are apparently abolished. Therapeutics. — Absinthium was at one time used as antispasmodic, febri- fuge, and anthelmintic. It has been generally discarded, however, and is only considered here owing to its present role as an intoxicant. A. C. E. MIXTURE. See Chloro- form. ACETANILID.— Acetanilid (formerly known under the name of antifebrin) is a white crystalline powder obtained by the action of glacial acetic acid upon ani- line. It is odorless and gives rise to a slight burning sensation when applied to the tongue. It is but slightly soluble in water, but completely so in alcohol and ether. Acetanilid is not soluble, but is readily suspended in syrupy mixtures, so that it can be combined with ammonia in any of its forms, salicylic acid, nux vomica, digitalis, codeine, ereasote, potassium bromide, or indeed almost any drug, and a prescription obtained that can be much more accurately adapted to the case in hand than any of the ready-made com- binations. The foundation of most of the coal-tar product combinations is acetani- lid, which has been combined with bi- carbonate of soda, caffeine, carbonate of ACETAXILIIX PHYSIOLOGICAL ACTION. 69 ammonia, etc. The combination may be chemical or mechanical, it matters little which, as it is practically broken up in the body into the acetanilid radicals and the other constituents. It is much more professional and scientific to write for the mixture than to be slaves to a propri- etary combination. Perhaps the most generally useful combination of acetan- ilid when used as an analgesic is the migraine tablet. This is the equivalent of several of the most widely-used secret mixtures that are sold under a specific name. It consists of 2 grains of acetan- ilid and Va grain each of caffeine citrate and monobromate of camphor. A useful combination that can be prescribed in capsule is acetanilid and quinine, 1 grain of the former and 2 of the latter. This makes a good adjuvant to other treat- ment in eases of coryza. In rheumatic conditions, and those in which there is a suspicion of intestinal fermentation, acetanilid and salol make a good com- bination in capsule. For disturbances of circulation and neuroses attending the menopause, 2 grains of acetanilid and 15 grains of bromide of sodium are efficient when combined in a drachm of simple elixir. When repeated sufficiently often in this form., it acts as an efficient hyp- notic. Acetanilid is a useful addition to mixtures for the relief of acute indi- gestion attended by fiatulence and great distress immediately after meals. As a substitute for iodoform and a host of antiseptic dusting-powders, acetanilid has been found most efficacious, especially when combined with boric acid. L. F. Bishop (Med. News, June 10, '99). Dose and Physiological Action. — When the drug was first placed on the market, some years ago, the doses administered were excessive. The normal dose in the healthy adult should not exceed 7 grains; 4 grains represent the proper quantity to be administered at a time. To give antifebrin in doses of 5 and even 10 grains, still more to repeat these after a short interval, is a highly-inju- dicious procedure. Such doses are ex- cessive, being equivalent to about 25 and 50 grains of antipyrine. This fact of its greater strength has been overlooked. Therapeutic Committee, British Med. Assoc. (Brit. Med. Jour., Jan. 13, '94). For children the dose should be small, but it need not be reduced to quite the proportion observed for most drugs. The action of acetanilid upon the heart may become pronounced unexpect- edly; its effects should therefore be closely watched in children and weakly individuals. Case of collapse occurring after a dose of 3 grains. The same dose had been given eight times in the four preceding days without evil result; possible in- stance of cumulative action. Kronecker (Ther. Monats., Sept., '88). Fatal case, in a child, from the admin- istration of 3 ■'/j grains every two hours during the day. By evening the child was cyanosed and in fatal collapse. Editorial (Provincial Med. Jour., Mar. I, '89). Case of a young woman who took 4-grain doses of the drug at frequent intervals, until, in three days, 48 grains had been taken. On the third day the patient suddenly fell from her chair, un- conscious and cyanosed. The prolonged use of acetanilid is cer- tainly not without danger. This may be of two kinds: 1. The production of marked and more or less transient changes in blood-composition from its long use. 2. Cumulative power in the drug. Robert Haley (Weekly Med. Ee- view, Nov. 9, '89) . Acetanilid used in 1100 cases of dis- eases of children, in 600 of which a record was kept. Conclusions are: (1) with due care it is a reliable remedy for infancy and childhood; (2) the re- sults are of longer duration and the de- pression not so great as from the use of antipyrine; (3) the cyanosis which may accompany its use is not dangerous and soon passes away: (4) small, but re- peated, doses should be used. I. N. Love (Jour. Amer. Med. Assoc, Mar. 29, '90). Acetanilid habit in a negro adult suf- fering from rheumatism. The man found that he was relieved by its administra- tion, but that on leaving off the drug a 70 ACETANILID. POISONING. few days the pain returned. He began taking it constantly each day and now uses 2 ounces a week. G. W. Gaines (N. 0. Med. and Surg. Jour., July, 1900). Its prolonged administration, even in small doses, may give rise to sudden and marked antemia and to temporary mental aberration. Experiments in animals have shown that prolonged use tends to cause fatty degeneration of the heart, liver, and kidn€ys. Two cases in which gradual loss of memory was produced by long-continued administration (5 to 30 grains) of ace- tanilid. Memory regained by stopping the drug. Joseph Haigh (Medical World, Oct., '89). Report of twenty-five physicians of New South Wales. Opinion that symp- toms of depression and collapse are more readily produced and are more marked than with antipyrine may be explained by the fall of temperature being greater and more rapid. Most of the reports mention cyanosis to a greater degree that after antipyrine. Anaemia may be induced by its continued use and become a grave condition. D. R. Paterson (Prac- titioner, No. 304, '93). Acetanilid Poisoning. — Aeetanilid gives rise to severe symptoms of intox- ication more frequently than any other agent belonging to the aromatic series, with the exception, perhaps, of antipy- rine. When poisonous doses are taken, there is marked cyanosis, prostration, shallow and labored respiration, palpitation of the heart, weak and thready irregular pulse, dilatation of the pupils, cold extremities, subnormal temperature, cold sweats, and other symptoms of collapse. The drug would therefore seem to be a depressant to the functions of respiration and cir- culation, with disturbance of the vaso- motor system and probably of the heat- regulating centres. Case of poisoning by acetanilid, in a lady 36 years of age, who had taken about 40 grains in divided doses, in the course of four hours. The chief symp- toms exhibited were semi-unconscious- ness; delirium; a very feeble pulse; short, rapid breathing; cyanosis of face and lips; and cold extremities. The patient recovered under tlie use of alco- holic stimulants and the hypodermic in- jection of strychnine. J. W. C. (Med. Review, May 21, '92). Case in a woman, aged 21 years, who, two weeks after her confinement, was given, for headache, V2 ounce of ace- tanilid in bulk in an envelope, with directions to take a small quantity of it on the end of a teaspoon every two hours. The patient took two doses as directed, and a few hours afterward, the headache still persisting, she concluded that a very large dose would be more efficacious, and swallowed a teaspoonful of the drug. Half an hour later weak- ness and dizziness, and an hour later she fainted and passed urine involuntarily. Later on she became cyanotic and semi- conscious. The pulse was slow and ex- tremely feeble, the respirations slow and shallow, the forehead bathed in sweat, and the face livid and perfectly expres- sionless. The tongue, lips, and finger- nails were intensely cj'anotic and almost black; the head, hands, and eyelids were cold, but her feet were quite warm; temperature was normal; there was tingling of the skin over the entire body and some slight mental confusion. There was suppi'ession of urine until noon the next day, and when passed it was of a dark-brown color and very abundant. Loud and continuous borborygmus noticed. The milk secreted by the breast was very much thinner than it had been before the poisoning. The cyanosis lasted for several da^'s. Treatment was that advised by Hare: Patient forced to maintain a recumbent position, the head kept low, and an hypodermic injection of aromatic spirit of ammonia, followed by sulphate of strychnine and sulphate of atropine, given. Hot bottles placed about the body, and '/« grain of strychnine every three hours given by the mouth, alternating with whisky and aromatic spirit of ammonia. Owing to the condi- tion of the milk, it was not considered wise for the patient to continue nursing ACETANILID. POISONING. 71 her child, as the milk failed to return to its normal condition after recovery, and the patient was much exhausted. G. Baringer Slifer (Ther. Gaz., May 15, '97). Case of acetanilid poisoning in a woman, aged 26 years, who had taken 8 grains. Collapse with strong convul- sive movements, partial loss of con- sciousness, and great retching. Whisky, nitrate of strychnine, and — for two hours — artificial respiration induced re- covery. 0. R. Summers (N. Y. Med. Jour., Mar. 24, 1900). Case of fatal acetanilid poisoning. The patient, a man of 37, had taken six "headache powders" each contain- ing 10 grains. He became delirious, complained of abdominal pain, vomited, and was slightly jaundiced. His tem- perature rose to 100.2° F., the lips and nails became intensely cyanotic, respira- tions shallow and frequent. The urine, of which 10 ounces were passed on ad- mission, was nearly black and strongly alkaline. Anuria occurred, and six days later the man died. There was alter- nate constipation and diarrhoea, and forty-eight hours before death the faeces constantly showed blood-pigment, blood-clots, and corpuscles. Philip Brown (Amer. Jour. Med. Sciences, Dec, 1901). Whik subnormal temperature may result from the administration of even small doses, it is not always present in cases of poisoning. Subnormal temperature, in a man aged 40 years, produced by a second dose of 7 grains two hours after the first. T. M. Dunagan (Memphis Med. Monthly, Mar., '91). The toxic properties of acetanilid too often appear wnen the drug is given in small doses. In some cases symptoms become so severe that a fatal result may be imminent, unless prompt treatment is employed. Having been widely adver- tised as a universal analgesic, a large number of remedies for the relief of pain, under catchy titles, contain this drug as an essential ingredient. Fifteen grains is commonly considered the maximum dose, yet one-third of this quantity has been personally seen to produce alarm- ing symptoms. Authors have occasion- ally advised that 3 grains be given each hour, but patients reach the danger-line long before the maximum quantity was given in this way. Two 4-grain doses caused nearly fatal issue in a case in an adult described by O. R. Summers. Personal case in which the patient had taken four headache powders. The head- ache powder had been taken each hour, beginning at nine o'clock and ending at noon. The surface of the body presented an ashen-gray appearance, the mucous membranes having a much darker hue. The temperature was 96 degrees; pulse, 60; and respiration, 10. Digitalis, sti-ychnine, and alcohol-baths with fric- tion were employed, with dry heat to the surface. AMien the patient was able to swallow, a combination of aromatic spirit of ammonia, brandy, and capsicum was given. Twenty-four hours later the temperature was slightly subnormal, the dusky appearance of the face disap- peared to a large extent, but the symp- toms of cyanosis did not wholly vanish until the second day. The powders con- tained 3 grains of acetanilid, 2 grains of bicarbonate of sodium, and 1 grain of caffeine; hence the total dose was 12 grains of acetanilid. Conclusion that under no circumstances should acetanilid be administered alone, but always guarded by a cardiac stimulant, while the intervals between doses should be sufficiently prolonged. Earps (Merck's Archives, June, 1901). The cyanosis is probably due to the liberation of free aniline in the blood, and is more likely to occur when the acetanilid is imperfectly manufactured. An excess of aniline is present when the acetanilid employed gives a reddish- orange precipitate with sodium hydro- bromite. Many of the toxic symptoms of ace- tanilid so closely resemble those of aniline poisoning as to suggest the pro- duction of that substance in the blood. There is a close relationship between the two bodies, and there is therefore some ground to suspect the occasional pres- 72 ACETANILID. POISONING. ence of aniline in samples. Editorial (Brit. Med. Jour., Dec. 22, '94). Cyanosis is due to the liberation of free aniline in the blood, which disap- pears soon afterward, as soon as it is eliminated by the kidneys and skin. A similar cyanosis, though more pro- nounced, is found in the workmen of aniline-color works. C. F. Baohmann (N. Y. Med. Jour., May 22, '97). Aeetanilid is an efiective agent for the treatment of wounds, causing rapid heal- ing in subjects whose powers of resist- ance to toxic effects are not greatly bfilow par. In infants and aged people, for instance, the possibilities of untoward effects are greater than in youths or adult subjects. Idiosyncrasy may also enter for a share in the cases of poison- ing reported. In the aged the resolutive process may be retarded by its use. Case of an infant, 16 days old, suffer- ing from haemorrhage from the umbilicus. A powder of equal parts of boric acid and aeetanilid applied locally twice daily for three days caused the face to become distinctly cyanotic; the lips, ears, finger- tips, and toes bluish; the hands and feet cold ; the breathing bordering upon ster- tor. The condition disappeared on ceas- ing the application of the powder. R. C. Rosenberger (Phila. Polyclinic, No. 45, '95). Case in an infant, aged 14 months, in whom excision of the hip had been per- formed for tuberculosis and the wound packed with aeetanilid. In four hours the temperature dropped five degrees and there were great pallor and feeble pulse. The temperature rose and symp- toms disappeared upon removal of the dressing. The second case was one of extensive suppurative superficial scald. At twelve o'clock 2 drachms of finely- powdered aeetanilid were dusted over the surface; at five o'clock the patient pre- sented grave toxic symptoms; all aee- tanilid Avas at once removed, digitalis and whisky were exhibited, and by mid- night he was in a normal condition. T. S. K. Morton (Phila. Polyclinic, Feb., '95). Case of eczema in which dusting- powder, composed of 1 part aeetanilid and 3 parts subnitrate of bismuth, was used three times a day. When it became necessary to secure a new supply, the second application produced alarming cyanosis, with labored breathing and other evidences of distress; discontinu- ance of the powder. Inquiry showed that cyanosis had followed every appli- cation of the powder. Charles Sauter (Louisville Med. Monthly, Nov., '95). Two cases: an amputation of the ear for epithelioma of the helix and an abscess of the maxillary sinus in elderly men, the one aged 73 and the other 84. Aeetanilid seemed to produce a great deal of irritation and to delay granula- tion; similar experience several times with iodoform. William A. Edwards (Pacific Record, Jan. 15, '96). Marked instance in an infant in which it had been applied to the navel. Face, lips, fingers, toes, and the whole of the skin and visible mucosa of a dark-blue color. Rectal temperature was 99° P.; respiration, 60. Oxygen, whisky, and digitalis were administered. No effect upon cyanosis noticed from the oxygen inhalations. Not until the fourth day did the child regain its former strength and disposition. I. M. Snow (Archives of Pediatrics, June, '97). In obstetrics aeetanilid used as an antiseptic in all injuries occurring in the course of the three thousand cases seen by her since 1894. It always caused rapid resolution of the woimd without suppuration. It also exerted a distinct analgesic action, which was particularly noticeable in the painful tears in the re- gion of the clitoris, the urethra, and the vulva. ProkopiefF (Vratch, xxi, No. 14, 1900). While aeetanilid forms an excellent dressing for wounds, burns, and exposed surfaces in general, it is easily absorbed by the latter, and may thus give rise to active toxic symptoms, especially in in- fants, as shown above. The following combination recom- mended in numerous diseases, applied in the form of a powder or a paste: — 1} Aeetanilid, 3j. Zinc oxide, Siij. Iodized starch (5 per cent.), 3iv. ACETANILID. THERAPEUTICS. 73 The iodized starch should be properly prepared and the acetanilid finely pul- verized. SufiSoient water is added to make a paint or paste, to be applied with a stiff brush. Liquid albolene, ben- zoin, or olive-oil may be used instead of water when the application is in- tended for dry surfaces or ulcers; a gauze bandage may be used to prevent it from being rubbed off. When dry the powder is of light-drab color, when wet of a slate color, but when in con- tact with pus it turns white, showing that the iodine has been liberated. This combination of the drugs gives an antiseptic, astringent, soothing, and protective remedy, having remarkable healing properties, useful in eczema, ulcers, dermatitis from all causes, in- cluding superficial burns, impetigo, sy- cosis, herpes zoster, and chancroids. T. G. Lusk (Jour, of Cutaneous and Genito- urin. Dis., Dec, 1901). Treatment of Acetamlid Poisoning. — In the treatment of poisoning by acetan- ilid cardiac, respiratory, and vasomotor stimulation is of great importance. . Ether, hypodermically, has been most frequently used. Belladonna is probably the best drug to fulfill the indications; it tends to equalize the blood-pressure, and with external warmth and some more direct cardiac stimulant — brandy, etc. — presents the needed qualities for antago- nizing the overaction of acetanilid. Therapeutics. Fever. — Acetanilid presents the re- quired qualities for the reduction of high fever, which alone warrants the use of antipyretics. Not only is a rise of three or four degrees harmless, but modern investigations tend to show that it is one of Nature's means of defense against pathogenic elements of various kinds. The many cases of marked depression that have followed its use even in moder- ate pyrexia of infectious fevers have caused its use to be abandoned. North- rup severely condemns its use in chil- dren. Malaria. — It has been found service- able by several observers in warding off the periodic manifestations of intermit- tent fever. Acetanilid possesses great merit in warding off chills in intermittent fever. If there is time, before the chill 1 Vs to 2 grains of calomel in Vi-grain doses half an hour apart are given; then, ac- cording to age, 2 to 6 grains of ace- tanilid twenty minutes or half an hour before the expected chill. Gentle per- spiration with natural sleep usually fol- low within half an hour; if not, a sec- ond dose of equal amount may be given. Used in several hundred cases without quinine. Benjamin Brodnax (North Carolina Med. Jour., Apr. 20, '95). Typhoid Fever. — Early in its career acetanilid was found more harmful than beneficial in this affection. It tends to depress vital energy, which, on the con- trary, should be sustained. Its use in this disease has been practically aban- doned. Classes of patients who exhibit sus- ceptibility to the influence of acetanilid. In a number of cases of pregnant and nursing women who were suffering from typhoid fever, disagreeable or alarming symptoms observed to follow the exhibi- tion of any but very moderate doses of the drug. Larger, but still moderate, doses were frequently followed by pro- fuse diaphoresis, or even collapse. Sem- britzki (Ther. Monat., June, '89). Phthisis. — The same reasons cause acetanilid to be contra-indicated in this disease. It has been used to counteract the afternoon rise of temperature, but the advantage gained is more than offset by the depression produced. Case of a young man, with acute pul- monary tuberculosis, in whom 10 grains produced collapse. James Wilding (Brit. Med. Jour., Sept. 14, '89). Nervous Disordbes. — Pertussis. — It is in the diseases of the nervous system that acetanilid has shown itself most 74 ACETANILID. ACETIC ACID. valuable. As an antispasmodic in whoop- ing-cough its effects are quite marked. In pertussis it lessens the discomfort and keeps the paroxysms in cheek better than any other remedy. I. N. Love (Jour. Amer. Med. Assoc, Mar. 29, '90). Case of a child, 5 years old, suffering from pertussis, who took, by mistake, 1 drachm of antifebrin. Cyanosis; res- pirations slowed. Large dose had an excellent effect on the whooping-cough. Spencer (Canadian Practitioner, Apr., '91). Acetanilid of great value in whooping- cough; Vi to Va grain every two hours to infants 1 to 2 months old, and propor- tionately larger doses to older children. W. L. Wade (So. California Pract., Aug., '94). Neuralgia and Kindred Disorders. — As an analgesic, especially in cases of neuralgic or neuritic nature, or in pain from reflex causes, acetanilid has been of marked benefit. In rheumatism, sciatica, lumbago, trifacial and other neuralgias, gastralgia, girdle-pain of locomotor ataxia, ovarian or other vis- ceral pain, the pain of optic neuritis and glaucoma, it has been freely used, and still maintains a well-deserved reputa- tion. It is also effective in the neuralgic pains associated with herpes zoster. Five-grain doses successfully relieve the lightning pain of locomotor ataxia. Stewart (Canada Med. Record, Jan., '88). Of great advantage in 5-grain doses, repeated every two hours, in painful menstruation, especially of young girls. H. B. Ely (Medical World, Jan., '91). Epilepsy. — In epilepsy, however, it has not shown itself effective, even when ad- ministered in sufficiently large doses to produce cyanosis. Vomiting. — Vomiting of nervous origin occasionally yields to its action. In obstinate vomiting, particularly when it seems to be due chiefly to nerv- ous disturbance or marked gastric irri- tability. Two grains every hour until 6 grains are taken often prevent this unpleasant sequel of operative interfer- ence. H. A. Hai-e (Therapeutic Gazette, Nov. 15, '94). ACETIC ACID. — Acetic acid is an organic acid obtained from vinegar, of which it represents the active principle. It is also obtained from crude pyrolig- neous acid. It is a clear, colorless fluid having a strong pungent odor and an intensely-acid corrosive taste. It con- tains 36 per cent, of glacial acetic acid: a monohydrate presenting the physical properties of acetic acid, which, in turn, becomes crystalline at 34° F. Dose. — The dilute acetic acid is offi- cinally prepared by adding 1 part of acetic acid to 5 of water, and is used as a local astringent and stimulant. Glacial acetic acid is employed as an escharotic. The crystalline form is mainly employed with sulphate of potas- sium in the preparation of smelling-salts. Experiments to ascertain whethar acetic acid cannot be used instead of alcohol to avoid the dangers of the alco- hol habit. Nux vomica, kola, cinchona, sanguinaria, ipecacuanha, and colchicum- seed successfully exhausted with varying strengths of acetic acid. Joseph P. Rem- ington (Amer. Jour, of Pharm., No. 3, p. 121, '97). The constituents of acetic-acid prepa- rations may be divided into (a) those which hasten the evaporation of the acetic acid (this group includes all pow- dery substances — kieselgur is the most active, then comes kaolin; sulphur and flour have a slighter effect); and (6) those which retard the evaporation of the acetic acid (glycerin comes first, then adeps benzoatus, and lastly vaselin). Following preparations of acetic acid recommended: — 1. Adeps lanse, 7 parts. Acetic acid (30 per cent.), 7 parts. Benzoated lard, 7 parts. 2. Adeps lanse, 6 parts. Acetic acid (30 per cent.), 7 parts. Benzoated lard, 2 parts. Kaolin, 6 parts. ACETIC ACID. PHYSIOLOGICAL ACTION. THERAPEUTICS. 75 3. Glycerin, 5 paits. Acetic acid (30 per cent.), 7 parts. Kaolin, 9 parts. Following "acetic - acid - and - sulphur paste" is very useful in acne: — 4. Adeps lanae, 6 parts. Acetic acid (30 per cent.), 7 parts. Benzoated lard, 6 parts. Precipitated sulphur, 2 parts. All these preparations contain 10 per cent, of anhydrous acetic acid, and con- sequently are strong preparations of the acid. Unna (Treatment, vol. ii, p. 373, '98). Physiological Action. — In free dilu- tion acetic acid is au excellent antiseptic; but, administered without the admixture •of bland liquids, it causes intense irrita- tion, owing to its property of effecting a partial soltition of albuminous bodies and •of dissolving gelatinous tissues. Acetic acid combines with the alkaline bases within the system, forming acetates that are diuretic and diaphoretic. Acetic- Acid Poisoning. — The escha- jotic action of acetic acid, by manifesting itself upon the mucous membrane of the pharynx and larynx, is liable to cause •oedema of the glottis: a danger to be at ■once thought of. The immediate mani- festations are severe pain in the mouth, throat, oesophagus, and stomach, with retching and vomiting and other symp- toms attending violent irritation of the ■digestive tract. Treatment of Acetic-Acid Poisoning. — Alkalies and demulcents should be em- ployed. The bicarbonate of soda in free solution is an effective remedy. Ordinary soap — one containing an alkali — can be used in solution until an alkaline salt is ■available. Therapeutics, — As an antiseptic, acetic acid is possessed of considerable power. As such it may either be applied locally •or its fumes may be inhaled. Good effects from inhalations of a 2- to 3-per-cent. solution of acetic acid in pachydermia laryngis associated with tuberculosis. Sittings lasting ten min- utes three times a day and continued several weeks. Scheinmann (Berliner klin. Woch., Nov. 21, '91). Acetic acid an excellent remedy in bronchitis and the broncho-pneumonia of children. Used in forty cases, in the form of inhalations. The acid is placed in a pan held over a lamp, and the patient, seated on a chair, is covered over with tents made of sheets. At first the lamp should be turned low, to avoid un- due irritation of the larynx by an excess of fumes. To be used ten minutes at a time, four to six times daily, and during the night in the sleeping-room. B. W. Switzer (Med. World, Apr., '96). In an emergency vinegar is useful for disinfecting the hands and the region operated upon. L. Fiirst (Deut. Aerzte- Zeit., June 15, 1900). Acetic acid is frequently used as a stimulant. When inhaled its stimu- lating effects upon the nervoiis supply of the nasal mucous membrane causes it to sometimes act rapidly in restoring consciousness after fainting. In the same manner it may also arrest vomiting and headaches of nervous origin. Vinegar as a remedy against vomiting in chloroform narcosis. Handkerchief moistened with vinegar applied to the nostrils and permitted to remain until patient returns to consciousness. War- holm (Univ. Med. Jour., Dec, '93). As an escharotic it is often used on corns, warts, condylomata, and fungous growths. The glacial acetic acid should be used for this purpose. Slcin Diseases. — Acetic acid is useful in many disorders of the skin. In alo- pecia it has been used with advantage as a vesicant. When alopecia is extensive the scalp should be shaved and acetic acid, in greater or less proportion, mixed with equal parts of chloroform and ether, ap- ACETIC ACID. ACETONURIA. plied. Or Besnier's formiila may be employed: — ' 19 Chloral hydratis, 75 grains. JEtheris, 6 drachms. Acid, acetic, cryst., 15 to 75 grains. M. These applications are repeated two or three times a week at first and later at long-er intervals. Between-times a stimulating oil — as of eucalyptus and turpentine^ of each, V2 ounce; cnide petroleum and alcohol, of each, 1 ounce — is applied. This is to be followed by a thorough massage of the scalp for five minutes by the patient. Once a week, or oftener, the scalp is to be thoroughly shampooed with tincture of green soap. Morrow (Jour, of Cut. and Genito-Urin. Dis., Oct., '91). In rodent nicer and Inpus vulgaris acetic acid is of use; but in the latter affection the benefit is only temporary. In eleven out of twelve eases ulcus rodens observed the ulcer was situated upon the lower lid. Treatment, by means of daily applications of a 75-per- cent, solution of acetic acid and subse- quent rinsing with water, followed by good results. Wagner (Grafe's Archiv f. Oph., B. 33, Ab. 3, '91). In rodent ulcer. Cure of a young girl attacked with vitiligo of the body and alopecia of the scalp, in which the treat- ment consisted of two applications of acetic acid, together with stimulating lotions (tincture of rosemary, Van Swle- ten's solution, and tincture of canthar- ides). Feulard (Le Bull. Mgd., Jan. 15, '93). Diseases of the Nose and Throat. — Acute coryza is sometimes arrested by the inhalation of acetic acid. Glacial acetic acid is useful in pre- venting the development of hay fever by applications to the nasal mucous mem- brane twice per week. In practically all eases, however, the applications must be renewed each year. (Sajous.) In hypertrophic rhinitis it may also be used in the same way; but chromic acid is more effective. In tubercular laryngitis it has given good results in arresting ulceration. The ulcers are first scraped and the acid is then applied with a laryngeal applicator. ACETONURIA.— Acetone (C3HeO = dimethylketone == CH3— CO— CH3) is a thin, watery, very movable, odorless liquid of neutral reaction. It has a curious aro- matic odor, resembling somewhat that of acetic ether or of oil of peppermint. It is soluble in water, in alcohol and ether in all proportions; evaporates at ordinary temperatures; boils at 56.5° C; and has a specific gravity of 0.81. Acetone can be obtained by the distillation of acetate of barium. Oxidation of acetone causes the formation of acetic acid and formic acid. As a product of metabolism, it was discovered by Fetters, in 1857, in the urine of a diabetic patient. Acetone is found in the urine of healthy individuals in quantities not ex- ceeding 10 milligrammes per day, which, during starvation (Mliller), can increase to 780 milligrammes per day. In some diseases it increases to 0.8 to 0.5 gramme daily. By distilling the urine examined, acetone can be obtained in a purer state, although still united with other volatile constituents of the urine. Physiological and Pathological Ex- cretion of Acetone. — Pathological ace- tonuria is observed (1) in fevers, (2) in diabetes, (3) in some forms of carcinoma which have not as yet induced inanition, (4) in psychoses, (5) in autointoxications, and (6) in different disorders of the digestion. Lorenz observed acetonuria and excretion of acetone with the fseces and the vomited matter in a case of peritonitis. In fevers acetonitria is con- stantly observed, and in the fevers of children as well (Baginsky). In cases of diabetes, acetonuria occurs when the dis- ease has continued for a long time, and ACETONURIA. ORIGIN OF ACETONE. especially when the patients are put on an exclusive diet of proteids or proteids and fat, or when the allowance of food is not sufficient to maintain the equilib- rium of metabolism. In fevers, as well as in diabetes, ace- tonuria is often accompanied by excre- tion of diaeetic acid and beta-oxybutyric acid. The Origin and Pathological Signifi- cance of Acetone, Diacetic Acid, and Beta-oxybutyric Acid. — The origin of acetone in the organism has not yet been ascertained. Cantani was of the opinion that it was formed in functional disor- ders of the digestive tract; Fetters and Kaulich argued that it was due to fer- mentations in the bowels. MarkownikofE ascribed it to a fermentative product of Aeetonuria of intestinal origin cannot be denied; but its occurrence from tliis cause is probably much rarer than many have imagined. S. Boeri (Revista Clin, e Terapeutica, Nov., "91). The development of aeetonuria from affections of the intestines of the most varied character is a phenomenon so con- stant that it would be well to add to the already recognized varieties of the con- dition a class caused by intestinal dis- turbances. In these cases of digestive fault it seems impossible to separate aeetonuria and diaceturia, in that the differences in clinical manifestations be- tween these substances are but slight, and really only quantitative in charac- ter, and the combination or alternation of the two conditions is almost always the case. The symptoms formerly attrib- uted to these substances do not appear to be due to them, but to lower oxidized forms. When albuminuria exists it does not seem to be in any way dependent upon either of these substances. Ace- tone is to be found (sometimes in large amounts) in the contents of the stomach and intestine in many cases. There is a great difference between the primary and secondarv gastro-intestinal affections, especially of nervous origin; in the for- mer the gastric contents almost always contain acetone; in the latter it is rarely found. In several cases oxybutyric acid was also found in the urine. Lorenz (Oesterr.-ungar. Cent. f. d. med. Wissen., '91). Experiments to ascertain whether Mayer's view that aeetonuria is an evi- dence that an acid intoxication of the organism exists are correct. Strychnine poisoning produced in a number of dogs, thus causing an acid in- toxication through the muscular spasm. In no instance was aeetonuria the result. Acetone looked for in 31 epileptics also, after convulsions, and found in only 13 instances and in but small quantities; several of these patients had acetone in their urine before the convulsions. To see whether acetone comes from the gastro-intestinal tract calomel was given to a diabetic girl that showed aeetonuria. Were the acetone formed in the gastro- intestinal tract it would seem probable that after the disinfecting and purgative action of the calomel the quantity of the urine would be less. On the contrary, the amount was rather greater than less, and at any rate it was not decreased. Hugo Liithje (Centralb. f. innere Med., Sept. 23, '99). The necessary condition for the pro- duction of aeetonuria is an insufficient decomposition of hydrocarbons, either from their absence in the diet or from impaired powers of decomposition on the part of the organism (diabetes). In ad- vanced diabetes aeetonuria is a grave symptom, threatening coma. This coma may be delayed by the administration of large doses of sodium bicarbonate. It is probable that the bodies of the acetone series are formed in considerable quantity in the organism, to disappear completely later. They doubtless represent links in a continuous series of transformations in which oxybutyric acid-beta is the pri- mordial term. H. C. Geelsuyden (Norsk Mag. f. Laegevidensk., July, 1900). Albertoni did not find acetone in the urine of animals which had received large doses of glucose (100 grammes) or 78 ACETONURIA. ORIGIN OF ACETONE. of difEerent primary saturated alcohol; when isopropylalcohol was ingested it was excreted partly unaltered and partly changed to acetone, and when acetone was given to animals it was discharged by the urine, even if the dose of acetone ingested did not exceed 8 centigrammes. When Gerhard detected the presence, in the urine, of a substance which gave a dark, wine-red color by means of a solution of perchloride of iron, he be- lieved this substance to be diacetic ether, and was of the opinion that acetone was derived from this substance, which can easily be disintegrated into acetone, alco- hol, and carbonic acid. Fleischer and Tollens proved this to be an error, and found that the coloring substance — at least, in the majority of cases — must be diacetic acid, which can be separated from the urine by the addition of sul- phuric acid and extracted with ether. This opinion is supported by von Jaksch. Minowski caused acetonuria by extir- pation of the pancreas, and von Mering by intoxication with phloridzin. Lustig foimd that extirpation of the solar plexus in animals provoked ace- tonuria, glycosuria, and emaciation, while Oddi obtained the same results by sugar injections. Acetonuria may not depend upon the extirpation of the cceliae plexus. It is to be noted that septic peritonitis is avoided with difficulty. Acetonuria ob- served for three days in a woman oper- ated on for salpingitis. On the other hand, it was not met Avith in a dog which had undergone, under all antiseptic pre- cautions, subdiaphragmatic section of the vagus and e.xtirpation of the ganglia. Contejean (Archives de Phys. Brown- Sequard, Oct., '92). Lorenz is of the opinion that diacetic acid and the beta-oxybutyric acid are the sitbstances from which acetone is de- rived, and that they are the real causes of the toxic symptoms observed in ace- tonuria, while acetone itself is relatively innocuous. Von Engel found a great quantity of acetone in the urine of a patient suffer- ing from lactonuria; when the milk was removed by a suckling apparatus the acetonuria disappeared. Very much ace- tone was found in the urine of patients suffering from severe chronic morphin- ism. In different acute fevers aceto- nuria is rather a constant symptom; in typhoid fever von Engel found it con- stantly; acetone was only missed when the typhoid fever was accompanied by obstipation. Acetonuria occurs not infrequently in children, especially in febrile affections and in acute gastro-intestinal derange- ments. It may, however, be absent even in high and continuous pyrexia. Diace- turia, likewise, is frequent in children, and is almost constant in high and con- tinued fever; and is common in the acute infectious processes, even if there be but little attendant fever, — as, too, is the case with acetonuria. Schrack (Fort- sehritte der Med., Oct. 1, '89). Acetonuria was studied in twenty-six cases. In physiological pregnancy at the ninth month acetonuria is more marked than in the non-pregnant state. In labor the acetonuria increases, especially if the parturition be prolonged. In the puer- perium it diminishes, remaining, how- ever, greater than in pregnancy till after the sixth day. The view that acetonuria can be regarded as a sign of fcetal death is not sustained. R. Costa (Ann. di Ostet.,e Gynec, xxiii. Mar., 1901). Becker found that acetonuria increased after narcosis, the case being the same with an already existing acetonuria. This would seem to explain why acetonuria has been observed after great operations. Operations are frequently followed by acetonuria, but, contrary to what has been claimed, this is not the result of opening the peritoneum or of the use of sublimate. It also causes no pathological reaction. Though traces of acetone may be met with in normal persons, this is ACETOXURIA. ORIGIN OF ACETONE. 7» not always the case, and it cannot, there- fore, be regarded as a necessary product of metabolism. Conti (Wratsch, Dec. 7, '93). In healthy subjects after narcosis ace- tonuria sets in, lasting from a few hours to several days. This post-narcotic aee- tonuria indicates an increased destruc- tion of albumin. Ernst Becker (Vir- ehow's Archiv f. Path. Anat. and Phys. u. f. klin. Med., Apr. 2, '95). Acetonuria follows anaesthesia in two- thirds of the caseSj the ansesthetie used making no difference; if acetonuria is present before, anaesthesia increases it. ' The practical outcome is that, except in eases of urgency, ansesthetics should not be administered to diabetic patients. Abram (Jour. Path, and Bac, p. 3, 430, '96). Marked and prolonged acetonuria de- tected during retrogression of fibroids after oophorectomy or ligature of the ovarian arteries. Bossi (Arch, di Ostet. e Ginec, vol. iv, p. 4, '98). Acetone, diaeetic acid, and beta-oxy- butyrie acid are found in great quanti- ties in the urine of diabetic coma, and different authors — Mnnser and Strassez, for instance — believe these substances to be the real cause of coma, perhaps by causing an excess of acidity in the or- ganism. In comatose patients who do not suffer from diabetes — as, for instance, in satur- nine encephalopathies, etc. — diaeetic acid is often found in the urine. Von Jaksch has proposed to give the name of "coma diaceticum" to these case's of coma. Nevertheless, neither acetone nor dia- eetic acid and oxybutyric acid have very prominent poisonous properties. Kuss- maul gave animals 6 grammes of acetone per day without effect. Buhl, Tappeiner, and Frerichs came to similar results. Albertoni found the lethal dose of ace- tone for dogs to be about 6 to 8 grammes per kilogramme of the dog's weight. Case of cerebral apoplexy in which sugar and acetone were detected in the urine. The coma had come on suddenly, and was regarded as diabetic from the urinaiy condition; but the autopsy re- vealed an extensive cerebral haemorrhage. Ruttan and Johnston (Montreal Med. Jour., Mar., '91). Geelsuyden draws the conclusion from many experiments on rabbits that, even when small (10 to 20 milligrammes} subcutaneous injections of acetone are given, the acetone is excreted with the urine; in larger doses more acetone i& excreted; but only a portion of the in- jected quantity reappears; another por- tion of it is excreted with the expired air; but still a portion is left which does- not reappear and must therefore have been disintegrated in the body of the animal. After the injections albumi- nuria takes place. An adult rabbit can bear an injection of 2 grammes of ace- tone, but is killed by the injection of S grammes. In starving auimals the ex- periments gave the same results; a por- tion of the injected acetone reappeared in the urine and the expired air, while- still another portion was disintegrated in the body. Geelsuyden draws from these experiments the conclusion that the ace- tonuria observed in starving individuals- is not caused by a diminution of the- power to disintegrate acetone already formed in the bodj', but to an increase- of the amoimt of acetone formed in the- body. Modern authors generally admit that acetone is a product of the metabolism of proteids. Honigmann and von Noor- den are of the opinion that acetone is only formed by diminution of the organ- ized albumin of the body, and never by the metabolism of the proteids ingested with the food, be the quantity ever so large. Honigmann supported this theory principally by experiments made on him- self, which proved that when he lived exchi.sively on large quantities of proteids- ACETONURIA. ORIGIN OF ACETONE. — that iSj when nutrition was insufficient — acetone and diacetie acid were found. The acetonuria was not augmented when more albumin was ingested, but disap- peared when he took plenty of carbohy- drates in addition to the proteids. Von Engel, on the contrary, is of the opinion that in all cases when great quantities of albumin are decomposed in the body the quantity of acetone excreted with the urine will increase considerably, — equally if the albumin is ingested with the food or taken from the stock of the body. Relations existing between patholog- ical acetonuria and azoturia in several diseases (diabetes mellitus, typhoid fe- ver, pneumonia, phosphorvis poisoning) : acetone seems to increase, especially in those cases where destruction of albumi- noid matters is also increased, whether they be of organic nature or belong to the albumin of alimentation. A direct proportion between the amounts of ace- tone and albumin has not been observed. A solution between the two is some- times observed, but it is by no means constant. Palma (Jour, de Med. de Chir. et de Pharm. Bruxelles, Feb. 2, '95). Twenty-six cases of acetonuria stud- ied. In physiological pregnancy at the ninth month the acetonuria is more marked than in the non-pregnant state. In labor the acetonuria increases, espe- cialh' if the parturition be prolonged. In the puerperium it diminishes, remain- ing, however, greater than in pregnancy till after the sixth day. The view that acetonuria can be regarded as a sign of foetal death is not sustained. R. Costa (Ann. di Ostet. e Gynec, xxiii, March, 1901). Weintraud and Hirschfeld are decided opponents of this theory. Weintraud argues that — in a case of severe diabetes where complete equilibrium of the me- tabolism, and especially of the metabo- lism of nitrogen, was maintained for a long time, so that no albumin contained in the tissues was consumed — acetone, diacetie acid, and beta-oxybutyric acid were constantly excreted with the urine; the diet was free from carbohydrates; when, also, the quantity of proteids was somewhat reduced the sugar disappeared after twenty-four hours; the weight of the body was maintained, but acetone and diacetie acid were still excreted. Carbonate of soda augmented the quantity of acetone excreted, without diminishing the quantity of oxybutyric acids. When, in periods of twenty-four hours, no food at all was taken, ace- tonuria was greatly increased. Inges- tion of carbohydrates diminished the acetonuria even in persons suffering from diabetes; levulose, milk, and sugar have the same property; glycerin, also, as observed by Hirschfeld. The addition of fat to the food has no power to arrest the acetonuria. Hirschfeld found that when he put two individuals on light diet, consisting only of proteids and fat, diminution of albumin of the body, as well as ace- tonuria, was produced. When carbohy- drates were added to the food the ace- tonuria diminished, and that to a much greater degree than the diminution of albumin. Ingestions of fat had abso- lutely no influence in diminishing ace- tonuria, although it diminished the loss of nitrogen. Acetonuria is more marked when the albuminous food is scarce than when it is given in great quantities. The ingestion of carbohydrates has an extra- ordinarily rapid effect on the production of acetonuria, the quantity of acetone being considerable within two hours. Experiments in persons who were almost starving have proved that a moderate quantity of carbohydrates was sufficient to bring about marked diminution of ace- tonuria in spite of the considerable loss of albumin and fat which still took place. Objections to the view that pathologi- cal acetonuria is due to autointoxication. ACETONURIA. TESTS FOR ACETONE. 81 It was formerly thought that, apart from diabetes, acetonuria might occur in the fasting state, in fever, and in special dis- eases, such as carcinoma. The increased production of acetone was loolced upon as the result of increased albuminous de- composition. This rests on a false basis. It was known that acetone was present in the urine in people fed exclusively on albuminous foodstuffs and fat, and that the increase disappeared when carbohy- drates were taken. The author showed that even small quantities of carbohy- drates had a very considerable eifect on the acetone excretion; that the acetonu- ria found in febrile affections and in car- cinoma could be made to disappear when abundant carbohydrate foodstuffs were given, and that it increased when the patient could eat less. The question of acetonuria in diabetes is in accord with the view of its connection with carbo- hydrate metabolism. There is very little difference between the healthy and dia- betics, as long as the latter can deal with the largest part of the carbohydrate food- stuffs supplied, but when the carbo- hydrates are excreted as sugar the ace- tone in the urine is increased. The difference between the healthy and dia- betics is that in the latter, notwithstand- ing abundant carbohydrate foodstuffs, acetone excretion is abundant, and that, whereas in the healthy the acetone in the urine does not exceed 0.9 gramme, in the diabetic it is much above 1 gramme. It is only correct to speak of a patho- logical acetonuria in diabetes. Hirsch- feld (Cent. f. inn. Med., June 13, '96). Geelsiiyden, from his experiments on rabbits and dogs already mentioned, readied the conclusion that acetone is formed in the tissues, not in the kid- neys; that the kidneys give passage to the acetone even when their blood con- tains a very small quantity of it; and that pathological acetonuria is not caused by a defect of disintegration of acetone in the body, but by a disorder of the general metabolism leading to the for- mation of an anomalous large quantity of acetone. Geelsuvden has further con- ducted a series of experiments in healthy individuals (medical students) put on dif- ferent scales of diet, which were strictly controlled. As all observers did, Geel- suyden found that when a person was put on exclusive flesh diet acetonuria appeared, and at the same time the body lost albumin as well as fat; when large quantities of proteids were ingested, ace- tonuria was less considerable than when less albumin was given. Complete star- vation, an exclusive fat diet, and a diet of proteids, with the addition of a great quantity of fat, cause a very considerable amount of acetone to be excreted. As exclusive diet of fat and complete star- vation give rise to the excretion of the largest quantity of acetone, it seems that acetone is formed by disintegration of fat, and that in this respect there is no difference between the fat of the food and that of the tissues. Carbohydrates have a great power to check the excre- tions of acetone; when individuals were put on a diet without carbohydrates and secreted itrine containing a great quan- tity of acetone, the acetonuria disappeared in a few hours when carbohydrates were given. From 150 to 200 grammes of carbohydrates per day are required to check an already existing alimentary acetonuria. In the opinion of Geelsuyden, ace- tonuria occurs when carbohydrates are not ingested in sufficient amount, and acetone is formed by the disintegration of fat, either of that of the tissues or of that contained in the food. Preliminary Tests for Acetone. — With an alkaline solution of sodium nitrocy- anide (of a slightly-red hue) acetone gives a ruby-red color, changing, after some time, to yellow, and after acidifying with acetic acid and boiling, to greenish- violet. The cyanide-of-soda test, after Legal 82 ACETONURIA. TESTS FOR ACETONE. or le Nobel (see below), may be employed as preliminary test; but, to make the presence of acetone positive, it is neces- sary to separate it from the urine by distillation. As the boiling-point of ace- tone is low (56° C), this may be done at a low temperature, and the use of a water-bath is recommended. Legal's Test. ■ — To ten cubic centi- metres of urine a small crystal of nitro- cyanide of soda or some drops of a freshly-made solution of this reagent are added; the fluid is rendered strongly alkaline by a 30-per-cent. solution of caustic soda or potash. When acetone is present a beautiful-red color will appear, which will change only after some time to yellow; the red color produced in the same manner by creatinin becomes yellow sooner. Legal adds that, when acetone is present and the urine, shortly after the addition of the solution of soda, is neutralized with acetic acid, the urine assumes a purple-red color, and, when diluted with water, a crimson hue. When the acetic acid is floated on the urine a crimson ring will appear at the point of contact, and, when much acetone is present, the color of the ring will be purplish red. Le Nobel's Test. — Le Nobel and Fehr hold that Legal's test is only re- liable when much acetone is present; and that, when there is only a small quantity of it in the urine, the test may be fallacious, since other substances con- tained in the urine can produce a red color with the nitrocyanide of soda. The most characteristic point of the test is, according to Fehr, the appearance of the violet hue, which causes the red color to become crimson or purple, and not pure red. Le Nobel proposes to substitute a solu- tion of ammonia for the solution of soda, when the test is, in other respect, made according to the indications of Legal; ■the fluid containing acetone is not im- mediately colored, but after some time, when the liquid is shaken with air or some drops of a strong acid added (the alkaline reaction being maintained), the fluid takes a rose-red color, increasing gradually and changing after some time to violet wine-red. By heating the fluid the color disappears, but returns on cooling down; when boiled with acids it changes into greenish violet. Le Nobel's test is more delicate than Legal's, and will reveal 0.00025 gramme of acetone. Fehr's Test. — Fehr also employs the test after the method of Legal, but pro- poses, when the color of the imne after the addition of solution of soda is pass- ing from dark red to yellow, to float some drops of acetic acid on the urine. When the test-tube is slightly rotated so that only a small quantity of the acid mingles with the urine, a beautiful violet color will appear when acetone is pres- ent, the intensity of the color being pro- portionate to the quantity of acetone contained in the urine. Chautaed's Test. — Eomine recom- mends, as a reliable test for acetone in the urine, a solution of fuchsin (1 to 2000) into which a current of sulphur- ous-acid gas has been passed. This rap- idly decolorizes the liquid and causes it to assume a clear-yellow tint, which is permanent and unaifected by an excess of acid. A few drops of such a solution, added to a urine containing acetone, produce a deep-violet color. The test is delicate enough to allow the detection of one part of acetone in one thousand of urine. Definite Tests for Acetone. — When no very great quantity of acetone is found in the urine it is absolutely necessary to distill the urine and to test the distillate with the different reagents. The distilla- ACETONURIA. TESTS FOR ACETOXE. 83 tion of two hundred to three hundred cubic centimetres of urine is made in a water-bath, and a temperature of 56° to 58° C. is employed. No acid need be added to the urine before distillation, as the acetone becomes distilled very well without acid and the acid might disinte- grate other substances present and thus cause the formation of acetone. There is no reason why special care should be taken lest a small amount of ammonia be distilled with the acetone. The distilla- tion is only continued until a sufficient quantity of fluid for the different tests to be employed has passed over into the recipient. The distillation is then sub- jected to the following tests: — • Lieben's Iodofoem Test. — To a few cubic centimetres of the distillate a few drops of a solution of potassium and some drops of a solution of iodine and iodide of potassium are added, the solu- tion of potassium being added in excess. AVhen acetone is present, a thick, yellow precipitate of iodoform will immediately form. This test will reveal 0.01 milli- gramme. By heating, the iodoform evaporates and accumulates on the sides of the test-tube in the form of small yellow plaques, consisting of the charac- teristic crystals of iodoform. The most serious objection to Lieben's test is that many (at least seventeen) other sub- stances, and especially alcohol, may give the same result. Lieben's iodoform test recommended both for delicacy and ease of application. A yellow opacity, with precipitation of iodoform, occurs if acetone be present. Nothing else that occurs in the urine, except acetone, is able to give this pre- cipitate of iodoform, without warning. When but small quantities are present the urine should first be made acid with sulphuric acid and distilled. When half the urine has been distilled all the ace- tone has been found to be in the dis- tillate. Euttan (Montreal Med. .Jour., Mar., '91). The most satisfactory test for acetone in the urine is Lieben's. It is performed by adding a few drops of Lugol's solution to the first 10 cubic centimetres obtained by distilling 400 cubic centimetres of fresh urine, then adding sodium-hydrox- ide solution until the brown color disap- pears. In the presence of acetone a milky precipitate of iodoform is produced, and may be recognized by its violet colora- tion with caustic soda and thymol, or by its yellow hexagonal crystals under the microscope. Ronsse (Annales de Gyn. et d'Obstet, Mar., 1900). Gunning's Test. — Gunning modified Lieben's test by using a solution of am- monia and tincture of iodine. Le Nobel prefers to use a solution of ammonia and iodine dissolved in iodide of ammonium; this certainly is the best way to make tlie iodoform test, as no alcohol is added with the reagents. According to le Nobel, 0.001 milligramme of acetone can be de- tected by this test, but von Jaksch could only detect acetone by it when present in a quantity of 0.1 milligramme. Errors caused by the presence of alcohol are avoided by this test. Eetnold's Test. — Freshly precipi- tated oxide of mercury is dissolved by acetone in the presence of alkali. Le Nobel prefers to make the test by pre- cipitating a solution of perchloride of mercury with an alcoholic solution of caustic potash, added until the mixture gives a strong alkaline reaction; then the fluid containing acetone is added and the whole well shaken in a test-tube. The fluid is then filtered and care taken that the filtrate be perfectly limpid. The combination of acetone and oxide of mercury in the filtrate can be detected by chlorate of stannum or by floating some drops of the filtrate on a solution of sulphide of ammonium: where the two liquids touch each other a black ring 84 ACETONURIA. TESTS FOR ACETONE. will appear. By means of this test 0.01 milligramme of acetone is revealed, and the test is at once very delicate and very reliable. The Nitkoctanide Test. — This test is made with the distillate quite in the same manner as with the urine either after the method of Legal or after le Nobel's modification of it. This test is less delicate, and the phenols, which possibly might have passed over into the distillate, are apt to give the same color as the acetone; the test, therefore, gives no proof of the presence of the latter substance. Penzoldt's Indigo Test. — Baeyer and Drewsen found that acetone forms indigo blue with orthonitrobenzaldehyde. Penzoldt has employed this reagent by dissolving urine crystals of orthonitro- benzaldehyde in boiling water; on cool- ing down the aldehyde forms a white, milky cloud; the fluid which is to be tested is now added and the mixture rendered alkaline with a solution of pot- ash. When acetone is present a yellow color will appear, which changes to green and, after ten minutes, to indigo; it also forms an indigo-blue precipitate. Very small quantities of acetone may be de- tected by shaking the mixtiire with a few •drops of chloroform. When left quiet ior some time the chloroform takes a blue color and sinks to the bottom of the test-tube. According to Penzoldt, acetone is re- vealed by this test in a solution of 1 to 2000. According to von Jaksch, the smallest quantity of acetone revealed by it is 1.6 milligrammes. Aldehyde ace- tophenone and other substances form indigo in the same way as acetone, but the color is not so marked. Maleeba's Test. — Malerba found that a ^/o-per-cent. solution of parami- dochmethylaniline with acetone gives a reddish color, changing into violet and blue-red. The violet color changes to rose and the next day to red. Under the spectro- scope two stripes are seen analogous to those of haemoglobin. The test is also good for uric acid^ the solution of the latter being left to evaporate, and when the residue is fairly dried some drops of the above solution added, when a blue coloration is obtained. Malerba (Eevue des Sci. Med. en France et a I'Etranger, Apr. 25, '95). Miscellaneous Tests. — With bisul- phite of soda, acetone, as well as the alde- hydes, combines to a crystallic compound in thin flakes resembling much those of cholesterin, even by microscopical exam- ination. (Limprieht.) Acetone in an alkaline solution com- bines with iodine to form iodoform. Freshly precipitated oxide of mercury is dissolved by acetone. Indigo is formed when acetone is combined with orthoni- trobenzaldehyde in an alkaline solution. (Baeyer and Drewsen.) Bichloride of mercury recommended as a reagent for acetone and albumin, as well as for the estimation of the quan- tity of glucose and nitrogen present in the urine. Pittarelli (GI' Incurabili Gior. di Clin, e di Terapia, Nos. 16 and 17, '94). Certain substances (sugars) yield the reactions usually characterizing acetone. This is due to decomposition of sugar and formation of aeetaldehyde. In test- ing by the ordinary method, the urine should, therefore, be moderately acidified and distilled slowly and not too long. Salkowski (Jour, de Med., de Chir., et de Phai-m., Bruxelles, Jan. 26, '95). From what has just been stated it will become apparent that none of the tests are specific for acetone alone. To be quite sure that acetone is contained in the distillate, it is, therefore, necessary to try successively by all the tests, and only when all tests give positive result is the presence of acetone proved. Von Jaksch has tried to employ the ACETONURIA. ACETO-ORTHO-TOLUIDE. 85 nitrocyanide test for a quantitative esti- mation of the acfitone, and the iodoform test has been recommended by Messinger and Huppert for the same purpose. The quantity of iodine used to form iodoform with the acetone is measured, and the quantity of the acetone present in the solution calculated by it also; but, al- though Engel and Devoto are of the opinion that it is possible to make pretty accurate estimations in this way, meth- ods for quantitative estimation of the acetone are not to be relied upon, as it is impossible to avoid errors caused by the presence of substances which are in- fluenced by the tests in the same way as the acetone. Diacetie acid (CJI.O, = CH3— CO— CH,— COOH) may be revealed in the urine by the aid of a solution of per- chloride of iron, which, with diacetie acid, produces a dark, wine-red color. The test is made by adding a soliition of perchloride of iron as long as a pre- cipitate of phosphates of iron is formed. The mixture is then filtered and some drops of perchloride are added to the filtrate. When diacetie acid is present, the filtrate takes a deep-red color, which vanishes in twenty-four hours, and more rapidly after addition of strong acids. Von Jaksch has, by a colorimetric method based on this test, tried to make an approximate estimation of the quan- tity of diacetie acid contained in the urine, but newly-passed urine can alone be used for the search of diacetie acid, as this acid, after some time — twenty- four to forty-eight hours — will disappear from the urine. Diacetie acid can be isolated from the urine by adding a few drops of sulphuric acid and shaking the mixture with ether. When diacetie acid is present, it is dissolved in the ether and can be detected by the perchloride- of-iron test. Beta-oxybutyric acid (C4ris03) is also found sometimes in the urine of fever patients, as well as in diabetes, with ace- tone and diacetie acid. This may also be the case in the dyspepsia of alcohol- ism and in carcinoma of the stomach. When beta-oxybutyric acid is cautiously oxidated, acetone is found. F. Letison, Copenhagen. ACETO-ORTHO-TOLTJIDE. — Aceto- ortho-toluide is an isomer of exalgin, and appears in the form of colorless needles, freely soluble in alcohol, ether, and hot water, but little soluble in cold water. Its melting-point is 224.6° F. and boiling-point 564.8° F., being com- parable in these respects to acetanilid and methylacetanilid, which it resembles chemically, being also, like these drugs, an active antipyretic. Physiological Action. — Aceto-ortho- toluide acts chiefly on the cord, and only in toxic doses on the brain and medulla. The heart is last affected. Doses of V» grain per kilogramme of the body-weight reduce normal temperature by about 1 V2° F., and bring febrile temperatures to the normal point. It does not alter the blood-pressure, but somewhat increases the frequency of the heart-beats, though leaving the vasomotor centres unaffected. It causes dilatation of the blood-vessels by direct stimulation of the nervous ele- ments of the vascular walls themselves. The fall of temperature is, moreover, due to the loss of heat consequent on this dilatation. (Barabini.) Therapeutics. — Although this product was introduced as one superior to ace- tanilid, owing to its being less toxic, it does not seem to have received much support from the profession. It was also credited with antiseptic properties even in a weak solution (5 to 1000). ACETYLENE. POISONING. ACETYLENE.— When calcium carbide (CaCo) is brought in contact with water, acetylene-gas is formed. Being capable, when lighted, of furnishing a degree of light far superior to that of ordinary gas, acetylene has recently been considerably used as an illuminant. When prepared from pure calcium carbide and purified by liquefaction, it has a pleasant ethereal odor and can be breathed in small quan- tities without giving rise to ill effects. Impure gas, prepared from coal or im- pure lime, may contain calcium sulphide and phosphide, and the acetylene pre- pared from it may then have a very unpleasant odor. Acetylene Poisoning. — Acetylene may be fatally poisonous when present in proportions as high as 40 per cent, by volume, as recently shown by G-rehant, Berthelot, and Moissant. A mixture of 20 volumes of acetylene — prepared from calcium carbide, 20.8 volumes of oxy- gen, and 59.2 volumes of nitrogen — was breathed by a dog for thirty-five minutes without any marked disturbance, and 100 cubic centimetres of the blood were found to contain 10 cubic centimetres of acetylene. With 40 volumes of acety- lene, the proportion of oxygen remain- ing the same, a dog died in less than an hour, owing to failure of the heart's action, and 100 cubic centimetres of blood contained 20 cubic centimetres of acetylene. With 79 volumes of acety- lene and 21 volumes of oxygen the poi- sonous effects were still more strongly marked. The poisonous action of acetylene it- self is feeble when the blood is at the same time supplied from the air with the usual amount of oxygen. In other words, acetylene inhaled in the open air is but slightly harmful. One hundred volumes of blood dissolve about eighty volumes of acetylene; the solution shows no characteristic spec- trum, and is reduced by ammonium sul- phide as readily as ordinary arterial blood. In a vacuum part of the acety- lene is evolved at the ordinary tempera- ture and part at 60° F. If the blood is allowed to putrefy, the volume of acety- lene given off at the ordinary tempera- ture remains practically the same, but the quantity liberated at 60° decreases as putrefaction advances. If any com- pound of acetylene and hEemoglobin is formed, it is very unstable, and is not analogous to earboxyhasmoglobin. Bro- ciner (Boston Med. and Surg. Jour., July 30, '96). In a closed room, however, where the oxygen is not kept up to the normal standard, when the accumulation of a foreign gas would prevent the constant renewal of air through window and door interstices or open chimneys, and where the products of respiration would be allowed to accumulate, it would quickly prove mortal by paralyzing the respira- tory function. Experiments on dogs, guinea-pigs, and other animals showing that acetylene has considerable toxic power. One pint of the pure gas caused severe symptoms of poisoning in dogs, and even when mixed with air (20 per cent.) it proved fatal after an hour. If the gas was adminis- tered rapidly, the animals recovered when placed in the open air, but if given slowly this did not occur, and the ani- mals died. Mosso and Ottolenghi (Rif. Med., Jan. 23, '97). A mixture of air and acetylene com- mences to be explosive when it contains 5 per cent, of acetylene, whereas it re- quires the presence of 8 per cent, of coal- gas to make a similar mixture explosible. If a rabbit is placed in a bell-jar into Avhich ordinary air and acetylene are pumped, the animal seems for a long period to experience very little incon- venience. It is not until ordinary at- mospheric air is excluded and only acety- lene admitted that symptoms gradually and slowly develop. After a more length- ened exposure to acetylene than that which is necessary for coal-gas the ani- ACETYLENE. mal becomes intoxicated, it falls over on its side apparently profoundly asleep, and, while all through the experiment its breathing has been somewhat short and rapid, stupor steals over the animal ap- parently painlessly. A few inhalations of atmospheric air are sufficient to re- store to the animal all its faculties. Should inhalation have been pushed fur- ther and the animal have been very deeply asphyxiated, death may ensue, cyanosis, hitherto observed, being rapidly replaced by extreme pallor. In minor and easily-recoverable stages of asphyxia the vascular tension is still maintained, and there is no difficulty in obtaining a drop of blood for examination; but when the deeper stages are reached so extremely contracted are all vessels that it is al- most impossible to obtain even a trace of blood. When this stage has been reached recovery is difficult. When blood of a rabbit was examined at different stages of intoxication from acetylene, and especially in deepest asphyxia, this fluid on spectroscopic examination al- ways exhibited two well-marked bands of oxyhsemoglobin; also that, unlike the blood in coal-gas poisoning, although re- sembling it in the cheriy-red color which it presented^ it was readily reduced on the application of ammonium sulphide and gentle heat. Thomas Oliver (Brit. Med. .Jour., Apr. 23, '98). It has been said that acetylene is very poisonous; the experiments of many ob- servers, and especially those of Grehant, do not confirm this statement. He proved that acetylene simply dissolves in the blood-plasma, while carbon monoxide forms a compound with the hoemoglobin of the blood. Acetylene, while slightly poisonous, is less poisonous than coal-gas, and vastly less than water-gas, which contains a high percentage of carbon monoxide. E. Renouf {Pharm. Era, July 20, '99). Treatment of Acetylene Poisoning. — That fresh air should at once be given the patient need hardly he mentioned. The patient should be removed from the poisoned atmosphere into a well-venti- lated room and artificial respiration prac- ticed. Hypodermic injections of strych- nia and digitalis should be administered, while oxygen is sent for. This gas should be inhaled as soon as practicable, while artificial respiration is continued with vigor, the patient being simultaneously rubbed. Eectal injection, of warm coffee are also useful. In all such cases the efforts of the phy- sician should be kept up a long time, the sespiration and pulse being unreliable guides as regards the presence in the system of sufficient life to render re- suscitation possible. Therapeutics. — Acetylene has not been used in therapeutics. ACNE. Definition. — Acne is characterized by the presence, on the face, of small eleva- tions or nodosities varying in size from a pin-head to a pea. These elevations, or pimples, are also present on the back, shoulders, and chest in many cases. Symptoms. — The elevations are con- ical or hemispherical, and, as a rule, in the earliest stage of the lesion somewhat painful, especially upon pressure. In most of the lesions there is a distinct tendency to suppurative change. In the centre of the lesion a whitish-yellow spot forms where the pus raises the epidermis. In from three to ten days, or even longer, the lesion breaks and a small amount of pus is discharged. At other times the pus dries to a thin crust, or occasion- ally the contents, especially in sluggish lesions, are absorbed. A red elevation is left which gradually flattens out, leav- ing a brownish stain, which eventually disappears. The surrounding skin is fre- quently oily and shiny. Tumors as large as a pea or a small nut, formed by re- tention-cysts of sebaceous glands, are sometimes seen; they may graduallv work to the surface or may persist lor ACNE. VARIETIES. months and finally disappear or form hard spherical indurations by retraction and inspissation of their contents. Scar- ring, usually consisting of small, white, cicatricial depressions, is to be seen as a consequence in some cases. In the majority of cases, however, permanent marks are not left. The regions most affected in acne are the face, shoulders, and anterior and posterior aspects of the shoulders. Occasional cases are observed in which the back, extending as far down as the sacrum, is the chief seat of the disease. In rare instances (acne cachec- ticorum, acne scrofulosorum, and acne medicamentosa) the eruption may be more or less general. Varieties. — There are several varieties of lesion observed in acne, one kind of which is apt to predominate, and this has given rise to the so-called varieties of the disease. Acne vulgaris, or acne simplex, is, by ' far, the most common clinical type. The lesions are usually of a mixed character, consisting of black-heads, pin-head to pea- sized papules, papule-pustules, and pustules. Each lesion may in its begin- ning have a small, red areola. There is also slight pain upon pressure. The lesions are rapid in evolution, running a course in several days to a week. As in all types, they are discrete and isolated. The term "acne papulosa" is given to a not uncommon type in which the lesions are usually small and show but little disposition to reach the pustular stage, disappearing by absorption or by desiccation and exfoliation. Acne punctata might be termed mi- nute papular, the lesions being, for the most, pin-head in size, with a central comedo, or black-head. Acne pustulosa is another type in which the lesions go rapidly into the pustular stage, the eruption appearing. for the most part, to be made up, almost entirely, of pustules. In size they vary from a large pin-head to a large-sized pea. "Acne indurata," or "tuberculosa," is a form of the eruption in which the lesions tend to be closely crowded here and there and in such places, and also with single lesions, the underlying base becomes hard, inflamed, and indurated, being also somewhat deep-seated. In acne phlegmonosa the inflamma- tory and suppurative process begins deep down in the sebaceous gland, forming veritable small dermic and intradermic abscesses, usually with but slight tend- ency to break through the surface. Acne cachecticorum characterizes an acneic eruption, more or less general, occurring in weak, cachectic individuals; the lesions are livid, indolent, violet-red papulo-pustules of moderate and large size and of slow evolution, leaving, as a rule, small cicatrices. Acne scrofulo- sorum is really a variety of the last named, — acne cachecticorum, — occur- ring in those of distinctly strumous or tuberculous temperament. Severe case of acne scrofulosorum in girl with no tubercular family history, but with enlarged cervical glands. Ac- neic pustules and comedones extremely numerous, developed in crops, suppurated freely, left deep livid-blue scars, most noticeable over buttocks and thighs. J. J. Pringle (Brit. Jour, of Derm., Apr., '95). Five cases of acne scrofulosorum in infants. Clinical features: an indolent, small papulo-pustular or acneiform erup- tion, occurring in infants, sparsely dis- seminated and not grouped, unaccom- panied by subjective symptoms. It aflfects chiefly the extremities, the lower in particular, and their extensor sur- faces. The buttocks and regions above are often involved. The lesions appear successively or by subacute outbreaks. The papules develop about the hair- follicles and become successively pust- ACNE. VARIETIES. ETIOLOGY. 89 ular and crusted. When the crust with a central plug is lost, a flattened, cra- teritorm, irregular lesion, like those of lichen planus, is left. After complete involution, a stain or faint scar remains. T. Colcott Fox (Brit. Jour, of Derm., vol. vii. No. 11, p. 341, '95). Acne artificialis sen medicamentosa is a form of acneie eruption produced by the ingestion of certain drugs, as the iodides and bromides, and also by the external applications of certain remedies, such as tar, the paraffin-oils, etc. An artificial type of acne may be seen on the ehestj abdomen, and back, the cheeks, forehead, and chin being affected in those who are taking iodide, while the chin is covered when the cause is either menstrual or intestinal. That as- sociated with rosacea begins around the nose. In the cachectic type or in those who are hard students or of a nervous temperament it is more frequently wit- nessed on the forehead. Those who present lesions upon the entire face are generally found to suffer from habitual constipation. The treatment should be based upon these facts. Dyer (New Orleans Med. and Surg. Jour., June, '94) . "Acne atrophica" is a name given to those cases of acneie eruption which tend to leave depressed scars. This probably occurs most frequently in those cases in which the lesions are sluggishly papular or papulo-pustular, the lesions disappear- ing by absorption or crusting and leaving behind small punched-out cicatrices. Acne hypertrophica is really the op- posite of the last-named variety, and occurring in about the same kind of cases, small, whitish, connective-tissue pin-point or small-pea sized projecting hypertrophies marking the sites of the lesions. It is rare. Etiology. — Acne begins usually near puberty, when the pilar system is more actively developing, and the functions of the sebaceous glands likewise; and is more frequent among patients with di- gestive troubles, constipation, dilatation of the stomach, menstrual irregularities, the strumous diathesis, possibly the ar- thritic diathesis, and disturbances of the nervous system. Anaemia, dyspepsia, constipation, amen- orrhoea, and dysmenorrhoea are all ex- ceedingly common functional derange- ments or disorders occurring simulta- neously with acne, but no more a cause of it than of psoriasis and scabies. Stephen Mackenzie (Brit. Jour, of Derm., Oct., '94). Constipation is a most important fac- tor. That nerve-influence considerably affects acne may be witnessed during menstruation and dyspepsia. Stopford Taylor (Brit. Med. Jour., Oct., '94). It has been also alleged that lesions of the genito-urinary organs and vene- real excesses may provoke the disease. Lesions may be due to mechanical irri- tation caused by the product of secre- tion remaining in the excretory canal or gland itself. Some drugs, as already stated, — such as the bromides and iodides, — are occasionally responsible for the eruption or an increase in an already existing eruption. Certain drugs applied externally may also provoke acneie lesions, such as tar and tar prod- ucts, juniper-oil, and the like. Workers in paraffin and paraffin products will not infrequently be found affected with papules and pustules, especially those of a furuncular or abscess type. Professional form peculiar to workers in paraffin; eruption papular, furuncu- lous, or acneiform; affects hairy portions of the skin. Gervais (These de Paris, '95). [As in artificial eruptions, individual predisposition here naturally plays a most important rSle. L. Brocq, Assoc. Ed., Annual, '96.] Stubborn indurated and pustular acne witnessed in persons exposed to chlorine- vapor. The condition is analogous to iodine and bromine acne. Treatment is 90 ACNE. PATHOLOGY. DIAGNOSIS. TREATMENT. very unsatisfactory. Herxheimer (Miinch. med. Woch., Feb. 28, '99). Pathology. — In most cases the process begins by a perifolliculitis, which later on gives rise to a purulent folliculitis. It would thus seem that the sebaceous glands play but a small part in the af- fection. In some cases, however, when comedones are present, the sebaceous gland itself is the starting-point of the inflammatory process. (Brocq.) Even when the foctis of irritation is in the follicle, it is frequently limited to the sebaceous or sebaceous pilary canal. (E. Besnier, A. Doyon.) The papillse surrounding the come- done and the superficial layers of the corium are filled with blood-vessels full to repletion, and of exudation cells which are found in dilated vacuoles. (Kaposi.) If the process is very intense, the seba- ceous gland may be entirely destroyed by the local inflammatory action, while the pilar bulba persists. (Kaposi.) The acneic process may be divided into two parts: 1. Closure of the sebaceous follicle and formation of comedo. 2. Suppuration, which only occurs in those follicles where the staphylococci aureus et albus have penetrated before the comedo formed. (Unna.) In true acne the bacillus described by Unna is invariably present. It always occupies the same portion of the com- edo, — namely, the bottom of the central cavity, only reaching the uppermost part in markedly developed comedones. Mena- hem Hodara (Jour, des Mai. Cut. et Syph., Sept., '94). Acne is a local disease whose anatom- ical element is the sebaceous gland, the physiological element being the over- secretion of fat, while probably there is a third bacteriological element. Malcolm Morris (Brit. Jour, of Derm., Oct., '94). Acne is due to an epithelial secretion of fat beyond what could be consumed by the integument: a deposit of unusual fat collected in the ducts of the glands. giving rise to microbic changes. Leslie Roberts (Brit. Jour, of Derm., Oct., '94). Bacteriological examination of come- dones and pustules: The staphylococcus pyogenes albus is constantly present in the pustules of acne; there are also present occasionally a yeast-fungus and a bacillus, but always in small numbers. In the non-inflamed comedo there is an abundant development of microbes, the staphylococcus albus always being pres- ent. At the moment that inflammation occurs in the comedo a considerable diminution in the number of kinds of microbes occurs. The skin of those not aflfected by acne is just as rich in microbic species as that of the acneic patient. The presence of certain microbes is not sufficient to explain the occurrence of the malady. One cannot accept the theory of a specific cause in acne. Unna's special bacillus is only a small virulent variety of the bacterium coli. Lomry (Derm. Zeit., B. 3, H. 4, '96). In all cases a high specific gravity of the urine and an increase of the crystal- line sediments noted. The increase of the salts in the blood causes an irritation in the sebaceous glands or in their vessels. Bardach (Derm. Zeit., vol. ii. No. 2, '96). Diagnosis. — Acne is to be differenti- ated from the papular, papulo-pustular, and pustular syphiloderms, and also from variola. Syphilis. — In the syphilitic eruption the distribution is more or less general, and more acute in its outbreak, darker hued, and occurring occasionally with special groupings and the presence of other symptoms of the disease. Vaeiola. — In small-pox the premoni- tory constitutional symptoms, the sudden outbreak, the uniformity of the lesions, and many other symptoms of differential character will serve to differentiate. Treatment. — In this connection acne may be divided into (1) an irritable or inflammatory variety, in which the skin is fine and thin and easily irritated by stimulating applications, and where gen- ACNE. TREATMENT. 91 eral treatment is important on account of the close union between the acneic eruption and various constitutional dis- turbances. Local treatment should, at first at least, be of a mild character. (2) An indolent variety, where the integu- ment is thick, rough, and oily, with en- larged and obstructed gland-orifices, and where the most energetic local applica- tions are well borne; here the local treat- ment is important. Probably most of the cases met with occupy a middle ground between these two extreme vari- eties. Geneeal Teeatment. — Prophylactic measures, such as the avoidance of ex- ternal irritants, drugs and food liable to cause acne, such as coffee, tea, alcohol, pure wine, pork, veal, game too far gone, preserved fish, shell-fish, fats, and cheeses. Increase in the solids of tlie blood causes an irritation of tlie sebaceous glands. Rapid cure is effected in these cases by increasing diuresis and local applications of a soap containing about 1 Vi per cent, of iodate and bromate of sodium. Bardach (Derm. Zeit., vol. ii, No. 2, '96). Any disorder of digestion must be counteracted in order to avoid the con- gestion of the face following meals. Attention to the condition of the ali- mentary canal and other disorders, as well as well-directed local treatment, is a quicker and more efficacious method than local treatment only. Eadcliffe Crocker (Brit. Jour, of Derm., Oct., '94). Acne can be cured with certainty and in a comparatively sliort time. The ma- jority of cases are benefited by the tonic and aperient iron and magnesia mixture between meals, others by an alkaline bis- muth mixture before food. In all cases an ointment which contains 30 grains of sulphur, 10 grains of ammoniated mer- cury, 10 grains of sulphide of mercury, and an ounce of vaselin should be used, oxide of zinc being added if there is much inflammation. Before its application the patient should bathe the face with hot water and a 10-per-cent. ichthyol soap well lathered on. An important part of the treatment is the careful application to each pimple of a minute drop of pure carbolic acid, just liquefied with a little water. P. S. Abraham (Lancet, Sept. 22, 1900). If the tongue is much coateS and shows prominent papillae, the following is recommended: — 1^ Sodium bicarb., 10 grains. Ext. of cascara sagr. liq., 10 to 20 minims. Tinct. of nux vomica, 7 to 10 minims. Peppermint-water, enough to make 1 fluidounee. — M. After this has been taken for a week or ten days, if* there is any indication for iron, a pill of reduced iron of 2 or 3 grains may be given after dinner or oftener. Constipation should be counteracted by gentle aperients. Any condition capable of maintaining the sympathetic system in a state of tension — such as genito-urinary trotibles or affections of the nasal fosste — should be eradicated if possible. If the patient is lymphatic and has a good digestion, codliver-oil is of value. Much benefit obtained from syrup of laetophosphate of calcium in acne, espe- cially when lumps are large. A favorable and palatable mixture when codliver-oil is required is the following: — B Gum arabic, 10 drachms. Water, 1 ounce. Syrup of laetophosphate of calcium, 3 ounces. Codliver-oil, 4 ounces. Essential oil of bitter almonds, 3 minims. The gum, water, and syrup sliould be rubbed together until a smooth mucilage is made, then the codliver-oil is to be added gradually, with constant stirring, and last the essential oil of bitter almonds. Made in this way, each table- 92 ACNE. TREATMENT. spoonful of the mixture contains 4 grains of lactophosphate of calcium and 50 per cent, of codliver-oil. H. S. Purdon (Dub- lin Jour, of Med. Sei., Feb., '98). Anaemia or chlorosis call for the use of chalybeates with arsenic. Iron often does harm unless its constipating effect is counteracted by using aperients. When the patient is arthritic, alkalies, espe- cially alkaline waters, are indicated. No really specific treatment is known against acne, but the following have been recommended : — Sulphur alone: powder or tablets, or with equal parts of honey. Ichthyol (Unna): — 1^ Ichthyol, 1 to 2 drachms. Dist. water, 5 drachms. M. Sig.: Fifteen to fifty drops in water, to be taken morning and evening. Ichthyol is very beneficial, both in acne vulgaris and acne rosacea. The best results are obtained when external and internal treatments are combined. In some cases of acne rosacea in which the skin is too thin and irritable to bear even weak solutions, the internal administration of ichthyol alone, with steaming, will be beneficial. Five grains of ichthyol may be given thrice daily after food, increasing the amount to 10 grains. Every night and morning the face is steamed for fifteen minutes, and is then washed with ichthyol soap. The lather is allowed to dry on the face, after which it is gently washed off with Avater. After each washing ichthyol salve, if it can be borne (often com- bined with ammoniated mercury), is applied. In acne vulgaris, after steam- ing, strong sulphur and ichthyol soap is used, with brisk rubbing with a flesh- glove. Brownlie (New York Lancet, May, 1901). Arsenic bromide in weak doses, ^/eo grain, in acne pustulosa. (Pifl'ard.) Mercurial preparations, such as cor- rosive sublimate or calomel, either alone or with jalap or colocynth extract, have been found useful. Ergotine, — alone or with calcium sul- phide, — digitalis, belladonna, hamamelis, and quinine have been recommended by Brocq. In stubborn cases iodide of potas- sium has been found eificacious. In stubborn cases iodide of potash in 5-grain doses three times a day in milk recommended. When a moderate iodism, showing itself in urticarial lesions is pro- duced and when the urine gives traces of iodine, the iodine medication should be discontinued, and local treatment substi- tuted. Leviseur (Med. Record, Nov. 11, '99). Potassium iodide in doses of 5 grains, three times daily, recommended. It should be discontinued when local reac- tion occurs or iodine appears in the urine. When inflammation subsides, the treat- ment should be repeated. Ichthyol soap and sulphur ointment are to be applied in the intervals. J. Galloway (Practitioner, May, 1900). Local Teeatment. — Constitutional treatment will rarely succeed alone, while in a large proportion a local treatment by itself will be found eSicacious. In the prevention of aene in persons predisposed to the disease three things especially are to be done: 1. Remove superfluous sebum and epithelial accu- mulations in the ducts of the glands. 2. Stimulate the sebaceous glands into healthy activity. 3. Keep the skin asep- tic, so as to prevent the pus-cocci from gaining admission to the follicles. The soaps with an alkaline basis are the most efficient as they are the most powerful. The most useful soaps are the sulphur, campho-sulphur, Peruvian-balsam, and creolin cake soaps; while, of the pow- dered soaps, the alkaline, brimstone, and creolin, and the neutral salicylic-acid- sulphur, and salicylic-acid-resorcin-sul- phur soaps are the best. AVhen the disease is developed all comedones should be expressed and all pustules opened. Stimulating soaps or applications, or both, should then be used. Sulphur is the most important constituent of both. When there is very much inflammation around the acneic lesions soothing treatment is necessary. ACNE. TREATMENT. 93 especially at first, while zinc oxide and calamin lotion and belladonna, locally applied, are sometimes of much service. When the more active lesions are reme- died the preventive treatment comes into play, and it must be impressed on the patients that, unless they are willing to take the trouble to cari'y it out in a thorough and continuous manner, they cannot expect to be free from acne. Stephen Mackenzie (British Journal of Derm., Oct., '94). Treatment of acne of young girls should accomplish the following ends: 1. Overcoming of coldness of lower extremi- ties by daily friction with cologne, spirit of camphor, or by flagellations with cold water. 2. Cure of any uterine difficulty. 3. Relief of habitual constipation. 4. Regulation of diet. Small meals with little fluid at a time, and plenty of out- door walking. 5. Avoidance of stiff cor- sets and stiff collars. Patients should never wash with sponges, but only with swabs of absorbent cotton, wet with a hot solution of borax and soda — 2 tea- spoonfuls of boric acid, and 1 each of borax and bicarbonate of soda to a quart of water. At night the face should be washed with a naphthol soap. After soap has been used the patient puts on each pustule a small amount of a pomade, prepared as follows: — B Resorein, 1 grain. Betanaphthol, Camphor, of each, 12 V2 grains. Cret. preparat., 15 grains. Sapon. nigris, 30 grains. Sulph. prsecip., 100 grains.. Lanolin, Vaselin, of each, 1 ounce. — M. Next morning patient should wash the face with spirit of camphor, and, if she has to go out, applies a little of follow- ing: — IJ Acidi salicyl., 15 grains. Zinci oxid., 3 drachms. Lanolin, 6 drachms. Vaselin, 12 drachms. — M. Face is then gently washed and dusted with starch-powder. Brocq (Rev. de Th6r., May 15, '98). Hot water and alcoholic lotions some- times act promptly. In mild cases thesj are applied at night with very hot water, either pure or combined with cologne- water or camphorated alcohol. The water is gradually reduced until pure camphorated alcohol or cologne-water is used. Boric acid or borax may be added to the lotions: 1 part to 50. Hot oil, used as a wash, easily dissolves solid fatty matter. The comedones are dissolved and the skin softened prepara- tory to the application of sulphur. Lano- lin should always be mixed with oil, vaselin, or benzoated lard. F. H. Barendt (Liverpool Medico-Chir. Jour., No. 38, 1900). Instead of camphorated alcohol there have been used with success: — Alcohol, 96°, saturated with boric acid, and alcohol with salicylic acid, 1 to 30. The latter is strong and must be used with care. Mercurial lotions are efficacious in some cases, employed as follows: — - J^ Corr. subl., 1 part. Alcohol, 90°, 100 parts. Dist. water or rose-water, 150 parts. At first this solution is weakened with one-half its quantity of water; afterward, if no irritation has resulted, the water is gradually reduced until the solution is employed pure. Other mercurial preparations, in oint- ment form, such as the biniodide, the iodochloride, white precipitate, and mer- curial plaster, viz.: — 5 Hydrarg. iodochloride, 24 gi-ains. Axungias, '/= ounce. M. Rub in vigorously. The local action is said to be very energetic. It should, therefore, be used at first with caution. Gailleton (Le Bull. Med., July, '89). The ammoniated-mercury ointment, 5 grains or 30 grains to 1 ounce, of great value. Stopford Taylor (Brit. Jour, of Derm., Oct., '94). 94 ACNE. TREATMENT. Face to be washed with water as hot as can be borne and some bland unirri- tating soap, and then, after carefully dry- ing the skin, following lotion is applied once a day: — R Hydrargyrum bichloridi, 12 grains. Spiritus vini rectif., 6 ounces. — M. Effect for first few days will be to render condition worse; but, after this, lotion prevents perforation of pustules. G. Gorden Campbell (Montreal Med. Jour., Apr., '98). Formaldehyde has recently been tried with success. Case in which intradermal injections of formaldehyde, in strength of 1 drop of the 40-per-eent. solution to 100 drops of water, were used. Injections are at- tended with a stinging pain. One-half to 1 minim was injected in each point selected, care being taken to pass the needle into, but not under, the skin. In a few moments a spot about the size of ten-cent piece presents an elevated sur- face resembling urticaria. A sufficient number of injections were made at each treatment to thus affect the whole area of disease, and treatment repeated at in- tervals of one week. Result had been most gratifying. J. T. McShane (Amer. Assoc. Jour.; Ind. Med. Jour., May, '98). Sulphur preparations are especially useful when much seborrhcea exists. In a few patients sulphur preparations cannot be used, owing to the irritation caused. Sulphur may be employed in the following ways: — Sulphur-soap: with hot water, the suds being allowed to dry on to the face. Sulphur-baths. Sulphur-lotions: hot water with 10 to 60 drops for every one-half glass of liquid potassium polysulphide. An effective method of using sulphur is the following: — After washing with hot water and soap, the following mixture is applied with a camel's-hair brush: — I^ Precipitated sulphur, Potassium bicarbonate, Glycerin, Laurel-water, Alcohol (60°), of each, 2 drachms. — M. The coating is left on during night- time and washed off in. the morning with an emulsion of almond-oil, and the skin is covered with oxide-of-zinc or bismuth- subnitrate ointment powdered over with fine starch. When the skin becomes irritated, the sulphur paste should be discontinued and the zinc ointment applied alone until the irritation has disappeared. The following are useful: — ly, Sulphate of zinc, Sulphuret of potassium, of each, 1 drachm. Water, 4 ounces. IJ Precip. sulphur, 4 drachms. Ether, 4 drachms. Alcohol, enough to make 4 fluid- ounces. ]^ Precip. sulphur, 2 drachms. Gum tragacanth, 20 grains. Camphor, 20 grains. Lime-water, 2 fluidounces. Water, enough to make 4 fluid- ounces. Sulphur ointments are usually made in the proportion of 1 in 10, with benzo- ated lard, simple cerate, vaselin, vaselin and lanolin, lanolin and sweet almond- oil or olive-oil, or castor-oil and cacao- butter. To the sulphur may be added oxide of zinc in equal parts; borax, 1 to 20; salicylic acid, 1 to 50; naphthol, 1 to 10 or 1 to 20; resorcin or camphor, 1 to 20 or 1 to 40. They may be perfumed with essence of rose, bergamot, or balsam of Peru if desired. ACNE. TREATMENT. 95 Sulphur soaps are sometimes more convenieut. The following may be used: — Soap and precipitated sulphur, equal parts. Soap, precipitated sulphur, and juni- per-oil, equal parts. Soap, precipitated sulphur, and lard, equal parts. Naphthol may be added to the first ol the series. The "scaling" method by the various medicated soaps advocated. The soap is applied by lathering well into the skin, and then partly removing it with luke- %\arm water, and allowing the remainder to dry into the skin. The soap contain- ing some combination of resorcin, sali- cylic sulphur, and balsam of Peru (Eich- hoff) gives the best results. Julius Miiller (Dermat. Zeitsch., Nov., '99). Among other local treatments recom- mended are the application to the pust- ules of tincture of iodine, carbolic acid, nitrate of silver, salicylic acid, or resor- cin. An ointment of ichthyol, 1 to 4 or 1 to 8, is also useful. Resorcin has been made use of in the treatment of ichthyosis and acne. W. Allan Jamieson (London Lancet, Sept. 12, '91). Results following the application of pure carbolic acid to each pustule most satisfactory. Very bad cases are soon benefited if the applications are care- fully made. P. Abrahams (Brit. Jour, of Derm., Oct., '94). ResOTcin-sublimate paste of great value. Unna (Brit. Jour, of Derm., Oct., '94). The following resorcin paste is recom- mended: — I^ Besorcin, 2 V, to 5 parts. Zinc oxide, Starch, of each, 5 parts. Vaselin, 12 V2 parts. — M. This paste may remain on a day and a night and then be removed with a piece of cotton. Cure is said to be speedy, occurring in three or five days. Salicylic acid acts well in from 1 to 2 ^/j per cent, in various ointments. Combination of the iodides and bro- mides of potassium with soap, the latter possessing keratolytic qualities. Two varieties: strong soaps containing from 2 to 6 per cent, of sodium iodide and from 1 to 3 per cent, of potassium iodide ; weak soaps, containing but from 1 to 3 per cent, of potassium iodide and bro- mide. Useful to allow suds to dry upon site of application. Bardach (Lyon Med., June 23, '95). [New treatments should be used with much prudence and with due thought to the susceptibility of the patient; there is a tendency to reject preparations of the iodides and bromides in acne, because these substances cause acne in many per- sons; yet in some rare cases I have per- sonally noted improvement in acne to follow the use of minute doses of sodium ■ or potassium iodide and of applications of tincture of iodine; it must never be forgotten, however, that idiosyncrasy may play a most important part in any medication. L. Beocq, Assoc. Ed., An- nual, '96.] Electrolysis has been recommended for the removal of the indurated masses left on the skin. In acne of the back the strongest ap- plications, as a rule, are demanded. Of especial value in some cases is the liquor calcis sulphuridis (Vleminckx's solution). This should be used at first diluted. Massage of the face has recently been recommended. Massering-ball for .use in the local treatment of acne. A ball set in a steel socket, the small sphere rotating within the cup of the latter, as in the ordinary ball-and-socket joint. The skin is first operated upon with disinfected needle and comedo-extractor, until all pustules and subepidermic foci are emptied. The surface is then rendered aseptic with a solution of formalin (40 per cent, of for- mic aldehyde), V= per cent, to 2 per cent., according to the sensitiveness of the 96 ACNE ROSACEA. patient's face. The massering-ball then rotated freely over the surface, and deep pressure made upon the affected region. James Nevins Hyde (Jour. Cut. and Genito-Urin. Dis., Mar., '96). Before undertaking the local treat- ment of acne it is well to open the pust- ules, empty the comedones and sebaceous cysts, etc. Other direct surgical meas- ures consist in cauterizations with the hot needle or electrolytic needle or in scarifications. These are often satisfac- tory in indurated and rebellious acne. The galvanoeautery recommended in acne. Infiltration anaesthesia is pro- duced, and a cautery needle, similar to that employed in epilation, is introduced to a depth of about two millimetres. Bloebaum (Deut. med. Zeit., No. 52, '98). Ichthyol is particularly beneficial both in acne vulgaris and acne rosacea. In the former strong external applications Massering-ball. {J. Nevins Hyde. can be borne, but in the latter much weaker strengths must be used. The best results are obtained when external and internal treatment are combined, and in some cases of acne rosacea in which the skin is too thin and irritable to bear even weak solutions the inter- nal administration of ichthyol alone with steaming will suffice to effect a cure. The general plan of treatment is to begin with 5 grains of ichthyol thrice daily after food, increasing to 10 grains. Every night and morning the face is steamed for fifteen minutes and then washed with ichthyol soap made into a lather and allowed to dry on, which is then gently washed off with water. After each washing, if it can be borne, ichthyol salve (often combined with am- moniated mercury) is applied. In acne vulgaris, after steaming, strong sulphur and ichthyol soap is used, with brisk rubbing by means of a flesh glove. The diet is regulated. Ichthyol itself relieves mild cases of constipation, but, if it does not, a compound pill of iridin and euonymin or podophyllin may be given. Alexander Brownlie (N. Y. Lancet, May, 1901). Exposure to Roentgen rays causes atrophy of the cutaneous follicles and checks pus-formation. Series of per- sonal cases with interesting results. Case I, aged 22, treated for hypertri- chosis, but had moderately severe acne simplex. The lesions were usually in- dolent, inflammatory papules without much induration and rarely with the formation of well-marked pustules. She was exposed to the x-rays for three months, with a production of some der- matitis, and she has been under similar treatment at intervals during the year. After the development of the first erythema her acne disappeared, and she had no lesions within the last year. Case II was practically identical with Case I. Case III, aged 26, treated for hypertrichosis, slight acne, comedones, and constantly recurring outbreaks of a few indolent, inflammatory papules. After the first erythema she has had no acne lesions. In all of the above cases the skin is smooth and soft, and the result is satisfactory from a cos- metic point of view. William A. Pusey (Jour, of Cutaneous and Genito-urin. Dis., May, 1902). Treatment of acne by exposure to the x-rays tried in fifteen cases. With one exception, satisfactory results were ob- tained. The cases were not selected. R. R. Campbell (Jour. Amer. Med. As- soc, Aug. 9, 1902). Henky W. Stelwagon, Philadelphia. ACNE ROSACEA. Definition. — Acne rosacea is charac- terized by a chronic congestion of the face, causing vascular dilatations; and by changes in the cutaneous glands and tissues, giving rise to seborrhoea, inflam- matory acne, and hypertrophic changes. Symptoms. — The nose and malar emi- nences are especially prone to this dis- order. It may also affect the forehead. ACNE ROSACEA. SYMPTOMS. ETIOLOGY. 97 chin, the neighborhood of the alae nasi, the cheeks, and less commonly the side of the neck. In women the chin is occa- sionally invaded. There are three forms of acne rosacea. The first is the erythematous and telangiedasic. It may be characterized by temporary congestive spots on the face, showing themselves especially after meals and in the evening. These spots may be accompanied by no other lesion. This form is usually present in connec- tion with more or less seborrhoea, espe- cially on the nose, which is generally very oily. Again, the erythematous variety may be characterized by small vascular dilatations on the nose or malar eminences, which dilatations develop gradually, unite with one another, and form a net-work. This net-work is uni- form in hue at a distance, but near by may be seen to be formed of congested surfaces over which are spread vascular dilatations. This degree of the erythem- atous form is almost always accompanied by seborrhoea, enlarged nose, and dilated glandular orifices, especially in women toward the menopause and in wine- drinkers. (Hebra.) The nose may become slightly violet- hued and be cold to the touch. The second form is the erythematous acne, or true acne rosacea. In addition to the erythematous and congestive feature, there may be found in this variety a true acneic element: papules and pustules. In some cases the acne appears before the congestion. There is a congestive red base with fine vascular dilatations and papulo-pustules of various sizes, often resting on an indurated violet-red base. In this variety there may also be in- crease in number and size of the vascular •dilatations, increase in size and depth of the acneic indurations, and proliferation and hypertrophy of the derma. The third form is the hypertrophic acne, or rhinophyma. In this variety the glandular orifices are much enlarged, while the glands themselves may be ten to fifteen times increased in size. The tissues around them proliferate, forming a variety of pachyderma. The nose may be red or violet-hued, covered with en- larged orifices, greatly increased in size, falling down to the chin. Its exterior may be mammillated. (Broeq.) Two subdivisions of this form are ren- dered necessary by the difference in the pathology of each. The first, glandular, presents an embossed aspect, the hyper- trophy being due especially to hyper- trophy of the pilo-sebaceous glands; the second, elephantiasic, presents a smooth aspect, being due to chronic oedema; there are also vascular dilatations, with sclerosis of the derma. (Vidal and Le- loir.) Etiology. — Women suffer more than men from the erythemato-telangiectasic and acneic forms. Men only suffer from hypertrophic acne. It usually appears between 30 or 40 years. In women, rosacea develops usually at from 30 to 45 years, and increases decidedly toward the menopause, after which it may re- cede. It may also, however, develop at puberty. In young women and girls it is frequently due to chlorosis, dysmenor- rhcea, or sterility. In some it recurs at each conception. Some authorities claim that, among the constitutional causes (which affect women more than men), heredity plays an important part. The disease is said to be more frequent in children of arthri- tic subjects, or of those who may have suffered from acne rosacea. Cold feet, urethral and uterine dis- turbances, and constipation are also re- corded as causes of the disease. The cause of acne may be found in the 98 ACNE ROSACEA. PATHOLOGY. DIAGNOSIS. mouth or teeth and be unilateral if the cause is one-sided. (E. Besnier, Doyon). Dyspepsia, neuralgia, hemicrania, working with the head inclined forward, and disease of the nasal fossse are among the less frequent etiological factors (which affect men more than women), while high heat, overheated rooms, high wind, sea-air, cold, and cold water are occasional causes, especially in men. The disease may become started in people who for several years have indulged in excessive hydrotherapeutic treatment (Kaposi). Certain occupations — such as those of coachman, baker, smith, fireman, glass- blower — may also become primary causes of the trouble. Indiscretion in diet and alcoholic beverages are well-known fac- tors. According to Kaposi, in wine- drinkers the nose is bright red, in beer-drinkers it is violet, while in spirit- drinkers it is soft, large, and dark blue. Pathology. — The vascular dilatations of the face have been considered by some authorities as due to circulatory troubles caused by compression of the veins in the cranial foramina. A certain paretic condition of the vas- cular walls may often be looked upon as a cause. (Brocq.) The cutaneous nerves of the region affected have been found normal by E. Besnier. According to Leloir and Vidal, however, there is congestion of the deeper venous net-work of the skin; dilatation of the same vessels and of the perifollic- ular vascular net-work, their walls being often diminished in thickness. There is also formation of new vessels. Diagnosis. — Ltjpus Erythematosus. — The superficial, congestive variety shows a brighter and better defined redness; crusts or squamae on the sur- face; sharper and more definite edges; greater sensitiveness to pressure; slight elevation above the surrounding surface. If any cicatrix be present, it is surely lupus erythematosus. ClHCUMSCEIBED CONGESTIVE SeBOK- EHCEA. — In this disorder there is a limited extent of patches, shallower and more uniform redness, with crusts cover- ing them. Keratosis pilaris is recognized by its inframalar and preauricular location, and the file-like feeling, to the finger, of the erythematous and telangiectasic patches. Sycosis Non-pa-rasitica. — This is- always an inflammatory disease of the hair-follicles and perifollicular tissues. There are numerous papules and pust- ules, each perforated by a hair, and often capped by a small circular scale. The upper lip and chin are sites of predilec- tion. The affection is usually painful. Congenital adenoma sebaceum also- has a special location: the naso-genial furrow, the parts aroimd the nose,, mouth, and chin. It presents a mame- lated aspect, and its predilection for early youth and its normal evolution serve to establish its identity. Eczema. — Erythematous, or pustulo- papular, eczema of the face may some- times present diagnostic difficulties. In this disease, the more or less constant, and usually intense, itching, the serous or sero-purulent secretion, and the des- quamation will suffice to establish the- diagnosis. Psoriasis of the Face. — Diagnosis is also frequently difficult in this dis- order. The patches are better defined and are generally covered by silvery- white scales situated on a red base, which bleeds easily on scratching. The pres- ence of typical psoriasie patches on other- portions of the body is an important sign. Chilblains. — Changeableness of the- ACNE ROSACEA. PROGNOSIS. TREATMENT. 99 lesions and pains are peculiar to this disorder. AcNEiFOEM Syphilides. — Here the manner in which the elements are grouped, the long duration of their evolution, their tendency to ulceration, and consecutive cicatrix are important. Complete failure of acneic remedies is .another diagnostic point. Ehinosclekoma. — In this disorder there are hard or ivory-like masses im- bedded in the nose. Prognosis. — Acne rosacea does not always increase; it may remain station- ary or even recede, especially in women after the menopause. It may also, how- ever, assume malignancy, hut this sequel is very rarely met with. Case of a man, 67 years old, with a well-marked hypertrophic acne of the nose; one of the masses having been re- moved by ligature, an epitheliomatous ulcer supervened, and tlie growth grad- ually' took on epitheliomatous transfor- mation. Matignon (Jour, de Med. de Bordeaux, Dec. 6, '91). Treatment. — As to general treatment, it is especially necessary to pay strict attention to the good condition of the stomach and intestines, by appropriate measures and suitable diet. Purgatives are absolutely necessary from time to time; laxatives should frequently be given and constipation should be avoided (Brocq). Proper circulation of lower limbs should be insured by adequate clothing. Any abnormal condition of the genito- urinary tract or of the upper respiratory tract, especially the nose, should be cor- rected, while anything tending to cause congestion of the face, such as tight collars or stays, should carefully be avoided. Sedentary intellectual work, especially by gaslight, frequently aggra- vates these cases. As a rheumatic diathesis is a dominant etiological factor, various alkalies have been recommended, especially bicarbon- ate of soda or the various alkaline waters. Where the face is intermittently con- gested, quinine, ergotine, belladonna, digitalis, and hamamelis have seemed useful. These may be combined in a mixture, with or without the tincture of aconite-root. * Vasoconstrictor drugs have but little influence. Perchloride of iron, tannin, ergot, and tincture of hamamelis are recommended by E. Besnier and A. Doyon. The following preparation is extolled by Brocq: — I^ Quinine hydrobromate, Ergotine, of each, 30 grains. Belladonna extract, 6 to 12 grains. Lithium benzoate, 30 grains. Excipient and glycerin, q. s. M. For forty pills. Sig.: Two before each of the two principal meals. Ehubarb or aloes may also be added if necessary. Amyl-nitrite may be inhaled or taken internally by patients suifering from congestive attacks of the face. (Sidney Einger.) The local therapeutic agents are the same as in acne vulgaris; though some irritable varieties of acne rosacea exist, it is usually necessary to act with greater energy. Hot water and mercurial preparations are often of value. Mercurial ointment may be rubbed in pure or weakened with lard, twice daily, according to individual susceptibility. (Hardy.) The following has been employed by Bazin with success: — I^ Mercury biniodide, 7 ^/^ to 15 grains. Lard, 1 ounce. — M. 100 ACNE ROSACEA. TREATMENT. Sulphur preparations are also useful; but, as the preparations should be strong enough to cause irritation of the integu- ments, it is well to use sulphur pastes mixed with green soap. In eases of average intensity derma- tologists frequently employ Vleminckx's solution, at first with 5 parts of water, then gradually making it stronger until it is used pure. It should be left on several minutes, and followed by very hot water. Green soap gives the best result in ob- stinate acne rosacea, alone or when used in conjunction with sulphur, naphthol, or salicylic acid. It may be used as in acne vulgaris or spread on a piece of flannel; the latter is then cut out to fit the affected region, and left on as long as possible. When the irritation be- comes too great, the application should cease and cooling preparations, such as the following, be used: — I^ Salicylic acid, 7 grains. Zinc oxide. Bismuth subnitrate, of each, 30 grains. Lycopodium, V2 drachm. Vaselin, 2 drachms. Lanolin, 3 drachms. Ichthyol does not seem to be as effi- cacious in acne rosacea as in some other varieties of acne (Brocq). Ichthyol is often better than sulphur as a reducing agent. Purdow (Dublin Jour. Med. Sci., May, '94). Unna recommends daily doses of 7 ^7, grains of ichthyol internally and lotions with ichthyol dissolved in water, washing with ichthyol-soap. Steam or sulphur- water douches, pyrogallic acid, and chry- sarobin have also been used with good results. Turpentine has also been found efficacious. Turpentine has a solvent action on the sebaceous secretion; it also exerts a disinfecting action that prevents the spread of the affection. Cases in which it proved very efficacious. It produces violent smarting and redness, but these effects disappear in a few hours. Betz (London Lancetj Jan. 30, '97). Liquor gutta perchse may be used to exert pressure on the vessels and thus encourage resolution of the parts. A solution of iodine in glycerin, ap- plied twice daily during three or four daj's, is recommended by Kaposi. Treatment of acne rosacea is divided into constitutional and local. In women any menstrual disorder should be cor- rected, all alcoholic stimulants should be stopped, and good plain diet taken. If tongue is very coated alkaline bitter tonic should be ordered. When skin is much thickened, and there are many acne papules and pustules, German green soap is best, used with hot water, and a piece of white flannel, every night, until the skin begins to peel consider- ably. In less severe cases white Castile soap is good. Five-per-cent. resorcin soap (Eiehhoff's) is very efficacious. Prescrip- tion for an ointment is as follows: — IJ Sulpli. prsecip., 1 to 4 drachms. Acidi salicyl., 10 to 30 grains. 01. amygdal. dulcis, 1 drachm. Lanolin, 1 ounce. M. Sig. : Apply at night after wash- ing. (The salve should not he gritty, but perfectly smooth.) T. C. Gilchrist (Maryland Med. Jour., Dec. 10, '98). Blisters, left on but four or five hours, are used by some dermatologists. Surgical treatment in this disease is the most efficacious. (Brocq.) Kummerfeld's solution, used in vary- ing strength according to severity of case, will be found efficacious, especially in connection with scarification: — R Sulph. prtecip., 1 to 3 drachms. Pulv. camph., 5 grains. Pulv. tragacanth., 10 grains. Aquae calcis, 1 ounce. Aquae rosse, 1 ounce. M. Sig.: Apply after washing at night. ACNE ROSACEA. TREATMENT. 101 Scarification or the application of the electrical needle is a very necessary ad- junct to the treatment. Scarification can he done in three ways: 1. By linear scarification. 2. By slitting up the dilated cutaneous blood- vessels. 3. By puncturing rapidly. The third plan is best. T. C. Gilchrist (Mary- land Med. Jour., Dec. 10, '98). In typical acne rosacea the pustules are first emptied, then cauterized with a fine-pointed thermo- or galvano- cautery. Vascular dilatations promptly yield to cauterization with a very fine point heated by electricity or a simple needle heated in the fire. Electrolysis is another satisfactory method. A fine platinum needle is in- serted alongside of the vessel, and, if possible, into it, and connected with the negative pole, while the patient holds in his hand a cylinder in communication with the positive pole. A large eschar must be avoided. (Hardaway.) The ordinary galvanic or faradic cur- rents have been recommended by Cheadle and Piffard. Scarification is a favorite method. The best instrument is Vidal's ordinary scarificator. The skin is cut obliquely or perpendicularly to the vessels, then slightly obliquely across these so as to form lozenges, and as near together as possible (from one to one and a half mil- limetres apart), and not deep enough to penetrate entirely through the dermis, so as to avoid cicatrices. An hoitr afterward the part is washed with a corrosive-sublimate solution, 1 to 1000; then in the evening or the follow- ing day compresses dipped into an am- monium-hydrochlorate solution, 1 to 100, or corrosive sublimate, 1 to 500, are applied. If too strong, warm water is to be added. If the reaction is too violent, starch-poultices, bland pomatums, or zinc-oxide plasters can be employed. The treatment should be renewed in from five to eight days. Amelioration will occur in from eight to ten sessions; and marked improvement in from fifteen to twenty-five sessions. Scarifying should be begun in the lower part of the region to be operated upon, in order not to be troubled by the blood covering the surface. (E. Besnier, A. Doyon.) In the early stage of hypertrophic acne the scarification must be made deeper, and in many cases it is essential to also cauterize the glands deeply. Electrolysis of each dilated sebaceous follicle with a negative platinum needle and a current of from 4 to 6 milliam- peres is an effective, though tedious, measure. The needle should be moved around in the follicle in order to thor- oughly destroy it. In the advanced hypertrophic form direct removal with the knife is the best procedure. (Brocq.) Hypodermic injections of alcohol have recently been recommended. Local subcutaneous injections of 95- per-cent. alcohol. The part is compressed with the fingers, and 20 or 30 drops of alcohol injected with a clean hypodermic syringe with a thin needle. The immedi- ate effect of the injection is a local swell- ing and ansemia, lasting but a few mo- ments; then an increased redness lasting from half an hour to three or four hours; this gradually disappears, and the treated skin-area assumes normal color. The dilated blood-vessels and papules, after repeated injections, un- dergo slow obliteration, until finally the whole lesion disappears and the affected integument appears normal. The treat- ment, in some cases, lasts eight or ten weeks; in others, a great deal longer. R. Abrahams (Amer. Med.-Surg. Bull., May 16, '96). Geoege H. Eohe. Baltimore. 102 ACONITE. PEEPAEATIOKS. PHYSIOLOGICAL ACTION. ACONITE. — The preparations of aco- nite usually employed are obtained from the root of the Aconitum napellus (monk's-hood): a conical tuber greatly resembling horse-radish. This resem- blance has caused many deaths. When scraped, however, aconite-root does not emit the pungent odor peculiar to horse- radish. Again, instead of irritating the palate, as does horse-radish, aconite-root, when masticated, soon produces in the moiith a sense of warmth and tingling, soon followed by local numbness varying in duration according to the length of time the mucous membrane is exposed to the efJects of the drug. The active principle of aconite, aconi- tine, will be considered in the next article. Preparations and Dose. — Aconite in substance is not employed, and the preparations made with the leaves are no longer of&cial. The tincture (tinctura aconiti rad., U. S. P.) is three times stronger than either the English or French tinctures. Dose, 1 to 3 minims, every three hours. Its effects should be closely watched, especially in anemic and corpulent indi- viduals and in those addicted to alcohol. Fleming's tincture is no longer offi- cial and should not be employed. The fluid extract (extractum aconiti fluidum, U. S. P.), V^ to 2 minims, every three hours. The solid extract (extractum aconiti, U. S. P.), V, to V4 grain. Physiological Action. — Within half an hour after its administration the drug commences to afJect the general system, slowing and weakening the heart's ac- tion, lowering arterial tension, increasing the action, of the skin and kidneys, and producing more or less muscular weak- ness in proportion to the amount taken. It causes a tingling sensation in the lips, extremities, and, perhaps, the whole body; it diminishes the rapidity and depth of the respiration, and causes dis- orders of vision and loss of tactile sensi- bility and sense of pain. According to Wood, aconite, when administered in sufficient dose, is a powerful depressant of the sensory nerve; and there is some reason for believing that the stage of nerve-paralysis is preceded by one of nerve-stimulation. Subsequently, how- ever, its action on the spinal cord was further ascertained, and Bartholow states that aconite affects the sensory nerves before the motor. It paralyzes first the end-organs, next the nerve-trunks, and finally the centres of sensation in the cord. It also impairs the reflex function of the cord, but, doubtless, secondarily as regards the sensory paralysis. The power of voluntary movement, which continues after the cessation of the reflex functions, is finally lost, owing to the action on the motor centres of the cord, and subsequently on the nerve-trunks. Pyraconitine, obtained from aoonitine by heating to separate a molecule of acetic acid, causes no tingling of the lips or tongue. It causes slowing of the heart, partly from vagus irritation, partly from depression in function of intrinsic rhythmical and motor mechan- isms. After its administration activity of respiration is reduced (by central de- pression) to a degree incompatible with life. Neither muscular nor intramus- cular nervous tissue is strongly influ- enced by pyraconitine, but the spinal cord is impaired in its reflex function, and tliere is a curious condition of ex- aggerated motility. Theodore Cash and W. K. Durstan (Brit. Med. Jour., Aug. 17, 1901). When aconite is applied directly to the heart, the number and force of the beats are lessened, and its action is finally arrested in diastole. It lowers the blood- pressure and pulse-rate when given in- ternally by a direct action on the heart ACONITE. POISONING. TREATMENT. 103 itself. Bartholow concludes that it is a direct cardiac poison, afEecting its gan- glia and muscle, and also a sedative to the vasomotor nerve-system. Hare calls attention to the fact that the fall in pulse-rate from poisonous doses is some- times preceded by a quickening due to a condition of weakness and abortive car- diac action. All agree that it is a re- spiratory poison by direct action on the muscles of respiration, but that the heart ceases before the respiratory movements. Aconite reduces the temperature when given in health. Bartholow tells of a medical student poisoned with aconite, in whom the temperature fell two de- grees. It also increases the action of the skin and kidneys, and with the increase of water there is augmentation of the solids excreted. (F. B. Stewart.) Aconite Poisoning. — The symptoms following the ingestion of a poisonous dose usually show themselves after a few minutes. The tingling, prickling, and numbness already mentioned rapidly ex- tend from the mouth and fauces to the face, thence to the body. Speaking re- quires marked effort. Great prostration and muscular impotency follow, and the skin becomes cold and clammy, the per- spiration covering the surface, and the cold tissues communicating to the hand an icy coldness. Muscular pains may be present in the early stages, especially in the face. There is usually experienced marked epigastric pain with nausea and vomiting. Later on, however, the nausea ceases, owing to paralysis of the stomach- walls. The heart-beats are greatly reduced in number and power; the pulse is usually irregular, compressible, and slow, and so weak, at times, as hardly to be felt. The breathing is labored, irregular, and shallow, the number of respirations being at first decreased then increased. The temperature may be considerably lowered. The pupils may be dilated or remain of normal size and react equally. The eyes may protrude or be sunken; there- fore they afford no differential informa- tion as to the nature of the drug. The mind is usually clear, and the patient calm, though apprehensive of impending death. Occasionally epilep- toid convulsions occur. Spasmodic purg- ing, the stools being sometimes bloody, and rectal tenesmus are frequently pres- ent. Aconite causes paralysis of respiration and circulation, death usually being due to sudden arrest of the heart in diastole. Case of poisoning from tincture of aconite-root. Two doses of 1 minim each, given one hour apart, produced tingling, mild delirium, diplopia, and other indica- tions of aconite poisoning. Frank Wood- bury (Phila. Med. Times, Jan. 1, '90). Personal case of death following a minimum dose. There are many cases of individual intolerance, and syncope may occur in certain patients from small quantities. Ferrand (La France M6d., Dec. 8, '93). Treatment of Aconite Poisoning. — Death in these cases usually follows exertion by the patient. He should, therefore, be kept perfectly motionless in the reciimbent position even during emesis, his head being slightly turned and the dejections received on a towel. An important feature of the treatment is to keep the patient as warm as possible by means of warm blankets and hot- water bottles, taking care not to place the latter against the skin. The head should also be kept warm. If the patient is seen early the stomach-tube should be used at once to empty the stomach. If no stoma ch-tube be at hand, apomor- phine, Vjo to Ve grain, should be ad- ministered hypodermically, or some other 104 ACONITE. POISONING. TREATMENT. active emetic, such as zinc sulphate, 15 to 30 grains, be given by the mouth. A point of practical importance, not mentioned in the text-books, is that of wrapping up the head and applying heaters there. This apparently gives especial comfort to the patient. Elevat- ing the foot of the bed is of some use. R. W. Greenleaf (Boston Med. and Surg. Jour., July 15, '97). Digitalis, sulphate of strychnine, and belladonna are the most effective reme- dies, but ether and ammonia should first be employed, owing to their great difEu- sibility. All these remedies should be used hypodermically, the stomach being unable to perform its functions. A drachm of ether, ammonia, brandy, or whisky should at once be injected, and, aftep a few minutes, tincture of digitalis, 15 minims; strychnine sulphate, ^/jo grain; or tincture of belladonna, 10 minims, according to what the practi- tioner may have. The dosage should be regulated so as to reach the point of physiological action by frequently repeated doses. Nitrate of amyl may be given by inhalation, and warm, very strong coffee be injected into the rectum. If the patient is seen when the stage of depression has begun through absorp- tion of the poison, the stomach-pump shoiild alone be used, emetics at this stage being liable to cause arrest of the heart's action. Tincture of digitalis, in 20-minim doses, should be injected hypodermically and repeated as required, besides the other measures indicated. Frictions under cover, the rubbing being directed toward the heart, serve a useful purpose. Twenty cases, six of which were fatal, found in the literature of the last ten years: — Case 1. Tincture, 7 drachms. Recov- ery. Emetics; morphine, V2 grain; fluid extract of digitalis, 6 drops; strychnine sulphate, V,5o grain; brandy, 1 ounce; all hypodermically. By the mouth, 2 gallons of warm water; fluid extract of digitalis, 20 drops; coffee, U pints; whisky, 3 pints; extract nueis vomica, V2 fluidraehm ; Port wine, V2 pint. P. F. Brick (Jour. Amer. Med. Assoc, vol. viii, p. 567, '87). Case 2. About 8 drops of concentrated fluid extract. Recovery. Emetics, coffee, whisky (dessertspoonful). Heat. Fric- tion and sinapism. T. H. P. Baker (Amer. Pract. and News, vol. iv, N. S., p. 122, '87). Case 3. Fleming's tincture, 1 '/j ounces. Recovery. Emetics, brandy, ether, digi- talis, ammonia carbonate. Amyl-nitrite and warmth. C. C. Bradley (N. Y. Med. Record, vol. xxxii, p. 155, '87). Case 4. Tincture, '/^ ounce. Recovery. Brandy by mouth and hypodermically. Ether. One quart of cold, black coffee. Heat and posture. S. Barnett (N. Y. Med. Record, vol. xxxii, p. 761, '87). Case 5. Amount not known. Patient intoxicated at the time. Symptoms of acute poisoning. Recovery. Emetics, brandy, ammonia, and digitalis by the mouth. Sixty minims of tincture of digitalis hypodermically. Heat. Clara T. Dercum (Med. and Surg. Reporter, vol. Ixi, p. 376, '89). Case 6. Tincture, amount not known. Child, 16 months. Marked toxic symp- toms. Recovery. Brandy and fluid ex- tract of digitalis frequently repeated in spite of vomiting. Byron F. Dawson (Med. and Surg. Reporter, vol. Ixii, p. 7, '90). Case 7. Tincture, 2 drachms. Death. Benjamin Edson (N. Y. Med. Record, vol. xxxviii, p. 365, '90). Cases 8, 9, and 10. Dr. Edson men- tions certain other cases known of, but not treated by him, three of which died. The amounts taken in these were from 1 to 4 drachms. Case 11. Tincture (B. P.), 1 ounce. Death in sixty-five minutes. Mustard, lavage, heat, ether, and brandy subcu- taneously. L. M. Whannel (Brit. Med. Jour., vol. ii, p. 791, '90). Case 12. Fleming's tincture, 1 drachm. Recovery. Sulphate of zinc, tincture of digitalis, 20 minims hypodermically. Whisky, 1 ounce, by the mouth, followed ACONITE. THERAPEUTICS. 105 by calomel, 8 grains. L. M. Whannel (Brit. Med. Jour., vol. ii, p. 791, '90). Case 13. Fleming's tincture, 1 tea- spoonful. Recovery. Mustard, spirit of ammonia comp. (B. P.), tincture of bella- donna, brandy. T. F. H. Smith (Brit. Med. Jour., vol. i, p. 1109, '93). Case 14. Fluid extract, 4 drachms. Recovery. Emetics, atropine and brandy subcutaneously. Henri E. R. Altenloh (N. y. Med. Jour., vol. Ixvii, p. 358, '93). Case 15. Tincture, 7 7= drachms. Re- covery. Mustard, digitalis, and brandy subcutaneously; digitalis, nux vomica and brandy by rectum; ether and am monia by inhalation; brandy and am monia carbonate by mouth later. G. H Tuttle (Boston Med. and Surg. Jour, vol. XXV, p. 678, '91). Case 16. Mentioned by, but not seen by. Dr. Tuttle. Tincture, 5 7: drachms. Death. G. H. Tuttle (Boston Med. and Surg. Jour., vol. xxv, p. 678, '91). Case 17. Preparation not noted. Four teaspoonfuls. Recovery. Sulphate of copper, digitalis, wine by mouth ; whisky by rectum ; whisky, 7=5 grain sti-ychnine, and digitaline, 7ki grain, hypodermically. M. A. Warriner (N. Y. Med. Record, vol. xxxix, p. 521, '91). Case 18. Tincture, 2 drachms. Recov- ery. Apomorphine, stomach-tube, tinct- ure of digitalis, 25 minims; aromatic spirit of ammonia, 45 minims; brandy, 2 drachms subcutaneously, heaters, sina- pism to praecordia. S. Q. Robinson (Bos- ton Med. and Surg. Jour., vol. cxxvii, p. 192, '92) . Case 19. Tincture (B. P.), 30 minims. Recovery. Salt and water one and a half hours after poison. Sulphate of zinc two hours after poison. Charcoal, brandy, and water by mouth. William Hard- man (Brit. Med. Jour., vol. i, p. 1320, '93). Case 20. Preparation not stated. Five drops. Recovery. Belladonna and stro- phanthus, champagne, brandy, heaters. J. D. Leigh (Edinburgh Med. Jour., vol. xl, p. 638, '95). Reported by R. AV. Greenleaf (Boston Med. and Surg. Jour., July 15, '97). Therapeutics. — Aconite is mainly used as an arterial sedative. By diminishing the force and the rapidity of the heart's action, it lessens blood-pressure, and, in doing this, tends to allay spasm and relieve undue excitability of the nerve- centres. It is, therefore, indicated while the pulse is high and resisting. Aconite causing increased perspira- tion, it is indicated where, with a high pulse, there is dryness of the skin. The evaporation of sweat from the surface and the heat-radiation due to the in- creased peripheral circulation resulting from relaxation of the cutaneous capil- laries also cause a reduction of temper- ature. Aconite also possesses diuretic properties. Hence it appears to be en- dowed with all the qualities requisite in the incipient stage of uncomplicated inflammatory disorders, as an anodyne sedative. In children aconite may be given when- ever the spasmodic element is clearly marked: in fever preceding attacks of quinsy, pharyngitis, etc.; in asthma and the asthmatic crises of bronchial ade- nopathy; in pertussis and other spas- modic coughs; in laryngismus stridulus; in palpitations associated or not with hypertrophy of the heart; and in con- vulsions. (Comby.) The tincture of aconite may be used with safety for the reduction of the tem- perature when dangerous symptoms, as restlessness, jactitation, and delirium (which are forerunners of eclampsia or coma) are present. A child of 8 years could take 1 minim, and one of 12 years 1 7= minims every three hours. J. Lewis Smith (Archives of Pediatrics, Dec, '91). By reason of its sedative and depress- ant action aconite is contra-indicated in all cases in which prostration exists or threatens. If the respiration is embar- rassed, if the heart is in asystole, if the patient is depressed, recourse must be had to tonics and stimulants. In bron- cho-pneumonia, pneumonia after the 106 ACONITE. THERAPEUTICS. primary stage, valvular affections of the heart, and in all cases of collapse occur- ring in acute infectious diseases, aconite is particularly contra-indicated. Fever. — The physiological effects enumerated afford sufficient ground for its value in the reduction of all the phenomena attending the febrile state: high temperature, dry skin, hard and frequent pulse, etc. The tincture is preferable here, as it is in all other disorders. The best effects are produced by means of small doses. One minim is first given, then another minim in one- half hour. After that, ^/a minim is given every half-hour until the febrile symp- toms are reduced or until physiological symptoms of the drug appear. Aconite should always be greatly diluted. Aconite is especially of value in the fever attending the incipient stage of catarrhal disorders. It may be used as an apyretie in continued fevers and infectious diseases, — variola, scarlatina, erysipelas, etc., — but large doses are usu- ally required, involving correspondingly great danger. In the reflex fever which sometimes follows the use of the catheter it is very efficient. (Wood.) DiSOEDEES OF THE ReSPIEATOET Teact. — In acute disorders of the nose, throat, and lungs the depressing effects exerted by aconite upon respiration through its influence upon the respira- tory centre and upon the muscles con- cerned in respiration are added to the qualities previously enumerated. Hence its value in acute coryza, pharyngitis, tracheitis, bronchitis, pleurisy, and pneu- monia. In all of these, 1 drop of the tincture every hour should be admin- istered iintil the physiological effects — tingling and numbness of the lips and tongue — are experienced, when the remedy should be given less frequently. After the initial stage of the affections enumerated, aconite should be discon- tinued, especially in pneumonia, in which affection its administration is positively harmful as soon as the asthenic stage begins. In the chronic disorders of the respiratory passages — including phthisis — it is more hurtful than beneficial. Eheumatism. — Aconite is consider- ably used in all forms of rheumatism as an anodyne. It is especially indicated when the skin is dry. The diaphoresis resulting from its use, added to its anal- gesic effect, tend to shorten the duration of the disease. This is especially the case in the acute rheumatic pains due to exposure. Neuealgia. — In the form of neural- gia characterized by exacerbations dur- ing damp weather aconite is sometimes very effective in small doses frequently repeated. If the painful spot does not cover much surface, application of the tincture over it with a camel's-hair pencil contributes markedly to hasten the relief. Meningitis, Pericarditis, and Per- itonitis. — These three inflammatory disorders of serous membranes are mentioned concurrently owing to the fact that their early manifestations are equally influenced by aconite. In peri- tonitis especially its effect as an anodyne tends to prevent vomiting: an important feature. In pericarditis it markedly in- creases the chances of recovery by re- ducing the number of pulsations, thus prolonging the resting periods between beats. Cardiac Disorders. — By lowering arterial tension and diminishing the number of heart-beats it may be of advantage in functional disorders, but when organic lesions are present it had better not be used. It is sometimes em- ployed in uncomplicated hypertrophy. ACONITINE. PHYSIOLOGICAL ACTION. POISONING. lor however, to antagonize exaggerated ac- "tion, but its effects should be closely watched lest incipient degeneration be present. ACONITINE. — Aconitine is an alka- loid obtained from Aconitum napellus, ■and represents the active principle of ■aconite. It occurs in colorless, tabular crystals, slightly soluble in water, but .soluble in alcohol, ether, and chloro- form. It is extremely poisonous. Dose. — The preparations entitled to •confidence are those of Merck and of Duquesnel, the latter especially, owing to its constant strength. The German preparations of aconitine are thought to be impure. The dose is from V300 to V230 grain. The virulence of aconitine causes the responsibility of the physician to be in- volved to a greater degree than in the •case of other poisons. It should be ad- ministered in small doses onl}', if used ■at all. Case of fatal poisoning by a single dose of aconitine in France. Physician fined 100 francs. Editorial (Gaz. des Hop., Paris, Sept. S, '91). Nitrate of aconitine given by practi- tioners in doses of V32, '/22J and Vis grain. These relatively large quantities are apt to be followed by serious results. Edi- torial (Medical Age, May 25, '92). The activity of aconitine is markedly increased when it is administered hypo- ■dermically. Injections of the alkaloid in various neuralgias excessively painful and pro- ductive of toxic symptoms. A. Cohn (Deutsche med.-Zeit, Oct. 22, '88). From experiments on rabbits and dogs it was thought that as much as V3 grain of aconitine could be given to the horse, whereas half that dose would be fatal. It is, therefore, illogical to calculate the toxicity of a poison by the weight of an animal, and still more so to draw con- clusions as to one species from experi- ments on another. Aconitine possesses great activity when given by hypodermic injection. Weber (Le Bull. M6d., Mar. 20, '95). The fact that the preparations dis- pensed vary greatly in strength accord- ing to the source of production militates against its use. Especial attention called to the various degrees of strength of the several varie- ties of aconitine on the market. The division into French, German, and Eng- lish aconitine is as unreliable as it is unscientific. William Murrell (Medical Bulletin, June, '90). PliysioiOgical Action. — Aconitine in minute doses reduces the action of the heart and thereby reduces arterial ten- sion. In large doses, or in persons pre- senting undue sensitiveness to the effects of aconite, this action manifests itself more markedly, reaching, in fatal cases, to arrest of the heart in diastole. Aconi- tine reduces temperature by this influ- ence on cardiac action; it also tends to inhibit respiratory action by its paralyz- ing influence upon the muscles of res- piration. On general principles, aconi- tine tends to reduce functional action through its paralyzing influence upon nerve-centres. Aconitine Poisoning. — The symptoms following a poisonous dose are those of aconite poisoning, but they occur more rapidly; hypodermically administered, aconitine may cause death in less than a minute. Tingling in the mouth and throat, numbness of the face and ex- tremities, reduction of the cardiac pul- sations, shallow breathing, dilatation of the pupils, cold sweats, purging, etc., follow in quick succession, death com- ing on through paralysis of the heart. Case of poisoning in which a stout German took eighteen tablets of aconi- tine each containing '/zoo grain, probably within half an hour's time. One hour and a half afterward there appeared 108 ACONITINE. ACROMEGALY. symptoms of paraplegia ; stertorous, irregular respirations, from six to thir- teen times a minute; strangling; and tingling in the fauces. Pulse irregular, pupils slightly dilated and sluggish. Re- covery under morphine hypodermically, emetics, whisky, and ammonia. Valen- tine (N. Y. Med. Jour., Dec. 15, '88). Treatment of Aconitine Poisoning. — The general indication is to prevent syn- cope. The recumbent position, warmth, and stimulants are pre-eminent among the measures to be employed. The stomach-tube may be used if the heart's action is not too weak, while the stim- ulation is procured by hypodermic in- jections of ether, ammonia, or whisky. Strychnine, digitalis, or caffeine are also valuable, but their action is not as rapid. They may be utilized to great advantage to sustain the heart's action, however, after the patient has shown evidences of reaction. Case in which Vo grain of crystallized aconitine was taken in mistake; the pa- tient saved through energetic measures, combined with large doses of caffeine, subcutaneously, to sustain the heart. Veil (La France Med., Sept. 29, '93). Therapeutics. — Aconitine is possessed of no advantage that the preparations of aconite usually employed do not offer, and is much more likely to give rise to untoward results. It has been used with advantage in neuralgia and pneumonia, especially in the broncho-pneumonia fol- lowing upon influenza. Erysipelas seems also to have been successfully treated with aconitine. Treatment of eiysipelas of the face by the use of nitrate of aconitine eminently successful in doses of Vp,« grain every two hours, taking care not to exceed a daily dose of '/„, grain. Course greatly lessened and great relief fi'om pain. Tison and Bourbon (London Med. Re- corder, Jan., '91). Spurious Preparations. — Aconitine has also been obtained from other varieties of aconite, — Aconitum ferox and Aconitum japo7iicum, — but the properties of the preparations are still insufficiently known. Aconitine obtained from Aconitum napellus possesses the same diaphoretic properties as pilocarpine. This effect is not obtained by the doses ordinarily em- ployed. Aconitine from Aconitum ferox and A. japonicwn has no such property. P. Aubert (Pharm. Centralhalle fur Deutschland, No. 22, '94). Pseudaconitine, a highly poisonous con- stituent of the aconite found in Nepaul, probably Aconitum ferox. Small, color- less, transparent, dextrorotatory crystals, verj' slightly soluble in water, readily in alcohol, chloroform, and acetone. Per- sistent tingling sensation on the tongue; slightly more toxic than aconitine. W. R. Dunstan and Francis H. Carr (Jour- nal of the Chemical Society, p. 3.50, '97). ACROMEGALY. — (Greek.) From axpoT, extremity, and ^dyag, great. Definition. — A non-congenital hyper- trophy of the bones, especially the su- perior, inferior, and cephalic extremities. It was first described by Dr. Pierre Marie, of Paris, in 1885. Symptoms. — In this disease there are two classes of symptoms: — I. Constant or almost constant. (a) Hypertrophy of the hands. This is often the first symptom noticed. They are spade-like, — namely, thick and wide, without notable increase in length. The bones, mitscles, cellulo-adipose tissue, and skin are all involved in the overgrowth. The skin is not oedematous, but is firm on pressure and somewhat darkened. The fingers are much enlarged, sausage- like, as thick at the distal as at the proximal extremities. The interphalan- geal furrows and the lines of the palms are exaggerated, while the thenar and hypothenar eminences are enlarged. The finger-nails seem short, widened, and are ACROMEGALY. SYMPTOMS. 109 usually striated longitudinally. The fingers are rarely club-shaped. The hypertrophy does not seem to affect the wrist to the same dee-ree as it Typical hand in advanced acromegaly. (Gaston and G. Brovardel.) does the remainder of the forearm and hand. The arm and forearm, therefore, though they may be slightly enlarged, do not appear so. There is no interfer- ence with the function of the hands. Sciagraph of the above hand, showing hyperostosis. (b) Hypertrophy of the feet. This is of the same character as that of the hand.?. They are widened, thickened, but not lengthened, and the hypertrophy ceases or appears to cease at the ankles. (c) Hypertrophy of the head. The skull is slightly increased in size, hut the face is much more affected: it is length- ened; the eyes seem small compared to the size of the eyelids and orbital bor- ders; the nose is enormous and flattened; the cheek-bones and chin project and the lips are much thickened. The lower jaw-bone is especially affected. The tongue is increased in size and may even Case showing typical hypertrophy of the feet. (Gifford.) protrude from the mouth and greatly in- terfere with speech. The hard and soft palate, the uvula, the tonsils, the pillars, and even the teeth may be enlarged, causing cough and difficulty in speaking and eating. Case with marked hypertrophy of the scalp. Hutchinson (Archives of Surg., Oct., '89). Case in which trophic lesion was anal- ogous to acromegaly; chief symptom was gradual, progressive enlargement of head and neck. Denomination of "me- 110 ACROMEGALY. SYMPTOMS. galocephaly" proposed. M. Allen Starr (Amer. Jour. Med. Sci.j Dec, '94). (d) Thorax. The vertebras are espe- cially affected, causing cerTico-dorsal kyphosis, which may coincide with lum- bar lordosis. The h3'pertrophy of the sterniTm, clavicles, ribs, costal cartilages, and scapula; causes the chest to seem Cheyne-Stokes variety, and inability to- retain either food or drink in his stom- ach. Enlarged pituitary body found at the post-mortem. The gland weighed 475 grains, instead of 5 to 10 in the nor- mal condition. J. E. Rathmell (Southern Practitioner, Dec, '95). (e) Headache is often one of the first symptoms. It may be continuous or Case showing characteristic alterations of the thorax. (Fritscli, Elebs, and Brlgldi.) flattened from side to side and increased in depth from behind forward. The de- formity of the chest may make respira- tion difficult and cause it to become abdominal in type. Uncommon symptoms: long-continued abnormal rhythm in respiration of the paroxysmal, diffuse, or, as is more fre- quent, localized in the occiput or nape of the neck. Two cases, one of which had suffered temporarily from exceedingly acute cephalalgia. Kalindero (Rev. Inter, de Med. et de Chir., Oct. 25, '94) . ACROMEGALY. SYMPTOMS. Ill (/) Amenorrhoea resulting in sterility is one of the first symptoms in women. In two women premature cessation of menses and hypertrophy of pituitary body. Ransom (Brit. Med. Jour., June 8, '95). Case appearing at 47 years; amenor- rhcea was only transitory, and menstru- ation was normal. Thomas (Revue M6d. de la Suisse Rom., June 20, '93). II. Secondary symptoms: — The neck is often short and thick. The thyroid gland may be normal, atrophied, or increased in size. The larynx is usually enlarged, causing in women a low voice and dyspnoaa. The nasal cavities may also be compromised by enlargement of the turbinated bones, another source of dyspnoea being thus afforded. Case of acromegaly complaining of pain in the left side of the nose and slight difficulty in breathing. The in- ferior turbinated bodies were enormously enlarged; the other structures in the nasal cavity appeared normal. The an- terior and posterior pillars, the soft palate, and the uvula were much thick- ened; also the tonsils and their capsules. The lingual glands were much hyper- trophied. An external examination showed that the larynx was very much enlarged. The epiglottis was thickened. The arytenoid cartilages and the ven- tricular bands were enlarged. The glottis was very small. While the patient re- mained quiet, respiration was only slightly impaired, but excitement pro- duced labored breathing and a crowing sound during both expiration and in- spiration. During one of these attacks of dyspnoea the patient died. W. F. Chap- pel (Amer. Medieo-Surg. Bull., Jan. 18, '96). Case in which, besides other typical symptoms, the cartilages of the nose and ears were greatly thickened, and prob- ably those of the larynx, as his voice had altered of late to a deep bass. The skin of the face was slightly pigmented; the orifices of sweat-glands enlarged. The tongue was enlarged enormously, the tonsils and uvula also. Difficulty in swallowing at times and slight asthmatic seizures. John N. d'Esterre (Brit. Med. Jour., Dee. 4, '97). In women the mammse are atrophied, the abdomen is enlarged and pendulous, and the pelvis and external genitalia en- larged and thickened. The uterus may be atrophied. In man the penis, scrotum, and tes- ticles may be enlarged or diminished. Sexual power and feeling may be abol- ished. Case of acromegaly of fourteen years"^ standing in which, although the patient is 52 years old, there is no impediment of the sexual function. J. R. Rathmell (Southern Practitioner, Dec, '95). The muscular system is usually atro- phied, though it may be normal or hy- pertrophied. Electrical excitability is- diminished (Erb) or increased (Ver- straeten). Case with amyotrophy, which appeared to be due to compression of the rachidian nerves. Duchesneau (Thfese de Lyon). Some articulations (knee, wrist) have been found enlarged and giving creak- ing sounds on movement, owing to re- laxation of the ligaments. Case in which there were, with great deformity of wrists, trophic lesions of the joints, — a certain amount of muscular atrophy similar to that occurring in the progressive atrophy of Duchenne. There were also a few symptoms of Raynaud's disease and a trace of albumin in the urine. Middleton (Glasgow Med. Jour., June, '94). Case in which there was a cystic tumor in the popliteal space, communicating- with the joint; in the latter were, be- sides synovial fluid, five small, solid masses. Roswell Park (Inter. Med. Mag., July, '95). The knee-jerk is not increased; it may be normal, decreased, or absent. Car- diac hypertrophy with palpitation some- times occurs. Arterial sclerosis and' 112 ACROMEGALY. SYMPTOMS. varicose veins have been noted. Hy- pertrophy of the lymphatic vessels and glands is not very infreqvTent. Hunger and thirst are usually in- creased. Sometimes there is dyspepsia. Duchesneau records enteroptosis and nephroptosis. Polyuria, glycosuria, peptonuria, and phosphaturia have been noted. Occa- sionally there is excessive sweating. Case of acromegaly with Graves's dis- ease and glycosuria. Lancereaux (La Sem. Mgd., Feb. 16, '95). Case of acromegaly in which there were, besides sarcoma of the hypophysis cerebri, diabetes and struma. Hanser- mann (Berliner klin. Woch., May 17, '97). Case of acromegaly in a man 37 years of age in which there was also aliment- ary glj'cosuria, peculiar joint swellings, and paroxysmal hsemoglobinuria. The joint swellings were probably of trophic and vasomotor origin. The paroxysmal hsemoglobinuria was probably dependent upon alterations in the vessels, almost constantly found in acromegaly, and a causative role in the production of this disease. It is probable that the hypoph- ysis secretes a substance that influ- ences the heart and vasomotor system. Chvostek (Wiener klin. Woch., Nov. 12, '99). Frequent observance of the coincidence of sugar in the urine in cases of acrome- galy. Three eases: one of genuine dia- betes mellitus, one of polyuria in which the sugar gradually disappeared after great variations in its percentage, and one of alimentary glycosuria. The last case attributed to a tumor of the hy- pophysis. W. Schlesinger (Wiener klin. Kund., Apr. 15, 1900). Analgesia and ansesthesia of the skin have been reported and abdominal pain and great sensitiveness to cold. The skin is yellowish-brown and darkest at the extremities. It is dry and wrinkled. Warts are frequent. The hair is thick and abundant. The body-hair is thick and stiff. Taste, smell, and hearing may be affected; but, above all, vision. There may be amblyopia due to papillary con- gestion, irregular contraction of the field of vision, and Argyll Eobertson's pupil. Especially interesting is temporal hemi- opia caused by pressure from the en- larged pituitary body. Case in which there was rotatory nys- tagmus, bitemporal hemianopsia, and atrophy of the optic nerves. Reinhold Bolty (Deutsche med. Woch., July 7, '92). Case beginning in the twenty-fifth year. Five years later there was atro- phy of both disks with complete blind- ness in one eye and diminished vision in the other. The thyroid could not be felt. Dresehf eld (Brit. Med. Jour., Jan. 6, '94) . Thickening of eyelids, prominence of orbital ridges, exophthalmia, periorbital pains, hypersecretion of tears, nystag- mus, etc., have been observed. Hertel (La Presse Mgd., July 13, '95). The following eye-symptoms have been noted by Maisonneuve: Exophthalmos; long, thick, bronzed upper eyelids; pupils reacting slowly to light, normally with accommodation. The movements of the eyes are slow, and, in raising them, there is a want of synchronism with move- ments of the lids. There is retinal en- gorgement. Case in which the visual fields at no time showed any tendency toward the hemianopsic type which has so often been noted. This defect of vision is, in all probability, due, in most cases, to pressure exerted by the hypertrophied hypophysis cerebri. The claim that this pressure, as almost universally stated, is exerted upon the posterior border of the optic chiasm is certainlj' incorrect. In spite of the gloomy prospect for good vision, which the case at one time presented after more than a year the sight was ™/3o with each eye, and it con- tinues to be good. Current accounts would lead one to expect progressive, optic nerve-atrophy, ending in blindness, in all cases where serious disturbance of ACROMEGALY. SYMPTOMS. DIAGNOSIS. 113 the sight has set in. H. Gifford (West- ern Med. Review, June 15, '97). There is general muscular weakness, and the patients are melancholy and irritable. The intelligence remains un- changed in the majority of cases. Case ot married woman, 68 years old, who first manifested signs of mental de- fect at age of 50 and was talcen to lios- pital for insane because of homicidal tendencies. Meanwhile the extremities became much enlarged, lingers sausage- shaped, featvires thickened, bones of chest thickened and enlarged, thyroid small, and thymus not discernible. Henry "Waldo Coe (Jour. Amer. Med. Assoc, Dec. 3, '98). Diagnosis. — Myxcedema. — In this dis- ease there is simple oedematous infil- tration of the soft parts, and a round, swelled face instead of the irregular face obseryed in acromegaly. Case in which a feature of especial importance was the marked increase in the bulk of the overlying tissues, which presented the appearance and sensation of hard cedema exactly resembling myxcedema. The treatment has been solely by thyroid extract, the result being an immediate and marked amel- ioration of the disease. C. L. Greene (Med. Record, June 8, 1901). Osteitis Defoemans. — In osteitis de- formans the face is triangular with the base upward; in acromegaly it is ovoid or egg-shaped, with the large end down- ward; in myxcedema it is round and full- moon shaped. (P. Marie, Oskr.) Leontiasis Ossea. — In this disease there is hyperostosis of the bones of the face and skull. The hyperostoses of the bones of these regions form boss-like masses; the hands and feet are normal. Elephantiasis. — The elephantiasie thickening is limited to the skin and is unilateral. Chronic Eheumatism. — In rheuma- tism there are characteristic deformities of the hands and feet, articular pains, muscular atrophy, and early impotence. Eachitism and Lymphatisii United. — Special deformities, absence of enlarge- ment of lower jaw, and macroglossia. Erythkomelalgia. — Here the soft parts of the hands and feet are red, the face is unaffected, and there is no in- volvement of the bones. Gigantism. — In true gigantism the body grows symmetrically. In acro- megaly the abnormal development is promiscuously localized. Gigantism and acromegaly may, however, be present in the same case. Acromegaly may be regarded as a par- tial giant-growth, but it differs very essentially from the latter. In gigan- tism the length of the body is over six times the length of the foot; in acrome- galy it is under six times the length of the foot. Virchow (Berliner klin. Woch., Feb. 4, '89). Case of an Indian, exhibited as a giant, who had, in addition to symptoms df acromegaly, facial hemihypertrophy. At the autopsy the pituitary gland was found to be much hypertrophied. Case of another professional giant seven feet and five inches tall, who had only some symptoms of the disease. Acromegaly is sometimes associated Avith giant-growth. Dana (N. Y. Med. Jour., Aug. 12, '93). Case in a man, six feet and seven inches in height. Another case cited, height seven feet and four inches, in which there was hemihypertrophy of the face, on the left side. This is a rare combination, being only the eleventh known. Dana (Jour, of Nervous and Mental Dis., Nov., '93). Case of acromegaly in a giantess. Byrom Bramwell (Edinburgh Med Jour., Jan., '94). Autopsy on a giant from Egypt, show- ing exosto-ses and diffuse porous osteo- periostitis. Sirena (La Med. Mod., July 18, '94). Autopsy on a German giant who had not begun to grow abnormally before 114 ACROMEGALY. ETIOLOGY. PATHOLOGY. the age of 36 years. Fritsch and Klebs (Corres. f. Sehweizer Aerzte, p. 662, '93). [In both cases there was acquired gigantism, which is the most common form. It would seem that gigantism, as well as dwarfism^ arises from a disease occasioning disturbances of growth, and that, owing to the osseous lesions fre- quently present, there is a certain anal- ogy with acromegaly. Unilateral hyper- trophy of the face is of rare occurrence. P. SoLLiER, Assoc. Ed., Annual, '95.] Pulmonary Osteoarthropathy. — In this disease there is hypertrophy with deformities, but of the osseous system only; no amenorrhoea nor enlargement of lower jaw. The third phalanx of the fingers is much enlarged, like a drum- stick, the nails are lengthened, widened, striated longitudinally, curved over the finger-tip. The carpus and metacarpus are almost normal, while the wrist is en- larged and deformed. The same lesions occur at the feet, and the lower portion of the leg may be larger around than the calf. The long bones, especially of the leg and forearm, are enlarged. The joints are swelled and move with diffi- culty. Kyphosis exists, when present, only in the lower dorsal or lumbar re- gion. The face is normal, except that the upper jaw-bone may be enlarged. Some chronic thoracic lesion is present. (Marie.) Case presenting certain features like those occurring in hypertrophic pneumic osteoarthropathy. Lavielle (Jour, de Med. de Bordeaux, Jan. 7, '94). Pulmonary osteoarthropathy may give rise to some little difficulty in diagnosis, principally owing to its rarity. It is most likely to be confounded with acro- megaly, but in the latter disease there is no alteration of the nails nor are the finger-ends nor the carpus and meta- carpus much thickened. The chief char- acteristics of the disease are great en- largement of the hands, wrists, feet, and ankles, associated with, and secondary to, some chronic pulmonary affection, such as phthisis, chronic bronchitis, and empyema. In the joints the changes are effusion with enlargements and ulcera- tion of the cartilages and articular ends of the bones. Marie is of the opinion that these changes are due to toxic poi- soning, but Thorburn looks on them as tuberculous. The evidence either way is slight and indefinite. G. A. Bannatyne (Laneet, Feb. 23, 1901). It is doubtful where acromegaly can be separated from pulmonary osteoar- thropathy. (Arnold.) PSEUDOACROilEGALIC SYRINGOMYELIji . — ASects usually the lower limbs only, — one only sometimes, and may not affect all the fingers. Deformities and trophic changes are present. Scoliosis and dis- sociation of sensibility are notable feat- ures. Case of hereditary syphilis presenting great length of diaphysis of long bones, wrist, and elbow. Nobl (Le Bull. M6d., Aug., '95). Etiology. — The disease usually begins between the ages of 20 and 40 years. It is more common in women than in men, and no influence can apparently be at- tributed to race, heredity, or antecedents. Case in a woman aged 63 years. Ganse (Deutsche med. Woch., Oct. 6, '92). Case in a young negro aged 10 years. Beavan Rake (Brit. Med. Jour., Mar. U, '93). Cases of acromegaly in father and son. In the latter a tumor of the pituitary body was found at the autopsy, together with generalized endarteritis and scle- rotic atrophy of the thyroid gland. Bonardi (Revue des Sci. Med. en France et a I'Etranger, Jan. 16, '94). Case following excessive weakness due to parturition. Middleton (Glasgow Med. Jour., Aug., '95). Case suggesting influence of trauma- tism upon development of acromegaly and diabetes. Marinesco (Le Bull. Med., June 26, '95). Pathology. — The skull may show dis- appearance of sutures, hypertrophy of ACROMEGALY. PATHOLOGY. 115 the external occipital protuberance, de- formity of the condyles, thickening of the frontal and occipital bones, and in- crease in size of the processes inside the skull and, above all, of the pituitary fossa. Both maxillaries are enlarged, the lower especially so; the alveolar processes and zj'gomatic arch are also increased in size. Sciagraph from a case of Dr. Sanger Brown's. The skin outlines are entirely lost; pointed chin shows striking prog- nathous type. The light area above the upper teeth is the antrum, distinctly bordered bj' an upper, bony plate. The outlines of the orbit are not shown. In normal cases the orbital arch shows itself almost as this region appears when a skull is viewed laterally. The frontal eminences protrude strongly. The light, semilunar area is not the frontal sinus, which often shows in sciagraphs, but is probably due to a more membranous bony formation than the outside layers. O. L. Schmidt (Medicine, July, '97). In the vertebral column the hyper- trophy especially affects the extremities of the cervico-dorsal spinous processes. The hypertrophy especially affects the bones of the extremities and the extremi- ties of the bones (Marie). There is dilatation of the air-sinuses of the skull, and changes in the temporo- maxillary articulation, permitting for- ward dislocation of the lower jaw. There is a tendency to formation of new bone, both in normal and abnormal situations. Thompson (.Jour, of Anat. and Phys., July, '90). The most characteristic lesion is a symmetrical thickening, which increases toward the projections. Arnold (Bei- triige z. path. Anat. u. z. Allge. Path., B. 10, No. 1). Histologically the growth consists in an hypertrophy of the medullary bone, while the periosteal bone is reduced to a thin layer. This attacks red marrow- bones especially. Duehesneau (Th6se de Lyon, '91). Case of a young man who entered the hospital for a tumor of the right thigh, requiring amputation of the limb. The tumor was a malignant osteoid growth of J. Miiller or chondrosarcoma of Virchow. The patient had recovered from the operation, which had been performed in December, 1894, when thoracic disturb- ances and symptoms of acromegaly de- veloped progressively. Death occurred toward the end of September, 1895. The lungs and pleurae contained enormous enchondromatous tumors, as large as a child's head in some cases; microscopic- ally they were found to be everywhere composed of cartilage- tissue at every period of development. Sciagraph of skull in acromegaly. {Soliviidt.) The pathological lesions of acromegaly existed in the limbs; the hyperplasia of the periosteum, instead of being limited to the extremities of the phalanges, e.x.- tended the entire length of the limbs to the hips. The shafts of the femur and humerus were surrounded throughout their entire length by osteophytes; on the ulna and radius some of the osteo- phytes could still be compressed by the finger. The epiphyses Avere normal, but were, from the youth of the patient, not yet connected to the shaft. The condi- tion of the pituitary body was not given in the autopsy. In its neighborhood, at the spheno-oecipital synchondrosis, a myxomatous enchondrosis was found. R. 116 ACROMEGALY. PATHOLOGY. Virehow (Berliner klin. Woch., Dec. 16, '95). Hyperplasia of the connective tissue and adipose tissue of the periosteum is present, while its inner layer gives rise to osseous neoformation. There is central absorption due to osteoblasts, with intense peripheral his- togenesis, in the periosteum and articu- lar cartilage. (Marie and Marinesco.) The lesion most frequently observed, and apparently the main feature of the disease, is one of the pituitary body. This organ may undergo various patho- logical changes, ranging from hyper- trophy to the more malignant forms of neoplasm, such as sarcoma. Of 19 published eases there was hyper- trophy of hypophysis in 3, hypertrophy with increase of connective tissue in 1, sarcoma in 3, adenoma in 2, softened ade- noma in 1, tumor with little cavities lined with epithelium in 1, glioma in 1, tumor with character not specified in 3, vascular hypertrophy in 1, colloid degen- eration in 1, sclerosis and atrophy in 1, and necrosis with softening in 1. Stem- berg (Zeit. f. klin. Med., vol. xxvii, p. 86, '95). Enough cases have been reported to refute the hypothesis that the enlarge- ment of the hypophysis cerebri in acro- megaly is, like the other hypertrophies, merely a symptom of the disease. If simple hypertrophy were the constant lesion, it might be claimed that it was a result and not a cause of the disease, but it hardly needs argument to show the improbability that any one disease would cause, in a single organ, so many and various morbid conditions as are enumerated in Sternberg's list. W. L. Worcester (Boston Med. and Surg. Jour., Apr. 23, '96). Analysis of thirty-four recorded ne- cropsies on cases of acromegaly. Changes in the pituitary gland foimd in all. In all but three there had been either hy- pertrophy or tumor. Percy Furnivall (Lancet, Nov. 6, '97). Of 97 reported cases of acromegaly, autopsy had in 15 cases: 12 showed changes in the hypophysis cerebri. There is a connection between the changes in the pituitary body and acromegaly. Per- sonal view that all organs have a double function : a negative, withdrawing some- thing from the organism ; and a positive, introducing something into the organism. The progressive development of one or- gan has progressive development of other organs as a consequence. Hansermann (Berliner klin. Woch., May 17, '97). Case of acromegaly in which death occurred in an accident. At necropsy the skull was found uniformly thickened and heavy, and all the air-spaces were dilated. The sella Turcica was deep and wide, and the pituitary body was con- verted into a cyst containing semifluid substance. Peycy Furnivall (Lancet, Nov. 6, '97). (1) Cases of acromegaly associated with true tumor of the hypophysis are certainly not so numerous as has been heretofore supposed; (2) there is not as much constancy in the pathological con- dition of the hypophysis as there is in the enlargement of the heart, the thyroid gland, or the sella Turcica; (3) acro- megaly does not depend, at least not solely, upon abolition of any function of the hypophysis; (4) a relationship be- tween the thyroid gland and the hypoph- ysis has already been amply proved; (5) it is not at all improbable that pro- liferation of the histological elements of the hj'pophysis may be instituted in some eases by primary enlargement of the sella Turcica; in other eases an oedema or hsemorrhage ex vacuo; (6) we have no reason for supposing that en- largement of the sella Turcica must be as constant an occurrence in acromegaly as the changes in other bones, or that it might not take place from the same cause or causes. Mitchell and Lecount (N. Y. Med. Jour., Apr. 29, '99). Necropsy of a case in a man who died at the age of 70 and which had the typ- ical characters of the malady. The pitu- itary body was three times its usual size ; the thymus was looked for in vain; and the thyroid body was goitrous fibrocystic, the two lobes — but especially the right — being much enlarged. The heart was large, without valvular lesions; so was ACROMEGALY. . PATHOLOGY. 117 the great sympathetic; but the diameter of tlie large blood-vessels was not sensi- bly increased. Microscopically the pitu- itary body showed in places small colloid masses, a very marked dilatation of the vessels, and hypertrophy of the cells. Pagniez {Bull, et Mem. Soc. Anat. de Paris, S. 6, vol. i, p. 942, 1900). The pituitary gland as a factor in acromegaly and giantism: (1) the pitu- itary body is still functional; (2) dis- turbances of its metabolism are the prin- cipal factors in both acromegaly and giantism, the difference between the re- sults being simply due to the stage of individual development at which the dis- turbance of the function begins; (3) the nature of the overgrowth in both these diseases is primarily on the order of a pure functional hypertrophy, later, how- ever, losing some of the definiteness of its impulse and either producing immature tissue of a mixed type or resulting in simple hsemorrhagic exudation, with either cyst-formation or complete break- ing down of the tissue-mass; (4) it seems probable, although upon this head the evidence is still uncertain, that some part is played by this body in "dwarf- ism," rickets, and the dwarf forms of cretinism; (5) a reflex disturbance of its function may possibly underlie the dys- trophy accompanying pharyngeal ade- noids; (6) it would appear to be a sort of "growth-centre," or proportion-regu- lator of the entire appendicular skeleton. Woods Hutchinson (N. Y. Med. Jour., July 28, 1900). The pituitary bod}' is sometimes en- larged from the size of a pigeon's egg to that of a hen's egg; it dilates the pitui- tary fossa and clinoid processes, and is lodged in a considerable depression in the base of the brain. Case in a woman, 35 years old, in whom symptoms of confirmed acrome- galy had been present for three years. In May, 1893, there were visual disturb- ances, and double optic neuritis was found to be present. In July, 1895, there were noted: complete blindness of the right eye, continuous headache, and pain in the limbs; the patient became somno- lent and died in a comatose condition. Autopsy showed the thymus to be abnormallj' voluminous and the thyroid gland normal. Some signs of adhesive meningitis were present at the vertex. The pituitary body was enlarged, soft- ened, and vascular. The dura mater of the sella Turcica had disappeared, and the bone had been worn away in that region. The hypertrophy of the pitui- tary body had compressed the two optic tracts and the chiasm, the right optic tract being partly destroj'ed and the left optic tract completely so. No other lesion was found. The pituitary body showed, microscopically, the appearance of a gliosarcoma. Roxburgh and A. Collis (Brit. Med. Jour., July 11, '89). Case of acromegaly with post-mortem, at which the thymus was found replaced by a mass of fibrous fat and lymphoid tissue. The thyroid was enlarged sym- metrically and filled with small cysts. The gland-substance was normal under the microscope, but there was increase in the interstitial tissue. Pituitary body was enlarged and a portion of it pre- sented consistence and microscopical ap- pearance of an adenoid tumor. Pearce Bailey (Phila. Med. Jour., Apr. 30, '98). Cases have been reported, however, in which, although typical symptoms of the disease were present, no disease of the pituitar}' body could be detected. Case with numerous cystic cavities in the brain, but with a normal pituitary body. Waldo (Brit. Med. Jour., Mar. 22, '90). Case in a man, aged 74 years, in whom there was no tumor of the hypophysis, but endarteritis with atrophy and sclero- sis of the thyroid body. Bonardi (Ri- forma Medica, Aug. 24, '93). Again, hypertrophy of the pituitary gland may not give rise to the manifes- tations of the disease. Case in which hypertrophy of the pituitary gland had caused no phenome- non of acromegaly. Packard (Amer. Jour. Med. Sciences, June, '92). The pressure of the growths of the pituitary body on the optic tracts gives 118 ACROMEGALY. PATHOLOGY. rise to the oc-ular disturbances enumer- ated. Case in which the pituitary body, which was the size of a walnut, was very soft and vascular. The mass had so pressed upon both optic tracts and the chiasm as to cause total disappearance of the left tract and partial destruction of the right. On the left side of the mass there was a blood-clot the size of a large pea. Roxburgh and Collis (Brit. Med. Jour., .July 11, '96). The hypophysis cerebri generally lies wholly or partly in front of, not behind, the chiasm, and its anterior part is so much nearer the optic nerves than its posterior part is to the chiasm (on ac- count of the nerves, chiasm, and tracts slanting upward posteriorly) that with a uniform enlargement of the gland the nerves in front of the chiasm would almost always be pressed upon sooner than the' chiasm itself. Zander (Deutsche med. Woch., vol. iii, p. 13, '97). The nervous symi^toms sometimes observed may also find in the pressure upon the surrounding cerebral tissues one of their causes. Case of acromegaly of many years' standing in a man, aged 54, who, in the last three years, had developed Jaekso- nian epilepsy limited to the right upper extremity and right side of the face. Hypertrophy of the pituitary gland con- stitutes a cerebral tumor capable of exciting from a distance the cortical psychomotor centres. Raymond and Souques (Centralb. f. Nerv., No. 82, '96). The viscera may take part in the hypertrophic process. The liver fre- quently shows fatty degeneration. Case of acromegaly in which the heart was enormously enlarged, weighing two pounds and nine ounces: one of the largest hearts on record. 0. T. Osborne (Med. News, May 22, '97). Case of a man, 23 years of age, who was quite well until 1893, when he had an attack of typhoid fever, after which typical acromegaly developed, including pigmentation, except that there was no great enlargement of the lower jaw. He died, soon after admission, of diabetic coma. Necropsy showed, in addition to the usual external signs of acromegaly, a general enlargement of the viscera. Liver weighed 90 ounces, the spleen 9 V, ounces, the heart 13, and the kidney 9. The pituitary body was so enlarged as to distend the sella Turcica, and contained several drops of a fluid resembling pus. It did not appear to have compressed the commissure, and there was no optic atrophy. Norman Dalton (Lancet, May 22, '97). The pigmentation noticed in the above ease might have been due to the condition of the thyroid, the association of acrome- galy with exophthalmic goitre being a recognized one; the disease had obscure relations with myxcedema, and had been successfully treated by means of thyroid extract, although the work of Schiifer and Oliver had shown that extracts of thyroid and of pituitary body were an- tagonistic in action. H. D. Rolleston {Brit. Med. Jour., May 22, '97). The skin of the extremities shows hyperplasia of the papillse, and hyper- trophy of the derma, all the connective- tissue system being enlarged, that of sweat-glands, sebaceous glands, hair- follicles, external and internal vascular walls, and, above all, the lamellated sheath of the infradermie nerves are likewise degenerated. There is marked sclerosis of the great sympathetic system, especially the lower cervical ganglion. The neuroglia in the brain is hyperplastic. Autopsy showing following conditions: The lymphatic ganglia of the neck pro- foundly altered, containing no more lymph-follicles; all varieties of white globules present, with single nucleus, with polymorphous nucleus, and with multiple nuclei. The striated muscular tissue of the neck show-ed atrophy and sclerosis, the nuclei had budded abun- dantly, and the sarcoplasma had under- gone vacuolar and granular fatty de- generation. The hypertrophied pituitary gland was undergoing process of necrosis, and liquefaction of its constituent parts had taken place; the portions escaping ACROMEGALY. PATHOLOGY. 119 this destruction consisted of lymphoid tissue similar to that of the lymphoid ganglia of the neck. The thyroid gland was affected both by atrophy and gland- ular hypertrophy, as well as by hyper- trophy of the connective tissue and lymphoid infiltration. The liver showed fatty degeneration and glandular atrophy, with slight lymphoid infiltration of the interlobular connective tissue. There was chronic interstitial and parenchymatous inflam- mation of the kidneys, hyperplasia of the splenic pulp and of the Malpighian follicles. The tongue was increased in size from hyperplasia of its connective tissue. Claus and Van der Stricht (An- nales de la Soc. de Med. de Gand, No. 71, '93). The blood does not show evidence of great alteration. In one case the amount of htemoglobin was 95 per cent, of the normal; the average of ninety-six countings showed 7,000,000 red corpuscles to the cubic millimetre. The proportion of white to red corpuscles was about 1 to 400. Church and Hessert (Med. Record, May 6, '93). The kidnej's show chronic parenchy- matons nephritis in the cortical sub- stance, moderate sclerosis of interstitial tissue, and peripheral infarcts. In the thyroid gland the follicles are either found hyperplastic or cystic, and contain hsemoglobin crystals. This organ is generally hj'pertrophied. The thymus is occasionally found to have persisted. Case showing a large glioma of the hypophysis, and each lobe of the thy- roid enlarged and containing a cyst. Bury (Med. Chron., July, '91). Typical case, which appeared to date from an old cerebral affection, in which hypertrophy of the thyroid gland was also observed. Bruzzi (Gaz. degli Osp., Aug. 4, '92). Case of diabetic acromegaly, with thick and heavy skull, and an occipito- frontal diameter of sixty-six centime- tres. The pituitary body was softened and voluminous; the thymus had per- sisted, and the thyroid body was cre- taceous. Lathuray (Lyon M6d., .July 11, '93). Case with hypertrophy of the pitui- tary body and persistence of the thymus; the thyroid gland was enlarged and weighed nearly two ounces. T. Coke Squance (Brit. Med. Jour., Nov. 4, '93). The thyroid gland was examined in 24 cases; it was normal in only 5 and hypertrophied in more than half. The thymus was examined in 17 cases; it was absent in 7, hypertrophied in 3, and persistent in 7. The sympathetic gan- glia were examined in 10 cases and re- ported as hypertrophied in 6. The only constant associated changes appeared to be those in the pituitary body; these changes were not uniform and might occur without acromegaly. Percy Fur- nivall (Lancet, Nov. 6, '97). The spleen and the lymphatic glands are generally sclerosed. Among the various theories as to path- ogenesis of acromegaly the following are the most prominent: — Acromegaly is due to an unusual de- velopment of the vascular system; it is a thymic angiomatosis. The endothelial elements originating in the thymus play the part of vasof ormator cells, causing an increase in the vessels, and hypernutri- tion and increase in growth of the ex- tremities where the blood-current is the slowest. (Klebs.) Case in which there was hypertrophy of the pituitary body compressing the optic nerves, persistence of the thymus, and hypertrophy of the great sympa- thetic. Cepeda (Revista Balear de Cien- cias Medicas, Jan. 15, '92). Case in which the tumor of the pitui- tary body was a typical spindle-celled neurosarcoma. The thymus was of considerable size, but without any change in its elements; the thyroid gland was enlarged and filled with small cysts containing col- loid matter. Mosse and Daunic (Soc. Anat., Paris, p. 6.33, Oct. 2.5, '95). It is due to disturbances in the evolu- 120 ACROMEGALY. PROGNOSIS. TREATMENT. tion of the genital life. (Freiind, Ver- straeten.) A trophoneurotic afEection, due to changes in the central and peripheral nervous system, causing hypertrophy of the extremities by means of the vaso- motor system. (Eecldinghausen and Holschewnikow.) A systematic dystrophy, something like myxoedema, and connected with some organ (pituitary body?) much as myxffidema is in connection with re- moval or alteration of the thyroid gland. (P. Marie.) The pituitary body has been destroyed in animals without causing acromegaly. (Marinesco, Vassale, Sacchi.) The cases described by Hagner, Fraent- zel, and Gombault -Marie must be con- sidered as a form standing between acromegaly and osteoartliropathy. Tlie disease begins in youth, without being preceded by any affection of the lungs; the bones of the face arid the cartilages are affected, and the pathological changes are more lilce those of acrome- galy than of osteoarthropathy. F. R. Walters (Progres Med., No. 3, '96). Three eases of acromegaly, in the first of which diabetes, gigantism, and splanehnomegaly were present; in the second arteriosclerosis, and in the third dyspepsia and a lesion of the pituitary body (sarcoma, cysts) ; but other quite different changes were likewise visible, namely: degeneration of the thyroid gland, periependymatous gliomatosis, and cancer of the viscera. When the embryological and anatom- ical relations of the ependyma and pitui- tary body are considered, it may be asked whether they do not, as a whole, form an anatomical and physiological system governing the processes of nutri- tion and capable, when diseased, of giv- ing rise to the dystrophic changes of acromegal}'. Dallemagne (Arch, de Med. Exp., No. 7. '96). Prognosis. — Progressive, slow, and in- terrupted advance of the disease, lasting from twenty to thirty years, and ending in death either by cachexia, by some complication, or, very rarely, by sudden syncope represent, in brief, the course of the vast majority of cases. Treatment. — At present it can be only symptomatic. The extracts of th3'roid gland and pituitary body will probably prove useless as curative agents. Pain and insomnia are relieved by antipyrine, sulphonal, etc. Arsenic has proved use- ful in some cases. Iron in large doses and hydrotherapy have done some good in one case in the hands of Brissaud, and ergot in those of Schwartz. Case of acromegaly treated with desic- cated thyroid gland with good results. Solomon Soils-Cohen (Med. and Surg. Reporter, May 26, '94). Case treated by extract of pituitary; no appreciable result. Analogy between mj'xoedema and acromegaly suggesting the thj'roid gland; rapid improvement. Caton .(Brit. Med. Jour., Feb., '95). Three cases of true acromegaly treated with tabloids of the pituitary body of sheep. In the first case the headache, which was, at times, exceedingly violent, diminished, and recurrence of the head- ache coincided always with momentary cessation of the treatment ; in the second case the headache, pains in the limbs, and parfesthesia of the hands diminished, and the tumefaction of the soft tissues was less. In the third case, a diabetic patient, no results were obtained. Mari- nesco (Soc. Med. des Hop., Nov. S, '95). De Cyon mentions a case of a child, 12 years of age, who suffered from acrome- galy. Under influence of treatment by hypophysin continued during six or seven weeks the condition of the patient was much ameliorated; weight fell from 121 V: to 101 V'.i pounds, and circumfer- ence of abdomen from 44 72 to 31 inches. Headaches had diminished in intensity and in duration, pulse had become regu- lar, and intelligence began to awaken. Lancereaux (La Sem. Med., Nov. 23, '98). Case of acromegaly in a woman aged 42 years corresponding in all respects to ACROMEGALY. ACTINOMYCOSIS. 121 the visual type of the disease. The em- ployment of thyroid tabloids produced a persistent and decided improvement. Gibson (Edinburgh Med. Jour., Dec, '99 ) . Our knowledge of the fact that the pituitary body is usually enlarged in oases of acromegaly is sufficient evi- dence that the gland is diseased and that administration of the dried pit- uitary body is indicated as much as thyroid extract in cases of myxcedema. The pituitary body may be found en- larged in other diseases than acro- megaly, and this may be compared with goitre where it exists without Graves's disease. The observations were upon three eases. In the first there was lit- tle or no general improvement, but when the drug was stopped the patient always requested that it be continued. In the second there was marked improvement Avhicli lasted over a year and a half; during this time the patient only suf- fered from headache once, and that was when the medicine was withdrawn for a day and a half. The third case was complicated by advanced renal disease and died suddenly from heart-failure, although he was considerably benefited by drug. The administration of pit- uitary body had little effect upon the first case, but the last two seemed to be considerably benefited in their sub- jective symptoms. Kuh (Jour. Amer. Med. Assoc, Feb. 1, 1902). Chaeles W. Burr, Philadelphia. ACTINOMYCOSIS.— Gr., axtlc,, a ray; uvxr,q^ fungus. Definition. — A parasitic, infectious, and inoculable disease due to the de- velopment of the actinomyces, or ray- fungus. First described in 1877 in cattle by Bollinger and in man by James Israel; it can no longer be considered a rare disease. From its frequent develop- ment in the lungs it has often been con- fused with tuberculosis. Symptoms. — The symptoms vary ac- cording to the locality of the disease. The affection is chronic and exception- ally rapid. The granulation tissue is abundant and the mass resembles a tumor. Previous to suppuration it is quite firm, and, if progressing rapidly, is surrounded by diffuse oedema. Pain and tenderness hardly ever exist. When suppuration occurs the mass increases rapidly in size. Total of 500 eases from literature showing that the various regions of the body are proportionately the site of the disease, as follows: Head and neck, 55 per cent.: thorax and lungs, 20 per cent.; abdomen, 20 per cent.; other parts, 5 per cent. In France the face and neck were affected in 85 per cent, of the 66 eases reported. Poncet and Berard (Le Bull. Med., Aug. 8, '97). Mammary actinomycosis may occur in two ways: primary and secondary. In the former infection occurs either from propagation of the actinomycotic grains in the milk-duets or from their penetration into the tissues through a continuity of the skin. Four eases of the primary form witnessed. The sec- ondary form spreads to the mammae from the lung (most frequently) or some other organ. The disease is not easy of diagnosis, and is liable to be confused with tubercle, cancer, inter- stitial inflammation, or syphilitic dis- ease: and repeated microscopical exam- ination of discharges or pieces of tissue should be made. The prognosis in the primary form is good, but in the second- ary form unfavorable. Mileff (Gaz. d. Hop., Jan. 1, 1901). 1. CuTANEOtrs Surface. — Usually, a lesion of the skin is secondary to the evolution of an underlying actinomy- cotic tumor, which, by its growth, bursts through the skin. A sanguineous or purulent liquid, containing the charac- teristic grains, issues from the ulcera- tions so formed. The grains are small, opaque, yellowish-white, or yellowish masses aboitt as large as a pin-head, which are composed of smaller grains. 122 ACTINOMYCOSIS. SYMPTOMS. measuring about one-tenth of a milli- metre. These smaller grains are formed by a central mass, of interwoven or straight fibres, whence extend toward the periphery spoke-like prolongations, with club-like terminations. Earely the affection may develop primarily on the fingers, hand, nose, or face. It forms a small, round, ligneous mass, which may soften in a few weeks, burst through the skin, and give a granulous and varied pus, containing actinomycotic granula- tions. The border of the granulation is uneven, violet-hued, and undermined. Around the original mass there arise secondary masses; so that the entire lesion forms a violet-red, indurated patch, deeply adherent, and somewhat resembling scrofuloderma. In cutaneous antinomycosis the lym- phatic ganglia are usually not enlarged. Pain is, in some cases, intense; in other cases it is awakened only by pressure. Pathognomonic spots, which are more or less deep in color according as the general color of the lesion is more or less pronounced. If the general color is pale, the spots are bluish-red or violet; if the tint of the mass is deeper, the spots present a blackish or slate color. These spots vary in size from that of a pea to that of a pin's head. They appear to correspond to the points at which the wall of the abscess is thinnest, and it is here alone that fistulse form. Derville (Jour, des Sci. Med. de Lille, Aug. 31, '95). Case of actinomycosis extensively in- volving the skin in a boy, aged 13, whose family lived over a stable-yard, and who suffered from an apparently simple at- tack of serous pleurisy, from which he re- covered with marked retraction of the af- fected side. Shortly afterward he was re- admitted to a surgical ward on account of abscesses over the front of the chest and right hip, which were regarded as tuber- lous, and scraped. He returned to the hospital seven months later with a very extensive tract of disease implicating the skin, chiefly on the back, the most im- portant feature being large sarcomatous- looking growths, ulcerating at various points, situated upon hard, brawny, and deeply-undermined skin. From the ul- cerative points pus excluded, mixed with characteristic yellow granules, readily recognized, microscopically, as actinomy- cosis. Treatment by iodide of potassium and thyroid tabloids appeared to be at- tended with benefit. (See colored plate.) J. J. Pringle (Trans, of the Royal Medico-Chir. Soc, '95). 2. Alimentary Canal. — Teeth. — -The fungus has been found in cariou . teeth (Israel), often side by side with leptothrix (Senn), or almost pure cultu with no manifestation of disease except chronic periodontitis (Partsch). Tongue. — In man three cases of this affection have been found on the tongue, one of which was of primary develop- ment; the other two are believed to have found origin in a carious tooth. Case of actinomycosis of the pharynx in a girl aged 15 years. The tonsils showed white projections resembling masses of moss, which seemed to grow in the crypts. The pharyngeal wall also showed these white masses. The diag- nosis was established microscopically. G. Didsbury (Revue de Laryn., d'Otol., et de Rhin., Oct. 15, '95). Lingual actinomycosis in cattle ap- pears as a nodular tumor, with prolonga- tions into the parenchyma, of ligneous hardness. Jaius. — The lower jaw is the most frequently affected. At first the disease resembles periosteal sarcoma, until the loose tissues of the neck are reached, when it often rapidly extends downward along the subcutaneoiis connective tis- sues and intermuscular septa. (Senn.) Early symptom: Every patient who without any ascertainable reason is un- able to open the mouth is attacked by actinomycosis (Poncet). Patient who had great difficulty in opening the mouth, yet in whom the most minute ex- -5 -^ ^ 3 CO 3 ACTINOMYCOSIS. SVilPTOMS. 133 amination revealed no cause. Five or six months later an abscess formed; pus containing the characteristic yellow grains appeared. Besnier (Lyon M<5d.; Eevue Med., Aug. 30, '99). Eight cases tending to show that a pro- portion of the cases ranking as alveolar abscesses may be due to the specific or- ganism of actinomycosis. Few cases enter hospital with advanced actinomy- cosis of the jaw, and many recover after simple incision and after rupture. Cer- tain cases of generalized disease in the lungs, intestinal tract, liver, etc., occur in which the organism gained entrance through the food, or was swallowed, and therefore the surgeon should aim at making external drainage. C. A. Porter (Boston Med. and Surg. Jour., Sept. 13, 1900). The upper jaw is rarely primarily affected. It then tends to attack rapidly the adjacent parts, and even the base of the skull and brain. Actinomycosis may attack any part of the body, but it is most frequently located in the cervico-facial region, espe- cially the angle of the inferior maxilla. In this location it may present itself in two forms: acu-te, the symptoms being those of a septic phlegmon; subacute, in which there is early and continuous trismus, softening, and cedema. Poncet (Archives Prov. de Chir., Mar. 1, "96). Case of intermittent otorrhoea suddenly attacked with fever and intense pain behind the right eye, then right-sided tri- facial neuralgia, and shortly a palsy of the abducens. The antrum A\as trephined and the carious ossicles removed. The jaws showed no disease. There Avas some temporary improvement, followed by re- euning trouble in the left ear, with a drawing over of the head like a torticol- lis. In an indurated swelling on the neck actinomycoses were found in pure cult- ure. Potassium iodide was given. The swelling rapidly disappeared, leaving fistulas behind. Then followed cachexia, diarrhoea, somnolence, and death. The autopsy disclosed an actinomycotic in- volvement of the base of the brain, and in the neck an actinomycotic meningitis. Quervain (Deut. Zeit. f. Chir., Apr., '99). Autopsy indicating that actinomycosis of the middle ear may arise from blood- infection from a primary focus elsewhere in the body, or from a neighboring ac- tinomycotic process in the mouth, phar- ynx, tonsil, or from carious teeth ; that the fungus may enter the middle ear through the Eustachian tube or through the external auditory canal. J. C. Beek (Prager med. Woch., Mar. 29, 1900). In thi'ce cases the predominant sign was a sharply-defined local movable mass, which is always strongly indicative of the disease. Hofmeister (Beit. z. klin. Chir., B. 26, H. 2, 1900). In the case of a butcher the first signs were in the floor of the mouth in the form of a pseudoranula : afterward swell- ing of the cheek showed characteristic yellowish discharge and granules. Le- noir and Claisse (Jour, des Praticiens, July 14, 1900). 3. Intestinal Canal. — The disease begins with a sharp lancinating pain in the abdomen and follows the course of chronic peritonitis. Swellings forming abscesses are found on the anterior ab- dominal wall which sometimes communi- cate with the intestine. It may also start from the vermiform appendix. There hare also been cases of primarj' actin- omycosis of the colon with metastatic deposits in the liver. Case in a man, 21 years of age, who passed through a febrile disease of sev- eral weeks. Shortly afterward a swelling formed below the crest of the ilium, which disappeared spontaneously, but eventually returned. The whole iliac fossa showed a hard, dense infiltration. Free incision proved the disease at once to be actinomycosis. At the bottom of the very large wound lay the perforated appendix. Later on the ascending colon became involved. Ascending colon re- sected and the appendix extirpated. F. Lange (Annals of Surg., Sept., '96). Case of abscess of abdominal walls in which the cavity contained actinomyco- sis and two fish-bones. The Avhole mass was excised, taking out the umbilicus and portions of the rectus muscle down 124 ACTINOMYCOSIS. SYMPTOMS. to the peritoneum, where an intestinal adhesion was met with. Though hernia necessarily resulted, no serious results ensued, and the patient is now quite well. The actinomycosis Avas probably a secondary infection, not present in the fish-bones when eaten, the parasite being swallowed later, and having entered the abscess from the intestine. Case of actinomycosis of the neck re- moved under the impression that it was a tuberculous abscess. Mixter (Boston Med. and Surg. Jour., July 6, '99). Analysis of 13 cases of ano-rectal ac- tinomycosis obtained from literature. The average age was 31 years. Eight were men, and 9 of the patients lived in the country. The ascending form of in- fection is rarely secondary, being most frequently the result of direct contact with materials infected with the ray- fungus, such as straw, hay, etc. In one of the cases the inoculation was made in a perineal scar in a woman who slept upon straw. In two others inoculation arose from a spike of wheat that the pa- tient had passed through the urethra. Descending actinomycosis is the most common ano-rectal form. It is due to the infection of the wall of the rectum by faecal matters that contain the micro- organism from a previously diseased point in the colon. Delacroix (Gaz. Heb. de Med. et de Chir., July, '99). 4. Genito-Ueinart Tract. — The uterus may also become invaded by the disease, the first manifestation being the discharge of a turbid foetid fluid contain- ing the characteristic shreds and masses. Case of actinomycosis of the uterus in a woman 64 years of age. For four years she had noticed a discharge from the vulva, usually consisting of blood, but sometimes yellowish and foetid. The uterus was prolapsed. General health good. The uterus found slightly en- larged, with gaping os. A drop of the foetid yellow liquid was found at the os. Under the microscope these shreds showed the characteristic appearances of actinomycosis. Vaginal hysterectomy. Recovery. Davide Giordano (La Clinica Chir., June, '95) . 5. Bronchial Tubes and Lungs. — In bronchitie actinomycosis the affection is less severe in winter than in summer, which is the contrary of what is observed in ordinary bronchitis. It can be classi- fied in three groups: (1) lesions of chronic bronchitis, (2) miliary actinomycosis, and (3) cases with broncho-pneumonia and abscesses. The lower lobe is attacked more frequently than the upper; the op- posite is the ease in tuberculosis. Keview of 14 recorded eases of actino- mycosis of the lung. The only 2 which recovered were those in which radical operations, with resection of four or five ribs, and cauterization of the diseased cavity in the lung were carried out. All those that were simply incised and drained ended fatally. The infection of the lung may be secondary to either cervico-facial or pharyngeo-oesophageal actinomycosis, or it may be primary, either through the bronchi or from an external wound. There are three forms clinically: (1) the pulmonarj', with in- sidious onset, going on to induration of a large area of lung, generally in the sub- clavicular or postero-lateral regions, the apices being usually free; (2) the bron- chial, with a diffuse bronchial catarrh, and foetid rauco-purulent expectoration, containing the fungus; (3) the pleural, with effusion; the co-existence of pleural effusion with retraction of some part of the thoracic parietes — due to fibrous changes in the lung — is pathognomonic. Another pathognomonic symptom is the presence of a swelling in the wall of the thorax where it has been invaded by the fungus, along with shrinking of the lung causing retraction of the thoracic walls; later on this softens and becomes sub- fluctuating without the formation of large abscesses. Puncture obtains a fluid containing fragments of fungus. Death may occur after months or years, ac- cording to the varying invasion of other organs by the disease; in one case of rapid diffusion of the fungus death oc- curred in twenty-four days. Parasean- dolo (Brit. Med. Jour., from Clinica Mod., Nov. 7, 1900). ACTINOMYCOSIS. DIAGNOSIS. ETIOLOGY. 125 6. Beain. — Here, tumor-like symp- toms exist during life, with headache, paralysis of the abducens, congestion of the optic papilla, and attacks of uncon- sciousness. Necropsy indicating the probable mode of infection of the orbit and brain. Sinus found leading from the orbit to the gum of the upper jaw; the ray-fungus had probably lodged in or near a tooth, as it has so often been found to do. The fungus Avas probably carried into the system on an ear of com chewed at har- vest-time. Having reached the orbit, it crept along its outer wall and in the wall of the right cavernous sinus to the base of the brain, ultimately setting up meningitis and small abscesses, and bur- rowing through the pituitary body and sella Turcica to the cavernous sinus of the left side. In all probability the dis- ease had reached the cranial cavity be- fore admission into the hospital. W. B. Ramson (Brit. Med. Jour., June 27, '96). Cerebral complications and death in a case of cervicofacial actinomycosis in a man aged 61. At first localized in the region of the left inferior maxilla, where it was mistaken for periostitis from den- tal caries, it invaded later the upper part of the neck and the temporal region. Here it caused a subperiosteal abscess, which, spreading to the spheno-maxillary fossa and the back of the orbit, finally infected the meninges through the sphenoidal fissure. A seeondai-y infec- tion by a slender bacillus produced an abscess in the left temporal lobe contain- ing foetid pus. This abscess burst into the lateral ventricle, which was consider- ably dilated, and produced coma and death about seven months and a half after the appearance of the first symp- toms. Bourquin and de Quervain (Rev. Med. de la Suisse Rom., Mar. 20, '97). Diagnosis. — When the process is very rapid, actinomycosis may stimulate acute phlegmonous inflammation and osteo- myelitis; or, when wide-spread, syphilis. Sarcoma. — This form of neoplasm does not suppurate or break down so early. In the jaws it is to be differentiated from dental affections: epulis. Tuberculosis. — In this disease the lymphatic glands are infected, and the apices are usually the first involved. CARCiNOiiA. — The skin or mucous membrane involved is in close connection with the tumor; in actinomycosis the skin will be found broken on microscop- ical examination. Syphilis. — A gumma will, in two or three weeks, be sensibly affected by large doses of potassium iodide, which does not act so rapidly in actinomycosis. The undoubted influence exercised by iodide of potassium countenances the suspicion that many patients supposed to be syphilitic have really been actino- mycotic. Poncet (Glasgow Med. Jour- nal, Apr., '95). Lupus. — The diagnosis depends, in this condition, upon microscopical ex- amination. Etiology. — Both men and animals are probably infected from vegetables or water (Israel), from eating ears of bar- ley, or rye, when the fungus penetrates through the wound or abrasion thus pro- voked, or in many cases through carious teeth. Intestinal actinomycosis is due to taking contaminated food or water, when the fungus becomes implanted upon an already diseased tissue, multiplies, and causes active proliferation of the submu- cous tissue. Case where the affection was trans- mitted by kissing, between bridegroom and bride. Baracz (Wiener med. Presse, Jan. 6, '89). [Farmers should be warned against the habit, so common among them, of chewing bits of straw, wheat, oat-chafi, etc., the most prolific cause of the dis- ease. E. Laplace.] Actinomycosis is frequently met with in shoe-makers. This is due to their habit of placing their needles in their mouths. Ullmann (Le Bull. Med., Nov. 17, "97). Actinomycosis of the lower jaw ac- 126 ACTINOMYCOSIS. PATHOLOGY. quired by a tootli-brush maker in the following manner: Hogs' bristles -nere washed, then held in mouth before stick- ing into the handle-holes in bundles. Guinard (Bull, et Mem. de la Soc. de Chir. de Paris, T. 26, No. 6, 1900). Total of 72 cases of actinomycosis from American sources collected. Six personal cases, 2 of which had not been previously reported. In one alveolar ab- scess followed chewing wheat-grains with a carious tooth. In a second case a quantity of pus collected in the right iliac fossa. The patient died of malnu- trition, having recurred after evacua- tion. J. Rfihrah (Annals of Surg., Feb., 1900). Pathology. — The actinomycoses were formerly thought to be mold-fungi (hyphomycetes), but Bostroem, in 1885, proved by cultivating them that they were a -variety of cladothrix, belonging to theschizomycetes. The mass is made up of granulation tissue, which, except for the presence of the ray-fungus, would be mistaken for a round-celled sarcoma. Epithelioid ele- ments and giant cells are also seen. In the granular mass, or in the pus coming from a case of actinomycosis, the fiingus itself appears under the form of small, yellow, brown, or even green masses, about a pin-head in siz€, which, on microscopical examination, are found to be composed of a central interwoven mass of threads, from which radiate club-shape-ended rays; in some speci- mens certain rays project far beyond the others. In man the clubbed bodies are frequently absent (Senn). The histo- logical lesions are alike in the actino- mycotic nodule and in the tuberculous follicle; only the foreign body differs. "Water or a weak solution of sodium chloride causes the rays to swell enor- mously and lose their shape; ether and chloroform have no action upon them. The yellow grains are not always to be found in fistulse, etc., unless they are carefully sought in scrapings, etc. An early diagnosis is essential, since later the disease may be beyond the resources of therapy. A. Poncet and L. Berard (Le Bull. Med., Mar. 28, 1900). Case in which microscopically there was no appearance of the ray-fungus in the fresh pus, and yet microscopical examination showed the presence of fun- gus at once. The absence of the typical grouping of the micro-organisms is not sufficient to exclude the diagnosis of actinomycosis, as the micro-organisms tend to arrange themselves in different waj's at different times. W. Silber- schmidt (Deutsche med. Woch., Nov. 21, 1901). At a certain stage there are in every colony three elements, — viz.: — 1. Club-shaped formations. 2. A centrally-placed net-work of fun- goits filaments of varying shape and size. 3. Fine coccus-like bodies (spores), which originate from the fungous fila- ments, and grow into long rods and branching twigs. Typical actinomycosis is the disease in which occur the characteristic mycelial masses, having club-shaped radiations. Atypical actinomycosis includes such diseases as Nocard's farcin de hmuf, and infections which clinically and anatomic- ally resemble actinomycosis, and are caused by branching mycelial organisms which correspond quite closely to the cultural peculiarities of the streptothrix actinomj'ces, but fail to form the char- acteristic grains in the tissues and pus. Berestneff (Zeit. f. Hyg. u. Infekt., vol, xxix, p. 94, '98). Staining. — The following stains have been used: — Wedl's orseille (Weigert). Eosin (Marchand). Cochineal — red (Dunker and Mag- nussen). Hffimatoxylin alum (Moosbrugger). Gram's method — section staining (Partsch). Safranin in aniline oil, followed by K. I. (Babes). ACTINOMYCOSIS. PATHOLOGY. 127 Solution of orcein in acetic acid (Israel). Picrocarmin — fungus, yellow; other parts, red (Baranski). The actinomyces in a section are best shown by Gram's method, first with methyl-violet, then with Bismarck brown (Tillmann). Cultivation. — It is difficult to culti- vate in coagulated blood-serum (0. Israel), coagulated blood-serum and agar-agar (Bostrom), and coagulated egg-albumin and agar-agar ("Wolff and J. Israel). From 5 typical cases of human ac- tinomycosis numerous inoculations were made upon various media, which were kept partly under aerobic, partly under anaerobic, conditions; growth of strepto- thrix actinomyces took place in only 20 of 64 primary cultures. After the first generation the organism did better when grown without oxygen; the actinomj'ces grew well when inoculated in eggs in the usual manner. The colonies consisted of longer and shorter threads, which stained by Gram's method, and always presented true branching, although sometimes the branches were hard to find; the cultures were rather short- lived; in one case the growths lived through 11 generations during 7 months; in two cases through 4 generations in 3 ^/s months, but in five cases death oc- curred after the first generation. In inoculation experiments on rabbits, guinea-pigs, and mice a fatal actinomy- cosis was not produced, although many features recalled the pictures of the disease. Francis Harbitz (Norsk Mag. f. Laegevidensk., vol. lix, p. 1, '98). Inoculation. — It has been successfully carried out by James Israel and Ponfick, from tissue and from pure cultures. In one inoculation experiment a char- acteristic deep-yellow tumor was found in the liver, proving a general infection. In all other inoculation experiments the author had found the tumor remaining limited to the peritoneal cavity and con- sequently improbable of causing general infection. Ma.x Wolfl' (Deutsche med. Woch., Mar. 1, 8, '94). Opinions differ as to its power of pro- ducing pus, a secondary infection by the pus-germs being thought the true cause of the pus sometimes found with actin- omycosis. Dissemination by ■ the lym- phatic system never occurs. Glandular enlargement indicates secondary infec- tion. In pure infection with the actinomyces fungus the pus secreted is not always tliin. This fungus alone, without the admixture of the ordinary pus-produeing (I, Ray-fungus or masses, showing central mycelium of actinomycosis. 6, White blood-corpuscles, showing their rela- tive size. (Poncet and Berard.) micro-organisms, can produce suppura- tion. The entrance of the common pus- producing micro-organisms into actino- mycotic foci does not kill the fungus ; but, on the contrary, may bring about such conditions as favor its develop- ment. Kozerski (Archiv f. Derm. u. .'^iyphilis, B. 38, H. 2, '96). 1. Cutaneous Sueface. — Around the primary lesion are small secondary lesions. Two forms are described: (a) The anthracoid, which pursues a rapid course, with fever, and sometimes septi- casmic in character. It is characterized 128 ACTINOMYCOSIS. PATHOLOGY. by flat tumefaction, with multitudes of small openings with yellow granulations, from which thick pus exudes. (&) The ulcero-fungous, which pursues a sub- acute course, with tendency to ehronic- ity. In the face it tends to form bur- rowing abscesses instead of recognizable tumors. 2. Bronchial Tttbes and Lungs. — Some observers believe that the peri- bronchial lymphatic vessels and glands disseminate the fungus or its spores in bronchitis and pain in the left side, but from this recovery had apparently taken place. Six ounces of curdy pus evacu- ated, revealing actinomycosis. The tem- perature remained high. Three swell- ings successively opened. As sinuses persisted, the patient was put in a hath of weak iodine and under iodide of potassium marked improvement, when death occurred under chloroform admin- istered for the extraction of a tooth. Left lung found quite collapsed, hut otherwise normal, and incased in a brawny material containing abscesses. «-0 o Eay- fungus (c, c, c), club-shaped bodies (d, d, d); and spores (a, a, a) found in the pus of actinomycosis. (Poneet and Birard.) the lungs; when the fungus reaches the lung-tissue proper, granulation tissue is formed, which, through secondary in- fection, suppurates. Amyloid degenera- iion of other organs may occur, or metastasis of the disease, in case a pul- monary vein has been pierced. At times the pericardium or peritoneum becomes affected. (Striimpell.) Case of actinomycosis of pleura and chest-wall in a child, aged 6, admitted into St. Bartholomew's, suffering from empyema of the left side. History of Prolonged search needed to discover actinomycosis. F. S. Eve (Brit. Med. Jour., Apr. 10, '97). 3. Alimentary Canal. — In the jaws the mass usually resembles a sarcoma, but, if incised before secondary infec- tion and suppuration has occurred, the reddish surface will be seen to be inter- mingled with yellowish spots, which are collections of actinomyces. In the intestines the fungus causes proliferation of the submucous tissue. ACTINOMYCOSIS. PROGNOSIS. TREATMENT. 129 and whitish patches in the intestines. External fistulfe are commonly found. Actinomycotic growths in the liver in man have a characteristic naked-eye appearance, from their peculiar honey- combed structure. The cases between the fibrous trabeculse are full of caseous matter in which the more or less sphe- roidal masses of the fungus are im- bedded. In museum specimens, which have been for some time preserved in spirit, the contents of the loculi may have fallen out^ and the honey-combed appearance is then much more marked than in recent specimens. Crookshank (Lancet, Jan. 2, '97). Condition of metabolism in patient sub- ject of toxic influence of actinomycosis. Of abnormal elements in the urine, al- bumin and peptone (?) were found in traces, while urobilin was present in ex- tremely slight amount. Acetone and sugar absent; nitrogen-excretion largely exceeded ingestion ; reaction of urine was not distinctly changed; urea was slightly decreased. AUoxur bodies varied propor- tionally to variation in excretion of nitro- gen. Uric acid bore no definite relation to amount of xanthin bases. Ammonia was not increased, while total sulphates bore direct relation to amount of nitro- gen, but ethereal sulphates are not in- creased. Excretion of phosphates not changed, except slight decrease in amount of earthy phosphates and chlo- rides. R. Schmidt (Centralb. f. innere Med., Feb, 26, '98). Prognosis. — The prognosis is serious in proportion to the rapidity with which suppuration occurs. Actinomycosis of the upper jaw is more serious than actin- omycosis of the lower jaw, as it has a greater tendency to invade the deep structures. Internal actinomycosis is almost always fatal, owing to its inacces- sibility. External actinomycosis may cause death from pyaemia, septicaemia, and exhaustion. When so placed as to be easily removed and treated early the prognosis is favorable. A permanent recovery usually follows a complete re- moval of the primary focus, as metas- tasis is rare. (Senn.) Actinomycosis has a pronounced tend- ency to spontaneous recovery except in internal organs. (Schlange.) From an analysis of sixty cases the fol- lowing conclusions are reached: When the disease involves the head and neck, except in a few cases when the base of the skull is invaded, the course is favor- able, recovery taking place in from three to nine months. It is exceptional for the fistula to persist or to form anew, after the lapse of a year. Pulmonary actinomycosis may terminate in recovery. The prognosis of actinomycosis is the more favorable as the anterior abdominal walls are involved and the posterior escape. Death usually results from amy- loid degeneration and wasting. If actin- omycosis present pyEemie manifestations, a fatal termination is to be expected, as a number of vital organs are likely to be involved. Actinomycosis may pursue a chronic course, continuing thirteen years or longer, if functionally important or- gans be not involved, as when the process confines itself to the connective tissue about the spinal column. Treatment. 1. General. — Potassium iodide was found useful in animals by Thomassen and Nocard. In man it should be thor- oughly tried before surgical intervention is resorted to, especially when the dis- ease is so extensive as to prevent com- plete removal by surgery. The results obtained from iodide of potassium have been remarkable in some eases and nega- tive in others. This divergence of views, according to Fernet, depends on the variation in the virulence of the disease, in its evolution in different individuals, in the difference existing in the receptiv- ity of the tissues, and on the influence of secondary infective processes. In recent 130 ACTIKOMYCOSIS. TKEATMENT. and purely actinomycotic lesions the re- sults may be excellent; in old-standing cases, and wliere the ray-fungus is asso- ciated with streptococci, staphylococci, and the bacterium coli commune, the drug treatment is less successful. Two easeSj one of severe jaw actino- mycosis and one of actinomycotic peri- typhlitis, cured by the use of iodide of potassium. Experiments showing that the remedy does not destroy the actino- mycosis, but hinders its development and reproduction. Josef Jurinka (Mitthei- lungen aus den Grenzgebieten d. Med. u. Chir., vol. i, H. 2, '96) . In two-thirds of the cases of chronic actinomycosis of the face and neck the results of iodide treatment are nil. In three-fourths of the recent cases recovery has been obtained by it, combined with surgical treatment, and in one-fourth by iodide treatment alone. Potassium iodide cannot be regarded as specific in actino- mycosis in man. If, at the end of some weeks, improvement is slight only, oper- ative interference should be carried out at once. Berard (France Med., '97). Iodide of potassium does not act on the parasite itself, as cultivations of the fungus in the usual media are not influ- enced by it in any way. The drug, to be efficacious, must be given in doses of from 15 to 90 grains a day for some weeks. Some observers record immedi- ate and lasting effects from its use; others regard the surgical treatment of primary importance. George Pemet (Brit. Jour, of Derm., Oct., '97). Drugs most successful in pulmonary actinomycosis are potassium iodide and eucalyptus. If there is any involvement of chest-wall, surgical treatment should be undertaken. Sabrazes and Cabannes (Revue de Med., Jan. 10, '99). Four caseSj in one of which the tumor was situated below the angle of the scapula. All the patients were given iodide of potassium, and the wounds were treated with peroxide, tincture of iodine in full strength or solution, and packed in iodoform gauze until all evidence of presence of the fungus had disappeared. J. C. Munro (Boston Med. and Surg. Jour., Sept. 13, 1900). The injection of a 5-per-cent. solution of permanganate of potassium into the cysts has been of advantage. Case in which a swelling over the twelfth rib near the spine caused severe pain. The hypodermic injection into the mass of 15 minims of a 5-per-cent. solu- tion of permanganate of potash followed by marked relief. Iodide of potassium, 45 increased to 90 grains daily, had no control over the progress of the disease. H. B. Mclntire (Boston Med. and Surg. Jour., Jan. 28, '97). 2. SuHGiCAL. — Local measures which do not completely remove the infected tissues do harm, as they frequently give rise to secondary infection, rapid exten- sion, and death. Cauterization with solid silver nitrate in actinomycosis of skin and soft parts in which suppuration and fistulous tracts have occurred possesses a specific action on the actinomycosis (Kottnitz). Case in which local applications and injections of nitrate of silver and nitrate of zinc, both into the sinuses and directly into the tissues, caused some argyriasis, but recovery. A. Mayer (Annals of Surg., Sept., '96). Case of pulmonary actinomycosis which at first had been mistaken for gangrene. For fcetid breath and expectorations, oil of eucalyptus was prescribed, in doses of 5 grains at first; later 10 grains in gela- tin capsules, every four hours day and night. Three inhalations daily were ordered of the remedy. Under this treat- ment a cure was rapidly attained. G. Butler (Nouv. Eem., xlv, p. 288, '98). 3. Electeotechnical. — Two plati- num needles, attached to the two poles of a constant-current battery, are to be inserted into the tumor. Through the two needles a current of 50 milliamperes is to be passed, while every minute some drops of a 10-per-cent. iodide-of-potas- sium solution are to be injected into the mass. The solution is decomposed into> ACTINOMYCOSIS. ACTOL. 131 nascent iodine and potassium. This is repeated every eight days, each session lasting twenty minutes, under an anaes- thetic. (Gautier.) Before suppuration all diseased tissues, glands, etc., should be removed and the parts, when possible, cauterized with the thermocautery. After suppuration the parts should be treated as if they were tuberculous, curetting and packing with iodoform gauze (Senn). Case of aetinom3'cosis of the lower portion of the abdomen, communicating with the bladder, in which, when all had failed, a cure was effected after the use of fifteen tuberculin injections, com- mencing with Vo minim and ending with 4 minims. After the usual disturbance, local and general, the growth disap- peared entirely. Billroth (Wiener med. Woch., Mar. 7, '91). The disease was first noted in America in 1888. Up to the present time 100 cases have been observed in America. Of the 5 cases observed in the hospital, the disease was primary in the cervico- facial region in 1, in the thoracic region in 1, and in the remaining 3 cases in the abdominal region. One of the ab- dominal eases died and 1 recovered. The sixth case, the disease being ab- dominal, terminated fatally. It is a curious fact that less than 20 of the 100 cases came from the Southern States, and only 2 of them were in negroes. Seventy-two of the whole number were men and only 23 women. The youngest case was a child of 6, the oldest a man of 70. In 36 of the eases the patients were more or less connected with farming and with the handling of grain. In most cases there was no definite history of infection, but in several the habit of biting straw and carrying it in the mouth had been in- dulged in. In 18 of the eervieo-facial eases it was found that a carious tooth was the point of entrance of the para- site. The author emphasizes the point that no diagnosis should be made unless the ray-fungus is found. It appears that in .53 of the cases the malady affected the eervieo-facial region, in 20 the thoracic region, and in 23 the ab- domen. Only in 4 cases was the disease primary in the skin, but there is a tendency for the malady to spread, and for metastases to occur. Recovery oc- curred in 45 cases, and improvement in 14. In 32 death resulted, and in 9 no improvement was noticed. Surgical treatment is indicated, but repeated operations may be necessary. Simple incision and drainage do not cure the disease, which is almost certain to recur if the treatment be limited to such pro- ceedings. Iodide of potassium seems to be of very doubtful efficacy. It has no action upon the ray-fungus, and, as it is said to act effectively only when used in conjunction with surgical operation, it follows that its influence is more than doubtful in most cases. W. G. Erving (Treatment; from Bull. Johns Hopkins Hosp., Nov., 1902). Eenest Laplace, Philadelphia. ACTOL. — Actol, or lactate of silver, is a bactericidal agent recommended by Crede and Baj'er as a powerful disin- fectant for wounds. It forms a soluble compound with the secretions, and this, being absorbed, influences beneficially not only the lesion treated, but also the neighboring tissues. It is non-poison- ous: a point of great superiority over other equally active antiseptics. Dose. — Subcutaneously, the drug is injected in '^/^-gia.m doses, dissolved in 1 drachm of water. This may be repeated frequently. Locally, actol is used in the proportion of 1 to 4000; stronger solu- tions tend to color the skin of the hands. Physiological Action. — Guinea-pigs were injected with 0.03 to 0.04 per cent, of their body-weight of lactate of silver, and received subsequently, after an in- terval varying from ten minutes to three hours, half a drop of a violent cholera culture. In every case the animals suc- cumbed as rapidly as those used in eon- 132 ACTOL. ADDISON'S DISEASE. trolling the results. Similar experiments with other animals and virulent diseases have given the same results, showing that actol possesses no value as a general disinfectant. A series of experiments performed by Marx, however, have shown actol to be a powerful local disinfectant. Two series of researches with anthrax bacilli showed that, in the first place, it protected the seat of injection completely against the swarms of micro-organisms in the blood and that it had an actual local bacteri- cidal action in respect to these bacilli. In spite of its failure to produce an antitoxic serum, actol is one of the most powerful and at the same time most harmless bactericidal agents at present 1 before the profession. Marx (Centralb. f. Bakteriol., Nos. 15 and 16, '97). Therapeutics. — Actol may be injected under the skin in surgical affections. Crede has thus administered 15 grains in solution without witnessing the least un- toward effect. Two grains to the ounce of water must not be surpassed in strength, however, lest the solution cause coagulation of the albumin of the sub- cutaneous tissue and arrest the dissemi- nation of the remedy. In anthrax, fu- runcle, and erysipelas it is said to be effective when used in the above manner. It may also be used in 1 to 4000 solu- tions as a mouth-wash, gargle, etc., in inflammatory and infectious disorders, owing to the favorable influence of silver salts upon mucous membranes in general. ACUTE RHINITIS. See Nasal Cavi- ties. ACUTE YELLOW ATROPHY. See LiVEK. ADDISON'S DISEASE. Definition. — A disease characterized by progressive asthenia, blood-impover- ishment, frequent disorder of the gastric and intestinal functions, cardiac weak- ness, and irregular pigmentation of the surface in the form of bronze-colored spots, and, when not interfered with, uniformly tending toward a fatal result. It was first investigated and described as a distinct form of disease under the name of "Bronzed Skin Disease" by Dr. Thomas Addison, of London, in 1855. Since that time it has very generally been called "Addison's disease," and as- sociated with disease of the suprarenal capsiiles. Symptoms. — Perhaps the earliest symptoms to attract attention in this disease are those of asthenia, or lack of energy and endurance, with a variable condition of the digestive organs, and slight anffimic appearance of the surface. As the disease progresses the asthenia is manifested by shortness of breath, hur- ried and irregular action of the heart, and great sense of weariness from very moderate exercise. Sometimes there are present vertigo, tinnitus aurium, and syncope. The appetite is variable, but generally impaired, with occasional at- tacks of pain in the epigastrium and left side of the chest, increased by attempts to exercise. Moderate constipation exists in most cases, but is interrupted by in- creasingly frequent attacks of diarrhoea, and sometimes vomiting. The foregoing symptoms are so much like those of pernicious anemia that Addison's disease might not be suspected until the characteristic pigmentation be- comes noticeable on some part of the surface. In most cases the pigmented, or dark-brown, spots appear first on the face and backs of the hands, varying much in size and in color. The latter is generally at first a light-brown or olive hue, but grows darker and the spots larger as the disease progresses. Spots Bronzmq of the Skin in Addison's Disease. (Byrom Bramwell I ^S OF CLINICAL MEOP Appearance of the tongue and nipple m Addison's Disease. (ByromBramweil LAS OF CLINICAL MEDICINE, ADDISON'S DISEASE. SYMPTOMS. 133 also appear around the nipple, in the axilla, on the genital organs, and where- ever the surface is exposed to much fric- tion from the clothing, and in some cases they spread until they occupy nearly the whole cutaneous surface, imparting to the patient much the same color as the mulatto or half-bred negro. {See colored Plate I.) The palms of the hands and soles of the feet generally remain white. Brown or pigmented spots in many eases appear on the tongue and other parts of the mouth and in the vagina. Spots have been described on the serous membranes in a very few cases. (See colored Plate 11.) In a majority of cases the patients have complained of asthenia for a con- siderable time prior to the appearance of noticeable pigmentation on the sur- face. In a few instances the bronzed spots have been the first symptoms to attract attention. Cases in which bronz- ing does not accompany the other sj'mp- toms are not infrequent. Case of subacute suprarenal cachexia without pigmentation. The patient had shown only two symptoms: (1) an un- interrupted rise of temperature during a month and a half, and (2) a progressive cachexia marked by loss of flesh and in- ability to undergo any muscular strain. Death followed about two months after the beginning of the affection. On post- mortem examination only the adrenals were found diseased; they showed a caseous suppurative degeneration of tubercular origin. The mucous mem- branes did not show the smallest sign of pigmentation. E. Marie (La Presse Medicale, July 24, '95). Cases in which there existed patholog- ical changes in the adrenals without the existence of pigmentary deposits in the skin or mucous membranes: Lejars (Bull, de la Soc. Anat., Mar.) ; Perry (Brit. Med. Jour., June 7) ; Pilliet (Bull. de la Soc. Anat., Xo. 2G) ; Bradshaw (Liverpool Medico-Chirurgical Journal, July); Davidson (Liverpool Medico-Chi. Jour., Jan.) ; Blackburn (Jour. Amer. Med. Assoc, Mar. 31, '88). Cases of marked involvement of adrenals failing in the symptoms or bronzing: Virchow (Berliner klin. Woch., Apr. 29) ; La- marque (Jour, de M6d. de Bourdeaux, May 5) ; West (Brit. Med. Jour., Nov. 9); Perry (Brit. Med. Jour., Oct. 21); Griffiths (Brit. Med. Jour., Feb. 2, '89). Girode (Bull, de la Soc. Anat., Apr.); Barth (London Medical Recorder, May 20); CouDsell (Lancet, May 3) ; Vaughan (Brit. Med. Jour., Kov. 15) ; Cagliati (Eiforma Medica, No. 6) ; Jacquemard (La Loire Medicale, Aug. 15); Ritchie (Edinburgh Med. Jour., July, '90), and others. Case of Addison's disease without pig- mentation. At the necropsy each suprar- enal body was found to be enlarged and adherent to the surrounding parts, and thickly studded with tubercles of the size of peas, some of which had softened in their centres and contained pus. There was no apparent implication of the solar plexus. J. B. Bradbury (Lancet, Oct. 3, '96). Addison's disease with phthisis pul- monalis and a typical pigmentation of the skin, consisting of melanoderma with symmetrical patches of leucoderma. C. 0. Hawthorne (Glasgow Med. Jour., Oct., '96). In addition to marked disturbance of the functions of the respiratory, cardiac, and splanchnic nerve, as indicated by shortness of breath, irregular action of the heart, and frequent gastric disturb- ances, a few cases have been recorded in which delirium, coma, or epileptoid con- vulsions occurred near the fatal termina- tion. Von Jaksch has attributed these sj'mptoms to acetonuria. Case of Addison's disease in a man, aged 57, who suiTered for months from violent attacks of delirium, convulsions, and eventually coma and death. The urine was always free from albumin. Later attacks were followed by coma, and, though treated with bleeding and injection of (artificial) serum, he died. The necropsy showed oedema of the cere- 134 ADDISON'S DISEASE. DIAGNOSIS. bral meninges, pericellular and perivas- cular increase of leucocytes in the brain- cortex, globules of myelin in the white substance, and disseminated sparse nerve- degeneration in the posterior and lateral spinal-cord columns. A toxic agent re- sulting from the Addison's disease looked upon as the cause of the encephalopathy. Klippel (Soc. de Neurol, de Paris, Dec. 7, '99). Case in a man of 46 in which peri- tonitis-like symptoms attended the final stage of addison's disease. The abdo- men was flat and palpation was painful in the epigastrium, but it was tympanitic everywhere. He vomited frequently. The diagnosis had been in great doubt, but a malignant tumor along the gastro- intestinal tract was suspected. Post- mortem examination showed caseation of both suprarenal glands, with swelling of the lymph-glands and brown atrophy of the heart. No other changes of much importance wei'e found. Some small, brownish spots were found on the left temple, on the under lip, and a few on the upper lip. There was no tuberculosis anywhere, excepting in the suprarenal gland. A diagnosis of Addison's disease is justified with this peculiar peritonitis- like symptom-complex if the conditions cannot otherwise be explained, even though all other symptoms of Addison's disease are absent. Zaudy (Zeit. f. klin. Med., B. 38, H. 4, 5, 6, 1900). The temperature during the whole progress of the disease seldom rises above the natural, and in the advanced stage is often decidedly below. Eoux men- tions a case in which the temperature was only 32.5° C. (90.5° F.) four hours before death. Again, in the advanced stage of many cases the hands and feet are uncomfortably cold, and the asthenia so profound that the patient cannot maintain the erect position without ver- tigo, cardiac palpitation,' or syncope. The disease usually runs its course and terminates in death in from one to three years. A few cases are on record that terminated in six months, and, per- haps, a larger number that were pro- tracted to eight and ten years. Those of longer ditration have generally been characterized by repeated periods dur- ing which they remained stationary for several months at a time. [One such well-marked case came under my own observation. The patient, aged about 35 years, had been exposed to much hard service and confined air on board of one of the naval monitors in active service during the war, between 1861 and 1864. Some symptoms of the disease were manifested as early as in 1865, but they made slov/ progress, and appeared to have several periods of re- maining stationary, and did not termi- nate fatally until 1875: a period of ten years. During the last year he had been unable to walk more than a few steps without feelings of extreme exhaustion, and the final collapse resulted from pro- tracted diarrhoea and vomiting. Large bronzed spots were on his forehead, temples, backs of his hands, and still more over the front part of his chest and abdomen. Like most cases of this dis- ease, his emaciation was not extreme, though the haemoglobin was notably diminished. N. S. Davis.] Addison's disease may terminate in sudden death. Case in which the patient was supposed to be suffering from ma- larial cachexia and died in syncope. Autopsy revealed the true nature of the disease. Letulle (Bull, de la Soc. Anat., No. 6, '94). Death two months after the onset of symptoms in a case in which one of the capsules presented an old tuberculosis, while in the other there were only recent granulations. Death hastened by inter- current erysipelas. Mouisset (Lyon M§d., May 27, '94). Diagnosis. — The presence of increased pigmentation of portions of the skin or mucous membranes, with progressive asthenia, frequent gastric disturbances, and cardiac weakness constitute the chief diagnostic features of melasma suprar- enale, or Addison's disease. Increased pigmentation alone is not sufficient to justify a diagnosis of this affection. ADDISON'S DISEASE. DIAGNOSIS. 135 Possibility of diagnosing Addison's disease wlien the characteristic discolor- ation of the skin and mucous membranes is absent: high-tension pulse or a very striking difference in tension between the peripheral pulse and that in the abdominal aorta. Neusser (Med. News, Sept. IS, '97). Case of Addison's disease in a phthis- ical man in whom hot applications or mustard plasters caused pigmentation. These applications, kept up a week, caused marked pigmentation upon the abdominal wall, the right hip, the shoulders, and the calves. Slight pig- mentation appeared spontaneously upon the patient's forehead before these ex- periments were tried. The same ex- periments produced pigmentation upon a patient with Pott's disease, in whom the autopsy showed tuberculosis of the suprarenal capsules. Jacquet and Tre- molieres (Bull, et Mem. de la Soc. M6d. des Hopitaux de Paris, July 25, 1901). Bronzed spots have been found in con- nection with a variety of malignant and other growths, especially in the abdomen and pelvis, with some cases of diabetes, exophthalmic goitre, and also in cases of pitlmonary and peritoneal tuberculosis. Case in which there was no tendency on the part of the discrete pigmented area to run together and become diffuse. The patches of pigmentation remained isolated throughout up to the time of death. These oases might be mistaken for various affections in which pigmen- tation occurs: idiopathic multiple sar- comata of Kaposi, xeroderma pigmen- tosum, pigmented lesions following syph- ilis, and lentigines. Trebitsch (Zeit. f. klin. Med., B. 32, S. 163, '97). Pigmentation of mucous membranes generally considered diagnostic of Addi- son's disease seems to be found under other conditions. It appears to occur in some cases as mere accident without ob- vious cause; it may also be associated with chronic gastric diseases, such as car- cinoma. Two cases of abdominal disease in which pigmentation was found on mucosa of mouth. In first case diagnosis lay between cirrhosis of liver and chronic peritonitis ; in second there was cholan- gitis due to gall-stones, with tubercular disease of lung and testicles. In neither could Addison's disease be absolutely ex- cluded, but group of symptoms by which it is distinguished did not occur. Nor can occurrence of this group be relied on as sure indication of disease of supra- renal bodies. Case noted in which weak- ness, anorexia, anasmia, vomiting, and diarrhoea were all present, but autopsy showed only chronic gastric catarrh without affection of suprarenals. In this case there was no pigmentation. Schultze (Deutsche med. Woeh., No. 46, '98). Addison's disease is not the only dis- ease in which the condition of body presents discoloration of skin. A fair percentage of cases also runs its course without bronzing. Addison's disease must be diagnosed by exclusion of ab- dominal cancer, tubercle or lymphoma, tuberculosis of peritoneum, pernicious ansemia, and others, as sun-bronzing, vagabond's disease, melasma gravidarum, amyloid kidney, pulmonary tuberculosis, yellow fever and malarial fevers, heredi- tary bronzing, arsenic long continued, diabete bronze of the French, pellagra in the chronic pigmentary form, Hodgkin's disease, chronic hepatic disease, and con- stipation in sedentary patients. A. J. Lartigau and W. H. Happel (Albany Med. Annals, Feb., '99). On the other hand, a few cases have been recorded in which there was pro- found asthenia, severe gastric disturb- ances, irregular and weak pulse, and early death from syncope, when the au- topsy revealed both suprarenal bodies much enlarged from caseous and tuber- culous degeneration, but no pigmenta- tion or bronzed spots on either skin or mucous surface. Letulle reported a case of this kind in 1894. The patient was supposed to be suffering from malarial cachexia, but died suddenly from syn- cope, and "the autopsy showed the two capsules to be transformed into fibro- caseous blocks as large as a mandarin orange." There is at present no known 136 ADDISON'S DISEASE. ETIOLOGY. reliable mode of completing the diag- nosis of such cases during the life of the patient. Direct relation between diseases of the adrenals and bronzing of the skin de- nied. Case where one suprarenal body was intact, the bronzing nevertheless ap- pearing. Two cases in which extensive tuberculosis of both adrenals was present without a trace of dermal discoloration. Where there is discoloration there is ex- tensive disease of the nerves and ganglia of the abdominal sympathetics. Lancer- eaux (Arch. Ggn. de M6d., Jan., '90). A similar view. Nothnagel (Med. Press and Circular, Jan. 12, 19, '90). Discovery of a pigmented body, the size of the head of a large black pin, and presenting the complete histology of a suprarenal capsule in contact with the semilunar ganglion. Pilliet (Bull, de la Soc. Anat., No. 10, '91). The true origin of the bronzing may still be said to be unknown, although several plausible theories have been ad- vanced. In the cutis there are chroma- tophorous cells, which, as is the case in the frog and chamelion, are under direct nervous control, and they yield an ex- cess of pigment of the Malpighian layer under certain conditions of nervous dis- order. Raymond (Lancet, July 2, '92). Examination of the skin in one case. Coloring composed of pigmented clas- matocytes, A\'hich, after penetrating by migration, fix themselves upon the sup- porting elements of the derma. Ch. Audry (Le Midi Medical, July 29, '94). Masses of medullary cells and even buds of the substance of the suprarenal capsules in the interior of veins, more frequently in the medullary than in the cortical substance found in man. The same peculiarities were noted in the horse, ox, pig, and sheep. The medullary tubes, the central portion of which is filled with brown, hyaline masses se- creted by the double row of cells seen on their interior, project into the lumen of the veins, at this point deprived of their endothelial covering. Conclusion that the brown, hyaline masses are secreted by the suprarenal capsules, and that they are carried into the circulatory stream after penetrating into the interior of the veins. P. Manasse (Revue des Sciences M6d., July 15, '94). The melanodermia of Addison's disease is to be observed whenever the periphery of the organ, the cortex, the nerve-fila- ments, or the ganglia of the region are involved. On the other hand, it is diffi- cult to distinguish which phenomena are due to toxaemia. Bedford Fenwick, Greenhow, Jurgens, Kalindero, BabSs (Brit. Med. Jour., Mar. 30, Apr. 6, '95). Etiology. — Well-marked cases of me- lasma suprarenale are of comparatively rare occurrence in this country. Of the cases on record, much the larger number were in persons between the ages of 20 and 40 years; and more than 60 per cent, were in the male sex. Greenhow collected 183 cases, of which 119 were males and 64 females. BelaiefE has recorded one congenital case, the child living eight weeks after birth, the skin presenting a yellowish-gray color, and an autopsy showed the suprarenal capsules enlarged and filled with cysts. Another case has been reported in a child only 8 days old. Its skin was "mottled and yellowish brown." An autopsy revealed enlargement and congestion of the mid- dle third of the right suprarenal capsule, and hsemorrhage with caseous degenera- tion in the left. Records collected of 48 cases of Addi- son's disease occurring during childhood. Youngest child was 7 days, eldest 14 Vj years. The affection, almost invariably due to tuberculosis, is usually first mani- fested by vague symptoms, such as weak- ness, ansemia, loss of weight, gastro- intestinal symptoms, nausea, vomiting, and diarrhcea. Pain and pigmentation are quite uncommon in children. Con- vulsions are usual, intermissions fre- quently occur, and the disease pursues a more rapid course than in adults. Dezirot (Jour, de M«d., Aug. 28, '98). Addison's disease in a 3-year-old child. It was taken quite suddenly with diar- rhcea, gastric disturbance, and prostra- ADDISON'S DISEASE. PATHOLOGY. 137 tion. At the end of three days asthenia was marked, and there were complaints of pain in the upper part of the abdomen and lumbar region. The vomiting, elevated temperature, and the character of the pulse pointed to a peritonitis. A slight pigmentation of the abdomen was all that suggested Addison's disease, but the previous history of the patient did not support such a diagnosis. At the autopsy an ancient tuberculosis of the suprarenal capsules was found. Peyer's patches were swollen, but not ulcerated. The spleen, which was enlarged, fur- nished a pure streptococcic culture. The case is interesting from what appears an acute Addison's disease, the more pro- nounced symptoms of which developed coincidently with a general streptococcic infection. Netter and Nattan-Larrier (La Presse M6d., May 2, 1900). On the other hand, one or more cases have heen recorded as occurring as late in life as 70 years. As predisposing causes, we find enu- merated excessive physical labor, men- tal anxiety and depression, caries of the spine, confinement in damp and ill-ven- tilated rooms, insufficient food, blows upon the abdomen, and tuberculosis of the peritoneum. Greenhow claimed that nine-tenths of the cases collated by him had occurred among the laboring classes. Nearly all the conditions mentioned as predisposing causes are the same as are generally alleged to predispose to pulmo- nary and other varieties of tuberculosis. The more efficient or direct cause of the disease imder consideration appears to be an interruption of the functions of the suprarenal capsules. According to Lewin, some degree of structural disease of these capsules is found in 88 per cent, of all the cases, and the most frequent of these changes is tubercular. Tuberculosis is the most frequent and important change in the adrenals in Addison's disease. The various other changes in these bodies — as chronic in- flammation, caseation, or calcareous infil- tration — are to be regarded only as the different results of the tuberculosis. Alezais and Arnaud (Eevue de M6d., Apr., '91). Typical case in which the suprarenals were both enlarged and cheesy, the ab- dominal sympathetics being enlarged and red to the naked eye, associated with pulmonary tuberculosis and Pott's dis- ease of the spine. Tyson (Univ. Med. Mag., Sept., '91). It has been proved that the etiological factors underlying Addison's disease are not dependent upon the presence or ab- sence of the adrenals alone. The chief symptoms of Addison's disease can be produced by lesions of ganglia in close association with the adrenal blood- supply. A. F. Jonas (Annals of Surg., Apr., '98). Analysis of several cases tending to suggest that certain toxic substances, such as pyrocatechin, phosphoric and lac- tie acids, are developed in the intestines and muscles, and that these are altered in the suprarenals and there prepared for excretion. When for any reason the suprarenal tissue is destroyed, these sub- stances will remain in the system and lead to a chronic intoxication. I. Huis- mans (Munch, med. Woch., Mar. 27, 1900). History of a family in w'hich the mother with her first pregnancy had be- gun to show pigmentation. With each subsequent pregnancy she had become more pigmented and more depressed, and at the time of the report she had marked disturbance of the gastro-intestinal tract, with irregular pains, attacks of giddiness and syncope, and numerous almost black spots resembling moles over the body. Four children showed similar symptoms, decreasing in degree and severity directly with their youth. The cases were dis- tinctly Addison's disease, but tuberculo- sis might have existed in the whole family and have involved the suprarenal glands. Family involvement in Addison's disease has been rarely noted. R. A. Fleming and J. Miller (Brit. Med. Jour., Apr. 28, 1900). Pathology. — The post-mortem exam- ination of the case reported by Jonas, 138 ADDISON'S DISEASE. PATHOLOGY. in addition to the bronzed spots on the surface, the cavities of the heart moder- ately filled with blood only partially co- agulated; the liver and spleen of natural size and color; the mucous membrane of the stomach and ileum congested, softened in some places with abrasions; and the suprarenal capsule much en- larged. No other morbid appearances were noticed in the abdominal viscera. An incision through the centre of the suprarenal capsules revealed a central caseous mass in each, of the consistence of new cheese, about thirty millimetres in diameter, inclosed in a sac of gray, fibrous tissue, with some spots and streaks of yellowish color. On the sur- face of the caseous mass next to the surrounding capsule was a thin layer of a creamy consistence, and the fibrous capsule under the microscope showed the presence of fusiform, lymphoid, and large granular or giant cells in consid- able numbers. Both capsules presented the same appearance and were undoubt- edly good specimens of tuberculous dis- ease. The two most constant anatomical changes found in Addison's disease are the pigmented spots consisting of gran- ular pigment deposited in the deeper layers of the rete Malpighi and the caseous or tuberculous degeneration of the suprarenal capsules. Of 375 cases collected by Lewin, in 288 the suprar- enals were found tuberculous, and in many other cases they were affected with inflammation, cysts, atrophy, carcinoma, or sarcoma. Case in which the tubercular nature of the lesions in the suprarenal bodies was demonstrated. Death took place with absolute suddenness. The autopsy showed slight evidence of tuberculosis of the lung. One suprarenal capsule pre- sented a very pronounced caseation, and was large and lumpy. In the other the lesion was much less pronounced. The capsule was not greatly enlarged, but its normal tissue had disappeared, and its place was taken by a general, homo- geneous, tough tissue, in which were a few caseous centres. Microscopical ex- amination demonstrated that the lesion was tubercular, and there were tuber- cular bacilli in the capsules. The bacilli were not numerous, but unequivocal. Joseph Coats (Glasgow Med. Jour., Aug., '92). Five cases of Addison's disease which had been examined, first clinically and afterward post-mortem. In all of them the suprarenal capsules were found dis- eased. In four they were extremely tuberculous, three showing the disease on both sides, and one on one side only. In the fifth case there was a carcinoma- tous degeneration of the left suprarenal as well as left-sided pulmonary cancer. Posselt (Centralb. f. klin. Med., Feb. 5, '95). Case of Addison's disease in a boy, 14 years old, suffering from old pulmonary tuberculosis, with recent miliary out- break; considerable epigastric pain dur- ing life. No pigmentation of skin. Post- mortem disclosed, in addition to lung condition, enlarged and pigmented bron- chial glands, enlarged and firm mesen- teric glands, with congestion of liver, kidneys, spleen, and intestines. Capsules of suprarenal bodies were thickened and adherent to surrounding tissues. Each suprarenal body was four times normal size. On section they were caseous, and contained cretaceous nodules. Micro- scopically mesenteric glands showed small-cell infiltration without giant-cells. Periphery of suprarenals was rich in typical small tubercles, many containing large, multinucleated giant-cells. Signs considered of diagnostic importance were extreme asthenia, emaciation, anorexia, vomiting, abdominal pain, and small, rapid pulse. J. Anderson (Lancet, June 18, '98). Autopsy of a case of Addison's disease in a girl who had had tuberculous cer- vical glands and tuberculosis of the lungs, with brownish skin and extreme ansemia. Both adrenal bodies were ADDISON'S DISEASE. PATHOLOGY. 139 found infected with tuberculosis. The object of the adrenal bodies is to absorb certain toxic substances manufactured in the intestines. Huismana (Miinehener med. Woeh., Apr. 2, 1901). Next in frequency to the suprarenal capsules, the ganglia of the sympathetic ■system of nerves have been found altered in structure, especially in the neighbor- hood of the capsules. In many eases structural changes have been found to co-exist in both the capsules and the ganglia of the sympathetic in the same patients. On the other hand, a few cases have been reported presenting all the clinical symptoms of Addison's disease, in which the autopsy failed to find any structural changes in either the suprarenal capsules or the nerve-ganglia. Case in which the typical changes were encountered, and in which there was found a chronic spinal sclerosis of the posterior root-zones, with a neuritis attacking especially the posterior roots of the spinal nerves. Marked by a swell- ing of the axis-cylinders, their rupture at places, and a multiplication of cells. Kallendro and Babes (La Seniaine Med., Peb. 22, '89). [The cases of adrenal involvement without co-existing pigmentary changes lend considerable weight to the asser- tions of those pathologists who find Addison's disease rather a disease of nervous origin than one involving a glandular organ. This opinion is further strengthened by the finding of pigment- ary changes in cases presenting no demonstrable change in the adrenals. Another point of no slight weight may be taken in the suggestion of .Jiirgens, that at least a certain class of pigmented instances are due to peripheral nervous irritation, possibly from epithelial de- generation or actual external irritation, mostly met about the flexures, folds, and in the face, from exposure. This last suggestion is further borne out physio- logically from the pigmentation often caused by the constant wearing of even non-metallic objects, as buttons, next the skin. The opposite view — i.e., of glandular destruction — cannot, however, be set aside, numerous careful observations and the results of various experimenters offer- ing weight in this direction. As to the nature of growth found in the suprarenals, there can be but little doubt that other new formations than tuberculosis are attended by the com- plex of symptoms of Addison's disease. TY.SON" and Smith, Assoc. Eds., Annual, '89.] Investigations upon rabbits and dogs showing that the adrenals stand in inti- mate relation with the central nervous system, and that their affection is the cause of the train of phenomena known as Addison's disease. Tizzoni (London Med. Recorder, Feb., '90). Case in ^¥hich, associated with the ordinary symptoms, there occurred a sudden attack of bromidrosis, indicating a rather serious involvement of the sympathetic nervous system. Ohmann- Dumesnil (Atlanta Med. and Surg. Jour., July, '90). Six cases of adrenal caseation, in some of which there was distinct round-celled infiltration of the semilunar ganglia without bronzing of the skin. Addison's disease cannot be said to be directly due to changes in the sympathetic abdominal ganglia, although, perhaps, this or that symptom of the affection may depend on such involvement of the sympathetic ganglia. Von Kahlden (Miinch. med. ■Woch., June 23, '91). Not the great sympathetic nerves and ganglia, not the suprarenal capsules themselves, but the pericapsular nerve- ganglia constitute the especial starting- point for the development of the symp- toms of Addison's disease. Alezais and Arnaud (La Semaine Mgd., Oct. 7, '91). Four autopsies suggesting that the dis- ease is due to irritation of the abdominal sympathetic from direct lesion of the nerve, its ganglia, or the suprarenal cap- sules. This lesion is most frequently primary or secondary to tuberculosis of the capsules with secondary involvement of the sympathetic. In less than 20 per 140 ADDISON'S DISEASE. PATHOLOGY. cent, it is not tuberculous, and in 12 per cent, of the cases the capsules remain normal. Thompson (Amer. Jour, of the Med. Sciences, Oct., '93). To be regarded as a functional whole, the cortex and the medulla doing the same work, but in unequal degrees. Atrophy of the suprarenal capsules oc- curs normally in old age, but may occur earlier in life and cause Addison's dis- ease. Hsemorrhage into the substance of the gland may be due to traumatism either later in life or in infants at birth. Fatty and lardaceous degenerations oc- cur. The glands have been found to contain ej'sts. Out of one hundred and thirty-one cases in which death was due to tuberculosis, the glands were tuber- culous in eighteen, without, however, there being any signs of Addison's dis- ease. Rolleston (Lancet, Mar. 23, '95). The primary morbid conditions or processes on which depend the develop- ment of the clinical phenomena of Ad- dison's disease have not yet been so clearly demonstrated as to remove the subject from the fields of controversy or doubt. Much the larger number of writers incline to agree with Dr. Addison, who ascribed all the essential symptoms and results of the disease to interruption of the function of the suprarenal capsules caused by some form of disease in those organs. Those holding this view assume that these bodies either destroy some toxic element resulting from natural metabolic changes in the blood or tis- sues, or secrete and return to the blood some substance necessary for the main- tenance of health. Pyrocatechin, found in the medulla of the suprarenal gland, becomes brown in contact with air or alkaline tissues. It is converted in Addison's disease into a poisonous compound on leaving the su- prarenal body and entering the circu- lation. In health the elimination of pyrocatechin occurs through the agency of the sympathetic ganglion-cells. The debility, etc., are the signs of chronic poisoning with pyrocatechin: an auto- toxieation. Miihlmann (Miinehener med. Woch., Feb. 16, '96). Certain changes in the suprarenal cap- sules — such as hypersemia, hypertrophy, etc. — are noted when certain poisons are introduced into the system, especially if slowly given: cloves, toluene-amin, tox- ins of bacilli, etc. (Eoux and Yersin, Roger, Pilliet, Charrin and Langlois.) The toxic power of the extract of suprarenal capsules was noted by Foi and Pellacani (1884), and has been ex- amined since then by many authors. It causes a rise in the blood-pressure com- bined with slowing of the heart. (Cy- bulski, Olivier and Schafer.) Capsules which are affected with hypei'ffimia still contain the principle which gives rise to the above effect (not pyrocatechin) ; but capsules hypertro- phied to double or more their original size no longer contain it. P. Langlois (Arch, de Phys., vol. viii, p. 152, '96). The suprarenal capsules are intended for the destruction of the red blood-cor- puscles, which give up their haemoglobin to the medullary cells of these organs under the form of pigment. Blood poi- sons — such as formol, aniline products, mineral poisons, sodium nitrate, and uranium nitrate — cause congestion of the capsule, excess of pigment in the cells of the medullary region, and haem- orrhages into the same region. The blood passes through the capsule from the centre toward the periphery, giving up its hfemoglobin to the medullary sub- stance or to the deeper portion of the cortical substance. When the gland has taken up all it can, other mesodermic elements assume its functions, such as white blood-globules and connective cells of the skin. This gives rise to the pig- mentation of the skin in certain de- structive lesions of the capsule. A. Pil- liet (Arch, de Phys., vol. vii, p. 555, '96). Brown-Sequard claimed that the pig- ment derived from the disintegration of red corpuscles of the blood was destroyed in the suprarenal capsules. If this is true, any disease affecting them suffi- ciently to suspend their function should ADDISON'S DISEASE. PATHOLOGY. 141 be followed by increased pigmentation and possibly give rise to all the other symptoms of the general disorder. Two cases of Addison's disease: one a typical instance of caseous degenera- tion of tlie adrenals with melanoderma, tlie other one of malignant disease of the suprarenals without discoloration of the skin. In both cases the blood-count was high. In the first the red corpuscles numbered from 6,500,000 to 7,200,000; in the second, 5,400,000. A. A. Christo- manos (Berliner klin. Woch., Oct. 16, '99). Experiments on animals for the pur- pose of determining the real functions of the suprarenal bodies by several in- vestigators have resulted so variously as to lead to contradictory conclusions. After total extirpation of both suprar- enal capsules in one hundred and fifty- three animals no changes in pigmenta- tion or other symptoms of Addison's disease vrere observed. (Nothnagel.) In neither of these cases, however, are we informed as to how long after the extirpations the animals were kept un- der observation. On the other hand, Tizzoni, who kept rabbits alive two and three-fourths years after crushing the adrenals, claimed that pathological pig- mentation and some multiple degenera- tions in the spinal cord developed. The experiments of Abelous and Langlois also appear to prove that animals deprived of these bodies die with symptoms of toxaemia. The symptoms of the affection indicate an intoxication, the experiments of Abe- lous and Langlois having shown that animals deprived of the capsules die poisoned, and that their blood shows a special toxicity. If a small portion of the suprarenal parenchyma be retained, the intoxication is neutralized and life remains possible. In Addison's disease, adynamia, gastric disturbances, and the terminal symptoms of cardiac collapse (hypothermia and coma) appear to be purely toxic phenomena, although these have not always been provoked with hypodermic injections of suprarenal juice. All the symptoms do not depend upon intoxication, however, the pigmen- tation of the skin and mucous mem- branes being in relation to lesions of the sympathetic. Chaufi'ard (La Semaine M6d., Feb. 14, '94). One of the functions of the capsules Is to destroy a part of the used-up red corpuscles. If this excretory or depura- tive function is interfered with, the cir- culation of the decomposition products of hsemoglobin causes Addisonian poison- ing. Role attributed to the medullary substance. The role of the cortical sub- stance is that of furnishing a secretion that is taken up by the lymphatics, and which is indispensable to the needs of the organism. Auld (Brit. Med. Jour., May 12, '94). [Auld thus appears to assign to the suprarenal bodies a double function. N. S. Davis.] The suprarenal bodies elaborate a sub- stance which has a very powerful action on the muscular tissues and more espe- cially on the muscular coat of the ar- teries. It causes, in very small doses, an enormous heightening of the blood-press- ure, dependent upon contraction of the peripheral vessels, due to a direct action of the substance on the muscular coat, and not to any action on the medullary vasomotor centre. It also acts directly on the heart, producing augmentation and acceleration, provided the vagi are divided. On the voluntary muscles its action is such that the period of contrac- tion is slightly and the period of relaxa- tion greatly prolonged. On respiration more marked effects are obtained in rab- bits than in dogs. In cases of Addison's disease no physiological action from the extract of the diseased capsules obtained. It is possible that the phenomena of Ad- dison's disease are due to the absence of this active principle. Schilfer and Oliver (Practitioner, Sept., '95). Results of experiments on one hun- dred and nine rats from which both suprarenal capsules were removed, and others in which these bodies were cauter- ized or otherwise inflamed. After the 142 ADDISON'S DISEASE. PATHOLOGY. lapse of a few months a large number of these animals showed an infiltration of the pigment in the subcutaneous cellular tissues, in the lumbar and mesenteric glands, in the peritoneum, mesentery, liver, spleen, and lungs. Muscular pare- sis had developed in some of them with increasing asthenia; and the injection of an extract from the muscles of such rats proved fatal to other rats. Boinet (La Semaine M6d., No. 8, '96). This view of the functions of the cap- sules, in connection with the fact that some form of disease has been found in them in nearly 90 per cent, of all the cases on record, certainly points directly to interference with or interruption of such functions as the first link in the chain of pathological processes consti- tuting the disease under consideration. Another class of writers and investi- gators, however, finding evidence of structural changes in a considerable number of cases of Addison's disease in the ganglia of some parts of the abdomi- nal sympathetic system of nerves, have claimed that these changes are the pri- mary pathological steps, and that all the general phenomena result from trophic influences. Prominent among those ad- vocating this view are Biesel, Burgen, and W. G. Thompson, while Alezais and Arnaud claim that the primary seat is neither in the ganglia of the sympathetic nerves nor in the suprarenal capsules proper, but in the pericapsular nerve- ganglia themselves. Case in which there was a sudden and maniacal attack the day before death, lasting several hours, dissections show- ing caseous suprarenal bodies and the thickening and matting of the tissues in the neighborhood of the semilunar gan- glia and solar plexuses. Lindsay Steven (Lancet, Oct. 31. '96). Certain vasodilator fibres run in the splanchnic nerves to the adrenals. In the dog the splanehnics, after traversing the diaphragm, give off on each side. before they enter into the formation of the solar plexus, a single large branch to the adrenals; these are thought to con- tain the chief vasodilator fibres, since, if divided, stimulation of the splanehnics in the thorax is Avithout influence, while stimulation of the distal extremities of the divided nerves is followed by active hypersemia. Arthur Biedl (Pfliiger's Arehiv, June, '97). The theories of the changes in the great sympathetic system and of insuffi- ciency of the capsules which have been opposed to one another as an explana- tion of the cause of Addison's disease each contain some truth, but are too ex- elusive. Where the capsules are either absent or not diseased, only the nervous theory can be upheld. Clinical research and experiments prove that pathological or experimental destruction of the cap- sules acts not only by the ascending and secondary degeneration of the great sym- pathetic and its ganglia, but also by capsular insufficiency. This suppression of the action of the capsules favors retention in the blood, viscera, and muscles of toxic products which appear to play a certain part either in the formation of pigment in the blood or in the production and in- crease of the asthenia. E. Boinet (Revue de Med., Feb., '97) . In this connection it is proper to state that F. Marino-Zucco, Director of the Chemico-Pharmaceutical Institute of Genoa, has obtained neurin from the normal suprarenal capsules in notable quantity, and has detected the same sub- stance in the urine of a patient with Addison's disease. This, with further experiments with neurin, led him to re- gard the retention of this substance, on account of disease of the capsules, as the probable caitse of the more general dis- order. The results of the more recent active investigations concerning the functions of the thyroid and other duct- less glands, and the therapeutic effects of extracts derived from them, add to the probability that the statement we ADDISON'S DISEASE. PROGNOSIS. TREATMENT. 143 have quoted from Auld will be found correct. That the suprarenal capsules contain true glandular structure, and also an abundance of nerve-ganglia and filaments connecting freely with the ab- dominal sympathetic system of nerves, was fully demonstrated by Henle and von Brunn. The existence of a true glandular structure plainly implies a secreting or transforming fimction, the suspension of which would lead to some kind of me- tabolic disorder, while the close nervous connection with the sympathetic would explain the coincident gastro-intestinal disorders and progressive asthenia. This pathological view also enables us to see why the clinical phenomena constituting Addison's disease may be developed, not exclusively by tuberculosis or any one special disease, but by any and every morbid condition capable of persistently interrupting the natural function of the suprarenal bodies. Case in which autopsy revealed eon- genital absence of the suprarenal cap- sules. No other lesions were found. Only two similar cases reported. Patient was 24 years old; the symptoms were melanoderma, pains, progressive asthenia, wasting, cachexia, and gastro-intestinal disturbance. Ended fatally in ten months. A. Rispal (Third French Med. Cong.; N. Y. Med. Record, Sept. 19, '97). Case of Addison's disease with simple atrophy of the adrenals in which, though the histological changes were compara- tively slight, the symptoms of Addison's disease were well marked and fatal. The cutaneous pigmentation appeared four- teen years before the onset of the pro- found constitutional symptoms. Carlin Philips (.Jour, of Exper. Med., vol. iv; Practitioner, May, 1900). Prognosis. — Until very recently the progno.?is in well-characterized cases of Addison's disease has been uniformly regarded as unfavorable. It is true that a very few cases of recovery have been reported, but nearly all writers of the highest aitthority regard such as ex- amples of mistaken diagnosis. "An absolutely fatal prognosis must always- be made. In all these cases which are recorded as having been cured there exists a doubt as to the accuracy of the diagnosis." (Merkel.) Osier, in 1894, declared that the dis- ease was fatal in every case. In the meantime, encouragement by the results- of the use of the thyroid gland or ex- tracts from the same in cases of acrome- galy led Oliver and others to use extract of the healthy suprarenal capsules in the treatment of Addison's disease, and with so much benefit that in the second edition of his work, in 1895, Osier had modiiied his previous declaration by saying: "The disease is usually fatal. . . . In rare instances recovery has taken place, and periods of improvement, lasting many months, may occur." Case of recovery in a man of 57 years who, in April, 1885, was suddenly at- tacked by weakness, ansemia, pigmenta- tion of the mucous membranes, bronzed skin, and, a little later, pain in the re- gion of the capsules. Strength returned., little by little; so that in September, 1886, he was able to pass half an hour out of bed. At the same time the pig- mentation grew less marked and grad- ually disappeared. At the end of two years the patient could be regarded as cured, and recovery has since been main- tained. H. Neumann (Deutsche med. Woch., Feb. 1, '94). As the disease, in a large majority of' the cases, has been shown to be tuber- culous, there is no reason why some cases may not recover, as well as in some cases of tuberculosis of the lungs or other - structiires. A very guarded prognosis, however, is most judicious in all cases of this disease. Treatment. — The tendency of medical investigators, in the last two or three ■ 144 ADDISON'S DISEASE. TREATMENT. decades, has been to seek for some one specific cause for each disease and for each a specific remedy. This has caused the careful consideration of the infl.uence of predisposing causes to be more neg- lected; less attention to be given to the influence of co-operative causes, espe- cially in the production and maintenance of chronic diseases; and less appreciation of the effects of retained excretory prod- ucts during the progress of diseases, both acute and chronic, and of consequent changes in therapeutic indications in dif- ferent stages of progress. In accordance with these tendencies most recent writers have devoted but few words to the con- sideration of the treatment of Addison's disease. Not being able to identify the specific or essential cause, we are assured that no specific remedy has been found, and that the treatment must be hygienic and palliative: i.e., we must endeavor to improve nutrition by suitable diet, and to mitigate the more important symptoms as they arise. The truth is, however, that very few chronic diseases arise from, or are perpetuated by, a single specific cause. Contrarily, most of them are readily traceable to the co-operation of several causes, some of which are called predisposing and others exciting factors. And even in the few chronic dis- eases that have been traced etiologically to a specific exciting cause or pathogenic germ, as tuberculosis of the lungs, it is generally admitted that the specific germ alone rarely proves efficient in developing the disease without the aid of such pre- disposing factors or conditions as had diminished the natural vital resistance of the system or of the organ attacked. In the treatment of all such cases, therefore, it is very important that we investigate carefully the history of each patient that we may appreciate whatever predisposing influences had been opera- tive, and execute such measures as will prevent their further influence. In the early stage of Addison's disease the pa- tient should be relieved as much as pos- sible from both hard physical labor and mental anxiety, and given free access to pure air of genial temperature and a fair variety of digestible food. As the autopsies reported have shown the presence of tubercular degeneration, not only in the suprarenal capsule, but also in other structures in a majority of the cases, patients should be encouraged to go early to mild and dry climates at moderate elevations, and to take persist- ently such remedies as have been most beneficial in the more common forms of tuberculosis. Of these, perhaps, for pro- tracted use none are better than creasote, in some form, and nuclein, as they are both antiseptic and tonic to the digestive and assimilative organs. If the creasote is given in capsules, V30 grain of strych- nine, added to each dose, will aid in sus- taining the fimctions of the cardiac and vasomotor nervous systems. Arsenic has been strongly recommended in such cases as will tolerate it in large doses without disturbing the stomach and intestines. In one case under my care the patient appeared to derive much benefit from potassio-tartrate of iron, given in mod- erate doses in connection with digitalis. In the later stage of the disease, when the asthenia is profound, the patient should be kept much in the recumbent position, and his gastric and intestinal disturbances combated by the use of bis- muth subnitrate, cerium oxalate, and sometimes creasote with codeine. Since it has been ascertained by very careful experiments that the healthy suprarenal capsules contain an active substance capable of producing a decided stimulant and tonic effect on the cardiac and other ganglia of the sympathetic ADDISON'S DISEASE. TREATMENT. 145 nervous system, and of efficiently in- creasing the vasomotor functions with slow heart-beat and greater blood-press- ure, their use in the treatment of Ad- dison's disease has been tested, more or less, by almost every physician having a case under his care. Oliver, who has been most active in investigating the action of preparations of the suprarenal capsules and their value in the treatment of Addison's disease, says they may be used in the form of alcoholic tincture and of either fluid or dry extract. The best mode of administration is by the mouth, and of the dry extract in the form of tablets of 2 V2 grains each, one of which may be taken three times a day, and slowly increased to five or six in the twenty-four hours. Extract or tincture of suprarenal cap- sules tried in several cases. Good results obtained not only as a means of restor- ing muscular strength and improving the general condition, but sometimes as a true curative remedy. Maragliano (Eiforma Med., Dee. 4, '94) ; Shoemaker (Univ. Med. Mag., Feb., '95) ; Lloyd Jones (Brit. Med. Jour., Aug. 24, '95) ; Oliver (Brit. Med. Jour., Aug. 31, '95). Case of a man, aged 44 years, some- what addicted to alcoholic excesses and subject to occasional attacks of asthma, who, during the months of February, March, and April, developed all the char- acteristic symptoms of severe Addison's disease. During the month of May he received a subcutaneous injection of suprarenal capsular juice, 1 cubic centi- metre every two days. During one month of this treatment his appetite and strength had returned and he had gained four kilogrammes in weight. On the 14th of June he had a violent quarrel with a neighbor, and all his former bad symptoms began to return, and caused his death on the 14th of July. No autopsy was made. Spillmann (Rev. Med. de I'Est., Jan. 15, '96). Case of a man, 46 years of age, suffer- ing from pulmonary tuberculosis and Addison's disease with marked pigmen 1—10 tation of the skin and of the mucous membrane of the palate, treated with an extract prepared from the fresh suprar- enal glands of the pig extracted and preserved in glycerin. One drachm of the extract corresponded to one suprar- enal gland, and the patient at first was given V= drachm three times a day. This treatment was continued for eight months, and the patient was discharged in a greatly improved state, having gained in weight and strength and the pulse-frequency being much lessened. Four months later the patient was still in good health. William Osier (Inter. Med. Mag., Feb., '96). Case in which the symptoms were typ- ical and characteristic of Addison's dis- ease. Very great improvement resulted from the administration of suprarenal extract. On careful examination after death both suprarenal capsules were ab- sent, the right being entirely, and the left almost entirely, replaced by fat. Byrom Brarawell (Brit. Med. Jour., Jan. 9, '97). Forty-eight cases of Addison's disease from literature, which were treated with adrenal gland. Of these, 6 seemed cured, 22 were improved, 18 unimproved, and 2 became worse. In many of the eases there was such a grave tuberculosis of other organs as to preclude expectation of marked improvement. F. P. Kinni- eutt (Amer. Jour. Med. Sci., July, '97). Man of 49, with well-marked Addison's disease, treated with tablets of suprar- enal gland, beginning with 10 grains daily and increasing up to 200 grains. At the end of the year the man was en- tirely well. C. W. Suckling (Brit. Med. Jour., May 28, '98). Case of Addison's disease in all respects very typical, and in addition a small phthisical lesion at apex of one lung. He was given daily 3 "/^ to 12 V2 drachms of fresh suprarenal glands of beef, veal, or mutton, and also during some part of the time hypodermic injections of solution of suprarenals in glycerin and water. For five months there was no obvious im- provement. After further lapse of time strength began gradually to return and pigmentation to diminish in intensity, so 146 ADDISON'S DISEASE. TREATIIENT. that finally he was able to resume his employment, and was still at work three years later. Beclere (Semaine Med., Mar. 2. '98). Case of Addison's disease treated with the fresh suprarenal gland, with distinct improvement of general health, but pig- mentation remained unchanged, and pa- tient died two years later. Hayem (Sem. Med., Mar. 2, '98). Case of Addison's disease in a man aged 54 years. The symptoms of the disease were marked. One-twelfth grain of the extract of suprarenal glands of sheep was given three times daily. Treatment has been continued for two years at intervals. Asthenia, nausea, faintness, and pigmentation have almost entirely disappeared. Twice, when the extract could not be obtained for ten days, attacks of severe faintness, clammy sweats, and muscular twitchings, with fever and bounding pulse, resulted; they were relieved on the exhibition of the drug. R. A. Bate (Amer. Pract. and News, vol. xxviii, p. 90, '99). Suprarenal extract should be tried in all cases. There is little hope in cases of tuberculous origin; in those due to atrophy, sclerotic or inflammatory changes; but, if a portion of the gland is still active, the extract will probably be found beneficial. J. V. Shoemaker (Jour. Amer. Med. Assoc, Mar. 23, 1901). Grainger Stewart, MeCall Anderson, and other observers have reported cases treated with the suprarenal extract with- out benefit. Case of Addison's disease treated with suprarenal extract. Much improvement took place during the first four weeks, after which the failure was rapid until death occurred. Reference to 9 other cases recorded in which improvement had taken place in 5, in 2 no improvement, 1 died early, and 1 continued treatment but a few days. Sydney Ringer and A. Phear (Brit. Med. Jour., Jan. 18, '96). Typical ease in which the patient had been taking suprarenal capsule by the mouth for some time. The only appar- ent effect was that the temperature, which had been subnormal, had returned to normal. T. E. Bradshaw (Lancet, Oct. 31, '96). Administration of suprarenal extract in case of Addison's disease caused a dis- turbance of nitrogen-equilibrium, leading to increased consumption of body-albu- mins and to loss of weight. Max Pick- ardt (Berliner klin. Wocli., Aug. 15, '98). Suprarenal capsules administered sub- cutaneously to a ease of Addison's dis- ease; within twenty-four hours patient died with subnormal temperature and great prostration and collapse. P. Cour- mont (Quatrieme Congres Frang. de Med. Int., '98). Series of 43 cases of the disease col- lected treated with suprarenal extract; of these, 13 were improved, 9 recovered, 11 died, 3 showed no improvement, and the result was not recorded in 7. W. W. Johnston (Amer. Med. Congress; Brit. Med. Jour., June 2, 1900). Case of Addison's disease in a man of 40 in which suprarenal extract was given twice daily without effect, though it was not used till late in the course of the dis- ease. Necropsy showed capsulated tuber- culous deposits in the spinal column, lungs, and bronchial glands. The sub- stance of both suprarenal bodies was re- placed almost entirely by fibrous tissue. E. G. Trevithick (Lancet, July 14, 1900). Report of 8 cases, in 6 of which an attempt was made to treat the disease with suprarenal preparations. The re- sults obtained so far have been disap- pointing, but do not warrant the giving up of all hope of some degree of ulti- mate success. Most of the patients suf- fering from this disease are already in the last stages when the diagnosis is made. C. R. Box (Practitioner, May, 1901). Contradictory results having been ob- tained ever since preparations of the suprarenal capsules were first used in the treatment of eases of Addison's disease, it is impossible to determine the real value of this treatment, it being well known that a considerable proportion of the eases continue a number of years, though they often show periods of im- provement. And for the same reason it ADDISON'S DISEASE. 147 is not possible to determine whether the cases reported as cured will prove perma- nent or only temporarj'. Moreover, if the clinical symptoms and conditions constituting Addison's disease result from the interruption of the functions of the suprarenal capsules, there must have been a prior pathological condition caus- ing such interruption. And, while we might reasonably expect the use of su- prarenal extract to relieve the pigmenta- tion and asthenia so long as its iise was continued, unless it also removed this primary pathological condition, the as- thenia and pigmentation would sooner or later return, certainly after the discon- tinuance of the remedy. The whole sub- ject needs more careful and protracted investigation. Eemoval of the diseased adrenal by surgical procedures is one of the latest means employed, — accidentally, it may be said, for the operation in the case reported had been performed for the removal of a malignant retroperitoneal growth that turned out to be a tuber- culous suprarenal capsule. Case of recovery after removal of a tuberculous adrenal lying directly on the spinal column and appearing as a small,, movable, firm, nodular tumor. Pressure over it brought on a characteristic at- tack of pain. The patient recovered in ttt'o weeks. All the symptoms disap- peared after the operation. Eight months later no evidence of the disease could be discovered. Oestreich (Zeit. f. klin. Med., B. 31, p. 123, '97). Nathan S. Davis, Chicago. ADENITIS.— Gr., ahriv.& gland; itis, inflammation. Definition. — Inflammation of a gland. Varieties. — Adenitis may be acute, due almost invariably to infection from an attack of angioleueitis and occasionally to injury or strains; or chronic, resulting from either of the preceding, especially in strumous or cachectic persons, and from slight sources of irritation, and not uncommonly resulting in permanent en- largement and induration or in tuber- culous degeneration. Adenitis of spe- cific origin will be described under Syphilis and Ueinahy System. Acute Adenitis. Symptoms. — The general symptoms depend upon the extent and severity of the infection. Eigors may occur when pus forms. The temperature is fre- quently elevated. If the infection is severe, symptoms of profound septiese- mia appear. The local symptoms are, by far, the most prominent in the majority of cases, and consist of pain, heat, and swelling. The suffering varies from a slight sore- ness only to intense pain, according to the position of the gland, its relations with the surrounding tissues, and the density of the tissue in which it is im- bedded. The heat may vary according to the degree of the congestion present. The swelling may either be great or slight. If the lesion be confined to the gland, it will be well defined; if peri- adenitis is present, the swelling will be more or less diffuse. Glands in any re- gion of the body may be affected, but those of the neck, axilla, and groin more than the others; this is due to the fact that infection generally enters the sys- tem through the mouth, throat, genital organs, and the extremities. In the congestive, or exudative, stage, pain and swelling are present in the region of the glands; if the glands are superficial the swelling is ovoid with the long axis coinciding with the direction of the afferent lymphatics, and palpation reveals several movable, hard, elastic, and tender rounded masses. When the glands are deep, as in the 148 ADENITIS. A.CUTE. DIAGNOSIS. ETIOLOGY. axilla, abdomen, or even the neck, the results of palpation are less definite and satisfactory. In the siTppurative stage the pain in- creases and becomes sharp and catching, the skin reddens, and the periglandular tissue swells. If the gland alone suppurates the skin remains normal, while under it may be felt the softened and enlarged gland. This latter opens outwardly or into the neighboring cellular tissue on from the sixth to the fifteenth day of the affection. When the gland opens outwardly, the cicatrix is much smaller than when it ruptures into the celMar tissue, as in the latter case it gives rise to an abscess. If the cellular tissue around the gland suppurates the skin becomes hot, swollen, and painful, and fluctuation may be felt. Two foci of suppuration are thiis estab- lished. . The skin is occasionally under- mined by the pus. Eecovery is possible, however, without suppuration of the gland. Both the gland and the cellular tissue around it may suppurate, either simul- taneously, or suppuration of the cellular tissue may precede that of the glands, •or the latter may suppurate and rupture into the surrounding cellular tissue and itoim an abscess. Pus is usually pro- duced in considerable quantity, and the affection is of long duration. Suppurative adenitis may result in •cicatrization after several weeks. This cicatrix may reopen to allow the exit of pus from a suppurated gland. On the other hand, a fistula may result, which may give exit to sero-pus or to lymph (Despres). A lymphatic gland or vessel will then be found at the bottom of the abscess-cavity, below the crater-like ■opening. As the suppuration usually starts in more than one focus in the gland, the first sensation to the touch will be one of bogginess, which periglandular con- gestion may render obscure. "Well- defined fluctuation is found only when considerable tissue is destroyed. Diagnosis. — The diagnosis of ordinary superficial acute adenitis is usually easy; it is more difficult when the neighboring cellular tissue is also inflamed; it may be impossible in cases of deep-seated or visceral adenitis. In adenitis of the inguino-crural re- gion the swelling is found in the external portion of the region if due to a lesion of the gluteal tissues, and in the inner portion of the region if due to a lesion of the anus, perineum, or external geni- tals. In both conditions the tumor will have its long axis directed more or less horizontally. The swelling will be found in the lower portion of the inguino-crural re- gion, with the long axis directed more or less vertically, if the lesion causing it is situated on the foot, leg, or lower part of the thigh. This disposition is due to the anatomical relations of the lym- phatic vessels and glands, and should be borne in mind. Operation for strangu- lated crural (femoral) hernia has been performed for an adenophlegmon of the crural canal. Etiology. — The lymphatic glands serve as reservoirs on the course of the lym- phatic vessels, through which any irri- tants or infection must pass. Cold and overexertion act as local depressants, and thus may indirectly favor the development of adenitis. Gen- eral debility has the same effect. The following varieties of adenitis, etiolog- ically regarded, are recognized: — 1. Adenitis by contiguity, resulting from the propagation, by contact, of a neisfhboring inflammation. ADENITIS. ACUTE. PATHOLOGY. 149 Three cases of suppurating inguinal glands accompanying gonorrhoea in which a bacteriological examination of the pus showed the presence of gono- eocci. Pure culture of typical gonococci obtained in one case; on being placed in the urethra of a healthy man this set up a characteristic gonorrhoea. In the two other cases, in which the abscesses opened spontaneously, examination of the pus from the fistulous tract showed the presence of gonococci and strepto- . cocci. An attempt to cultivate the cocci on Wertheim's medium, made in one of these cases, failed. Hansteen (Arehiv f. Derm, und Syph., vol. xxxviii). (See Ukethea.) 2. Adenitis by continuity or following lymphangitis. 3. Adenitis by embolism, due to the transportation of septic or irritating matter, produced in the system or com- ing from the outside. Adenitis of the mesenteric glands may be due to dysentery or to the inflamma- tion of Peyer's patches in typhoid fever. Adenitis occurs in carbuncle, furuncle, vaccination, erysipelas, and eruptive or infectious fevers. Pathology. — If suppuration does not occur, resolution may take place, or chronic enlargement of the gland may follow hyperplasia of the connective- tissue stroma of the gland. If suppuration does occur the sur- rounding connective tissue may, and usually does, suppurate; then the more or less disintegrated gland lies in a sitp- purating cavity formed by the circum- jacent connective tissue. There are two forms of acute adenitis depending upon the degree of inflamma- tion present: — 1. Exudative adenitis. In this form the gland is swollen, and it feels hard and elastic. On section it appears red- dish brown, like the spleen, with small foci of hffimorrhage, all of which indicate excessive dilatation of the capillaries. The lymphatic stream is arrested by the dilatation of the cortical lymph-sinuses and their obstruction by fibrin, granular material, and portions of altered white corpuscles. The Ij'mph-f ollicles are filled with fibrin and accumulated lymph-cells. The stroma of the gland is swollen and infiltrated with cells. If the section of the gland is scraped, a milky liquid will be obtained, which contains white corpuscles and epithelial cells, the latter showing several nuclei. 2. Suppurative adenitis. In this va- riety the gland softens, its tissues become more brittle, hsemorrhagic infiltration centres form that soon change into yel- low, purulent foci. These, at first dis- tinctly separate, soon unite, forming an abscess within the fibrous capsule of the gland. Sometimes the periglandular tissue suppurates, while the gland does not. The glandular abscess and the peri- glandular abscess may open externally, each one separately or both simulta- neously. The suppurating gland may rupture into the cellular tissue. Occa- sionally the gland is hard and elastic; it may be difficult to separate it from its fibrous capsule. The afferent Ijinphatics are enlarged and thickened. The lymph- cells and cortical follicles are few in number and have undergone granulo- fatty degeneration. Seven cases of articular rheumatism in which the lymphatic glands situated above the affected joints were swollen and painful, the pain or tenderness in- creasing with that of the joint-affection. During the attacks some were of the size of a nut and rolled under the finger. No periadenitis or diffuse swelling was present. In almost every case some previous in- fectious disease was to be found with which the chronic rheumatism could be connected. Bacteriological examinations, however, carried out either with the 150 ADENITIS. ACUTE. PROGNOSIS. TREATMENT. intra-articular liquid withdrawn by- aspiration or by fragments of glands removed aseptically, gave almost no re- sults. A. Chauffard and F. Ramond (Rev. de Med., May 10, '96). Prognosis. — The prognosis is usually favorable; it may be unfavorable, how- ever, when extensive abscesses form in the neighborhood of important organs. Deep-seated suppurative adenitis may give rise to dangerous complications, especially in certain regions, like the neck and mediastinum, on account of the purulent extensions (through burrowing) and the difficulty of evacuating the pus. Ulceration of the great vessels of the neck giving rise to grave haemorrhages may also occur. Case, in the practice of Johnston, in which the internal jugular vein was ligated for profuse hseniorrhage, caused by a sloughing adenitis following malig- nant scarlet fever. L. H. Adler, Jr. (Univ. Med. Mag., Dec, '91). Treatment. — The first indication in acute adenitis is to remove any source of irritation or infection. Any wound, abrasion, opening, or any natural cavity with which either of these may connect should be so treated as to bring about absolute local asepsis. If the case is seen early enough, cold applications should be made to the af- fected region. Cold inhibits the multi- plication of bacteria, but when applied late it favors the death of cells, and should consequently be avoided. The region in which the affected gland is situated should be kept at rest and, if possible, elevated. In this manner the afl'erent arterial current is diminished, while the efferent venous and lymphatic currents are increased. To prevent suppuration gray mercurial ointment, very gently rubbed in, is use- ful. The injections of from 5 to 10 minims of a 3-per-cent. carbolic-acid solution into an inflamed gland have also proven satisfactory. Case in which injections of carbolic acid destroyed the tendency of the glands to develop. Schwartz (Revue Gen. de Clin, et de Ther., Mar. 4, '91). In cervical adenitis it is necessary be- fore the skin is altered to treat abscess by punctures with a fine needle and modifying injections. If this method adopted, cure without cicatrix in 99 per cent, of cases. When \\'ith general treat- ment and stay of six months or more at sea-side, gland remains swelled and in- durated, neither showing signs of reso- lution nor advancing toward softening, injections of l-in-50 chloride-of-zinc solution gives best results. Injection re- peated three or four times, at two days' intervals, with 30 to 60 drops of this solution. This nearly always leads to commencement of softening, which is finished by injections of camphorated naphthol. Calot (Presse Med., Oct. 22, '98). If it is desired to hasten sitppuration, warm antiseptic fomentations are to be used in preference to poultices. The compound resin cerate of the pharma- copoeia is efEective for this purpose, and is antiseptic as well. When pus has formed the gland should be opened by a generous incision, sinuses, if present, being opened throughout their entire length to facilitate treatment. The contents are then carefully removed, and the infiltrated wall scraped with a sharp curette. The cavity should then be packed with iodoform gauze, or gauze impregnated with camphorated naphthol or salol. The dressing may be removed on the third day. In the treatment of cases of simple chronic adenitis, applications of iodine, compression, and local blistering have given the best results. Blisters, nitrate of silver, or iodine tincture should be applied around, but not over, the inflamed gland. ADENITIS. CHRONIC. SYMPTOMS. 151 In adenitis complicating articular rlieumatism the beat results are obtained from the tincture of iodine given in- ternally; 100 drops in divided doses are given daily; long continued use is ad- vised. A. Chauffard and F. Ramond (Rev. de Med., May 10, '96). Excision may be performed if the mass be large or disfiguring. 1. Whenever fluid — that is, pus — can be detected in connection with a dis- eased lymphatic gland, the operation should be done before the skin becomes red and thin. 2. When the diseased gland is subcutaneous — that is, not be- neath the deep fascia or muscle, and has been completely removed — the least scar will result if neither stitches nor drainage-tube be used, especially if it be possible to leave the wound uncovered by dressing and exposed to the air, so that the edges may be drawn and glued together by drying lymph. 3. If the diseased gland be beneath the muscle or muscular fascia, then a drainage-tube must be used and the edges of the wound must be united by suture. The best drainage-tube is the gilt spiral wire, especially as it ihay have to remain from two to eight or ten weeks, accord- ing to the depth of the wound or the completeness of the removal of the gland. 4. Where many glands have to be re- moved, it is better to remove them through a series of small incisions and thereby avoid very extensive ones. All sinuses and suppurating cavities should be thoroughly cleansed by means of scraper and lint, so as to leave a fresh surface free from granulation or decayed or decaying tissue, and that a drainage- exit should be maintained until all the deep parts are healed. Teale (Brit. Med. Jour., No. 1717, '93). Important to avoid tearing or wound- ing the gland in removing it, to keep close to its surface in order to prevent haemorrhage, and to use transverse in- cisions. W. K. Treves (Brit. Med. Jour., No. 1717, '93). Electricity, preferably the constant current, is highly recommended by some authors. Daily sittings of ten minutes each, using 5 to 15 milliampei'es, are required. The great majority of the cases of cervical adenitis are to be treated medi- cally, since they only come under ob- servation after suppuration has oc- curred. In the cases of tubercular adenitis which are not yet suppurating, extirpation through a small incision is indicated at once, with medical after- treatment to prevent recurrence. When one hard, caseous nodiile exists, it should at once be extirpated, unless the resulting scar will cause marked de- formity. When these are multiple, im- mediate extirpation is the treatment to be followed. Should the adenitis be- come purulent, extirpation is only in- dicated after all other methods of treat- ment have failed. Local injections are advised, with a long sojourn at the sea- shore, especially should fistulae occur. Clean dressings must be applied to the fistulae to prevent secondary infection. When extirpation is done, it should be complete. A. Broca (Jour, des Prati- ciens, Oct. 26, 1901). Codliver-oil, the iodides, and iron are indicated in all cases when the digestive organs do not rebel against their use. Arsenic and strychnine are the agents next in order, and sometimes prove very effective. Out-of-door life and plentiful nourishment are of primary importance. Chronic Adenitis. Symptoms. — The symptoms vary ac- cording to the period of development in which the diseased gland is found at the time of examination. Three periods of development are commonly recognized in tuberculous adenitis: the period of induration, or indolence; the period of inflammation; and the period of suppuration. 1. Period of Induration, or Indolence. — This period may last for years, and resolution may even take place, though the gland always remains somewhat en- larged and indurated. The glands are felt as hard, elastic, enlarged bodies, 153 ADENITIS. CHRONIC. SYMPTOMS. rolling' under the finger, with more or less distinctness as they are situated superficially or deep. No h€at, pain, or redness of the skin is perceived. 2. Period of Inflammation. — In this period we have pain, redness of the skin, and tenderness on pressure. The gland, if solitary, may adhere to the skin. Fluctuation may be present. 3. Period of Suppuration. ■ — In this period we notice much more softening of the contents of the gland than a real suppuration. The skin may ulcerate through almost without inflammatory symptoms, and the contents — consisting of caseous matter half-dissolved in a whitish watery fluid — may be evacuated. When periadenitis occurs, true pus may be present. If chains of glands are tuberculous, the latter inflame alternately and dis- charge their contents in the same order, a series of abscesses being thus formed. When the contents of the gland are discharged, the skin may become ulcer- ated in the neighborhood, form fistulje, and a depressed, adherent, violet cicatrix finally form. In some cases a fistula may form and last for years; the skin may be under- mined, and disfiguring cicatrices may be formed. Cretaceous transformation occurs at times in the deeper glands, but rarely in the superficial ones. Some caseous glands undergo a process which trans- forms them into a cyst-like cavity con- taining a serous liquid. Chronic adenitis may assume various forms. 1. General Tuherculoiis Adenitis. — This presents itself especially in negroes. Organs other than the glands are but little affected, and continuous fever exists. The retroperitoneal, bronchial, and mesenteric glands are the most en- larged. It resembles, in many ways, an acute attack of Hodgkin's disease. 2. Local Tuberculous Adenitis. — (a) Cervical. This form is usually met with in children, and begins in the submax- illary glands, which are generally more enlarged on one side. (&) Bronchial. This form is thought to be always secondary to a fociis in the lungs, by some authors, but this opinion is contested by many others. Osier among them. Local lung-infection, pericardial infection, and general infection are to be feared, however. (c) Peribronchial. In this form we must realize the importance of lesions resulting from caseation. There is a softening of the lymphatic glands situ- ated aroimd the lower end of the trachea and main bronchi. Evidence from per- cussion is of doubtful value; alterations in breath-sounds are much more impor- tant, especially when unilateral; divided respiration, with prolonged expiration, is found vmaccompanied by any adven- titious sounds. In cases in which the enlarged glands ulcerate through the air- tubes, the breath has a very offensive odor, and co-existence of fcetor with haemoptysis and evidence of pulmonary consolidation are suggestive. When vomiting of blood and its passage by the bowel is added, the diagnosis of glands rupturing into bronchus and oesophagus is the most likely one. The annexed colored plate distinctly shows the ana- tomical relations of the peribronchial glands. {d) Mesenteric. This form may be primary, and is thus very common in children, or secondary to local intestinal tuberculosis. The sufferers are usually weak and wasted; the abdomen is en- larged and tympanitic, and diarrhoea is a common symptom. Some fever is usu- Cervico -Bronchial Lymphatic System IBourqery J a a a a Glands involved in bronchial adenopathy ANATOMIE OU CORPS HUMAIN ADENITIS. CHRONIC. DIAGNOSIS. ETIOLOGY. 153 ally present. This form may exist in adults. (Osier.) The majority of children presenting symptoms of tuberculosis also have gen- eral adenitis, the swollen glands being felt everywhere; they never change in size or consistence. Suddenly a bron- chitis develops, followed by a broncho- pneumonia, from which the child dies. Microscopical examination reveals ca- seous spots and the presence of tubercle bacilli throughout the affected glands. The name of "generalized peripheral adenitis" suggested for this condition. Grancher and Marinescu (L'Union M6d., Dec. 2, '90). Diagnosis. — Chronic adenitis is gen- erally limited to one or two glands; when the glands are tuberculous, chronic adenitis is apt to affect an entire mass. The former is often associated with an external simple lesion; the tuberculous form is apt to be more frequent in chil- dren, young soldiers, and negroes. Ltmphadenoma. — This variety of tu- mor is usually more voluminous and is not suppurative. The diagnosis, how- ever, is exceedingly difficult. Simple Adenitis. — This is an acute affection usually ending in a few days in suppuration. Syphilitic Adenitis. — When a pri- mary sore is present, numerous, small, hard, indolent glands can be felt if the region is supplied with a chain of lym- phatics. WTien in secondary syphilis there is glandular enlargement, a large number of external lymphatics take part in the process. Carcinoma. — The enlarged glands are small and hard, and can generally be dis- tinctly traced to the growth. Ltmphosaecoma. — This persists longer and is much larger before degen- eration occurs. Polyadenitis is a diagnostic sign of tuberculosis in children. Marinescu (Re- vue Men. des Mai. de I'Enfance, Mar., '91). [As observed some years ago by Huti- nel, the majority of children presenting sj'mptoms of tuberculosis also have gen- eral adenitis. The swollen glands are to be felt everywhere, forming a general adenitis, and are found in regions where there is no other trace of tubercular in- volvement. Suddenly a bronchitis de- velops, followed by broncho-pneumonia, from which the child dies. Ernest Laplace, Assoc. Ed., Annual, '92.] In chronic adenitis the glands may become painful by the compression of small nerves, or of neighboring organs; when they are inflamed a small, hard mass usually appears, either alone or imited with others, which may become enlarged and suppiirate, or persist with practically no change for years, or finally disappear if the cause of irritation be removed. Chronic adenitis is frequently a com- plication of malignant tumors. Supra- clavicular adenitis appearing during the course of visceral cancer is usually situ- ated on the left side (foimd twenty-seven times on that side by one author). It may be solitary or accompanied by adeni- tis in other regions; it usually appears late and develops rather rapidly. When occurring early it may be very useful for diagnostic purposes. Twenty-nine cases of visceral cancer in which supraclavicular adenitis was pres- ent on the left side in twenty-seven. The symptoms are not very decided at first and the diagnosis may be more difficult. As to pathogenesis, it must be looked upon as due to direct propagation or to the formation of a cancerous embolism. H. Rousseau (Paris Thesis, '95). From a clinical point of view this adenitis may be known by its ligneous hardness, its painlessness, its freedom from adhesions, and by the tinion into one solid mass of all the glands forming it. Etiology. — This form of adenitis fre- quently follows some neighboring super- 154 ADENITIS. CHRONIC. PATHOLOGY. ficial lesion, such as eczema, impetigo, conjunctivitis, or the exanthemata. Ca- tarrhal inflammation of the mucous membranes predisposes to tuberculosis of the glands. The resistance of the lymph-tissue is weakened. This explains the frequent development of tuberculous bronchial adenitis after whooping-cough and measles, and of mesenteric adenitis in children with intestinal disturbances. Cervical adenitis is not a manifestation of an already generalized tuberculosis; the bacillus penetrates, by solution of continuity of the mucous membranes or the skin, to the ganglion, which becomes a seat of infection. (Duhamel.) A distinction should be made between hereditary (congenital) and acquired tuberculosis. In the latter case the au- thor's views seem rational and correct, being comparable with and analogous to the phenomena observed in carcinoma and syphilis. When the infection is acquired there is, at first, a local seat, or focus, of infection in which the disease- germs develop and from which, after proliferation, they spread until the dis- ease becomes more or less generalized, — the germs being transmitted through the lymphatic system to the lungs and thence in the blood-stream to the various organs of the body; the various glands along the course or path of transmission become affected and in turn become ad- ditional possible foci of infection. On the other hand, when the trouble is hereditary the glandular manifestation is an indication of an already generalized tuberculosis. Youth predisposes to caseous adenitis on account of the predominance at that period of the lymphatic system. Crowd- ing, humidity, and bad or insufRcient food are also predisposing factors. Tu- berculous adenitis is frequently observed in temperate regions. Negroes brought to such climates are especially prone to become sufferers. The absorbent power of the lymphatic system is so great that the morbific prin- ciple of tuberculosis may be transported to the glands without visible external lesion of the skin or mucous membrane. Axillary adenitis is frequently second- ary to chronic tubercular lesions of the lungs. (Lepine.) The cervical glands are occasionally found affected in phthisical patients. Proof of this has been lacking, and experimental attempts to induce tuber- culosis of the cervical glands by intro- duction of tubercle bacilli into the ton- sils have failed. J. Solis-Cohen (Amer. Jour. Med. Sci., May 9, '95). In post-mortem examination upon bodies of twenty-five tubercular patients tuberculosis of the tonsils was found in twelve, in every case in which the lymph- glands of the neck were also affected. Kruckniann (Virchow's Archiv, B. 138, '94). A considerable proportion of the eases of enlargement of the tonsils and of ade- noid vegetations of the pharynx are tuberculous in nature. Dieulafoy (Lon- don Practitioner, July, '95). A suppuration of cervical glands may be derived from the pharynx, as a rule, without tuberculous lesion of that part. Eustace Smith (London Lancet, May 25, '95). Instance of tuberculous inoculation through a small wound on the chin by kisses of tuberculous mother. In this case cutaneous tuberculosis was followed by a tuberculous lymphangitis. Eemy (Jour, de Clin, et de Ther. Infantile, Mar. 14, '95). [If the mother were tuberculous, there is a reasonable doubt that her offspring was a "healthy child," as stated in the original article. C. Sumistee Wither- STINE.] Pathology. — Usually an entire group of glands is affected. The glands are isolated when the irritation and rapidity of growth are not great; this usually ADENITIS. CHRONIC. PATHOLOGY. 155 occurs in secondary visceral adenitis. In other cases — especially when the glands are superficial, where the adenitis is pri- mary — the glands are united into a large lobulated and irregular mass, the size of which may vary from that of a small nut to that of an orange. If the adenitis follows a visceral tuber- culosis the afEerent lymphatics show, in some cases, signs of tuberculosis, as is the case in pulmonary and mesenteric tuberculous meningitis. Two varieties of lesions are to be noted: 1. Lesions of chronic adenitis affecting the stroma and the elements of the gland, which becomes hypertrophied. 2. Specific lesions of tuberculosis, con- sisting in miliary granulation at first, ending in caseation. As one or the other of these two processes is the more promi- nent, so will the lesion vary in appear- ance. Deep adenitis is never so sclerous as the superficial variety, the latter being characterized by a more vigorous reac- tion. On section of a gland in the early stage of tuberculous infection we find it redder than usual, though at times gray and somewhat translucent. The tiibeiculous granules may be perceived by a glass. They are formed from the vascular and Ij'mphatic vessels foimd in the cortical and medullary portions, and resemble ordinary follicles, but contain many small cells. Caseation rapidly occurs in them, beginning at the centre of the cells, where giant-cells are first formed, proceeding to coagulation-necrosis and caseation. A number of these granula- tions united form the small, yellowish masses, which may be seen by the un- aided eye. Caseation is due to vascular obliteration. The small, yellowish masses, softened at their centres, are surrounded by fibrous tissue due to sclerosis of the stroma of the gland. When this tissue gives way, several masses form a large collection of yellowish, softened material resembling putty. Calcification may occur when the process is very slow. The specific lymphadenitis blocks the lymph-spaces and thus, for a time at least, mechanically prevents the bacilli from penetrating into the general circu- lation. Glands not in the stream become infected, this probably being due to the transportation by migrating cells of the motionless bacillus. However, infection usually takes place in the direction of the lymph-current. As the lymph-spaces are obstructed by inflammation products, and entrance of fresh bacilli into the gland is thus prevented, it is the multi- plication of those already entered into the gland which gives rise to the tuber- culosis. When caseation occurs, nearly all the bacilli have disappeared, but the spores remain, and are capable of repro- ducing the disease. Suppuration is due to a secondary infection by pyogenic micro-organisms. (Senn.) The virus of tubercular adenitis is less potent, for the caseous material of a lymph-gland kills guinea-pigs, while rabbits escape, the latter being less sus- ceptible to tuberculous infection. Taken as a whole, tuberculous aden- itis (a) is a local disease which may frequently undergo (&) spontaneous reso- lution, but which (c) frequently tends to suppuration, the pus being nearly always sterile. It is, however, a constant danger to the system. Chronic adenitis may, in some cases, be due to continued irritation; ulcers; chronic lesions of the skin or mucous membrane of the bones: periosteum; articiTlations; chronic inflammation of the viscera; and certain new growths where the adenitis is purely irritative and not yet specific. 156 ADENITIS. CHRONIC. PROGNOSIS. TREATMENT. Researches on the relation existing between caries of the teeth and simple chronic and tuberculous adenitis in chil- dren. In 41 per cent, of the children examined no etiological factor for cer- vical adenitis found except concomitant dental caries. Caries of the teeth to be locked upon as relatively the most im- portant cause of cervical adenitis in children. H. Stark (Beit. z. klin. Chir., vol. xvi, No. 1, p. 61, '96). Prognosis. — A chronic adenitis may end in resolution, suppuration — casea- tion (see Pathology), cretaceous for- mation, or cyst-formation. If all the tuberculous matter can be eliminated, either by nature or art, a recovery may be obtained. The deeper glands are more dangerous than the superficial, as they are extirpated with more difficulty. The great danger of local tuberculous adenitis is that it may give rise to other tubereiUous lesions, either local (pulmo- nary phthisis, tuberculous osteitis, white swellings, or abscesses) or general (gen- eralized tuberculosis, with rapid death). Acute miliary tuberculosis may be caused in two ways: either by convey- ance through the lymphatic system un- til the venous system is reached or by the perforation of a vein and the en- trance of tuberculous material. (Wei- gert.) Treatment. — The general treatment should receive considerable attention. Good food, country air, and sea-bathing are of the greatest value. The sea-shore advised for a short time, — not longer than two months, — after which tuberculous children fall back into their previous condition from loss of appetite. Iscovesco (La Seniaine M6d., Sept. 17, '90). Aeropathy and salt-water baths are useful in the treatment of local tubercu- losis. The children are in the open air all day, playing on the beach. A climate of mild temperature should be selected, one allowing patients to partake of the baths surcharged with chloride of so- dium the year around. Of eight patients suffering with Pott's disease, coxalgia, and scrofulous glands, si.x were cured. The others improved in the course of a few months. Frangois Hue (La Nor- mandie Med., Apr. 15, '91). In peribronchial adenitis the same general methods are to be resorted to. When due to tuberculosis and kindred diatheses and uncomplicated by fever or involvement of lung-tissue, the sea-shore or the country is indicated. At the sea- side children should not bathe in the sea, and should be as quiet as is consistent with life in the open air. Brisk frictions, milk, a nutritious diet, and iodotannic syrup (2 to 4 teaspoonfuls per day) are effectual measures. After three to four weeks, emulsion of calcium lactophos- phate and codliver-oil should be given. Counter-irritation between the shoulder- blades favors the curative action of the other remedies (Marfan). Applications of tincture of iodine between the shoul- ders, or in some cases blisters or, even better, ignipuncture, will fulfill the latter indications. Iron-iodide syrup, iodotan- nic syrup, iodine tincture, potassium iodide, or large doses of codliver-oil, either alone or with cinchona-wine, ar- senic, or arseniate of sodium are the standard remedies usually recommended in these conditions. Not much is to be expected from them, however, unless out- door life is insisted upon. Every case of cervical adenitis coming under observation tested. Tuberculin used was 1-per-eent. solution of Koch's original product. If in from six to twenty-four hours after injection there occurred weakness, sensations of heat and cold, general malaise, nausea, ano- rexia, severe headache, pain in back and limbs, and if these symptoms were sharply defined in both their beginning and ending, reaction was considered to have occurred. All cases were prac- tically without fever at time of injec- ADENITIS. CHRONIC. TREATMENT. 157 tions. No bad results followed. In only | one case was reaction excessive. It gen- erally occurred in from 8 to 14 hours after injection and continued from 12 to 36 hours. From 1 to 5 milligrammes | constituted usual dose. On 29 cases there were positive reactions in 18 and doubtful in 2. In 6 of 11 cases in which there was no reaction glands had been enlarged only for from 1 to 3 weeks. In majority of positive cases they had existed for six months or more. Of the 29 patients studied, 22 were females. In 17 patients diseased glands were on left side. General and local treatment ad- vised in positive cases, local treatment consisting in excision of glands when possible, or free incision and drainage when suppuration has taken place. Ed- ward O. Otis (Phila. Med. Jour., July 16, '98). Extirpation is recommended, but the possibility of giving rise to a tuberculous process elsewhere by facilitating absorp- tion through exposed tissues should be borne in mind. Senn states that early operative inter- ference is as necessary in the treatment of tubercular adenitis as in the treat- ment of malignant tumors, and holds out more encouragement, so far as a permanent cure is concerned. Tillmann argues that glandular tuberculosis should be operated as soon as possible, in order to prevent general miliary tuberculosis by the passage of the bacilli into the system. Immediate excision of infected glands in tubercular inguinal adenitis advised. Brault (Lyon Medical, No. 10, '94). 1. Whenever fluid — that is, pus — can be detected in connection with a diseased lymphatic gland, the operation should be done before th§ skin becomes red and thin. 2. When the diseased gland is subcutaneous — that is, not beneath the deep fascia or muscle, and has been com- pletely removed — the least scar will re- sult if neither stitches nor drainage-tube be used, especially if it be possible to leave the wound uncovered by dressing and exposed to the air, so that the edges may be drawn and glued together by drying lymph. 3. If the diseased gland be beneath the muscle or muscular fascia, then a drainage-tube must be used and the edges of the wound must be united by suture. The best drainage-tube is the gilt spiral wire, especially as it may have to remain from two to eight or ten weeks, according to the depth of the wound or the completeness of the removal of the gland. 4. Where many glands have to be removed, it is better to remove them through a series of small incisions and thereby avoid very extensive ones. Con- sidering the subject from a pathological point of view, all sinuses and suppurating cavities should be thoroughly cleansed by means of scraper and lint, so as to leave a fresh surface free from granulation or decayed or decaying tissue, and a drain- age-exit should be maintained until all the deep parts are healed. Teale (Brit. Med. Jour., No. 1717, '93). Extirpation is indicated when internal medication has failed; when glands in- volve the face and produce deformity; when they are isolated and not numer- ous; when they have undergone fibrous degeneration; when they are not freely suppurating. It is contra-indicated when there is impaired general health and tubercular deposits in the lungs and joints; when ramifications of glandular chain are very extensive. Le Dentu (Revue Int. de Med. et de Chir., Sept. 10, '95). [To be of real value extirpation must be done before infection has extended beyond the glands involved, else the in- fection will proceed, nevertheless, to generalization. When done later, it may prevent that secondary infection which follows from an overswollen or suppurat- ing gland, and may be of cosmetic value; that is, to prevent unsightly and exten- sive scars. C. Sumner Witheestine, Assoc. Ed., Annual, '96.] Sternal adenitis falls into three groups due to the anatomical position, whose principal symptoms are as follow: I. Deep adenitis; phenomena of constric- tion; extension to the mediastinum and the axilla. 2. Medium adenitis; no phe- 158 ADENITIS. CHRONIC. TREATMENT. nomena of constriction; position, sub- sternal; deep cicatrix, retrosternal. 3. Superficial adenitis; position, prester- nal. Maurice Patel (Gaz. Hebdom., Sept. 16, 1900). Tuberculous adenitis of the cervical region is almost always local, and takes place through the buccal cavity. A suppurating gland is always dangerous, and should be removed entirely. Small groups or single, slowly growing glands are likewise to be removed. Nature will provide a new and equally perfect pro- tection against external invasion, to take the place of the glands that are lost by operative procedures. H. Horace Grant (N. Y. Med. Jour., Oct. 20, 1900). Sigmoid incision for the removal of cervical glands. (Senn.) After incision, thorough curetting followed by iodoformization and closure should be performed. The wonnd should be drained. The operator should not only feel, but see, €Yery gland he re- moYes. In cervical adenitis an S-shaped incision gives more room and a better cicatrix. (Senn.) In other regions the incision should be made so as to bring its axis parallel with the cutaneous folds. Local recur- rence should be treated in the same way. Three or foiir operations in as many years have been performed by Senn on the same patient, with final successful result. One thousand cases of extirpation of tuberculous glands, without a single case of pyfemia or septicaemia and only two cases of erysipelas, in both of which the infection was traced to a nurse. One of the best eriterions of the success is the ever-increasing number of patients who present themselves for operation, and who nearly all enter the hospital asking for the removal of their enlarged glands. Milton (St. Thomas's Hospital Reports, vol. viii) . Out of 3.35 children treated, the tuber- culous glands were removed in 102. The operated cases gave a percentage of 83.34 cured, and the non-operated 68.77 per cent.; that is, 14.56 per cent, in favor of the operation. Generalization of the disease could be found only in 1 per cent, of the cases. Cazin (Lyon M6d., Jan. 11, "90). Five hundred and six cases: 286 oper- ated; 220 medically treated. Of the operated cases 149 were carefully fol- lowed during three years; 93 (62.4 per cent.) have not shown the least sign of return of the affection. In the re- maining 56 cases there was a return. Of the 149 non-operated cases, 28 died in sixteen years (18 per cent.) from general tuberculosis, and 14 are still alive, but have developed pulmonary tuberculosis. Von Noorden (Schmidt's Jiihrbticher, July, '90). When many glands are involved and suppuration has occurred, or when peri- adenitis is present, excision is not to be recommended, as extensive connective- tissue infiltration renders it impossible to remove all the infected tissue. Sub- cutaneous extirpation may be resorted to, but the method allows of but imperfect evacuation of the glandular contents and can hardly be recommended. Subcutaneous extirpation. Incision at the nape of neck, beginning on a level with the external auditory meatus, 1 centimetre from hairy border, and pass- ing with a slight convexity downward 5 centimetres backward, downward toward the median line. Dollinger (Cent. f. Chir., No. 36, '94) . ADENITIS. CHRONIC. TREATMENT. 159 Drainage of the abscess is a measure which may be recommended for many reasons. A small incision is sufficient for all purposes, and there is practically no scar left. Observations upon 170 cases of tu- berculous cervical adenitis show the disease to be more prevalent among negroes than among whites, males pre- ponderating over females in the propor- tion of 3 to 2, the majority being be- tween 10 and 30 years of age. A family history of tuberculosis was present in about half the cases, though only 4 per cent, showed positive evidence of the disease in the lungs. The condition is regarded as a local manifestation of infection through the tonsil, adenoids, or carious teeth, and the tuberculin test in diagnosis was found to be reliable and harmless. After discussing the constitutional, local, and conservative operative treatment by curetting, par- tial excision, and application of iodo- form, the radical operation for removal of all the glands and surrounding fat is described as follows: By a T-shaped incision, the long arm of which curving forward over the sterno-mastoid muscle and starting from the mastoid process joins the short arm along the clavicle, the dissection is carried from below up- ward and outward from the middle line, the external jugular vein being tied and divided. The omohyoid muscle is then divided, and by using it as a retractor the internal jugular vein is exposed and the sterno-mastoid muscle pulled aside. In dissecting out the mass of glands the greatest difficulty is experienced with the chain connecting the anterior and posterior triangles behind the sterno-mastoid muscle, as the spinal ac- cessory nerve passes through the mass and is generally very adherent. It is only when there is very extensive mis- chief that it becomes necessary to di- vide the sterno-mastoid muscle or spinal 1 accessory nerve, or even to tie and divide the internal jugular vein, and these steps should only be resorted to when the advantages of free exposure outweigh other considerations. The wound is closed with a subcutaneous silver suture and drained at its most dependent part and the resulting scar is usually slight. Mitchell (Bull. Johns Hopkins Hosp., July, 1902). Less radical measures sometimes bring about a cure. A transformation of the tuberculous tissues into a sclerotic mass may be obtained. A solution of chloride of zinc injected about the tuberculous foci excites a growth of new fibrous tissue, which encapsulates the diseased portion. Twenty-three patients suffering with joint and gland tuberculosis treated in this manner. Fibrous-tissue formation occurred in every case. Injections made of 2 to 5 drops of a 10-per-cent. solution of the zinc chloride, and often repeated. Lannelongue (Le Bull. Med., July 8, '91). Solutions of iodoform and ether, after Verneuil, in cases where operative pro- cedures are indicated, give a lasting cure, without a cicatrix. These injections seem to exert a beneficial action, not only on the tuberculous glands treated, but also on those at a distance from the seat of the injection. Impure glycerin always contains a certain amount of formic acid. In the treatment of tuberculosis by the iodo- form-glycerin injections the irritating properties of the formic acid may have some share in the curative effects of iodo- form emulsions. Iodoform itself in the body is converted by oxidation into formic acid and hydriodic acid. When oxidation is sufficiently active to decom- pose it, iodoform is more effective than when oxidation is feeble. Hence formic acid added to iodoform emulsions should be effective. Favorable results where iodoform has proved ineffective. In eases of tuberculous adenitis and in one ease of tuberculous arthritis of the ankle-joint formic acid used alone, the formate of soda in solution being injected. Excel- lent results obtained. Senger (Deutsche med. Woch., No. 17, '91). Camphor-naphthol has proved valu- able in some cases. It is claimed in favor of camphor- naphthol that there is no danger of 160 ADENITIS. CHRONIC. intoxication and that the treatment is almost painless. Menard and Calot, how- ever, have reported cases of intoxication following injection of camphor-naphthol into abscess-cavities. The patient suf- fered from frequent rapid pulse, loss of consciousness, and epileptiform attacks. The quantity of the drug injected was about 6 drachms. This patient recov- ered. In another case, 8 years of age, 1 V2 ounces of the solution were injected. In the third case, aged 12, 5 drachms. In the last two cases life was saved by freely opening the cavity and washing it out on the first appearance of toxic symptoms. Camphorated naphtliol is prepared and used as follows: — IJ Betanaphthol, Camphor, of each, 10 parts. Alcohol (60 per cent.), 40 parts. A few drops are to be antiseptically injected here and there throughout the mass of indurated glands. Courtin (Jour, de Med. de Bordeaux, May 17, '91). Of 47 cases 28 were cured and 19 im- proved. Reboul (Marseille-medical, Jan. 30, '91). Camphorated naphthol recommended (1) for dressings, (2) in cases of recur- rence after excision, (3) in cutaneous gummata of the face, and (4) in subjects with an inoperable tuberculous mass. In the last cases the injections gave a result not obtainable by any other method. Moty (La France Med., July 9, '93). Solution of lactic acid recommended as a parenchymatous injection, beginning with weak solutions of not more than 15- or 20-per-cent. strength, and gradu- ally increasing to 35- or 40-per-eent. strength. A 15-per-cent. solution of the lactic acid alone generally causes con- siderable suffering, but when combined with from 2 to 5 per cent, of carbolic acid it causes but little pain. Twenty or 30 minims of the solution injected, then withdrawn after a few minutes, re- peating in a week or two. E. F. Ingals (Inter. Med. Mag., June, '96). Interstitial injections, frequently rec- ommended, usually fail or cause suppura- tion, owing to the fact that the tincture of iodine is employed. Metallic iodine, however, gives a better result. Metallic iodine has a special affinity for tuberculous glands. Eight or ten ap- plications usually insure cure, provided the cavity is filled with crystals. Guer- monprez (Gaz. des Hop., June 25, '95). C. SUMNEE WiTHEESTINE, Philadelphia. ADENOID VEGETATIONS. See Kaso-phaetns. ADENOMA. See Tumors. ADIPOSIS. See Fatty Heaet and Obesity. ADONIS. — Adonis is a ranunculace- ous plant, closely related to the anemone, growing wild in Europe, Asia, and Africa. Several species of adonis are employed, — - Adonis vernalis, A. cestivalis, A. capeusis, A. cupaniana, and A. amurensis, — but all seem to possess the same properties, although the several varieties are vari- ously employed in the different countries in which they grow. In Eussia, for in- stance, it has long been employed in cardiac diseases, and in Africa as a substitute for cantharides, the bruised leaves, when fresh, possessing vesicating properties. Dose. — An infiision of 4 to 8 parts of the plant in 200 of water may be given in tablespoonful doses three or four times a day (Huchard). The tincture may be administered in doses of ^/„ to 1 drachm. Adonidin, a glucoside of adonis, is ad- ministered in doses varying from ^/„o to Vio grain. It acts more promptly than digitalis. (H. C. Wood.) Physiological Action. — Adonis resem- bles digitalis in its action upon the heart. AGALACTIA. 161 It increases the cardiac energy and gives rise secondarily to an increase of arterial tension. The increased contractions eventually diminish and a period of quiet follows, varying in duration with the dose administered. Cervello isolated a glucoside from Adonis vernalis, — adonidin, — a yellow powder having a bitter taste, obtained from the leaves. It is soluble in water and alcohol, but insoluble in ether or chloroform. Inoko also obtained a glucoside — adonin — from the Japanese plant, Adonis amunnsis. This substance is free from nitrogen, amorphous, colorless, of a bitter taste, and soluble in water, alcohol, and chloroform. The symptoms observed on the heart of a frog were pre- cisely those seen when digitaline is used. It is about twenty times weaker than the adonidin obtained from the European Adonis vernalis. Adonis Poisoning, — In poisonous doses adonis paralyzes the peripheral extremi- ties of the vagus, tends to excite the ac- celerator system, and it finally produces paralysis of the cardiomotor nerves. Therapeutics. — Adonis is useful in cases of uncompensated heart affection in which grave circulator)' disorders exist. The marked diuretic powers of the drug cause it to be of value in cases of dropsy and fatty heart. It is also valuable in palpitation dependent upon irregular in- hibition and in aortic and mitral regurgi- tation (Oliver, Wood). As it does not seem to possess cumulative tendencies, it may be administered with more freedom. Adonis vernalis used in thirty-three cases. It will sometimes succeed where digitalis has completely failed, but it is often not given in sufficiently large dose. Case illustrative of the tolerance of large doses of the infusion. Boy-Teissier (Marseille-medical, Mar. 30, 'SS). Adonis employed in a large number af eases of different cardiac disorders. One drachm to one ounce of the infusion daily constitutes an excellent cardiac tonic. In fatty degeneration of the heart it in- creases diuresis and regulates the circu- lation. In many cases of heart disease the drug is effective when digitalis is useless or injurious. F. Borgiotti (Deutsche med.-Zeit., Aug. 30, '88). Obesity. — As a remedy for the reduc- tion of superfluous adipose tissue, adonis aestivalis has proved of value. Owing to the fact that it does not possess a tend- ency to cumulation, it may be continued for a long time. Case in which the patient weighed 342 pounds and suffered severely from dyspnoea when the administration of adonis was begun. After taking 10 drops of the tincture three times daily for twelve days there was a loss in weight of 17 pounds, the respiration had become easier, and there was general euphoria. R. Kessler (Amer. Medico-Surg. Bull., Aug. 15, '94). EpiUpsy. — To reduce the active cere- bral hypersemia present during a par- oxysm, adonis has been recommended, owing to its power of stimulating the vasoconstrictors. It may be advanta- geously combined with the bromides. Several years of the use of adonis vernalis have shown its ability to cause almost immediate cessation of the fits in some eases. Bechterew (Neurol. Centralb., Dec. 1, '94). AGALACTIA. — From a, priv., and yala. milk. Definition. — Absence of the mammary secretion after parturition. The term is generally understood as meaning defect- ive lactation, especiallj' as to quantity. Symptoms. — Absence of the mammary secretion after labor is rarely observed. The appearance of milk may be delayed days and even weeks, but evidence of functional activity usually appears, al- though frequently the quantity secreted 162 AGALACTIA. ETIOLOGY. PATHOLOGY. TREATMENT. is insufficient or the quality of the milk is not of a character to afford sufficient or proper nourishment to the infant. Statistics of 126 lying-in women in the obstetrical wards of the Halle clinic from February to May, 1895, inclusive. Out of the 126 cases, 83 (or 65.9 per cent.) had sufficient milk when discharged be- tween the tenth and twelfth days. Buch- mann (Centralb. f. Gynak., No. 25, '96). Deficiency of secretion may occur from the start and continue throughout the entire period of lactation, or it may be normal in amount at first and gradually diminish. Etiology. — Heredity is a prominent factor in case of tru« agalactia. Puech has reported the case of a woman who had given birth to thirteen children, but whose breasts, though normal, had never yielded milk. Her mother, who had given birth to twenty-three children, had likewise been absolutely sterile as regards the secretion of milk. Case of complete agalactia in a woman, aged 25, primipara, whose mother is living and in good health, having borne 9 children, 3 of whom are now living; 4 died at about five years of age, 1 at eight, and 1 at twelve months. The patient is the eighth child, and says her mother has often told her that in none of these puer- peria had she any milk, although the breasts were natural in appearance. The patient has one married sister, who at 25 years gave birth to a full-term child, and she never had a drop of milk for her baby. J. Ives Edgerton (Med. News, Feb. 6, '97). General ill health in which anemia plays the leading role is the most fre- quent cause of retarded, defective, or imperfect lactation. Lack of confidence, on the part of the mother, of her ability to nurse; excitement, fatigue, highly spiced food, overfeeding, and insufficient sleep may be mentioned as the most fre- quent auxiliary factors. Injudicious dressing whereby the mammas are compressed, the pressure interfering with their circulation and proper nutrition, is a frequent cause of deficient lactation. Advanced age, especially in women who have suffered frequently from miscarriages, may also be included among the etiological fac- tors. The habit of weaning early or avoiding lactation tends to cause atrophy of the breasts and to repress the lacteal secretion. Prolonged suckling, specific affections, and iodide of potassium are also consid- ered as causes of mammary atrophy, and, therefore, of deficient lactation powers. Intercurrent affections, especially when acute, frequently arrest the flow of -milk. High fever, when temporary, usually causes diminution of the secre- tion for the time being, and it may act as the primary factor of gradual cessa- tion. Pathology, — When there is total ab- sence of mammary secretion, both breasts are usually affected. When the secretion is only defective, the involvement of the glands in the pathogenic process, local or general, is usually unequal, one mamma being less productive than the other. Large breasts, owing to the quantity of adipose tissue present, are more likely to be agalactic than the smaller and thinner ones. The ducts and glands are usually found deficient in number and size, while the adipose tissue or the fibrous stroma is unduly abundant. Treatment. — The first indication is to carefully inquire into the cause of the condition. In the majority of cases there is general deficiency in the per- formance of metabolic processes due to general physical apathy. The patient should, therefore, be provided with nutritious food and appropriate tonics, especially strychnine, which is peculiarly effective in these eases. AGALACTIA. TREATMENT. 163 The bowels should be regulated by proper dieting and massage or exercise rather than by laxatives, and it is highly desirable that there should be at night uninterrupted sleep for six hours for mother and child. Galactagogues are valueless in the ma- jority of cases, most of them exerting practically no influence upon the gland. Occasionally a slight stimulating effect may be noted, but this lasts only a short time, and the organ soon lapses into its former torpor. Beer, ale, porter, and other malt liquors, especially alcoholic beverages, are more hurtful than beneficial, and what improvement may show itself is due mainly to the confidence in the bev- erage taken, through the agency of auto- suggestion. The quantity of milk may be increased, but its quality is compro- mised, especially when poor beer is con- sumed by the mother. It encourages the production of fat at the expense of the casein or milk-sugar. Pure malt may be substituted with great advantage. It is an error to suppose that stout or porter improves milk. Another error is the belief that beef-tea and chicken-broth are good for nursing mothers. Angel Money (Austral. Med. Gaz., Jan. 20, '97). Somatose exercises a specific effect upon the mammary glands of nursing mothers; it produces an ample secretion of the mother's milk, and causes the ail- ments occurring during nursing to disap- pear quickly. The dose consists of 1 tea- spoonful in a cup of warm milk, soup, cocoa, etc., from three to four times a day. Felix Heymann (Deut. med.-Zeit., Nos. 59, 63, '98). Probably the mcst satisfactory among the galactagogues is jaborandi. The fluid extract or the tincture may be given in ^/o-drachm doses. The active perspiration and salivation produced are objectionable, however, while the effects of the remedy are not lasting. Case where the administration of 10 drops of the fluid extract of jaborandi every four hours to a patient whose milk had ceased for a fortnight effected a re- establishment of the secretion. The pa- tient, however, soon began to suffer from extreme nervous excitement with delu- sions. On stopping the jaborandi the nervous and mental symptoms disap- peared and also the secretion of milk. Waugh (Lancet, Dec. 24, '87). Castor-oil leaves have always borne considerable reputation. A decoction is made by boiling well a handful of them in 3 to 4 quarts of pure water. The breasts are bathed with this decoction for fifteen to twenty minutes. Part of the boiled leaves is then thinly spread over the breast and allowed to remain until all moisture has been removed from them by evaporation, and probably, in some measure, by absorption. The pro- cedure is repeated at short intervals until the milk flows upon suction by the child, which it usually does in the course of a few hours. (Eouth.) Galega is credited with galactagogue properties, Va to 1 drachm of the dried leaves being administered daily. Electricity sometimes proves effective. A mild current (3 to 5 milliamperes) is passed through each breast after care- fully wetting the sponges in salt-water and applying them on each side of the gland. By changing the position of the electrodes, every minute or so, to a neighboring spot, all the acini may be traversed by the current during a sitting ■of ten minutes. The applications should be made every two or three hours. A strong current is more hurtful than beneficial. Artificial suction with the breast-pump and massage are greatly used. The extract of thyroid gland has recently given very satisfactory results. Nine cases showing the value of thy- roid-gland extract as a galactagogue, the object being to increase the activity of 1G4 AGALACTIA. the metabolic processes. In one of the cases the administration of four tabloids was sufficient to restore the lacteal se- cretion, which continued as long as the tabloids were regularly taken. Neglect of the tabloid caused the milk to fail. In six cases the milk-supply returned in three days and became plentiful. In two, no influence on the milk observed, the patients being delicate, nervous, and worn out. E. R. Stawell (Intercolonial Med. Jour., Apr. 20, '97). As to the diet, it should he as gen- erous as the patient can digest. There is little to be gained by the common practice of prescribing two or three extra meals a day. The milk-supply as well as the general health of the woman will depend more upon what she digests and assimilates than upon the amount of food taken into the stomach. Three daily meals with, at most, a single liquid meal at bed-time, will generally be better than &Ye or six. Milk should constitute a portion of the dietary. The difficulty in digesting milk, of which many patients complain, is, for the most part, imagi- nary. If taken as a part of the meal and not in addition to it, it will, as a rule, be well borne. Frequently patients who •cannot use cold milk can take it hot without difficulty. The secretion of milk is said to be greatly diminished by fatty food. A vegetable diet reduces the proportion of butter and casein and diminishes the sugar. A meat diet has the opposite effect. Systematic nursing with strict obseryance of stated intervals is essential for its influence upon both the quantity and quality of the milk-secretion. {Charles Jewett.) C. SUMNEE "WlTHEESTINE, Philadelphia. AG ASIC IN. — Agaricin is obtained from white agaric. It is a white, crys- talline powder, soluble in alcohol, and but slightly so in cold water and ether. Agaricic acid, the pure active principle of agaricin, is generally used. Dose. — The dose of agaricic acid is ^/„ to V2 grain, administered in pills. Hypo- dermically its effects are more active and the dose should be one-half smaller. Physioloi^cal Action. — ^The physiolog- ical effects of this drug are not known, but they are supposed to resemble those of pilocarpine, or to act mainly upon the nervous supply of the sweat-glands. Agaricin checks pathological sweating, not by a central action, but by directly influencing the glands themselves. In this only does it resemble atropine. Small doses, Vs to 'A grain, preferred to a single large dose. The action is slow, but lasts a long while. Hofmeister (Ar- chiv f. Exp. Path, und Pharm., vol. xxv, '89). Therapeutics. — Agaricin is especially valuable in the treatment of the night- sweats of phthisis. If the gastric diges- tion is good, it will be well tolerated and produce its effects in from two to six hours. Administered before retiring, it sometimes acts as a preventive of the exhausting perspiration attending ad- vanced cases. It is not effective in all cases, however. (Hare, Butler.) Sweat is always decreased, thirst and the excretion of the urine are dimin- ished, the functions of the lungs and skin are not interfered with, and there are no bad efi:eets. The administration of pure agaricic acid greatly lessens the danger of vomiting and purging. The subcutaneous injection of the soluble sodium salts should not be used, as vio- lent inflammation may follow. W. T. Thackeray (Chicago Med. Jour, and Ex- aminer, June, '89). Seventeen cases in which agaricin was found to possess most excellent anti- sudorifle properties, the effect being pro- nounced not only in tuberculosis, but in other forms of poisoning and infection. This agent, even in the third stage of pulmonary tuberculosis, was able to AGARICIX. 165 suppress the distressing night-sweats, its action being manifested in from two to six hours after the ingestion of the drug and lasting about six hours. No evil after-effects of any kind were observed. The dose employed was from 'A to Vi grain in pill form. Combemale (Bull. G6n. de Th6r., May 30, '91). Agaricin most successful of all drugs in combating night-sweats in phthisis. Its active principle, agaricic acid, may be used in ^Z,- to 1-grain doses. Method of administering which has given most ex- cellent results is as follows: Give Vs grain at first dose and follow with Vs grain every four hours until the sweating is checked, then continuing its use — but lengthening the interval — until the small- est quantity necessary to control sweat- ing is reached. Eufus D. Boss (Amer. Therap., Mar., '98). Minute doses are sometimes as effect- ive as the larger ones, and had better be tried before resorting to the full doses. Agaricin in pill form, in doses of 'A, grain at bed-time, or given late in the afternoon and repeated in four or five hours, was the most successful of all the drugs used in the night-sweats of pul- monary tuberculosis. Conkling (Brook- lyn Med. Jour., July, '94). AGRAPHIA. See Aphasia. AINHUM. — African word meaning "to saw ofE." Definition. — Ainhum is a disease oc- curring exclusiTcly in negroes and con- sisting in the spontaneous amputation of the little toe by an adventitious fibrous band. Symptoms. — The first indication of the disease is a furrow on the lower surface of the little toe, and occasionally other toes, at the proximal interphalangeal joint. This furrow, the result of the circumferential pressure exerted by a fibrous ring, gradually deepens until the bone is reached, this process taking sev- eral years, sometimes as many as ten. The distal portion of the toe becomes greatly hypertrophied, then finally drops off, the stump healing without further complication in the great majority of eases. It does not give rise to much suf- fering, owing to its very gradual progress. It is sometimes mistaken for leprosy. Ainhum is an affection apart from leprosy. Cases of circular constriction in leprosy are exceedingly uncommon, are always located on the fingers, and are always accompanied by other morbid manifestations, which indicate a more or less intense infection of the blood by the virus or a localization of the affection in the nerves, the skin, or the mucous membrane. H. de Brun (Bull, de I'Acad. de Med., Aug. 25, '96) . Etiology. — Ainhum is always observed in negToes, especially of the western coasts of Africa and South America. A number of cases have also been reported in the United States by Bringier. Hin- doos are said to also suffer from this disease. Self-mutilation has been sug- gested by some observers, but the like- lihood of this cause is very slight. Heredity does not seem to play any role in its production. Pathology. — The lesions observed have been hypertrophic thickening and retraction of the derma, with consequent atrophy of the underlying bone (Her- mann, Weber, Wucherer, Schllppel). It has been confounded with congenital amputation, but, as stated, ainhum is never congenital. That the disease bears some connection with leprosy is insisted upon by some authorities. In all cases of true ainhum undoubted symptoms of leprosy are present. It should be looked upon as an attenuated form of the latter disease. Its relations to scleroderma are explained by the fact that this latter affection is a special for>3 of leprosy. Zambaco Pacha (Bull, de I'Acad. de M6d., July 28, '96). Treatment. — Surgical measures alone prove of value in these cases. Early 166 AIROL. PEEPAKATIOXS. POISONING. THERAPEUTICS. section of the fibrous ring is sometimes sufficient to arrest the progress of the disease or division of the skin down to the periosteum on the opposite of the seat of disease may be resorted to. Case successfully treated by dividing the skin and all the tissues down to the periosteum, on the side opposite to the seat of the disease. Murray (Lancet, Jan. 30, '92) . AIEOL. — Airol is a compound of der- matol and iodine discovered and intro- duced by Llidy as a substitute for io- doform. It occurs as a tasteless and odorless powder, unaffected by light, and containing 44.5 per cent. BioOj and 24.8 per cent, of iodine; its color is gray- green, but moist air or the discharge from a wound rapiidly converts it into a red substance, with liberation of iodine. It is insoluble in ordinary reagents, but readily dissolves in strong caustic soda or weak mineral acids. Preparations and Dose, — The powder is employed in the same manner as iodo- form in the treatment of superficial lesions. It has also been used dissolved in glyc- erin, but Aemmer has recently shown that the poisonous efEects of the drug were thus increased. Bruns, of Tiibingen, recommends airol paste as an ideal dressing for sutured wounds. It dries rapidly and adheres closely; it is powerfully antiseptic, and absolutely unirritating to the most sen- sitive skin; but its chief advantage is that it permits the secretions to ooze through it. He has used it for six months, especially after laparotomies, herniotomies, and ignipunctures, and did not observe an instance of stitch-hole suppuration with it. He concludes that occlusion with airol paste furnishes the simplest means of obtaining healing by first intention. His formula is: Airol, mucilaginous gum arable, glycerin, of each, 10 parts; bolus albus, 20 parts. He employs it even in wounds with drainage. Airol Poisoning. — The untoward ef- fects of airol were recently shown in a case treated by Aemmer: after using injections of iodoform-oil without benefit in an abscess resulting from hip disease, this surgeon evacuated the pus and in- jected 9 drachms of a 10-per-cent. emul- sion of airol in equal parts of olive-oil and glycerin. The immediate efEects were acute local pain, headache, and coryza; but three days afterward symp- toms of bismuth poisoning supervened: foetid breath, blackish line on the gums; swelling, tenderness, and idceration of the lips, gums, and pharynx interfering with mastication and deglutition; head- ache, anorexia, nausea, and prostration. To relieve these symptoms, which were becoming more serious, it was necessary to open the abscess and remove the emiil- sion of airol. The patient rapidly grew better, but a slate-colored pigmentation of the buccal mucous membrane per- sisted for a month. Aemmer has found that a certain quantity of airol is dis- solved by glycerin, and that intoxication is, no doubt, favored thereby. It is, therefore, better not to use glycerin in combination with airol. Goldfarb has also drawn attention to the fact that applications of airol are sometimes very badly tolerated. Zelenski found that its use on a burn was followed by intense jDain and the formation of large bullae containing yellow fluid, and that a sup- pository containing 3 grains of airol introduced into an anal fistula caused suffering comparable to the red-hot iron. Therapeutics. — The delay in the growth of organisms produced by airol is slightly greater than that resulting from iodoform, and infinitely more than AIROL. THERAPEUTICS. 167 the effect of dermatol. It is found that the iniluence of antiseptic powders is greater the earlier their use is com- menced; in acute phlegmonous proc- esses, however, they do but little good, while, the more chronic the inflamma- tion, the better the results obtained, whence their special indication in tuber- culosis. The two great advantages in this respect which airol has over iodo- form are: first, the fact that a small quantity of its iodine is liberated as soon as it comes in contact with the tissues, and, secondly, that the presence of bis- muth exercises a powerful desiccating influence upon the secretion, thereby greatly aiding antisepsis. Two thousand cases treated with airol not one of which showed sign of bismuth poisoning. Airol gauze (20 per cent.) also employed as a dry dressing. Its value is particularly striking in super- ficial lesions, such as ulcers and burns. In tuberculous abscesses the form em- ployed is a 10-per-cent. emulsion in equal parts of glycerin and water. It is ex- tremely bulky, being four times as light as iodoform, and twice as light as derma- tol. Haegler (Brit. Med. Jour., Apr. 24, '97). In treating wounds the paste is per- fectly unirritating and non-toxic, dries rapidly, and adheres firmly, and pos- sesses hygroscopic and antiseptic quali- ties which render it superior to any other preparation. The paste is equally adapted to all parts of the body, and the dressings cannot become loose or movable. V. Bruns gives the following formula: — R Airol, 1 drachm. Mucilage, 2 drachms. Glycerin, 2 drachms. Argilla alba (kaolin), sufficient to make a soft paste. If the paste becomes too dry, glycerin may be added; if it be too soft, kaolin should be rubbed up with it. No metal instruments should be employed in pre- paring the paste, since many metals liberate iodine from airol. For the same reason no water, but always glycerin, is to be used in the preparation. The paste is preserved in well-stoppered glass or porcelain jars, which are not to be left open after use. Honsell (Deut. med. Woch., xxvii, No. 17, 1901). Disorders of the Skin. — It is in this class of affections that airol is most effective. In ulcers, eczema, and inter- trigo its beneficial influence has been conspicuous. Leprosy has recently been added to the list. One case, however, is hardly sufficient to warrant much confidence. Remarkable improvement in a case of typical leprosy of five years' standing, consequent on the use of airol dusted on the ulcers and open abscesses, together with a 10-per-cent. vaseliu ointment ap- plied to the conjunctivse and injected into localities where softening had com- menced. Tonics were also prescribed and general massage practiced. The drug was well borne, but the gums became dis- colored by the bismuth in the airol, and when very large doses were given a cer- tain degree of prostration was observed. Fornara (Lancet, July 3, '97). DiARRHCEA. — Airol has recently been tried by Italian ph3'sicians in the treat- ment of diarrhoea, the alterative prop- erties of iodine and the antiseptic action of bismuth having suggested its employ- ment. The effects seem to have been satisfactory. In 9 instances of pellagrous intestinal disease, airol, in 5- to 8-grain doses, fre- quently repeated, gave excellent results. Not only its astringent properties should be mentioned, but its iodine content ap- pears to be responsible for the greater part of its good effects. F. Cerato (Gaz. degli Osped. e. delle Clin., No. 142, p. 1502, '98). Suppurative Processes. — In condi- tions accompanied by the destruction of tissue by suppuration — boils, carbuncles, 168 AIROL. ALBUMINURIA. etc. — airol seems to be entitled to recog- nition as a valuable remedy. GoNOERHCEA. — The known value of bismuth in the treatment of catarrhal disorders of mucous membranes due to local infection and the alterative effect of iodine tend to support the claims of airol as an effective remedy for gonor- rhoea. Four cases of gonorrhoea completely cured after three to five injections of an airol solution. The anterior urethra is first washed with a borio-aeid solution. Two and one-half drachms of the follow- ing solution are then injected: — IJ Airol, 30 grains. Glycerin, '/s ounce. Water, 75 minims. This procedure is repeated four or five days in succession. Legueu and Levy (Revue de Thgr., May 15, '96). Special attention called to the value of a 10-per-cent. emulsion of airol in glyc- erin as injection in gonorrhoea. Used in three cases of acute and three of chronic gonorrhoea, all of which have recovered in ten to fourteen days after three to ten injections, never repeated more often than once daily. No toxic efi'ects were observed. Tausig (Wiener med. Presse, Oct. 11, '96). ALBUMINURIA. — From Lat., aTbu- min; and Gr., oiiped', to pass the urine. Definition. — The presence of albumin in the urine. Albuminuria may be true — when the albumin is dissolved in the urine — or spurious, when caused by ad- mixture of semeUj pus, or blood in the urine. Spurious albuminuria is easily distinguished from the true form by the aid of the microscope. Both kinds of albuminuria may occur simultaneously. Domenico Botugno discovered, in 1770, that urine may contain albumin; by boiling a sample of urine he foimd that pure albumin was precipitated. It was long maintained by all authors that albuminuria has always been a symptom of disease, but of late many authorities have admitted that albuminuria may be compatible with perfect health. Posner maintains that albumin is always found in the urine, but normally in too small quantity to be revealed by the ordinary reagents. To demonstrate the presence of albumin in normal urine Posner evaporated large quantities of urine at low temperature and tried the different reagents in the concentrated urine. His experiences have been re- peated and his views supported by Senator and by Leube, who, however, did not find albumin in all cases. Von Noorden, Winternitz, Lecorche, Tala- mon, and different other authors do not admit that albumin is a constituent of the normal urine. At any rate, only traces of albumin can be considered as physiological. Different kinds of albumin may be present in the urine; generally the pro- teids contained in the blood-serum are to be found, — viz.: (1) the serum-albu- min, or serin, and (2) the globulin, or paraglobulin; in most cases both these proteids are present, but in varying pro- portions. In some cases there may also be found (3) hemialbumose, or propep- ton, a mixture of different albumoses which are not precipitated by boiling; (4) nucleo-albumin, which has also er- roneously been called "mucin"; and (5) pepton. Five proteids are found in the urine, viz.: (1) serum-albumin; (2) serum- globulin; (3) nucleo-albumin, or mucin; (4) pepton; (5) albumose, or propep- ton. The first two are of special im- portance because of their association with nephritis. Mucin is usually present normally in small amount in the urine. Pepton and albvimose should never ap- pear in normal urine. Serum-albumin ALBUMINURIA. PHYSIOLOGICAL. 169 in the urine may be due to (1) renal disease or (2) to the pressure of pus, spermatozoa, blood, or elements of tumors. Urine containing these sub- stances will give the albumin-reaction. Renal albuminuria may be divided etiologically into (1) that following cer- tain febrile diseases; (2) nervous albu- minuria, following some diseases of the central nervous system; (3) hsemato- genetie albuminuria; (4) toxic albu- minuria; (5) albuminuria of pregnancy; (6) congestive albuminuria; (7) albu- minuria due to long-continued exposure. The appearance of pepton in the urine is pathological. It is expected in cases of empyema or other extensive pus-for- mations: (I) the ulcerative stage of typhoid fever, (2) suppurative processes, (3) pneumonia at the crisis, (4) after childbirth, (5) in carcinomatous affec- tions, and (6) in phosphorus poisoning. T. P. Prout (Phila. Med. Jour., Feb. 10, 1900). The urine may, of conrse, also contain albumin in connection with hsematima and hemoglobinuria, but such cases can- not be classed as true albuminuria. Physiological Albuminuria. — Eegard- ing the origin of the albumin in the urine only guesses can be made; two theories are possible: (1) the albumin may come from the glomeruli; (2) from the tubular epithelial cells. Formerly the opinion predominated that the fluid which escaped from the glomeruli was albuminous, but that the albumin was absorbed during the passage through the healthy renal tubules, dis- eased tubular epithelium being unable to absorb the albumin. This has not been proved, however, and most modern authors believe that albumin is not contained in the urine coming from the glomeruli, except when these are diseased or when the pressure of blood in the glomeruli is abnormally great. Euneberg, on the contrary, is of the opinion that albuminuria is caused by low pressure of blood, and supports this opinion by experiments with animal membranes, but experiences with dead membranes cannot be regarded as con- clusive for the action of the living kidney. Von Noorden and different other au- thors regard the tubular epithelium as the unique source of albuminuria. These epithelial cells are subject to successive disintegration: when this is minimal and successive traces, only, of albumin are found in the urine, the albuminuria is physiological; when the decaying of the tubular-epithelial cells is augmented and quickened by disease, a morbid albu- minuria takes place. In his opinion, this theory is supported by the fact that nucleo-albumin, of which the protoplasm of the cells undoubtedly is the source, is always found in normal urine. Nucleo-albuminuria always arises from the disintegration of the nuclei of cells that are shed on account of a lesion of the renal epithelium or of an irritation of the vesicle and genito-urinary epithelium. In rare eases it may have an haematic origin. At the same time nucleo- albiunin should be sought for and esti- mated in proportion to the amount of al- bumin whenever its presence is suspected. It should not be confounded with mucin, which exists in very small quantities in the normal urine. Evano (Gaz. Heb. de M6d. et de Chir., Jan. 11, 1900). From a pathological point of view the causes of albuminuria may be divided into three groups: 1. Disturbances of circulation. 2. Changes of the tubular epithelial cells or of the walls of the blood-vessels of the kidney. 3. Changes in the composition of the blood. 1. All disorders of circiTlation causing a venous renal congestion will increase the blood-pressure in the capillaries of the kidney, and may thus give rise to a transudation of albuminous liquid; when 170 ALBUMINURIA. PHYSIOLOGICAL. the congestion is very great the urinary tubules may even be compressed and the escape of the urine rendered difficult. When this is the case and when, also, the supply of arterial blood is dimin- ished, the tubular epithelium will be damaged, and the first result of all this is albuminuria. It is very improbable that arterial congestion ever produces albuminuria, although the experiments of Mimk and Senator tend to prove the contrary. Functional albuminuria may be re- garded as due to vascular changes and as explainable by the mechanical theory. A temporary condition of anoxsemia, whether due to either arterial or venous obstruction, induces albuminuria, through diminished cell-activity and vitality. Results of experiments per- formed upon healthy kidneys prove that albumin is secreted by epithelial cells of glomeruli, in capsule of Bowman, and that retardation of blood-current through the vascular plexus of glomeruli is an essential condition; also that anoxaemia of blood-current of the tuft causes al- buminuria. J. C. Young (Med. Exam- iner, July, '97). 2. Changes of the tubular epithelia and the walls of blood-vessels of the kid- neys maj', as already stated, be due to disorders of circulation, but they may also be caused by different poisons and toxins. When albuminuria is chiefly caused by degeneration of the tubular epithelia, their protoplasm dissolves in the urine, and nucleo-albumin in great quantity is contained in it, combined with serum-albumin and globulin. Urinalysis of 400 cases of variola, show- ing that albuminuria is met with in 95 per cent, of cases, 32 per cent, having abundant albumin. The albuminuria is subject to marked oscillations in amount, and may be absent on certain days. The maximum amount is usually present at the beginning of the febrile period, less commonly during suppuration and desic- cation. The albumin often appears in considerable amount when solid food is first taken and when the patient is allowed to get out of bed. Albumin was present in the urine in 75 per cent, of the cases during convalescence, usually in very small amounts. As a general rule, there was abundant albumin in the se- vere eases. There is no such thing as a distinctive albuminuria of convalescence. The albuminuria is due to a lesion of the kidneys, this lesion being of either the interstitial form or of the epithelial form. Some chronic lesion of the kidneys prac- tically always persists, being, however, extremely slight, as a rule, and causing practically no symptoms. F. Arnaud (Revue de MSd., May 10, '98). Albuminuria accompanying litheemic attacks can only be due to irritation or delicate kidney-structures of child, re- sulting from attempt at elimination from blood of poisonous and irritating prod- ucts which are causes of lithsemie attacks. Not infrequently small quan- tity of albumin found in infants and children suffering from acute lithsemic attacks. Autointoxication is responsible for this albuminuria either in early or late life. In middle or later life it is due to arteriosclerosis developed by this au- tointoxication. Comparative infrequency of lithtemic albuminuria in late child- hood and early adult life is due to better developed and more resisting structure of kidney and to the fact that arterial changes found in old litliaemics have not yet had time to develop. Rachford (Pediatrics, July 1, '98). Toxaemia of pregnancy is that condi- tion which occurs as the result of pres- ence in excess of toxic material; so far as is known, the poison is of the nature of an alkaloid or alkaloids. The excre- tion of waste-material is mainly effected through the kidneys, and this may ac- count for the albuminuria of pregnancy, rather than mechanical pressure or reflex spasm. Kynoch (Brit. Med. Jour., May 21, '98). Conclusions of previous researches on subject of albuminuria during preg- nancy: 1. In most pregnant Avomen there is a certain degree of autointoxication; ALBUMINURIA. PHYSIOLOGICAL. 171 this is the normal toxseraia of pregnancy. 2. In lesions or disease of the kidney or liver the toxic condition becomes aggra- vated and may lead to grave complica- tions, notably urtemia. 3. Toxaemia of renal origin is the most common, asso- ciated with albuminuria and oedema. 4. Albuminuria is not the cause of eclamp- sia, but a symptom owning a common origin. 5. Grave complications — such as coma, dyspnoea, and paralysis — may prove fatal in the absence of eclampsia. 6. In most cases toxic eclampsia breaks out in albuminuric women; albuminuria is therefore an important precursory sign which should not be neglected. 7. Per- sonal statistics show that 1 pregnant woman in 40 is albuminuric, and that, of 4 albuminurics, 1 develops eclampsia; eclampsia without albuminuria is rare — 1 case in 9 — and is less serious. S. Al- buminuria alone without eclampsia has often serious or fatal consequences — in 110 eases, 8 women and 20 children died; there were 61 premature labors, 8 post-partum heemorrhages, and 3 cases of threatened convulsions. 9. Al- buminuria should be looked for in all pregnant women. 10. Every albuminuric pregnant woman should be actively treated, a milk diet being the best. 11. In ease of threatened danger premature labor is indicated, and gives excellent results. Charles {.Jour. d'Accouche- ments, Apr. 3, '98). By many the malarial poison is re- garded as an efficient cause of chronic nephritis. Out of a series of 712 cases of malaria studied personally, only 3 were found suffering from chronic nephritis; and in 2 out of these it was probable that the renal affection was due to causes other than malaria. It would thus seem that malarial fever cannot be regarded as a cause of nephritis in the sense that scarlatina, diphtheria, etc., are. J. H. Brownlow (Amer. Med. Times, Mar., 1900). Case in a man, aged 41, suffering from an acute articular rheumatism, with a mitral systolic murmur, the urine con- taining albumin and casts. Under the usual treatment he recovered in three weeks. Four recurrences were attended by albuminuria, the amount of the albu- min decreasing with the decline of the iheumatic symptoms. The heart com- plication was only temporary. The articular symptoms, the pyrexia, and the renal attack thus constituted a rheumatic symptom-complex. The renal cells had probably been affected by rheu- matic toxins. Parkes Weber (Ed. Med. Jour., Jan., p. 48, 1900). The alterations in the blood which produce the albuminuria and the ascites are due to the presence of toxins which are derived from the gastro-intestinal tract. This fact has been demonstrated beyond all doubt experimentally by Do- minicis. In man intestinal antiseptics will cure such cases, and cause the albu- minuria and the ascites to disappear. If the treatment is suspended for a time, and the patient allowed to eat beyond his digestive powers, these phenomena soon reappear. Three cases in which the above conditions were noted. G. K. Filocamo (Gaz. Inter, di Med. Pratica, Mar. 31, 1900). 3. When the composition of the blood is altered the urine, very often, will be albuminous. This can be proved ex- perimentally by injecting egg-albumin, soluble casein, haemoglobin, etc., into the veins of animals, for generally the quantity of albumin excreted after the injection will exceed the injected quan- tity. Similar results may be obtained by the injection of pepton and propepton, whereas the albuminates are generally inoffensive. Ingestion of a very large quantity of egg-albumin is liable to provoke albuminuria. Fifty-five cases of nephritis, either chronic or subacute, with albuminuria, in which the haemoglobin and specific gravity of blood and amxDunt of albumin excreted in urine per day were esti- mated. There is more or less constant relation between the degree of hydrsemia and the amount of albumin excreted. The blood of women is, on an average, about 2.12 lower in specific gravity than the blood of men. The hydr^^mia bears no relation to the haemoglobin, but varies inversely as the specific gravity 172 ALBUMINURIA. PHYSIOLOGICAL. of the blood. No definite relation ap- pears to exist between the hydraemia and the dropsy; but it seems as if there must be some etiological relation be- tween the albuminuria and the hydras- mia. Geza Dieballa and Ladislaus von Ketly (Deut. Archiv f. klin. Med., Sept. 6, '98). Semmola has tried to prove that albu- minuria is always caused by changes of the blood characterized by abnormal diffusibility of its proteids, and, in his opinion, the pathological changes in the kidneys are consecutive to the albumi- nuria. Though his theory is not gener- ally accepted, Eosenbach has adopted it for the albuminuria which is not caused by nephritis, and regards it in such cases as a salutary and regulating process. In most clinical cases different causes are simultaneously in action, and it is generally very difficult to determine which is the preponderating etiological factor. Although albumin is not recognized as a normal constituent of the urine, it is, nevertheless, a fact that traces of albumin, and even a rather considerable amount of it, may be found in the urine of persons otherwise healthy and pre- senting no symptoms of disease of the kidneys or of the organs of circulation. Case of intense, continuous albumi- nuria of seven yaers' duration in an ap- parently healthy man, 67 years of age, who, seven years before, because of a little disturbance of appetite, had con- sulted a physician, of whom he learned that his urine contained both sugar and albumin. There was no hereditary taint, no previous illness, no alcoholism or syphilis, that could in any way account for the urinary findings. The most care- ful examination failed to reveal any le- sion in any organ. Dieulafoy, who exam- ined the patient, did not look upon the case as one of Bright's disease, but as a sort of diabetic albuminuria which can be regarded as an exaggeration of physi- ological albuminuria. M. de Cresan- tignes (.Jour, de Med. de Paris, p. 125, '96). Albuminuria after exercise. Specimens of urine from 108 soldiers examined. Albumin was present in 41.73 per cent, of specimens of urine taken before drill, and in 63.23 per cent, of cases after it. Levison (St. Barth. Hosp. Rep., xxxv, 169, '99). Albuminuria after exertion. Urine of 9 members of the Rugby foot-ball team examined after playing in the final cup tie. In every instance albumin was pres- ent, and in some cases hyaline casts also. Herbert Hawkins (Brit. Med. Jour., ii, 1598, '99). Albumin in the urine after severe exer- cise. Eighty-three specimens of urine taken from oarsmen at Harvard Uni- versity, when in training for races, and examined for albumin. Of these, 48 con- tained albumin. After time-rows and races the urine was invariably albumi- nous. Darling (Boston Med. and Surg. Jour., cxli, 205, '99). Cyclical albuminuria has been ascribed by Stirling to the sudden shock of the kidneys from the pressure of blood upon assuming the upright position on arising. The shock from sudden rising plays but slight, if any, role. Even when the up- right position is assumed very slowly, albumin appears in the urine in such cases. The kidneys are merely unable to stand the increase of pressure that occurs with the upright position. Cyclical albuminuria is not necessarily related to gout. There is also no evi- dence that cyclical albuminuria is due to a slight nephritis resulting from a previ- ous attack of acute nephritis. It is a form of albuminuria from venous stagna- tion, the result of previous inflammation of the kidneys and lack of elasticity of the vessel-walls of the glomeruli. Ru- dolph (Centralb. f. innere Med., Feb. 24, 1900). Albuminuria following renal palpation. Renal hsematuria with albuminuria noted in several cases in which the kidney had been examined bimanually and in which no albumin had been present in the urine before examination. The pressure to which the kidney is exposed causes cir- culatory changes which permit of the ALBUMINURIA. LIFE-INSURANCE. 173 transudation of serum from the renal capillaries. C. Menge (Miinchener metl. Woch., June 5, 1900) . Many clinicians therefore admit that albuminuria may be regarded, in some cases, as physiological; this is, however, contested by as many. Virehow described a physiological al- buminuria in infants, occurring in the first days of life, and explained it by the sudden changes of circulation taking place immediately after delivery. The children of mothers suffering from eclampsia or chronic albuminuria may show this condition from birth. In 10 children whose mothers were non-albu- minuric 1 only showed traces of albumin, while in 4 whose mothers were eclamptic 3 showed albuminuria, while the mother of the fourth was only very slightly affected. Albuminuria may thus be transmitted from the mother to the child, and this condition in the child may be prolonged considerably over early in- fantile life, probably preparing the way for future attacks of nephritis in the course of the ordinary diseases of child- hood. Many cases of so-called albu- minuria may be hereditary. Should a mother be known to suffer from albu- minuria, the children should be carefully examined, and every effort made to pre- vent the occurrence of scarlet fever or other febrile disorders. Fieux (Jour, de M6d., July 25, '99). Fleusburg and Sjoquist have recently proved that albuminuria regularly oc- curs in the first days of life, and that the urine also contains an extraordinary quantity of itric-acid crystals; probably the albuminuria is then owed to the irritation of the kidneys caused by these crystals. Ebstein and Nicolaier have experimentally shown that, when the kidneys are forced to excrete a surplus of uric acid which cannot be dissolved, but goes to the bottom in the form of crystals, the urine commonly contains albumin and sometimes even blood. Gull found a certain form of physio- logical albuminuria in adolescents about the age of puberty, especially in weak and pale individuals. Other authors, among whom is Quain, have noticed that this condition is frequently associated with masturbation. Slight traces of albumin met with ex- tremely commonly, especially betweeft the ages of 18 and 25 years. The urine found to be albuminous in 45.5 per cent, of 129 hospital patients between these ages. Levison (St. Earth. Hosp. Rep., xxxv, 169, '99). Physiological Albuminuria and Life- insurance. — The question of physiolog- ical albuminuria in adults has been much disciissed during the past few years and has particularly engaged the interest of the medical men employed in insurance- work. Statistics of life-insurance, etc., show- ing that physiological albuminuria is met with in America in 2 per cent.; in England in 3 per cent. Privations, scanty food and clothing, unsanitary surroundings, cold bathing, severe phys- ical exercise, and mental strain fre- quently give rise to albuminuria. Shep- herd (New Eng. Med. Monthly, '89). Albuminuria, natural or artificial, never occurs except as the result of pathological changes in the kidney, and is consequently never normal or physio- logical, and is never to be regarded with- out distrust. Millard (N. Y. Med. Jour., May 9, '91). Instance where a special examination of a case was referred to author by the medical officers of a prominent life-insur- ance company with a mere trace of albu- min in the urine. He sought and found other evidence of a renal involvement, and advised strongly against the risk; another company accepted the risk for $10,000, and, before the second annual premium, the patient died. Purdy (N. Y. Med. Jour., Feb. 28, '91). There is at present a tendency to un- derrate the importance of albuminuria in life-assurance. While the possibility of ephemeral and unimportant attacks in 174 ALBUMINURIA. LIFE-INSURANCE. adolescents is undoubted, the presence of albuminuria in persons of over forty years is vei-y significant. F. de Haviland Hall (Brit. Med. Jour., Feb. 20, '93). The presence of albumin in persons over middle age of exceeding importance, especially the variety of albuminuria in ■which, with a low specific gravit.y, the quantity of albumin present is only to be perceived with the greatest care. This form is indicative of gout of the kidney : a form in which the disease might ad- vance to such an extent as to threaten the life of the patient, though the merest trace of albumin might be present in the urine. If properly treated with a non- nitrogenous diet and warmth to the sur- face, these cases might go on for j'ears. Lauder Brunton (British Med. Jour., Feb. 20, '93). It is necessary, especially in women, to take steps to ascertain that the albumin in the urine is not of extravesical origin. One frequent cause of the presence of albumin in the urine of females is hsemorrhagic endometritis. Routh (Brit. Med. Jour., Feb. 20, '93). Necessity of having the patient urin- ate in the presence of the examiner, in order to prevent the substitution of other urine. Mackenzie (London Lan- cet, June 16, '94). Quite young subjects who have albu- minuria should be considered as below the average. Douglas Powell (London Lancet, June 16, '94). Albuminuria is not always patholog- ical; andj if albumin be not found at the second or third examination, the case should be recommended for accept- ance. Symes Thompson (London Lan- cet, June 16, '94). In cyclical albuminuria the prognosis is generally admitted to be good, al- though it is commonly assumed that the kidneys in such eases are specially vul- nerable. If this be so, it is remarkable that the occurrence of fevers, even scar- let fever, does not produce a notable increase in the amount of albumin. The contrary may, in fact, occur, as in one of Keller's cases, in which the amount of albumin was actually diminished during an attack of scarlet fever, the favorable influence of rest in the recumbent atti- tude more than counterbalancing the un- favorable influence of the febrile attack. Editoi-ial (Practitioner, June, '97). Phj'siological albuminuria believed to be due to ingestion of a greater amount of albumin than the individual can per- fectly oxidize, result being excretion of albiunin. The habit of overeating is usually associated with this condition. W. H. Porter (Columbia Med. Jour., vol. XX, No. 4, '98). The mass of evidence which has come to us of late from the autopsy-table shows conclusively that chronic nephritis exists and is an unrecognized cause of death in a proportion of cases far beyond ordinary belief, and the comparison of carefully kept records of cases before death with autopsy findings shows that little reliance can be placed on the mere urinary examination, either positive or negative, as a means of absolute diag- nosis or prognosis of Bright's disease. The writer's own experience leads him to believe that (1) Bright's disease may exist without the ordinary urinary manifestations, — viz., albumin or casts: (2) albumin and casts may be found in the normal urine and do not necessarily mean Bright's disease; (3) given a case of chronic Bright's disease with albu- minuria, the fact of its presence, its con- stancy, or its amount has absolutely no prognostic significance. C. A. Tuttle (Jour. Amer. Med. Assoc, Mar. 31, 1900). Series of experiments show that the albumin present in nephritic urine is derived from the blood and is different from the specific kidney albumins. L. Aschoff (Lancet, Sept. 6, 1902). It is characteristic of physiological albuminuria that the quantity of albu- min is generally small and that the ex- cretion is, in most cases, intermittent, or cyclical. Leube, Pavy, Fiirbringer, Klemperer, and many other authors have studied this condition. Pavy introduced the denomination "cyclical albuminuria" for the cases in which the albuminuria ceases and re- turns at regular intervals. ALBUMINURIA. LIFE-INSURANCE. 175 Case of a clilorotie girl, 15 years old, in whom albuminuria was of the cyclical type: albumin appeared about 11 a.m., and reached a maximum about 3 o'clock in the afternoon, diminishing thereafter until it disappeared completely by 8 o'clock p.ic, and remaining absent dur- ing the night. Recalling an observation of Heubner's, who found cyclical albu- minuria in several members of the same family, the author examined the urine of two sisters and two brothers of the patient and found the same condition in one of the sisters, a girl of 13 years, also chlorotic. Treatment of the chlorosis had no effect upon the albuminuria. Schon (Jahrbuch f. Kinderh., B. 41, S. 307, '96). Pavy likewise insists upon posture as the invariable cause of cyclical, or in- termittent, albuminuria, the excretion ceasing when the subject is in the re- cumbent position and going on only ■when he is walking or standing. The cycles are commonly completed within the day, but in a case narrated by Klem- perer there were two cycles, the maxi- mum of albuminuria taking place in the forenoon and afternoon. Effect of rest in bed: in one case, in a girl 8 years of age, of wasting and loss of appetite, the average daily amount of albumin passed for five days, while the child was running about, was 51 centi- grammes. She was then kept in bed for five days, and the average daily amount of albumin sank to 4 centigrammes; in the next five days, during which she was running about again, the average daily amount of albumin rose to 36 centi- grammes. The fall on going to bed and the rise on getting up were immediate. The proteids present in the urine in these cases are serum-albumin, serum- globulin, and nucleo-albumin. Keller (.Jahrb. f. Kinderh., B. 41, p. 356). In many instances bicycling gives rise to an albuminuria that cannot be dis- tinguished with the microscope from that of genuine kidney disease, but one that must be looked upon as physiological, since it disappeared within a few days after cessation of the exertion, leaving absolutely no signs of disease. Observa- tions made on twelve bicyclists, eight of whom were trained and four untrained. Among the eight trained wheelmen there was only one whose urine contained al- bumin before the exercise, but after it the urine was albuminous in seven. In six of them, including the one whose urine was free from albumin, there were at the same time present in the urine easts in numbers as great as are gener- ally met with in acute or chronic paren- chymatous nephritis; and the two others had a few hyaline casts. Most of the casts were hyaline ; the minority showed distinct renal epithelia and were granu- lar. Free renal epithelia were found in every instance. White blood-corpuscles appeared sparingly, but red corpuscles were not met with at all. Among the four untrained wheelmen, in all of whom the urine was free from albumin before the exercise, two showed albuminuria and one cylindruria after riding from an hour and a half to three hours. Mueller (Miinchener med. Woch., No. 48, '96). Three cases of intermittent albumi- nuria which occurred in the same family. As often as six times, based upon as many observations, attention has been called to the family character of this disease. In the family of the children mentioned above gout is hereditary : a very important fact as regards the eti- ology of the disease. Lacour (Lyon Med., No. 25, '97). Albuminuria, particularly cyclical or irregular albuminuria, may be frequently due to gastro-intestinal autointoxication. Case in which hydatid cysts of the liver caused marked constipation and icterus and distinct albuminuria; latter disap- peared after operation upon the cysts and recovery from disturbed condition of di- gestive organs. The function of the liver and of thyroid gland is particularly im- portant in such albuminuria, since dis- turbance of either organ may lead to production of toxic substances which cause albuminuria. A. Praetorias (Ber- liner klin. Woch., Apr. 4, 11, '98). The diagnosis of physiological albu- minuria ought not to be made except in 176 ALBUMINURIA. LIFE-INSURANCE. eases when persons presenting no other symptom of disease excrete, constantly or intermittently, a urine containing a scanty quantity of albumin, but no morphotic elements and especially no casts. The centrifugal apparatus, now coming into general use, will certainly contribute to restrain the number of these cases. Even when no casts can be found, albuminuria ought never be regarded .as absolutely inoffensive. Although a cyclical albuminuria continuing years may be compatible with perfect health, :still many authors (Johnson, Greenfield, Bull, etc.) are of the opinion that it sig- nifies the first stage of the evolution of granular atrophy of the kidneys. The albuminuria often found in parturient women (Aufrecht saw it in 56 per cent, ■of all cases) must also be regarded as physiological. Protest against the indiscriminate re- jection of candidates foi' assurance on account of albuminuria: that is, after a merely chemical examination of the urine. In every case in which albumin is found microscopical examination of the sediment obtained by centrifugali- zation is essential for the avoidance of unnecessary rejections. There are two fundamentallj' distinct forms of albu- minuria, the renal and the extrarenal. The latter is indicative merely of a functional or organic lesion of the gen- ito-renal tract, which is not necessarily or even usually dangerous to life. Ex- trarenal albumiuuria is characterized by its transitory and intermittent nature. Since, however, some forms of renal albuminuria are equally transitory and intermittent, the final distinction be- tween the two is based on the micro- scopical examination of the sediment. The presence of blood, pus-cells, epi- thelium from the mucosa of the urinarj' tract, spermatozoa, and shreds of mucus, in the absence of renal elements, is decisive of an extrarenal origin. Prob- ably in many cases of so-called physi- ological albuminuria the origin of the albumin is extrarenal. Zeehnisen found albumin in the urine of 21 out of 144 ophthalmic patients; in 60 per cent, the presence of blood, vesical or urethral epithelium, pus, or spermatozoa pointed to an extrarenal origin. Von Noorden found albumin in the urine of 154 ap- parently healthy soldiers, which in 106 originated extrarenally. Flensburg ex- amined the urine of those soldiers in which he had unexpectedly found albu- min at the end of their two years' service; in the majority every trace of albumin had disappeared, and in the remainder there was no single symptom of nephritis. In every case of albumi- nuiia the presence of blood should be excluded, for traces of blood too minute to be detected by Heller's or the spectro- scopic test will nevertheless give the reactions of albumin. In extrarenal al- buminuria nucleo-albumins preponder- ate. In doubtful cases the urine should be obtainea by catheterism, so that every source of contamination may be avoided. Albuminuria of renal origin may be either temporary or permanent, functional or organic. Organic lesions are characterized by persistence. But persistence is not an absolute bar to acceptance, for eases occur, though rarely, in which albvuuinuria with renal casts continues indefinitely without any disturbance of health. If, however, there are polyuria, casts, cardiac hyper- trophy, or dilatation, arteriosclerosis, retinitis, urtemia, and oedema, nephritis is obviously present. Every case should be judged on its merits. Even without albuminuria, endarteritis, or any one of the above-mentioned symptoms, com- bined with persistently-increased diu- i-esis and a specific gravity between 1.010 and 1.012, is extremely suggestive of an organic renal lesion. The functional form of renal albuminuria is transitory or intermittent, and is principally due to intoxication or autointoxication. The toxie symptoms produced must de- cide in each case Avhether the applicant should be accepted. The most impor- tant variety is that which occurs after exercise, and which points to a meta- bolic instability which may possibly be- come dangerous. Renal albuminuria which persists during convalescence ALBUMINURIA. PATHOLOGICAL. 177 from infectious diseases is of no more significance as a sequel than slight bron- chitis; if there are no cardiovascular changes the candidate may be passed. Some of the most difficult problems are connected with cases of ascending infec- tion from the bladder. If the process is tuberculous, the candidate should clearlj' be rejected. In other cases the question whether the kidney is involved will be decided by the effect produced and the condition of the heart and ar- teries. Many eases of functional al- buminuria are due to circulatory dis- turbances. Of this nature is probably that form known as "cyclical," or "pos- tural," in which there is usually some circulatory disturbance, as evidenced by cardiac dilatation, tachycardia, palpita- tion, or anfemia, though doubtless hered- ity and other factors are involved. It is the rule to reject these applicants ; but, as the prognosis is usually excel- lent, there is no reason why they should not be accepted after a period of pro- bation. This form of albuminuria is practically identical with the albumi- nuria of cardiac disease. Stokvis (Brit. Med. Jour.; from Wiener med. Woch., May 3 and 10, 1902). Pathological Albuminuria. — Patho- logical albuminuria is found in patho- logical changes of the blood — as ana- mia, leukffimia, pseudoleitkasmia, scurvy, icterus, and diabetes — even when the kidneys do not present pathological changes. It is also found in many disorders of the nervous system, as epilepsy, mi- graine, psychosis apoplexy, neurasthenia, and Basedow's disease, etc. Delirium tremens has also been mentioned as a nervous disease often complicated with albuminuria. Delirium tremens is alwaj-s accom- panied by fever and is probably provoked by a microbic toxin or an autointoxica- tion. Jacobson (Hospitalstidende, p. 193, '97). Although the kidneys, theoretically, are believed to be healthy in the diseases mentioned above, there is no doubt that albuminuria, in many cases of this class, is caused by pathological changes of the kidneys. In all febrile and especially in all in- fectious diseases albuminuria is a very frequent symptom. It has been noticed in enteric fever, diphtheria, variola, after vaccination, in erysipelas, influenza, rheumatic fever, etc. In these cases the albuminuria is caused by changes in the composition of the blood, increase of blood-pressure, rise of temperature, and finally by changes in the structure of the kidneys, especially of the tubular epithelial cells. Albuminuria has been observed in diseases of the intestines, dilatation of the stomach, ileus, ruptures, etc., and in renal venous congestion caused com- monly by disease of the heart or the great vessels. Albuminuria may be produced by in- testinal disorders in children; may be due to the injurious action on the renal epithelium of the toxic products of ab- normal fermentations. Jacobi (N. Y. Med. Jour., .Jan. IS, '96). It is present in all diseases of the kidneys. Acute as well as chronic albu- minuria is generally found, whether the diffuse form of nephritis or as circum- scribed diseases — such as infaretus, ab- scesses, or tumors — ^be present. After retention of urine the portion of urine first passed is frequently albuminous. Certain remedies may also give rise to albuminuria. Case of a syphilitic subject who, after antisyphilitic treatment with 4 '/^ ounces of mercurial ointment and the iodide of potash, developed osdema of the lower extremities, and 8 per cent, albumin in the wine. Another attempt at treat- ment by inunction caused the albumin to increase to the enormous quantity of 178 ALBUMINURIA. TESTS. 60 per cent.; after discontinuing it he slowly recovered, ivhile the albumin de- creased decidedly in amount. Saalfeld {Deutsche med.-Zeitung, No. 1, '95). Chlorate of potash, which is often used to prevent mercurial stomatitis, is fre- quently the cause of the appearance of albumin in the urine. Case of a young physician who died after employing small quantities of this drug in a mouth-wash. Acute poisoning by this drug is easily recognized by the large quantity of al- bumin and blood in the urine. Mankie- wicz (Deutsche med.-Zeitung, No. 1, '95). Case in which albuminuria and uraemia were apparently produced by the applica- tion of a blister. Huchard (Eevue de Th6r. Medico-Chir., Apr., '96). Examination of 8000 specimens of urine derived from 201 syphilitic men, 79 syphilitic females, and 35 persons who were not syphilitic. Albuminuria found in 25 of the men, and in the women marked albuminuria in 4 cases. In 35 cases of bubo, the urine of which was examined 363 times, a trace of albumin was only found on 2 or 3 occasions. The administration of mercury in no case gave rise to very marked albuminuria. Lewin, who has used hypodermic injec- tions 80,000 times with sublimate, has never seen nephritis result. It seems evident that the bichloride is the prefer- able preparation for hypodermic injec- tions. Julius Heller (Schmidt's Jahr- biieher. No. 1, '97). The prognosis and treatment of albu- minuria, therefore, depends entirely on the origin and causes of it, and the reader is referred to the various diseases in which it occurs as a sj'mptom. Tests. — • By means of the tests com- monly employed the presence of albu- min in the urine is revealed, but no attempt is made to discern between the different proteids; the differential diag- nosis between the serum-albumin, glob- ulin, etc., will be given later on. The sample of iirine to be examined must be very limpid without deposits of any kind; if this be not the case, the urine should be filtered previous to the examination, because a slight cloud of coagulated albumin will only be discern- ible when the fluid is very clear before the reagent has been added. When the urine contains many bacteria, even re- peated filtration will be insufficient to make it clear; this can then be done, however, by addition of a solution of sulphate of magnesia and of carbonate of soda. By shaking the mixture a precipitate of carbonate of magnesia is formed, and when this is removed by filtration the filtrate will be perfectly clear. In many cases a few drops of caustic soda will clear the urine, but urine treated in this manner will not give a precipitate of albiimin by boiling, while the test of Heller is practicable also in this ease. Test by Boiling. — A few cubic cen- timetres of urine are heated to the boil- ing-point and some (5 to 10) drops of nitric acid added. When the urine is acid the albumin will ordinarily coagu- late by boiling alone and precipitate as a whitish powder or in small flakes. The nitric acid is nevertheless in all cases to be added, as well in order to complete the precipitation of albumin as to avoid mistakes caused by the presence of a precipitate of phosphates or carbonates, • — which will immediately dissolve when nitric acid is added. This test is ver}^ delicate and will reveal 0.01 to 0.005 per cent, of albumin. Instead of nitric acid, acetic acid can be employed, but while the nitric acid is to be added after boil- ing and in a quantity of 5 to 10 drops, acetic acid is added before the boiling, and only a sufficient quantity should be employed as to make the urine but slightly acid. This is especially neces- sary when the urine is alkaline, because the alkaline albuminates with a surplus of acetic acid give a compound which is not coagulated by boiling. ALBUMINURIA. TESTS. 179 Heller's Test. — Three to four cubic centimetres of urine are poured in a test- tube and two cubic centimetres of nitric acid are cautiously floated down along the sides of the tube. The nitric acid collects on the bottom of the test-tube, and where the fluids are in contact a dis- tinctly limited disk of grayish-white pre- cipitate will appear. When only traces of albumin are present the precipitate will only take place after some minutes. The more or less distinct yiolet coloring which also appears at the point of con- tact of the two fluids is due to decom- posed indican. This test is very delicate and reliable; 0.003 per cent, of albumin is revealed by it. Fallacies. — By the addition of nitric acid the urates are also precipitated; these will not form a limited disk, but render the urine turbid. Eesinous acids (copaiba) are precipitated by nitric acid, but are dissolved by the addition of con- centrated alcohol. Urea may also become a source of error by giving a precipitate of nitrate of urea. Long (N. Y. Med. Jour., Apr., '91). Test bt Acetic Acid and Potassic Feekoctanide. — The urine is rendered acid by acetic acid, and some drops of a solution of potassic ferrocyanide are added. This reagent, the serum-albu- min, the globulin, and the albumoses are precipitated, while none of the normal constituents of the urine are (Huppert). Hetnsius's Test. — A still more deli- cate test than Heller's is that of Heyn- sius, by acetic acid and sulphate of soda. The iirine is rendered acid by acetic acid, and an equal volume of a saturated solu- tion of sulphate of soda (or of common salt) is added. The mixture is boiled, and all kinds of albumin will then be precipitated in white flakes. The Magnesium - Xiteic Test (TiOBERTs's). - — One cubic centimetre of nitric acid is mixed with five cubic cen- timetres of a saturated solution of sul- phate of magnesium, and a small quan- tity of this mixture is added to the urine. The albumin will be precipitated as a distinct ring. Metaphosphoeic acid (Hinden- laxg) also precipitates albumin in the same manner as nitric acid; but this test is not as delicate as that of Heller. The solution of metaphosphoric acid must be freshly prepared for use, as the solution easily changes to orthophosphoric acid upon standing, which does not precipi- tate albumin. PicEic-AciD Test (Johnson). — A few drops of a saturated solution of picric acid will cause a white precipitate when albumin is present; this test is only indicative of the presence of albumin, however, when the precipitate appears immediately. After some time the iirates and the creatinine will also be precipitated (Jaffe). Fallacies. — By addition of picric acid the peptons, the resinous acids, — such as those of copaiba, — and alkaloids — such as morphine — are precipitated. Peechloeide-oe-Meecuet Test. — A 5-per-cent. solution of perchloride of mercury will precipitate albumin in urine which is rendered acid by addi- tion of a few drops of acetic acid. Fallacies. — Xanthin is also precipi- tated by this reagent. Millen's Test. — A solution of nitrate of mercury is added to the urine and the mixture heated to boiling. ISTitrate of potash is then added; the albumin pre- sents as a precipitate of red flakes. Taneet's Test. — The reagent of Tanret is composed of perchloride of mercury, 135 grammes; iodide of potash,. 3.33 grammes; glacial acetic acid, 30' cubic centimetres; distilled water, sufii- cient to make 100 cubic centimetres. 180 ALBUMINURIA. TESTS. Some drops of this mixture are added to the urine, and will coagulate the albu- min. It will also, however, precipitate the urates. Many other reagents have been recommended, which cannot be mentioned in detail. A small crystal of trichloracetic acid is added to 1 cubic centimetre of urine previously filtered; when the acid dis- solves a sharply-defined zone of turbidity arises on the juncture of the clear urine and that saturated with the acid. Eaabe (Merck's Bull., Apr., '91). A solution of carbolic acid in absolute alcohol is a very delicate test for albumin in the urine, comparing very favorably with nitric acid. The urine should first be diluted until the specific gravity is about 1.010; a few cubic centimetres of carbolic acid is then poured on top of this, and a white ring is immediately formed, from which milky drops fall to the bottom of the tube, and adhering to this are the flakes of albumin. The test is sufficiently delicate to show 0.000012 gramme in 1 cubic centimetre of urine. W. Colquhoun (Lancet, May 6, 1900). Xanthopeotein Test. — Albuminous urine heated with a surplus of con- centrated nitric acid will take a yellow color, and some of the albumin coagu- lates in yellow flakes, which are soluble in alkalies with an orange-red color. Thanspoetable Eeagents foe Al- bumin". — Hoffmann and Aazette employ strips of test-paper previously placed in a solution of the double iodide of potas- sium and mercury until saturated, then removed and dried. The urine which is to be tested should be ckar and rendered acid by means of a few drops of acetic acid. If there be albumin present, upon immersion of a slip of paper in the urine a distinct precipitate will appear. Pavy recommends test-pellets contain- ing ferrocyanide of soda and picric acid; when albuminous urine is well shaken with a parcel of the pellet, albumin will l)e precipitated. The relative delicacy of the tests most frequently employed is graphically represented by Unger-Vetle- sen, in the diagram shown on the oppo- site page. The longest columns indicate the most delicate tests. Sulphosalicylic acid, a white crystal- line substance produced by heating sali- cylic acid with concentrated sulphuric acid, precipitates all proteid substances. It shows traces of albumin in a dilution of 1 to 50,000. This reagent was first discovered by Eeoeh, then by MaeWill- iam, who employs sulphosalicylic acid in the form of a saturated solution. Per- sonally employed by adding some of the crystals to a small quantity of filtered urine contained in a test-tube. The tube is then shaken. If albumin is present, a white homogeneous precipitate appears instantly. The urine should be acid. If the urine is alkaline it efi'ervesces after the sulphosalicylic acid is added. If albumin is presented in the smallest traces, a cloudiness appears. When nitric or acetic acid is used for tests, small traces of albumin give rise to stringy, multiform particles suspended in a clear menstruum, the interpretation of which often gives rise to doubt. Sulphosalicylic acid gives a uniform opalescence which is unmistakable. Richard Stein (Med. Record, Jan. 16, '97). Fifty samples of urine investigated each of which, from character of sedi- ment, was judged to contain albumin. Those urines were selected in which small traces only of albumin were assumed to be present. With Millard's test, reaction was obtained in forty-eight of the fifty specimens. Two samples showed no re- action with any test; so that with Mil- lard's test comparative efficiency would be 100 per cent. Roberts's test shoAved 86 per cent.; potassium ferrocyanide, 66 per cent.; nitric acid, 60 per cent.; heat, 52 per cent. Dilutions up to 1 in 320 showed positive results with all the reagents. When strength was reduced to 1 in 640, only Millard's test showed re- action, and the limit to the reaction was about 1 in 1280. Unless peptoii is pres- ent in large quantities, it is not precipi- tated by action of Millard's reagent. J. ALBUMINURIA. TESTS. 181 W. Garratt (N. Y. Med. Jour., July 16, '98). A glass pipette is used and the urine allowed to run up the tube one or two inches. The index finger is then placed on the top and the urine washed and dried off the outside of the tube. It is then inserted into nitric acid and the index finger partially removed to allow the acid to flow up the tube. The presence of albumin al- ways causes a white ring to form at the line of contact. Globulin, albu- raoses, and peptones may also cause a small ring at the zone of contact, but method which gives fully reliable re- sults is the gravimetric method. One hundred cubic centimetres of urine are cautiously heated to the boiling-point; if precipitation does not take place a few drops of a weak solution of acetic acid are added; the liquid is now brought on a weighed filter and the precipitate repeatedly washed with hot water. When the water has been removed from the filter by strong alcohol, the filter is dried by a temperature of 120° to 130° Ferrocyanide of potassium and ace- tic acid Solution of picric acid Test-paper Solution of sulphate of soda and acetic acid Heller's test Picric acid in crystals Magnesium-nitric test (Roberts) . . . Trichloracetic acid Metaphosphoric acid Boiling and nitric acid 12 2A ^r^ .44'. 6 c 2 84 96 lOR I' la. they are seldom present. If suspected they may be tested for by boiling the urine. A cloud appears just before the boiling-point is reached, but disappears when boiling occurs. Urates may cause a similar ring. Similar experiments have been tried with twelve other re- agents which have been recommended for detecting albumin in urine, but the results were never so satisfactory as when nitric acid alone was used. L. N. Boston (New "York Med. -Jour., May 24, 1902). Qtjaxtitative Tests. — The only C, and the percentage of albumin de- termined by weighing. For clinical use several approximate methods have been invented. Esbach employs an albuminometer, — i.e., a graduated glass tube: this tube is filled to one mark {TJ) with the urine and then to the mark R with the test- solution consisting of picric acid, 10 grammes; citric acid, 20 grammes; water, 1 litre. The tube is then closed with a rubber stopper and the contents cau- 182 ALBUMINURIA. TESTS. tiously mixed. The mixture is allowed to stand undisturbed for twenty-four hours and the quantity of precipitated albumin then read off. The reading in- dicates in grammes the amount of albu- min per litre. Christensen recommends another method: the albumin contained in five cubic centimetres of urine is precipitated by ten cubic centimetres of a watery solution of tannic acid (1 per cent.). The albumin having been precipitated, 1 cubic centimetre of an ordinary gum- arabic mucilage is added, the volume brought up to 50 cubic centimetres with water, and the whole converted to an emulsion by agitation. Upon a piece of white paper, ruled with black lines 0.5 millimetre wide and at equal intervals, is placed a cylindrical glass measuring- four centimetres in diameter. This is half-filkd with water, and as miich of the emulsion run in as possible without obscuring the black and white lines be- neath the vessel. From the number of cubic centiiuetres required, reference to a table of calculations arranged by Chris- tensen furnishes the proportion of albu- min present in the emulsion. When tlie urine is alkaline it should be faintly acidi- fied with acetic acid before the precipita- tion of albumin. This test can be made as well by daylight as by the light of a good lamp, and requires only ten or fifteen minutes; but is not applicable to urine containing a small amount of albumin, the variations amounting to two-thousandths. The polariscope is sometimes employed to estimate the quantity of albumin, but this test is not very reliable. It is true that albumin is Isevorotatory, but this is also the case with normal iirine, and sometimes the color of the urine is too dark to allow the use of the polariscope. Miscellaneous. — Bv the tests above mentioned, as well qualitative as quan- titative, the different coagulable proteids contained in the urine are precipitated; it is rarely of any use to differentiate them one from another. Pure globulinuria without the simul- taneous presence of serum-albumin does not occur. In order to precipitate the globulin alone the urine is rendered alkaline with solution of ammonia, after some time filtered, and the filtrate mixed with an equal volume of a saturated solution of sulphate of ammonia. If globulin be present a flaky precipitate will appear. [The same result can be obtained by using a solution of sulphate of magnesia, which does not precipitate the other proteids of urine, or by diluting the urine until it reaches a specific gravity of 1002 and leading a slow current of carbonic acid through it for tA\o or four hours. After twenty-four to twenty-eight hours the globulin will be precipitated. Levi- SON.] The hemiallniniose, or propepton, which seems to be a mixture of different albumoses, may be revealed by saturation of the urine with chloride of soda and addition of acetic acid. When hemialbu- mose is present a precipitate will appear which dissolves by the addition of much acetic acid and heating, but reappears when the liquid cools again. Nucleo-albumin, in small quantity, seems alwa3rs to be contained in the urine. It is revealed by the addition of an excess of acetic acid to the itrine, which becomes turbid, indicating the presence of a larger quantity of nucleo- albumiu. When the urine is very much concentrated it should be diluted with water before adding the acetic acid, as the nucleo-albumin is held in solution by the salts of the urine. F. Levison, Copenhagen. ALCOHOL. PHYSIOLOGICAL ACTIOX. 183 ALCOHOL. — Alcohol of the pharma- copceias is one of a series of hydrocarbon compounds, all of which have as their base a radicle called ethj'l, whose chem- ical composition is expressed by the formula CH. Chemically, alcohol is a hydrate of eth)^, or hydrated oxide of ethyl. To distinguish it from other members of the group, particiilarly fusel-oil (amyl-alcohol) and wood spirit (methyl-alcohol), the alcohol of medicine is called ethjd-alcohol. It is known in the British Pharmacopceia as rectified spirit or rectified spirits of wine, from its being obtained by distillation and subse- quent rectification, or purification, from a mash of potatoes or grain, or from wine. What is known as strong alcohol contains 91 per cent., by weight, of pure spirit (U. S. P.), and has a specific grav- ity of 0.820. Dilute alcohol contains 45.5 per cent., by weight, of pure spirit (U. S. P.), with a specific gravity of 0.928. Alcohol is usually exhibited in medi- cine in different diluted forms, known as beverages, which may be grouped ac- cording to the percentage of alcohol present in them. The so-called spirits (whisky, brandj^, rum, gin, arrack) con- tain about 50 per cent, of alcohol. The heavy wines (port, sherry, Madeira, etc.) contain about 20 per cent., but are usually too sweet for the use of sick persons; when "dry" (free or nearly free from sugar), they are frequently useful to convalescents and to thos* who are debilitated. The light table-wines (claret, Burgundy, champagne, Tokay, Moselle, hock, and Bhine wines) contain from 5 to 10 per cent, of alcohol; many of the Ehine wines are, however, not suited to those having a tendency to the oxalic diathesis, on account of the oxalic acid which they contain. Malt liquors (ale, stout, beer) contain diastase, which aids the digestion of starchy foods and tends to produce obesity. They are especially tonic in their effects and contain from 3 to 15 per cent, of alcohol. Pure alcohol is also used in combi- nation with various tinctures and aro- matics, to secure accuracy of dosage, to avoid the effects of the more irritating ingredients of poor or bogus liquors, and often in private practice to avoid colli- sion with the prejudices of the laity, or again when there is a tendency toward the abuse of alcoholic beverages. Dose and Physiological Action. — Alco- hol, in prolonged contact with the skin, evaporation being prevented, penetrates the tissues beneath the cuticle, owing to its tolerably-high diffusive power, and excites a sense of heat and superficial infiammation. It may be thus employed as a counter-irritant. Owing to its vola- tility, alcohol is sometimes used topically to cool the surface of the body. It co- agulates albumin, and is sometimes used to cover sores or wounds with a thin, protective, air-excluding layer, which promotes healing. Taken internallj', the effects vary ac- cording to the size of the dose taken. When a small dose is taken, it con- stringes the mucous membrane of the mouth and throat (often used diluted as an astringent gargle in relaxed throat, scurvy, salivation, etc.), and, on reach- ing the stomach, it produces a sense of warmth, which is quickly followed by a feeling of general well-being, com- fort, and restfulness. The heart-beat is sometimes accelerated; the arteries are relaxed. The muscular fibres of the skin are relaxed, and the blood becomes more equally distributed over the different parts of the body; if the extremities are pale and cold, they may resume their natural color and temperature. The glands are stimulated generally; the 184 ALCOHOL. PHYSIOLOGICAL ACTION. perspiration is increased; the amount of urine is augmented, and the secretions of the mucous glands throughout the alimentary tract respond to the increased stimulus. The appetite, when poor, is improved, the special senses rendered more acute, and relaxation and meteor- ism of the intestines are relieved. In the stomach a double action is ob- served on both the gastric juice and the secreting membranes. A small quantity of alcohol produces an insignificant ef- fect on the pepsin of the gastric juice; a larger quantity, however, inhibits or destroys entirely its food-dissolving ac- tion. In like manner, a small quantity of alcohol augments the secretion of the gastric juice; larger quantities cause inflammation of the mucous membrane, with increased secretion of a thick, te- nacious mucus and a loss of secreting power. The appetite becomes impaired or lost and a feeling of nausea is induced. Conclusions as to the influence of alco- hol upon tissue-growth and cell-growth summed up as follows: 1. Alcohol acts primarily on the nerve-cells, changing their granular matter, breaking up their nutrition, and changing their dynamic force. 2. This action is followed by con- traction and atrophy of the dendrites; shrinking of cell-walls, as in fatigue ; and coalescence and disappearance of the granular protoplasm. 3. The special in- jury from alcohol seems to be on proto- plasm and terminal hbres of nerve- trunks; the irritation and inflammation of the nerve-walls and fibres ending in sclerosis are common. 4. Alcohol acts on the leucocytes, checking their activity, and destroying their function. These are driven in masses by the increasing rapid- ity of the heart, and become blocked in the capillaries, forming centres of ob- struction and injury. 5. The use of al- cohol is followed by diminution of the carbon dioxide and all waste-elimination, with marked sensorial palsy and slow- ing of all mental actions. T. D. Crothers (Jour. Amer. Med. Assoc, Nov. 26, '98). Alcohol has, in general, a very slight germicidal action. At normal tempera- tures it may kill non-spore-bearing bac- teria, but not the spore-bearers. Its action is strongest in 50- to 70-per-cent. strength and weakest when in strongest concentration (absolute alcohol). When boiled, or heated under pressure, it acts according to its percentage of contained water. Alcoholic solutions of disinfect- ants have less efl'ect than the correspond- ing aqueous solutions, and their germi- cidal power varies inversely as the strength of the alcohol in which they are dissolved. Eafael Minervini (Zeitsch. f. Hyg. u. Infects., Oct. 25, '98). Actual state of scientific knowledge on the total-abstinence question. After tak- ing small amounts of alcohol there is an apparent temporary increase of brain- activity, which is but as an evidence of the paralyzing and deleterious efifect of alcohol. It destroys the special function of the cerebellum, and produced tremor and weakness of the lower limbs. In chronic alcoholism the dendrites of the pyramidal nerve-cells show swellings and shrinkages, and there is wide-spread pig- mentation in the nerve-cells. Even small doses of alcohol at meals have a dele- terious influence, and total abstinence must be the course of those who wish to follow the plain teaching of truth. Vic- tor Horsley (Lancet, May 5, 1900). Alcohol decreases elimination and in- creases waste-products. The clear in- dication of the autointoxication of alco- hol is seen when functional and organic symptoms disappear by abstinence. Crothers (Jour. Amer. Med. Assoc, Apr. 27, 1901). Alcohol is a narcotic poison. Its food- value iTnder ordinary conditions is prac- tically nil, and, put in the most advan- tageous light, can only be temporary, and then of an extraordinary slight and wasteful character. G. Sims Woodhead (Edinburgh Med. Jour., Aug., 1901). Series of experiments to determine the influence of alcohol upon the secretion of the gastric juice: upon a case of gastroptosis, one of hysteria, one of atony of the stomach, after gastro-en- terostomy, and one of gastro-enteritis. The alcohol was administered per ree- ALCOHOL. POISONING. 185 turn, and the patient took no nourish- ment by the mouth. It was found that the enema caused an active secretion of gastric juice provided the amount of alcohol was not less than 7 to 10 cubic centimetres. The acidity reached its maximum about an hour after the in- jections, and then gradually decreased. In two cases of achylia due to carcinoma of the stomach no effect was observed. E. Spiro (Miinchener med. Woch., No. 47, 1901). Alcoholic Poisoning. — The toxic ef- fects of alcohol are those of an irritant poison, and may be acute or chronic. The acute form of alcoholic poisoning occurs when an excess has been taken at once or within a short interval of time. In the milder form the ingested alcohol produces intense irritation of the stom- ach, with increased secretion of a mucus altered in character, nausea, and vomit- ing. The kidneys are the seat of irrita- tion, the result of which is an increased secretion of urine. If the irritation be too intense, the glomeruli may become so swollen as to diminish or even pre- vent the secretion of urine, in which latter case acute temporary suppression of urine results. The blood becomes charged with the abnormal products (through the abnormal condition of the stomach and its secretions), and these are excreted by the renal organs in the form of uric and oxalic acids, oxalate of lime, and urates; and, from over- stimulation of the nervous system and excessive glandular activity, the triple phosphates, with altered pigment-matter; so that, following an alcoholic excess, a large quantity of pale urine is followed later by a highly-colored, strong-smell- ing secretion. When enormous quantities are ingested, more serious symptoms, sometimes even followed by death, re- sult. The symptoms point to intense gastro-intestinal irritation, with irrita- tion of the cerebro-spinal system so great as to produce convulsions, coma, or death. Definite quantities of the different al- cohols administered to rabbits b}' means of (Esophageal tube. Three degress of in- toxication were distinguished according to their severity : ( 1 ) slight paralysis of motion and sensibility; (2) total paraly- sis of motion with almost complete aboli- tion of sensation; (3) coma, often ending in death. The toxicity rose with the boiling-point of the alcohol, methyl being least toxic and ethyl coming next, while propyl was twice, butyl three times, and amyl four times as toxic as ethyl. Ad- dition to ethyl-alcohol of 4 per cent, of an alcohol of higher boiling-point in- creased the toxicity of the former to a marked extent. The addition of 2 per cent, was much less powerful, while 1 per cent, had practically no effect in increasing the toxicity. Conclusion is that the symptoms of acute alcoholism are not due to impurities in the ethyl- alcohol; but it is left an open question whether these may not have some share in producing the more chronic results of alcoholic excess. Baer (Arch. f. Anat. u. Physiol., Oct., '98). Conclusions regarding effects of alcohol on blood are as follow: 1. In acute alco- holic intoxication the carbonic acid as well as the alkalinity is greatly reduced, due to the fact that there is an increase of volatile fatty acids, which, for the moment, displace the carbonic acid. The decrease of the red corpuscles cannot be of importance, as it is not constant. 2. The effects of chronic alcoholism make themselves fully manifest only after several months. The alkalinity remains about normal; the oxygen decreases, and later also the carbonic acid. Thomas (Arch. f. exper. Path. u. Pharm., B. 41, H. I, Mar., '98). Fatal acute alcohol poisoning in a child six years and three months old, who between 8.30 and 9.30 a.m., on an empty stomach, drank about 3 ounces of whisky. Death occurred by cardiac failure about twenty hours after the drinking of the whisky. M. A. Walker (N. Y. Med. .Jour., Aug. 19, '99). Case of blindness from drinking meth- 186 ALCOHOL IN THERAPEUTICS. ylic alcohol, the tenth case recorded, the patient, a German^ aged 45, who drank about V3 pint of a mixture of one-third ^yood-aleohol and two-thirds water. The following day he had some of the same potation; and, on the day after, violent vomiting set in, with extremely severe headache and foggy vision. A fortnight later he had no light-perception, and the pupils were large and irresponsive to light, the outer halves of the disks were decidedly atrophic, and their margins very slightly blurred. Some improve- ment in vision proved to be but tempo- rary; he is now quite blind. "Wood- alcohol," or methylic alcohol, is a very poisonous substance, and has been the cause of a number of deaths. Giflord (Ophth. Record, Sept. and Dec, '99). Retardation of the pulse is brought about by an irritation of the vagus centres, and of the peripheral ends of the vagi, in part due to a direct cardiac action. The fall in blood-pressure is due to a direct injurious influence upon the heart-muscle. Ladislas Haskovec (Wiener med. Blatter, Get. 11, 1900). Treatment of Alcoholic Poisoning. — The treatment of acute alcoholic poison- ing (drunkenness) is best begun by wash- ing out the stomach either by emetics or by the stomach-pump or by ingestion of large quantities of warm water. Com- plete rest, induced, if necessary, by large doses' of one of the bromides, and relief of nausea and depression by large doses of ammonia (spirit of Mindererus, or aromatic spirit), are of prime importance. The cold pack is also of great use. The use of coffee in large doses (in both acute and chronic cases) refreshes and stimulates the nervous system, and with rest and warmth assures a rapid recovery. If convulsions and coma are present rectal injections of chloral ma}^ be used, followed by the cold pack. Atropine, digitalis, and morphine may also be of service, though the prognosis is usually fatal. (See Alcoholism.) Therapeutics. — There is considerable divergence of opinion as regards the use of alcohol in disease. The older view is that it is a valuable agent when judi- ciously employed, and that stimulants are especially indicated in cases of fa- tigue, in convalescence from acute dis- eases, in persons who live a sedentary life, or who suffer from poor digestion, and in others who are prostrated from acute illness. In all these cases a glass of wine or a little brandy diluted with water, taken shortly before or with the food, is thought to stimulate the digest- ive organs and enable the patient to take more food. Pure alcohol is sometimes given alone or in combination with some bitter tincture, as tincture of calumba or quassia, or compound tincture of gentian or cinchona. Observations in man on the influence of alcohol on muscular work, by means of Mosso's ergograph: an arrangement something like an extension apparatus, with a weight and pulley on which mus- cular traction can be made, the amount of work done being registered in kilo- grammeters graphically. Summary of the results: — 1. Moderate quantities of alcohol have an appreciable influence on the working capacity of muscles; but this differs in the fatigued and fresh muscle. 2. In the unfatigued muscle alcohol lessens the extent of its maximum con- traction, owing to decrease of peripheral irritability of the nervous system. 3. In the fatigued muscle alcohol in- creases the working capacity, as its extensibility is increased. 4. A fatigued muscle, however, under the influence of alcohol, never attains to the working power of an unfatigued muscle, because the lessening of the peripheral nervous Irritability by the alcohol interferes with the development of its full working power. 5. The action of alcohol on muscle is developed in a very few minutes after it has been swallowed, and lasts a con- siderable time. 6. In all cases the alcohol diminishes ALCOHOL IN THERAPEUTICS. 187 the feeling of fatigue, and the work ap- pears easier. 7. After moderate amounts of alcohol the increase is not followed by any de- crease in the muscular power of fatigued muscles; after large amounts of alcohol the sj'mptoms of muscular paresis are prominent, and increase with the dose. Alcohol, therefore, has a twofold action on muscular work: first, on the nervous system it diminishes centrally the feeling of fatigue, and peripherally the excita- bility; while, secondly, it furnishes food- material Avhieh can be oxidized to pro- duce energy and work. Hermann Fey (Edinburgh Med. Jour., Sept., '97). Series of investigations on effects of alcohol. One ounce of alcohol greatly reduced the perception (Ach). Capacity for calculating lessened, but, while alco- hol lessened the ability to reckon accu- rately, the work was easier (Vogt). The capacity for physical work increased about one-third after the ingestion of alcohol, but in ten minutes this increase had almost entirely disappeared. It did not really increase the strength. When alcohol is added to the fatigue products of the muscles the depressing effect be- comes very marked. Kest after taking alcohol prevents any noticeable diminu- tion in strength; but, if the action demands the utilization of strength, fatigue rapidly comes on (Gluek). The effect of alcohol varies remarkably in different men; the degree of sensitive- ness to the poison might at times be less in those not addicted to its use than in those accustomed to it (Eudin). General conclusion that whoever knows the effects of alcohol will not class this substance among the harmless agents. Kraepelin (Miinch. med. Woch., Oct. 17, '09). According to Harnack, who has closely ■studied the question, alcohol in small or medium doses exercises simultaneotisly a stimulating action upon certain func- tions and a depressing action upon others. This fact should never he lost sight of; otherwise the physician exposes himself to the danger of injuring instead of benefiting his patient. It should also never be forgotten that, even in small doses, the paralyzing action of alcohol is exercised most rapidly and most ener- getically upon the tonus of the blood- vessels, — the importance of which tonus for the regularity of the circulation and the preservation of cardiac energy is well known. For this reason alcohol should be given with caution in cases in which the heart is already enfeebled, as in acute diseases of long duration, or in convalescence from such affections. It sometimes happens that the patients themselves refuse alcoholics; in which case they should never be compelled to take them, but should be given digitalis instead, which, even in small doses (5 minims in 6 ounces of water), acts solely upon the heart, but in this way estab- lishes the tone of the blood-vessels. The acceleration of pulse, often observed after the administration of digitalis, is doubtless due to the improved nutrition of the cardiac muscle. The use of alcohol as a stimulant or tonic in the treatment of disease is de- lusive and more or less injurious. By diminishing the internal distribution of oxygen and the activity of the leucocytes it directly diminishes man's vital resist- ance to the action of all morbific causes, while by its ansBsthetio effect on the cere- bral convolutions, it lulls him into a false feeling of security. N. S. Davis {Med. Pioneer, Oct., '94). Alcohol removes, in great measure, the controlling influence of the smaller arter- ies on the heart, and causes, also, paresis of the vagus. The result is increase in the number of cardiac beats, dilatation of surface-vessels, a feeling of surface- warmth, with reduction of the tempera- ture of the body. It can scarcely be considered a food, as in itself it contains no one of the constituents of which the body is made. It gives no warmth to the body. This is proved by the ther- mometer. The disuse of it by deer- stalkers, Canadian hunters, and Arctic explorers is additional proof of this. It 188 ALCOHOL IN THERAPEUTICS. gives no strength. It distinctly weakens the muscles. Professor Parkes realized this by experiment in the last Ashantee War. Acting on the same views, the Great Western Raihvay, during the alter- ation of rails along the whole line, sub- stituted oatmeal-gruel for alcohol, be- cause the work had to be done with rapidity and with unusual energy. The relief of Chitral tells the same story, and so do our great national games. It does not lengthen life. Long Fox (Bristol Medico-Chir. Jour., Mar., '96). Fevees. — While alcohol is very useful in many cases of fever, there can be no reasonable doubt that all cases of fever do not require it, while many cases are best treated without it. The special in- dications for its exhibition are: general debility; rapid, small, or irregular pulse; the condition known as the typhoid state and recognized by the presence of hebe- tude, indifference, jactitation, muscular twitching, subsultus tendinum, mutter- ing delirium; coma vigil or even a more active delirium, with signs of great weak- ness; a dry or brown tongue, sordes, and, perhaps, involuntary evacuation of urine or fasces. If the patient is being benefited by the use of stimulants, the following effects will be observed: The tongue becomes moist; the pulse becomes slower; the skin becomes comfortably moist; the breathing becomes more and more tranquil; sleep is produced; delir- iiim is quieted or disappears. While alcohol should not be given in every case of fever, certain definite indi- cations exist which imperatively call for its use: 1. Persistence of a high tem- perature. 2. Persistence of a rapid, feeble, irregular, dicrotic pulse, whether associated with high, low, or irregular temperature. 3. Persistence of marked prostration. If, however, after giving alcohol the pulse becomes quicker and more irreg- ular, the skin hotter and drier, tongue browner and drier, breathing shallower and hollower, it means that the alcohol is doing no good even if it is doing no harm; it means that the little patient has passed from the stage of depression, in which alcohol is of decided utility, to the stage of exhaustion of the vital pow- ers, in which it is of no value; nor is any other remedy, for that matter. Un- der such circumstances alcohol had best be discontinued. Depression of vital powers, no matter how alarming, can be successfully combated by alcohol in con- junction with other powerful and quickly acting stimulants. Exhaustion of the vital powers, whether in old age or in- fancy, means death. A. E. Bieser (Pediatrics, Apr. 1, 1901). Poisoned Wounds. — Alcohol is a valuable remedy in the toxaemia pro- duced by poisoned wounds, snake-bites, etc., if used immediately and freely. In these conditions the dose is to be regu- lated by the effect, as very large doses are not only tolerated, but required, to be of any use. Aconite Poisoning. — Stimulants, freely administered (best by hypodermic injection for rapid action), are useful in this grave condition, in which the whole plan of treatment is directed toward stimulation and the prevention of syn- cope. (See Aconite.) Externally. — Alcohol used exter- nally is detergent, antiseptic, disinfect- ant, astringent, and haemostatic. These properties make it a valuable agent in the treatment of woimds, especially if the seat of infection. Whisky, plain or diluted (1 to 4), may be used. For non- infected wounds and granulating ulcers the vinum aromatieum (U. S. P.) is a valuable dressing. In snake-bites and insect-stings, strong alcohol combined with ammonia is a useful lotion after the poison has been sucked out of the wound. Alcohol (8 p.) combined with am- monium chloride (1 p.), vinegar or dilute acetic acid (4 p.), and water (64 p.) makes ALCOHOL IN THERAPEUTICS. 189 a valuable evaporating lotion, which may be perfumed if desired. This is useful in headache; strained and swollen joints, muscles, and tendons; abscesses, ery- thema, erysipelas, and slight burns. For bathing fever patients, alcohol is useful, alone, or combined with vinegar when there is diffuse diaphoresis. Alcohol is used as a detergent, alone, or combined with sodium bicarbonate (2 p.), alcohol (8 p.), water (80 p.), or in the form of soap liniment. Applied to irritated, fissured, or excoriated nip- ples, dilute alcohol hardens the surface, and coats the raw surfaces with a deli- cate protective film (by coagulating the albumin in the secretion of the raw sur- face) and diminishes the sensibility of the terminal nerve-filaments. Ulcers or aphtlije are benefited by the local application of strong alcohol. The disinfecting properties of alcohol are asserting themselves increasingly. A dilution of alcohol of 55 to 100 is toxic to staphylococci and is but slightly inferior to 1-to-lOOO corrosive sublimate, and equal to carbolic acid in 3 parts per 100. Alcohol to which is added an alkali for the purpose of saponifying fat greatly increases the disinfecting powers. A dilution of 80 parts in 100 is an ex- ceedingly efficient disinfectant for the hands. G. Fisher (La Presse Med., July 7, 1900). Property of alcohol in the sterilization of the hands. It is in abstracting air from the pores and fissures of the skin that the true value of the application lies; a previous treatment with alcohol enables subsequent aqueous solutions to penetrate much more thoroughly and completely into all the macroscopical and microscopical interstices of the cuta- neous surface. Braatz (Miinch. med. Woch., July 17, 1900). Permanent applications of strong alco- hol of great service in combating all in- flammatory conditions in which there is a tendency toward suppuration. It causes a local dilatation of the blood- vessels, and thereby the formation of alexins and consequent greater capacity for resisting the spread of infection. Thick layers of gauze are saturated with alcohol and then covered with some im- pervious material. The dressing is left in place for days at a time, resaturating it with alcohol once every twelve hours. Graeser (Miinch. med. Woch., July 17, 1900). In disinfection with alcohol the vapor is the effective element. Von Brun (Miinchener med. Woch., Feb. 12, 1901). In the various preparations of alcohol, those W'ith a higher specific w-eight have more energetic disinfectant action. The most energetic preparation is 40-per-cent. alcohol, which boils at about 90° C. Frank (Miincliener med. Woch., .Jan. 22, 1901). Inhalations. — Inhalations of alcohol have proved useful in the treatment of shock, collapse, and the profound asthe- nia met with in fevers and toxic condi- tions, especially when alcohol cannot be taken by the mouth or given by the rec- tum. A 10-per-cent. solution of alcohol may be administered by steam or hand- spray apparatus, or by pouring alcohol or spirits into a vessel of hot water, throwing a towel over the vessel and the patient's head. IN.TECTIONS. — Tumors. — The use of alcohol in carcinoma has been productive of encouraging results. Interstitial in- jections of very strong alcohol have been used by Vulliet, of Geneva, as a palliative in inoperative cases of cancers of the uterus. The beneficial action obtained this author ascribed to the local ischsemia induced. Carcinoma of the uterus was also treated in 1878 by Hasse with alcohol, injections being made into the circum- ference of the growths in three cases with good results. After twenty-three years the patients were alive and well. There had been formation of connective tissue around the neoplasm, obliteration 190 ALCOHOL IN THERAPEUTICS. of the blood-vessels, and shrinking of the tumor. To prevent the recurrence of growths a mixture of 30 parts of absolute alcohol to 70 parts of water should be injected twice a week around the tumor. 0. Hasse (La Semaine Med., Oct. 16, '95). Alcohol as a curative measure, inject- ing it into various tumors. Ten to 20 minims are injected in one side of tumor, then as much in another place; con- tinued till every part is touched with alcohol. J. W. Young (Charlotte Med. Jour., July, '95). More recently this treatment has been employed in cancer of the breast with encouraging results. Case of cancer of the naso-pharynx in which the injection of unfiltered ery- sipelas-prodigiosus toxins had failed. In view of the inevitable fatal outcome, in- jection of alcohol after the method of Sehwalbe and Hasse tried. The injec- tions Avere begun on October 14, 1896, beginning with 3 minims of absolute alcohol and rapidly increasing to 30 minims. The reduction in size began after the seventh injection, and after the eleventh but few remnants of the growth remained. After a dozen or more injec- tions the needle would not penetrate into tissues capable of retaining the alcohol, and after a few additional attempts, at , intervals of a week or longer, they were discontinued. In February, 1S97, the naso-pharynx was found both by inspec- tion and palpation to be entirely free from growth or any suggestion thereof. Examination of secretions of tumor con- firmed the diagnosis of cancer. Edwin J. Kuh (Medical Record, Apr. 17, '97). Case of cancer of the breast treated by injections of alcohol. On February 20th, with a mixture of 40 parts absolute alcohol and 60 parts distilled water, 23 syringefuls, each of 20 minims, were in- jected deeply into the tissues all around the tumor, and into the axilla in the neighborhood of the enlarged glands. The injections, averaging from 22 to 25 syringefuls each time, were repeated about every fifth day until May 2. Each sitting occupied about three-fourths of an hour; the injected fluid had a great tendency to run back again, to obviate which a smear of collodion over the needle-pricks is the best preventive. The patient experienced considerable immedi- ate pain from the injections, lasting from one-half to one hour. After the second series of injections the patient declared that the sensations in the breast were altered, the shooting pains were no more felt, and the itching on the surface of the breast, which she had complained of, disappeared and never recurred. After the subsidence of the immediate painful effects of all the other injections, the patient felt more comfortable in every way. When the process had been con- tinued for five weeks, "'.he parts around the tumor began to be oedematous, but still the injections were continued into- and beyond the oedematous parts. Dur- ing the sixth week the patient and her nurse stated that they considered that the growth was less, and certainly at the- beginning of the eighth week (Aprii 11th) the whole breast, including the tumor, had diminished in size. After this date, all the parts, breast and tumor, rapidly shrunk, until in May there was actually nothing left of the mamma to be felt bj' the hand, and prac- tically nothing left of the tumor but the nipple and slight thickening under it. There was still oedema in the injected' area. The glands in the axilla could not be detected. At this time Mr. Windsor examined the case (May 12th) and stated "that whilst the right was a fairly large hanging breast, the other — the left breast — had practically disappeared, the nipple only remaining; that he did not find any thickening under the pectoralis nor enlarged glands in the axilla." After these seventeen injections, a complete structural change to all appearance hav- ing taken place, it was intended to con- tinue the injections at longer intervals for a considerable time, but unfortu- nately the patient became ill otherwise. She lost her appetite, became slightly jaundiced, and on examining her in bed on May 16th it was found she was suffer- ing from cancer of the liver with ascites. This being the case nothicg further was done; the patient rapidly got worse, and died on June 10th. The mamma was ALCOHOL IN THERAPEUTICS. 191 found to be replaced by a dense, fibrous- looking mass with several processes ex- tending into the surrounding fat and firmly connected with the subjacent pec- toral muscles. The skin was rough, superficially ulcerated at one place, and adherent to the subjacent tissue around the nipple. The nipple was depressed, but not considerably retracted. William Yeats (Brit. Med. Jour., Sept. 25, '97). In cases of shock, collapse, typhoid state, and profound asthenia, where stimulants cannot be swallowed, whisky or other spirits may be injected hypo- dermicallj', with the advantage of rapid absorption and speedy action, according to some authors, but the belief is gaining ground that it is more harmful than beneficial. [We are glad to observe that the truth concerning the noxious action of alcohol in narcosis from anaesthetics, determined by Wood in his able, experimental re- searches, has begun to be disseminated, aB it certainly deserves. We believe that the use of hypodermic injections of alco- hol in chloroform or ether narcosis, as recommended and employed heretofore, has been an error, and should be aban- doned. Griffith and Cerna, Assoc. Eds., Annual, '93.] Alcohol is a useful food in the small quantity which increases, but does not impair, digestion; which quickens the circulation and the secreting function of the glands, but does not overstimulate; and which can be oxidized in the body. This amount, says Bartholow and others, is from 1 ounce to 1 Va ounces of absolute alcohol for a healthy adult in twenty- four hours. All excess is injurious. In small doses alcohol stimulates the stomach, and consequently promotes hyperchlorhydria and hyperacidity of that organ. In large doses it loses its stimulating action, and the chlorhydric action upon albuminoids :s either weak or wanting. M. P. Haan (Piogres M6d., Dec. 21, '95). The prolonged indulgence in alco- holic drinks in time produces a chronic catarrhal inflammation of the gastric mucous membranes, accompanied by a proliferation of the connective tissues.. This latter, by subsequent contraction,, obstructs and finally obliterates the- secreting follicles and the cells whiclv line them. In this way the mucous- membrane becomes thickened, indurated,, and uneven, and covered with a coating of thick, tenacious mucus that excites- fermentation, with gas and various acids (butyric, acetic, etc.); whence acidity and heart-burn. These harmful effects on the stomacb are much less marked in fever patients- and in those who are convalescing from exhausting diseases. In infectious diseases alcohol should never be given unless the patient is near collapse. Even in small doses it weakens, the resistance, and so favors the action of the invading microbe. It is a cause of still-bora infants, with more or less wide-spread fatty degeneration. Gruber- (Wiener klin. Woch., May 9, 1901). As the diffusive power of alcohol is great, it passes readily into the blood;, little finds its way very far into the in- testines. The effects of alcohol on the other organs of the body (liver, kidneys,, brain, and vessels), as it passes through them on its way in the circulation, will be considered under Poisoning. Even in large qvtantities, alcohol ap- pears neither to promote nor to hinder- the conversion of starch into sugar. Parkes and WoUowicz hold that alco- hol does not diminish the oxidation of the body. G. Harley found that alcohol, added in small quantities to blood with- drawn from the body, lessened its ab- sorption of oxygen and its elimination of carbonic acid. As to the effect of alcohol on the body- temperature, it would seem that a small quantity, in a subject not accustomed to its iise, causes increased activity in all. 193 ALCOHOL IN THERAPEUTICS. the bodily functions and a slight eleva- tion of temperature. Considerable doses of alcohol cause a decline in temperature of the body, which is even more marked when fever is present, except in patients in whom a decline of temperature does not follow in doses short of lethal. This reduction of temperature produced by alcohol is, doubtless, referable to the diminished rate of tissue metamorphosis, for it has been ascertained that the excretion of both urea and carbonic acid is lessened by alcohol; the combustion of the nitrogenous and carbonaceous foods is retarded. This action results in an increase of body-weight, as seen in the rotundity of those who take spirits moderately. The action of alcohol on the heart is most important. When the heart is weakened by debilitating diseases (pulse always quick and weak), it strengthens the contractions and, by its tonic influ- ence on the heart, alcohol strengthens the pulse and reduces its frequency. It stands first as a safe and efficient cardiac stimulant. Cases in which it is contra-indicated: endocarditis, pericarditis, meningitis, epi- lepsy, eclampsia, chorea, acute diseases of the skin and certain chronic forms (as eczema, psoriasis, etc.), nodular rheuma- tism, and the gouty diathesis. Jules Simon (Med. Age, July 25, '90). Alcohol ought to be given very spar- ingly, indeed, to people with chronic car- diac disease, and one great consideration is that, having once begun to give it in such cases, it is very difficult, if not im- possible, to leave it off. It is obnoxious in that it tends to diminish the desire for food, and perhaps may actually aggra- vate the tendency to induration, arterial and valvular, which already exists. Al- cohol should certainly be sparingly given. Sidney Coupland (Clinical Jour., Mar. 21, '94). The condition of the svstem causes great variation in the physiological ef- fects of alcohol. In convalescence from acute diseases, in the condition of shock from serious injury, loss of blood, or snake-bites, quantities which would, un- der normal conditions, cause intoxica- tion, are taken with impunity. The extremes of life (infants and the aged) bear alcohol well. Habitual use modifies more decidedly the influence of alcohol on temperature, circulation, and the nervous system. In the diseases of childhood all forms of gastro-intestinal disturbance can be excluded from the list of diseases in which alcohol is beneficial. In acute eases, even in cholera infantiim, large quantities of water with a small amount of black coffee or tea will stimulate better than alcohol, while it is not irritating to the already diseased mucous membrane. It is especially irrational and harmful to administer alcohol in the diarrhoeas of children before the stomach and bow- els have been freed from all putrefying material. In the typhoid fever of childhood Seibert rarely gives alcohpl. The disease usually runs a mild course and relapses seldom occur if proper diet is adhered to. In pneumonia the enormous quantities of alcohol which are frequently given are irrational; they should only be used when collapse threatens or is present, and then in large doses and in concen- trated form. Alcohol-fed children digest less perfectly in pneumonia than others, and do not regain their appetite and digestive power after the attack is over as those do who are treated without it. Alcohol prepared in the form of pen- cils, for the treatment of superficial im- petigo, sycosis with small pustules, pustular acne, and pustular rosacea. The patient carries the pencil with him, wrapped in tin-foil, and is instructed to rub it over the papules and pustules as ALCOHOL. ALCOHOLIC NEURITIS. 193 frequently as possible. The formula for the pencils is as follows: — IJ Sodium stearate, G grammes. Glycerin, 25 grammes. Alcohol, 100 grammes. The glycerin is added to prevent brit- tleness. P. G. Unna (Monats. f. prakt. Dermat., xxxi. No. 11, 1900). C. Sumner Witherstine, Philadelphia. ALCOHOLIC NEURITIS. Definition. — Inflammation of the pe- ripheral nerves, especially those of the extremities, due to the excessive use of alcohol. Symptoms. — The first symptom of alcoholic neuritis consists usually in neu- ralgic and tingling pain, especially in the lower limbs, less commonly in the upper limbs. Long prior to these first painful sensations there generally are feelings of debility, lethargy, anorexia, or uneasi- ness, with disturbed sleep. The sufferer labors under malaise, cannot tell what is the matter, and rarely seeks medical advice till the pains become severe. Alcoholic paralysis of the upper limb usually affects the muscles animated by the mnsciilo-spiral nerve, and is often complete, which is the opposite of what is usually seen in plumbism. Wrist-drop and foot-drop occur from the extensors being more affected than the flexors. The facial muscles and the sphincters may be affected in very rare ■cases. These pains are usually followed by difficulty in walking, which in turn is due to paresis of the leg-muscles and ataxia. A distinctive walk, called the high- stepping, or pseudotabetic, gait, consists in raising the foot and throwing it for- ward, the toes hanging down causing the patient to raise the heel, the sole being visible from behind. This "high-step- ping" is seen only when foot-drop is distinct. It resembles the gait of a man meeting obstacles while walking. When the lower limb is affected, and when the patient is lying down, the foot forms an obtuse angle with the leg, its outer edge is lower than the inner, and the phalanges are fixed. The patient cannot move his toes or raise the outer edge of the foot. The foot can be ex- tended on the leg, but only slightly flexed on it. Usually the paralysis be- gins by the extensor proprius hallucis, followed by the extensor communis and the peronei; the quadriceps may be also affected, and may indeed be the only muscle paralyzed. (J. Babinski.) Two cases of paralysis of the left vocal cord due to alcoholic neuritis. In the first case there had been, for fifteen days, such a feebleness of voice that the pa- tient, a clergyman, was unable to fulfill his duties. There was no thoracic affec- tion and no sign of locomotor ataxia. The left vocal cord was ir. the cadaveric position. The patient gave a history of recent sciatica in the left leg, but ac- companied also by a pronounced anaes- thesia of that member. The patient, although never drunk, was accustomed to drink a quart of strong, English beer at luncheon and dinner, and in the even- ing a considerable quantity of brandy. Complete abstinence was enjoined and carried out, and fairly large doses of nux vomica prescribed. By the end of four weeks the voice had completely returned and the vocal cord had regained its nor- mal functions. Dundas Grant (Archives de Laryng., May, June, '97). Later on, atrophy of the muscles may be noted, supplemented sometimes by degeneration reaction to electricity. The knee-jerk is lost early in the history of the case. The hands and feet may be- come swollen and congested when al- lowed to hang down. AuEesthesia of the legs, and even of 194 ALCOHOLIC NEURITIS. DIAGNOSIS. other portions of the body, is frequent. Indeed, disturbances of the sensibility may be noted when motor disturbances are of little importance; the opposite, however, does not occur. On the other hand, parsesthesia may be present, press- ure on the muscles and nerves causing great pain. Cutaneous reflexes are some- times diminished in extent and rapidity. Convulsions and fever rarely occur. Mental symptoms are occasionally pres- ent, but they are frequently slight, amounting only to irritability, unrest, and suspicions. In a proportion of cases there are delirium and extravagant hallucinations resembling those of general paralysis, the most characteristic being a loss of appre- ciation of time and place. (Wilks.) Eecent events are forgotten, while ancient ones are remembered. The ocu- lar disturbances of alcoholism are bilat- eral, symmetrical, and affect both eyes equally. They chiefly consist in a cen- tral scotoma, ellipsoid in shape, with the longer axis horizontal; red and green are the first colors not seen. Ophthal- moscopically, the temporal side of the disk is discolored. Paralysis of the motor externus, ptosis, and external ophthal- moplegia have been noted. The pupils may react more slowly than normally to light. (J. Babinsld.) Diagnosis. — Eheumatic pains in the early stages. The failure of sodium salicylate to alleviate the pain, with the temporary lull from opiates, though the pains thereafter persist, soon excludes rheumatism. General Paeesis. — It can be differ- entiated from this disease by the absence of paralysis of the tongue and lips and of grandiose delusions, by the presence of muscular wasting with wrist- and foot- drop, by the tearing or stabbing pains, by the lost knee-jerk, extreme pain on pressure, and by a feeling of coldness on being touched. Alcoholic paralysis is the disease most frequently mistaken for general paraly- sis. An important differential point is the mode of development of each disease, general paralysis always commencing in- sidiously, alcoholic paralysis frequently Avith great suddenness, and it is believed that this sudden development, associated with the pen'ersion of the affections, is almost sufficient to confirm the diagnosis. These features have also been insisted upon by Charpentier. E. JI. de Montyel (Eevue de Med., Feb. 10, '98). LocoMOTOE Ataxia. — In this affec- tion there are girdle pains; urinary and ocular disturbances are almost constant, while atrophic paralysis belongs more especially to alcoholic neuritis. In non- alcoholic locomotor ataxia the toes are raised, but in alcoholic neuritis they hang down. The non-alcoholic comes down on his heel, the alcoholic neuritic on his toes. The paralysis of the former is not so symmetrical and his gait is more un- even and jerky than the latter. Lead Paealysis. — It may be differ- entiated from this disorder by the ab- sence of the blue gum-line, and by the much greater prospect of recovery. Disseminated Sclerosis. — This dis- ease can be eliminated by the absence of head rhythmical tremors, spastic paraly- sis, and hyperalgesia, which occur in alcoholic paralysis with nystagmus. From special ateophic paralysis by the absence of pain in the non-alco- holic. From Landry's acute ascending paralysis by tue legs being affected first, the arms next, and then the trunk (if at all), and the foot-drop, there being no foot-drop in Landry's, and in the latter the trunk being affected immediately after the legs; besides, Landry's has no muscular atrophy and no alcoholic elec- trical reaction of degeneration. From PEOGEESSIVE musculae ateo- ALCOHOLIC NEURITIS. ETIOLOGY. PATHOLOGY. 195- PHY by the presence of pain and the alcoholic degeneration reaction; so also from chronic anterior poliomyelitis. From TOXIC htstekical paralysis by the suddenness of the hysterical onset and cessation. From CEHEBEAL HEMIPLEGIA in that hemiansesthesia is rarely met with in that disease. From various nervous affections of a mixed character. Etiology. — Alcoholic neuritis is more common in women, and in those who have drunk quietly for a long time. It is especially due to the inordinate use of spirits and alcoholized wines, such as sherry, Madeira, etc. One hundred and twenty cases of al- coholic nervous affections, of which only nineteen could be classed as polyneu- ritis. The motor form was the more fre- quent, and the ataxic second. Freyhan (Deutsches Arch. f. klin. Med., vol. li, p. 6, '94). Child, 3 V2 years old, who, after a large drink of whisky, went into stupor vaiy- ing in depth and lasting more than two months; had a large number of convul- sions, partly general and partly limited to the left side; developed right-sided paralysis, which was especially marked in the arm; extreme contractures, espe- cially of the left side, and loss of faradic irritability with wasting, and during the first two months had pupillary symp- toms, strabismus, and repeated vomiting. During six weeks there were the signs of complete consolidation of the right lower lobe. Recovery. Herter (N. Y. Med. Jour., Nov. 7, '96). Case of alcoholic multiple neuritis fol- lowing prolonged debauch. In the spinal cord very marked lesions were found in the anterior horns, the posterior horns, the columns of Clarke, and the nucleus of Stilling, and in the ganglion-cells, the changes being especially marked by their great variety. The most common was central chromatolysis. There were also distinct degenerative changes in the cor- tex of the brain. Fatal alcoholic mul- tiple neuritis causes grave changes in the ganglion-cells characterized by extreme- polymorphism. J. H. Larkin and Smitb Ely Jelliffe (Med. Record, July 8, '99). Pathology. — Until recently (1881), when Clarke discovered a softening of certain portions of the spinal tissue, the post-mortem appearances seen had been peripheral. Eichhorst found a few dis- eased patches in the middorsal region besides disease of smaller vessels through- out, and increase of the connective tissue in the lateral column. Schafer, Paj'ne, and Sharkey found ganglionic inflam- matory changes and degeneration. Pal noted degeneration of Lissauer's poste- rior root-zone in the lumbar region and general involvement of Goll's columns; in another case degeneration of GoU's columns in cervical region, less marked in the dorsal, appearing again in the lumbar. Thomson found disease of the nuclei of some of the cranial nerves in the pons and medulla oblongata. Hun and Kojewnikoff observed slight degen- erative changes in the ganglion-cells of the cortex cerebri. Dejerine and Sharkey have described disease in the vagi and phrenic nerves. Congestion of pia mater has been noted. Campbell also noted these ("Trans. Path. Sec. Liverpool Med. Inst.," vol. xsiii, No. 2, '"93). The prin- cipal changes have been met with in the periphery, generally limited to the finer nerve-terminations, the morbid intensity diminishing with the distance from the periphery. These degenerative changes are generally symmetrical in the upper and lower limbs, the latter being most frequently involved. This peripheral in- flammatory degeneration is parenchyma- tous, the iniiammatory process being secondary to strangulation of the nerves higher up. Sometimes the part affected is swollen; at other times the microscope alone reveals the lesion, disclosing a dull appearance from fatty myeline degener- 196 ALCOHOLIC NEURITIS. ALCOHOLISM. ation. The degenerated cloudy portion gradually separates till the segments surround the axis-cylinder as fatty par- ticles. In the sheath and intestinal tissues there is a great increase of the nuclei of the sheaths and infiltration with leucocytes, with thickening of the perineurium. Finlay found wasting of the fibres of the wrist extensors, leu- cocytes and nuclei crowding the inter- stitial spaces. In peripheral neuritis are found peripheral lesions; in alcoholic insanity and dementia the lesions are central: brain shrinkage and softening, shallowing of interconvolutional fur- rows, tortuous atheromatous vessels, and ventricular eflEusion. In the optic nerves the interstitial tissue is first affected; there are found many healthy fibres, which is the oppo- site of what occxirs in the optic neuritis -of locomotor ataxia, and which explains the clinical aspect of alcoholic ambly- opia. Most important effects of alcohol on the tutular neurin are shrinking and hardening, transmission of impulses being impaired; on vesicular neurin the disso- lution of phosphorus, protagon, and lec- ithin, with selective affinity for the neurin of the cerebellum. Wilkins (N. Y. Med. Jour., Sept. 22, '94). [Statement as to hardening of the neurin and other tissues by alcoholic in- gestion requires further corroboration. Frequently microscopical appearances are deceptive. Norman Kerr, Assoc. Ed., Annual, '96.] Prognosis. — Complete recovery may be obtained in the great majority of cases if alcohol be completely renounced. In very grave cases, especially when the patient is not seen in time, total paral- ysis, and even death, may supervene. The amyatrophy of alcoholic neuritis may become extremely marked, and end in the formation of fibrotendinous re- tractions. Treatment. — Alcohol must be given up at once and always. Electrotherapy; cold, tepid, hot, or Turkish baths; sponging, and strychnine preparations are recommended. So also are arsenic, nux vomica, cinchona, and the iodides. The food must be easily assimilable. Alcoholic paraplegia in a woman 30 years old, who was completely cured by combined galvanization of the spinal cord and the paralyzed muscles. Later fara- dization was employed. Massy (Jour, de Med. de Bordeaux, Apr. 23, '93). KOHIIAN KeKE, ALCOHOLISM. Definition. — The various pathological changes and attendant symptoms caused by the ingestion of alcoholic beverages. Varieties. — Two forms are recognized: the acute, in which alcoholic poisoning speedily manifests active excitement and disturbance, or in which a sudden ex- acerbation of the disorders attending the chronic type gives rise to correspond- ingly marked symptomatic activity; the chronic, in which the continued ingestion of alcoholic beverages in more or less appreciable quantities sets up patholog- ical changes, the morbid transformations gradually involving the various organs and tissues and giving rise to chronic disorders of each of the parts thus at- tacked. The older denomination of "delirium tremens" is now considered under the heading of "acute" alcoholism, as are, also, acute alcoholic poisoning, intoxi- cation, acute alcoholic insanity, acute alcoholic paralysis (alcoholic neuritis and alcoholic toxic hysterical paralysis), acute alcoholic epilepsy, etc. To make this article more intelligible, it was deemed best, however, to adopt the fol- lowing subdivisions: Acute Alcoholic Intoxication, drunkenness; Acute Al- ALCOHOLISM. ALCOHOLIC INTOXICATION. ACUTE. SYMPTOMS. i9r coHOLic Delieium, delirium tremens; Acute Alcoholic Mania, mania a potii; and Cheonic Alcoholism, the meaning of which has already been given. Acute Alcoholic Intoxication. Symptoms. — Three stages are discern- ible in this condition. The first is vas- cular relaxation, when the intoxicated is usually lively, merry, agile, and joy- ous; all excitement and energy; in the highest spirits, cheerful, hopeful, and communicative; mercurial and confid- ing, often telling his private affairs to strangers. There is a warm glow of color on his countenance, he looks at his best. Gradually his spirits rise still higher; he becomes more demonstrative in love or in argument, more emphatic in his gestures, more furious in his fun, and very much louder in his laughter, as the second stage is ushered in. With this he is becoming much less reasonable and amenable, incoherence of thought and speech gradually set in, the imagina- tion revels, exaggeration is a prominent feature, and his emotions dominate him, intellect, reason, will, and conscience rapidly fading in the background. In some cases his thoughts, speech, and actions are exaggerated. In other cases these are transformed, the usually modest, retiring man becoming a boaster and a braggart, the truthful a liar, the meek violent. With all this, speech thickens, the lower and then the upper limbs cease to act in unison, the intoxi- cated cannot stand, but staggers with paralytic drunken unsteadiness of gait, the muscles becoming flabby and feeble. The third stage of "dead drunkenness" reveals an unconsciousness with the pallor of apparent death on the face, extreme coldness, accompanied by total insensibility and an utter disregard of the "world without" and the "world within." Sensation, perception, volition, and emotion, all are absent. Through this living death in the heart and cir- culation lingers the only spark of vitality which keeps the unconscious drunkard just alive till the faculties, if they do emerge, have emerged from the depth of narcotism into which they were plunged. In some cases the first pleasurable stage and the second, less pleasant, may vary in intensity and duration, but the last insensible stage usually lasts from six to twelve hours. These successive groups of symptoms, or stages, may be described as "the three acts of the drama of in- toxication." Alcoholic acute poisoning is some- times manifested as epileptic explosions. These are, in some cases, with a known epileptic neurosis, the indirect effect of alcoholic provocation; but there are other cases in which acute alcoholic excitation seems to directly, after a cer- tain cjuantity of poison has been taken, set up epileptic seizures (these seizures appearing only after the ingestion of alcohol), in which cases no epileptic at- tacks or tendencies are ever observed so long as alcohol is not drunk. Purely hysterical paroxysms are also excited in some cases by the consumption of even small doses. Some of the subjects so apt to be toxically affected in this way never display hysterical symptoms at other times. Etiology. — Though the toxic action of alcohol in the causation of alcoholic in- toxication is the same in kind, all kinds of alcohols being poisonous, the toxic action is modified, in a minor degree (1) by the variety of the alcohol; (2) by the idiosyncrasy of the drinker. The heavier and less highly rectified spirits (anlylic and butylic) are more toxic than the lighter (ethylic and methylic). Spirits are more acutely toxic than equal 198 ALCOHOLISM. ALCOHOLIC INTOXICATION. ACUTE. PATHOLOGY. quantities of wines and beers, from the greater concentration and quantity of the alcohol in the former, tending more intensel}' to acute congestion and irrita- tion of the gastric mucous membrane, the liver, kidney, heart, and brain. Absinthe induces epileptic convulsions; and meth- ylism is miieh more rapid in its course than ethylie alcohol. The temperament and constitution of the drinker also oc- casion some difference of symptoms, one subject getting drunk at once "in the legs," another "in the tongue." In dogs wine-alcohol produces depres- sion and inebriety lasting four to five hours; beet-root alcohol, comatose sleep and anossthesia lasting twenty-four houi's, followed by illness; maize-alco- hol, the same plus subsultus tendinum. Magnan (Le Bull. Med., July 31, '95). Of all alcoholic drinks the most dan- gerous are the liquors containing essen- tial oilSj such as the various absinthes and anisettes. The least harmful are those made without essential oils — from chemically-pure industrial alcohol, brandy, bitters, etc.^=— by means of non- toxic flavoring materials. For an iden- tical proportion of alcohol, wines are more toxic than wine-brandies^ which, in turn^ are more toxic than brandies artificially prepared by means of well- rectified commercial alcohol. Generally white wines are less toxic tlian red wines. Wines treated with plaster and diseased wines are exceedingly toxic. Experi- ments made by means of intravenous in- jections in rabbits demonstrating the above. Daremberg (Archives de Med. Expgr., vol. vii, p. 6, '95). Drinking habits existed in one or both parents in all of 350 cases examined ex- cepting 10. The father was usually the drinker. In another series of 210 cases the percentage was much lower: 25 per cent, gave a negative hereditary history. Mechanics, artisans, and small trades- men furnish the greatest proportion of cases, the in-door workman being often- est the victim. About one-third of in- ebriates are women. C. L. Dana (Med. Record, July 27, 1901). Pathology. Post-mortem Appearances. — In a fatal case seen by me, of a mar- ried woman, aged 41, who had died mthout recovering consciousness in 5 ^/^ hours after swallowing at a draught 2 ^/^ piints of whisky, the face was pale, the eyes suffused and dull with dilated pupils, the temperature 91° F.; the ptilse was thin, compressible, and barely per- ceptible; the breathing stertorous, the skin cold and clammy. There are some- times also congestion of the liver, cere- bral congestion with ventricular serous effusion, and distension of right heart- cavities with semifluid blood. In another case, that of a man who was found dead after a drinking-bout, the mucous mem- brane of the stomach was so inflamed and angr}^, with patches of a deeper hue extending over the pyloric surface to the duodenum, and a grumous, slightly muco-puruleut exudation from bleeding- points, that arsenical poisoning was sus- pected. Tardieu in one case found pulmonary . apoplectic extravasations of blood. The first pathological stage of intoxi- cation is one of vascular relaxation, with vasomotor paral3'sis and reduced inhi- bition; the second, one of continued inhibitory reduction, with incomplete partial paralysis of the brain- and nerve- centres, with intellectual automatism, accompanied by loss of co-ordination. The third stage is one of advanced pa- ralysis, for the moment complete, with automatic existence and the reduction of temperature by 3 to 7 or more degrees. Poisoning with alcohol in considerable doses, continued over a moderate time, will produce decided and ascertainable lesions of the nutrient structures and nervous elements of the cerebrum, very similar in character to the pathological lesions produced by other more virulent soluble poisons. Henry J. Berkley (.Johns Hopkins Hosp. Keports, vol. vi, '97). ALCOHOLISM. ALCOHOLIC INTOXICATIOX. ACUTE. DIAGNOSIS. 199 Differential Diagnosis. — In the first two stages, the exhilarative and the preliminary automatic, simple nerve ex- citement, opiate or other narcotic excita- tion, and apoplexy may simulate the symptoms of alcoholic intoxication; but the non-alcoholic rapidly subside, the apoplectic either passing ofE or going on quickly to coma. Usually the history or the surroundings reveal the presence of alcohol. In the last, or third, stage of alcoholic insensibility the difficulties are much greater. The breath may smell of liquor, but that alone is not a safe guide; I have known abstainers taken to a police-cell, owing to some by-stander having poured brandy down the throat of the uncon- scious nephalist. Apart from a history of drinking, only withdrawal of alcohol from the stomach can prove an alcoholic origin. It has been asserted that press- ure on the supra-orbital notches, thereby compressing the nerve, will elicit signs of life in the alcoholized. Coma. — The comatose state of diabetes and albuminuria (in ursemia there may be albuminuric retinitis "with normal or enlarged pupils) may be differentiated by a urinary analysis, though it must be remembered that both of these condi- tions may exist with alcoholism, and also with the odor of acetone from the breath. The renewal of the alcoholic symptoms by inhalation of the vapor of ammonia has been suggested by Waters. Opium or Belladonna Poisoning. — From opium poisoning, pin-point pupils, and from belladonna poisoning, the equal dilation of the pupils usually exclude alcoholism, but alcohol may be present with either of the other poisons. Some- times the greatly lowered temperature points to alcoholism. Apoplexy. — The respiration is usually stertoroiis and the coma deeper. Hemi- plegia may be evident from the greater flaccidity of the limbs on one side. The urine may contain albumin; ausculta- tion may reveal some cardiac lesion; the breath will not smell of alcohol, unless the attack has occurred in a person who has been drinking, or some one, since the attack, has administered some alco- holic stimulant. Conjugate deviation of the eyes may exist. Epilepsy. — In this disease there is a history of clonic convulsions. The pulse is rapid, dicrotic (Trousseau), and rather fast; frequently the urine and faeces have escaped, while the tongue may have been bitten. The frequent mistakes in diagnosis committed by medical experts have dem- onstrated the practically insuperable dif- ficulty in forming an accurate judgment till time be given for the disappearance of alcoholic symptoms. "For a time it may be impossible to determine whether the condition is due to ursmia, profound alcoholism, or hsemorrliage into the pons Varolii." Diagnosis between acute alcohoUsm and traumatism: external injury sug- gests the possibility of grave internal lesion. However, no mark of violence may be found upon the closest inspec- tion; a fracture of the skull or a hem- orrhage within the cranium may have no outward sign. Or a heavy wagon may pass over the body, fracturing the ribs, rupturing the liver, perforating the in- testines, or injuring other vital organs without producing any external mark. (See Abdomen, Contusions.) Primary shock, following immediately upon the injury, will exhibit a subnormal tempera- ture and a small and fluttering pulse, nausea, vomiting, cold and clammy skin, and relaxed sphincters. Depressed fractures at the vertex may be detected by palpation. Fissured fract- ures may be found upon inspection, with the help of an incision if necessary, or the finger-nail or a probe may be passed 200 ALCOHOLISM. ALCOHOLIC INTOXICATION. ACUTE. TEEATMENT. across the surface. When the blood is wiped from a suspected part and no fresh blood appears, there is a suture; if fresh blood oozes to the surface, there is a fis- sured fracture. In fracture of the base there will usually be found haemorrhage from the nose, mouth, and ears, and eechymosis into the conjunctiva or sub- cutaneous cellular tissue; or vomited blood may have been swallowed after fracture of the ethmoid or sphenoid, fol- lowed by hseniorrhage into the posterior nares. But absence of such haemorrhage does not necessarily indicate absence of fracture. A rare, but positive, symptom of fract- ure of the base is the escape of a watery fluid, probably cerebro-spinal fluid, from the ears, the nose, or the mouth. Fract- ures of the petrous portion of the tem- poral bone involving the tympanum may produce in the temporal or mastoid re- gion a pneumatocele: a smooth, circum- scribed, resonant, non-fluctuating tumor. Cerebral irritation usually follows a blow upon the forehead or the temple. The patient lies on one side, is restless, with the extremities flexed and the eye- lids firmly closed. If the eyelids are forcibly opened, the pupils are found con- tracted and intolerant of light. The sur- face is pale and cool, or even cold. The pulse is small, feeble, and slow. The patient is irritable, muttering, and grinds his teeth when disturbed. The sphincters are not usually afi'ected and thei'e is no stertor. There will be a rise in temperature iu head injuries, except in primary shock and in large uncomplicated haemorrhage, when the temperature is likely to be sub- normal (Phelps). Other signs of intra- cranial lesion are photophobia, with the eyelids firmly closed, intolerance of sound, the carotids beating forcibly, a blowing of the lips, a flapping of the cheeks, rigid contraction of limbs, and clonic or tetanic convulsions. The Cheyne-Stokes respiration is found in injury to the brain and cerebral haemor- rhage. The breathing becomes, by de- grees, deeper and more rapid up to a cer- tain point, and then subsides in the same gradual manner until there is a complete cessation of respiration, with a deep silence, the pause before the next respira- tion lasting a variable time. Unilateral phenomena point to in- tracranial lesions; for instance, unequal pupils or ptosis of one eyelid or drooping of one corner of the mouth. There may also be found in the radial pulse a want of symmetry in fullness and strength upon the two sides of the body. • In a suspected case the patient should be kept under observation until the efi'ects of a debauch have worn off; symptoms of head injury, which may have been masked by the acute alcohol- ism, may then become manifest. John B. Huber (Med. Record, Feb. 20, '97). Quinquaud's sign of alcoholism: The patient is to separate the fingers and rest them firmly across the observer's hand at right angles. For the first two or three seconds nothing unusual is noted, but then follow slight blows as if the bones of each finger were thrown back suddenly, the one upon the other, and struck the palm. The crepitations vary in character according to the individual ; sometimes a slight rubbing and again a true crackling, which resembles that of a joint affected with dry arthritis. The pressure on the observer's hand should be moderate. In 52 epileptic women this sign was obtained but once: i.e., in a woman who had been com- mitted many times for drunkenness. M. B. Damon (Northwestern Lancet, July 15, 1901). Treatment. — External heat should be applied, especially to the abdomen and feet; the room should be heated; the stomach should be emptied and washed out with warm or tepid water. No alco- hol is to be given, but warm milk; if emesis occur, milk with soda or lime- water, barley-water, or rice-water; if there is collapse cinnamon (or ammonia in small doses) may be added to the milk, or cardamoms, cinnamon, and ginger in warm water. Chloroform, given with care, has been recommended against con- vulsions. ALCOHOLISM. ALCOHOLIC INTOXICATION. ALCOHOLIC DELIRIUM. 201 In slight eases, an emetic and warmth. Ipecac or an hypodermic injection of Vio grain of apomorphine may be used to produce emesis. Ammonium carbonate has been used with great success in doses of 1 drachm dissolved in water. It acts as an emetic and antidepressant. The patient should be deprived of alco- hol, confined in bed, an i then given blue pill, followed by a saline cathartic. In- somnia should be met by the wet pack. Strychnine nitrate, 'A:; to 'Ao grain, should then be administered and nutri- tion supported by water, milk, koumiss, broths, soups, meat-juice, raw eggs, arrowroot, fruits, etc. When required, bromide and chloral or duboisine is ordered. Peterson (Jour. Amer. Med. Assoc, Apr. 15, '93). In acute alcoholism apomorphine hy- drochloride does in minutes what bro- mides and chloral do in hours. It is far superior to morphine, as it eliminates the poison, while morphine dries up the se- cretions. Injected hypodermically '/,o grain of apomorphine hydrochloride caused free emesis in four minutes; rigidity changed to relaxation, and ex- citement to sleep. Tompkins (Merck's Archives; Can. Pract., Dec, '99). In study of carefully kept records of 10 hospital cases and personal expei'ience in the use of digitalis in 6 cases the fol- lowing personal conclusions are offered: 1. The indiscriminate use of large doses (half an ounce) of digitalis in acute alco- holism is fraught with danger. 2. The kind of cases in Avhich it should be given are the strong, robust patients in early life, suffering from no complications, and with violent delirium. In these cases the result will be exceptionally favorable. They become quiet, go to sleep with a certainty and promptness that is not ob- tained by other methods. 3. If after three doses no narcotic effect is noted a continuance is not advised. In the above class of eases it can be used with perfect safety for a limited number of doses. 4. The failures in personal cases were in chronic alcoholic subjects, in middle and advanced life, in ansemio individuals with bad nutrition. 5. One fact noted in tlie cases which showed marked results from the treatment was that when they re- covered and awoke from their sleep they were in such good condition that they were able to leave the hospital at once. This is an unusual experience, as ordi- narily convalescence is delayed for two or three days. H. P. Looniis (Med. News, Aug. 18, 1900). Many deaths ascribed to acute alco- holism are really due to acute nephritis, but usually to an acute exacerbation of chronic alcoholic nephritis, as acute ne- phritis, following an alcoholic debauch, in previously normal kidneys, is ex- tremely rare. If drunkards were taken to a hospital instead of to a jail, were put into a warm bed, then catheterized, and an ex- amination of the urine made at once, the latter would often be found loaded with albumin, urea, blood-casts, uric acid, and epithelium: a condition which, if allowed to continue, soon results in ursemic coma and death. Many cases treated by means of active purgation, diuresis, dia- phoresis, and active cupping would be restored to normal health. N. B. Ormsby (Cleveland Med. Gaz., No. 4, 1901). Acute Alcoholic Delirium (Delirium Tremens). — This disorder chiefly occurs in habitual drinkers; but it is also obseryed in ordinary temperate per- sons after a prolonged drinldng-spell. Though mostly met with in spirit- drinkers, it is seen occasionally in beer-, wine-, and cider- drinkers. Symptoms. — There are two forms, — the traumatic and the idiopathic. They differ little except in the prodromata. In the traumatic form, after an accident (sometimes a slight traumatism) the characteristic tremors, etc., appear fre- quently without warning; but, in the idiopathic form, the patient who is about to have an attack is restless, uneasy, irri- table, sleeps badly if at all, suffers from digestive troubles, and has little desire for food. Delirium then appears. The 202 ALCOHOLISM. ALCOHOLIC DELIRIUM. ACUTE. SYMPTOMS. patient cannot rest, but must be in con- stant motion. He is shalving all over ("the shakes"), is consumed with terrors, continually in deadly fright of things which he mentally sees, or of persons whom he thinks are after him for the commission of some crime. At other times his dread is of something terrible, though he cannot tell what it is. He is all the while trying to escape from these well-defined or undefined horrors, and, in attempting to escape, fatalities some- times occur. Hallucinations of sight are most common: snakes, rats, mice, loath- some things, flames, and, in a case of the writer's, roaring lions bounding down the chimney, below the chairs, and rush- ing in at the windows. The delirium is best described as one of busy wakeful- ness and suspicion. There is a third non-febrile innocent form, in which the temperature does not rise above 100° F. The visual imagery of acute alcoholic delirium is also characteristic of chronic alcoholic alienation. They are not pri- mary, but secondary or illusional hallu- cinations. The uniformity of the animal visual imagery arises from the influence of physical conditions on nervous tissue made abnormally susceptible by alcohol. Normally there is objective projection of appropriate images in motion, and it needs but a retinal condition sufficient to intensify the retinal images of these entoptic objects, and a cortical state of higher impressionability permitting them to dominate consciousness, to induce a kind of ideation in which the idea of objective motion is paramount. This condition is brought about by alcohol. Chaddock (Alienist and Neurologist, Jan., '92). Compression of the eyeball causes per- ception of Purkinje's figures in healthy individuals, visions of objects and per- sons in four-fifths of patients suffering from alcoholic delirium. Liepmann (Ber- liner klin. Woch., Apr. 8, '95). Confirmatory experiments; vision of animals noted in 50 per cent, of cases of alcoholic delirium. Jolly (Berliner kliu. Woch., Apr. 8, '95). Visions of animals are present in 40 per cent, of cases at most. Such patients cannot estimate distances. Liepmann (Berliner klin. Woch., Apr. 8, '95). Visions cannot be attributed solely to suppression of the influence of the light. Conclusion then reached that in those cases in which external excitations do not provoke the visions these are due to internal mechanical excitations upon the retina. The increase of the intra-ocular pressure due to the contraction of the ex- trinsic and intrinsic muscles of the eye, produced when the eye is fixed upon anything, may be so considered. The inner imaginations of delirious alcoholic patients do not refer with a strange predilection to certain animals or to scenes of anguish or fright. Their character rather is decided by the nature of the peripheral excitation than by an anterior tendency given to the mind. If manifestations of anguish and the ap- pearance of certain animals predominate in spontaneous visions, the cause should be sought for outside of the patient. The author looks upon his method as to the study of sensorial illusions in alcoholic patients as superior to simple observation or questioning. H. Liep- mann (Archiv f. Psych., vol. xxvii, p. 172, '96). Hallucinations of hearing are not so common, but exist in probably 10 to 20 per cent, of cases. Delusions (false per- ceptions concerning self) are found in from 5 to 9 per cent., mostly delusions of persecution. Sometimes there is one hallucination, illusion, or delusion throughout, sometimes there is a suc- cession. Case of an army-engineer, a chronic inebriate, in whom delirium of grandeur and self-satisfaction, with intense ambi- tions to attain political prominence, came on in a few hours, after a long period of drinking. Subsidence when spirits were withdrawn and recurrence on the re- sumption of spirits. Editorial (Quarterly Jour, of Inebriety, July, '97). ALCOHOLISM. ALCOHOLIC DELIRIUil. ACUTE. PATHOLOGY. 203 The tongue is white and furred. Tremor of this organ, and especially of the muscles, is a more or less marked, "but generall}' present, symptom. The fever is not very high, being about 100° to 103° F. If higher, it is an unfavorable omen. The pulse is soft, rapid, and readily compressed. The skin is clammy. Insomnia is constantly pres- ent; but usually sleep and improvement occur on the third or fourth day. In unfavorable cases the patient grows gradually worse and dies of heart-failure. Diagnosis. — Acute alcoholism may be mistaken for the delirium of menin- gitis, of typhus and typhoid fevers, and •of chronic alcoholism. The history and progress of the case determine the first two, and the absence or significance of thirst, tongue trembling, and tremors the third. Pulmonary disorders; congestion, es- pecially when of trarmiatic origin; and pneumonia may also give rise to delir- ium simulating that of deliriiTm tremens. Fractured ribs may thus become the pri- mary factor of violent accesses. The same may be said of erysipelas. Pathology. — Acute alcoholism is due to gradually produced changes in the nerve-tissues, and especially to retained products of metaholism. The cerehral lesions in alcoholic delirium are of two varieties. The first is observed in all alcoholics, and is due to the alcohol it- self: atheromatous degeneration of the vessels, the degree of disorder increasing as the calibre of the vessel is reduced. The nerve-cells also show granular pig- mentation and fatty degeneration. The second variety is derived specially from the character of the delirium, and not from the alcohol itself. It consists in congestion, haematic pigmentation in the capillaries and nerve-elements, and defeneration of the nerves and fibres of the cortex, the precursors of general paralysis. Peddie's view, propounded a quarter of a century ago, that acute alcoholism is really poisoning from the accumulated effects of alcohol on a nervous and ir- ritable temperament, has much in its favor. Delirium tremens occurs when a brain, deteriorated by chronic alcoholism, is in- fluenced by a toxic agent, either due to the action of bacteria or to autointoxi- cation from diseases of the digestive tract, the kidneys, or the liver. The therapeutic treatment is quite incapable of abbreviating the duration of the dis- ease; the critical sleep caraiot be in- duced by any drug. Jacobson (Hos- pitalstidende, p. 143, '97). Microscopical examination of the cen- tral nervous system and spinal ganglia of seven cases of delirium tremens. The changes were quite uniform, and con- sisted essentially, first, in thickening of the walls of the arteries, proliferation of the connective tissue in the media, and dilatation and infiltration of the lymph- spaces. These changes were more pro- nounced in the cortex, and frequently led to minute hssmorrhages, as many as two hundred of these having been counted in a square centimetre of the cortex. The capillaries appeared to be proliferated, particularly in one case, but they and the veins showed no pronounced anatomical alteration. The neuroglia- fibres of the cortex showed, according to "Weigert's new method, considerable pro- liferation. The Weigert cells were more numerous than normal. The fi-ee nuclei, both the small and large varieties, were increased in number in the second and sixth layer of the cortex, and appeared to be accumulated around the degener- ating cells. The spinal cord was ap- parently normal. There was no degener- ation of the fibres in the spinal cord, but the tangential fibres of the cortex were somewhat thinned. The changes in the cells were, as is usual in such cases, lim- ited to certain cells, and not uniform. In the spinal ganglia, the cells stained less distinctly. The nucleus was contracted, 204 ALCOHOLISM. ALCOHOLIC DELIRIUM. ACUTE. TEEATJMENT. and in the end its membrane appeared to have become dissolved; the nucleolus showed a curious angular deformitj'. The cells of the anterior eornua showed in the lumbar region central chromatol- ysis without staining of the ground- substance, and an increase in size and decrease in part of the chromaphilic bodies, with alterations in the nuclei. In some eases vacuolation of the cells had occurred. The cells of Purkinje showed slight change or no alterations. The pyramidal cells of the cortex were usually degenerated, showing contrac- tion, alteration of the nucleus, and al- terations in the ground-substance. The giant pj'ramidal cells of the paracentral lobule were nearly all diseased. In gen- eral, it was noted that the parietal and occiptal regions were less affected than the others. Tromner (Archiv f. Psy- chiatric, B. 31, H. 3, '99). Brain-cells in 10 cases of acute alco- holism studied, the brains being investi- gated by the Nissl method of staining with methyl-violet: (a) patients who died of alcoholism with all the symptoms of meningitis showed on necropsy simple congestion of the membranes (pia arach- noid), with some oedema in its texture; (6) microscopical examination rarely showed any migration of leucocytes or anything approaching encephalitis; (f) the larger (pyramidal and giant) nerve- cells showed pigmentation to an intense degree, the pigment being diffused through the cell-body; (d) the cyto- plasm showing various degrees of degen- eration (fatty and granular) ; (e) the cell-body generally was shrunk, and the nucleus partially so; (f) pericellular nuclei had proliferated, and were freely present in the pericellular sacs. In cases where death was due to exhaustion the shrinkage of cells was marked. Dana (Quart. Jour, of Inebriety, Jan., '99). Etiology. — Aciite alcoholism may be due to a temporary exacerbation during continnons alcoholic intoxication, — the idiopathic form; or to an accident, sudden shock, or an acute inflammation^ especially pneumonia, — the traumatic form. Study of 247 recovered personal cases of delirium tremens. Of these cases 202 were uncomplicated and 45 complicated by other diseases. Although the delirium tremens cannot be regarded as caused by the action of the pneumocoeeus, it resembles, in all features, an infectiou.s disease: it has a stage of incubation, — a duration of about four days ; it end.s with a critical sleep; is accompanied by rise of temperature and almost in all cases by albuminuria ; and when autopsy is made the spleen is generally found to be the seat of parenchymatous degen- eration, as well as the heart, the kid- neys, and the liver. Jacobson (Hos- pitalstidende, p. 143, '97). Prognosis. — In private practice the prognosis is favorable in ordinary cases; in hospital practice it is much less so. Of 1241 cases admitted to the Philadel- phia Hospital ditring a fixed period, 121 died. Eecurrence occurs if drinking is continued. [I have noted recurrence from one to five times in 104 out of 442 cases treated in a special institution. Noeman Kerb.] Treatment. — The patient must be kept in bed and carefully watched. Strapping in bed should not be prac- ticed, as the restraint causes muscu- lar movements and delirium. A sheet tied across the bed is preferable, as this allows more freedom of motion. Attend- ants or a padded room is best of all. No alcohol should be given, the strength being sustained by foods, milk, soups, etc. Experience based on 2012 cases of al- coholism warrants the statement that alcohol in any form or quantity is in- jurious, and that its absolute and im- mediate withdrawal is important. Lati- mer (Boston Med. and Surg. Jour., .lune 16, '92). If the delirium comes on abruptly, the exciting causes are acute and point to the formation of toxins. If the delirium has been preceded by mental ALCOHOLISM. ALCOHOLIC DELIRIUM. ACUTE. TREATMENT. 205 eliaiiges, and transient alterations of thought and conduct occur, gradually becoming constant and fixed, there are indications of organic lesions of the brain. It is important to ascertain whether the delirium follows from a long period of continuous drinking or whether the drink was preceded by some physical or mental disturbance arising from organic disease, traumatism, or mental strain. T. D. Crothers (Med. Record. Dee. 14, 1901). Potassium bromide, V2 drachm, with tinctiu'e of capsicum, given every three hours, is recommended for mild cases by Osier. Sleei3 should be procured, and the strength supported. As an hypnotic, chloral may be given if the heart be not weak. In alcoholic delirium the real chance of recovery lies in sleep. The patient is therefore isolated in a quiet, dark, and, if necessary, padded room, no physical restraint being employed. To procure sleep the patient is given 1 to 1 V: drachms of chloral-hydrate, with V, grain of hydrochlorate of morphine, in an infusion of limes. If sleep does not come on in about ten minutes, from Vc to V3 grain of morphine is injected hyp- odermically. After the alcoholic disturb- ance has subsided strychnine or nux vomica is given, followed by hydrothera- peutic measures. If there should be gas- tric complication, an antacid, such as sodium bicarbonate, is administered. Lancereaux (Bull. Gen. de Th(5r., Feb. 15, '93). In the young, with elastic arteries and sound kidneys, opium can be given freely. In older patients, where the vessels are not in such good condition, chloral is less dangerov\s than opium. A. Guepin (Gaz. Med. de Paris, Feb. 10, '94). The heroic doses of these narcotics, with the cardiac depression apt to follow their exhibition, call for deliberation in their administration to aged and infirm inebriates, and I prefer, as an hypnotic. a simple febrifuge frequently repeated, such as repeated doses of liquor am- monias acetatis. Sleep, thus quietly and safely induced, has proved much more curative than the sleep for which the author formerly resorted to narcotics. Twenty-five cases of alcoholic delirium in which trional was used with advan- tage. Conclusions: 1. Delirium was con- trolled with greater rapidity and safety by trional than by other hypnotics. 2. In the majority of cases a marked stimulant effect was observed, possibly on account of the methylic and ethylic elements which enter into the composi- tion of the drug. 3. On account of the low temperature noted in all cases, tri- onal must possess antipyretic proper- ties, thereby simulating its allies of the phenol group. 4. It was always well borne by the stomach, and in one case «'as rapidly absorbed when administered per rectum. 5. No unpleasant after- effects observed. Bellamy (N. Y. Med. Jour., July 21, '94). Trional of great value in insomnia. Morphine or opium retards the action of trional. C. H. Springer (Med. and Surg. Reporter, Sept. 22, '94). A very hot bath gradually cooled and trional, 20 grains, in water containing 10 minims of tincture of capsicum recom- mended. If in thirt3' minutes there is no abatement, 10 more grains of trional are given. Forced feeding: milk, eggs, soups, etc. Bellamy (N. Y. Med. Jour., vol. Ix, p. 72, '94). In all cases of acute mania, or delirium tremens, the use of hyoscyamine, or the alkaloid hyoseyine hydrobromate, in large doses is recommended. I. A. Mar- shall (Med. Brief, Jan., '98). A harmless remedy that will produce sleep in a few minutes, even when the patient is suffering with the wildest de- lirium, is apomorphine. Just enough is injected subcutaneously to produce light nausea, but not enough to cause vomit- ing. One-thirtieth grain is the average quantity required, but individual sus- ceptibility greatly varies. In a few min- utes after administering the remedy 206 ALCOHOLISM. ALCOHOLIC DELIRIUM. ACUTE. TREATMENT. perspiration appears and the patient voluntarily lies down, when a sound and restful sleep immediately follows. This sleep lasts at least an hour or two, and, if other sedatives are previously given, it will last six or eight hours. It is of special value in all forms of mania, regardless of the cause. It may also be given in full emetic doses in many cases of alcoholism with marked benefit. It seems to frequently act as almost a spe- cific in relieving the alcoholic craving. Charles J. Douglass (N. Y. Med. Jour., Oct. 28, '99). In delirium tremens the patient should be put to sleep with apomorphine, which can be done in a few minutes without danger and without emesis. He should not be restrained by physical force, and allowed alcohol in some form. He should be nourished w ith milk, eggnog, or some other liquid and easily assimilable food. C. J. Douglass (N. Y. Med. Jour., Nov. 17, 1900). Opium, if given, should be adminis- tered cautiously, in the form of mor- phine, hypodermically. If, after three or four ^/4-grain doses, tlie patient is still restless, no more is to be given. If fever is present, cold douche, bath, or preferably the wet pack may be tried. If the pulse becomes too rapid and weak cinnamon, with very small doses of digi- talis in aromatic spirits of ammonia, should be given. Digitalis in large doses is dangerous. (Osier, Delpeuch, Kerr.) Cold baths in febrile delirium tremens at 18° C, or tempered according to in- dividual cases, induce rapid resolution of symptoms. The infection and auto- intoxication are directly antagonized. Well-marked cardiovascular disease is a contra-indication. Salvant (These de Paris, 1901). The patient should be carefully fed, milk and concentrated broths being especially useful. If necessary, nutrient enemata are to be administered. If the delirium occurs during an acute malady or following an injury, two in- dications must be attended to: — 1. Sustain the patient's strength by frequent assimilable nourishment. 2. Obtain sleep. For this purpose opium may be given at the outset in one full dose, or laudanum may be given by the rectum. Chloral may be given in doses of 2 ^/^ to 3 drachms unless some cardiac or pul- monary complication or depression ren- ders its use dangerous. If the delirium appears without ap- parent cause, during chronic alcoholism or following recent excesses, the adminis- tration of alcohol as a remedy may be- come necessary. If the fever be not too high, the delirium too violent, and if the strength of the patient be preserved, it may be withheld; but, if the patient be adynamic, recoiirse must be had to alco- hol, as well as to other diffusible stimu- lants: caffeine, subcutaneous injections of ether, or draughts of ammonium acetate. Any form of narcotics should be avoided in these cases. (Delpeuch.) Several cases of delirium and cerebral excitement (sometimes followed by loss of consciousness) witnessed in inebriates, after a full dose of caffeine. The ad- ministration of this remedy is therefore contra-indicated. In any event it should always be prescribed with caution, be- ginning with small doses, with instruc- tions to discontinue the medicine on the appearance of the slightest agitation. Czarkowsky (Amer. ]Medico-Surg. Bull., July, '93). The intravenous infusion of saline so- lution in delirium tremens increases the amount of the circulating medium in which the toxic materials are dissolved, thereby diluting the poison and bathing the nerve-centers with a more attenu- ated solution of the same. The amount of circulating fluid is increased above the normal, so that the excretion of fluids through all the fluid-excreting channels is increased, thereby carrying off in so- lution much of the contained toxins. ALCOHOLISM. ALCOHOLIC ilAXIA. ACUTE. SYMPTOiLS. TREATMENT. gO": The action of the heart is improved by the filling of the relaxed vessels. These suffice to restore the physiological equi- librium and turn the balance in the favor of recovery. J. P. Warbasse (Med. News, Mar. 2, 1901). Acute Alcoholic Mania (Mania a Potu). Symptoms. — The patient, in wild, un- governable fury, shouts, stamps, strikes, or kicks, and is, for the moment, un- controllable. The eyes roll, the face is flushed, and the veins distended and en- gorged; the miiscles are at their highest point of tension and are in continuous violent action. The pulse is strong, bounding, and tumiiltuous. Though mechanically conscious, the subject is filled with "blind fury." He is carried away in a tempest of nervous excitation and passion. The paroxysms of violence sometimes last only a few minutes, at other times for from an hour to several days with quiet intermissions. Earely are there delusions, though the infuri- ated subject may vent his violence on the first animate or inanimate object in his way. In a few cases the fury is directed against a certain person or thing. Vio- lence is succeeded b}' calm; a few min- utes after a storm the temperature is normal, and during the parox3'sm rarely raised. In some constitutions a parox- ysm may be provoked by a small quan- tity of alcohol. Differential Diagnosis. — It may be differentiated from delirium tremens by the absence of tremors, terror, hallu- cinations, delusions, the white tongue, nausea, and the delirium of the latter. Further, mania a potu may arise from a small quantity of an intoxicant taken in a short time, while delirium tremens is due to large quantities taken in rapid succession, or from smaller quantities long continued. Etiology and Pathology. — Alcoholic mania is occasionally seen in chronic inebriates, and most frequently in peri- odic tipplers. In the latter it often occurs when, soon after an interval of abstinence, an intoxicant is freely par- taken of. Some chronic inebriates in- variably suffer acute mania if they drink a single glass of spirits, wine, or beer beyond their usual allowance. The par- oxysms of acute mania resemble those of epilepsy, and a large proportion of police-court drunken offenders are patients of this class. The symptoms are evoked by the pathological action of acute poisoning bj' alcohol, in nervous systems liable to such excitation, either congenitally or from the effects of in- temperance, traumatism, or brain-tire. The forms of insanity met with which result from alcoholism are: (1) amnesic, (2) delusional, and (3) chronic varieties which end in dementia. The best work- ing hypothesis for the prevention and cure of all forms of alcoholic disorders, whether mental or physical, must be based upon the practice of total ab- stinence. R. Jones (Lancet, Oct. 25, 1902). Prognosis. — The prognosis is mucii more favorable than in acute mania, the paroxysm usually rapidly passing away, leaving the patient exhausted and peace- ful. Earely is there relapse unless alco- hol be again taken. Treatment. — Little treatment is gen- erally needed. Non-alcoholic liquids, such as milk, iced milk, milk and soda,, or saline draughts with ipecacuanha and small doses of the bromides are sufficient to bring about recovery. Sometimes cold affusions and, in prolonged paroxysms,, wet packs prove valiiable adjuncts. When violent mania is present, apo- morphine, Vs to Ve grain, hypodermic- ally, causes nausea and vomiting and rapid removal of the violent symptoms. 208 ALCOHOLISM. CHRONIC. SYMPTOMS. Study of 958 cases of alcoholism, of which 40 suffered from acute excitement, or mania a potu. No stimulants given in any case. The uniform prescription was 30 gi-aing of bromide of potassium every two hours in maniacal cases, and every three or four hours in other cases. In cases of noisy mania, ^A grain of morphine sulphate was occasionally given hypodermically at bed-time. All the cases recovered. Lati- mer (Johns Hopkins Hosp. Bulletin, No. 119, '91). Chronic Alcoholism. Symptoms. — The intensity of the symptoms corresponds with that of the functional and organic disorders pro- duced. In average cases the earlier symptoms are those indicating nervous disorder, the most important being mus- cular tremor. The hands are unsteady and shake; but, in the majority of care- fully examined cases, the lower limbs are found to be afiectfid before the upper (particularly in females). The trouble is especially marked in the morning, and may be such as to render the use of the limbs difficult. At first an efEort of the will enables the patient to control the movements of his hands and feet, but this power gradually wanes. Eestlessness, the limbs starting invol- imtarily, especially after retiring, is the first indication of impending trouble in some tipplers. The mind becomes irri- table; there is headache, dizziness, tin- nitus aurium and muscse volitantes, while flashes of light are frequently complained of. Besides the irritability there is usually mental disquietude, the patient being unable to settle down to his duties. He frequently labors under the apprehen- sion that bodily harm is awaiting him, whether through the act of some enemy, an accident, or illness he cannot tell. In walking he experiences at times the sensation of falling down a precipice: a bad omen, according to Anstie. As the disease advances the chronic alco- holic is apt to become a prey to delu- sions of suspicion, while a prominent feature is what may be designated "nar- comaniaeal imtruth," the confirmed sot asseverating that he has drunk no liquor even when seen in the act. Delusions as to locality are a promi- nent symptom in chronic alcoholic men- tal derangement. Mason (Quarterly •Jour, of Inebriety, July, '92). Pains around the limbs — especially at the wrists and ankles, the shoulders, along the muscles of the spine, and down the spine proper — are common. These pains are intermittent and par- oxysmal, usually appearing late in the day or after prolonged exertion, accord- ing to the fatigue to which the patient has been exposed. These neurotic and muscular pains were at one time credited to rheumatism. [Henry Monro narrated the cure of a number of cases of what he supposed to be alcoholic rheumatism, by the simple withdrawal of alcoholic liquor. The cases were most probably alcoholic multiple neuritis at an early stage. NoKMAN Keer.] Besides the disorders of locomotion attending muscular inco-ordination, there may be impairment of sensation. The lower limbs are frequently found wasted, while the abdomen is found en- larged and, perhaps, pendulous, owing to the presence of adipose tissue. Epi- leptiform convulsions are occasionally observed, while mania, melancholia, and dementia are frequent sequelse. Gastric disorders may be present early in the history of the case. Nausea and vomiting are common; these usually occur in the morning, and have been known to extend to hsematemesis and death. ALCOHOLISM. CHRONIC. DIAGNOSIS. ETIOLOGY. 209 Case of profuse and fatal haimatemesis consequent upon chronic alcoholism. Hancock (Med. Chronicle, May, '91). The appetite is absent for the break- fast in almost all advanced cases; the tongue is coated, and the breath usually very foul. A sensation as if the stomach were sinking is a frequent symptom: an important one in that it usually prompts the patient to drink to obtain temporary relief. The eyes are congested and watery, the features expressionless. The skin of the face is red and frequently papular: a condition known as "acne rosacea" {q. v.). The latter disease does not occur only in drunkards, however, functional gastric and menstrual disorders being active as etiological factors in perfectly temperate people. [Indeed, the most aggravated and ob- stinate case of "acne rosacea" which I have ever seen was a merchant whom I have known to have been a strict ab- stainer for some fifteen years. Norman Kerb.] The chronic alcoholism of ardent spirits (whisky, brandy, and gin espe- cially) has a distinguishing characteris- tic of emaciation with shrunken, though fiery or bluish, countenance, while that of malt intoxicants and sweetish wines (particularly if not alcoholically very strong) exhibits usually a generally bloated appearance, with adipose super- abundance. Differential Diagnosis. — In most cases the alcoholic history, with the symptoms, easily discriminate chronic alcoholism. Among the latter, especially morning nausea, or sickness; foul ethereal breath; furred tongue, eructations, gastralgia and gastrodynia, anorexia, and cephalalgia; diarrhoea or, more generally, constipa- tion; tremors, restlessness, fear. In ad- vanced stages bloated, puffy, or pinched features; shuffling, ataxic gait; listless- 1- ness, perverted sensations, and untruth. In alcoholically paralytic cases the pa- retic symptoms are antedated. Drunkenness should be discriminated from inebriety. Drunkards drink when they have the opportunity; inebriates are diseased persons who drink when their attack seizes them. The drunkard may so injure his brain, structurally or functionally, that he may become an inebriate; the inebriate, however, is one who is generally bom with an unsound brain. This is a transmissible cachexia. The child of an inebriate, born after the lesion has been established, inherits some nervous diathesis. The only security is by life-long abstinence on the part of the child. Stewart (Lancet, Jan. 9, '92). Etiology. — Heredity has, by most authorities, been considered to be the chief predisposing influence. Crothers traced a family history of inebriety in one-half of his cases, besides 25 per cent. of defective brain-states from a neurotic or other morbid inheritance inclusive of insanity. [In over 3000 cases I have found fully one-half with an inebriate ancestry, in addition to 6 per cent, with a pedigree of mental disease. Almost the same proportions have been the experience of the American, Fort Hamilton, and the English Dalrymple Homes. Bevan Lewis attributed 64 per cent, to parental ine- briety, some form of transmitted neu- rosis, or insanity. Piper, likewise, puts the proportion of hereditary to acquired eases at two to one. In my opinion, the number of cases in which an ancestral history of alcoholism has been traced is much below the actual amount, as it is frequently difficult to get relatives to admit the existence of an alcoholic taint. Norman Kerr.] Heredity is said to be crossed when, in its single parental form, the children of the opposite sex to the inebriate parent only are affected. An important fact is that all these and other forms of alcoholic transmission may be handed down by a parent or parents who have 14 210 ALCOHOLISM. CHRONIC. ETIOLOGY. never been known to have been intoxi- cated, or to have exhibited any uncon- trollable impulse to intoxication. Double parental alcoholism causes al- coholism; absinthism causes epilepsy; and combination of absinthism and epi- lepsy a common cause of epilepsy in children. Legrain (Brit. Med. Jour., July 20, '95). The proportion of hereditary cases has increased 50 per cent, over the acquired during the past twelve years. Holmes (Med. Pioneer, Aug., 95). Neurotic intemperance possesses feat- ures which serve to distinguish it from the common vice of occasional and de- liberate drunkenness. Whereas the vice, once so prevalent and even fashionable among the men of all classes, is now all but confined to what are called the lower orders, the disease is confined to no class, and to neither sex, and instead of dimin- ishing seems decidedly on the increase. The occasional drunkard seeks com- panionship in his cups, and is generally more or less noisy and uproarious in his intoxication; but the victim of this dis- ease inclines rather to shrink from obser- vation, and is generally quiet and morose under the influence of alcohol. J. Strachan (Brit. Med. Jour., Oct. 1, '98). Careful study of four hundred alco- holics has been made during the last fifteen years at Zurich, under Forel's supervision, and again the fact of hered- ity is emphasized. Forty-three per cent, of the cases had one or both parents alcoholic, and 40 per cent, of the parents were wholesale or retail dealers in liquors. One hundred and thirty-two, out of three hundred and forty-six, had become alcoholics without drinking liquors, consuming merely beer, wine, or ciders. Alcoholism is most frequent be- tween 20 and 60 (93.5 per cent.). Below that age a case is most sure to be direct heredity. All the cases showed various physical, mental, and moral alterations; degeneration of heart, arteriosclerosis, affections of the stomach, tremor, ataxia, pupillary troubles, general denutrition, etc. One-fifth were sexual per\'erts (hypersesthesia, precocious debauchery, inversion). Fourteen per cent, were epi- leptics; in six cases the attacks followed alcoholic excess and disappeared entirely Avhen the patients refrained from alcohol. Editorial (Quart. Jour, of Inebriety, Jan., '98). Alcoholism and evil disposition, with criminal tendencies, are ascribabk to heredity, according to Moreau. It has generally been found that the major portion of inherited alcoholism is due to the alcoholism of one or both parents. [This may be estimated at nearly two- thirds, after an examination of the records. Noejian Kerb.] The transmissibility of an alcoholic inheritance has been very generally ad- mitted, among other writers by Plutarch, Aristotle, Darwin, Eush, Morel, Lan- cereaux, Grenier, Magnan, Day, Wright, Mason, Carpenter, Thompson, Eichard- son, Forel, and Demme. Alcoholic heredity may be divided into single or double, mediate (parental) or immediate (grandparental, etc.), homo- geneous (transmitted as alcoholism) or heterogeneous (transmitted as some other neurosis). An innate tendency to alcoholic excess has been observed in children of tender years, — from two years old and onward, by Barlow, More-Madden, Langdown Down, Kerr, and others. Examination of two groups of 10 families each in a children's hospital. One group of 57 was affected, more or less, by alcohol; the other of 61 was unaffected, or slightly so. Of the first group 20 had inebriate fathers, the mothers and grandparents being mod- erate drinkers. Only 45 per cent, of these had healthy constitutions; 31 had inebriate fathers and grandfathers, but temperate mothers and grandmothers; only 2 of these, or a little over 6 per cent., were healthy. Of the 61 children belonging to temperate families, 82 per cent, were in good health. Demme (Brit. Med. Jour., Sept. 27, '90). Among 819 descendants of 215 alco- holic families there Avere 121 premature ALCOHOLISM. CHRONIC. ETIOLOGY. 211 deaths, generally from convulsions, 38 cases of physical debility, 55 of tuber- culosis, and 145 of mental derangement. Among the remainder were many cases of epilepsy, hysteria, idiocy, etc. Legrain (Med. Press and Circular, June 13, '94). When double parental alcoholism is of sufficient duration to induce nerve- central organic disturbances, a weekly mind in the offspring is inevitable. Wil- kins (K. Y. Med, Jour., Sept. 22, '94). Large percentage of insane children in Germany due to habitual drinking. Al- cohol produces acquired insanity by act- ing as exciting cause, and hereditary insanity by causing organic changes, which are transmitted to descendants. Habitual drinking is most detrimental to offspring. Eust (Med. Pioneer, Aug., '95). The generative cells of drunkards alco- holized and their children are degener- ates; their resisting-force against alcohol is thus diminished. Evolutionary adap- tation of mankind to alcohol is impos- sible. Fiirer (Le Bull. Med., Aug. 25, '95). Experimental dosing of hens' eggs with alcohol delays and modifies develop- ment, monstrosities and anomalies result- ing. Frere (Jour, de I'Anatomie et de la Physiologic Xormales et Pathologiques de I'Homme et des Animaux, Mar., Apr., '95). Report of 141 eases of idiocy, epilepsy, dementia, etc., directly traced to alcoholic parentage and demonstrating the alco- holo-neuropathic heredity of the drink- crave, the drink-habit, and the drink- vice, and vice versa. SoUier (Alienist and Neurologist, Apr., '97). Influence of maternal inebriety on the offspring. Series of cases of chronic drunkard women who have borne chil- dren were selected from the female popu- lation of Liverpool prison, among whom habitual inebriety had been very preva- lent. Of 120 female inebriates whose his- tories were ti-ustworthy there were born 600 children, of whom 265 (44.2 per cent.) lived over two years, while 335 children (55.8 per cent.) died when under two years of age, or were still-born. With a view to establishing comparisons with a healthy non-alcoholic standard, it was found that 21 of the women were able to give details regarding female rela- tives (sisters or daughters) of sober habits who had contracted marriages with sober males and had borne childi'en. Thus, of sober mothers, 28 in number, there were born 133 children, of whom 33 (23.9 per cent.) died when under two years of age. Thus the death-rate among the children of the inebriate mothers was nearly two and a half times as great as that among the infants of sober women of the same stock. The progressive death-rate in the alco- holic families when three or more chil- dren were born is shown in the following table:— C.1SE5. Dead and Stjll-bor.v. Per Cent. 80 80 SO lU 93 50 Fourth and fifth-ljorn . . . Sixth- to tenth-born 65.7 72.0 Of the children comprised in the series, 219 lived beyond infancy, and of these, 9, or 4.1 per cent., became epileptic: a proportion extremely high as compared with the frequency of epilepsy in the general mass of population, which, ac- cording to Bruce Thompson, is less than 1 per 1000. W. C. Sullivan (Jour, of Mental Science, July, '99). Case of alcoholism in a boy, aged 30 days, whose nurse had given him 1 V* drachms of brandy daily. He vomited regularly after nursing and slept very soundly all night. After ceasing to give the brandy, the infant lost weight for two weeks, but then gained rapidly. Follet (Archives de Med. des Enfants, Aug., 1902). Chronic alcoholism diminishes the re- sistance of the organism, while acute alcoholism aggravates the infectious diseases and quickly causes death. Small doses of alcohol have no action upon disease, either one way or the other. Yet the fact remains, that after illness, alcohol in moderate amounts is an excellent rebuilding stimulant. Mar- cel Labbe (La Presse M6d., Aug. 16, 1902). 213 ALCOHOLISM. CHEONIC. ETIOLOGY. Sex. — The proportion of females as compared to that of males has, until recent years, probably been, en an aver- age, about one woman to six men. But during the past fifteen years or so there has been an enormous increase of chronic alcoholism among females, especially in England, France, and the United States, though a considerable increase has been observed in other countries. The disease seems to be more inveterate in them than in males. Out of 500 patients treated in the out- door department of the Laennee Hospital, in Paris, 156 were females presenting symptoms of chronic alcoholism. Grand- maison (British Med. Jour., Apr. 16, '97). In more than two hundred female ine- briates, the author has not been able in any way to reform more than 10 per cent, of them, the results being less fav- orable than in the ease of male drunk- ards. I. N. Quimby (Boston Med. and Surg. Jour., Oct. 28, '97). Age. — As a rule, aboiit one-half the whole number have occurred between 40 and 50, though there has been an increase in adolescent life, from 18 to 25, these younger chronic alcoholists specially developing an homicidal mani- acal tendency (as noted by Magnan, in Paris). Even boys of 7 years and up- ward having been treated for delir- ium tremens and chronic alcoholism in England, and children are sometimes sent drunk to school in Austria. The use of alcohol by children is one cause of the depopulation of France. The conclusion reached is that it is as dangerous as is an excess of alcoholic beverages for an adult; for the adoles- cent they are deadly, because they cause organic changes, hinder physical develop- ment, and impair the normal faculties even to the extent of degeneracy. For these reasons, then, alcohol should be proscribed as drink for children. Lan- cereaux (Jour, des Praticiens, No. 42, p. 665, '96, second series). [I have known cases originating over 70 and even over 80. There is an ine- briate climacteric, beyond which period nervous periodicity, energy, and function fail in response to alcoholic excitation, placed by Parrish at between 40 and 50, and by Kerr 15 years later in life, be- tween 55 and 65. Norman Keer.] Beligion. — Brahmanism, Buddhism, and Mohammedanism predispose against alcoholism more than other religions. Race. — Eastern peoples, generally, are more susceptible than Western to alco- holism. The latter (also some savage races), with their intenser energy, take to alcohol more impulsively and die sooner from it. The Jewish community pos- sesses a striking racial inhibition which has largely contributed to their marked general freedom from alcoholism. Atmospheric qnd telluric conditions predispose a substantial number of per- sons to alcoholism. The form of the alcoholism is to some extent modified by atmosphere and climate. Education. — In civilized communities cultitre and refinement endow many in- dividuals with a more delicate suscepti- bility to alcoholic poisoning. Occupation. ■ — Occupations with a de- pressant or exciting influence on the nervous system predispose to alcoholism. Marital Relations. — Between single and married males there is little differ- ence, but, in women, the proportion of spinsters is only one to from four to six married, widowed, or divorced women. Temperament. — The nervous and san- guine temperaments are, by far, the most susceptible to alcoholic toxication; the phlegmatic rarely yielding. Associated Habits. — Though the bulk of the subjects of alcoholism are smok- ers or users of tobacco in some form, the popular idea that tobacco-use largely predisposes to alcoholism seems to be without foundation. ALCOHOLISM. CHRONIC. PATHOLOGY. 213 [I have seen only a very few such instances. Only to a limited extent does any othei- narcotic, such as morphine or cocaine, act as a predisposing influence. Norman Keek.] Diseases and Injuries. — In no incon- siderable ntimber of cases syphilis pre- disposes to chronic alcoholism. Phthisis, gout, rheumatism, malarial poisoning, the neuroses, diabetes, and other ail- ments exert a similar influence. In- juries and sun-strokes, head-lesions, and heat-apoplexy often leave mental im- pairment and inability, which induce sus- ceptibility to take on alcoholic narcotic disturbance and addiction. An intelligent and educated woman never becomes a drunkard but from some deep-rooted and often carefully- concealed cause, which may be physical or mental. Lawson Tait (Brit. Med. Jour., Oct. 15, '92). Diet. — Improper, defectiye, and badly- cooked food, with bad hygienic condi- tions, frequently act as predisposing fac- tors. A considerable degree of alcoholic predisposition, in the person of the regu- lar, limited drinker and his progeny, is the direct effect of chronic alcoholic poisoning. The gradual alcoholic paral- ysis of inhibition induces a lessened capacity to resist the narcotizing action of the alcohol. Most of these influences operate also as causes exciting to intoxication. In addition, there are nerve-shock in both sexes, the functional crises of puberty, menstruation, pregnancy, maternity, lactation, and the menopause of women, monotonous dullness, and medical pre- scribing. Nerve-shock of some kind probably accounts for from a seventh to a sixth of chronic alcoholics. [In my experience about 2 per cent, of cases have arisen from head injuries immediately after the excitation conse- quent thereon; and V2 of 1 per cent, from alcoholic intoxicants medically prescribed. Alcoholic drinks and pro- prietary preparations containing alcohol are also taken or given as a "remedy" or "medicine" under non-medical advice, by nurses and other unqualified persons. XOKIIAN Kekr.] A common assertion is that doctors' prescriptions are one of the chief causes of drunkenness. In a study of the sub- ject in over 3000 eases of inebriety I was unable to trace the initiation of the alco- holism as due to medical prescription in more than ^/„ per cent. Pathology. — Protoplasm. — The experi- ments of Dogiel, B. W. Eichardson, and others indicate that alcohol, even in very small quantities, affects protoplasm, and therefore the entire system. It tends to cause cessation of the amoeboid move- ments of the white blood-corpuscles, and, through this, increases the liability to suppuration and the sluggish reparative action observed in drunkards. Its gen- eral effect is to inhibit vital phenomena inherent in the protoplasm, hindering thereby the resistance of the body to infectious diseases, while the multiplica- tion of various bacilli in the presence of even minute quantities of alcohol would seem to indicate that the life and growth of destructive elements are promoted. The blood is improperly aerated and waste material is unduly retained in the body. The ■walls of cells inclosing germinal matter are dissolved, free albumin is coagulated, red globules are deprived of part of contents, leaving them shrunken; growth of tumors favored, metabolic action limited, organization of neuro- dynia of gray matter reduced or pre- vented. Wilkins (N. Y. Med. Jour., Sept. 22, '94). Alcohol lessens the absorption of oxy- gen by the blood-corpuscles and the exhalation of carbonic dioxide. Every function of the body is thereby affected. Prout, Edward Smith, Harley, Schmiede- 214 ALCOHOLISM. CHRONIC. PATHOLOGY. berg, Yierordt, Kerr, and others (Med. Pioneer, Oct., '95). The continual ingestion of alcohol causes atrophy of elementary organisms, tending to destroy cellular protoplasm and vitality. Gaule (Le Bull. Med., Aug. 25, '95). Even in minute quantities alcohol favors the growth of many pathogenic organisms, including those of pus and diphtheria. Ridge (Med. Pioneer, Oct., '95). Alcoholized animals not only show the effects of inoculations earlier than do non-alcoholized rabbits, but, in the case of the streptococcic inoculations, the lesions produced are much more pro- nounced than are those that usually follow inoculation with this organism. A. C. Abbott (Jour, of Exper. Med., vol. i. No. 3, '96). Cases showing marked inhibitory in- fluence of alcoholism on the growth of children. Lancereaux (La Presse Med., Oct. 14, '96). Stomach. — The interior of the stomach presents a dark bluish-red hue, some- times looking very fiery and angry; while ulcerative erosive patches, thinning of muscular coat, with an increase of con- nective tissue and atrophy of gland-cells, are also conditions usually observed. In malt-liquor chronic alcoholists there is dilatation. The irritation of the gastric mucous membrane hinders digestion, and thereby interferes with the nutrition of the patient. Autopsy of nineteen inebriates. Five showed inflammation of the stomach alone. In two of these the mucous membrane of the stomach was black and thickened, and in places ulceration had taken place. Of the other seven, three had suffered from both gastritis and en- teritis, while the remaining four had suffered from extensive inflammation of some part of the intestinal canal, a majority of them suffering fi'om colitis. A remarkable feature in these twelve gastro-intestinal cases was that every- one had, at some period of their lives, suffered from pleurisy or pleuro-pneu- monia, for pleural adhesion existed in every case. Carpenter (Western Med. and Surg. Reporter, Jan., '91). Digestion. — The irritation of the gas- tric mucous membrane hinders digestion. Alcohol impairs all the gastric functions, and thus interferes with the general nutrition. Experiments on five young men: Al- cohol used in a 25- and 50-per-cent. solu- tion, of which 3 y, fluidounces were taken ten or twenty minutes before the pa- tient's dinner (consisting of soup, cutlet, and bread). Conclusions: 1. During the first three hours after the ingestion, the gastric digestion is markedly retarded, and dependent upon a decrease in the proportion of hydrochloric acid. 2. The diminution is especially pronounced in persons non-habituated to the use of al- cohol. 3. Stronger solutions of alcohol act more energetically than weaker ones. 4. During the fourth, fifth, and sixth hour after the meal the digestion be- comes considerably more active, the pro- portion of hydrochloric acid markedly rising. 5. Under the influence of alcohol, the secretion of the gastric juice becomes more profuse and lasts longer than under normal conditions. 6. The motor and absorptive powers of the stomach, how- ever, are markedly depressed, the de- crease being directly proportionate to the strength of alcoholic solutions ingested. 7. Alcohol distinctly retards the passage of food from the stomach into the duo- denum. 8. On the whole, alcohol mani- fests a decidedly unfavorable influence on the course of normal gastric digestion. Even when ingested in relatively small quantities, the substance tends to impair all gastric functions. 9. Hence, an habit- ual use of alcohol by healthy people can- not possibly be approved of from a physi- ological stand-point. Blumenau (Inaugu- ral Dissertation, No. 17, p. 60, '90) . Ptyalin of saliva and pepsin precipi- tated; gastric vasodilators paralyzed, while the constrictors are stimulated, preventing flow of gastric juice and ac- counting for irritability, anorexia, etc. Stomach inflamed and covered with thick mucus. Duodenal and panci'eatie func- ALCOHOLISM. CHRONIC. PATHOLOGY. 215 tion prevented. Stearin dissolved out of the fat by alcohol, remaining elements contributing to fatty degeneration of various organs. Excessive use continued any length of time prevents rehydration of glycogen and its transfer to the blood, and oxygenation of bilirubin to form biliverdin. In this sense, even a small quantity of alcohol is inimical to life. Wilkins (N. Y. Med. Jour., Sept. 22, '94). [Sir William Roberts's view, that we are, as a rule, suffering not from slow, but from too rapid, digestion, and that we therefore need alcohol, not to aid digestion, but to hinder it, can hardly be accepted. Clinical observations of performance of digestive function in liv- ing human subjects does not exhibit, as a rule, improved digestion after the ad- ministration of alcohol. NOKiiAN Kerb, Assoc. Ed., Annual, '96.] It would appear, from a study of many cases, that, so far, no general rule can be found, and each case must be studied from the facts of its history. Thus, in some cases, a meat diet is literally poi- sonous, and its removal is the first essen- tial for a cure. Again, a grain or fruit diet is clearly injurious, and more rapid recovery follows a change. In all cases states of starvation and autointoxica- tions exist the removal of which condi- tions may be of equal importance to that of alcohol. The study of the diet brings out many unsuspected causes which re- quire removal and treatment before a cure can be effected. Editorial (Quar- terly Journal of Inebriety, Oct., '97). Liver. — The liver is frequently af- fected by one of the various forms of cirrhosis. The proclivity of each indi- vidual bears considerable influence upon the development of this disease, however. The other hepatic chronic disorders most apt to be encountered are fatty and nut- meg liver. Acute hepatitis is less fre- quently met with. The lesions found in the acute form of alcoholic hepatitis are like those ob- ser\-ed in infectious, suppurative hepa- titis, showing the identity of effects between infectious and toxic processes. Pilliet (La Tribune Med., Apr., '90). The ascites of cirrhosis is habitually absent in connection with the cirrhotic alterations of the liver in the alcoholic insane. Klippel (Annales M6dico-psy- chologiques, Sept., Oct., '94). Case of acute alcoholism in which the hepatic functions were suppressed during twenty-one days. Cassaet (Le Bull. Med., Oct. 31, '94). Experimental alcoholism in animals causes preliminary gastric catarrh, then fatty degeneration of the liver. Koulbine (La Med. Mod., Jan. 16, '95). Histological examination, in two rab- bits which were subjected to progress- ively increasing doses of wine. There were traces of an irritating influence upon the liver, which were found princi- pally in the central parts of the lobes. The connective tissues of the portal spaces did not present lesions that were very clear, but the subhepatic veins and the capillaries were filled with leucocytes and proliferated endothelial cells. The glandular parenchyma was remarkable for the considerable size of its nuclei, which were vesicular; the cellular proto- plasm seemed to be intact. One had died at the end of twenty days, without presenting any visceral alterations. The other had died after thirty days, and presented haemorrhage of the stomach. The liver was of a pale-grayish color and tlie spleen was tumefied. Lancereaux (La Presse Med., Oct. 14, '96). With the above conditions is often associated a special facies, consisting in watery, blood-shot eyes, sometimes yel- lowish from bile, and in enlarged venules on the nose and cheeks; at times, acne rosacea. At an early stage the eyes of chronic drunkards present the following symp- toms: Catarrhal conjunctivitis, conges- tion of the iris, spasm of accommodation, contracted pupils, photophobia, nycta- lopia, a glimmering sensation in bright light, scotomata, amblyopia, and partial atrophy of the optic nerve. (May.) Pancreas and Intestines. — The inter- ference presented by alcohol to the 216 ALCOHOLISM. CHRONIC. PATHOLOGY. proper digestion of fats is mainly respon- sible for the fatty degeneration of the heart and other organs generally en- countered at autopsies. The pancreatic secretion being coagiilated by the alco- hol, the fat is not emulsified. Although the coagulated secretion is redissolved into its former elements by pure water, it is impossible to restore it in the presence of alcohol, as there is a mixture of water and alcohol in which the secretion will not dissolve. The stearin of the fat is dissolved by the alcohol out of the fat-globules. This dissolution is probably aided by the duodenal secretions. The remainder of the fat becomes a foreign body in the circulation and, being a compound of palmitin and olein only, does not possess the property by virtue of which it is attracted to the adipose vesicle, but is deposited in the different tissues, cavi- ties, and organs, thus constituting fatty degeneration. Wilkins (New York Med. Jour., Sept. 22, '94). The intestinal tract bears the brunt of the irritating action of improperly digested food, and gastro-intestinal trouble is frequent, especially in chil- dren. Many infants suffering from acute or subacute gastro-intestinal disease are the victims of unrestrained administra- tion of whisky or brandy, no definite direction having been given as to dose. Henry Koplik (Med. Pioneer, Feb., '94). The ingestion of alcohol causes migra- tion of microbes from the intestines to the peritoneum and to the blood of the vena porta. Wurtz and Hudelo (Le Bull. M6d., Jan. 30, '9.5). Kidneys. — The structural definition of the kidneys is frequently lost in ad- vanced cases. Their functions are inter- fered with, and cumulation of products of metabolism is imposed upon the sys- tem. The various forms of nephritis are natural consequences of the irritation produced. Lh-ic-acid and calciuni-oxalate crystals are found in the urine of persons in good health after taking alcoholic drink, be- sides an increased number of leucocytes with cylinders and cylindroids. It may, therefore, be concluded that, even in moderate quantities, alcohol irritates the kidneys, the augmented leucocytes, cylinders, and crystals being due either to the increased metabolism of the tis- sues or an alteration by alcohol of the relations of solubility of the urine salts. After a single indulgence this action lasts for thirty-six hours. But contin- uation is cumulative. Glaser (Quarterly Jour, of Inebriety, Apr., '92). First and most frequent effect on kid- neys is polyuria, then diabetes insipidus, followed by diabetes mellitus in predis- posed alcoholics. Wilkins (N. Y. Med. Jour., Sept. 22, '94). There is a true diabetes, in which an affection of the liver is found preceding by a long period the diabetes, and to which the diabetes is due. These pa- tients have been considered until now as suffering merely from diabetes, and not from the liver, since an examination of the liver was necessary in order to recog- nize them as suffering from that organ. The alternate phases of amelioration or the contrary in the diabetes coincides with the development of the process in the liver; it may be recognized by the changes in the volume, form, density, and sensibility of the liver. Of six cases seen by the author, there were three in which diabetes with hyper- trophic liver had existed for years who suddenly developed a cirrhosis, while the polyuria, glycosuria, and thirst van- ished, to be replaced by atrophy and cirrhosis of the liver. Glenard (Mer- credi Med., No. 44, '94). Heart. — The heart-failure of chronic inebriates has for the past quarter of a century been continually presenting it- self in my experience, often preceded by, or contemporaneous with, dilatation of the muscle. Alcohol has a direct action on the involuntary muscular system, and the heart is more responsive to its dilat- ing action than any other part of the bodilv structure. ALCOHOLISM. CHRONIC. PATHOLOGY. 217 The three cardinal symptoms of heart- failure are generally observed early in alcoholic cases, though the prognosis is good providing alcohol he abandoned as soon as the immediate therapeutic neces- sity for its use has ceased. Graham Steele (Med. Chronicle, Apr., '93). Dynamometer shows that the muscular strength is diminished under influence of even moderate doses of alcoholic drinks. Furer (Le Bull. M6d., Aug. 25, '95). The heart is fatty and covered in parts by fatty tissue. It is usually flabby, pale, and antemortem clots are likely to be formed in the cavities. These conditions predispose to sudden death. Alcoholic myocarditis, with consecutive hepatic disturbance and temporary al- buminuria, is found as a clinical form in men of middle age, between 25 and 50 years; in women it is much more un- common. In all cases abuse of alcoholic drinks may be looked upon as the cause. It begins slowly and progressively. The first symptom consists in dyspneea, when the patient speaks or goes upstairs, later during walking. Fragmentary myocar- ditis i5 found anatomically. An increase in the size of the liver is added to the dilatation of the heart. The kidney is finally afi^ected. Aufrecht (Deutsche Archiv f. klin. Med., vol. liv, p. 615, '95). Blood-vessels. — There is general arte- rial dilation with atheromatous thicken- ing and brittleness, due to a cribriform condition resulting from the aneurismal dilatation. The motor cells are enlarged and pigmented, and their processes are covered with nuclei. Case of oesophageal varicose veins in a chronic alcoholic subject who died from frequent and severe hsematemesis. The varices ascribed to the direct effect of alcohol on the intima. of the veins. Le- tulle (La Semaine Med., Oct. 22, '90). It paralyzes the vasoconstrictors and, at times, vasodilators of capillaries, causing local hypertemia and stasis. Hypertrophy results from vasoconstrictor paralysis, and atrophy from vasodilator paralysis. Wilkins (N. Y. Med. Jour., Sept, 22, '94). Lungs. — Chronic alcoholism, by lower- ing the condition of the system, renders more liable to both acute and chronic tuberculosis. Pleviral adhesions and other evidences of active processes are frequently seen. Post-mortem examinations of phthis- ical eases at St. Thomas's, London, showed that in 75 cases there was a strong history of alcoholism. In only 10 of these was there any history of in- herited phthisis; in 46 (or over 60 per cent.) the liver was cirrhotic. Mackenzie (Brit. Med. Jour., Feb. 27, '92). One of the most eflSeient prophylactic measures against tuberculosis would be the repression of alcoholism. Thorain (Revue des Sciences Med. en Fi'ance et 3. I'Etranger, July 15, '94). Alcoholic excesses one of the main causes of tuberculosis by predisposing the system to bacillary action. The phthisis of drunkards presents peculiar characteristics in localization and evolu- tion: the lesion, instead of being in left apex in front, is located at the right apex toward the back. Improvement usually follows the first attack, and recovery frequently ensues if the alcoholic habit is corrected. If continued, the disease suddenly assumes alarming character, involvement of both lungs, peritoneum, and meninges quickly causing death. Lancereaux (Le Bull. Med., Mar. 6, '95). The increase of tuberculosis is propor- tionate to that of alcoholism in France. Lagneau (Le Bull. Med., June 26, '95). Brain and Nervous System. — The meninges are often adherent and show inflammatory white patches and thicken- ing. The brain is shrunken, with flat- tened, narrow convolutions and serous, ventricular, and subarachnoid effusion. There is general wasting of nerve- cells and fibres, with atrophied, tangled nerve- centres and great increase of connective tissue. In the brain-substance congestive bleeding-points are sometimes observed on section. Scavenger calls are met with in profusion, preying on nerve-elements. (Bevan Lewis.) 218 ALCOHOLISM. CHKONIC. PATHOLOGY. Mental disorders and crime are shown, by statistics, to have, in alcohol, one of their most potent etiological factors. It is perfectly certain that from one- fourth to one- third of the lunacy of the United Kingdom is a result of the cus- tom of drinking alcoholic liquors. J. J. Ridge ("Alcohol and Public Health," p. 63, '92). Women charged in American police- courts with drunkenness and associated offenses are profoundly degenerate in body as well as in mind. T. D. Crothers (Brit. Med. Jour., Dee. 31, '92). In fifteen years lunacy has, in Paris, increased 30 per cent., due to the ad- vance of general paralysis and alcoholic insanity. The latter is now twice as prevalent as fifteen years ago. Alcohol is responsible for a third of the lunacy cases at the Depot Infirmary, the tend- ency being more and more to homicidal mania in youths of barely twenty. Gar- nier (Quarterly Jour, of Inebriety, Apr., '92). Histological examinations have shown that alcohol causes swelling of the den- drites; this is followed by nuclear changes, then by degeneration of the cell-structures. Examination of an alcoholic brain by the Golgi method. Lesions of the neu- raxon of the nerve- cell slightly involv- ing the cell-body and dendrites. Colella (Arch. ItaL de Biol., p. 216, '94). Alcohol produces well-marked changes in the nerve-cells, especially in those of the anterior horns of the spinal cord and in the sympathetic ganglia. They first lose their cliromatin structure, the fine granular appearance gradually being replaced by an homogeneous swelling. Golgi method. Vas (Archiv fiir exper. Path. u. Pharm.. B. 34, p. 141). There is gradual disintegration of the cell-body after the apical processes have suffered. Here and there, in the neigh- borhood of the cell-body, the protoplasm seems to become frayed or eroded. In other cases the cell-protoplasm becomes vacuolated from within until the entire protoplasmic structure is channeled by holes and seams of liquefaction. Golgi method. Andriezen (Brain, '94). Forty per cent, of crime and bad con- duct come from inebriate parental de- generation. Corre (Quarterly Jour, of Inebriety, Jan., '94) . The form of alcoholism is determined by pre-existing anomaly of subject; al- coholic psychopathia often the conse- quence of parental addiction; psycho- pathia and alcoholism cause one another. FUrer (Le Bull. Med., Aug. 25, '95). [A large share in the genesis of mel- ancholia is due to agencies lowering the general health, among which alcohol is conspicuous. Farquharson found 11 per cent, of asylum cases of melancholia due to intoxicants, while many victims of suicidal melancholia who had no insane heredity had a family history of ine- briety. NOKMAN Kerb, Assoc. Ed., An- nual, '96.] The literature of the past two years has demonstrated, more than that of previous periods, perhaps, the pathogenic influence of alcohol upon the brain. It has shown that, in proportion as it is used, so are mental disorders prevalent, the ratio of the increase of insanity cor- responding to that of increased consump- tion of alcoholic beverages. Neurological and pathological evidence, together -with recent experimental work, show that in the early stages of the insanities there is a profound nutritive and dynamical failure in the nerve- elements of the brain, which finds ex- pression in the insomnias, the melan- cholias, and the commencing loss of memory, with easily-induced mental fatigue which their subjects experience, and that the pathological facts ascer- tained, in so far as they afford us any light, force on us the conviction that we are dealing with serious nutritive and dynamical changes in the central nervous organ. W. Lloyd Andriezen (Quarterly Jour, of Inebriety, Jan., '96). During four years, of 2169 patients re- ceived into the lunatic asylum at Rome, 340 (15.7 per cent.) owed their psy- chopathy to alcohol: 23 per cent, of the males, 4.6 of the females. Every form of mental disease to which alcohol may give rise is included in these 340 cases. ALCOHOLISM. CHRONIC. PATHOLOGY. 219 all doubtful cases being carefully ex- cluded. Tables showing that, as the pro- duction and' consumption of alcoholic liquors in Italy generally have increased, the number of insane patients admitted to the Roman asylum for alcoholic dis- eases has grown. A. Volpini (II Poli- clinico, '96). Alcoholism contributed to the popula- tion of the asylums of France, in 1894, 775 patients: 624 males and 151 females. The forms in the males comprised 282 cases of alcoholic delirium, 332 of chronic alcoholism, and 10 of absinthism. The females included 90 cases of alcoholic de- lirium, 60 of chronic alcoholism, and 1 of absinthism. Besides these, if we take account of the cases in which excesses in drink caused the entry into the asylum of patients who, without this cause, would have been able to get on outside, we find further 166 males and 63 females. The two groups — simple alcoholic cases and the insane with alcoholic causation, a total of 1004 patients — give a percent- age of 38.42 of the males and 12.82 of the females admitted. Thus, on the average, one-third of the insanity of the Depart- ment of the Seine is due to alcohol. Magnan (Progres Med., May 23, '97). Out of 1900 male insane patients treated in the Municipal Asylum of Dresden during the last five years, 500 were clearl}' traceable to alcoholism. Luhrmann (Archives de Neurol., No. 15, '97). In England drunkenness is increasing, not only among the poor, but also among the upper classes, and especially among women of all classes. Out of 442 male inebriates treated at the Dalrymple Home and discharged as cured, 101 were university men, and 316 of the remainder were well educated; 235 were married, and the others were widowers or bach- elors. In 228 cases sociability was said to be the cause, ill health caused the downfall in 36 cases, and overwork was ■given as the excuse for taking to drink in 32 cases. In 55 per cent, of the cases the excess was traceable to predisposing hereditary causes. About one-third of the cases treated are permanently cured. Out of the 442 patients discharged from the Dalrymple Home, 372 were kept trace of, and of these 149 were said to be en- tirely cured, 24 had improved, 164 had relapsed, 31 were dead, and 4 were in- sane. Editorial (Med. Record, Sept. 25, '97). There are three types of cell-degenera- tion, viz.: (1) intense pigmentation of the larger cells, chiefly with degeneration of the cytoplasm; (2) a general cell- atrophy of the body and nucleus; (3) a great deal of change in the cell-body, with many neurogliar nuclei in the peri- cellular spaces. In the cases of alco- holism and alcoholic meningitis it was not possible to make out a distinct type of cell-degeneration, nor could this be ex- pected, as these patients die, not so much fi'om the alcohol, as from autotoxaemias and from the febrile process. Charles L. Dana (Med. News, May I, '97). Manner in which the pathological le- sions and the symptoms correspond with one another: the sensory disorders, the exaggeration of the sensibility of the skin, the anaesthetic troubles, and the ocular and auditory disorders would cor- respond to the beginning of the vascular disorders, when the nerve-cells, irritated by an insufficient supply of proper nutri- ment, and excited by the presence of a poisonous stimulus, overact for the time; then, as nutriment is still withheld from them, altered metabolism results. The beginning sweUing of the dendrites of tJie sensorimotor region is marked by parsesthetic symptoms, those of the purer sensory region by visual and ocular troubles, and some amnesia, especially for recent events; or, in other words, cells that have the function of evolving and transmitting thought cannot work properly, and defective memory results. Later, as the motor cells are more and more involved and nuclear changes Tyegin, continuous tremor becomes apparent, the muscles no longer co-ordinate perfectly, unless for a moment under the direct influence of the will. Still later, when a portion of the cell-structures have be- come highly degenerated and the altered cells have l)ecome more nimnerous, the already tottering will-power becomes more and more deadened, memory and judgment fail, and, when the degenera- tive process is far advanced, an incom- 220 ALCOHOLISM. CHRONIC. TREATMENT. plete dementia is the final result. Henry J. Berkley (Johns Hopkins Hos. Reports, vol. vi, '97). Beer. — Even iTuder the excessive iise of malt liquors, subjects rarely fail to put on fat. The blood shows an increased proportion of red and a diminished pro- portion of white corpuscles. Sudden cessation of drinking causes no other disturbances than a temporary longing, a rapid loss of flesh, and a decline in color. Stone in the bladder and cystic diseases are uncommon. Digestion is not re- tarded. Excess in beer is apt to produce subacute gastritis, especially in the sum- mer. Cirrhotic kidney and hobnail liver are not found in beer-drinkers. Acute alcoholism is much more common than delirium tremens. (Lambert Ott.) Four quarts of beer may be estimated to contain 240 grains of carbohydrates and scarcely 32 grains of albumin. Striimpell (Quarterly Jour, of Inebriety, Jan., '94). The diminished vital resistance caused by the imbibition of alcohol renders the inebriate more liable to the development of disease than the temperate. Clinical experience has clearly sustained this view. Experience in India and other warm countries has indicated an extreme fatal- ity from sun-stroke in persons using alcohol to excess. Fifty cases of sun- stroke brought into the Presbyterian Hospital of New York. The use of alcohol seemed to have a direct unfavorable influence. The habit was marked in 32 per cent., moderate in 46 per cent., denied in 10 per cent.; in the remaining 12 per cent, no history could be obtained. Eight persons were markedly alcoholic on admission, and of these four died. Editorial (Quarterly Jour, of Inebriety, Apr., '97). Study of 247 recovered personal cases of delirium tremens: of these cases 202 were uncomplicated and 45 complicated by other diseases. Twenty-two cases were complicated by pneumonia, and when, also, the lethal cases observed by the author are taken in account, more than 12 per cent, of all eases of delirium tremens were combined with pneumonia. The delirium usually began on the fourth day of the pneumonia, but the evolution of the two diseases was individual, the one in no way influencing the other dis- ease. Jacobson (Hospitalstidende, p. 143, '97). The normal vital resistance of rabbits to infection by streptococcus pyogenes (erysipelatos) is markedly diminished through the influence of alcohol Avhen given daily to the stage of acute intoxi- cation. A similar, though by no means so conspicuous, diminution of resistance to infection and intoxication by the bacillus coli communis also occurs in rabbits subjected to the same influences. AVhile in alcoholized rabbits inoculated in various ways with staphylococcus pyogenes aureus, individual instances of lowered resistance are observed, still it is impossible to say from these experiments that, in general, a marked difference is noticed between alcoholized and non- alcoholized animals as regards infection by this particular organism. It is interesting to note that the re- sults of inoculation of alcoholized rabbits with the erysipelas coccus correspond in a way with clinical observations on human beings addicted to the excessive use of alcohol when infected by this organism. A. C. Abbott (Quarterly Jour, of Inebriety, Oct., '97). Treatment. — The essential condition of cure is the entire discontinuance of all alcoholic beverages, whether spirits, wines, beers and other malt liquors, cider, etc. Eecords of reliable scientific hospitals and homes throughout the world show that, on an average, fully one-third of the cases so treated have been permanently cured. Under scientific treatment one-third of inebriate patients are permanently cured. After an interval of from seven to ten years, in two thousand cases treated at Fort Hamilton, the proportion was 38 per cent. After eight to ten years, 35 per cent, of the survivors who had been ALCOHOLISM. CHRONIC. TREATMENT. 221 discharged (numbering, in all, three thou- sand) from the Washingtonian Home, in Boston, under Day, were temperate. Of two hundred and sixty-si.x who passed through the Dalrymple Home, in Eng- land, full 40 per cent, have kept firm. Crothers (Quarterly Jour, of Inebriety, Apr., '92). Development of patient's will-power most important part of curative meas- ures. Norton (Brit. Med. Jour., May 25, '95). After a prolonged trial of the Keeley and other treatments, that described by C. de Martines was adopted at the Cery retreat for inebriates. Almost always the patient during the first few days be- comes violently agitated, throws things about and attempts to hurt himself and others; so, as restraint has a bad effect, he is allowed free movement in a room with padded walls and devoid of furni- ture. Two glasses of wine a day are allowed during the first week or two, but no longer. As soon as the mental e.xcite- ment subsides, the patient is made to walk in fresh air until tired, and takes a warm bath for half to one hour each day. The only drugs used are chloral- hydrate, 20 to 30 grains, to produce sleep, preferably given in a little wine or beer, or, if this is refused, ^/„j grain of duboisine or hyoscine hypodermically. Morphine is never employed, as it is con- sidered responsible for many untoward effects in the treatment of these cases. The bowels are regulated by artificial Carlsbad salt or other saline purgative. The lungs are examined every morning, as at any time a pneumonia may develop. Any medication is more rapidly absorbed if it is given in a slightly alcoholic mixt- ure. (Revue Med. de la Suisse Rom., Mar. 20, 1900). There is no specific. After treating the immediate symptoms of breakdown, delirium, etc., by flushing the intestinal canal and administering food and effer- vescents suited to the harassed and irri- tated digestive apparatus, the chief drug reliance should be on nerve-tonics, such as strychnine and nux vomica, combined with cinchona, quinine, iron, chiretta. gentian, and calumba. Complications must also be attended to, as syphilis by mercury or potassium or sodium iodide, and ague by quinine, bebeerine, or ar- senic. The indications are to prevent the alcoholic poisoning going further, by the immediate withdrawal of alcoholic bev- erages, which superabundant experience — in prisons, work-houses, hospitals, and homes for the treatment of the disease of alcoholism — has shown to be quite safe; to antagonize or remove the exciting causes; and to reconstruct healthily body and brain. The highest iniluences of art, intellect, morals, and religion should be invoked to restore inhibition and re- establish the lost will-power. Massage, galvanism, muscular exercise, especially in the open air, working at a congenial occupation, bathing (including the Turk- ish or Eoman bath), with all healthful and invigorating hygienic exertions, are useful adjuncts to medicinal therapeusis. The bath is applied with advantage to promote elimination, restore natural function, and quiet irritated and in- flamed organs. Patients debilitated from acute inflammation and pain have en- joyed the bath twice daily for months. Shepard (Jour. Amer. Med. Assoc, Jan. 9, '92). The peculiarities of each case should be studied, and it is important to instill into the alcoholist's mind the necessity for life-long abstinence from the toxic substance, just as in chronic lead or arsenic poisoning, with both of which intoxications alcoholism has much in common. Strychnine hypodermically has been recommended. The nitrate or sulphate is usually administered in doses of ^/ao to ^/c grain daily, or oftener, as indicated by the gravity of the case. Strychnine used, 'As grain hypoder- mically, gradually increasing the dose till 222 ALCOHOLISM. CHRONIC. TKEATMENT. physiological effects declared themselves, the highest dose thus injected being Vig grain. At the same time Vm grain of strychnine nitrate is given by the stom- ach every two hours, together with from VzK to Vooo gi'ain of atropine sulphate in gentian infusion. J. H. Ward (Med. World, Dec, '93). History of twenty-five cases of alco- holic mania treated with nitrate of strychnine subcutaneously injected. The dose varied from Vao to Ve grain twice daily for ten days, then once daily for ten days, the highest dose being reached about the third or fourth day and con- tinued to the close of the treatment. This administration is in accord with Spitzka's experiments, that to maintain its action the doses of strychnine must be at first increased; later the interval increased and the doses lessened. The border-line of tolerance was reached, in most cases, when 15 minims were used of a solution containing 2 grains of strychnine nitrate to 4 fluidrachms of water: equal to Vis grain. Internally, cinchona, peroxide of hydrogen, and cap- sicum were frequently prescribed in com- bination. When sodium bromide failed to procure sleep paraldehyde ahvays suc- ceeded. In the latter case, strychnine, in doses of 7=0 grain, with elixir of phos- phates and calisaya, was ordered to be taken once or twice daily for four to five weeks after ceasing the injections. There were fourteen relapses known in these twenty-five cases from within one to eleven months. Though strychnine is useful in restoring temporary health, it does not prevent the possibility of fur- ther relapse. J. Bradford MeConnell (Quarterly Jour, of Inebriety, Jan., '94). Several cases in which nitrate of strychnine, in doses of from Vso to ^/o grain, twice daily, was administered for ten days, then once daily for ten days, with temporary benefit. In many of the cases there was a relapse, sooner or later, showing the need for prolonged seclusion, with the operation of moral and hygienic conditions. J. Bradford MeConnell (N. y. Med. Jour., June 3, '93). In the alcohol wards of the Bellevue Hospital the use of strychnine and the solanacese, with certain adjuvant tonics and moral influences, is employed in cases of periodic alcoholism. The drugs selected are those which the experience of ten years in the care of these cases has shown to be most useful. Selected patients, after having passed through an attack of acute alcoholism, and are con- valescent, are allowed to remain two daj's. Only persons who have reasonable intelligence and who show real evidence of sincerity are chosen. The following solutions are used: — li Strychnine nitrate. Vis grain. Atropine sulphate, Vsoo grain. Distilled water, 10 minims. M. Sig.: Inject t. i. d. First day injection. B Strychnine nitrate, V:o grain. Atropine sulphate, V=oo grain. Water, 10 ounces. M. Sig.: Inject t. i. d. Second day injection. C. L. Dana (Post-graduate, July, '96) . Once insomnia has disappeared, the propitious moment for the use of strych- nine has arrived. The period of depres- sion will be more or less prolonged; the malnutrition, already great during the acute attack, will increase; all the func- tions will droop unless a stimulant is found to increase the vital forces, and, usually, alcohol is the stimulant instinct- ively sought for by the victim, who thus treads in a vicious circle. To avoid this a stimulant other tlian alcohol must be selected for the patient, and not by him: a medicine, and not a sort of food. The most appropriate for this purpose is strychnine, as it meets all the require- ments rendering its employment neces- sary. Combemale (Le Bull. Med., Apr. 12, '96). The principal indication for the strych- nine treatment is found in cases of con- firmed alcoholism without acute attacks. But, in fatty degeneration of the organs, the strychnine treatment does not and cannot produce any modification of the symptoms. It even constitutes a danger. Strychnine is slowly eliminated by the urine, the saliva, and the bile, even when the organs are intact and prevent accu- mulation. Hence, cirrhosis of the liver and renal impermeability are two more ALCOHOLISM. CHRONIC. TREATMENT. 223 great contra-indications to the employ- ment of this drug. Case of an alcoholic, who suflfered from cirrhosis of the liver with ascites, in whom tetanic symptoms occurred after the fifth injection. Mer- cier (Gaz. Heb. de Med. et de Chir., May 16, '97). Strychnine is a valuable drug both as a tonic and a stimulant, but should not be given alone except immediately after the withdrawal of the spirits. T. D. Crothers (Penna. Med. Jour., Apr., '98). Nothing gives results equal to strych- nine. One patient will do well on Vii grain, four times daily; another will get worse on so small a dose as Vco grain. It is most important, therefore, to study each case. The proper dose can usually be determined in two days. Patients gain from 5 to 20 pounds in from three to four weeks. If no improvement oc- curs, either too much is given or not enough. G. de Nike (Med. World, Feb., 1901). Having found liquor ammonise acetatis in acute alcoholism, and strychnine (both by the mouth) in subacute and chronic alcoholism, quite as effectual as the sub- cutaneous administration, I eschew the latter method. The simpler and safer the remedies used, the more permanent and helpful will be the treatment to the sufferers. Hypnotism has been lauded as a cura- tive agent, but I cannot recommend it, having seen many cases in which it has failed and some in which it has kft mental injury. Still less can I advise recourse to alleged remedies, or remedial processes, the composition or particulars of which are kept secret. I have seen substantial mischief after the use of various "cures" of this description. Hypnotic suggestion successfully em- ployed in twenty-three cases. Bushnell (Times and Register, Sept. 14, '95). "Gold-cures," whenever analyzed, con- tain no gold whatever. Gold is non- assimilable, and inebriety is not reached by drugs alone or by special, concealed plans of treatment. In many cases of inebriety which have been cured in gold- cure asylums, there is concealed periodic- ity. There are no facts to show that gold has any value in the treatment of this disease. Crothers (Jour. Amer. Med. Assoc, Oct. 8, '98). The strong claims for the efficacy of a remedy for drunkenness led to a curi- osity to determine what it contained. Some of these remedies, as is well known to physicians, are merely alco- holic preparations, others contain tartar emetic. The article in question sells at one dollar per box, containing twelve powders, weighing about 9 grains. The powder gave no evidence of any of the ingredients expected. On being heated in a platinum crucible, it charred, emitted an odor of burnt sugar, and finally burned away, leaving but a trace of ash. No antimony nor mercury com- pound was present. Ammonium chloride was detected. There was no alkaloid nor alkaloidal salt. The only materials that could be found were milk-sugar and ammonium chloride. Henry Leff- mann. Laboratory of the Philadelphia Medical Journal (Phila. Med. Jour., Jan. 24, 1903). To Produce Distaste for Liquors. — Time, patience, control, and study of individual peculiarities are required. Strychnine, sometimes atropine, judi- ciously employed, are at times useful; but there is no specific. Small doses of atropine, less than '/loo grain, hypodermically, three or four times a day, produce distaste in from one to five days. Carter (Med. News, Mar., '95). Same effect produced by ipecac, 20 minims of the fluid extract used as an hypnotic. Waugh (Med. Age, June 25, '95). To overcome longing for drink, due to irritation of gastric nerve-supply: — IJ Chlorinated water, 2 drachms. Decoction of athsea, 5 ounces. Cane-sugar, 2 drachms. M. Sig. : A tablespoonful every two or three hours. Zdekauer (La M6d. Mod., Jan. 12, '95). 224 ALCOHOLISM. CHRONIC. TREATMENT. Disgusting an inebriate of alcoholic intoxicants -is not to cure the disease of inebrity, or narcomania. Excessive irritatioii following the re- moval of alcohol is often very quickly removed by the bromides. They should be given in large doses of at least 2 drachms every four hours in large quan- tities of water flavored with peppermint or tincture of cinchona. As soon as the bromidial effects are noticeable, small doses of bitartrate of potassa and sul- phate of magnesia should be given, with warm shower-baths, twice a day. Bro- minism is usually very slight after this, and only the slight sedative effects re- main. Bromide of sodium seems to be the most powerful and prompt in its ac- tion. In vigorous plethoric inebriates, with a high degree of mental irritation and delirium, the sudden withdrawal of spirits and the substitution of bromide of sodium, 100-grain doses every three or four hours, is followed by rapid recovery. Many cases cannot bear the bromides: they ^eem to intensify the debility and depression from spirits. Chloral should never be combined with bromides for its sedative effect, especially in inebriates. ■^Tien the temperature ' falls and the heart becomes feeble, all bromides should t)e stopped. When low muttering de- lirium comes on, with muscular enfeeble- ment, the bromides are dangerous. Its indiscriminate use for all cases is un- safe, and its action should be watched ■ carefully. Editorial (Quart. Jour, of In- ebriety, Apr., '98). Exception taken to Reid's theory of immunity against drunkenness obtained hy use of alcohol for successive genera- tions. A certain degree of immunity to the action of alcohol on the tissues may Toe attained, but not to the taste or lik- ing of alcohol. A direct transmission of the taste for alcohol never occurs. Drunkenness as a disease is not trans- mitted, but only the weakly and imbal- anced condition of the tissues of alco- holic parents. G: Sims Woodhead (Lan- cet, July 29, '99). Conclusions regarding the use of apomorphine hydrochlorate as hypnotic in alcoholism are: 1. To obtain a hyp- notic action with apomorphine it should be given hj-podermically. 2. The dose cannot be fixed. It is best to begin with a small dose, — V30 grain or less, — and to repeat this or give a slightly larger dose within a short time. Fur- ther doses should not be given after vomiting occurs until several hours have passed. 3. Doses repeated in two or three hours have but little beneficial efi'ect. 4. The administration of apo- morphine should not be repeated in pa- tients who are weak. 5. The duration of the hypnotic action is only a few hours, and when the patient awakes his condition is practicallj' unchanged, except in "ordinary drunks." 6. The best results are obtained from apomor- phine when it is followed in two or three hours by some recognized hyp- notic, as bromide, chloral, paraldehyde, etc. 7. Solutions of apomorphine are unstable, and should be freshly made for use. Old solutions should never be used. 8. Apomorphine may be employed as a hypnotic in selected cases of alco- holism. The best results were obtained in "ordinary drunks" and in eases verg- ing on delirium tremens. But in some of these cases the drug has no effect whatever. 9. The administration of apomorphine to patients in delirium tremens was, as personally observed, without beneficial result, and may even be attended with danger from its de- pressing action. Warren Coleman and J. M. Polk (Amer. Med., March 8, 1902). Fresh fruits (oranges, etc.), an emetic, or a cup of hot tea', coffee, or cocoa are frequently sufficient to counteract the drink crave or impulse. For insomnia, hyoscine hydrobro- mate, 7=00 to Vioo grain, cautiously given, or a hot, wet pack is useful. The use of hyoscine hydrobromate is to be recommended, but its abuse will do more harm than good. The dose is from V300 to ^/loo grain, increased cau- tiously to ^/so grain. Lionel Weatherley (Jour, of Mental Science, July, '91). Lott's treatment of alcoholic and morphine habits with hyoscine tried in ALCOHOLISII. PKOPHYLAXIS. 225 6 cases: The patients can take massive doses for daj'S at a time, as much as 'A gi'ain each day liypodermically, with no evil effects on any vital func- tion. They suffer very slightly, if at all, from the immediate withdrawal of the morphine. The desire for the drug is largely, if not entirely, dissipated after a few days. H. A. Hare (Med. News, June 7, 1902). Chloralose has also been recommended as an hypnotic in these cases, its soothing effect continuing even after its influence as a soporific has been exercised. In heart-failure the preparations of ammonia, especially the aromatic spirits, are effective. In the heart-failure of chronic inebri- ates rest in bed and digitaline granules, one of Vm grain being usually sufficient. Graham Steele (iXed. Chronicle, Apr., '93). Nitroglycerin is recommended against the vomiting of alcoholism. E.. Hum- phreys (Brit. Med. Jour., Apr. 1, '93). The influence of surroundings should not be disregarded. The patient should be separated from those of his associates ■who cater to his weakness, and made to enjoy, if possible, the company of those who, on the contrary, tend to counteract his habits. 1. The patient should be instructed in regard to deceptive and injurious influ- ences of alcoholic drinks, so that he is actually convinced that their use is, on all occasions, unnecessary. 2. The patient should be placed under good physical and social surroundings. For impaired di- gestion, ii-ritable ners'ous system, and dis- turbed sleep, Veo grain of digitaline with '/so grain of strychnine at each meal, with from 20 to 30 minims of diluted hydrobromic acid at bed-time, will give excellent results. For constipation, 30 minims of fluid extract of rhamnus pur- shiana may be added to the acid. In- stead of the digitalis and strychnine, a pill or capsule of a grain of extract of hyoscyamus, with 3 grains of cerium oxalate, may be given. Before an antici- 1- pated period of dissipation a pill of 2 grains of quinine sulphate, the same amount of extract of eucalyptus globu- lus, and '/j grain of extract of cannabis Indica should be given with each meal for two weeks. 3. The patient should be separated from his associates, and, if this cannot be done in any other waj', he should reside in a well-regulated a-sylum for six to twelve months. N. S. Davis (Quarterly Jour, of Inebriety, Apr., '97). Prophylaxis. — Successful prophylactic measures must include power to compul- sorily seclude chronic alcoholics who are too will-paralyzed to apply for curative seclusion voluntarily; the teaching of the young in the poisoning influence of alco- hol; the protection of infants against contamination from alcoholic nurses; the abstinence propaganda, especially among the rising generations; and suppression of the liquor trafBe, either by a vote of localities or by general national prohibi- tion. In Switzerland, in the Canton of St. Gall, by a law passed in 1S91, anyone rendering himself obnoxious or danger- ous to Ms family or to the community, through drinking, may, with a medical certificate, be sent to an inebriate asy- lum, and be paid for out of the public poor-funds, if his friends are unable to defray the expense. Editorial (Quar- terly Jour, of Inebriety, Oct., '92). The disorders to which infants are exposed when nursed by women who partake too freely of stimulants — ^infant nervous attacks, convulsions, etc. — are frequently attributed to other causes. (Vallin.) The majority of the posteritj' of drunkards and of persons of an ill-bal- anced nervous system should abstain al- together from alcohol, or, at least, be- fore partaking of it, consult a com- petent physician. Sir Dyee Duckworth (Lancet, Aug. 26, '93). Cases of alcoholism in children show- ing importance of not prescribing alco- hol. Goriatchkine (Wratsch, No. 15, '96). •15 226 ALCOHOLISM. MEDICO-LEGAL CONSIDERATIONS. Serum-therapy has also been tried in alcoholism. The serum is obtained from a horse previously subjected to a course of alcohol. It is injected hypodermic- ally, 80 minims at a time, every three or four days, until a peculiar morbillic eruption appears. The patient is then given a rest of about a week's duration, after which a final injection completes the cure. A gradually increasing dis- gust or intolerance for liquor culminates in an absolute abhorrence of it. Sug- gestion plays no part in the cure, success having resiilted when the patient was unaware of the object of the treatment, while no restriction was placed on the ordinary habits. Of fifty-seven cases thus treated by Thiebault (La Tribune Med., p. 566, 1900), all except those who either had some organic disease or else discontinued the remedy before its physiological effects had been produced are said by him to have been cured. Immunization by ethylic alcoliol. Dogs were subjected to increasing doses of alcohol administered, well diluted, through the oesophageal tube until toler- ance was established for a larger than an ordinai-y lethal dose. The serum of these animals was employed in the ex- perimentation. The author concludes that (1) it is possible to confer a real immunity in dogs by administering pro- gressively increasing doses of this poison, ultimately reaching very large doses without producing functional disturb- ances or organic degenerations; (2) the serum of such a dog rendered immune to alcohol contains a special antitoxin capable of neutralizing the toxic action of a dose of alcohol one-fourth larger than the minimum fatal dose; (3) nor- mal blood-serum does not possess the power of augmenting the organic resist- ance to alcohol, much less to explain the curative action in acute poisoning. Dott. Luigi Maramaldi (Gaz. Inter, di Med. Pract, No. 1, p. 9, '99). Medico-legal Considerations. — Though there is some difference in the medico- legal treatment of alcoholism in different countries, there is a general agreement as to the form of civil law in the premises. Insurance. — The concealment by pro- posers and their referees of the intoxica- tion of the assuring may render a policy void. There are probably at least 600,- 000 reformed drunkards in the world. Some offices reject such lives, others accept them. The writer believes that they are mostly insurable, after a certain term of years of abstinence, with a weighting of the premium. It is some- times difficult to settle whether a person has died from accident or from acute or chronic alcohol poisoning. Insurance companies lose largely by the alcoholism of the insured. (Crothers, Mattison, Fox, Kerr.) Eeport of British Medical Association on the mortality from alcoholism, based on an examination of 4222 cases. It also contains returns as to the alcoholic habits of the inhabitants of Great Britain, and as to the relative alcoholic habits of dif- ferent occupations and classes. The fol- lowing conclusions reached: — "1. Habitual indulgence in alcoholic liquors beyond the most moderate amounts has a distinct tendency to shorten life, the average shortening be- ing roughly proportional to tlie degree of indulgence. "2. Men who have passed the age of 25, the strictly temperate, on an average, live at least ten years longer than those who become decidedly intemperate. We have not, in these returns, the means of coming to any conclusion as to the rela- tive duration of life of total abstainers and habitually temperate drinkers of alcoholic liquors. "3. In the production of cirrhosis and gout alcoholic excess plays the very marked part which it has long been recognized as doing: and that there is no other disease anything like so dis- tinctly traceable to the effects of alco- holic liquors. "4. Apart from cirrhosis and gout, the ALCOHOLISM. MEDICO-LEGAL CONSIDERATIOXS. 227 effect of alcoholic liquors is rather to predispose the body toward attacks of disease generally than to induce any special pathological lesion. "5. In the etiology of chronic renal dis- ease alcoholic excess, or the gout which it induces, probably plays a special part. "6. There is no ground for the belief that alcoholic excess leads in any special manner to the development of malignant disease, and some reason to think that it may delay its production. "7. In the young alcoholic liquors seem rather to check than to induce the for- mation of tubercle, while in the old there is some reason to believe that the effects are reversed. "8. The tendency to apoplexy is not in any special manner induced by alcohol. "9. The tendency to bronchitis, unless, perhaps, in the young, is not affected in an}' special manner by alcoholic excess. "10. The mortality from pneumonia, and probably that from typhoid fever also, is not especially affected by alco- holic habits. "11. Prostatic enlargement and the tendency to cystitis are not especially induced by alcoholic excess. "12. Total abstinence and habitual temperance augment considerablj' the chance of death from old age or natural decay, without special pathological le- sion." Isamberd Owen (British Med. Jour., June 23, '89). Evidence. — ETidence of an intoxicated witness is not receivable. Confession of an intoxicated person is valid, if no inducement has been beld out (England). Contracts executed while intoxicated are voidable. Wills made while intoxicated have been voided. Intoxication and incapac- ity, it was held, must be complete, till 1892 (Tyler v. Maxwell, Court of Session, Edinburgh, Nov. 1, 1892), when Lord Wellwood ruled that the defensive plea of intoxication having to be total, though true in a sense, did not mean total dis- ablement by drink. And (Morgan and another v. Kitchen, Probate and Divorce, High Court, London, 1891), though a first will was held good, one executed a year later was pronounced bad, on the ground that the testator had (though not intoxicated when he made the second disposition) become, after the earlier date, mentally incapacitated after fre- qiient (not intoxication but) "taking his drops,'" and after deliriiim tremens. At- testation is invalid if done by an intoxi- cated attestator, but presumption is in favor of validity. Criminal Jurisprudence. — Under Greek law crime committed in intoxication was liable to double punishment. Eoman law remitted capital punishment to intoxi- cated soldiers. Mohammedan law does not admit a plea of intoxication. New York Penal Code holds no act less crim- inal by having been committed while intoxicated, but intoxication considered to determine purpose, motive, and intent. Voluntary intoxication is not a defense in homicide without provocation. De- lirium tremens, as a disease secondary to voluntary intoxication, has been accepted in many trials in England and the United States as a valid plea for irresponsibility (Justice Stephen, Newcastle, 1881; Jus- tice Hawkins, Shrewsburj', 1895), though this ruling has not been followed by some other judges. In other trials the accused has been acquitted as having been unable, from intoxication, to have been capable of any intent, or as having been the subject of a well-defined mental disease, as having (through inherited or acquired mental weakness) been unable to drink intoxicants without insane se- quelaa like the average man. English law also takes drunkenness into account (Lord James) "if it produces a sudden outbreak of passion causing the commis- sion of crime under circumstances which, in a sober person, would reduce a charge 228 ALCOHOLISM. MEDICO-LEGAL CONSLDERATIONS. of murder to manslaughter." Altogether there has generally been a growing tend- ency of judges and juries to take alco- holism (with mental disturbance) into account, during the past thirty years. German and Swiss law prescribes a dif- ference in the punishment of offenses committed in culpable and inculpable intoxication. Minor Offences. — In theft and other minor offences, in England, committed in alcoholism, intoxication and delirium tremens have been accepted as an answer in some cases, while many such offenders have been liberated, to come up on their own recognizances with a limited time if called on, on the understanding that they would forthwith go to a Home for Inebriates. Inebriety is a disease of the brain, a form of insanity wholly dominating the volition, and beyond the power of the victim to control. Clark Bell (Medico- Legal Jour., Dec, '92). The affirmation of irresponsibility should involve prolonged commitment to an insane asylum. Motet and Vidal (Quarterly Jour, of Inebriety, Jan., '93). The knowledge of right and wrong may exist without the power of discrimi- nating between the two. T. L. Wright < Quarterly Jour, of Inebriety, Jan., '93). Criminal acts come from inability to understand the relation of surroundings, and to adjust the conduct to the vary- ing conditions of life. The criminal acts of the inebriate spring from this con- fusion of senses and judgment. This shows the irresponsibility of inebriates. T. D. Crothers (Quarterly Jour, of Ine- briety, Jan., '93). At meetings of creditors, by the au- thor's advice, legal advisers have re- frained from calling as witnesses persons whose brains had been so affected by intoxicants as to dim the perception of truth and render their evidence value- less. Norman Kerr ("Inebriety," third edition) . By existing British law, habitual drunkenness, as such, forms no defense. either in civil or criminal cases, except in so far as it may be admissible as evi- dence with a view to prove facts which can be construed as establishing legal incapacity or insanity. J. R. Mcllraith (Proceedings of the Soc. for the Study of Inebriety, Aug., '93). Statistics based on 1500 cases (1200 men and 300 women) of alcoholic in- sanity having required entrance into an asylum show that more than two-fifths of delirious alcoholic patients had com- mitted crimes or misdemeanors. Of these acts the most frequent are those directed against the life, and especially attempts of suicide. Serre (Paris Thesis, '96). In some of the more recent trials certain diseased inebriate mental states, short of what is generally regarded legally as insanity, have granted exemp- tion from responsibility. This recogni- tion of such abnormal mind conditions as a legal answer has, however, had to be entered as a plea of insanity and not inebriety. It is greatly to be desired, in the interests alike of equity and justice, that certain abnormal, inebriate, disor- dered mental states should be accepted as a valid plea altogether from the stand- point of insanity. The alternative would be the classification of such pathological states of mind as a variety of mental unsoundness, as in Belgian law. The former method of a distinct, independ- ent, legal recognition is, however, pref- erable, if for no other reason than that the inebriate should not be associated in treatment with the insane. On the first of January, 1900, all the German States will have a common civil law. The sixth paragraph of the new Code runs thus: The Interdicted can be: 1. He or she who, in consequence of mental insanity or mental weakness, can- not provide for his or her affairs. 2. He or she who brings himself or his family into the danger of need by prodi- gality. 3. He or she who, in consequence of inebriety, cannot provide for his affairs, ALCOHOLISM. ALKALOIDS. 229 or brings himself or his family into the danger of need or endangers the safety of others. The interdiction is to be revoked as soon as the reason for interdiction ceases to exist. William Bode (Proceed, of the Soc. for the Study of Inebriety, Nov., '97). NOEIIAN KeKE, London. ALEXIA. See Aphasia. ALKALOIDS. — The alkaloids are or- ganic basic substances, the active prin- ciples of most poisonous plants. They are termed "alkaloid" owing to their be- havior with acids, which simulates that of alkaline substances: ammonia, etc. Combining with acids they form salts which are convenient, owing to the smallness of their doses and their com- parative precision as to the effects to be produced. Dose ajid Properties. — A point of im- portance in prescribing alkaloids, when they are administered in tablet form, is to avoid too rapid drying of the tablets, the preparation otherwise becoming de- teriorated. Case showing that certain alkaloids are so delicate that thej' are injured if the tablets are dried too quickly. A prescription of his, calling for a tablet of hyoscyine, morphine, and atropine, was dried in a half-hour instead of a day and a half, as recommended to him by druggists. J. A. Cutter (Medical Bul- letin, June, '90). The following alkaloids are official in the United States Pharmacopceia, but many others are employed that will be considered imder their appropriate head- ings:— Apomorphine hydrochlorate, dose, ^/le to V4 grain. Atropine, dose, ^/ooo to '/oo grain. Atropine sulphate, dose, V200 to Vco grain. Caffeine, dose, 2 to 10 grains. Caffeine citrate, dose, 2 to 5 grains. Caffeine effervescent citrate, dose, 1 to 3 drachms. Chinoidine, dose, 3 to 30 grains. Cinchonidine sulphate, dose, 5 to 40 grains. Cinchonine, dose, 5 to 30 grains. Cinchonine sulphate, dose, 5 to 30 grains. Cocaine hydrochlorate, dose, Vj to 2 grains. Codeine, dose, ^/^ to 2 grains. Hydrastine hydrochlorate, dose, '/j grain. Hyoscine hydrobromate, dose, V150 to Vioo grain. Hyoscj'amine hydrobromate, dose, Vsi to V32 grain. Hyoscyamine sulphate, dose, Veo to V3„ grain. Morphine, dose, ^/lo to ^7, grain. Morphine acetate, dose, ^/^ to ^/j grain. Morphine hydrochlorate, dose, ^/g to ^/j grain. Morphine sulphate, dose, ^/^ to ^/z grain. Physostigmine salicylate, dose, Vei to> V20 grain. Physostigmine sulphate, dose, Vioo to Vso grain. Pilocarpine hydrochlorate, dose, V12 to V3 grain. Piperine, dose, ^/^ to 10 grains. Quinidine sulphate, dose, 5 to 30 grains. Quinine, dose, 1 grain to 1 drachm. Quinine bisulphate, dose, 1 to 15 grains. Quinine hydrobromate, dose, 1 to 20 grains. Quinine hydrochlorate, dose, 1 to 15 grains. Quinine sulphate, dose, 1 grain to 1 drachm. 230 ALKALOIDS. PHYSIOLOGICAL ACTION. Quinine valerianate; dose, 1 to 20 grains. Sparteine sulphate, dose, Vs to 1 grain. Strychnine, dose, ^/gg to '^/jo grain. Strychnine sulphate, dose, Vgo to ^/^o grain. Veratrine, dose, ^/^o to V30 grain. Physiological Action. — Alkaloids have various degrees of physiological activity when introduced into the animal body. Many are slow in their action, and a large dose is required to produce any observable efEeet, while others act more rapidly, and are so potent that even a minute dose may destroy life. Compare, for example, narcotine, one of the al- kaloids of opium, with nicotine, the alka- loid of tobacco. Twenty to 30 grains of the former have been taken by the hiTman subject without producing any marked symptoms, while the twentieth part of a grain of the latter may induce symptoms so severe as to threaten death. It is also well known that alkaloids may have a different kind of action on difEerent animals. Thus, ^/^ grain of atropine will produce serious symptoms of a complex character in a dog, while 3 or even 4 grains may be given to a rabbit without causing any more marked effect than dilatation of the pupil. In considering the physiological actions of those substances, the following general- ization may, in the present state of science, be made tentatively: 1. As a general rule, the more complex the or- ganic molecule, and the greater the sum of its atomic weight, the more intense will be the action of the substance. 2. Substances that split up quickly into simpler bodies produce rapid, but tran- sient, physiological effects, whereas sub- stances which resist decomposition in the blood or tissues may produce no appreciable results for a time, but, when they do begin to break up, the effects are sudden and violent, and usually last for a considerable time. 3. Alkaloids have frequently a double action on different parts of a great physiological system; and their action in a particular group of animals will depend on the relative de- gree of development of the parts of the system in that group. Thus most of the alkaloids of opium have such a double action: a convulsive action resembling that of strychnine, due to their influence on the spinal cord or on the motor cen- tres in the brain; and a narcotic, or soporific, action resembling that of anaes- thetics, due to their influence on sensory centres in the brain. Hence, in animals, where the spinal system predominates, as in frogs, these alkaloids act as convul- sants; while in the higher mammals their principal action is apparently on the encephalic centres, which have now become largely developed. (J. G. Mc- Kendrick.) Besides the individual physiological properties of alkaloids (these will be described under their respective head- ings), a few possess a property in com- mon: that of reducing temperature when applied to the surface. This question was studied by Guinard and Geley, of Lyons. Of eighteen substances tried by the authors in solution or as ointments applied on the inner part of the thighs, four were found to possess a constant regulating effect upon thermic reaction. These were cocaine, solanine, sparteine, and helleborine. In cases of true hyper- pyrexia a lowering of from 0.9° to 5.4° F. was produced, the average fall being from 1.8° to 2.7° F., the effect varying according to the patient, and especially according to the disease. They produced a more marked change at the beginning and end of acute affections than in the middle of the attack, and in mild rather ALKALOIDS. ALOES. 231 than in grave forms. In healthy sub- jects the effects were less apparent. It may be hoped to influence the tempera- ture in this manner without administer- ing the remedy internally. Therapeutics. — As these agents are extensively administered hypodermically, it was at one time feared they might serve as vehicles for micro-organisms which in themselves might become pa- thogenic. In a series of experiments having for their object to answer these questions and to determine a method for the sterilization of such medicines Mari- nucci found (1) that, while all prepara- tions studied contained microbes, all these microbes are not harmful. (2) That sterilization by heat does not alter solutions of strychnine, curare, bihydro- chlorate of quinine, or borate of eserine. It enfeebles, but does not alter, the char- acter of morphine and atropine. After sterilization, however, these drugs must be used in larger doses. The sulphate of eserine was found to be seriously altered, so that the solutions were, in a great measure, rendered inert. (3) That, to those solutions which are altered by heat, corrosive sublimate should be added in the proportion of 1 to 10,000. This seems to be eiiicacious, and in no way to injure the value of the alkaloid when given hypodermieally. Legal Medicine. — In medical juris- prudence alkaloids often come into play, the smallness of the dose of many of these salts serving the purpose of evil- doers or suicides. By well-known means their presence may be determined in the majority of cases; but still obscure in this connection is the influence of putre- factive processes — such as those which take place, after death, in the body — upon alkaloids which may have been administered during life. Ottolenghi recently conducted a number of experi- ments in order to ascertain the action of saprophytic micro-organisms on atropine and strychnine. lie first tried the effect of adding a known quantity of atropine to some sterilized bouillon (1 to 10,000), which was afterward tested by dropping a couple of drops of it into a rabbit's eye. The usual effects of atropine ensued: the pupil dilated fully under the influence of the unaffected atropine. He then substituted for the sterilized, bouillon separate cultures, in bouillon, of bacillus mesentericus, bacillus vulgatus, bacillus liquefaciens putridus, bacillus subtilis, and bacillus diffusus, which he had ob- tained from a human cadaver, the result being that the mydriatic eifect of the atropine was entirely destroyed in four or five days by the action of the micro- organisms. A similar series of experi- ments were made with strychnine, the test for the alkaloid being that of inject- ing a certain quantity of the solution into a frog, the quantity being propor- tionate to the weight of the frog. It was found that for the first few days the toxic action of the strychnine, subjected to the influence of the bacteria, was distinctly increased; subsequently it was diminished. Some separate experiments made with cultures of bacillus coli and strychnine showed that, with this bac- terium, the toxicity of the alkaloid ma- terially diminished from the first. After an exposure of three months the alkaloid had lost one-half of its potency. (J. Dixon Mann.) ALOES. — The preparations of aloes employed in the United States are ob- tained from two varieties: the Aloe Bar- hadensis, or Vera, and the Aloe Socotrina. The former is the inspissated juice of the Barbadoes, or Curacoa, aloes and oc- curs in orange-brown, opaque, resin-like masses that give off an odor of saffron, 232 ALOES. ALOIN. and are extremely bitter to the taste. The Socotrine aloes is the inspissated juice of the Aloe Perryi. It varies in color from a yellowish brown to an opaque, reddish brown and also occurs in resinous masses and emits the same safEron-like ordor and is as bitter to the taste. 1. Curagoa aloes are as eiBcient as and, being much cheaper, should be preferred to Socotrine aloes; the greater portion of the latter as sold to-day is made up of the former. 2. The resin of aloes is an ether or organic salt, and varies ac- cording to the kind of aloes and the varying constituents of the acid, the al- coholic constituent being aloresinotannol, and being the same in both Barbadoes and Cape aloes: the only specimens thus far examined. 3. Aloin contains emodin, to which its laxative properties are prob- ably due. 4. Many laxative drugs beside aloes — such as senna, cascara sagrada, rhubarb, buckthorn-bark — owe their lax- ative property to this substance, emodin, or some substance like it, derived from anthraquinone, and homologous or iso- meric with it. A. E. L. Dohme (Amer. Jour, of Pharm., No. 8, '98). Dose. — Both varieties of aloes may be given in doses of from 1 to 5 grains as a laxative, and 10 grains as a purgative. The purified aloes {aloes purificata) of the U. S. P. should invariably be pre- scribed, since the commercial aloes con- tains impurities. The other official prep- arations of aloes are the following: — • Aqueous extract of aloes. Dose, ^/n to 5 grains. Pill of aloes containing 2 grains of the purified aloes. Pill of aloes and asafoetida, containing 1 Va grains of each drug to the pill. Pill of aloes and iron, containing puri- fied aloes, sulphate of iron, and aromatic powder, 1 grain of each to the pill. Pill of aloes and mastic (Lady "Webster pill), containing 2 grains of purified aloes and V2 grain each of mastic and red rose. Pill of aloes and myrrh, containing 2 grains of purified aloes, 1 grain of myrrh, and ^/j grain of aromatic powder per pill. Tincture of aloes and myrrh, contain- ing 10 per cent, purified aloes. Dose, 1 to 8 drachms. Tincture of aloes, containing, also, 10 per cent, of purified aloes. Dose, 1 to 2 drachms. Aloes acts slowly; it can, therefore, be given at bed-time and its effects be counted on for the next morning. It tends to cause griping; a carminative — belladonna or hyoscyamus — should, therefore, be simultaneously adminis- tered. The pill of aloes and myrrh of the U. S. P. is intended to avoid this untoward effect of aloes. Applied to a wound in the form of powder aloes exercises its laxative action. It also acts upon a nursing infant when given to the mother. Aloin. Aloin is the active principle of aloes. The drug extracted from the Barbadoes aloes is identical with that taken from the species of Curagoa and Natal. Aloin occurs in yellowish-white, acicular crys- tals, is soluble in hot water and alcohol, much less so in acetic ether, and spar- ingly soluble in chloroform, ether, and benzol. Dose. — The dose of aloin is from ^/jo grain to 2 grains. Physiological Action. — The main ef- fect of aloes is upon the large intestine, but it is likewise a cholagogue, actively promoting the flow of bile. These effects, combined, cause increase of the peristal- tic action of the bowel. Aloes causes engorgement of the hsemorrhoidal blood- vessels and thus tends to render hffimor- rhoids painful at the time it is used, if any be present. The other pelvic organs ALOES. 233 — the uterus and appendages — are also congested. Hence, pregnant women should use aloes most carefully, if at all. The active principle, aloin, acts as a po\Yerful purgative when given by the mouth or subcutaneously. Natal aloin acts in cats and dogs only after very large quantities, but the effects are promptly produced when an alkali is added to the drug in order to decompose it. In man fed on meat exclusively aloin is very active, but not so in persons subjected to a mixed diet. Aloin in itself, there- fore, has little or no purgative properties, and, in order to produce its characteristic effects, it must undergo decomposition in the intestines and a new and more active substance be formed. The slowness of its action is thus explained. (Meyer.) Therapeutics.' — It is, of course, in con- stipation that aloes is especially used. It is indicated when there is intestinal atony, but when its administration is prolonged it tends to aggravate the condition it is intended to counteract. Aloin possesses two advantages over aloes, namely: smaller doses and com- paratively slight tendency to induce ir- ritation in normal doses. It is usiially combined with extract of belladonna and nux vomica or strychnine in small doses. An active laxative pill is thus obtained, which tends to counteract constipation without overtaxing the normal functions of the intestine. Chlorosis. — In chlorosis aloes is usu- ally combined with iron: the pill of aloes and iron of the U. S. P. It is best, however, not to use this pill, owing to the constipating effect of the preparation of iron utilized in it. The pyrophos- phate of iron or dialyzed iron is to be preferred. AiiEXOKEHCEA. — When this condition is due to ansemia a pill of aloes and pyro- phosphate of iron is of great value. In uncomplicated cases the pill of aloes and myrrh is to be preferred, the congestive influence of the active drug tending greatly to facilitate physiological men- struation. H^MOHEHOiDS. — Aloes is said by some to be valuable in this disorder, especially when due to general relaxation of the vascular system, the haemorrhoidal veins bearing the brunt of the latter. ALOPECIA.— From Gr.,a?.(j7t>7^,fos. Definition.- — Partial or general falling of the hair while the pathological proc- ess is in progress. Varieties. — Alopecia may be physio- logical or be due to an acute or chronic general morbid state. It may be eon- genital or occur as a consequence of old age. Senile alopecia, when occurring in younger individuals, without apparent lesion, is recognized as premature alo- pecia. Pathological alopecias, due to a gen- eral morbid condition, may be acute or chronic. The acute form presents itself espe- cially during the recovery from scarlet fever, scarlatinoid erythema, small-pox, typhoid fever, and child-birth. Certain forms of rapid alopecia are due to un- known causes of nervous origin. Neurotic alopecia is a rare affection. Two varieties are to be noted. The par- tial neurotic alopecia that occurs in the area of distribution of a nerve aft«r an injury of that structure is occasionally seen. General and complete alopecia from neurotic causes is even less com- mon. In almost every case a severe nervous shock precedes the falling of the hair. Illustrated case. William S. Got- theil (Med. Record, Aug. 21, '97). There are two distinct forms: 1. Occip- ital baldness, which is common in young people, begins over the occiput, extend- ing slowly, is rarely contagious, and is 234 ALOPECIA. SYMPTOMS. curable. 2. Seborrhoeic alopecia (of Bate- man) which appears in adult and middle life. The original area is succeeded by secondary patches at soine distance. It is due to a microbic infection of the seborrhtEic glands, and is but slightly contagious. M. Sabouraud (Jour, des Pratieiens, Sept. 29, 1900). The chronic variety may be due either to want of care of the hair; bad cos- metics; heavy hats; poor general hy- giene; lack of sleep; excesses; poor food; poor constitution; arthritism; struma; chronic poisoning (mercury); ansmia and chlorosis; diabetes; phthisis; cancer; syphilis; leprosy; in the two latter with or without visible lesions. Alopecia may also be due to a local disease of the scalj), and occurring in that case as one of the secondary phe- nomena of the chief affection. The principal affections in which alopecia may thus occur are erysipelas, eczema, seborrhoeic eczema, psoriasis, lichen, pityriasis rubra, pemphigus foliaceus, impetigo, acne (atrophic acne), sycosis, lupus erythematosus, and scleroderma. In another class of affections alopecia occurs as the principal symptom, namely: seborrhoea, pityriasis capillitii, etc.; fol- liculitis due to drugs; keratosis pilaris; alopecia areata; trieophytosis, and favus. (Brocq.) There are also indefinite varieties: such as the form due to a constant scratching of the head: the tricho- mania of Besnier. That occurring in weak and hydro- cephalic children from constant pressure of the head of the bolster. Alopecia of the vertex in women, due to combs and hair-pins, is also classed among the indefinite varieties. A variety of alopecia which occurs rapidly, but only temporarily, is fre- quently observed in connection with menstrual disturbances in women. Symptoms. — Congenital Alopecia. — This form of alopecia is uncommon; it may be local or general, temporary or permanent. Keratosis pilaris and moniliform aplasia may coincide with it. It may be due to lack of development of the hair-follicles, due to backwardness in the development of the hair; or to a pathological condition occurring during intra-uterine life, ichthyosis, xeroderma, or trophoneurosis. Congenital alopecia is frequently associated with slow and late dentition. Senile Alopecia. — Senile alopecia may begin at 45 or 50 years. The hairs first become gray, then white, dry up, and their root atrophies. They finally fall, while the scalp shows the signs of senile cutaneous atrophy. This form usually begins at the vertex, rarely at the temples. Senile and precocious alopecia ig usu- ally severe and progressive. It is con- fined to the antero-superior portion of the scalp, beginning on the top of the cranium and moving forward, leaving a little tuft of hair above the forehead. The posterior and lateral portions of the scalp preserve their hair almost, or quite, intact. Fournier (La Med. Mod., Dec. 11, '90). Alopecia Following Acute and Chronic General Diseases. — Though usually not marked, alopecia in these cases may be intense and general. Seborrhoea is fre- quently present concomitantly. The alopecia is not especially localized; it affects uniformly the scalp, thinning out the hair. The alopecia of convalescence pro- gresses rapidly, being produced in the course of a few weeks. It generally affects all parts of the scalp equally, and rarely results in complete baldness. Cachectic alopecia occurs in the course of pulmonary phthisis, cancer, cirrhosis, malaria, scorbutus, diabetes, etc. It affects the entire scalp impartially. The remaining hairs are dry, lustreless, and ALOPECIA. ETIOLOGY. 235 brittle, often breaking off before falling out. Fournier (La M6d. Mod., '90). Syphilitic Alopecia. — This variety of alopecia is usually found in irregular thinned-out patches or streaks over al- most all the scalp. The hairs are dry and their roots are atrophied; they fall out rapidly. Every degree may be ob- served, from simple thinning of the hair to general alopecia of the body. Some seborrhcea of the scalp is frequently present. The eyebrows are frequently thinned. In some cases syphilitic alopecia is due to secondary or tertiary lesion of the scalp. Syphilitic alopecia occurs in the third to the sixth month of the disease, or, rarely, in poorly treated cases, at the end of one or even two years. It comes early in the disease or not at all. There are two forms of syphilitic alopecia: the symptomatic, accompanied either by pustulo-crustaceous, "acnei- form" lesions, forming the little brown- ish or blackish crusts so common in the scalp from the third to the sixth month of syphilis, or, more rarely, by a very slight pityriasis-like eruption, sometimes only to be distinguished by a lens; the idiopathic, which is the most common, and which, in reality, is accompanied by a lesion. (Giovaninni and Darier.) There is a proliferation in the hair- bulb, and the fallen hair is often found to be atrophied at its root. There is no itching, redness, nor other symptom oc- curring in connection with syphilitic alo- pecia, other than the mere falling of the hair. It is asymmetrical, affecting any locality by chance. Sometimes the fall of hair is diffused, resulting in a general thinning; at other times it occurs in patches; occasionally both forms occur together. Fournier (L'Union Med., Dec. 4, '90). Premature Idiopathic Alopecia.— This form of alopecia may begin early. The falling hairs are replaced by smaller hairs, which in their turn fall out, until finally only a smooth, shining scalp is left. Frequently, besides the fringe of hair always left at the back of the head a small tuft of hair is left at the anterior portion of the scalp, just above the middle of the forehead. (Jackson.) Two cases of alopecia universalis ob- served in male adults presenting the sequelae of iridochoroiditis. In one case the ocular disease appeared subsequent to the loss of hair; in the other it pre- ceded it by about a year. Froelich (Re- vue Med. de la Suisse Rom., Dec., '90). Case of complete generalized alopecia combined with partial anaesthesia and analgesia in a man 20 years old. Bissett (Maritime Med. News, Feb., '94). Etiology. — Alopecia following acute and chronic general diseases is due to le- sions of the hair caused by the disease, aided by neglect of the hair during ill- ness. It occurs most frequently after typhoid fever, the eruptive fevers, espe- cially scarlatina, and, less frequently, erysipelas. The severer phlegmonous diseases and typhus are followed by alo- pecia, as also occasionally severe acci- dents, hffimorrhages, and pregnancy. Many women lose their hair after a perfectly normal labor. (Fournier.) All prolonged debilitating influences; excessive work, intellectual labor espe- cially; genital excesses, overindulgence at the table, watching, and late hours may give rise to alopecia. Excessive intellectual work, however, is less likely to produce alopecia than the other forms of excess. As regards premature idiopathic alo- pecia, women are less frequently affected than men. In many cases this form of alopecia seems to be hereditary. Study of 300 cases. Conclusion that baldness is more common in men than in 236 ALOPECIA. PATHOLOGY. women. It seems to be more common in unmarried men. Most patients are found to lead in-door lives, and belong to the intellectual class. Usually the loss of hair begins before the thirtieth year. In women it usually constitutes a gen- eral thinning; in men it affects the top of the head. Dandruff is usually a factor in the causation; heredity is also active. When complicating diseases are present, they are usually those that affect the general nutrition. G. T. Jackson (Med. Record, May 26, 1900). Excessive mental work, excesses, and a bad hygiene of the scalp seem to be factors in its development. (Brocq.) Pressure of the anterior temporal, pos- terior temporal, and occipital arteries by a stiff hat has been mentioned as a cause of this form of baldness. (F. A. King.) The escape of the little tuft of hair above the forehead has been attributed to the fact that the supra-orbital arteries escape from pressure by their passage between the two frontal eminences. (Jackson.) The blood-supply to the scalp is con- veyed by the frontal, temporal, and occipital arteries, situated just where a tight hat would press on them and bring about a gradual starvation of the hair- follicles. A woman, on the other hand, wears her hat resting lightly on top of the head, bringing no pressure whatever on the arteries, and thus escapes bald- ness. The maximum of hat-pressure in a man comes on the frontal arteries, and in consequence we find baldness gener- ally commences on the regions supplied by those vessels. M. C. Black (Indian Lancet, Apr. 16, '98). Alopecia is a symptom resulting from many different sources of irritation of peripheral nerves. The commonest and therefore the most important of these causes is dental irritation, as shown in three hundred consecutive cases. Jae- quet (Annales de Derm, et de Syph., Feb. and March, 1902). That frequent washing of the head encourages loss of hair is the opinion of the majority of dermatologists. Pathology. — In alopecia following acute and chronic general diseases the hairs are no longer formed; their roots become atrophied, and they finally fall out. The alopecia of convalescence is due to disturbance of nutrition of the tissues. Premature idiopathic alopecia is due to a fibrous transformation of the derma, which strangles in its meshes the ele- ments found in the scalp, especially the hair-follicles. As to the pathogenesis, alopecia may be considered a specific microbie affection. The specific microbacillus of fatty seborrhcea, when introduced into the pilosebaceous follicle, produces four constant results: (a) sebaceous hyperse- cretion; (b) sebaceous hypertrophy; (c) progressive papillary atrophy; (d) death of the hair. These phenomena result from seborrhoeic infection vipon smooth regions as well as upon the hairy ones. The vertex is the seat of election of this infection. Common baldness is only a chronic fatty seborrhcea of the vertex. Not only is follicular seborrhoeic infec- tion indispensable in the production of baldness, but this seborrhoeic infection remains intense, pure, and permanent until the baldness is fully and perma- nently established. (Sabouraud.) Seborrhcea oleosa is due to a micro- bacillus which had already been dis- covered, but not rightly interpreted by Unna. This microbacillus forms a mass in the upper third of the hair-follicle, between the surface of the skin and the point where the sebaceous gland opens into the follicle. This mass is the oily cylinder which may be extracted from the follicle by pressure on the skin. Secondary infections may be superadded to seborrhcea of the face, giving rise to acne or furunculosis. On the scalp it causes seborrhosic alopecia. Ordinary alopecia areata is closely re- lated to seborrhcea. Any patch of alo- ALOPECIA. PROGNOSIS. TREATMENT. 237 pecia areata is the seat of an intense localized seborrhoeic infection, both pre- vious to the loss of hair and while the latter persist. In chronic alopecia areata the infection of the hair- follicle is a permanent one; acute alopecia areata is a localized acute seborrhoea; alopecia decalvans is a gen- eral chronic seborrhoea. E. Sabouraud (Ann. de I'Inst. Past., Feb., '97). Alopecia probably due to autoinfec- tion, the poison — "trichotoxicon'' — being absorbed by the blood from the air-ves- icles of the lungs. The poison would then be elaborated dui'ing decomposition of organic matter normally present in respired air. Parker (Med. Record, July 13, 1901). These opinions of Sabouraud are not at present accepted by dermatologists generally. Prognosis. — In senile alopecia the prognosis is unfavorable, the chances of cure being practically nil. In alopecia following acute general diseases, on the contrary, the prognosis is generally good, and the hair soon re- covers its former state, though in some eases seborrhoea persists and requires careful treatment to prevent relapse of the alopecia. In serious chronic diseases, however, such as phthisis or cancer, the prognosis is unfavorable. The alopecia of convalescence is tem- porary and reparable; entire repair of the loss occurring in young people; after forty years of age the hair is rarely reproduced in its integrity. Fournier (La Med. Mod., Dec. 11, '90). [By no means is this always the case in youth in my experience. A. Van Haklingen, Assoc. Ed., Annual, '92.] Syphilitic alopecia, when not due to a local lesion, is only temporary and is soon recovered from by an appropriate specific and hygienic treatment. When due to a local lesion the alopecia may be incurable if the hair-follicle has been destroyed. Syphilis never causes permanent and complete baldness. Properly treated, it is accompanied by e.xtensive alopecia in only one case in twenty. Fournier (L'Union M6d., Dee. 4, '90). Premature idiopathic alopecia is usu- ally looked upon as beyond treatment. Treatment. — Premature Idiopathic, Senile, and Congenital Alopecia. — In these varieties general treatment is of importance. Arsenic and iron, continued for a long time and in small doses, alter- nately, should precede all the methods resorted to. (E. Besnier.) A tonic treatment should be given where the nervous system seems to be at fault. The following pill should be taken thrice daily: — ij Strychnine sulphate, Vao grain. Reduced iron. Quinine bisulphate, of each, 1 grain. For one capsule. When starvation of the nerves seems to be present, the compound syrup of the hypophosphites (Fellows's) is ordered in 1-drachm doses, thrice daily, with Vso grain sulphate of strychnia in each dose. Doses of '/s to Vb grain of muriate of pilocarpine in a powder, daily, at bed- time, in water, are also of use. Ohmann- Dumesnil (New Orleans Med. and Surg. Jour., Juty, 92). Mercuric bichloride or calomel inter- nally, alternately with tincture of ignatia amara, 30 drops daily in three doses, or sulphurous acid, internally, are also rec- ommended. (Shoemaker.) Excesses of any nature should be re- frained from, and any habit or occupa- tion tending to depress the general vital process be counteracted. Alopecia should be treated not onlj' by local application, but by remedies which influence the entire system. Strong sul- phur-baths of thirty to forty minutes, followed by massage for ten or twenty minutes and hot spray for three to five minutes, are useful. A half-pint of sulphur-water should be taken morning 238 ALOPECIA. TREATMENT. and evening, while iodine tincture and hot sulphur-water should be sprayed over the scalp. Ferras (Annales de Derm, et de Syph., vol. iv, No. 10, '94). Eesorcin is of great serTice in the treatment of alopecia. (Bulkley.) Broeq recommends the following methods of using this remedy: — Ix Eesorcin, 1 V2 grains. Hydrochlorate of quinine, 3 grains. Pure vaselin, 1 ounce. This is to be appHed to that part of the scalp which is devoid of hair or from which the hair is rapidly falling. If the falling of the hair persists it is well to incorporate with it 5 to 15 minims of the tincture of cantharides, or to use the following: — ]^ Eesorcin, 3 grains. Hydrochlorate of quinine, 5 grains. Precipitated sulphur, 30 grains. Pure vaselin, 1 oimce. Should these preparations produce much irritation of the scalp, an oint- ment composed of 20 grains of borax to 100 of vaselin should be applied. After the irritation is relieved, weaker prepa- rations of resorcin and quinine can be employed, of which the following is an example: — ]^ Salicylic acid, 5 grains. Eesorcin, 3 grains. Hydrochlorate of quinine, 5 grains. Precipitated sulphur, 30 grains. Pure vaselin, 1 ounce. Should the falling of the hair be as- sociated with seborrhoeic eczema, a mer- curial ointment, sitch as that of yellow oxide of mercury, varying in strength from 1 in 25 to 1 in 10, according to the severity of the trouble, shoitld be used. This is only to be rubbed upon isolated patches at a time. After it has been employed and an alterative effect upon the skin produced, resorcin may again be resorted to: — I^ Eesorcin, 4 grains. Salicylic acid, 7 grains. Pure vaselin, 1 ounce. When the scalp is excessively greasy the ointment previously employed and the natural oil of the skin should be removed by washing the scalp with a weak solution of ammonium acetate or by using Castile soap and warm water. Under no circumstances should the oily preparations be used continuously with- out occasional cleansing of the scalp. (Brocq.) For seborrhoea of scalp with beginning alopecia foUow'ing procedure should be carried oiit daily or once or twice weekly according to the severity of the case. 1. Wash scalp with tar-soap for ten min- utes. 2. After rinsing, wash scalp with V:-per-cent. solution of corrosive subli- mate in hot water. 3. Dry scalp, and rub into it a 5-per-cent. naphthol pomade, removing any excess of the same. Bayet (Med. News, May 21, '98). The following lotion sometimes proves beneficial at the beginning of the afEec- tion: — I^ Acetic acid, ^/^ ounce. Pulverized borax, 1 drachm. Glycerin, 3 drachms. Alcohol at 60°, y, ounce. Eose-water, V„ pint. Another procedure that proves oc- casionally effective is to rub the scalp lightly twice or thrice weekly, for three or five minutes, with a soft brush or sponge dipped in I^ Sodium bicarbonate, 1 drachm. Distilled water, 5 ounces. A small amount of oil is to be put upon the hair the first or second day following each of the above applications. (Pincus.) The head may be washed with the ALOPECIA. TREATMENT. 239 yelks of eggs, or white almond-oil soap or with tar-naphthol or ichthyol soap, according to the degree of tolerance of the scalp. Any alcoholic preparation to which has been added a small amount of tinct- ure of cantharides, tincture of nux vomica, acetic acid, salicylic acid, or citric acid, from ^/o to 5 per cent., is recommended by Besnier and Doyon. It is applied with a piece of absorbent cotton after carefully drying the scalp. The tinctura saponis viridis, often used to shampoo the scalp, is sometimes too strong. An ordinary soda-soap, made by dissolving about 1 ounce in 1 pint of water, and adding some soda or potassa, may be used instead. When the scalp is cleansed, 1 part of benzol (from coal- tar), mixed with 10 parts of alcohol, is to be applied. If this fails a 1- to 3-per-cent. alco- holic solution of naphthol, or the follow- ing formula may be used: — B Eesorcin, 5 parts. Alcohol, 150 parts. Castor-oil, 2 parts. Other formulae of value are: — R Quinine sulphate, 1 part. Alcohol, 60 parts. Cologne-water, 1 part. Either of these may be applied locall}', after carefully washing the scalp. After cutting the hair short and wash- ing with soap the following lotion is applied. Perchloride of mercury, '/^ part; acetic acid, 1 part; alcohol, 100 parts; ether and alcoholic solution of lavender, of each, 50 parts. After dry- ing the head is rubbed with lactic acid, about 30 per cent. Balzer (Jour, des Pratic, Aug. 24, 1901). Alopecia Followinig Acute and Chronic General Diseases. — Any general treat- ment appropriate to the primary disease naturally tends to improve the local process. A tonic treatment further assists the curative efforts. After careful brushing out of the hair the head should be washed with a decoc- tion of saponaria, or three yelks of eggs beaten up with one part of lime-water, or with warm water and good soap, and then carefully dried. This should be followed by the following lotion rubbed in daily: — I^ Alcohol at 80°, 2 V2 ounces. Camphorated alcohol, Eum, Tincture of cantharides. Glycerin, of each, 75 minims. Santal-wood essence, Wintergreen-essence, of each, 5 minims. Pilocarpine hydrochlorate, 7 ^/j grains. This is to be rubbed in lightly once daily. Any exciting application containing rum or camphorated alcohol with spirit of rosemary — and to which may be added quinine, in the proportion of 4 to 30 of either tincture of nux vomica, tincture of capsicum, or tincture of cantharides — may be employed. If the hair be very dry some almond- oil or castor-oil may be applied from time to time. Prevention through massage-exercise is nine points in the law of treatment of baldness. This should be begun in early life, at the time when the youth is developing into the more sober man, when his occipito-frontalis muscle has become more and more subordinated to his will. Massage should be performed the same way as in other regions, first freeing the vessels farthest from the seat of trouble, and gradually approach- ing the centre. It should be done at night as well as in the morning, par- ticularly at night, as gravity has little, or comparatively little, chance through the day. If the scalps of men received enough exercise as the scalps of women, there should be on the vaults of their craniums a luxuriant tonsure. George Elliott (Dominion Med. Monthly, March, 1902). 240 ALOPECIA. ALOPECIA AREATA. It is well to keep the hair cut short until it begins to grow again. Universal alopecia arrested in a case by thyroid extract, 5-grain tabloids three times a day. H. R. Beevor (Brit. Med. Jour., July 13, '95). [I cannot too strongly warn the reader against placing too great confidence in the marvelous results obtained recently in numerous dermatoses from the thy- roid treatment. The subject requires considerable control study before these results can be accepted. L. Bkocq, Assoc. Ed., Annual, '96.] The influence of thyroid extract shown in the case of a woman, aged 66 years, suffering from myxoedema, in whom the 2. Wash the scalp with soap and warm water every morning. 3. Apply the following ointment: — ]^ Salicylic acid, 75 grains. Precipitated sulphur, 2'/, drachms. Lanolin, Vaselin, of each, 1 ounce and 6 drachms. Every evening rub in with a soft brush the following lotion: — ]^ Spirit of rosemary, 3 ^/j ounces. Cantharides tincture, 2 ^/j drachms, or salicylic acid, 15 grains. Influence of thyroid extract upon hair-growth and geneial appeal ance m mvxoedema. The same patient, a woman aged 66, as she appeared before treatment and as she appeared after taking two thyroid tabloids daily for fifteen months. (T. F. Raven.) growth of hair during fifteen months was striking (see wood-cuts). Does not the remarkable influence of thyroid ex- tract upon hair-growth suggest that the thyroid gland in its function is largely occupied with nutrition of the skin? Thomas F. Raven (Brit. Med. Jour., July 31, '97). Syphilitic Alopecia. — The best treat- ment consists in early and thorough anti- syphilitic measures. Local treatment is not really necessary, but, if applied, should consist in lotions containing mer- curic perchloride, 1 to 500 or 1 to 1000, or ointments containing either yellow oxide or sulphate of mercury. (Broeq.) The following treatment is recom- mended by E. Besnier: — 1. Cut the hair short. Syphilitic alopecia is easily curable by the internal use of mercury. Local appli- cations are useless. Fournier (L'Union Med., Dec. 4, '90). [Here I must differ from Fournier; local applications are valuable adjuvants. A. Van Haklingen, Assoc. Ed., Annual, '92.] George H. Rohe, Baltimore. ALOPECIA AREATA. Definition. — A disease of the hair characterized by the rapid development of more or less circular or oval bald patches on the scalp and sometimes in other parts of the body. Symptoms. — Alopecia areata usually presents itself in the form of rounded ALOPECIA AEEATA. DIAGNOSIS. 241 or oval patches, situated on the scalp or other hairy regions of the body. The skin of these patches is white and smooth, and in some cases discolored and some- what depressed. At times the afEeetion extends over the entire cutaneous surface. The hairs become dry and colorless, their roots are atrophied, and they rap- idly fall out. Three main forms of alopecia areata have been recognized: alopecia areata archromatica (Bazin), in which the bald patches are discolored and excavated, as described above; false alopecia areata, in which the patches of baldness are more or less covered with thin, brittle hairs, which can easily be pulled out along with their roots: a form of ringworm. The third variety is alopecia areata de- calvans, in which the entire scalp, or the skin of other parts of the body, becomes bald in a few days, the hair falling with great rapidity. In alopecia areata the hairs are dry, lustreless, thin, and brittle. Their roots are either atrophied and thread-like or swollen into irregular nodules. The medulla has disappeared, and air-bubbles may be seen in their interior. They fre- quently break close to the scalp, their free extremity being brush-like in ap- pearance. In the so-called false alopecia areata the few hairs left retain their hue and consistency. Deductions based on a study of 257 cases: — Four classes of cases are included under the generic name alopecia areata: 1. Universal alopecia; it is very rare. 2. Baldness occurring in one or more patches at the site of an injury or in the course of a recognizable nerve. This is comparatively infrequent. 3. A form first described by Neumann as "alopecia circumscripta seu orbicu- laris." The patches are small, from lentil- to pea- size, much depressed below the surface, with often a marked de- crease of the sensibility. The prognosis is unfavorable. The first three classes form less than 10 per cent, of all the cases classed as alopecia areata. They are undoubtedly of trophoneurotic origin. 4. The largest, numerically, is due to a vegetable parasite. Crocker (Lancet, Feb. 28, Mar. 7, '91). Two cases in which the nails were af- fected in patients suffering from alopecia areata of the scalp. One was a delicate nervous young woman. The nails became affected some months after alopecia had manifested itself on her scalp. The sec- ond case was that of a young man who had a typical patch of alopecia areata on the scalp. The nails in both cases presented a discolored granite-like ap- pearance due to minute punctiform depressions, which gave them a dirty, unpolished look. C. Audry (Jour, des Malad. Cutan. et Syph., Mar., 1900). Diagnosis. — Alopecia areata should be distinguished from syphilitic alopecia; biTt usually in this latter affection the patches are merely thinned out and arranged irregularly over the head in streaks; other symptoms of syphilis are frequently present. The alopecia in patches resembles, in a certain way, alopecia areata, but it has certain characters which are perfectly pathognomonic. Alopecia areata makes a clean sweep, all the hairs on the patch falling out. In syphilis, however, some hairs always remain on the affected patches, which also are never so regular, rounded, or extensive as those of alopecia areata. Another diagnostic point is that the area-like alopecia of syphilis is al- ways accompanied by the disseminate form, whereas in alopecia areata the hair is usually normal up to the very edge of the bald spot. Finally, alopecia areata decolorizes the skin, which be- comes dead-white, while the bald areas of syphilis retain their natural color. Fournier (L'Union M6d., Dec. 4, '90). Premature Idiopathic Alopecia. — From ordinary alopecia, alopecia areata should 16 343 ALOPECIA AREATA. ETIOLOGY. be recognized by its white, smooth ap- pearance and rounded, limited form. Heredity plays a small part in pro- ducing early alopecia. Only four incon- testable instances were found in over three hundred cases treated. Over 90 per cent, are due to the one disease: eczema seborrhoeicum. Two varieties of diploeocci isolated, both of which inoc- ulated upon healthy subjects produced lesions characteristic of the disease. One was a non-chromogenic organism which produced pityriasic manifestations; the other, chromogenic, produced lesions cov- ered with yellowish, greasy scales. Both together cause greasy, crumbling scales. Elliot (Amer. Derm. Assoc, Sept. 17 to 19, '95). Trichophytosis. — Microscopical exami- nation in this disease shows at once that no distinct parasite is found in alopecia areata, while in trichophytosis the hair is filled with spores. The hairs, when seized with forceps, become crushed, while they do not yield in alopecia areata. Case of a boy presenting a perfectly bald spot about two inches in diameter on the top of the head, with the typical features and hair of alopecia areata. It had begun, however, as a scaly patch. Miscroscopical examination showing the presence of spores, it was pronounced to be trichophyton by Bulkley. White- house (Jour. Cut. and Genito-Urin. Dis., Oct., '93). Etiology. • — In the great majority of cases alopecia areata occurs as a result of contagion. This has been fully dem- onstrated clinically and experimentally. The implements of the hair-dresser are almost the only agents of transmission of contagion, doubtless because they alone can cause the abrasions necessary for sowing the organism with which con- tamination occurs. This explains why alopecia areata seems, at iirst sight, to be a sporadic affection in cities, and why in solleges and barracks it may take the shape of an epidemic. Every disease propagated from one individual to an- other supposes an active cause capable of multiplication and reproduction: that is to say, a living pathogenic parasite. There is a close relationship between tinea tonsurans and alopecia areata. Cases with all the signs of alopecia areata may arise, not in children only, but in adults, from contact with ordi- nary tinea tonsurans. It is not the bald form of tinea tonsurans, because the short hairs, as in alopecia areata, are club-shaped, whereas, in tinea tonsurans,, they are bent and twisted. Crocker (Lancet, Feb. 28, Mar. 7, '91). Ringworm and alopecia areata are in many ways connected. Of 137 oases of the latter seen by the author, 32 per cent, gave a history of ringworm, either per- sonal or occurring in some member of the household. P. Abrahams (Med. Press and Circular, Nov. 22, '93). Eight boys, all between the ages of 12 and 13, belonging to the same gym- nasium — six in one class and two in an- other — were within a very short time attacked with a most typical alopecia areata: the hair fell out, while the skin remained perfectly smooth without the formation of any crusts or scabs. All the six pupils were sitting near one an- other on the same bench. This epidemic proves the contagiousness of alopecia areata beyond any question. Kober (Berliner klin. Woch., No. 15, '98). Conviction expressed that alopeciar areata is contagious under certain cir- cumstances. Lassar (Phila. Med. Jour., Apr. 16, '98). Two epidemics of alopecia areata in an Institution for homeless girls between the ages of 3 and 14 years. The first case occurred in a girl, 11 years old, who,, when first seen, presented three round, bald patches upon the crown of the head, clinically typical of alopecia areata. Several weeks later another girl was- found to have a bald patch upon the crown, which increased rapidly in size for a time. Four months after the dis- covery of the first case a large number of the girls in the asylum were suddenly found to be affected. After cutting the hair of all the children it was found that ALOPECIA AREATA. PATHOLOGY. 243 63 of the 69 girls had bald areas upon the scalp. One girl, who had just entered the institution, acquired a patch in three days. After two months the disease ap- peared to come to a stand-still; at the end of six months almost all the bald patches were covered with hair. No trace of micro-organism was found. No adult inmate of the asylum was attacked. Bowen (Jour. Cutan. and Genito-Urin. Dis., Sept., '99). Alopecia areata maj' also be caused by shock, worn', overwork, traumatisms, or epileptic paroxysms. Case following prostration through shock, continued until there was com- plete denudations of hairy portions of the body. Morton (Brooklyn Med. Jour., Sept., '95). Two instances of alopecia areata oc- curring in epileptics after paroxysms, in which the neurotic rather than the para- sitic origin seems the more probable. The hairs finally recovered their thick- ness, volume, and color. In both cases alike the evolution of the lesions was not interfered with by any medical in- tervention, either general or local. F6r6 (La Nouv. Iconog. de la Salpetriere, '95). The neurotic theory of the origin of alopecia areata is still held by many der- matologists. Prolonged exposure to the vacuum- tube of an x-ray apparatus may give rise to localized falling of hair. Case of dermatitis and alopecia after the use of the Roentgen rays in a young man, aged 17, in whom experiments were carried out during four weeks, once or twice each day. The dermatitis re- sembled that caused by bums. An improvement soon occurred. Marcuse (Deutsche med. Woch., July 23, '96). Case of alopecia areata as a result of exposure to the Roentgen rays during forty minutes, using a Thompson double- focus or standard vacuum-tube. The dis- tance between the tube and skull was a little over eighteen inches. A large area of hair missing upon that side of the head exposed to the vacuum-tube; no premonitory symptoms of itching or in- flammation; the hair had suddenly fallen out three weeks after the exposure. The integument appeared bald and somewhat elevated, and slightly oedem- atous; no redness; sensibility not im- paired; no scaling. Under stimulating and hygienic treatment downy hairs are beginning to show themselves. F. S. Kolle (Buffalo Med. and Surg. Jour., Dec, '96). True alopecia areata seems to occur in syphilitic subjects more frequently than in other persons. Areas of absolute alopecia which occur in the scalp or beaid in syphilis may be small and few, well circumscribed, last- ing a short time, but recurring often. This is very different from that general thinning of the hair seen early in the disease, which never returns. A Foumier (Jour, des Pratieiens, Jan. 19, 1901). The percentage of alopecia areata in various countries is approximately as follows: France, 3 per cent.; England, 2; Scotland, 1.5; Vienna, 0.75; North Germany, 0.75 to 1; America, 0.5. (Crocker.) In LillCj of 5000 cases of skin disease, 149 cases were alopecia areata; in Lyons, of 2765 eases, 17; in Vienna, of 5000, 40; in Berlin, of 1050, 9; and in another series of 3008 cases, 30 were alopecia areata. In America, as shown by the statistics of the American Dermatological Association, alopecia areata was found in 794 cases out of 123,746 cases. E. Besnier ("Sur la Pelade," Travail lu a. I'Acad. de Med., July 31, '88). Pathology. — The initial stage alone of ordinary benign alopecia areata is microbic. As soon as the patch be- comes smooth, microbes can no longer be found, neither in the skin nor in the follicle. In the beginning of the disease almost all the follicles are infected with innumerable microbian colonies belong- ing to a single bacillary species always the same. In benign cases the follicular infec- 244 ALOPECIA AEEATA. PATHOLOGY. tion is transitory; in chronic or total alopecias the same microbe is found constantly, with the same localizations. The invariable presence of this microbe wherever there is a beginning lesion gives it a value other than that of an ordinary secondary infection. However, this mi- crnbacillus, notwithstanding certain dif- ferences of form, cannot be distinguished with absolute certainty from the microbe which Hodara has described as the bacil- lus of acne. If the bacillus of Hodara and that of alopecia areata arc the same, we must ascertain why in every case of alopecia this secondary infection is con- stant, and what role it plays. If they are different, they must be differentiated ex- perimentally. Finally, they may be the same bacilli which, under different vital conditions, may or may not secrete a toxin capable of producing alopecia. (Broeq.) According to Sabouraud, alopecia and alopecia areata are practically identical. The patch of alopecia areata is only an attack of acute circinated seborrhoea: in other words, the bald only become bald by a diffused process of chronic alopecia areata. Alopecia areata is a contagious disease, the extension of which is marked by the appearance of a special form of hair: the club-shaped hair. This hair appears with the disease, disappears at the same time that it ceases to extend, and reappears with the renewal of ac- tivity. Where the malady is active it is never wanting. The microscopical examination of the ckib-shaped hair shows that its special form is due to a progressive atrophy of the papilla which forms it. A histolog- ical examination will separate alopecia areata clearly from the cryptogamic tineas. In 300 cases examined by him, Sabou- raud found that all the morbid conditions indicate a pre-existent intoxication, the cause of which had disappeared. In the earlier stages, however, he found that one out of every two or three follicles at the margin showed an ampuUiform dilatation at its upper part, which he calls the utricle. {See colored plate.) This, when first perceptible, is roofed by a dome having a minute window in its centre. In this cavity alone the micro- organism is to be found. So long as the aperture remains closed the microbacil- lus exists in a pure state, but when it opens it disappears, and saprophytic fungi enter. The bacillus is one of the smallest known, and is in innumerable numbers. It is, according to him, con- stant in the early stage of the benign form. In total alopecia of this type there seems to be two stages: in one the bald skin is oily and shining, and in the second it is dry and rather scab', and in which there is a tendency to restoration of hair. If, in the seborrhoeic stage, the contents of the follicles are expressed by massage, the same organisms found in the utricle are recognizable in immense numbers, less numerous in the drier stage, and not to be found when healthy lanugo hairs begin to clothe the surface. Sabouraud hesitates to pronounce the microbe he has discovered as the causal element, for one both identical in ap- pearance and in reaction to stains has been found habitually in the comedo and in seborrhoea of the oily type. The microbes which are found in the hair are diverse; they are habitually ob- served even upon scalps that are not affected with alopecia, but only in hairs which show evidence of papillary altera- tion anterior to the microbic invasion. Indeed, none of these microbes, almost all of which have been described by vari- ous authors as specific, can, according to Sabouraud, have any causal importance in the disease. FkiJ Fir/. 2. Alopecia Areata, I Sabouraud ) Frqure I Section of normal ham implanted portion Figure 2 Section of hair showing the peladic utricle ALOPECIA AREATA. PROGNOSIS. TREATMENT. 245 Three facts which militate in favor of the infectious nature of alopecia areata: (1) the erythematous tint of recent patches; (2) tumefaction of occipital lymph-nodules, which often accompanies the beginning of the disease; (3) the fact of experimental contagion. Blaschko (Third Cong, of Derm, and Syph., '97). Prognosis. — The prognosis of alopecia areata is exceedingly variable; in many cases treatment must be continued for years. The more ancient the patch is, the more difficult it is to promote a return of the hair. Occipital or temporal alopecia areata recovers more slowly than that of other regions of the scalp. ^Ylien the hairs begin to grow anew they are frequently white at first, and only later, by the continuance of the treatment, do they resume their normal hue. Treatment. — The general treatment usually recommended has for its object to strengthen the patient. Increased nutrition and general tonics play an im- portant part in the methods indicated. Country-air, physical exercise, rest from mental overwork, warm sulphur shower- baths (Besnier and Doyon), cold shower- baths on the vertebral column, iodide of iron, codliver-oil, strychnine, sodium arsenate, the preparations of cinchona, and the valerianates have each their sponsors. Food containing much butter, fat and milk, phosphates and fish, strychnine, and phosphoric acid are of service. Patients should be well fed. The fats and phosphates should be increased. Milk taken alone and between meals, crushed wheat, cream, and fish the most valuable aliments for this purpose. The best results have been obtained under the free and continued administration of strychnine with phosphoric acid. Arsenic should be given alternately with the for- mer. Bulkley (N. Y. Med. PLCcord, Mar. 2, '89). The progress of the disease must be arrested by shaving the hair around each patch for about half an inch or, even better, by shaving the entire head. Epil- ation may be done, instead of shaving, around the bald patches. (Brocq.) To effectively treat alopecia areata, it is necessary to act upon the derma, and the horny layer must first be destroyed by the application of a vesicating fluid, preferably the ethereal solution of can- tharides. On the following day a 15- per-cent. solution of nitrate of silver is applied upon the denuded chorium, with or without previous cocaine anaes- thesia. This may he renewed in ten or fifteen days if necessary. The results of this treatment greatly surpass in effectiveness those following other pro- cedures. (Sabouraud.) The success of epilating a ring of hairs in the early stage as a means of protective demarkation against extension is explained, if Sabouraud's discovery should be verified. In facial alopecia areata rubbing of the affected region daily with tincture of cantharides, either pure or mixed with spirit of rosemary, according to the irri- tability of the skin, is another valuable measure. I> Tincture of cantharides, 1 ounce. Spirit of rosemary, 3 drachms to 1 ounce. The hair should be cut short. Van Swieten's solution rubbed in, and each diseased patch painted with a thick coat- ing of 1 part of iodine to 30 of collodion. At the end of a week this film loosens and begins to separate. Frictions with the sublimate solution are then used, morning and evening, until all the re- maining pellicles of collodion have been removed, when a new coating of iodized collodion is applied. After three applica- 246 ALOPECIA AREATA. TREATMENT. tions the downy, new hairs begin to appear. Tison (Jour, de M6d., Apr. 24, '92). Antiseptic preparations have been recommended by a large number of authorities. In parasitic alopecia areata (tricho- phytosis) the hair is cut close, and a solution of corrosive sublimate (1 to 750) or, preferably, — on account of its non-toxic qualities, — a 3-per-cent. solu- tion of creolin is applied. This is used all over the scalp as a p)reventive. Sapo viridis is rubbed into the affected areas, and allowed to remain on for five min- utes. After washing this off, a small quantity of the following ointment is rubbed in: — I^ Hydrarg. bichlor., 1 grain. Lanolin, 1 ounce. To be thoroughly mixed. The latter should be applied twice daily, as a usual thing, but sometimes a less frequent application suffices. In neurotic alopecia areata the same internal treatment is used as in presenile alopecia. Externally, in some cases, cantharidal collodion is applied to the affected area, and, after vesication has been established, a dressing of some bland ointment. As the collodion varies in its effect, it is to be applied at greater or less intervals. Bulkley's method, with some modifi- cations, is as follows: The pure carbolic acid is applied twice a week, and over the entire area of the patch, however large, by freely swabbing. Those por- tions which are affected by the acid turn milky white in a few moments, and, if they do not do this, are touched again after awhile. If the parts that turn white show any very marked inflamma- tory action, they are passed over at the next sitting. Generally, however, there is, at most, but a slight amount of des- quamation. (Ohmann-Dumesnil.) Case of alopecia areata of the beard treated by Martin's method of locally applied mercuric-bichloride solution, made to penetrate the follicles by elec- tricity. Beall (Va. Med. Monthly, Feb., '91). Aflfected area covered with solution of corrosive sublimate in glycerin, 1 to 100. The scalp is then tattooed with a sharp instrument: an aseptic needle, for in- stance. The punctures need only be slight, — sufficient to permit penetration of the antiseptic. Successful results in most inveterate cases. M. A. Martin (Gaz. des Hop., .July 9, '95). Successful treatment of alopecia areata by means of lactic acid, applied gradu- ally in increasing strengths, beginning with a 50-per-cent. solution. Ristema (Brit. Jour, of Derm., July, '98). A 50-per-cent. aqueous solution of lac- tic acid has a remarkable effect in alo- pecia areata. As the remedy is quite irritating, it should not be used more than once a day. If the pain should be very severe the acid is to be suspended temporarily and anodyne applications used. In the large majority of cases cure was complete in three months. Stojanovitch (Ann. de Dermat. et de Syph., Sept., '99). The local use of strong solutions of carbolic acid has been advocated by Duhring and Bulkley. Three cases cured in five weeks by painting the patches with iodized collo- dion, 1 to 30. It is supposed that the impervious coating formed by the collo- dion kills the micro-organism. Chatelain (Revue GSn. de Clin, et de Th6r., Dec. 31, '90). The scalp is thoroughly washed for ten minutes with tar-soap, first using hot water, then cold. The parts having been thoroughly dried, a solution of bichloride of mercury. 1 to 900 (equal parts of water, glycerin, and cologne), is rubbed in. The scalp is then anointed with a pomade containing ALOPECIA AREATA. TREATMENT. 247 B Salicylic acid, 2 parts. Tincture of benzoin, 10 parts. Neat's-foot oil, 100 parts. — M. This treatment should be carried out daily and continued for six weeks or more. Lassar and Groetzer (Brit. Jour, of Derm., Feb., '91). A 95-per-oent. solution of carbolic acid is applied to the affected region and its periphery. It is somewhat painful at first. The skin whitens, shrivels, and desquamates. Two weeks later a second application may be made. Bulkley (Jour. Cut. and Genito-Urin. Dis., Feb., '92). Tricresol is a very efficient remedy for alopecia areata. In nine cases an aver- age cure was obtained in two and one- half months. The area should be thor- oughly cleansed with benzin, and then tricresol applied pure to the scalp. It is well rubbed into the denuded patches and into roots of hairs one-half inch be- yond each patch, by the friction of a small swab of cotton tightly wrapped on a wooden tooth-pick. The burning and pain soon pass away. These applications are made according to the local effect produced, but on the average every five to seven days till desired result be ob- tained. Granville MacGowan (Pacific Med. Jour., Aug., '99). The methods advocated by Besnier and Doyon are much employed on the continent of Europe. Every morning the head is washed with warm water and tar-, ichthyol-, or naphthol- soap, followed by rubbing in a weak alcoholic liniment: — ^ Spirit of lavender, 4 ounces. Salol or salicylic acid, 7 V2 grains. — M. Every evening the following ointment should be applied: — ^ Peruvian balsam Salicylic acid, Eesorcin, of each, 15 grains. Precipitated sulphur, 3^/2 drachms. Lanolin, Vaselin, of each, 14 drachms. Every morning the patches and their immediate neighborhood should be lightly rubbed with a piece of absorbent cotton dipped in the following solution: 3^ Chloral-hydrate, 4 scruples. Ether, 7 drachms. Crystallized acetic acid, 15 to 60 grains. — M. Or in a mixture of acetic acid and chloroform varying in strength accord- ing to the susceptibility of the patient. If the face be affected, it should be washed every morning with warm water to which a small quantity of one of the antiparasitic solutions mentioned above has been added. When the trunk and limbs are affected the treatment should consist in sulphur, salt, with electric baths, and in rubbing the body with a horse-hair brush dipped in a stimulating liquid: — IJ Eesorcin, 2 drachms. Orange-flower water, 12 ounces. — M. Morrow recommends the following procedures: — Constitutional means of improving the general nutrition are at once begun. The hair is clipped around the affected patches, the loose hairs are removed, and the following preparations are then applied: — ^ Chrysarobin, SO to 40 grains. With or without Salicylic acid, 10 to 15 grains. Ointment of gutta-percha, 1 ounce. A moderate dermatitis should be ex- cited and maintained. When the alopecia is severe and ex- tensive the scalp is shaved and acetic acid is applied in greater or less propor- tion, mixed with equal parts of ehloro- 248 ALOPECIA AREATA. TREATMENT. form or ether, producing a superficial vesiculation followed by desquamation. Between the applications the bald spots are anointed with a stimulating oil:— ^ Eucalyptus, Turpentine, of each, '/o ounce. Crude petroleum. Alcohol, of each, 1 ounce. — M. This is followed by a thorough mass- age of .the scalp by the patient. Once a week or oftener the scalp is thoroughly shampooed with tincture of green soap. At a later stage sulphur and resorcin ointments and salt-water douches may be used. For the face weaker solutions of acetic acid should be employed, or applications of a mixture of equal parts of tincture of capsicum or tincture of cantharides and glycerin be made. For the body mercurial and tar- soaps and sulphur- baths are to be used. Chrysarobin is the best remedy, pre- pared as follows: A stick composed of R Chrysarobin, 30 parts; Resin, 5 parts; Yellow ointment, 3.5 parts; Olive-oil, 30 parts; is rubbed every evening over the affected part, which is washed clean with olive- oil in the morning. In some days the skin becomes irritable and red, when zinc ointment is substituted for a time. Leistikow (Ther. Monat., Jan., '94). Pilocarpine, locally and internally, has been recommended, but this agent is ex- pensive : a fact militating against its use in ointments. The following ointment is highly rec- ommended: — R Pilocarpine, Quinine, of each, 4 parts. Precipitated sulphur, 10 parts. Balsam of Peru, 20 parts. Beef-marrow, 100 parts. — M. Sabouraud (Concours Med., June 19, '97). Pilocarpine acts not only in increasing perspiration, but produces also marked and persistent vasodilatation, which in- creases the nutrition of the hair-bulb. He employs the nitrate in solution of Va per cent., mixed with 1 to 1000 bichlo- ride of mercury, by intradermie injec- tion. Before injecting the plaque is rubbed with 90-per-cent. alcohol. The syringe is filled three-quarters full by drawing in first Vj cubic centimetre of the mercurial solution, then ^/., cubic centimetre of the pilocarpine solution, and finally '/^ cubic centimetre of the mercurial solution. This makes the proper proportion. The injections are made just beneath the skin in as hori- zontal a manner as possible, 1 centimetre apart, and repeated every four or five days. A patch the size of a dollar requires about 12 injections. After four or five sittings the hair begins to grow. In sixty cases treated over a period of three years there was no instance of failure. Scheffer (La Med. Mod., May 19, 1900). Eesorcin has given satisfactory results in the early stages. Electricity is sometimes of value. The negative pole of a battery of from four to ten cells should be applied to the bald spot stifficiently long to produce a red- ness of the skin. It should be used only in connection with other remedies. (Hayes.) An ointment of chrysarobin, from 3 to 10 per cent, in strength, can be recom- mended as an effective application. In prescribing this the physician must not forget to mention the fact that it will stain the bed-linen, and caution the patient not to get any ointment in his eyes lest a severe conjunctivitis result. George Henry Fox (Amer. .Jour, of Obst., Jan., '96). Treatment by the arc light, the bald spots and their shaved borders being subjected to daily treatment of an hour and a quarter's duration. The number of sittings varied in accordance with the size and number of the spots. The re- sults were good, the hair beginning to grow in a short time. In one case two or three bald spots were treated with ALOPECIA AREATA. 249 the light; these became completely cov- ered with hair, while the untreated spots remained hairless until treated later in the same manner. Jersild (Annales de Dermat. et de Syph., Jan., '99). Case of a successful cvire in four months by x-rays. The patient, a male aged 18, suffered from several patches for five months. The patches varied in size from a pea to an- egg. As a control experiment one patch was not treated by the rays, but an area cover- ing the other patches, together with the healthy scalp, was exposed for a total period of two hours, made up of frequent short exposures. A week after exposure the hair fell off all the ex- posed parts. In three weeks the alo- pecia areas became red; the normal areas were bald, but not red. In an- other month there was a growth of new hair on the alopecia spots, while the rest of the scalp remained bald. The condition was thus the reverse of that at the beginning of treatment. After four months' treatment the whole area exposed was covered with hair; the un- treated patch, however, was still bald. This was afterward cured. The author does not consider the effect due to bac- tericidal action, as he finds that expo- sure of bacteria to the strongest rays at a focal fiiteen centimetres for an hour only hinders their growth for a time. The same exposure to the scalp would cause severe ulceration. Holzkneeht (Wiener klin. Rund., Oct. 9, 1901). Geokge H. Rohe, Baltimore. ALUM. — The alum generally used is an aliTminium and potassium sulphate. This salt is likewise official in the U. S. P. It occurs in the form of translucent, whitish, octahedral crystals having a sweetish and strongly-astringent taste. Alum is soluble in water, insoluble in alcohol, and soluble in heated glycerin. Physiological Action. — Alum is an active astringent. It coagulates albu- min, and when, therefore, it is applied to moist mxicous membranes, it causes them to turn white. . This is intensified by its power over the blood-vessels of the part, which it firmly contracts, probably by stimulating the local vasomotor nerves. It also contracts the tissues, depleting them of their blood. Upon the blood itself it acts as an effective coagulant, and is, therefore, an excellent styptic. When administered to animals, such as dogs, eats, and rabbits, by subcutaneous injection, a soluble salt of alum caitses no symptoms at all for three or four days. Then the animal experimented upon suffers from loss of appetite and obstinate constipation, emaciation, lan- guor, and disinclination to move. Xext there is vomiting and loss of sensibility, as a deep prick with a needle is scarcely felt. When forced to move, the leg is raised, but trembles and twitches vio- lently, and is with difficulty placed on the ground. Sometimes there is general tremor or convulsive twitching and sometimes extreme weakness or partial paralysis of the posterior extremities. There is complete loss of sensibility to pain, while the animal retains its senses. Then the power of moving the tongue and of swallowing is completely lost; even the saliva cannot be swallowed. The symptoms are precisely those of human acute bulbar paralysis. (Mayer and Siem.) Case in which, through gargling with a concentrated alum solution, a portion of the fluid was accidentally swallowed. This was followed by severe abdominal pains, vomiting of mucus and blood (thirty-nine times), and voiding of blood-stained urine. Recovery only after the lapse of thirteen days. Kra- molin (Therap. ilonats., 32.5, 1902). Alum is credited with antiseptic power by some observers: a quality probably due to its property of coagulating albuminoid bodies. When ingested in sufficient quantities alum irritates the gastric mu- cous membrane and causes vomiting. 250 ALUMINIUM. Therapeutics. — Alum may be said to be useful as an astringent in all catar- rhal conditions of the mucous mem- branes — those of the upper air-passages, the vagina, and the urethra particularly — in aqueous solutions of from 5 to 20 grains to the ounce. Strong solutions are rarely indicated, their secondary ef- fects being those of undue stimulation, namely: irritation. Laeyngologt. — In diseases of the nose and throat the best effects are obtained from a 15-grain-to-the-ounce solution frequently applied. In acute coryza the following snuff is effective if used early: — ■ R Alum, 3 grains. Morphine sulphate, 3 grains. Cocaine hydrochlorate, 1 grain. Camphor, Bismuth, of each, 2 drachms. To be thoroughly mixed. Sig.: To be used as snuff every two hours, a small quantity being used in each nostril. The giycerite of alum (a 10- to 20- per-cent. solution of alum in glycerin — heat is necessary to produce such a solution of the salt) is very effective in subacute inflammatory disorders of the pharynx and larynx, especially if there is a tendency to oedematous infiltration. As a styptic alum is a valuable agent. It is foiind almost everywhere and is easily dissolved with the fluid always at hand, water. Typhoid Fever. — As an astringent for the intestinal hsemorrhage sometimes occurring in the course of this disease it has been recommended by many cli- nicians, Whitla especially. It is also thought to act as an antiseptic. Epistaxis. — In epistaxis alum some- times acts rapidly, a saturated solution being used. Pledgets of cotton dipped in this solution are packed in the bleed- ing cavity and left in until all danger of recurrence has passed: generally about twelve hours. The solution may be sprayed in in slight hemorrhages or powdered alum may be taken as snuff. Meteoeehagia. — In uterine hasmor- rhages of all kinds alum is an excellent styptic. E. Beverly Cole has recom- mended the insertion into the uterine cavity of an egg-shaped piece of alum. The styptic effect is not only produced, but the tissues and the organ itself are stimulated and caused to firmly contract. Ceoup. — As an emetic, alixm is very frequently employed in children. A tea- spoonful may be dissolved in six table- spoonfuls of syrup and water, equal parts, and a teaspoonful administered every fifteen minutes until the desired effect is produced. This sometimes serves to quickly arrest an impending attack of croup, the astringent effect of the salt upon the mucosa of the throat counter- acting the local hypersemia. ALUMINIUM. — Numerous prepa- rations have been obtained from this metal: a boroformate, a borotartrate, a hydrate, a borotannate, and a sulphate. The double salts of aluminium are rec- ommended as powerful antiseptics, supe- rior to carbolic acid and sublimate in being strongly disinfecting, though but slightly poisonous. The best of them is the acetotartrate, prepared by mixing a 5 to 100 solution of basic acetate of aluminium with a 2 to 100 solution of tartaric acid and evaporating to dryness. It crystallizes in shining needles, which smell slightly of acetic acid and are freely soluble in water, but insoluble in alcohol. (Athenstadt.) Boroformate. — The boroformate is a valuable preparation which combines astringent and antiseptic properties, al- ALUMINIUM. ALUMNOL. 251 though the latter cannot be considered as being marlced. It occurs in the form of pearly scales crystallized from a solu- tion prepared by saturating, with freshly precipitated and well-washed aluminium, a solution of 2 parts of formic acid and 1 part of boric in 6 or 7 parts of water. It is an hygroscopic salt, dissolving com- pletely, though slowly, in water. The solution has an astringent, sweet taste, and does not coagulate solutions of albu- min. Boroformate of aluminium has been used in the Prince of Oldenberg's Chil- dren's Hospital at St. Petersburg, where it has supplanted all other preparations of aluminium. Martenson (Pharmaceu- tische Centralhalle fUr Deutschland, No. 41, '94). Borotartrate. ■ — The borotartrate, or "''boral," is a combination of aluminium, boric acid, and tartaric acid, and forms w^hite crystals, non-irritant, antiseptic, freely soluble in water, and valuable in ■diseases of the nose and naso-pharynx; it is useful in erysipelas, and, in solution with tartaric acid, has given good results in gonorrhoea. Borotannate. — The borotannate, or "cutol," is a combination of aluminium, boric acid, and tannic acid, and is a b)rownish, insoluble powder. It com- bines with tartaric acid to form soluble cutol. Cutol may be prescribed for oint- ment and is of great service in the treat- ment of weeping eczema and pruriginous affections in the following formula: — • T^ Cutol, 1 drachm. Olive-oil, 2 ^/„ drachms. Lanolin, q. s. to make 10 drachms. When the secretion has disappeared the following powder may be used:— - 19 Cutol, Oxide of zinc. Talc, of each, 2 V„ drachms. Soluble cutol gives good results in the treatment of burns of the second de- gree, and a solution of soluble cutol and glycerin, 1 to 10, applied locally, causes rapid retrogression of follicular angina. The same solution may be employed in catarrhal metritis. Cutol may also be employed in the treatment of hemor- rhoids. For liEemorrhoids an ointment contain- ing 10 per cent, of cutol may be applied, while fissures of the hands may be treated by applications of R Cutol, Vi drachm. Oil of sweet almonds, Lanolin, of each, 3 Vt drachms. Orange-flower water, 2 Vi flui- drachms. Koppel (Ther. Monat., Nov., '9.5). Hydrate. — The hydrate of aluminium is prepared, by decomposing a solution of an aluminium salt by an alkali or alkaline carbonate. It is a light, white powder, soluble in acids and fixed alka- lies. This is also a light astringent, em- ployed in skin afEections. Sulphate. — The sulphate of alumin- ium, prepared by dissolving aluminium hydrate in sulphiiric acid, is soluble in water, but insoluble in alcohol. Injected in the blood it induces powerful contrac- tion in the capillaries, especially those of the lung. It is used in strong solution as an antiseptic in diseases of the nose, throat, uterus, and vagina, and as a lotion for foul ulcers, vaginal discharges, etc. ALUMNOL is an aluminium salt of the naphthol-sulphur acids. It is a fine, white, non-hygroscopic powder, easily soluble in cold water, slightly so in alco- hol, and insoluble in ether. Its unirri- tating quality in weak solutions makes it available for the treatment of cavity wounds and chronic catarrhal processes. In acute cases, however, it is usually irri- tating. Mode of Employment. — It is not in- 252 alujMnol. therapeutics. compatible with sublimate, resorcin, etc., and may be combined with them in order to strengthen their reciprocal action, if it is desired to combine the action of several antiseptics. Therapeutics. — A general review of the literature does not warrant a final opinion as to its merits, but the pub- lished reports, a few of which are given below, do not indicate that it is worthy of much confidence in the treatment of the genito-urinary tract: its main stronghold. It has been tried in gynfe- cological, dermatological, surgical, and laryngological eases as an astringent, and when used in weak solutions seems to have given more encouraging results. Gynecology. — In V2 to 1-per-cent. solution it has been found useful in en- dometritis of gonorrhoeal origin, and in colpitis, if non-gonorrhceal in character. (Heinze and Liebreich.) Used in sixteen gynsecological cases: catarrh of the neck and endometritis with or without inflammation of the annexa. Cervical catarrh and simple perimetritis yielded to its repeated use. In endometritis complicated with lesions of the annexa the pains were augmented on account of the irritation produced. Gonorrhoeal vaginitis was readily cured. The following preparations were used: A solution of 3 per cent, for lavages; a powder and bougies of 20 per cent.; and a 10-per-cent. solution as an astringent in the treatment of endometritis and of erosions. A. Kontz (Wiener med. Presse, No. 18, '93). Tried in 12 cases of acute gonorrhcea, 20 chronic cases (in 8 of which gonocoeci were present), 4 cases of gonorrhceal epi- didymitis, 2 of post-gonorrhoeal adenitis, and 2 of soft chancre. In the first cases mentioned, treatment was begun by intra-urethral injections of a 1- to 2-per- cent, solution of alumnol three times daily. Later the same solution was used once daily, or else a feebler solution (from 0.25 to 1.00 per cent.) several times during the twenty-four hours. In 8 cases treatment was begun from one to three days after the appearance of the secretion, and from three to ten days in the other 4 cases. The drug was not found superior to any other drug gener- ally used. Found inferior to nitrate of silver. Cases of soft chanei-e were the ones cured. Casper (Berliner klin. Woch., No. 13, '94). That alumnol does not possess the antigonorrhoeal merits granted it by Chotzen shoAvn by a trial in twelve cases. E. Samter (Berliner klin. Woch., No. 13, '94). Marfan uses bougies of alumnol, 3 per cent., in the treatment of vulvo-vaginitis. M. Storer (Boston Med. and Surg. Jour., Jan. 20, '98). Surgical Dressing. — In the dressing of wounds and in ulcerations of specific or non-specifie character it produces, ac- cording to Eraud, no irritation or pain. This author considers it as efficacious as other powders for the desiccation of wounds. It appeared to be useful in cer- tain varieties of pruritus, especially that of the anus and scrotum. Laryngology. — Alumnol has been found valuable in simple chronic and hypertrophic rhinitis, ozjena, catarrhal and follicular tonsillitis, and acute and chronic catarrhal and follicular phar- yngitis, in a 1-per-cent. sohition as a douche; in a watery, glycerin solution (1 to 5) for application to the affected parts; or in a powder mixed with starch (10 to 20 per cent.) for insufflation. In acute laryngeal afi^eetions the roughness of voice generally disappeared after a single inhalation of a 1-per-cent. solution. In chronic eases good results were obtained by the use of insufflations of a mi.xture of alumnol and starch (2 to 10 per cent.). A 1-per-cent. solution was of signal service as an hfemcstatic in cases of haemoptysis. A. Stepanicz (An- nual, '95). Two years' experience showing that alumnol is of the greatest value as an astringent, especially in conditions ac- companied by oedema, whatever be the AMENOERHCEA. 253 direct cause of the latter. Metzerott (Amer. Therapist, Sept., '97). Deematology. — It has been found useful in powder, 13 to 25 per cent.; collodion, 5- to lO-per-cent. strength; and ointment, 1, 5, and 12 V2 P^r cent., in dermatitis, in acute eczemas of all sorts, in chronic eczemas; in syphilis and the parasitic skin' affections it was not of much benefit. In acne and rosacea as good results have been obtained by it as by most methods of treatment. (Gottheil.) Found efficacious in acute superficial inflammatory affections of the skin, as ^^•ell as in chronic processes in which the inflammation was deeper; in para- sitic diseases, such as erysipelas, favus, lupus, soft chancre, and erosions; and in acute and chronic inflammations of the mucous membrane. Chotzen (Ber- liner klin. Woch., No. 48, '92). AMENOERHCEA. — (Lat.). From d, priv.; [.lYjv, a mouth; and pdi', to flow. Definition. — Absence of the menstrual flow in women of a suitable age who are not pregnant. Suppression of menses, the menstruation having ceased through some local or remote disorder, is also termed amenorrhcea. Varieties. — Amenorrhcea may be com- plete, when the menstruations have com- pletely ceased; comparative, when it ap- pears occasionally; primary, when the menstruation has not presented itself at the age of puberty nor subsequently; secondary, transitory or accidental, or when, having already appeared, the men- struation ceases. Symptoms. — No other symptom than absence of the menstruation may be pres- ent, or the monthly flow may be absent and the general attendant phenomena usually preceding menstruation occur. Frequently the patient complains of headache, heat-flashes, fever, nausea and vomiting, and heaviness in the abdomen. Concomitant nervous disorders may form the basis of acute manifestations, hys- terical especially. "When the retention is due to uterine stricture, there is consid- erable pain radiating from the uterus to the surrounding parts, including the lumbar region. Pure suppression of the menstruation usually gives rise to no symptoms, espe- cially when the impending general dis- order is the cause of the amenorrhcea. Wlien, however, it is due to a local dis- turbance, the symptoms of a congestive disorder of the genital tract appear, soon followed by an inflammatory process, which may be general or local. Peri- tonitis sometimes appears as a result of such a process. Eemote symptoms may also present themselves, doubtless of reflex origin. Amenorrhcea virginalis a new disease, in no way connected with cessation of menstruation from chlorosis, anaemia, etc., which occurs in young women. The first symptom is the amenorrliosa, which may or may not be associated with vicarious menstruation. After awhile cardiac symptoms supervene, especially palpitation, dyspncea, and cyanosis; the right heart fails, and cedema and death result. Two such fatal cases. The sup- pression of the menses led to general plethora, cardiac hypertrophy, valvular incompetence, and finally pulmonary con- gestion. Edelheit (Wiener med. Presse, Aug. 16, 23, '97). Series of cases which present certain well-defined clinical features. These prominent characteristics are: (1) di- minished or arrested menstruation; (2) local symmetrical imperfect oxygenation of the blood of the extremities, especially the arms and hands — a condition known as "Raynaud's phenomena"; and (3) pulmonary tuberculosis. The presence of any single one of these symptoms in patients is observed every day, but at- tention has not hitherto been called to the remarkable association of all of these clinical features in the same individual. 254 AMENORRHCEA. ETIOLOGY. This trilogy of symptoms did not always I appear contemporaneously in any of the patients who are affected. In all of them when first seen the local asphyxia and the irregularity of menstruation were marked; in two of the patients pulmonary tuberculosis was also co- existent with the other clinical features mentioned, while in two other patients it developed at a subsequent period. J. W. Byers (Lancet, Aug. 26, '99). Etiology. — In cases of primary men- struation imperfect or instifiicient de- velopment is the most usual cause. In cold countries, where growth of the sys- tem at large is more gradual, the men- struation appears later than in the warmer countries, where development is rapid, but where, also, women enter the stages of decrepitude earlier. Anatom- ical imperfections and anomalies, the absence of any of the genital organs, or a rudimentary or infantile utertts may thus account for the total absence of menstruation. Imperforate hymen is a frequent, though easily recognized, cause. On general principles, the causes of amenorrhcea may be divided into four classes: — Nervous Disoedees. — Grief, anxietj^, fright, and anger are as many possible primary causes, especially if the patients are poorly fed. Women who either greatly fear or greatly desire tO' become pregnant; newly-married women, and women who are confined in prisons or insane-asylums furnish a large propor- tion of the cases. Eemoval from country to city or vice versa, especially when coupled with nostalgia, is a prolific cause. On general principles, change in the mode of living or of climate, especially with an intervening sea-voyage, appears to frequently act as the etiological factor. Probably not less than 33 per cent, of women emigrants under 30 years of age suffer from suppressed menstruation after a sea-voyage. Many have abdom- inal distension, and not infrequently girls have been innocently charged with being pregnant. Obstinate constipation a common symptom. The true etiology is largely psychical and neurotic. H. C. Bloom (Univ. Med. Mag., Dec, '96). In those cases where the follicular stroma of the ovary has been the seat of an inflammatory process during the in- fectious fevers, the patient may have an amenon-hosa which may remain and be- come permanent. Alexander Simpson (Practitioner, Aug., '98). Case of a young married woman who found that, as soon as she left London and went to the country, her menstrua- tion Avould return at the regular times, but would not if she remained in town. By leaving town for two days each month it was possible for her to regulate the monthly function. W. J. H. Hep- worth (Lancet, Nov. 10, 1900). Geneeal Affections. — Amenorrhcea frequently occurs after a serious illness, such as typhoid fever, eruptive fevers, mumps, pneumonia, or during the course of any chronic disease, diabetes, cancer, malaria, at the onset of severe syphilis, or when any intoxication of the system occurs, as in morphinism, alcoholism, and hydrargyrism. Eighteen cases in which the morphine habit caused amenorrhcea. It is usually complete and accompanied by loss of sexual desirCj but the functions are re- established if the habit be broken. Lutaud (Eevue G6n. de Clin, et de ThSr., May 2, '89). It may be consequent upon an acute or chronic surgical affection, a blow, or injury. Luxurious living and want of exercise, obesity, and excessive intellect- ual labor at the period of puberty, when not counterbalanced by fresh air and active exercise, may retard the develop- ment of the generative organs and thus induce the disorder. Case of a young woman who presented many of the usual signs of pregnancy, including cessation of the menses, promi- AMENOERHCEA. ETIOLOGY. 255 nence of the abdomen, etc. On examina- tion deposits of adipose tissue were found in the abdominal walls, while the uterus was small — smaller, indeed, than usual. Subsequent events proved it to be a ease in which obesity had led to disturbance, if not, indeed, early appearance, of the menstrual function. Robert A. Keid (Mass. Med. Jour., Aug., '98). Blood Disorders and Wasting Dis- eases. — Ansmia and idiopathic chlo- rosis, pernicious ansemia, leuksemia, and Hodgkin's disease are the most promi- nent factors. The following causes of waste — and directly, therefore, of amen- orrhcea — are also to be remembered: Haemorrhage, albuminous discharges; hsemorrhage from piles, scurvy, purpura, and injury, as in hsemophilia; hsemor- rhage from the stomach, as in gastric ulcer; from the lungs, or from the nose, and from a rare disease produced by a parasite in the duodenum: the anchy- lostoma duodenale. Long-continued suppuration, albuminuria, chronic diar- rhoea, malignant ulcers, tubercular dis- ease, all impoverish the blood, and so may cause ansemia. All diseases that cause wasting of the body finally cause the menstruation to cease. Chief among these are phthisis, diabetes, caries of bone, protracted or febrile illness; ano- rexia nervosa, the patient wasting be- cause she will not eat; and gastric ulcer. Lesion of Genito-Ueinart Organs. — Any lesion of the genital apparatus may cause amenorrhcea, especially me- tritis, endometritis, and parametritis (both acute and chronic), and flexion or malposition of the uterus. Adhesion due to a previous pelvic peritonitis is an occasional cause of hyperinvohition of the uterus following pregnancy. At- rophy of the ovaries, senile atrophy fol- lowing pregnancy, and cystic ovarian de- generation are among the less common etiological factors. A most complete examination of the pelvic organs should be made, if necessary, under ether in such cases. If menstruation does not appear at the age of puberty, a careful scrutiny on the part of the physician is obligatory and imperative. Case of a young woman, 24 years of age, in whom the amenorrhcea Avas of organic origin. A dermoid and a suppurating multilocular cyst were found and removed: Report of the pa- thologist harmonizes with the theory of the case both from physiological and pathological stand-points: 1. That the dermoid had usurped the place and de- stroyed the function of the right ovary. 2. In one of the cyst-walls of the mul- tilocular ovarian cyst was found a. shrunken ovary the size of a large lima- bean, and within this ovarian stroma, was found a corpus luteum spurium. To the presence of this ovarian stroma was due the womanly development, with, ovulation and the futile effort of men- struation and its consequent suffering.. 3. The case demonstrates the possibility of ovulation without menstruation. 4. It leaves doubt whether the absence of the oviducts was primary or secondary to the grave disease of the ovaries, with, the possibility that they were congeci- tally absent. 5. It presents the rare and. exceptional condition of a perfectly de- veloped woman who had an ovary and. a uterus, who ovulated, was sterile, and. never menstruated, and yet was ruinsd. in health by Nature's effort to establish an impossible normal function. W. B. Chase (Amer. Jour, of Obstet. and Dis. Women and Children, Oct., '98). Exposure to cold during menstruation,, by inducing congestion of the pelvic or- gans, is one of the most active exciting causes, especially when supplemented by a local chronic disorder. The most important condition with, which this disorder might be confounded is pregnancy. The reader is referred to the article under that head. Case of a healthy girl, aged 15, who- had been subject for a year to gradual swelling of the abdomen. The period. 256 AMENORRHCEA. PATHOLOGY. DIAGNOSIS. PROGNOSIS. TREATMENT. had ceased for two months only. The breasts became hard and tense. The hymen was intact. Peritonitis of tuber- culous origin suspected. On opening the abdomen an enormous cyst, which con- tained twenty pints of fluid, discovered. Its pedicle was twisted and had risen in the parovarium. On the day after the operation the catamenia reappeared and tlie abdomen soon resumed its normal form. Cortiquera (Anales de Obst., Gine., y Ped., Jan., '96). Pathology. — A pathological identity can hardly be attributed to amenorrhcea, owing to its complex causes, the diverse physiological conditions peculiar to the cases, and the diathetic conditions that may be present. The fact that the true nature of menstruation itself is not known adds another objection; and it may safely be said that the pathology of amenorrhoea is that of the diseases causing it, until the local disorders brought about by each will have been determined. The following extracts are given to indicate the present trend of thought regarding the cause of menstru- ation. Blood-pressure varies greatest at the commencement of menstruation, least im- mediately after; remains about the same height seventeen days, when it again begins to rise. Derangement of this cycle leads to various pathological phenomena. A. W. Johnstone (Amer. Jour, of Obstet., May, '95). Evidence recently furnished by Heape justifying opinion that ovulation is not tlie cause of menstruation. We should not speak of menstruation as occuiTiiig once a month, but as occupying a whole month. Lawson Tait (Provincial Med. Jour., Jan. 1, '95) . All evidence favors the theory that ovulation and menstruation are inde- pendent; ovulation in a modified form continues during pregnancy. Byron Robinson (Amer. Gyn. and Obst. Jour., Aug., '95). Study of over three thousand cases showing that earlier menstruation in tropical countries is not due to climate, but to too early sexual excitement. Jou- bert (Indian Med. Gazette, Apr., '95). Diagnosis. — Primary amenorrhcea — that is, total absence of menstruation — is usually due, as already stated, to the absence of one or more of the organs of generation. It must be distinguished from retention of the menses, due to atresia of the cervical canal, of the va- gina, or of the vulva. In the latter case no menstruation has existed, but the general premonitory symptoms of men- struation have occurred, though followed by no menstrual flow. Cases in which one or more of the organs are absent are not very infrequent, while cases of imperforate hymen are comparatively common. Prognosis. — Amenorrhcea due to ab- sence of any of the organs is, of course, incurable. The same may be said of cases in which the approach of meno- pause or other conditions pointing to senility of the uterus. Although amen- orrhcea, when due to a serious chronic disease, is usually cured with difliculty, hope may always be entertained when the causative disorder is not in itself a fatal one. Eeturn of the menstruation in any chronic disorder, when the blood presents its normal appearance, is an encouraging sign. [The prognosis of secondary atrophy with amenorrhcea depends greatly on the condition of the ovaries, and is practi- cally hopeless if they are atrophied. MuNDE, Assoc. Ed., Annual, '90.] Treatment. — Women who object to becoming pregnant represent a large pro- portion of the cases of amenorrhcea met with. Special care, therefore, should be taken not to administer emmenagogues, under such circumstances, or to intro- ditce instruments into the uterus. In bona fide cases, however, amenorrhoea be- ing more of a symptom than a disease per se, the original cause should be dili- AMENORRHCEA. TREATMENT. 257 gently sought after and removed, if pos- sible. When diagnosis between functional amenorrhoea and pregnancy is difficult, aenecio may be safely prescribed before deciding, as it will probably cure the one, and certainly will do no harm to the other. Senecio will not cause abortion nor in any way influence the course of pregnancy. W. E. Fothergill (Edinburgh Med. Jour., May, '98). Emmenagogues may be classified into two classes: medicinal and physiological. Severe physical shock or fright some- times causes the menstruation to return suddenly. When the arrest of menstruation is due to exposure to cold, warm baths and vaginal injections, sinapisms to the thighs and calves of the legs, saline laxatives and manganese-binoxide pills (3 grains each), one or two after each meal, are frequently successful. This drug acts by increasing the vascularity of the pelvic organs. The permanganate of potassium, or the lactate, in 1-grain doses three or four times daily, after meals, act in the same manner. The following treatment is highly rec- ommended in suppression of the menses: B Liquor ferri et quinia citratis, 1 ounce. Liquor potassii arsenitis, 3 drachms. Sti-ychnine, Atropine, of each, V= grain. Elixir of orange-peel, enough to make 8 ounces. M. Sig. : Teaspoonful in water, before meals, three times daily. The ingredi- ents, or dose, to be increased according to the tolerance of the patient. This is continued until there is mani- fested the peculiar menstrual discomfort, when it is discontinued and the following given: — IJ Potassii permanganatis, 10 grains. Divide into pills No. x, compressed or in capsule. Sig. : One pill followed by one-half- 1—17 glassful of water, before meals, three times daily. Also: — 1} Manganesium binoxide, 10 grains. Divide into 10 compressed pills or into as many capsules. Sig.: One pill after each meal, three times daily. By the second or, at most, the third day after taking these the flow usually becomes fully established. If the man- ganese does not fully effect this at the first attempt, the first prescription is re- lied on during the interval, and the pills commenced about three days before the expected time. In ordinary menstrual suppression the last two formulae, used as above, are es- pecially effective. De Wees (Med. and Surg. Reporter, June 30, '88). In amenorrhoea, associated with mental diseases, the potassium permanganate is to be given in 1-grain pills three times daily, and after three months in 2-grain doses. The pills should be given for fully three months after the courses appear, and must be taken without intermission. Macdonald (London Practitioner, June, '88). Of the manganese compounds the bin- oxide seems to give the best general re- sults, though it cannot always be relied upon. The lactate is also an efficient and irritating agent. Segur (Med. Record, Feb. 2, '89). When manganese-binoxide pills are given they should be followed by a little water fifteen minutes later, in order to avoid the burning pain in the stomach, which they are liable to cause. E. J. Hauck (Va. Med. Monthly, Aug. 30, '91). When there is any faulty constitu- tional condition, this should be treated. Anaemia especially requires iron with ar- senic and strychnine or nux vomica, and, as the ansemia improves, menstruation is more likely to be established. As to the action of reputed emmenagogues, such as manganese dioxide, potassium perman- ganate, senecin, etc., the results in per- sonal experience have not been encour- aging. After a reasonable trial of drugs, if no result is obtained, it is usually ad- 258 AMENOERHCEA. TREATMENT. visable to examine the pelvic organs, preferably nnder an anaesthetic, for, if a condition of under-development be present, prolonged drug treatment is futile, and is disappointing to the pa- tient. Under these circumstances it is best to explain the condition and leave matters alone. Stimulation by electric- ity is usually undesirable and unneces- sary in the ease of single patients, though it may be tried in exceptional cases if the fact of amenorrhoea is a source of worry to the patient. The most effective stimulus is that supplied by marriage. A. E. Giles (Clinical Jour., Jan. 30, 1901). In the amenorrlicea following sea- voyages the preparations of manganese and oxalic acid hold the first place. In amenorrhcea following a sea-voyage a valuable combination is peptonate of iron with manganese. Oxalic acid com- bined with the iron and manganese in the following formula especially valu- able: — 3 Oxalic acid, 4 grains. Peptonate of iron, 46 grains. Peptonat ' of manganese, 160 grains. Elixir of Curasoa, 2 ounces. Water, 6 ounces. M. Sig.: A tablespoonful in a glass of milk three times a day. This simple plan, with a well-regulated diet of eggs, fish, meats, oysters, milk, and vegetables that are rich in organic iron may be all that is required. H. C. Bloom (Univ. Med. Mag., Dec, '96). When the manganese preparations fail, santonin, 10-grain doses at bed-time, is especially valnable in chlorotic subjects. [Santonin, given in 10-grain doses at night, is a most reliable emmenagogue, particularly in chlorotic patients. Ex- perience based upon a large number of cases. RiNGEE. Corr. Ed., Annual, '89.] [We have seen it used with good effect. MuNDE and Wells, Assoc. Eds., Annual, '89.] The preparations of manganese and santonin may be given simultaneously: 1 grain of santonin at night and potas- sium permanganate -n 1- to 2-grain doses thrice daily. Panecki (Amer. Jour, of the Med. Sciences, July, '94). Senecio jacobtea is useful in functional amenorrhoea, as it not only anticipates the period, but increases the quantity. In many cases it relieves the accompany- ing pain and not infrequently the head- aches from which some women suffer at such periods. The action of senecio jacobaea resembles that of potassium per- manganate and is especially valuable in functional amenorrhoea. It causes the regularity and the copiousness of the flow. William Murrell (Brit. Med. Jour., Mar. 31, '94). In stout chlorotics the amenorrhoea should be combated by tincture of sene- cio vulgaris, in I- to 2-drachm doses three times daily. This drug tends to reduce the local pain and the headache. R. J. E. Young (Edinburgh Med. Jour., Sept., '94). Six cases. Blood-count in one case showed: red cells, 3,000,000; hemoglo- bin, 52 per cent. Placed on ferratin, 8 grains four times daily, with aloetic purges, combined with perfect rest, and rose to: red cells, 4,600,000; haemoglo- bin, 92 per cent. The following combination is recom- mended: — B Ferratin, 3 drachms. Ext. of aloes, 14 grains. Ext. rhei comp., 9 grains. M. Sig.: Make into 30 tablets; take 1 or 2 tablets twice daily. C. E. Williams (Amer. Therapist, Aug., '97). In amenorrhoea, following combination gives good results: — R ]\Iyrrh, Aloes, Reduced iron, of each, 75 grains. Extract of valerian, a sufficiency. M. Divide into 120 pills, to be kept in powdered cinnamon. Dose, five pills three times a day. Oesterlen (Centralb. f. die gesammte Ther., Feb., '98). The general system should be invig- orated by attention to diet, sleep, and clothing. Out-of-door, light exercise and sunlight are most important. This is especially the case when there is rap- idly increasing obesity. In the latter AMENORRHCEA. TREATMENT. 259 case the diet should be regulated, saline laxatives administered, or a cure at Marienbad recommended. Stimulation of the ovaries and uterus by the faradic current is especially efficient in these cases. Cupping or scarifying the cervix is sometimes successful. These means in- crease the pelvic congestion and tend to counteract uterine or ovarian torpidity. Eudimentary organs or atrophy of the uterus, if not too great, should be treated by dilatation of the uterus with tents and stimulated by tlie faradic current. Exercise and nourishing food should also be given. Sea-bathing is of assistance in such cases. The rheumatic diathesis occasionally plays a part as an etiological factor. In such cases the ammoniated tincture of guaiac, 1 drachm in milk three times a day, or the tincture of colchicum-root, 10 drops every three hours vmtil the bowels become free, will sometimes re- store arrested menstruation. The salic- ylate of sodium is also valuable in this connection. Apiol, 4 grains daily in l-grain pills, for fifteen days, has given good results. Apiolin is best combined with iron. Iron should be given uninteiTuptedly until a few days before the expected ap- pearance of the menses. Then^ continu- ing the iron, apiolin should be prescribed in 5-minim doses three times daily until the appearance of the menstrual flow. W. A. Newman Borland (Amer. Thera- pist, July, '92). Eumencl, an extract made from the root of a plant called tang-kui, a Chinese remedy which contains nothing poison- ous or capable of producing abortion, tried in 14 eases. In two of these there was no appreciable result. In all the others, although the medication was com- bined with hydrotherapy, massage, and the administration of iron. The good effect of the drug appreciable. Acting as a general tonic, it brought on the flow at the correct period, besides increasing it and making less sever3 the pre- menstrual pain. The refined extract as prepared by Merck is called eumenol. Hirth (Munch, med. Woch., June 6, '99). Electricity is of great value, faradism, static electricity, galvanism, and galvanic intra-uterine pessaries being applicable according to the nature of the case. Besides general treatment, percutane- ous electrical application, viz.: spinal and combined spinal and abdominal ap- plications of the galvanic current. In the former the anode is applied im- movably over the lumbar region, while stabile application of the cathode is made over cei-v'ical and dorsal regions for the space of one minute, the dose being 10 to 15 milliamperes; in the latter the anode is applied as before, and the ca- thode over each ovarian region, for fiftetn to thirty minutes. In case of retarded development the faradic current is used, the anode over the back and hypogastric region; the cathode, a well-insulated sound, is intro- duced into the uterus. The duration of the sitting is five to ten minutes, dose 5 to 25 milliamperes. In some cases Apostoli's bipolar electrode is best used when an electrolytic action on the mu- cous membrane is sought for. In the majority of cases the ovaries must be included in the treatment by a cup- shaped electrode to cervix (cathode) while the anode is placed over each OA"arian region ; the dose is 10 to 60 milliamperes for three minutes eveiy third day. H. N. Hinton (Occidental Med. Times, '90). Series of cases treated by negative intra-uterine electrization, with currents of 30 to 40 milliamperes, for five minutes, the applications to be made about the time the menses are expected. These applications act by a complex action upon the uterus and ovaries, causing great congestion, and upon the nervous plexus presiding over the ovarian func- tions. It should be reserved for cases in which amenorrhcea is only transitory, depending either upon some fault of vitality in the ovary (obesity, premature 260 AMENORRHCEA. AMMONIA. menopause, retarded menstruation in young girls near the age of puberty) or upon a lesion of the ovaries (chronic sclerocystic ovaritis) or of the uterus (chronic interstitial metritis, destruction of the mucous membrane by chloride of zinc; or by curetting, with or without Schroder's operation). It is eonti-a-indicated in cases of physi- ological amenorrhoea dependent on preg- nancy, the menopause, or lactation. It is useless in cases following a severe disease of which it is but a symptom or sequel ( chloransemia, morphinomania, tuberculosis). It constitutes the most efficacious treatment known for amenorrhoea not dependent upon an organic irremediable cause. Nitot (Jour, de Med., June 26, '92). [We can only approve, in confirming it, of the author's conclusions. In rebell- ious cases the action of galvanic currents may sometimes be powerfully aided and completed by sinusoidal cun-ents, which favor the flow of blood, either during the menstrual period or outside of it. Apostoli and Grand, Assoc. Eds., An- nual, '93.] Extract of cows' ovaries has been used with success, but further trials with this agent are required to establish its actual value. Experiments with three fresh eow- ovaiy preparation (Merck's) ; the entire ovary, the canals, and a precipitate of the contents of the follicle-contents. The remedies were administered in form af tablet containing 4 grains each of the ovary preparation and common salt. The results obtained in eleven cases do not warrant any positive conclusion, although encouraging as to future trials. R. Mond (Miinchener med. Woch., xliii. No. 14, '96). Ovarian treatment, administered under the form of dried powder of the ovaries of heifers, in the dose of 4 or 5 grains daily, is not dangerous. In order to act it should be continued for some months; it is indicated in amenorrhoea, chloransemia, artificial menopause due to removal of the genital organs, and acci- dents of the normal menopause. L. Touvenaint (Revue des Sci. Med. en France et a, I'Etranger, Jan. 15, '96). Extract of ovaries found especially valuable in amenorrhoea attending chlo- rosis among a large number of cases in which it was tried. Muret (Revue Med. de la Suisse Rom., July, '97). E. E. Montgomery, Philadelphia. AMMONIA. — Ammonia is a transpar- ent, colorless gas very acrid to the taste and giving a markedly alkaline reaction. It is made, in large quantities, from coal- gas, by heating the ammoniacal liquor with calcium hydrate, then conducting the gas through tubes containing char- coal. It may also be obtained by heating a mixture of dry slaked lime with chlo- ride of ammonium. It evaporates with exceeding rapidity. It is very soluble in water. Dose and Preparations. — The prepara- tion used in medicine is a strong solu- tion, or water of ammonia, the aqua ammonise fortior, U. S. P., which con- tains 28 per cent., by weiglit, of gas; it is used mainly as a vesicant. A weaker solution (hartshorn), the aqua ammoniae, U. S. P., is more generally employed, and contains 10 per cent, of the gas by weight. Liniment of ammonia: composed of water of ammonia, 30 parts; cottonseed- oil, 70 parts. Camphorated liniment of ammonia: composed of water of ammonia, 30 parts; camphor-liniment, 70 parts. Aromatic spirit of ammonia: composed of carbonate of ammonia, 40 parts; water of ammonia, 100 parts; oil of lemon, 12 parts; oil of lavender-flowers, 1 part; al- cohol, 700 parts; water enough to make 1000 parts. Dose, 30 to 60 minims. Spirit of ammonia: an alcoholic, col- orless solution containing 10 per cent.. AMMONIA. PHYSIOLOGICAL ACTION. POISONING. THERAPEUTICS. 201 by weight, of the gas. Dose, 10 to 30 minims. Fcetid spirit of ammonia: composed of 1 part of asafoetida to 21 parts of spirit of ammonia. Dose, ^/^ drachm. Ointment of ammonia: composed of 17 parts of water of ammonia, 32 parts of lard, and 2 parts of oil of sweet almonds. Physiological Action. — Ammonia is a most powerfiil irritant to the tissues; if the exposure be long, local death and sloughing ensue. Inhaled it may also produce rapid death by oedema of the glottis or spasm. Moderate inhalations cause bronchitis, or at least tracheitis. Upon the nervous system it acts as a spinal excitant, increasing reflex action and spinal activity. Applied directly to a nerve, either motor or sensory, it par- alyzes it; in very weak solution it seems to increase its functional activity. The circulation is increased to a great extent: the pulse-rate, pulse-force, and arterial pressure being due to stimulation of the accelerator nerves of the heart. The force of the action of the ventricles is much increased, and this, in turn, in- creases arterial pressure. In moderate amounts ammonia does not change the blood, but in poisonous quantities it causes it to cease absorbing oxygen. The rate of respiration is increased by stim- ulation of the respiratory centre; the respiratory movements become not only more full, but more rapid. Inhaled in small amounts, it causes the same action to a smaller degree. When large amounts are taken, ammonia is eliminated by the breath, is burnt up in the system, and is excreted in the urine. Special research showing that the elim- ination of this gas by the lungs is doubt- ful. Paul Binet (Revue M6d. de la Suisse Rom., .June 20, July 20, '93). Ammonia exercises a depressing action on the liver, producing an increase in the amount of iron and a diminution in gly- cogen. T. Lauder Brunton and S. Dele- pine (Proceedings of the Royal Soc, No. 334, '94). Ammonia Poisoning. — -True poisonous effects are rarely observed, the intense caustic action of ammonia upon the mucous membranes of the mouth and throat causing the liquid to be coughed out almost immediately in the majority of instances. Spasm of the glottis and oedema may cause death. If the liquid is swallowed the mucous layer of the oesophagus becomes acutely inflamed, softened, and itlcerated, and stricture of the oesophagus usually follows. Treatment of Ammonia Poisoning. — The antidotes are vinegar and lime-juice. Bland liquids — such as oil or milk — - should be given, and stimulants — such as strong coffee — should be administered by rectal injection if the patient is un- able to swallow. Hypodermic injections of ether or digitalis are valuable to sus- tain cardiac action if there is marked depression or shock. Therapeutics. — Asphyxia, Collapse, AND Shoce. — In asphyxia, whatever be its origin, ammonia is a valuable agent, taken internally and simultaneously in- haled. During the latter procedure, how- ever, care should be taken to not spill the liquid into the mouth or nose of the patient, which is likely to occur when he is in the recumbent position. Serious in- jury has followed accidents of this kind. In collapse and heart-failure, from 10 minims to a drachm of the water of am- monia, mixed with 6 drachms of sterilized water, may be injected into a vein. Hypodermic injection of aromatic spirit of ammonia valuable in asphyxia and allied conditions. Case of ursemic convulsions following scarlet fever, in which respiration and pulsation had apparently ceased; the injection of 1 drachm above the cardiac region caused the patient to return to consciousness 262 AMMONIA. AMMONIUM. four consecutive times. Then used in other eases, including one of gas poison- ing. The aromatic spirit of ammonia should always be diluted in order to pre- vent sloughing of the tissues in the vicinity of the injection. A. J. C. Saunier (St. Thomas's Hosp. Reports, London, June 1, '94). ' In infants, the stage of collapse occur- ring in summer diarrhcea may also he counteracted with a few drops of ammo- nia occasionally administered. In extreme stupor Fischer sometimes gives 3 drops of aromatic spirit of am- monia, with 10 drops of water. (Post- graduate, Sept., '92). Gasthic Hyperacidity. — In this con- dition, characterized by "heart-burn," acid eructations, and in fermentative processes following the ingestion of cer- tain kinds of food, a few drops (3 to 5) of water of ammonia or 10 drops of the aromatic spirit in a little water fre- quently afford prompt relief. The fact noted by Sir Benjamin Ward Eichardson that ammonia was antiseptic probably accounts, in a measure, for its effective- ness in arresting fermentative processes. Alcoholism. — In acute alcoholic in- toxication the various preparations of ammonia are considerably used. (See Alcoholism.) Lavage of the stomach, followed by 10 drops of water of am- monia in a half-tumblerful of water, promptly counteracts the effects of in- toxication. Cholera. — For the algid stage, am- monia internally and ether hypodermic- ally, besides the free administration of alcohol, have been highly recommended by Giacich, the aim being to support the failing heart. Marked improvement in the general condition was noted within two hours after the institution of this mode of treatment, and over 50 per cent, of those who had reached the algid stage are said to have been saved. Dumont- pallier also recommends for the same purpose the hydrochlorate of ammonium. Besides the return of heat and perspi- ration caused by this salt, it increases diuresis, and therefore increases the elimination of the toxic elements of the disease. Stings of Insects, Snake-bites, etc. — In lesions produced by venomous rep- tiles and insects, and carnivorous ani- mals the antiseptic and corrosive effects of ammonia can be utilized to great ad- vantage. The best plan in snake-bites is to apply it directly to the wound and to inject into a vein a solution of 30 to 60 minims in 6 drachms of water. The pure ammonia-water applied over the bites or stings of insects is effective; it reduces markedly the pruritus and pain. Rheumatism. — The liniment some- times quickly relieves mild forms of rheumatism and lumbago. When the skin is delicate, as it is in women, it acts as an active rubefacient. AMMONIUM.— When an acid gas and ammonia-gas are brought together with- out liberation of hydrogen, a compound of ammonium is formed, which varies with the acid radicle forming the basis of the combination. We thus have formed the following salts: — • Ammonium arseniate, dose, Veo to ^/as grain. Ammonium benzoate, dose, 10 to 30 grains. Ammonium bicarbonate, dose, 10 to 60 grains. Ammonium borate, dose, 10 to 20 grains. Ammonium bromide, dose, 10 to 60 grains. Ammonium carbonate, dose, 2 to 10 grains. Ammonium chloride, dose, 5 to 30 AMMONIUM CARBONATE. 263 Ammonium fluoride, dose, Vioo to V25 grain. Ammonium formate, dose, 1 to 5 grains. Ammonium iodide, dose, 3 to 5 grains. Ammonium nitrate (employed in the manufactures). Ammonium nitrite, dose, 20 to 40 grains. Ammonium phosphate, dose, 10 to 20 grains. Ammonium picrate, dose, ^/o to 1 grain. Ammonium salicylate, dose, 10 to 40 grains. Ammonium siilphate (employed in the manufacture of aqua ammonise). Ammonium sulphite, dose, 20 to 60 grains. Ammonium valerianate, dose, 2 to 10 grains. Physiological Action. — Some of the salts of ammonium stimulate the spinal cord and have no marked paralyzing influence npon the motor nerves, while others have no distinct stimulating ac- tion on the cord, and paralyze both it and the motor nerves. Many ammonium salts stimulate the vasomotor centres. These varied actions are mainly due to the acid radicle entering into the com- bination of the majority of ammonium salts. These, including the arseniate, the benzoate, the picrate, etc., will be treated under the headings including their acid radicle: Aesenic, Benzoic Acid, Picric Acid, etc. Others owe their properties mainly to the ammonium acting as base. The most important of these will be treated of in the following sections. Ammonium Acetate. The ammonium acetate is seldom used in its natural state; but it enters into the preparation of spirit of Mindererus (liqiTor ammonii acetatis), which, in turn, is extensively employed. This is prepared by saturating dilute acetic acid with am- monium carbonate. This forms a color- less liquid, which gives ofE a very faint odor of acetic acid. It has an unpleasant saline taste. Dose. — The dose of spirit of Minde- rerus is 1 drachm to 2 tablespoonfuls, repeated every two or three hours. Physiological Action. — • Although the general use which this preparation enjoys indicates that it possesses some active virtues, all that can be said of it is that it is a weak stimulating diaphoretic pos- sessing also diuretic properties. The latter it exerts without irritating the kidneys, increasing both the quantity of fluid and the excretion of solids. In the light of our present knowledge, however, the properties just mentioned would seem to fulfill precisely the con- ditions desirable for the elimination of toxic products, in which process the skin and the kidneys play so prominent a part. Therapeutics. — It is especially used at the outset of adynamic fevers and, in fact, should only be used during this period of any disease, before the stage of depression is near. Sweet spirit of nitre is generally preferred, owing to its more agreeable taste. It affords relief in some cases of dyspepsia as an antacid. Ammonium Carbonate. Ammonium carbonate is prepared by heating a mixture of ammonium chloride and calcium carbonate, then condensing the product. It occurs in white translu- cent masses, which, on exposure, become opaque and friable, owing to the fact that it parts with its ammonia and passes from a sesqui- into a hi- carbonate. It has a pungent odor, a sharp taste, and an acid reaction. It is soluble in four and a half times its weight of water. Dose. — The dose of ammonium car- bonate is from 5 to 10 grains, which 364 AMMOXIUil CHLORIDE. should be repeated in two hours at the longest, the effect of the drug being evanescent. Physiological Action. — Ammonium carbonate possesses to a smaller degree the stimulating properties of ammonia. It excites the functions of the skin, the kidneys, the bronchial glands, and the epithelium. It reduces the normal gas- tric acidity and tends to irritate the stomach and cause vomiting if given in too large doses. It is thought to play an important role in the formation of urea and glycogen when penetrating the liver with a carbohydrate, the adminis- tration of food with ammonium salts being known to encourage the excretion of urea. Carbonate of ammonia also possesses antiseptic properties. A 5- to 8-per-eent. ammonium solution will preserve rabbit-fat ten months from decomposition. A 5-per-cent. solution of ammonium carbonate also acts as an antiseptic. Meat, animal organs, etc., kept in fumes of this drug, look nearly the same after six months. C. Gott- brecht (Arehiv fur exp. Path, und Pharm., B. 25, H. 5, 6, "90). Therapeutics, — This drug is especially valuable in diseases of the respiratory tract. It acts as an active expectorant. In bronchitis, especially in the chronic form, when the dyspncea is marked and the general adynamia is caused by inter- ference with the functions of the pitl- monary tract, it probably represents the best agent at our command. H. C. "Wood regards it as the best preparation for continuous use in typhoid pneumonia. In both of the diseases mentioned it may be given in doses of from 5 to 10 grains, repeated every two hours, the effects of this dose upon the system lasting no longer than that time. It is a valuable drug as a cardiac and nervous stimulant in the capillary bron- chitis — broncho-pneumonia — of chil- dren. In acute coryza it is also employed with satisfactory results. The best means of aborting an attack of acute coryza is the administration of rather large and frequently-repeated doses of carbonate of ammonia. Beverly Eobinson (Boston Med. and Surg. Jour., Nov. 14, '89). Ammonium Chloride. Chloride of ammonium — or, as it used to be preferably called, muriate of am- monia, or "sal ammoniac" — is a white, translucent salt, having no odor, but a sharp, saline taste. It dissolves in three parts of cold and in one part of boiling water, and sublimes without decomposi- tion at red heat. Dose. — The usual dose is 5 to 10 grains, but when a sudden effect is to be produced, as in alcoholism, from 30 to 60 grains may be administered, with a copious draught of water. Physiological Action. — Applied in its solid form or in saturated solution, am- monium chloride acts as an irritant upon mucous membranes. When given con- tinuously for some time, it is thought to produce a profound impression upon the blood itself, lessening its plasticity and impairing its constitution; it may then cause prostration accompanied by the extravasation of blood under the skin, hsematuria, and hfemorrhages from the mucous membranes. In smaller doses long continued it tends to impoverish the blood, the latter containing less than the normal percentage of solids. It in- creases very notably all the solids of the urine, except the uric acid. It affects the mucous membranes, encouraging nu- tritive changes and the exfoliation of epithelium. Its chief elimination takes place through the kidneys. Ammonium-Chloride Poisoning. — The AMMONIUM CHLORIDE. THERAPEUTICS. 265 experimental evidence published is con- tradictory, but it tends to show that this salt does not possess much toxic power even in large doses. Gourinsky, after some experiments on frogs and pigeons poisoned with am- monium chloride, reached the following conclusions: In frogs whose spinal cord has been divided below the medulla oblongata, ammonium chloride produces from the first a marked augmentation of reflex acts. In frogs deprived of cer- tain parts of the central nervous system (spinal cord, medulla oblongata, the cerebellum alone being retained) this augmentation is preceded by a marked depression. In normal frogs and pigeons chloride of ammonium produces at first depression of the central nervous system, then convulsions: that is, the higher centres exercise a great inhibitory influ- ence on the spinal reflexes. 'V\Tien the poison is introduced rapidly the flrst stage (that of depression) is but slightly marked, and soon gives place to the second stage (that of irritation, ushered in by convulsions). When the poison is introduced slowly the general nervous depression is well marked and lasts a long time. In frogs and pigeons de- prived of the cerebral hemispheres onl}', whatever be the method of introducing the poison, convulsions are not preceded by depression, but the latter is sometimes replaced by irritability. All the facts can be explained only by the reciprocal action of the nervous centres on each other, modified by the poison. In a case in which a large quantity of ammonium hydrate had been talven the mucous membrane of the anterior part of the mouth was denuded, and the peculiar fact was noted that after three days, when solid nourishment was again taken, the food appeared to be saltless. P. Carles (Jour, de Med. de Bordeaux, .July 13, '90). Therapeutics. — Ammonium chloride is especially valuable in all disorders in which the mucous membrane is involved. Gasteic Cataeeh and Hepatic ToEPOE. — That ammonium chloride is valuable in catarrhal disorders of the stomach, especially in children, is sus- tained by the frequency with which it is still resorted to. It may be given in compressed pills, but a half-tumblerful of pure water should be taken simulta- neously to prevent the irritating action of the salt itself upon the gastric mucous membrane. Milk may be used instead of water. In all conditions characterized by torpidity of the liver, whether due to subacute hepatitis or general asthenia, chloride of ammonium is very valuable, in doses of 20 grains three times a day. In doses of I Vi drachms per day it enhances the assimilation of fattj' arti- cles of food, increases the diuresis, and diminishes the body-weight. W. V. Mali- nine (These de St. Petersbourg, '93). In dailj' doses of 75 grains chloride of ammonium increases the assimilation of nitrogenous food. The elimination of improperly-oxidized products of neutral sulphur and of nitrogenous waste is augmented. It diminishes the number of the stools, but increases the absolute quantity of urine and the urinary salts. The reaction of the urine remains acid, but its specific gravity is diminished. V. S. Tchernycheff (These de St. Peters- bourg, '93). Ammonium chloride acts as a stimu- lant to the liver, causing at the same time a slight diminution in the amount of free iron in the organ. T. L. Brunton and S. Delepine (Proceedings of the Royal Soc., No. 334, '94). Encouraging results from the use of ammonium chloride in dj'sentery. Sixty grains may be given every four hours; this rapidly decreases the amount of blood and the severity of the pain. J. W. S. Attygalle (Brit. Med. Jour., Jan. 29, '98). 266 AMMONIUM CHLORIDE. THERAPEUTICS. DiSOHDERS OF THE EeSPIEATOET Teact. — •Ammonium chloride lias long been used as an effective remedy in al- most every disorder of the respiratory tract. In recent years, however, the car- bonate has replaced the chloride in the treatment of pulmonary disorders, but the chloride is still considerably used in chronic bronchitis. The fumes generated by the action of hydrochloric acid upon ammonia are considerably used as inhalents and are quite effective in mild chronic disorders. Nascent ammonium chloride may be used to advantage in pneumonia. It may be generated by shaking together two cloths, the one wet with strong am- monia and the other with commercial hydrochloric acid. The nascent am- monium chloride is suspended like smoke in the room^ and is inhaled by the pa- tient. This substance is a germicide, the free ammonia is a tonic and stimulant to the lungs, and the acid supplies the deficiency of chloride. This method does not disturb the patient. T. Ashburton (Albany Med. Annals, No. 7, p. 360, '97). The value of chloride-of-ammonium troches as a stimulant for pharyngeal disorders is well known. It serves the double purpose of increasing local lubri- cation by stimulating the acini, and of gently enhancing hepatic action. It may also be used in the form of spray. Ammonium chloride in the form of a spray is valuable in the various catarrhs of the respiratory tract. Krakauer (Centralb. f. klin. Med., Oct. 15, '89). Middle-Eae Disoedees. — The use of ehloride-of-ammonium vapor in af- fections of the middle ear has been prompted by its effectiveness in the treatment of catarrhal affections of the nasal mucous membrane, with which many aural disorders are intimately con- nected. Chloride-of-ammonium vapor may be generated by attaching a Richardson continuous-spray apparatus, by the prox- imal end of the elastic ball to the dis- tributing-tube of a Vereker chloride-of- ammonium inhaler, and a Eustachian catheter to the distributing-end of the spray-apparatus. A few squeezes must first be given to the ball so as to fill the apparatus with gas before introducing the catheter. Again, if such a catheter, or even a glass tube drawn to a point, be affixed to a Higginson syringe, one of the best and handiest means of syringing the ex- ternal ear will be afforded. The small and practically continuous jet, applied with any force desirable, almost imme- diately tunnels a hole in the hardest cerumen and quickly allows of that reflex current necessary for its removal, doing away with the need for clumsy ear- syringes. J. MacMunn (Brit. Med. Jour., Oct. 19, '95). Cystitis. — In catarrhal inflammation of the bladder chloride of ammonium sometimes proves very effective, espe- cially if taken with a tumblerful of water. Ten grains every four hours the first day and 5 grains the second day and thereafter soon cause the local distress to at least greatly diminish. Ammonium chloride valuable in cys- titis, primary or secondary. A capsule containing 5 grains of pulverized purified drug should be taken three of four times in twenty-four hours, preferably when the stomach is empty, and followed im- mediately by a half-gobletful or a goblet- ful of pure cold water. Faithfully tried in a large number of varied conditions with most satisfactory results. In the majority of cases the urine was rapidly cleared of mucus, blood-corpuscles, pus- corpuscles, urates, and phosphates, and the distressing symptoms speedily disap- peared. Corrie (Virginia Med. Monthly, vol. XX, No. 6, '93). Alcoholism. — In. alcoholic intoxica- tion the chloride of ammonium acts as effectively as ammonia. Its beneficial infiuence upon the liver renders it pref- erable to the latter. Thirty grains, re- AMMONIUM. AMYLENE. 267 peated in thirty minutes, effectively brings the sufferer to his normal con- dition, as far as the mental aberration is concerned. This action will be con- tinuous if an emetic or lavage of the stomach have previously been resorted to. Case of delirium tremens in wliich 1 grain of morpliine hypodermically did not produce tlie slightest effect. After the symptoms had all become aggra- vated, 1 drachm of chloride of ammonium given. This was promptly vomited. After a short time another drachm given, which was retained. In fifteen minutes the hallucinations — snakes, etc. — disap- peared, and the patient became quite rational. In forty minutes he was asleep Gilbert G. Cottam (Medicine, Nov., '96) Case of a woman who had been in toxicated for eight days. She had "rep tile" hallucinations, etc. Chloride of am monium, '/, drachm in a large quantity of water, taken in two gulps. In fifteen minutes she was quieter; in fifteen min- utes more the other half-drachm was - given. In a short time she was asleep. W. B. Gossett (N. Y. Med. Jour., .Jan. 23, '97). Neuealgia and Migraine. — In these disorders ammonium chloride frequently gives considerable relief, especially if given with tincture of aconite. Twenty grains of ammonium chloride with 2 minims of the tincture used every half- hour three times usually procures con- siderable diminution of the suffering. Chloride of ammonium in supra-orbital neuralgia relieves the pain at once. It should be administered internally, and a small amount of it, finely powdered, be drawn, into the nostril of the affected side. Chetan Shah Naug (Indian M d. Gaz., Apr., '88). Good results obtained from doses of 20 grains in obstinate neuralgia. Green (Med. Press and Circular, Sept. 22, '88). Wounds. — In the treatment of wounds its antiseptic qualities have been empha- sized by H. C. Wyman, who obtained good results from an antiseptic gauze steeped in an ammonium-chloride solu- tion, 1 ounce to V, pint of water, espe- cially in contused wounds. The circu- lation of the blood is increased in the parts which have been deprived of the wholesome influence of the blood-current. AMYL-HYDEILE. See Pentane. AMYLENE is a derivative of fermen- tation of amyl-alcohol, which in the pure state has an oily character and an odor resembling that of old whisky. It ap- pears in the form of a liquid with a specific gravity of 0.689 at 60° F. and a boiling-point of 95° F. It is soluble in water in the proportion of 1 part to 9319 parts, and is readily soluble in alcohol and in ether. It is said that water dis- solves 2.35 per cent, of amylene-vapor, the water tasting of amylene for a long time. It has antiseptic properties, like nitrite of amyl, and prevents the putre- faction of blood. The odor evolved from a bottle that has contained blood and amylene resembles that of rosemary. The drug prevents decomposition of fresh flowers, but changes their color. Physiological Action. — Amylene was at one time considerably used as an an- esthetic. It causes a slight excitement, a rapid inebriation, followed soon after- ward by weak extremities, sudden col- lapse and coma, with total insensibility to pain, and, though rarely, with an equivalent loss of consciousness. Ex- periments on human beings have shown that the vapor of amylene, by inhalation, produces a state of anaesthesia in which acts of consciousness, previously con- ceived and carefully carried out, may be performed, without remembering after- ward any single fact connected with the action. This is a remarkable phenome- non, and seems to show that the human 268 AMYLENE-HYDRATE. brain may exhibit objective conscious- ness apart from the subjective conscious- ness of life; in other words, a conscious- ness of which it is itself unconscious, and this under the mere influence of a volatile fluid which mixes so indifEer- ently with blood at 98° F. that one part of it only will combine with a little over 10,000 parts of blood. This action of amylene and the phenomena of somnam- bulism seem to present a certain analogy. Untoward Effects. • — in sufficiently- large doses amylene produces death, and the only post-mortem change observed is engorgement of the right heart. No change in the color of the blood is pro- duced; neither is there any alteration in the corpuscles or in the natural period of coagulation of the blood observed. It lessens muscular power, but this effect is not lasting. The fatal action of amy- lene is attributed not to any inherent powers of its own, but to the fact that when the drug finds access to the circu- lation it separates in the form of vapor, producing bubbles, and thus acts like air introduced into a vein. Therapeutics. — The insensibility caused by amylene is quite complete, but exceedingly transient. After the drug is removed, recovery is rapid. Before complete insensibility is produced, three well-marked stages are observed: The first is one of mild excitement, during which the face becomes red and con- gested; the second is a period of stag- gering inebriety; and the third stage one of collapse and insensibility. A peculiar muscular tremor is frequently noticed. Locally, in the form of a spray, amylene acts as an efficient anaesthetic, being more rapid than anhydrous ether and more stable than amyl-hydride, which it closely resembles in its physiological action. (Benjamin Ward Richardson.) AMYLENE-HYDEATE. — Amylene- hydrate, a tertiary amyl-alcohol, is a volatile, colorless liquid giving oi£ an unpleasant peppermint-like odor. It is soluble in eight parts of water and is miscible with alcohol in almost all pro- portions. It was introduced by von Mehring as an hypnotic, and has since held a favorable position as such. Dose. ■ — For adults, the dose is 30 to 45 minims by the mouth, and 40 to 75 minims by the rectu.m. It should be kept in well-stoppered bottles. The disagree- able taste may be avoided by administer- ing it in capsules. The following formula has been rec- ommended as efficient, while agreeable to the patient as well: — IJ Amylene-hydrate, 1 drachm. Water, 2 ounces. Orange-fiower water, 2 ounces. Syrup of bitter orange, 1 ounce. — M. Of this mixture one-half may be taken at night. Amylene-hydrate leaves no bad taste in the mouth or disagreeable odor on the breath on awaking, such as are noticed after paraldehyde. The dose need not be increased, as a rule, even after repeated use. Morphine may sometimes prove a val- uable adjunct to amylene-hydrate when an analgesic effect is also required. The following formula has been recommended by Fischer: — • I^ Amylene-hydrate, 1 V2 drachms. Morphine hydrochlorate, V4 grain. Distilled water, 3 ounces. Extract of licorice, 2 V2 drachms. M. Sig.: To be taken in two doses two hours apart. If, owing to the nature of the case, it is necessary to administer the above agents by the rectum, the following may be used: — AMYLENE-HYDRATE. PHYSIOLOGICAL ACTION. THERAPEUTICS. 269 IJ Amylene-hydrate, 1 drachm. Morphine hydrochlorate, V^ grain. Mucilage of acacia, 5 drachms. Water, 1 Va ounces. — M. Physiological Action. — Like alcohol, it first excites and then successively para- lyzes all the nerTC-centres. Toxic doses paralyze the cord and medulla, finally abolish reflex activity, arrest respiration, and paralyze the heart. The fatal doses were found to be 15 to 30 minims per kilogramme weight of animal. A very marked diminution of temperature is produced, intensifying the danger of life. Muscular spasms produced by poisons, such as santonin and picrotoxin, are de- layed or alleviated. It cannot be em- ployed subcutaneously, owing to the severe pain produced. (Harnack and Meyer.) As an active antipyretic in warm- blooded animals it has also been credited by Harnack and Meyer with considerable power. The smaller the animal, the more marked the fall in temperature, which sometimes is as much as 11° C. (19.8° F.): from 38° to 27° C. (100.4° to 80.6° F.). This lowering is due to the direct action of the drug iTpon the thermic centres; at all events, the dila- tation of the vessels is less pronounced than after the administration of chloral- hydrate. In man, however, amylene-hy- drate does not influence the temperature to any degree, even in fever, and clinical observations are necessary to prove its value. It acts but feebly upon the res- piration, heart, and vessels of warm- blooded animals; in man the sphygmo- graph shows some modifications in the pulse-curve. Experiments made upon the isolated frog's heart and the muscles in general show it to be a muscular poison; the muscles, at first excited, become paralyzed. It is regarded as an excellent antidote to all convulsants, espiecially when the convulsions are of cerebral origin (as in poisoning by san- tonin). Given internally, it diminished the elimination of urea; but, adminis- tered subcutaneously, it augmented its elimination. This latter phenomenon is due to its local irritating action (phleg- monous inflammation, abscess, or necro- sis of the tissues). The property possessed by amylene- hydrate of modifying secretions has been generally lost sight of, according to Brackmann, Scharschmidt alone having noted that some patients perspire at the beginning of its use. In the single instance in which it was used, a ease of diabetes, an evening dose of 50 grains diminished the thirst, lessened the quan- tity from 230 to 100 ounces, and raised the specific gravity from 1005 to 1011 in six days. On the omission of the remedy the symptoms returned. Amylene-hydrate Poisoning. — Un- toward effects were noted by Dietz. In four instances a large overdose was given through neglect to shake the bottle in which the drug was mixed with syrup; deep sleep followed, from which the pa- tients could not be aroused. There was total paralysis and suppression of tactile sensibility, including that of pain, and of corneal reflex. The pupils were dilated, and reacted but slowly to light. Ees- piration was retarded, superficial, and irregular; the pulse small, soft, and slow; the temperature lowered in two cases to 95° F. Artificial respiration was required in the case of one patient. During re- covery there were confusion of ideas and inco-ordination of bodily movements. The author likens the toxic effect to that produced by alcohol. He advises that to avoid such accidents the drug be admin- istered in capsules. Therapeutics. — Amyl-hydrate is justly 270 AMYLENE-HYDRATE. THERAPEUTICS. considered by the majority of observers as an excellent hypnotic. It may be ad- ministered during long periods, owing to a quality not possessed by chloral: i.e., it does not tend to increase nitrog- enous waste. Experiments showing that the action of amylene-hydrate is entirely opposite to that of chloral-hydrate, the latter in- creasing the quantity of nitrogen elimi- nated by the urine, the former lessening it about two grammes. That -excreted by the faeces showed no change. Amy- lene-hydrate, therefore, prevents the de- struction of albuminous substances, and it is preferable as a narcotic to chloral- hydrate whenever the hypnotic effects are to be continued for a long time, and in all affections in which there is an exaggerated decomposition of albumi- noids; fever, more or less intense; very pronounced dyspnoea; anaemia and hectic diseases, especially pulmonary phthisis and diabetes; and also cases of digestive troubles with concomitant anorexia. J. Reiser (Fortschritte der Med., No. 1, '93). It is especially in the insomnia of mental disorders that it has been em- ployed. Headache sometimes follows its use. It acts especially well in insomnia resulting from nervousness, excessive mental exertion, anemia, fevers, cardiac diseases, insanity, and after the with- drawal of narcotics that have been con- stantly used. It is contra-indicated in insomnia from pain, cough, and fre- quently in cardiac and ursemic dyspncea, and in gastric disorders attended with irritation or nausea, but in such cases its administration by the rectum is followed by the usual beneficial results. Many patients and children do not tolerate it on account of its taste and odor, but it is readily taken when administered in soft capsules. Unusual effects are pro- duced only by large quantities, and con- sist in loss of reflexes, paralysis of ex- tremities, mydriasis, low temperature, feeble pulse, and shallow respiration. No cases have been observed in which an amylene-hydrate habit was engendered, or a cachexia developed, due to the rem- edy. (W. H. Flint.) To produce sleep in the above dis- orders it may be administered by the mouth or by enema with gitm arable and water. Unlike chloral, it has no irritative action on the mucous mem- brane of the rectum. Sleep comes on after fifteen to forty-five minutes, though often sooner, and occasionally no effect at all is produced. On the whole, it is a reliable hypnotic, if given in sufficient dose: two to three times as large as that of chloral, though it is somewhat less certain in its effects than is this substance or morphine. Unpleasant secondary ef- fects, as excitement or slight drunken- like stupor, are very seldom witnessed. It does not lose its efficiency, — though given during three months in some cases, — and the deep and refreshing sleep is praised by the patient oftener than in the case of any other hypnotic. The drug is more powerful than paraldehyde or urethan, and is to be preferred to them. It should always be chosen in heart disease in place of chloral, though it is not so strong as the latter. It is fully equal to sulphonal, and, indeed, superior to it in many respects. Three capsules, each containing 15 minims, are easily taken on retiring, and will almost certainly produce sleep. The effect fol- lows much more promptly than after sulphonal, and it has not the same tend- ency to produce sleepiness and giddiness on the following day. (E. Kirby and J. P. C. Griffith.) Epilepsy. — Evidence is not lacking to show that it is valueless and even dangerous in epilepsy. Umphenbach noticed from its use increased mental AMYLENE-HYDRATE. AMYLIFORM. 271 confusion and decided disturbance of sleep. Dunn experimented upon four- teen cases. He noticed from the drug at first an apparent transient improve- ment in some cases, though in others the number and severity of the attacks were increased from the beginning. A marked tendency' to the development of status epilepticus manifested itself in some cases, while others sank into a state of coma, with subnormal temperature and slow, heavy respiration. The men- tal condition of patients under this treatment did not improve at all, even in those which appeared at first to be benefited in the ninnber of attacks. Insanity. — Amylene-hydrate has been thoroughly tried in cases of mental dis- order. It is an hypnotic of a high order, occupying a position between paralde- hyde and chloral. It is superior to the first in its less injurioiTS action on the heart, and to the second in the absence of unpleasant odor on the breath. In a large number of cases Lehmann obtained good results, though in mania large doses were required. Paralysis of the insane was benefited, but the in- somnia of melancholy was aided to a less degree. Lehmann considers it more efficacious and less unpleasant than paraldehyde. It is quite effective in alcoholic delirium. In 149 observations 83 per cent, showed marked benefit, 15 to 75 minims . being administered. Large doses were required in mania; tlie insomnia of mel- ancholia was aided to a lesser degree than that of other disorders. It is more efficacious and less unpleasant than paraldehyde. Lehmann (Ther. Monat., Dec, '87). In 300 observations sleep came on be- tween 15 and 45 minutes; occasionally no effect was produced. Although, as a rulCj no unpleasant secondary effects were noted, 37 minims caused a condi- tion resembling drunkenness in an hys- terical woman. Avellis (Deutsche med. Woch., No. 1, '88). Opium Habit. — Sleep, lasting through the night with but little or no intermis- sion, was obtained by Kirby and Griffith in a case of opium habit, in which chlo- ral, bromides, paraldehyde, and hyoscine, given singly or variously combined, had produced but indifferent results. Like re- sults have been noted by other observers. PuLMONAET DisoEDEES. — In pulmo- nary disorders, G. Mayer found amylene- hydrate a reliable and pleasant hypnotic. It appeared not only to produce sleep, but to have a decided sedative influence on the cough. In phthisis it proved it- self useful in this respect, after morphia had had but little effect. When there is pain or very troublesome cough, how- ever, it is not so uniformly successful. AMYLIFORM.— Amyliform is a true chemical combination of formaldehyde and starch. It occurs in the form of a white powder, without odor, insoluble in all liquids, and is very stable and not easily altered. It is gritty, or feels like sand when rubbed in the hands. In the body it is decomposed slowly into formic aldehyde and starch. Therapeutics. — Formic aldehyde being a powerful bactericide, antifermentative, and antiputrefactive, amyliform proves useful in antiseptic surgery. Employed as a powder, it was found to diminish in a rapid manner the secretions upon sores, particularly those which have a bad odor. It is strongly antiseptic, deodorant, and absorbent. Amyliform is absolutely free from ir- ritating properties, and non-toxic. It favorably affects the secretion, prevents tissue-necrosis, does not form a dry crust which retains secretion, and will absolutely prevent the foul odor from gangrenous wounds. Classen (Therap. Monat, Jan., '97). 272 AMYL-NITRITE. AMYL-VALERIANATE. ANiEMIA. See NiTEiTES. AMYLOID LIVEK. EASES OF. See Lives, Dis- AMYL- VALERIANATE. — Amyl-vale- rianate, introduced by Blanc, represents the odoriferous principle of the apple: that is, the essence extracted by distil- lation together with alcohol. Dose. — Its toxic properties being very slight, as many as 5 or 6 capsules, con- taining 2 grains each, can be taken daily, but it is necessary to guard against gas- tric disturbance. Physiological Action. — Cider has long been believed by the laity to have some effect on calculous formations, and this seems to be borne out by the fact that valerianate of amyl really has some solvent action on cholesterin. It is a colorless liquid, of pleasant taste when taken in .small quantities, and can be prepared in the laboratory by the action of valerianic acid on amylic alcohol. Fifteen grains of cholesterin are dis- solved by 70 grains of valerianate at 99° F., and by 46 grains at 104° P. Therapeutics. — Physiologically, its action resembles that of ether, but the special qualities lie in its being a stimu- lant and sedative to the liver in cases of hepatic colic. It is said not only to im- mediately subdue the attack, but to pre- vent recurrences. If the stomach is irri- table, it may be necessary first to employ sulphuric ether, following this with 2 or 3 capsules of 2 grains each, given every half-hour until the crisis is past, and continued at long intervals during the following days. According to Blanc, in nephritic colic the drug acts as an anti- spasmodic and general stimulant only, but no effect is produced on the renal calculi; muscular rheumatism is fre- quently relieved, and much benefit is also derived from its use during menstrual uterine contractions. It is also consid- ered valuable as a sedative in hysterical manifestations. AN.a;MIA. — From Gr., d, priv., and aLf.ia. blood. Definition. — A symptomatic disorder of the blood characterized by a deficiency of some of its important constituents, espe- cially red corpuscles. Varieties. — Anaemia may be classified into two general forms: (1) that due to defective haemolysis and (2) that due to defective haamogenesis. Stephen Mac- kenzie recognizes four degrees of anaemia according to the number of red corpus- cles present in the blood, but, with other observers, he regards the classification given by Hayem, in which the proportion of haemoglobin in the corpuscles is taken as a standard, as more scientific. This is especially the case, since the number of red blood-corpuscles has not been con- sidered as important a factor as it was once held to be. According to Germain See, alterations of the blood in true anaemia are conform- able to one of three types: (1) the anae- mia from hemorrhage, characterized by a diminution in toto of all the elements of the blood; (2) a type characterized by hypohaemoglobinfflmia, — i.e., a deficiency of haemoglobin, either quantitative or qualitative; (3) a type in which the num- ber of red blood-corpuscles is reduced. Symptoms. — The main symptom of this condition is an abnormal pallor of the skin and mucous membranes, which varies in different cases from yellow to absolute whiteness. The finger-nails also show, by their whiteness, the general condition present. The pallor is asso- ciated with various phenomena indicat- ing involvement of the nervous system. Marked depression of physical and men- ANAEMIA. DIFFERENTIAL DIAGNOSIS. 273 tal powers is evident; there is tendency to inertia or indolence, especially during digestion. Inordinate palpitations are frequent, this condition causing, in the patients, a state of continuous fear as regards the presence of heart disease and anxiety concerning their general health. Shortness of breath on exertion, head- ache, and, in women, menstrual disturb- ances, amenorrhcea especially, and con- stipation, are also complained of. The surface of the body is cool and the extremities are usually cold. Sensitive- ness to the variations of temperature is the rule. The urine has a low specific gravity through deficiency of urea. The globes of the eyes may appear blue, owing to semitransparency of the conjunctiva. Auscultation over the vessels of the neck reveals a venous hum; this symp- tom is often absent in mild cases, how- ever. A systolic bellows-murmur is also frequently heard over the carotid arter- ies. A systolic murmur is occasionally heard over the aorta and the pulmonary artery. These are valuable guides when the effects of treatment are to be closely watched, their intensity varying with that of the degree of anemia present. Alterations in the size of the heart in anaemic subjects. Dilatation is com- monly met withj and sometimes, espe- cially in chlorosis, elevation of the diaphragm displaces the heart upward and an apparent dilatation is found. Anaemic dilatation is to be considered true idiopathic dilatation resulting from overstrain. None of the usual symptoms are present; gastralgia alone is com- plained of. Wybauw (Jour. Med. de Bruxelles, Mar. 15, 1900). Ansemio dyspnoea is mainly due to vasomotor failure; the disease is preva- lent in the female sex, whose vasomotor system is more unstable than that of the male; it usually occurs at puberty, when this system is unusually active. J. Hen- 1- ton White (Birmingham Med. Eev., Oct., 1900) . Case of simple anaemia in a young mu- latto in which the disease followed preg- nancy. On admission, examination of the blood showed 12 per cent, of haemo- globin, 750,000 blood-cells, and 33,000 wliite cells. The case is classed as one of simple anaemia because of the rapidity and degree of the recovery. Floyd and Gies (Med. Record, Apr. 27, 1901). Case in a woman, aged 38 years, who had suffered from anaemia for twelve years, attended by repeated nasal dis- charge of blood and pus. Examination of the blood showed 23 per cent, of haem- oglobin, 475,000 red blood-corpuscles, 1400 white corpuscles, color index of 2.40, and the presence of nucleated red cells, both normoblasts and megalo- blasts. Under treatment a great im- provement resulted, but a recurrence of the blood-disorder took place and death resulted. The case is thought to have been one of secondary anaemia which had passed into pernicious anaemia. W. Edgecombe (Brit. Med. Jour., May 4, 1901). Differential Diagnosis. — The symp- tomatic evidence is such, in the majority of cases, as to readily suggest the true nature of the disease. It is to be dif- ferentiated from the more severe forms: chlorosis, pernicious anaemia, leucocy- thsemia, and pseudoleucocythsemia. Chloeosis. — The greenish pallor of this disease is quite characteristic. The reduction of hemoglobin is dispropor- tionate as compared to the number of red cells, which is not, as a rule, greatly reduced. Pernicious Anemia. — Examination of the blood is required to thoroughly establish the diagnosis, although the lemon-colored skin peculiar to these cases is quite distinctive. Leucoctth^mia. — The diagnosis is early established by the microscope, which shows the increase of white cor- puscles, their ratio to the red corpuscles 274 ANEMIA. ETIOLOGY. PATHOLOGY. being sometimes 1 to 30 instead of 1 to 600, the normal proportion. PSEUDOLEUCOCTTH^MIA. In thiS disease tlie presence of enlarged glands is characteristic. Etiology. ■ — The principal causes of benign ansemia are: (1) loss of blood, haemorrhages; (2) improper assimilation of nutritive products or insufficiency of blood; (3) abnormal expenditure of blood-constituents, as in pregnancy and lactation. The first etiological factor is especially common in women, menor- rhagia, metrorrhagia, and abnormal bleeding during labor being the most frequent causes. The second class affects the poor, in the majority of instances, through lack of proper food, insufficient sunlight, and crowded quarters, to which exposure to a vitiated atmosphere the greater part of the time is added. The third class of cases, those due to preg- nancy and lactation, are frequently met with, and explain, with the other causes, the greater frequency of ansemia in women than in men. The latter, how- ever, are more exposed to another class of causes, — that due to introduction into the system of such toxic agents as lead, malaria, etc., — which also tend to cause organic alterations of the blood-constit- uents. Anaemia occurring in anchylostomiasis is often due to the habit frequently as- sociated with the disease: of eating dirt. This often gives rise to oedema of the face and feet, anaemia, emaciation, and exhaustion. A. J. B. Duprey (Lancet, Oct. 27, 1900). Histories of four of fifteen cases of splenic anaemia described in a previous paper. The etiology of the disease is not known. Heredity usually plays no part; but Brill has reported three cases in one family. Among the symptoms are, first, the remarkable duration of the disease; the enlargement of the spleen withoui apparent cause; the haematemesis recurring for a number of years; the anaemia, which is character- ized by a moderate reduction of the number of corpuscles, a great reduction in the percentage of haemoglobin, and leucopenia. There is often pigmenta- tion or bronzing of the skin. In some of the patients cirrhosis of the liver occurs, and in a small number ascites is present. Among the other symptoms- jaundice sometimes occurs. The condi- tion found in the spleen is chiefly a fibrosis or hyperplasia, with atrophy of the pulp and hyaline degeneration of the Malpighian bodies, or a change by which the normal texture is largely re- placed by fibrous tissue and large en- dothelial cells with clear protoplasm containing two or more nuclei, and among them giant cells. The disease- probably represents a chronic toxic^ rather than an infectious, process. The. best name is probably splenic anaemia. The treatment consists in splenectomy. In the author's series it was performed on three patients, two of whom died as a result of the operation. W. Osier (Amer. Jour Med. Sciences., Nov., 1902). Pathology. — There may be a diminu- tion of the quantity of the blood in the system, a deficiency of haemoglobin, and reduction of the number of red corpus- cles or of other constituents of the blood, all of which are to be determined by careful examination. The quantity of hsemoglobin is not always proportionate to the number of red corpuscles, the percentage of hemoglobin in the latter being subject to variation according to- the character of the disease present. In the benign form of antemia treated of in this article, examination shows but a slight diminution of the number of red corpuscles and a relative reduction of Repeated experiments showing the same result, that the production of the hsemoglobin and the increase in the num- ber of red corpuscles depend upon differ- ent factors, certain substances increas- ing one while others increase the other... AN.EMIA. TREATMENT. 275 Arsenic certainly increases the number of red blood-cells, while iron causes the production of new haemoglobin. F. Aporti (Centralb. f. innere Med., Jan. 13, 1900). Basophile granules. To determine whether they result from the degenera- tion of the nuclei or the cell-protoplasm itself, an artificial anaemia w-as estab- lished in several rabbits by drawing off as much as one-third of their blood. The granules were not found at once after venesection, but appeared one or two days later, chiefly in polychromatophilic cells, and many of these without gran- ules were also apparent. The late ap- pearance of these changes speak for cell- degeneration, rather than breaking down of the nucleus. It is known that large losses of blood are followed after seveial days by an hydrtemic condition of the circulating fluid. This is also seen in all forms of ansemia except chlorosis, and it stands in definite relation with and is the chief causative factor in the cell- changes. M. Cohn (Miinchener med. Woch., Feb. 6, 1900). In all cases of anaemia uncomplicated with glandular involvement there is an increase in the percentage of lymphocytes and correspondingly a diminution in the quantity of the multinuclear neuirophile elements. Leucopenic anaemias asso- ciated with glandular disease (spleen, lymphatic glands) show a varying quantity as to the relative percentage between the multinuclear and uninuclear elements. A. V. Decastello and Ludwig Hofbauer (Zeits. f. klin. Med., vol. xxxix, Nos. 5 and 6, 1900). Treatment. — The treatment of benign ansemia may be summed np as follows: (1) on removal of the cause, if such be found; (2) on exercise of hygienic meas- ures, — light, air, rest, and exercise; and (3) on proper medication. Of drugs, iron stands first, and is especially useful where hamoglobin is greatly reduced. Next to iron is arsenic: useful particu- larly where haemoglobin is not so much reduced as the corpuscles. Experiments on dogs and chickens and search through literature show that cop- per, zinc, manganese, and mercury act like iron in cases of anaemia and chloro- sis. Under their use the haemoglobin readily increases. Cervello (Jour, dea Praticiens, Jan. 12, 1901). Ansemia being in reality but a symp- tom, the causative affection must be care- fully sought after. In women, as stated, uterine disorders are the most active factors. In young girls it is frequently met with, owing, probably, to temporary inequality in the development of various physiological functions. Hence the in- frequency of complications in such cases. The possibility of complications should always be borne in mind, however, and every precaution taken to forestall ag- gravated forms, by food adjusted to the taste of the patient and made attractive to her. Disorders of digestion usually yield to bismuth and aromatic powder. As result of investigations into effect of exercise on haemoglobin with reference to the value of rest and treatment of anaemia, it is concluded that (1) there is a normal daily fall and nightly rise in the worth of the corpuscle, represent- ing a daily destruction and regeneration of haemoglobin; (2) active exercise in- creases the extent of the daily fall and the nightly rise; (3) active exercise stimulates a slight overproduction of haemoglobin; (4) passive exercise [mass- age] diminishes the volume of the blood, but has no effect in diminishing or in- creasing the amount of haemoglobin; (5) rest reduces the extent of the daily fall in worth, representing a diminished de- struction of haemoglobin. Wilfrid Edge- combe (Brit. Med. Jour., June 25, '98). Although iron is especially effective- after the cause of the disease has beep removed, even when the causative ail- ment is still present it exercises its beneficial effects, which are generally as- cribed to the fact that iron is a normal constituent of the red corpuscles. 276 AN.EMIA. TREATMENT. As regards the best preparation to be employed, it is difficult to make a selec- tion. Theoretically, the best preparation, according to Herschell, is the nascent ferrous carbonate formed in the stomach itself by the reaction between sulphate of iron and carbonate of potash, while the worst preparations are the albumi- nates, peptonates, and colloid forms. In the latter, contact with the hydrochloric acid of the gastric juice produces a pre- cipitate of insoluble ferric carbonate of iron. The alleged fact that these prep- arations are better borne in disease is evidently due to the fact that they are almost inert. In a comparative study of the subject, during which the hemo- globin was estimated both before and after treatment by means of Fleischl's hsemometer, Herschell found Blaud's pills in tabloid form to be the most efEective, having shown an average daily increase of 1.2 per cent, of haemoglobin. Ferratin has also been recommended by many observers. Banholzer observed a 5-per-cent. increase of haemoglobin in eight days. Whatever preparation is used, it should be changed for another after a few weeks and returned to, if its effects have manifested themselves actively. The remedy should invariably be administered after meals. Anaemic patients are usually imaginative and frequently assume that iron will not improve their condition. They must be assured that they will be benfited provided the instructions given them are carefully carried out. Iron exists in the blood only in the form of a phosphate. Soluble citro- phosphate of iron, for the production of this salt, is not followed by constipation. Jolly (Provincial Medical Journal, May, '89). Albuminate of iron is especially serv- iceable when anaemia and debility are associated with weak and irritable di- gestive organs. John A. Ouchterlony (Amer. Pract. and News, Nov. 23, '89). Blaud's pills preferred to any other preparation of iron; next to iron comes arsenic. Arsenic acts with most effect in cases in which the relative percentage of haemoglobin remains normal or is actually increased, the type of "which is pernicious antemia. Laache (Wiener klin. Woch., Sept. 18, '90). The double sulphate of iron and mag- nesium recommended in doses of 10 grains three times a day. B Sulphate of iron and magnesium, 2 drachms. Chloroform-water, enough to make 6 ounces. M. Sig.: Half an ounce thi-ee times a day. Woods (Brit. Med. Jour., May 23, '91). Daily dose of ferratin for adults is 15 to 23 grains. Schmiedeberg (Arch. f. exp. Path.imd Pharm., B. 23, H. 23, '94). In anaemia following acute disease haemoglobin quickly increased (over 5 per cent, in eight days), also number nf red cells, by the use of ferratin. Banhol- zer (Centralb. f. klin. Med., Jan. 27, '94). In marked anaemia and chlorosis Blaud's pills in large doses recom- mended. As many as forty-eight on the fourth day have been given and con- tinued for three or four weeks. It is necessarj' to keep the patient in bed in a large, airy room; hospital patients are more likely to recover quickly than pri- vate ones for this reason. Byrom Braiu- well (Med. Record, Aug. 22, '97). The most satisfactory result is ob- tained with the peptomanganate of iron; it is easily absorbed by the entire intestinal tract, and evokes no concomi- tant effects. In 12 out of 23 cases the haemoglobin was normal after fourteen days, in 5 after three weeks, and in 5 after a month. In acute anaemia good results were also obtained by this mode of treatment. H. Metall (Med.-Chir. Centralb., June, 1902). Some eases do not yield to the prep- arations of iron as long as constipation exists. Aperients may either be given separately or with the iron. Aloin and AX.i:]VIIA. TREATMENT. 277 belladonna extract are useful in these cases. Iron and rhubarb may be combined as follows: — B Protoxalate of iron. Powdered rhubarb, of each, 1 grain. Make into a cachet. Give two or three of these cachets each day. Editorial (Jour, des Praticiens, Mar. 28, '96). Iron may be administered hypoder- mically. This method is of great value when the anemia is far advanced and a sudden reaction becomes necessary. The subcutaneous injections of iron salts in the form of a 10-per-cent. solu- tion of iron and ammonium citrate, 1 grain and upward of the dmg being given in each injection, tried. In every instance in which the injections were continued sufficiently long, the percent- age of hsemoglobin regularly increased, and simultaneously the phenomena of ansemia. both subjective and objective, decreased. This shows that the ansemic condition can be markedly benefited by iron when given subcutaneously. Eiva- Kocci (II Polielinico, Xo. 8, p. 168, "96). Case of grave auEemia in which pro- longed treatment with many preparations of iron and arsenic taken internally pro- duced no effect. The hjemoglobin sank below a sixth of its normal amount. The patient apparently dying, subcutaneous injections of a 4-per-cent. solution of citrate of iron tried, 45 to 60 minims being injected daily. Marked improve- ment took place almost at once, and the percentage of haemoglobin rapidly rose. In a month's time the patient was con- valescent. A 4-per-cent. solution is quite strong enough. The 10-per-cent. solution gen- erally employed is too strong. Hypo- dermic injections of 3 grains of citrate of iron have been known to cause vomit- ing and fever. The kidney is liable to be damaged by too concentrated solu- tions, leading to anuria and haematuria and even nephritis. Hypodermic injec- tions of iron are not indicated in cases where the kidneys are not sound. E. Lepine (La Semaine Med., May 26, '97). While iron is the most active of the chalybeates, other drugs tend to increase blood-formation, namely: manganese, phosphorus, arsenic, hydrochloric acid (indirectly), and oxygen. Manganese sometimes proves useful when amenor- rhoea is present. Phosphorus and arsenic encourage nutrition and probably act as germicides, preventing ptomaine forma- tion in the intestines. Waters containing small quantities of iron give better and quicker results than pharmaceutical preparations, and all the unfavorable symptoms so often produced by the latter are avoided. Th. Bernard (Gaz. Med. de Paris, Apr. 8, '93). Iron increases in a marked degree oxi- dation, while arsenic, on the contrary, exerts a powerful moderating influence on this process. The indications for one of these drugs are consequently exactly the opposite of those of the other. Treatment by iron h called for in cases of auEemia with reduced co-eflScient of oxidation, whereas arsenic should be ordered when the oxidation is increased. A. Robin (Med. Week., Apr. '2, '97). Case of a girl of 20 who had tried all remedies recommended in anaemia, but Avithout effect. Xettle-soup ordered first, every second day; then, when she im- proved, twice a week. Patient was com- pletely cured. The author himself was cured of anaemia, when he was 17, by taking nettle-soup. The common or stinging nettle {Vrtica dioica) and the dwarf nettle {Vrtica wans) possess the same virtues, but the first is used almost exclusively. The best time for collection is spring; the best part to use is the roots and stalks with only half-developed leaves. It may be used as an infusion — a handful to two quarts of water, 2 or 3 glasses of this to be taken during the day; but it is much pleasanter to use in the form of a freshly-prepared soup from the fresh herb. Hjalman Agner (Bull. Gen. de Ther., June 8, '98). Hfemoglobin continued until the nor- mal standard is reached — 1 V2 grains daily — has met with favor. If there is no digestive trouble, other preparations 278 AN.EMIA. TREATMENT. of iron can be given at the same time, and the results be more prompt. Haemogallol, the dose of which is 1 grain, given a quarter of an hour before meals gradually increased to 1 V2 grains and over, has been recommended by T. Lang and others. A number of agents have been rec- ommended with the view to lessen the destruction of blood-corpuscles; arsenic, quinine, mercury, phosphorus, betanaph- thol, iodoform, carbolic acid, sulphocar- bolate, and menthol represent this series. Arsenic probably accomplishes this in the manner indicated, namely: by pre- venting the formation of ptomaines. Direct transfusion of blood is also of value in cases of chronic progressive ansemia, by stimulating the blood-mak- ing organs. This measure is sustained by von Ziemssen. The introduction of goat's serum di- rectly into the veins, using about 50 cubic centimetres (1 V* ounces) has been advocated by Lepine. Striking curative results have been obtained by Simon Baruch, by means of hot-air baths in boxes, followed by cold douches. Hot baths in more than fiftj' eases of ansemia in patients who for the most part had been under medical treatment without benefit. A bath at 104° F. is given three times a week. Its duration should not exceed fifteen minutes, and at its close the patient should be douched with cool \\'ater. Immediate effect of such a bath is a feeling of lightness in the individual, and in four weeks' or a less time there is a noticeable improve- ment in the general condition. Rosin (Centralb. f. innere Med., Apr. 30, '98). Hayem in 1889 recommended the hyp- odermic injection of arsenical prepara- tions in cases where irritability of the stomach prevented its administration by the mouth. The best means of admin- istering Fowler's solution is in cherry- laurel water, in 10-drop doses, as much. as 20 drops being sometimes given in a day. Report of thirty-five cases of severe anaemia due to various causes — such as pernicious anaemia ; anaemia after typhoid fever, round ulcer, cancer, tuberculosis; and that due to tape-worm — in which a solution composed of 2 parts of water and 1 part of Fowler's solution was em- ployed. Of this mixture, an ordinary hypodermic syringeful was given daily. In all instances a marked improvement in the anaemia noted. Kering (.Jour, des Praticiens, Jan. 18, '96). Oxygen does not possess the confidence of the profession, although some rather remarkable cases have been reported. [Nothing is to be expected from oxy- gen, for the blood-corpuscles, few in number though they be, are well charged with haemoglobin and consequently with oxygen. In chlorosis the case is difl'er- ent. F. P. Hekry, Assoc. Ed., Annual, '89.] In marked anaemia and chlorosis the inhalation of oxygen has been tried, but without much benefit. F. Taylor (Med. Record, Aug. 22, '97). Series of cases in which oxygen in- halations with marked benefit were used. The most interesting was that of a woman of 22 with grave anaemia, the red cells being reduced to 2,000,000, the hasmoglobin to 30 per cent., and the red cells were much defonned. The woman had frequent attacks of syncope and was veiy weak. Upon the failure of iron and arsenic treatment she was given oxygen inhalations, and rapidly im- proved. Within four months the red cells had increased to 4,000,000, and the hfemoglobin was about normal. She ulti- mately became entirely well. The ap- paratus which is recommended is similar to the one used for the administration of nitrous oxide. P. G. Lodge (Lancet, Apr. 7, 1900). Insomnia is a frequent accompaniment of anemia and tends greatly to increase the weakness of the patient. Amylene- hrdrate is the best a?ent in this condi- ANiEMIA. ANEMIA, PERNICIOUS. 279 tion, 30 to 45 minims being administered in capsules on retiring. In insomnia of anaemia, amylene-hy- drate. For adults the dose is 30 to 45 minims by tlie mouth, or 40 to 75 minims by the rectum. It should be administered by the mouth in soft cap- sules, or in a solution disguised by some aromatios. The mixture should be well shaken before use, to avoid an overdose. W. H. Flint (Ther. Gaz., Jan., '90). Submammary infusions of salt solution in primary ansmia from haemorrhage, in shock, were recommended recently by J. G. Glark. As a stimulant after severe blood-loss or shock, its benefits are so marked, and the procedure so free from bad results of any kind, that it has been used with signal success by Howard Kelly, of Baltimore, in 41 of the last 285 cases of abdominal section in the Johns Hopkins Hospital. A quart of 0.6 sterilized solution of common salt is used, and is infused into the submammary cellular tissue in the following manner: A bottle containing the solution is connected by five feet of rubber tubing to a slender aspirating- needle. The breast, after being carefully disinfected, is grasped and lifted well from the thorax, while the needle, with the fluid flowing from it, is quickly thrust beneath the gland. Usually simple elevation of the bottle is suffi- cient to force the fluid into the loose cellular tissue; if this be insufficient, stripping the tube or the reversed as- pirator pump can be used. The breast rapidly distends, and in some instances the fluid may actually spurt from the nipple. After a quart has been injected, the needle is rapidly withdrawn and the puncture closed with adhesive plaster. In thirty minutes complete absorption has taken place. Manifest improvement in the patient's condition is rapidly apparent, especially with regard to pulse, which shows greater volimie and strength, while the patient herself feels better and is brighter. A critical stage occasionally occurs in some cases within half an hour. This consists in a violent chill, with sensations of extreme cold, rise in temperature, and strong, rapid pulse; but this is followed by a marked reaction. From its safety this procedure is strongly to be recommended instead of arterial or venous infusion. J. G. Clark (Amer. Jour. Obst., June, '97). Bone-marrow has recently been ex- tensively used in anjemia, with varying results. This subject is reviewed under Animal Exteacts. Fourteen cases of anaemia in tuber- culous joint diseases and in osteomalacia treated by the administration of a prep- aration of red bone-marrow and bullocks' blood called "carnogen." The substance was given in 2-drachm doses twice daily, the improvement in the condition of the patients as rapid as it was marked and sustained. This method appears to be of especial use in cases where arsenic, iron, strychnine, and codliver-oU had been exhibited without benefit. C. H. Jaeger (N. Y. Med. Jour., July 31, '97). Action of red bone-marrow on the blood in anjemia: 1. Subcutaneous injec- tions of bone-marrow have no action on the red corpuscles or haemoglobin of a healthy animal. 2. When the red cor- puscles and haemoglobin fall below their normal limits, injections of marrow pro- duce a decided rise in both. This rise is well marked, sudden, and of short duration. 3. Along with the increase in the red corpuscles, there is no correspond- ing improvement in the form of the cells. 4. The active principle is present in an aqueous, but not alcoholic, extract of marrow; it is not precipitated by boil- ing, does not contain iron, and may pos- sibly be a deuteroproteose. Fowler (Scottish Med. Jour., Sept., '99). Aiir.a;MiA, peeniciotjs. Definition. — A form of ansemia which tends toward a fatal issue. Symptoms. — The most evident symp- tom is extreme pallor of the face and body, which gradually assume a lemon- yellow tint. This yellowish color deep- ens as the case progresses; it may appear suddenly, but in the majority of cases it 280 AN.EMIA, PERNICIOUS. SYMPTOMS. DIAGNOSIS. develops gradually, following the insidi- ous course of the disease. There is great weakness with all its at- tending symptoms: inordinate palpita- tions and dyspnoea on exertion, sighing, and slow delivery in speaking. The pulse is regular, but rapid, in the majority of cases, more or less fever be- ing usually present. The temperature is extremely irregular. Cardiac murmurs are generally heard, and signs of fatty degeneration may be detected by auscultation, although there Fundii.s oeuli in a case of pernioioiis anaemia, showing retinal haemorrhages. (BramiveU.) is usually no arterial degeneration or valvular disease. A loud venous hum can sometimes be detected in the vessels of the neck, ffidema of the ankles, face, and lungs and dropsical effusions may appear at any stage. Eetinal hasmorrhage is a symptom of great value. There may also be haem- orrhages into the mucous membranes, epistaxis, menorrhagia, and purpuric eruptions in advanced cases. Gastric and intestinal disorders are the rule, although the general nutrition is apparently preserved, the appetite be- ing sometimes voracious, and the patient becoming obese. Dyspepsia, vomiting, and diarrhcea usually prevail. The gas- tric region is tender to pressure, and the tongue is pale and smooth. Involvement of the osseous system is occasionally indicated by sensitiveness of the bones, especially those of the ster- num. Drowsiness is present in the majority of cases, but insomnia is occasionally observed. Headache, vertigo, tinnitus, apoplec- tiform attacks, delirium, and other dis- orders of the nervous system, such as paresthesia, neuralgia, and extensive paralyses, have been noted. Absence of the knee-jerk is often pres- ent, and is indicative of degeneration of the posterior columns of the cord. Jaundice is occasionally met with. The urine is dark and highly colored; it is of low specific gravity, and shows an increase of urea and uric acid and pathological urobilin. When the end is approaching the temperature recedes markedly, and the patient enters into a torpid condition, ending in coma. Diagnosis. — While pernicious anemia possesses characteristics that readily dis- tinguish it from other blood afEections, — the color of the skin, the retinal hem- orrhages, etc., — the early stages are gen- erally s^Tch as to suggest diseases that do not present the same degree of danger. Benign Anemia. — Intractability of the disease, after the removal of supposed causes and the faithful use of appropriate measures of treatment, strongly suggests the presence of pernicious anemia. CHLOROSis.^From this affection per- nicious anemia may readily be differ- entiated by the blood-examination. In- stead of relative increase of hemoglobin, ANiEMIA, PERNICIOUS. ETIOLOGY. 281 the presence of gigantoblasts, marked oligoeytheemia, and macrocytes differ- entiate. The red corpuscles, in chlorosis, may be normal in number and in size, the only change being a deficiency of haemoglobin. Again, the corpuscles may be normal in number, but diminished in size, while the percentage of haemoglobin is normal; finally the corpuscles may be diminished in number with either a diminished, normal, or perhaps an in- creased percentage of hemoglobin. Leucoctth^mia. — This disease may be excluded by the absence of the char- acteristic blood-change: excess of white corpuscles. PsEUDOLEUCOCYTH^MiA is excluded by the absence of the affection of the lymphatic glands which characterizes this disease, more commonly known as Hodgkin's disease. Leukemia.- — In leukaemia the patient often does not show enough pallor to make the physician suspect the disease. The lips have a dirty-red color rather than a peculiar pallor. The number of white corpuscles would cause pallor in a patient with simple anemia, but in this disease the opacity of the blood is great and the pallor fails to show. (Janeway.) Gastkic Cancee. — ■ This condition almost always shows itself after the age of forty years, whereas pernicious ane- mia is generally observed early in life. In cancer the skin is pale; in pernicious anaemia the peculiar lemon color is strik- ing in the majority of cases. While gastric symptoms and absence of hydro- chloric acid are prominent features of cancer, the digestive disorder is slightly marked in anemia and examination of the gastric contents is negative. Finally increasing emaciation attends a cancer- ous disorder, whereas in cases of perni- cious anemia the patient not only retains his adipose tissues, but sometimes be- comes corpulent. In rare cases, however, there was extreme emaciation. Attention drawn to the impossibility of marking off pernicious anaemia from all other anfemias. There is no marked boundary-line; one ansemia passes in- sensibly into another. T. G. Stewart (Clinical Joumal, Sept. 14, '98). The difference between the pernicious anseniia and other grave anaemias lies in the clinical course, that of the former be- ing characterized by the fact that, even after the removal of the apparent cause, the hsemapoiesis persists in a faulty di- rection, manifested by insufficient new formation and perhaps increased destruc- tion of corpuscles. There is in this dis- ease then a morbid cell-activity that tends to persist with great pertinacity in the wrong direction. E. Grawitz (Ber- liner klin. Woch., Aug. 8, '98). Etiology. — Although the disease occa- sionally occurs in children, it is most common in adults between the ages of twenty and forty years. Males are attacked more frequently than females, with a slight difference in favor of the former. The disease is more prevalent among the better than in the lower classes, and is most common in Europe, especially in Switzerland: e.g., in regions in which the people are badly fed, and who live in poorly-ventilated and badly-lighted houses. Fright and grief are prominent etiological factors. The following group of etiological fac- tors has been established in pernicious anfemias: 1. Gastro-intestinal disease of long standing, poor food, impaired di- gestion; chronic constipation, especially in women frequently pregnant; irregular defecation in women and girls, especially those of hysterical temperament. In such cases it is due to intoxication from the gastro-intestinal tract. 2. Pregnancy. Here, too, probably, there is an autoin- toxication from the intestinal tract, on account of pressure exerted by the gravid uterus on the bowel. 3. Chronic hsemor- rhages, especially of small size. 4. Con- stitutional syphilis, particularly when associated with sclerosis of the marrow 282 AN.^MIA, PERNICIOUS. ETIOLOGY. of the long bones. 5. Bad hygienic con- ditions of various kinds, especially In the female sex; hard work, with insuffi- cient food, bad air, and emotional ex- citement. In higher social strata the disease may be found in women who are subjected to intense mental strain as the result of a desire to equal men in phys- ical efforts. Frequent pregnancy and prolonged lactation are also factors. 6. Chronic poisoning, as, e.g., by carbon monoxide. 7. Bothrioeephalus and an- chylostomuin — those eases belong here that are not cured after the expulsion of the worms. E. Grawitz (Berliner klin. Woch., Aug. 8, '98). Scarcity of hsematoblasts and loss of contractility of blood-clots are the most important signs. In severe ansemia it is usual to find that some nucleated red blood-corpuscles are present; but, apart from leucocythsemia and fi'om blood in- fections, such corpuscles are not merely scarce, but are also of small size. Hayem (La Presse Med., Oct. 7, '99). In 110 personal cases of pernicious ansemia, there were 57 males and 53 fe- males, and only four cases followed par- turition. Late middle life predisposed to it, as shown by the fact that in 82 of the eases the patients were over 40 years of age. Pernicious anaemia is much more frequent than the text-books would lead one to suppose. Some cases had pre- viously been diagnosed as tuberculosis. There was very little, if any, relation between the menopause and pernicious anaemia. It had nothing to do with syphilis. Haemorrhage was quite com- mon, especially of the nose and gums. The striking constancy of the symptoms in almost all eases, even in some of the so-called mild ones, was noted, viz.: muscular weakness, dyspnoea, gastro- intestinal disturbance (paroxysmal diar- rhoea) . The appetite was poor in all but three cases, and in these it was ravenous. In two-thirds of the eases there had been a temperature of 99° to 100° F., and even higher. The urine in 53 cases was normal, while others had had a trace of albumin with granular casts. Nervous symptoms had not been constant. Some cases had had myelitis. As to the blood, the white corpuscles were subnormal; the number of red corpuscles was 2,500,000. The diameter of the white corpuscles was greater than normal. The proportion of lymphocytes was relatively high. There was no relationship between the symp- toms and the blood condition. The aver- age duration of this disease was from one to two years. The longest-lived case was five years. All treatment was hopeless, unless the use of laxatives would be of service, woi-king along the line of Hun- ter's idea, that of gastro-intestinal tox- Eemia. Arsenic did little, if any, good in these cases. R. C. Cabot (Med. Record, May 12, 1900). Pregnant women represent the largest proportion of cases. Eepeated parturi- tion is probably the most prolific cause of the disease, for it is seldom met with in primiparse. Excessive and prolonged lactation and puerperal hsemorrhages and other exhausting conditions frequently appear as the primary element in the cairsation of the disease. Certain atrophic conditions of the gastric mucous membrane, ulcers of the stomach, malaria, syphilis, cancer, and alcoholism have also been considered as etiological factors. Infection through solutions of con- tinuity or purulent foci may possibly act as a primary cause. Intestinal parasites — the anchylostoma duodenale and the bothrioeephalus latus — are also considered as possible etiolog- ical factors. In twenty-six fatal cases in Fiji eighteen found to have anchylostoma in duodenum. Hirsch (London Lancet, Dec. 1, '94). Of t^^•enty-three native African ne- groes, representing various parts of East and West Africa, the following parasites were found: Anchylostoma duodenale, twenty-one times; trichocephalus dispar, eight times; ascaris, eight times; an- guillula stercoralis, four times; taeniae, four times; amoebae, twice. The tiegroes showed no sign of anmmui, — so striking a symptom in Europeans with anchy- ANEMIA, PERNICIOUS. PATHOLOGY. 283 lostomiasis. Zinn and Jacoby (Bei-liner klin. Woch., No. 36, '96). A severe form of anaemia due to anehylostomiasis is found among native Egyptians, in the East and West Indies, South America, and Europe. The promi- nent symptoms of this condition are coliclcy pains, irregular bowels with oc- casional attacks of diarrhoea, nausea, and more rarely vomiting. There is great weakness in some cases, with ema- ciation, and the circulatory symptoms found in the extreme anaemias, dizziness, palpitation, and hasmic murmurs are noted. Eight cases of the same kind re- ported in the United States, in which the para.site has been identified. It may be more frequent than is believed, because the intestinal discharges are not exam- ined for the parasite, the anaemic con- dition being thus regarded as primary. H. B. Allyn and M. Behrend (Amer. Med., July 13, 1901). Pathology. — The two prevailing the- ories as to the pathogenesis of pernicious ansemia are the following: 1. That the •disease is due to breaking up of the blood-corpuscles (hsemolysis). 2. That, owing to some defect in the blood-mak- ing (htemogenesis), the blood becomes vulnerable to the destructive influence ■of micro-organisms. Alterations in the size of the heart in ansemio subjects. Dilatation is com- monly met with, and sometimes, espe- cially in chlorosis, elevation of the dia- phragm displaces the heart upward and an apparent dilatation is found. Anaemic dilatation is to be considered true idio- pathic dilatation resulting from over- strain. None of the usual symptoms are present; gastralgia alone is complained of. Wybauw (Jour. M6d. de Brux., Mar. 15, 1900). Anaemic dyspnoea is mainly due to vasomotor failure; the disease is preva- lent in the female sex, whose vasomotor system is more unstable than that of the male, it usually occurs at puberty when this system is unusually active. J. Hen- ton White (Birmingham Med. Rev., Oct., 1900). The cord and nerve changes sometimes met with probably result from the same irritant. These, with the irregular course, fever, and gastro-intestinal dis- turbance, indicate a toxic cause. The general condition does not seem to bear any definite relation to the blood-state, at least as far as the number of erythro- cytes is concerned, for one individual with only 1,000,000 per cubic millimetre may be capable of prolonged efforts, while another with 4,000,0j0 may be weak and easily exhausted. Weakness, then, is not proportionate to the anae- mia, is often the earliest symptom com- plained of, and may precede the pallor. McPhedran (Lancet, Jan. 19, 1902). Deficiency of red corpuscles (oligo- cythsemia) is always very great; the blood is, therefore, pale and thin, resem- bling sherry-wine. The oligocythasmia is sometimes so marked that the normal proportion of 5,000,000 red corpuscles to the cubic millimetre is reduced to one- twenty-fifth of that number. Quincke reported a case in which there were only 143,000 to the cubic millimetre imme- diately before death. The liEemogiobin is also greatly re- duced (oligochromaBmia), but not in proportion with the cell-reduction. The haBmogiobin percentage was greater by 10 per cent, in a case seen by Osier. Emphasis upon the reduction in the number of the red blood-corpuscles. There is no disease, except pernicious anaemia, in which the number of red corpuscles is at any time reduced below 20 per cent. This affords a distinction between pernicious anaemia and latent gastric cancer: a disease with which the former is most likely to be confounded. The relativelj' high percentage of haemoglobin depends upon increased aver- age size of the corpuscles and in some oases on the presence of an unusual number of highly colored and minute microcytes. It also depends, in a meas- ure, upon the time at which the exami- nation is made. The icteric color of the skin and the dark urine are caused by 284 AN.EMIA, PERNICIOUS. PATHOLOGY. dissolution of the red blood-corpuscles, and the haemoglobin estimated at one of these periods will thus be higher, owing to the more highly colored plasma. The red blood-corpuscles show marked signs of reversion to the type of blood which is normal in the cold-blooded animals. F. P. Henry (Amer. Jour, of Med. Sciences, Aug., 1900). Besides the above, there is a species of degeneration closely resembling co- agulation-necrosis, and an alteration of the corpuscles, characterized by the ap- pearance in their interior of one or two corpuscles composed of modified haemo- globin, — degeneration hemoglohinemique. The process of regeneration is mani- fested by the presence of nucleated red corpuscles, which are divided by Ehrlich into two varieties: the normoblasts and the megaloblasts, the former correspond- ing to the haamatinic evolution of adults, the latter to that of the embryo. The nucleus of the normoblast is extruded to form a new red corpuscle, while the nucleus of the megaloblast is absorbed. Fresh blood shows nucleated red cor- puscles of large size, divided by Ehrlich into megalocytes and gigantocytes. Others are termed macrocytes. Fiirbringer has shown that a case is to be considered as one of true perni- cious anaemia only when one-fourth of the red corjDuscles are macrocytes. The presence of megaloblasts is a sign that certain pathological changes are taking place in the red marrow rather than a distinctive feature of pernicious anaemia. The macrocytes and metrocytes are more characteristic of pernicious anaemia, because they are the direct pre- cursors of the large red marrow-cells. Engel (Wiener med. Woeh., No. 20, '98). By the subcutaneous injection of the muriate of phenylhydrazin into animals a condition of the blood similar to that in pernicious anaemia is obtained. The view that pernicious anaemia is a true haemoglobinaemia questioned. S. Kami- ner and E. Eohnstein (Berliner klin. Woch., July 30, 1900). Misshapen corpuscles (poikilocytes) are very frequently observed, oftener, indeed, than in any other afliection. Many small, imperfectly developed cor- puscles (mierocytes) are generally found. In marked cases corpuscles endowed with motion are occasionally observed. Red blood-corpuscles of normal blood are motionless. The elements observed in eases of high degree of anaemia are endowed with four kinds of motion: 1. A movement of the entire mass of the corpuscle. 2. The projection of mobile prolongations. 3. A movement of oscil- lation, manifested slowly by minute cor- puscles. 4. A movement which results in changing the position of the cor- puscles. These movable coi-puscles are bodies arrested in their evolution and still retaining the contractile properties of the haematoblasts from which the red corpuscles originate. On superficial ex- amination they might readily be mis- taken for parasites. Hay em (La Mede- cine Moderne, Feb. 26, '90). [Several years ago I observed distinct movements in the red corpuscles in a case of pernicious anaemia, but made no public mention of the interesting fact. F. P. Heney, Assoc. Ed., Annual, '91.] Large number of amoeboid corpuscles found in fresh-blood preparations, larger than red corpuscles, and possessed of very active movements. Perles (Medical Press, June, '93). [In view of the fact that the red blood- corpuscles of pernicious anaemia have been observed by Hayem and others to be possessed of amoeboid movements, I would hesitate, in the absence of further proof, to regard the bodies described by Perles as other than degenerated blood- constituents. F. P. Henry, Assoc. Ed., Annual, '94.] Small, mobile bodies ob.served, staining the same as red coi-puscles and resem- bling fragments of haematins, thought to possess pathognomonic value. Senator (Le Bulletin Medical, May 26, '95). AN/EMIA, PERNICIOUS. PATHOLOGY. 285 study of flfty eases. Most typical points in the blood: 1. A reduction of the number of red cells to about 1,000,- 000. 2. The absence of leucocytosis. 3. Possibly a relatively high percentage of hfEmoglobin in some cases. 4. Increase in average diameter of the red cells. 5. The presence of large number of poly- chromophilic red cells. 6. The presence of nucleated red cells, a minority being normoblasts. 7. The presence of mye- locytes. 8. A relatively high percentage of small lymphocytes at the expense of the poljanorphonuclear cells. Cabot (Boston Med. and Surg. Jour., Aug. 6, '96). Pernicious anaemia is essentially a htemolytic disease, the haemolysis being due to some as yet unknown poison comparable in its effect on the blood and blood-organs to the action of toluylene-diamine — vs'hether autointoxi- cation or infection remains yet to be determined. The poison of pernicious anaemia stimulates the phagocytes of the spleen, lymph- and haemolympli- glands, and bone-marrow to increased haemolysis (cellular haemolysis). Either the phagocytes are directly stimulated to increased destruction of red cells or the latter are so changed by the poison that they themselves stimulate the phagocytes. The haemoh'sis of perni- cious anaemia differs only in degree, not in kind, from normal haemolysis or the pathological increase occurring in sep- sis, typhoid, etc. It is not improbable that from the destruction of haemoglo- bin poisonous products (histon ?) may be formed which has also a haemolytic action; a vicious circle of haemolj'sis may thus be produced. Ko proof of this exists at present. The haemolysis of pernicious anaemia is not confined to the portal area, as according to Hun- ter, but in some cases at least takes place also to a large extent in the pre- vertebral lymph- and haemolymph- nodes and bone-marrow. In the majority of eases the spleen is the chief seat of the blood-destruction. No evidences of haemolysis in the liver, stomach, and intestinal capillaries were found in the eight cases. The haemosiderin of the liver and kidnevs is carried to these organs as some soluble derivative of liaemoglobin, is removed from the cir- culation as haemosiderin by the en- dothelium, and then transferred to the liver- or kidney- cells. The deposit of iron in these organs is of the nature of an excretion. In the majority of cases only slight reaction for iron is found at the sites of actual haemolysis (spleen, Ijonph- and haemolymph- glands, and bone-marrow). The greater part of the pigment in the phagocytes of the spleen, Imyph- and haemolymph- glands does not give an iron reaction while in a diffuse form. ^Vhen changed to a granular pigment the iron reaction may usually be obtained. The change to haemosiderin is for the gi'eater part ac- complished by the endothelium of the liver and kidneys. The varying path- ological conditions found in these dif- ferent cases of pernicious anaemia can be explained only by a theory of cyclical or intermittent process of haemolysis. This theory is also borne out by the exacerbations so frequently seen clin- ically. The autopsy findings, in so far as evidences of haemolysis are concerned, Mill depend on the relation between the time of death and the stage of the haemolysis. The changes in the haem- olymph - glands found constantly in these eight cases were: dilatation of the blood-sinuses and evidences of in- creased haemolysis, as shown by the in- creased number of phagocytes contain- ing disintegrating red cells and blood- pigment. In some of the cases these changes were accompanied by great in- crease in size and apparent increase in the number of hasmolj'mph-glands ; in other cases there was no hyperplasia, the only evidence of the changes present being that obtained by the microscopical examination. The changes found can- not be regarded as a specific of per- nicious anemia, since it is probable that they may be produced by other infections or toxic processes character- ized by great haemolysis. The lymphoid and megaloblastic changes in the bone- marrow do not form an essential part of the pathology of pernicious anaemia, and are to be regarded as of a com- pensatory nature: an increased activity of red-cell formation to supply the defi- 286 ANEMIA, PERNICIOUS. PATHOLOGY. ciency caused by the excessive hae- molysis. A. S. Warthin (Amer. Jour. Med. Sciences, Oct., 1902). In cases in which the urine is dark the latter is found to contain patholog- ical urobilin: a substance known to be derived from the disintegration of haem- oglobin. Peculiarity of highly colored urine is that it presents a low specific gravity, averaging 1.014. Presence of patholog- ical urobilin described by MacMunn of high diagnostic significance. W. Hunter (Brit. Med. Jour., July 5, '90). Case in which the urine, instead of presenting the appearance upon which so much stress is justly laid by Hunter, was habitually pale. R. Douglas Powell (Clinical Journal, Aug., '96). The gastric and intestinal disorders are probably due to the formation of a toxin, which, in turn, acts as the etio- logical factor of the general disease. Two ptomaines — cadaverin and pu- trescin, which are never formed except by the action of micro-organisms — found in the urine of a case. They are not the result of ordinary putrefactive changes, for, in scarlet fever, diphtheria, typhoid fever, and other affections in which putrefactive processes in the intestines are in excess, they are absent from the urine. They have been found in no other condition but cystinuria: three cases, the first of which was studied by Udranzky and Baumann, the last two by Brieger. The presence of these ptomaines in this case indicates the action of special micro-organisms in its causation. W. Hunter (Brit. Med. Jour., July 5, 12, '90). The addition of putrid serum causing normal blood to rapidly form haemo- globin crystals suggests the probability that the disease is dependent upon the formation of some poison or ferment as- sociated with micro-organisms. F. W. Mott (London Lancet, Feb. 8, '90). The so-called idiopathic, or "crypto- genetic," varieties are probably due to the destruction of the red corpuscles by poisonous substances : toxins or enzymes formed within the bodv itself or intro- duced into it from without. Birch- Hirschfeld (La Semaine Medicale, Apr. 23, '92). Typical case in which, although no special derangement of digestion was complained of, there was found at the autopsy a high degree of atrophy of the glandular structure of the stomach and intestines. Eisenlohr (Medical News, Apr. 2, '92). It is a question whether there can be any more satisfactory explanation of certain cases of surgical infection than this theory of the possible infection of wounds, not from outside, but from bac- teria circulating in the tissues, which, under normal conditions, are destroyed and rendered harmless, but which under the abnormal traumatic conditions of the operation are now able to pro- liferate and set up local disturbances. The usual explanation of the abun- dant growth of bacteria in the vari- ous organs after death is that, while there may oftentimes occur an agonal invasion of bacteria, the essential cause of putrefaction is the entry of bacteria, more especially through the intestines after death. This explanation is based on the observation of large numbers of intestinal bacteria in the tissues about ten hours after death. The author be- lieves this appearance of post-mortem in- vasion of the tissues is only apparent, not a real fact ; it occurs because there is a preliminary period in which the bac- tericidal action of the tissues continues and the number of bacteria to be ob- tained from the tissues by ordinary methods is singularly small; following this there is multiplication. The ex- istence of a condition of subinfection is considered probable. The Avriter has found minute diplococcoid bodies pecul- iarly frequent in the liver-cells in cases of hepatic cirrhosis. The frequency with which the colon bacillus has been found by other observers, associated with more acute hepatic disease, renders it not im- possible that this bacillus may have some part to play in connection with the con- dition. A careful study of material from cases of hsemochromatosis with the high- est power shows that when the pigment has not clumped together into too large ANEMIA, PERNICIOUS. PATHOLOGY. 28r masses in the liver-cells for example, or in the abdominal lymphatic glands, there are, in a very large proportion of the ultimate fine masses of ■pigment, distinct diplococcoid forms or bodies. In short, the condition of hsemochromatosis is of bacterial origin. Anderson, one of the writer's demonstrators, has made a spe- cial study of the bacteriology of the stomach in three cases of pernicious anaemia. He has found in all a complete absence of hydrochloric acid, with the presence, however, of considerable quan- tities of lactic and some butyric acid, and in all the eases he obtained by plat- ing pure cultures of the colon bacillus, and, what is more, on making sections from one of the stomachs he found numerous diplococcoid forms in the sub- mucous tissue. This was long before the nature of the pigment in the liver had been realized. In order to confirm the result. Ford made an independer-t exam- ination in a case at the Royal Victoria Hospital, which absolutely confirmed the findings of Anderson in every respect. J. George Adami (Jour. Amer. Med. Assoc, Dec. 23, '99). Carious teeth are seen extremely com- monly in this disease; inflammation of the mouth and tongue is also exceedingly common, as are gastric symptoms; the gastric catarrh is of an infectious nature and is dependent upon the caries of the teeth. The original infection may usu- ally be traced to the teeth. Sometimes to drain poisons. Hunter (Lancet, Jan. 27, 1900). Case of pernicious anaemia following on traumatic stricture of the small in- testine. The necropsy confirmed the diagnosis of pernicious anaemia. The ex- amination of the blood presented a typ- ical picture of that disease. The patient had always had bad teeth, with alternate alveolar and ethmoidal suppuration, and chronic gastric catarrh, thus bearing out Hunter's idea as to pernicious anaemia being due to self-intoxication from the intestinal tract. A. E. Barker (Lancet, July 21 IPOO). Eighteen cases of bothriocephalus latua anaemia and 3 of pernicious anae- mia showed that, before removal of the worm, increased decomposition of albu- min was present, while after removal of the parasite albuminous metabolism was not as greatly affected. Decomposition of albumin is probably due to some toxin produced by the worm. E. Rosen- quist (Berliner klin. Woch., June 24, 1901). Conclusions regarding the enteroge- nous origin of pernicious anaemia from experiments performed on metabolism are not tenable because we do not al- ways know under what form of diet the disease occurs. Personal disposition must be taken into consideration. Many theories are exaggerated; the symptoms present in pernicious anaemia, frequently exist without serious blood- changes being present. E. Grawitz (Ber- liner klin. Woch., June 17, 1901). The spleen is generally thought to pre- sent no characteristic lesion, although the amount of iron in it is usually in- creased. Case in which there was, besides severe haemolysis, sclerosis of the spleen and. pancreas, with marked changes in the suprarenal capsules. Douglas Stanley (Brit. Med. Jour., Feb. 16, '95). Case in which a microscopical exami- nation of the spleen showed no increase- of connective tissue and a marked diminution of cellular elements, both of the Malpighian bodies and of the spleen pulp. In many of the Malpighian bodies the small, round cells were entirely want- ing. A slight reaction for iron, haemo- siderin, was developed by potassium ferrocyanide and acidified glycerin, but it was much less marked than in the liver. There was no granular pigment observed as a result of the extensive de- struction of the red blood-cells. James Ewing (Med. Record, Sept. 5, '96). Case in which the total quantity of iron found in the liver was 0.2433 per cent, by weight calculated to the fresh undried tissue. This is equivalent to- about 0.72 per cent, in the dried tissue. The estimation accords fully with the observations of previous observers, as showing the very great increase in the iron contained in the liver in this disease. E. F. Euttan and J. G. Adami (Brit. Med. Jour., Dec. 12, '96). 288 ANEMIA, PERNICIOUS. PATHOLOGY. The jaundice is probably due to accu- mulation of iron in the hepatic system. Fatal C£Lse of pernicious anaemia in a woman aged 49. Chemical examination of liver, spleen, and kidney showing that the liver contained a large proportion of iron in the ferric state, while the spleen was free from iron in appreciable amount. F. W. Mott (London Lancet, Feb. 8, '90). Autopsy of a case. Iron reaction well marked in liver and kidneys, but absent in spleen; the amount of iron in the liver found by quantitive analysis to be five times greater than normal. T. N. Kelynack and F. J. H. Coutts (Medical Chronicle, Sept., '92). Inquiry into the after-history of 22 cases. Tlie disease believed to be due to an increase in the destructive action of the liver upon the red blood-corpuscles. While the 22 cases were thought to be "cured" by various means, 10 died of the disease, and only 2 were known to be living at the time of the investigation. H. C. Colman (Edinburgh Med. Jour., Mar. and Apr., 1901). The posterior and lateral spinal tracts present changes resembling those ob- served in tabes. Study of seventeen eases. The degree of nervous affection not necessarily pro- portionate to the degree of anaemia. In pernicious anaemia any of the spinal symptoms of tabes may be present, while symptoms entirely foreign to tabes may also occur. Diseased centres in any por- tion of white substance, preferably in posterior columns; gray substance, zone of Lissauer, and intermedullary roots re- main unaffected. Nonne (Deutsche Zeit- schrift filr Nervenh., vol. v). Microscopical appearances of brain in a case: haemorrhages in the substance of the hemispheres; round, structureless bodies, resembling corpora amylacea, ar- ranged in groups; fatty degeneration of the cells of the motor region; shrinkage and vacuolation of the cells of Purkinje. Biruli (St. Petersburger med. Woch., June 30, '94). In nine cases localization of centres found to be the same as that given by others, — Nonne, for instance. A primary and possibly toxic affection of the nerve- fibres supposed. C. W. Burr (University Med. Mag., Apr., '95). Three cases of pernicious anaemia with spinal-cord symptoms, one ending fatally after several weeks. Angel Money (Aus- tralasian Medical Gazette, June 15, '95). Changes in spinal cord similar to those met with in pernicious anaemia may occur in a variety of other diseases, com- bined with cachexia and marasmus, Ad- dison's disease, diabetes, etc. W. Miiller (Berichte der 24 deutscher Chirurgentag, '95). Case with arteriosclerosis, parsesthesia, chronic enteritis, and increased knee-jerk. Small haemorrhages found post-mortem in the corpora striata and corpora quad- rigemina. Microscopical examination showed, besides changes described by others in the posterior columns, haemor- rhages in both the gray and white matter, with degeneration in the anterior and lateral columns of the cord. The change in the gray matter is of chief importance in this disease. Teichmiiller (Deutsche Zeitsch. filr Nervenheilkunde, B. 8, H. 5, 6, '96). Study of nine cases: small haemor- rhages and consecutive sclerosis are fre- quently met with in the spinal marrow. These haemorrhages have no significance from a clinical point of view. The vessels often show thickening and com- mencing hyaline degeneration (not, how- ever, as a rule) , combined with degenera- tion of the nervous elements. From a study of the literature it appears that comparatively few cases of pernicious anaemia present a real disease of the spinal cord. The symptoms of anaemia remain unchanged in cases in which it does occur, and it is difficult to explain why the cord should be affected in some cases and not in others. The disease of the cord manifests itself witli somewhat varying symptoms, certain of which, however, are exhibited in all eases. From an anatomical point of view the alterations have considerable variations; but this is accounted for, to a great ex- tent, by the fact that the process has been observed at a different stage in the ANEMIA, PERNICIOUS. PATHOLOGY. 289 various cases. From a closer analysis of the cases it appears that the degenera- tion progresses in a fairl.y regular man- ner. It is presumable that these cases of disease of the spinal cord form a special group, even from a neurological point of view. It may be admitted that some toxic condition is the common, immediate cause of the disease of the spinal marrow as well as of the anaemia. The altera- tions of the spinal cord are here wholly diflferent from those found in tuberculo- sis and diabetes, where the changes can easily be distinguished by slightly- marked and chronic degeneration, such as is often found in Addison's disease. Charles Petren (Inaugural Dissertation, Stockholm; Universal Medical Journal, Feb., '96). Evidence showing that extensive changes may be present in the cord in cases of pernicious anaemia without any marked clinical symptoms, and that the lesions are of somewhat diverse charac- ter. Whether the degenerations of sys- temic tracts depend on haemorrhagic or myelitic foci in all cases there seems hardly yet sufficient evidence to show; the predominant affection of the pos- terior columns in the majority of cases, and their degeneration throughout the whole length of the cord on both sides, rather point to an independent affection of these tracts. J. Miohell Clarke (Brit. Med. Jour., Aug. 7, '97). In cases of pernicious anaemia the de- generative changes in the cord sometimes observed are not the result of mere anae- mia, but are more probably the result of hitherto undiscovered chemical agents. A thorough examination of the metab- olism in pernicious anaemia might, per- haps, throw further light on the question. G. von Voss (Deutsche Arch. f. klin. Med., vol. Iviii, p. 489, '97). Study of pathological lesions found in the spinal cord in cases of pernicious anaemia showed that there was usually a degeneration affecting the posterior columns, sometimes the posterior and lateral together, but never the lateral alone. This degeneration was chiefly in the nerve-fibres, and was unaccompanied by shrinking of the cord, such as was seen in locomotor ataxia. Seventeen 1- cases analyzed in which initial nervous symptom was always a persistent parses- thesia, usually of the foot, associated with some weakness. This was generally followed quickly by ataxia and loss of motor power, and severe pains in the back and limbs were not uncommon. The disease progressed rather rapidly, so that often within one or two months the symptoms were well developed. In from si.x months to a year the progress com- monly reached its acme, and during this time the anaemia became marked. After a time the control of the bladder and the rectum was lost and in fatal cases death occurred in from six months to two years. The essential nature of the process was a primary nerve-degenera- tion affecting the neuraxons first, par- ticularly in the columns of Goll and the crossed pyramidal tract. The same poison which caused pernicious anaemia was responsible for this disease. It usu- ally developed between the ages of 50 and 60 years, and followed the acute infections, prolonged diarrhoeal or dysen- teric attacks, lead poisoning, malarial infection, etc. In 10 per cent, or more of the cases pernicious anaemia un- doubtedly co-existed. Charles L. Dana (N. Y. Med. Jour., Nov. 19, '98). Examination of the spinal cord in cases of pernicious anaemia by the Marehi method. Resvilts summarized as follows: (1) the changes in the spinal cord in fatal cases of anaemia are not systematic, but should be regarded as acute disseminated myelitis; (2) the foci exhibit a local association with the blood-vessels; (3) it is probable that a noxious material is carried to the cord by the blood-vessels, and this acts upon the nervous tissue; similar changes are found in old age; (4) even in advanced cases the gray matter may escape in- volvement; (.5) if diseased, it is not pri- marily affected^ — that is to say, it and the white matter are involved as the re- sult of a single cause; (6) the diffuse character of the degeneration in these conditions justifies the conclusion that there is a trophic alteration, and not a functional injury of the nervous element: (7) the greater part of degenerated fibres are found in the posterior roots 290 ANJJMIA, PERNICIOUS. PATHOLOGY. and the anterior commissure. Nonne (Dent. Zeits. f. Nervenheilk., Mar. 9, '99). Case of combined sclerosis of Lielit- heim-Putnam-Dana type accompanying pernicious antemia. Tlie condition thought to be a primary sj'stemic de- generation dependent upon the perni- cious antemia. Brown, Langdon, and Wolfstein (Jour. Amer. Med. Assoc, Mar. 2, 1901). There is a well-established relation of diffuse cord degeneration with per- nicious aneemia. In seems highly prob- able that the haemolysis and the cord- changes are due to the same toxin. While the source of the toxin is un- known, the fact that gastro-intestinal disturbance is so common in the disease would lead one to suppose that it is of intestinal origin. The diffuse de- generations of the spinal cord which occur in conditions without pernicious anaemia do not appear to differ essen- tially from those of pernicious auEemia. It is possible that a common blood- circulating poison exists, which may expend its force upon the blood in one individual, upon the nervous apparatus in another, and coincidently upon the blood and spinal cord in others. Fi-ank Billings (Boston Med. and Surg. Jour., Aug. 28 and Sept. 4, 1902). The bone-marrow usually presents changes. Those most frequently found, according to Muir, are (a) increased num- ber of nucleated red corpuscles in the marrow; (6) transformation of the fatty marrow in the shafts of the long bones into red marrow; (c) absorption of the bone-trabeculEe between the red marrow. Bone-marrow of a case com] mainly of hsematoblasts. Normally, the formation of red corpuscles is probably due to the constricting off, from the nu- cleus, of the hajmatoblast of protoplasm, colored with hasmoglobin. In pernicious ansemia this process does not take place. Rindfleisch (Virchow's Archiv fiir path- ologische Anatomic, B. 121, p. 176, '91). Autopsy showing that the marrow had returned to the foetal condition. A. Pineau (La France Med., Mar. II, '92). From the point of view of the function of the bone-marrow, three types of per- nicious ansemia may be made: (1) cas«s without any reaction on the part of the bone-marrow; (2) those in which the reaction is insufficient; (3) those in which there is a degeneration of the bone-marrow, on account of which it fur- nishes almost exclusively disintegrating megaloblasts. The condition of the blood is not always an evidence of the changes taking place in the bone-marrow. The percolation of the bone-marrow seems not to occur in a uniform manner, that it does not seem to affect all the elements in the same way. Neusser (Wiener klin. Woch., Apr. 13, '9^). Five cases of grave anaemia in which the bone-marrow apparently had lost its power of forming red corpuscles at a comparatively early period, as the exam- ination of the blood showed no nucleated or polyehromatophilic red corpuscles. An absence of nucleated red corpuscles in the blood in cases of grave anaemia indicates that there is no new formation of red coi-puscles taking place. The prog- nosis for such cases is extremely bad. When the number of red corpuscles is above 1,500,000 per cubic millimetre, the presence or absence of nucleated red corpuscles is of little significance ; but, when they are below that number and nucleated red corpuscles are absent, a fatal result may be confidently pre- dicted. J. S. Billings (N. Y. Med Jour., May 20, '99). The albuminoid constituent of the or- ganism may be at fault. Fatal case in which examination of the- blood-serum showed that the proteids of the plasma were altered in their respect- ive proportions. Adami (Montreal Med. Jour., Aug., '93). Analysis of the blood-serum removed from the right heart: it was clear, al- most colorless, had a specific gravity of 1026.1. This is below the figure usually given as being that of the specific gravity of serum, namely: 1027 to 1030. It con- AN.EMIA, PERNICIOUS. PROGNOSIS. TREATMENT. 291 tained only 5.2 per cent, of proteids (by weight). These proteids consisted of 2.3 per cent, of globulins precipitated by saturation with magnesium sulphate, and 2.9 per cent, of serum-albumin proper. There was 0.875 per cent, of ash. It will thus be seen that not only were the total proteids reduced about 40 per cent, below the average normal quantity, but also that the normal ratio of the globulins to the serum-albumin was considerably al- tered; the ash, also, was about I2,'/2 per cent, above the normal. R. F. Ruttan and J. G. Adami (Brit. Med. Jour., Dec. 12, '96). As ill understood as the etiology of the disease is the actual condition of the blood. The microscopical appearances are well known, but the true chemical changes have almost entirely been neg- lected. The blood in pernicious aniemia contains a larger quantity of water than normal blood, a smaller quantity of solids, a higher proportion of chlorine, and a lower proportion of potassium, iron, and fat. There is not sufficient so- dium to hold the chlorine fixed, and the potassium is also deficient. In various tissues the proportion of water was higher than normal in the heart, and lower in the liver, spleen, and brain. Treatment of pernicious anaemia with potassium carbonate, tartrate, and cit- rate, in four cases, three of which were dying, resulted in recovery. Th. Rumpf (Berliner klin. Woch., May 6, 1901). The disease may be due to some hitherto undiscovered organism. Two cases in which 5-milligramme in- jections of sublimate daily for the space of two months were followed by rapid improvement. Patera (Riforma Medica, May 23, '96). The causes of the disease are of a complex nature. Some cases present no appreciable lesions. Case in which death occurred from gradual asthenia. Entire absence of or- ganic disease in all the organs examined ; blood-count gave 1,600,000 red corpuscles per cubic millimetre (32 per cent.), while haemoglobin amounted to 16 per cent. J. H. Musser (University Med. Magazine, July, '93) . [A disproportion of this kind is cer- tainly unusual in pernicious anaemia. F. P. Henby, Assoc. Ed., Annual, '94.] A high degree of ansemia usually fol- lows numerous predisposing causes. In some it tends to cause degenerative changes in vessels, leading, in turn, to capillary haemorrhages, conferring per- nicious character. R. Stockman (Brit. Med. Jour., May 4, '95). [I have for many years maintained that the arguments in favor of the "idio- pathic" nature of pernicious anaemia are very faulty. F. P. Henry, Assoc. Ed., Annual, '96.] Prognosis. — The mortality, from very nearly 100 per cent., has been greatly re- duced since the introduction, by Byrom Bramwell, of Edinburgh, of arsenic. A guarded prognosis should always be given, however, relapses being exceed- ingly common. About one-half of the fatal cases last from one to six months; the remaining seldom reach beyond the second year. In attempting to reach a decision as to the efficacy of any plan pursued in the treatment of pernicious anaemia, it is to be borne in mind that periods of transitory improvement, of varying dura- tion, are often a part of the natural course of the disease; so that too much importance must not be attached to the favorable results that may follow the special line of medication employed. Even if such improvement continue for a long time, the conclusion must not be too hastily reached that the disease is cured. Editorial (Med. Record, Nov. 14, '96). Treatment. — Arsenic cures the cur- able cases and benefits the others. Iron is worse than xiseless, having shown it- self injurious in several cases reported. Fowler's solution may be given in 3- minim doses three times a day, increased 292 ANEMIA, PERNICIOUS. TREATMENT. by 1 minim daily until 30 minims are taken after each meal, provided the stomach do€S not rebel, which is seldom the case. The patient should be watched and the drug reduced or discontinued temporarily on the appearance of any of the physiological effects of arsenic: cedema of the lids, etc. Arsenic is as much of a specific in per- nicious ansemia as mercury is in syphilis. Warfvinge (Transactions of the Eleventh International Medical Congress, '94). Iron produces no permanent benefit. Acid preparations of phosphorus exert a temporary tonic effect. Intestinal antiseptics, advocated by Hunter, only of use in eases complicated by gastro-enteric fermentations. Alcohol (that is, distilled liquors) does no good; malt liquors — ale or beer — if borne well, retard progress of disease. Arsenic, when tolerated in heroic doses, is very beneficial, but no permanent cures have been authenticated. I. N. Danforth (Boston Med. and Surg. Jour., June 25, '96). Case, which came under observation in 1892, of a man whose blood showed only 1,600,000 red corpuscles to the cubic millimetre. Under arsenic the red cor- puscles rose to 4,000,000 and the man was practically well. In 1893 he re- lapsed, and on ascending doses of Fow- ler's solution he improved and went back to work as roller in a rolling-mill. In the following year he returned to the hospital in a worse condition than pre- viously. Again, on arsenic he improved. Now, two years later, he is large and portly, weighing 250 pounds. His haemo- globin is 90 per cent, and blood-corpuscles 4,800,000. M. H. Fussell (Boston Med. and Surg. Jour., June 25, '96). Marked case (mentioned under Pa- thology) in which large doses of arsenic (for several days the patient took no less than from 50 to 60 minims of Fow- ler's solution in the twenty-four hours) caused remarkably rapid recovery. The condition of the blood improved and the jaundice removed along with other symp- toms. Table Showing the Condition of the Blood and Dose of Arsenic at Different Dates. Date. i i is |^P.i May 5th May lObh May 16tli May 20th May 23d May 26th 810.000 970.000 1,710,000 20 28 40 S 46 64 64 88 13,000 12,000 50 minims. 60 minima. 40 minima. 40 minima. 40 minima. 40 minima. 2.650,000 2.9.50.000 2,700,000 3,420.000 4,010,000 Juna 14th July 20th 12,000 14,000 Byrom Bramwell (Lancet, July 24, '97). At least two years should elapse before a patient is reported cured. Patient who has been cured of pernicious ansemia for the space of two years by the use of arsenic pushed to the point of tolerance. The gentleman now an active business- man. F. P. Henry (Boston Med. and Surg. Jour., June 25, '90). There is no specific remedy for per- nicious ansemia. Rest in bed is one of the first requisites, the assimilation of food must be stimulated. Lavage of the stomach, intestinal irrigation, and saline laxatives are useful. In rare eases with diarrhoea, calomel may first be given; later astringents, such as tannin. If the urine contain much indiean intestinal antiseptics are indicated. Iron is of no value, and in the beginning is contra- indicated. Arsenic is the best remedy; can be given with quinine. Inhalations of oxygen have been employed with ad- vantage. Massage and gymnastic exer- cises are often of service. After apparent recovery the patient must be carefully observed, as relapses are likely to occur, particularly if the hygienic and dietetic conditions are unfavorable. E. Grawitz (Berliner klin. Woch., Aug. 15, '98). When the gastric disorder, which is a usual symptom, prevents the admin- istration of arsenic, the latter may be given subcutaneously, while the stomach is treated directly by lavage. An excess of hydrochloric acid is not uncommonly found in the gastric secre- tions. In such cases See recommends an almost exclusive diet of meat and AN./EMIA, PERNICIOUS. TREATMENT. 293 other albuminous foods: raw meat to the extent of 10 to 12 ounces daily. Bone-marrow sometimes proves cura- tive. Case successfully treated with bone- marrow, uncooked, 3 ounces daily. In a ease in which the prolonged administra- tion of iron and arsenic in both medium and large doses was proved useless. Thomas R. Fraser (Brit. Med. Jour., June 2, '94). The plain marrow cannot always be administered on account of the abjection of the patients. The red marrow from the tibia of the calf, mixed with an equal quantity of glycerin and rubbed up in a mortar, results in a preparation of pleas- ant taste and one that can be eaten with bread without disturbing the stomach. The preparation may be made more fluid by the addition of claret or port wine. Alfred Stengel (Therapeutic Gazette, No. 13, '96). Severe case of pernicious anaemia, com- plicated with oedema, ascites, and cardiac symptoms; 2 Vi-ounce doses of fresh bone-marrow administered daily in soup or on bread. The patient was cured in two and a half months. Blumenau (Pediatrics, June 15, '97). (See also Animal Extracts.) In pernicious anaemia bone-marrow is not by any means of constant value. Such cases with large doses of iron and arsenic do very often improve. But herein lies the difference clinically be- tween simple and malignant antemia: in the former complete cure results, but with tendency to relapse, when the case is appropriately treated. In the latter, at the best some improvement occurs. The amount of h.-emoglobin increases, but does not attain the normal, and in no long time the patient is as bad as ever. T. G. Stewart (Clinical Journal, Sept. 14, '98). Transfusion of blood should be re- sorted to when improvement does not follow the administration of arsenic. Transfusion of blood recommended. Blood a very indigestible substance. The practice of drinking it at slaughter- houses is not to be commended. Laache (Wiener klin. Woch., Sept. 18, '89). Case treated successfully by trans- fusion of blood defibrinated and mingled with a 2-per-cent. solution of phosphate of sodium in the proportion of 5 '/j ounces of the former to 3 ounces of the latter. W. G. Evans (London Lancet, May 13, '94). [Transfusion should never be omitted if improvement does not follow the free use of arsenic. The best method is that employed by Brakenridge, of Edinburgh (Edinburgh Med. Journal, Oct., '92). The blood is kept fluid by admixture with one-third part of its bulk of a 1-to- 20 (5 per cent.) solution of phosphate of soda in distilled water kept at blood- heat. John Duncan, who performed the transfusions in Brakenridge's eases, in- sists upon the necessity of slowness in operating. He regards thirty minutes as the minimum time that should be occu- pied in injecting 8 ounces of the fluid. — F. P. Henry, Assoc. Ed., Annual, '94.] Defibrinated blood has been used sub- cutaneously by Westphalen, with success. Suhcittaneous injections of normal saline solution may replace transfusion. Case of a man, aged 55 years, in whom blood-count showed 480,000 per cubic millimetre; hsemoglobin, 20 per cent. There was delirium, vomiting, and diar- rhcea. Treatment by subcutaneous injec- tions of normal, saline solution on every alternate day, and the intervening by saline enemata, with arsenic internally. Patient practically well. Alexander Mc- Phedran (Canadian Pract., Nov., '97). Protonuclein seems to possess curative properties. Marked case in which protonuclein was used as a last resort. A 3-grain tablet ordered to be taken every three hours and all other remedies suspended. Two days later kidneys were acting more freely, but patient's condition otherwise unchanged. The tablets then given every two hours. Three days later very de- cided improvement. The kidneys were acting freely, skin moist, cedema passing away, and a decided gain in general. 394 ANEMIA, PERNICIOUS. ANALGEN. Improvement continued several weeks, after which the treatment was altered, the tablets being taken every three hours, together with V20 grain arsenous acid thrice daily. Recovery. R. P. Beggs (Amer. Medico-Surg. Bull., Dec. 19, '96). Intestinal antiseptics have been rec- ommended. The best intestinal antiseptic is beta- naphthol and salol, along with arsenic when that can be borne. William Hunter (Brit. Med. Jour., Apr., '94). [I would take exception to Hunter's statement that salol is an intestinal an- tiseptic. "An intestinal antiseptic," ac- cording to Bouchard, — and there is no better authority, — "must be more or less insoluble and e.xert no toxic action on the organism. This definition excludes salol, which no sooner comes in contact with the alkaline secretions of the intes- tine than it splits into carbolic and salicylic acids, both of which are rapidly absorbed." The best intestinal antiseptic is un- doubtedly thymol: a fact which seems to be more fully appreciated in Italy than elsewhere. In accordance witli the view that pernicious anaemia is due to the absorption from the intestine of sub- stances foreign to the healthy body, and destructive to the red corpuscles, its treatment by intestinal antiseptics is certainly most rational. F. P. Henry, Assoc. Ed., Annual, '95.] "When the disease is due to the an- chylostonia diiodenale, thymol, 2 to 3 drachms daily, is a very effective vermi- cide, according to Bozzolo. Senim-therapy seems to merit further trial. Antistreptococcic serum used with gratifying results in two cases of anoe- mia: one pernicious, the other simple. In the former, examination of the blood showed 4000 white and less than 1,000,- 000 red corpuscles to the cubic centi metre, and 30 per cent, of htemoglobin Eight injections of 8 cubic centimetres each were given at intervals of two or three daj's. After the third, improve ment began and progressed steadily. Three days after the last injection the blood contained 5000 white and 4,960,000 red corpuscles, and 90 per cent, of haemo- globin. W. H. de Witt (Cin. Lancet- Clinic, Ixxxiv, p. 61, 1900). Case of a man, 37 years of age, whose symptoms, on coming under observation, were: (1) weakness and extreme anae- mia — the red corpuscles were 27 per cent, and hsemoglobin 35 per cent., with poiki- loeytosis; (2) a lemon color of the skin with urobilinuria ; (3) a sore tongue, dental neci-osis, suppuration of the gums, and gastric pains; (4) tingling and numbness of the fingers and irregular pyrexia. The treatment consisted of oral and gastric antisepsis. During July three in- jections of antistreptococcic serum were given. After the first the red corpuscles rose to 30 per cent.; after the second to 52 per cent.; and in three weeks the red corpuscles rose to 65 per cent, and the hsemoglobin to 72 per cent. In Septem- ber arsenic was added to the other treat- ment, and by December the red corpus- cles had risen to 94 per cent, and the hsemoglobin to 100 per cent. William Hunter (Lancet, Mar. 30, 1901). Feederick p. Heney, Philadelphia. AN.a:STHESIA. See individual anaes- thetics. ANALG-EN. — Analgen is a derivative of quinoline and occurs as a white crys- talline powder readily soluble in hot alco- hol, slightly so in cold alcohol, but in- soluble in water. It is tasteless. Dose. — The dose is from 4 to 10 grains, repeated every three hours if necessary. Maximum single dose 15 V= grains and the maximum daily dose 1 drachm. Schreiber (Amer. Medico-Surg. Bull., Jan. 25, '95). Although of no pathological signifi- cance, the fact that analgen causes a red discoloration of the urine sometimes frightens the patient, and he should be informed of this phenomenon. ANESIN. 295 Physiological Action. — Analgen seems to act upon the sensitive centres, lower- ing their excitability. The separation products of the drug are frequently elim- inated by the urine, which is of a red color, rendered more marked by the ad- dition of acetic acid, — 1 to 10 (Dujardin- Beaumetz and Dubief). Bicarbonate of soda, given internally, is said to prevent this discoloration. Therapeutics. — Analgen is mainly used in the treatment of conditions in which pain is a prominent feature. jSTeukalgia. — In this disorder it often proves very efficient. Antineuralgic action tested in 22 oases. In 10 of simple neuralgia, 8 recoveries, the 2 failures being in hysterical sub- jects. In 3 cas.es of migrr.ine, 1 cured. Succeeded in 3 cases of rheumatic pains. Failed in zona and tabetic pains. Un- toward symptoms: an intense headache in 1 patient and buzzing in the ears. Spiegelberg (Munchener med. Woch., Apr. 4, '93). Used in about two hundred cases, the majority neuralgia. The full dose of 15 grains necessary to produce relief. Foy (Med. Press and Circular, June 13, '94). Febeile Conditions. — In the various disorders presenting fever as a promi- nent symptom, whether due to malaria, infectious processes, or to the undue presence in the blood of products of elimination, it has been credited with considerable merit. Analgen is valuable as an antipyretic and germicide. One and one-fourth to 1 'A drachms daily cause fall of tem- perature of from 3 1° to 5° F., within half an hour after the first dose of 15 to 30 grains, continuing for three days, often accompanied by profuse perspira- tion. Phthisical patients experience a peculiar feeling of well-being from its use. In doses of ^/,, to 1 drachm it acts remarkably on muscular or acute articu- lar rheumatism. It does not, however, prevent relapses or complications. Maas (Zeit. f. klin. Med., B. 28, H. 1, 2, '95). Used exclusively in 59 cases of chil- dren, ages of the patients ranging from 20 days to 13 years, 33 being various manifestations of malarial poisoning. The dosage varies from 3 '/, grains to 45 grains in twenty-four hours. No un- favorable action upon the respiration or circulation. Urine deep yellow or red, albumin or sugar never present. Action prompt and efficient, reducing tempera- ture and shortening the period of the disease. Moncorvo (Bull, de I'Acad. de M6d. de Paris, Nov. 10, '96). ANALGESINE. See Anxipteine. ANCHYLOSTOMTJM. See Paeasites, Intestinal. ANESIN. — Anesin is a trichlorpseudo- butyl-alcohol, or acetone chloroform, a 1-per-cent. solution of which is said to possess the anesthetic power of a 2 ^/o solution of cocaine hydrochlorate. It is also reported by Vamossy as capable of standing unimpaired as a solution for a long time. It is said to be sterile and non-poisonous and to produce no local irritation. Dose. — The 2-per-cent. solution is used as a local aniesthetic in the same manner as cocaine. It may also be injected sub- cutaneously. Physiological Action. — "When applied to the tongue, anesin first gives rise to a sensation suggesting the presence on the organ of a foreign body. This soon disappears, and is replaced by local an- ajsthesia. It acts in the same manner when injected subcutaneously. Therapeutics. — Anesin has so far been tried as an anassthetic in diseases of the eye and throat and in minor surgery. It is also credited with hypnotic proper- ties by Kossa. Ophthalmology. — Its main use has been as a local anesthetic in ophthal- mology. Grosz has recommended it. 396 ANEURISM. owing to the fact that it does not cause mydriasis. In important operations, however, lie prefers cocaine. Anesin only anaesthetizes the spot to which it is applied, its power of diffusion being small. It does not produce anesthesia of the iris. Laeyngologt. — Anesin was found by Israi to cause prompt local anaesthesia of the nasal mucous membrane of the phar- ynx and larynx without giving rise to untoward symptoms. It does not, how- ever, produce, even in strong solutions, the profound anaesthesia resulting from the use of equally strong solutions of cocaine. Minor Surgery. — Antal has tried anesin in dental operations and found it very useful. Hiild found it equally valuable in all kinds of operations, and emphasizes the fact that its harmless- ness should insure its preference over cocaine in all minor operative proced- ures. Anesin in a 2-per-eent. solution gives rise to no local irritation or general poisoning. It is an effective anaesthetic. V. Vamossy (Deutsche med. Woeh., Sept. 2, '97). ANEURISM. — From Greek, dvd, through, and evpvi'Cd, I widen. Definition. — A tumor containing blood or formed by a localized dilatation of a blood-vessel, communicating with the interior of that vessel. It may involve an artery or a vein, or both conjointly. Arterial Varieties, — As to cause, arte- rial aneurisms may be divided into two classes: — Idiopathic, or spontaneous, in which the aneurism is due to disease of the arterial walls. Traumatic, in which it is due to an injury of a perfectly healthy vessel. Idiopathic Aneurisms. — These are subdivided into three varieties: — 1. Tubulated, or fusiform, in which the three coats of the artery are dilated simultaneously. The dilatation affecting the circumference as well as the length of the vessel, it presents the appearance of a circular enlargement rather than that of a tumor. It is usually observed in the cranial, thoracic, and abdominal cavities, and is generally smaller than the other varieties of aneurism. 2. Sacculated, in which the aneurism projects from the side of the artery or from that of a tubular aneurism. These are usually divided into true aneurisms, in which all the coats of the artery are dilated, and false aneurisms, in which but two coats of the artery remain: the internal and the outer. The former do not attain great size, while the latter may assume enormous proportions. [The distinction made between true aneurisms, -where all the coats of the artery are dilated, and false aneurisms (traumatic aneurisms), where the walls do not consist of all three arterial coats, is artificial and incorrect, according to Cohnheim. J. McFadden Gaston.] A false, sacculated aneurism may be circumscribed, the sac in that case re- maining whole, or diffuse, the sac having ruptured, allowing the blood to become diffused into the surrounding tissues, where it may become imprisoned by an artificial cavity formed by the neighbor- ing cellular tissue. 3. Dissecting, in which an early rupt- ure of an atheromatous abscess in the arterial wall has enabled the blood to dissect its way between the internal and external coats until, sooner or later, it makes an issue for itself into the inte- rior of the vessel or exteriorly. In the former ease it assumes the shape of a sessile growth. This form occurs espe- cially in the aorta, where it may suggest the presence of a double aorta, and in the smaller cerebral arteries. ANEURISM. SYMPTOMS. 297 Symptoms. — The patients are some- times made conscious of the formation of an aneurism by feeling something give way, or a sndden, sharp pain, or, in orbital aneurism, hearing a sound like a percussion-cap. The subsequent symptoms vary ac- cording to the stage of development at the time the case is examined. During the first stage — i.e., the period intervening between the onset and the time when the sac has become firm — pulsation of the tumor is clearly felt at each beat of the heart. If both hands are placed over it, the expansion of the growth will tend to separate them. When it is possible to apply pressure on the artery above the tumor, its size is diminished, while, if applied below, the contrary is the case. The reason for this is obvious: when the pressure is applied above the aneurism the flow of blood into the cavity is interfered with, while the blood-pressure is increased within the cavity when pressure is exerted be- low. This method of examination, how- ever, is not altogether safe. The pulsations of the heart above the seat of the aneurism are weaker and slightly retarded. Sphygmographic trac- ings are also modified from the normal type. Auscultation will reveal a blowing or rasping bruit not only in the aneurism, but also in its artery, extending some distance beyond the sac. This bruit is not present in every case. It is also heard in malignant vascular tumors, but it is strictly localized to the growth, being never transmitted along the artery. The second stage begins when the aneurismal sac has become firm and resisting, on account of the deposit of laminated fibrin within it. In some cases no fibrinous deposit is formed, so that no second stage can properly be taken as a guide. The pulsation becomes more indis- tinct, or even altogether lost, on account of the thickening of the aneurismal wall and the deposit of fibrin. If the layer of fibrin is not of the same thickness everywhere, the pulsation may be more distinct at some points over the sac. Pressure over the sac causes cessation of the pulsation, but the aneurismal tu- mor will not vanish, on account of the fibrin deposited within it. A bruit will generally be heard over the sac and along the artery, but, like the pulsation, will be detected with vary- ing distinctness according to the portion of the sac examined. Pain may he an early symptom of aneurism; it is more commonly found in the second stage, when it may be sharp and lancinating or resemble the aching or boring of v.lceration. It is due to the pressure produced by the tumor on the nerves, and is consequently intense in popliteal aneurism along the course of the popliteal nerve, which is, at times, flattened out upon the tumor. Case in which there was no pain: a very constant symptom in thoracic aneurism. Nevertheless, the face flushed Avhen the head was lowered, there was tracheal tugging; no fremitus could be felt over the left side of the chest; there was no pulsation in the left carotid, and the radial pulse on the left side was small. The loss of fremitus is one of the earliest signs of aneurismal pressure. Glynn (Brit. Med. Jour., Feb. 6, '97). If located in one of the extremities, oedema of the limb constantly occurs after the aneurism has reached a cer- tain size. It is due to pressure upon the veins, and may not only be painful, but also terminate in ulceration and slough- ing. Gangrene is a late symptom and may 298 ANEURISM. DIFFERENTIAL DIAGNOSIS. suddenly be caused by an embolus. Usu- ally it is due to excessive oedema. An aneurism may press upon various organs. If bone is compressed the pain is boring and gnawing, and results in the absorption of the osseous tissue. Glands may, through this cause, cease their functions. Compression of the trachea causes dif- ficulty in respiration; of the oesophagus, trouble in swallowing. If the thoracic Aneurism of the ascending, transverse, and upper portions of the descending aorta, a, Point of rupture. (A. A. Smith.) duct is interfered with, nutrition is im- paired. A peculiar brassy cough is produced by compression of the recurrent laryn- geal nerve. Hiccough is frequently a result of pressure on the phrenic nerve, while marked capillary congestion may be caused by pressure on the sympathetic nerve. Intracranial aneurism may give rise to hemiplegia, facial paralysis, deafness, ptosis, blindness, or strabismus, caused by pressure on various nerves. Case of aneurism of the middle cere- bral artery in a male 65 years of age. The attack had begun with a very marked vertigo. Soon after he was dis- covered he became speechless. Breathing was very slow and irregular, and face was flushed. Both pupils were con- tracted, the right one slightly more than the left. Paralysis of the left side, which gradually increased and extended to the left leg. Death on the second day. On autopsy, very decided hardness of the middle cerebral artery found, and an aneurismal sac dissected out, which measured one centimetre in length and one-half centimetre in diameter, and Avas ovoid in shape. On first examina- tion it had closely resembled an ordinary cerebral haemorrhage. T. M. Prudden (Med. Record, Nov. 1.3, '97). Differential Diagnosis. Abscess. — Although in abscess the pulsation is distinct, it is not expansile. If the artery above the abscess be com- pressed, pulsation will be felt as soon as pressure is removed, and not, as in aneurism, only after the aneurismal sac has been filled. A case of aneurism of tlie femoral artery in a child which simulated, to a certain extent, an abscess resulting from coxalgia. Differential diagnosis was made on the presence of expansile pulsa- tion, a AA-ell-marked thrill and bruit, and the presence of heart disease. Sac was opened and cleared of clot. Johnson (Quart. Med. Jour., Oct., '98). Pulsating Tumors. — • Vascular sar- coma, pulsating encephaloid, hsematocele, and erectile tumors in general are, as a rule, not expansile. This differential sign is especially valuable when a tumor overlies an artery. Eheumatism. — The pain of aneurism sometimes suggests rheumatism at its onset, especially when the aneurism is popliteal. ANEURISM. DIFFERENTIAL DIAGNOSIS. 299 Neuralgia. — Pain is strictly local- ized, and none of the symptoms denoting an expansile growth are present. Aeteeial Pulsation. — Localized, Thoracic aneurism. Examination with fluoro- scope: Tire curved line in the upper part of patient's left chest and the curved line on his right chest indicate the outline of the aneurism as seen in the fluoroscope. The lower curved line on the left chest marks the outline of the heart; the lowest curve on the right front, part of the outline of the diaphragm; the dotted line, the cardiac area as determined by percussion. This case shows how a large aneurism may exist in the chest without giving rise to niai'ked physical signs. (F. H. WiUiams, Amer. Jour. Med. Sci., Dec, '97.) but not persistent, pulsations of arteries may simulate aneurisms, and have been described by Paget and West under the nam-es of mimic or phantom aneurisms. Hjsmothoeax and Empyema. — These complications of pleuro-pulmonary dis- eases may be simulated when an aortic aneurism has ruptured. Value of x-rays in the diagnosis of thoracic aneurism in which the outlines of the aortic swelling are clearly shown. In one case (possibly of tuberculous adenitis), in which the symptoms sug- gested an aneurism, the sciagraph showed no enlargement of the aorta. The arrest of the x-rays by an aneurismal tumor is due to the blood and probably to the iron contained in it. Tuberculous de- posits are thought to be impervious to the rays, but this is still a matter of some uncertainty. In the cases in which aneurism existed, the diagnosis had al- ready been made, but the picture made by Roentgen rays confirmed this diag- nosis. William Pepper (Med. Record, Nov. 28, '90). Aneurisms of the thoracic aorta can sometimes be detected eai'lier by x-ray examination than in any other way. In obscure cases, where an aneurism of certain portions of the aorta is suspected, but does not exist, it may be excluded by an x-ray examination. (See wood- cuts.) Francis H. Williams (Amer. Jour. Med. Sciences, Dec, '97). As aneurisms of the valves are chiefly dependent on endocarditis and atheroma, the symptoms are those of these diseases, and they have no separate symptoma- These two figures show a smaller aneurism of the aorta. The arrow on the dorsal side points to where the pulsation was best seen. (F. H. Williams, Amer. Jour. Med. Sci., Dec, '97.) 300 ANEURISM. ETIOLOGY. tology; yet the auscultatory phenomena may have diagnostic significance. Aneu- rism of the mitral may produce a rudimentary murmur immediately fol- lowing the systole. Frequently in per- forated aneurisms the sounds are most peculiar: humming, blowing, groaning, hissing, singing, whistling, scratching, piping, or musical. A musical murmur, especially in the aorta, which was not present in an apparently-healthy indi- vidual the day previously, may be looked upon as dependent on valvular aneurism. Musical murmurs due to aneurisms may disappear for days and then return. They may vary in time, place, and quality. They can only be properly in- terpreted when taken in connection with other physical signs yielded by the heart. Drasehe (Wiener klin. Woeh., Nov. 10, '98). Diagnosis between aneurism and me- diastinal tumors based upon 150 cases of aneurism, 200 cases of stenosis of the ffisophagus, and a large number of other eases of mediastinal tumor. The most important signs of mediastinal disease are stenosis and pressure-paralyses of the recurring nerve. Tracheal stenosis is the most important of the various forms of stenosis, and if it is present the probability of the presence of aneu- rism is very great. Permanent signs of stenosis of the oesophagus constitute almost secure evidence of mediastinal disease, and exclude aortic aneurism. Hampeln (Zeits. f. klin. Med., B. xlii, H. 3 and 4, 1901). Five eases in which the Roentgen rays proved of value in the diagnosis of tho- racic aneurism. A transverse position of the heart is an important sign. AValsham (Edinburgh Med. Jour., Apr., 1901). Etiology. — Age is an important fac- tor, aneurisms being observed especially in adults in their prime: i.e., between thirty and forty years of age. This is due to the fact that men are still en- gaged in vigorous occupations at that age, neither the heart nor the muscles having lost their strength, while it is then that arteries begin to show symp- toms of degeneration. In very young people aneurisms are exceedingly un- common. As to sex, females, owing to their less active life, are but little affected with aneurism, the proportion being one to seven, as compared to males. Spontaneous aneurism is usually due to degeneration of the artery-wall caused by atheroma or adipose infiltration. As a result, the artery is imable to con- tract during the cardiac diastole, and its diminished resistance to the pressure of the blood caused the vascular walls to gradually dilate. As atheroma presents itself chiefly during middle life, while physical use of the system is still violent, this class of aneurism is most frequently met with in people between thirty and forty years of age. Inflammatory changes are also considered as a proliflc cause. Aneurism i3 solely a consequence of alterations of the arterial walls, particu- larly arteritis. Alcoholism accounts for great frequency of this affection in cer- tain countries. Localization in arterial coats depends upon the more or less ad- vanced degree of sclerosis or atheroma. Duplaix (Des Anevrysmes et de leur Traitement, "95). The old theory that degeneration of the wall of the artery always precedes aneurism of any vessel is the true one. Loss of vascular tone can scarcely be accepted as a sufficient cause. A. Mc- Phedran (Can. Pract., Aug., '98). Aneurism of the abdominal aorta noted in a boy, 9 years of age, who had been repeatedly the subject of rheuma- tism. There was also atheroma of the aorta, and in two places there were be- ginning aneurisms of the arch. The aneurism of the abdominal aorta was as large as a golf-ball. It was at the divi- sion of the common iliac arteries. R. K. Aitken (Brit. Med. Jour., June 25, '98). Syphilis is a common etiological factor. Importance of syphilitic arteriosclero- sis in the production of aneurisms in- sisted upon. Of twenty-eight cases syph- ANEURISM. ETIOLOGY. 301 ilis found to e.vist in twelve. Heiberg (La Semaine Medicale, July 27, '92). Of nineteen patients 47 per cent, had had syphilis, all under fifty years of age. This illustrates the relation of precocious arteriosclerosis and syphilis. Fraenkel (Med. Record, N. Y., Nov. 17, '94). Among European residents of Japan aneurisms of the abdominal and thoracic aorta are very frequent; syphilis is very common. Eldridge (N. Y. Med. Jour., Feb. 10, '94). Syphilis found to be a possible cause in one hundred and si.xty-six cases out of two hundred and forty. In twenty- eight of the one hundred and sixty-six cases syphilitic lesions were present. The greatest frequency of aneurisms occurs between five and ten years after syphi- litic infection. In the great majority of cases aneu- risms due to syphilis cannot be distin- guished from aneurisms due to other causes, nor are any special pathological lesions present. Differentiation by treat- ment is not reliable. Etienne (Ann. de Dermatologie, vol. viii, p. 1, '97). The term "dissecting aneurism" has been applied to a form in which, the inner walls of the aorta or one of the large arteries having ruptured, the outer coats remain intact, the blood dissect- ing a passage between the layers of the middle coat. There are altogether about two hundred cases of this condition re- corded, and in by far the larger number of these death evidently occurred either immediately or within a few hours, most frequently by the blood forcing its way into the ascending aorta and thence into the pericardial sac. Only in a small percentage of the cases was compensa- tion established and the dissecting chan- nel repaired either by the development of secondary openings into the vessel or by the organization of the blood, which, after escaping between the walls, became clotted. There are singularly few cases on record of this last mode of repair; it is more common to find that, where death is not the direct result of the con- dition, the dissecting channel gains an endothelium, a channel being formed, opening above and below into the aorta or one of the larger arteries, and resem- bling the primitive vessel so closely that it is not to be wondered at that some of the earlier cases of the condition were described as congenital abnormalities. (Adami.) Dissecting aneurisms may be due, in the old, to atheromatous change; in the 3'oung to congenital malformation of the central organs of the circulation; some- times, also, to traumatism. Hypertrophy of the heart, especially in its left half, is often present. Traces of peri- or endo- carditis are often to be noted. The rent in the inner coat sometimes precedes, sometimes follows, the distension. A number of rents may occur in the same subject. Double aorta and dissecting aneurism. The upper and posterior wall of the aorta exhibited an opening one-fourth of an inch in diameter and nearly round. The aneurism had its origin in a rupture, not of the main artery, but in a channel to the left of it. It had stripped oflf the pleura on the left side and had broken through this, causing the fatal haemorrhage into that cavity. A careful examination showed that there was a duplication of the aorta- from the left subclavian down^ the two portions be- ing separated by a complete septum. The right was the larger and was in line with the descending limb of the arch. The left branch did not exhibit arterio- sclerosis. This condition is very rare. Krause cited five examples of double aorta. In view of the fact that in the development of the human embryo the right and left systems of arterial arches fuse together at a very earlier period, it is astonishing that the man should have lived to a good age in health and comfort. Williams (Med. Record, Aug. 1, '96). As to the etiology of dissecting aneu- 302 ANEURISM. PATHOLOGY. risms, it is probable that neither trauma nor disease plays any part in the ma- jority of instances. It is more than likely that the initial tear in the inner coats is due to the distension of the lumen of the vessels in consequence of the increased action of an hypertrophied left ventricle. That the intima and media, and not the adventitia, should be torn is explained by the fact that the adventitious coat is more elastic than the other two. Floekmann (Miinehener med. Woch., July 5, '98). Aneurisms are sometimes of parasitic origin and caused by embolism or by ero- sion of the arterial wall from without, — ordinarily due to tuberculous foci as found in cavities in the lungs. Sponta- neous aneurisms are common in patients with increased intravascular pressure, as in Bright's disease or valvular disease of the heart. Every horse has an aneurism, from the size of a pigeon's egg to that of a man's head, in the mesenteric artery of the caecum, caused by the sclerostomum armatum. Czokor (Inter, klin. Rund., Kov. 26, '93). Exciting Causes. — Weakness and thinness of the internal and medial coats of the arteries predispose to aneurisms, especially in localities like the popliteal space, subject to frequent movements. Small, incomplete tears occur in the wall of the vessel, and these gradually increase. Violence may then produce a rupture of one or two of the coats of an artery and act as an exciting cause. An artery may be torn or unduly stretched by a fracture or dislocation, or by attempts made to reduce the latter. Case of traumatic aneurism of the axil- lary artery due to attempts at reduction of a dislocation of the shoulder. Death soon after the operation. A small open- ing found in the axillary artery only large enough to admit the end of a probe; the sac was enormous and dur- ing life had not pulsated. The veins, which had been also injured, opened into the aneurism. Case of traumatic aneurism due to at- tempted freeing of the shoulder-joint, in a case of ankylosis following gonorrhoeal arthritis. Sonnenburg (Berliner klin. Woch., p. 681, July 27, '96). Any violent or sudden exertion may also act as an exciting cause either by unduly stretching the artery, by forcing blood under a high pressure through it, or by causing the heart to act irregularly and forcibly. Case of child which, when first seen, when nine days old, had in the left axilla a tumor, soft and compressible, dilating synchronously with the heart, and over which a bruit could be heard, but there was no aneurismal thrill apparent. This tumor had not been noticed at birth by the midwife, but some days later a small, soft swelling was observed which gradu- ally filled the entire axilla. The tumor was flattened and soft, covering the an- terior aspect of the shoulder and a small part of the upper arm; beneath, it ex- tended beyond the posterior border of the axillary space. The child had been roughly handled a day or two after birth, during the performance of some occult ceremonial rites, part of which rites con- sisted in handling the child dangling by one arm from one person to another over the banisters. When shown, child was in excellent health, after having passed, however, through a period of some months' suffering. W. C. Mardorf (Med. Rev., May 14, '98). Eiders are frequently the subjects of popliteal aneurisms. This is due to ob- struction of the arteries caused by the bending of the legs and the contraction of the leg-muscles, to which may be added the jars which are constantly given to the column of blood thus formed. Pathology. — The structure of a sac- culated aneurism, from mthout inward, is as follows: — - 1. An adventitious sac formed of con- densed areolar tissue. ANEURISM. PATHOLOGY. 303 2. The real sac, which may consist of the thickened external coat and, per- haps, a portion of the middle coat (false aneurism) or of all the coats (true aneu- rism). The atheromatous and calcareous patches may serve to distinguish the in- ner and middle coats. 3. Concentric decolorized fibrinous lay- ers, harder and drier toward the exterior and toward the interior softer and redder. 4. A soft, currant-jelly coagulum, which may, however, be formed previ- ous to or after death. The fibrinous deposit on the wall of the sac acts favorably by diminishing the dilating force of the circulation in the sac and by strengthening the wall. The mouth of the sac is round or oval, and measures much less than a section of the sac. If the contents of the sac be exam- ined they will be seen to vary according to the stage of the disease. The wall of the sac is very thin in the first stage, and contains fluid blood only; in the second stage the centre only of the sac will contain fluid blood, around which are placed laminae and fibrin; at the periphery a much thicker wall of fibrin is present. The laminse of fibrin next to the wall are dry, friable, and opaque, while, as the centre of the aneurism is approached, they are soft and red. Fibrin is rapidly deposited in sac- culated aneurism, being more rapidly formed where the obstruction to the free passage of the blood into and out of the sac is greater. Many sacculated aneurisms are prob- ably true aneurisms at first, but, on in- creasing in size, the inner coats of the artery rupture and the aneurism becomes a false aneurism. In tubular or fusiform aneurism the vessel is also elongated. Several tubular aneurisms may exist in the course of the same vessel, the artery remaining healthy between them. In tubular -aneurism the three coats of the artery are preserved, but the middle coat, not undergoing hyperplasia, its ele- ments no longer form a continuous layer, but are separated one from another. The sac, in this form of aneurism, being, in realit}^, only an enlargement of the lumen of the vessel, exposed to the full current of the blood, no laminated fibrin is found in it. As compared to other tissues, the skin resists longest the pressure from aneu- rism. Aneurisms are most common in the thoracic aorta (ascending and transverse portions) and next in the popliteal, ca- rotid, subclavian, innominate, and axil- lary. The most important aneurisms on small arteries are those in the brain, lungs, and heart. Case of aneurism at apex of heart ; the patient, 'a woman, 86 years of age, had never complained of any cardiac trouble, and death resulted from apo- plexy. The autopsy showed a small an- eurism at the apex of the heart, with complete absence of cardiac muscle at the apex of the left ventricle. There was a replacement fibrosis at this point. Some parts were quite calcareous, and there was also slight interstitial myo-- carditis. The coronary artery was the seat of atheroma. Larkin (Med. Eecord, Aug. 28, '97). Case of multiple aneurism of pulmo- nary artery in a boy, aged 12 years, in whom a loud, roai-ing, pulmonary sys- tolic bruit and very highly-accentuated second sound were present during life, with haemoptysis, epistaxis, and dropsy. Four of the secondary branches in one lung and three in the other led into aneurisms as large as walnuts, filled with blood-clot. The boy had been ill for a year. Churton (Brit. Med. Jour., May 15, '97). 304 ANEURISM. PROGNOSIS. Case of hepatic aneurism in which the clinical picture included pains in the right hypochondrium or epigastrium, intermittent jaundice, and repeated, profuse haemorrhages from the upper part of the bowel. The diagnosis is made but seldom, and cholelithiasis or duodenal ulcer is generally thought of, especially since all three symptoms do not always occur together. The most constant of these is the pain. In the pathogenesis trauma plaj's an important role, and rather often there is a history of some jjreceding infectious disease. A. Sommer (Prager med. Woch., Sept. 8, 1902). Prognosis. — Spontaneous recovery oc- curs but seldom; a deposit of fibrin due to a slow current takes place in the sac and completely fills it, forming a firm and solid mass. The process may extend still further into the artery, thus ren- dering the cure still more secure. The formation of an embolus is only to be expected, however, when the diseased artery is small. Spontaneous recovery may occur in other ways: from a clot being washed out of the sac into the arterj^, forming an embolus which com- pletely arrests the current in the sac, the latter being filled with a firm coagulum. The sac may also be heavy enough and so situated as to stop the current •of the blood in the artery by causing flexion of the aneurismal neck. In some cases inflammation of the sac and coagulation of the blood contained in it also effect a spontaneous cure. Only small aneurisms are cured by spontaneous formation of a thrombus in the sac and its conversion into cicatricial tissue. Death may result in various ways: — 1. By rupture of the sac. In this case death may occur instantly, if the opening be into a serous cavity, one of the pleural cavities (generally the left), or into the pericardial or peritoneal cavities, the serous membrane giving way in a rent. Ten cases of sudden death due to rupt- ure of thoracic aneurisms previously unsuspected. Deaths, although sudden, not instantaneous; sometimes consider- able period may intervene. F. W. Draper (Boston Med. and Surg. Jour., Mar. 14, '95). Cases of rupture of intrathoracic aortic aneurisms met Avith in the Pathological Department of the Manchester Royal Infirmary. Number and proportion of cases: Among the last 4593 cases submitted to pathological examination rupture of a thoracic aneurism has been noted in 32 cases. This gives a percentage in all "general" cases of 0.G9. Sex: Of the 32 cases, 30 were men and only 2 women; that is, a percentage of 93.75 males and 6.25 females. Age: The exact age was obtained in 30 of the cases; the others were middle- aged males. The average was 40 years. The males averaged 40.4 years. The females averaged 34 years. The young- est subject was aged 20 years and the oldest was aged 65 years. Seat of aneurism: In many instances the greater part of the arch was involved. Grouped, however, according to the chief area of affection, they may be arranged as follows: Ascending portion of arch, 12; transverse portion of arch, 11; descending portion of arch, 4; and descending thoracic aorta, 5. Point of rupture: This can be best indicated in tabular form: — P.vRT Ruptured i Pleni-!i (riglit) Lung (left) Bronchus (right).. No. OF Cases. Percentage, Nature of death : Of the thirty-two cases, six were observed in medico-legal investigations, the subjects being brought ANEURISM. TREATMENT. 305 dead to the hospital, having been found dead or suddenly seized in the street or elsewhere. In one instance a man, while riding in a cart, suddenly fell out of the vehicle and was picked up dead. Id nearly all the eases where rupture oc- curred while in hospital or where a clear history could be obtained death was sudden, in many instances being practically instantaneous. In one case, where rupture occurred into the oesoph- agus, death took place in five minutes. In another, where the aneurism burst into the pericardium, the patient felt faint and was dead in three minutes. In one subject, where the pericardium was found filled with blood, and where there was commencing erosion into the trachea, with also extension into the left lung, a small quantity of frothy blood was brought up for some hours before death, which was sudden. In a ease where there was general aneurismal dila- tation of the arch of the aorta, rupture took place into the pericardium through a vertical slit two and a third inches in length. The patient was brought to the hospital in what appeared to be a syncopal attack, and died suddenly four hours later. In one case where death occurred suddenly, blood-clot weighing eighty-five ounces was found in the left pleural cavity. T. N. Kelynack (Lancet, July 24, '97). Death is not so rapid when the aneu- rism reaches to the skin or to a mucous membrane, such as the trachea, oesopha- gus, intestine, or bladder. The rupture of an aneurism through a mucous surface occurs by the forma- tion of a small, circular abscess; through a serous surface the rupture is by a iis- sured or star-like opening. In the skin a small slough is formed, which, on fall- ing, leaves a minute opening, through which the blood passes. This is soon arrested by clotting, but the haemor- rhage soon recurs and death is finally caused by repeated hemorrhages. 2. Death may occur from the compres- sion of important organs. Pressure upon 1- I the trachea, bronchi, or lungs causes suf- focation; upon the oesophagus or tho- racic duct inanition. In tubular aneurisms death may be caused by syncope due to impediment to the circulation or by compression of the oesophagus or bronchi or by rupture into the pericardium. When the vertebrje and ribs are com- pressed these bones are absorbed and spinal irritation and even meningitis are produced. Pressure upon the intercostal nerves gives rise to severe neuralgia. 3. Inflammation and suppuration of the sac may cause death by inducing septicaemia and pytemia. 4. If the aneurism is in the arch of the aorta a clot may be carried to the brain by the cerebral arteries, causing embolism and death. 5. Gangrene of an extremity caused by obstruction may cause death by septic infection. A sacculated aneurism usually forms upon a tubular aneurism and causes death more rapidly than the tubular aneurism alone would have done. Duration of An&urism. — Though an aneurism may grow very rapidly, it lasts several years, in the majority of cases. So long as the cause is present it tends to develop. The various causes which influence the duration of an aneurism are its situ- ation, the size of the mouth of the sac, the condition of the latter, the force of the blood-current, the state of the blood as to coagulation, and the mode of life of the patient. Treatment of Aneurisms in General. — Obliteration of the sac and occlusion of the afferent and efferent vessels are the aims to be reached. The best results may frequently be ob- tained by combining several modes of treatment. 20 306 ANEURISM. TREATMENT. Obliteration of the sac can be obtained by diminishing the force of the circula- tion of the blood in it, thus encouraging coagulation. TuFFNELL^s METHOD. — The bcst- known method in this connection is that of TufEnell, which, though usually em- ployed for internal aneurisms, has also been advantageously used for aneurisms of the extremities. Fig. 2. Pathological speeimena of ruptured aneurisms. {Scarpa.) Fig. 1.— Ruptured aortic aneurism, a, Thoracic aorta stripped of its pleura and cellular coat: c, c, Rupture of the posterior wall of the aorta; f, Aneurismal sac covered by the pleura; h, Rupture of the aneurismal sac. Fig. 2.— Ruptured aneurism of the arch of the aorta. 6, h, Bottom of cavity showing the location of the rupture of the artery. Fig. 3.— Ruptured carotid aneurism. I, Inferior orifice of left carotid artery, ruptured ; m, Superior orifice of the left carotid artery; h, Right carotid; r, Aneurismal sac. Fig. 4.— Ruptured popliteal aneurism, a, a, Ruptured popliteal aneurism farther opened; 6, Artery; c, Superior orifice of artery; d, d. Portion of aneurism torn. ANEURISM. TREATJIENT. 307 The object of Tuffnell's treatment is to reduce the watery elements of the blood and to increase the solid elements. The patient is kept in the recumbent position for at least three months; this causes the rate of pulsation to diminish greatly. In one case it fell in a few days from 96 to 66: a reduction of 30 beats a minute, 1800 beats an hour, and 43,200 beats a day. No drug can cause such a diminution without danger to the patient. The recumbent position, according to TufEnell, acts upon the cir- culation in internal aneurism as does mechanical compression in external aneu- rism. The food is diminished, amount- ing to but 10 ounces of solid and 6 ounces of fluid in the twenty-four hours. TufPnell's food consists of 2 ounces of bread and butter and 2 ounces of milk for breakfast; 2 or 3 ounces of meat and 3 or 4 ounces of milk or claret for dinner; 2 ounces of bread and 2 ounces of milk for supper. Best and restriction of liquids are the most important parts of the treatment. Tuilnell published his first observa- tions in 1875. Of ten cases treated seven were cured and three died during the treatment. One case of popliteal aneu- rism made a recovery in twelve days. To induce sleep lactuearium is recom- mended, and, with the view of dimin- ishing the liquid portion of the blood, the patient is purged from time to time with compound powder of jalap. Results of study of effect upon tlie blood of Tuffnell method of treatment, combined with calcium salts, in manage- ment of two cases of aortic aneurism. Restriction of fluids caused decrease in elimination of calcium salts, while in- crease of fluids caused marked increase in their elimination. Water should be given in abundance, if it is desired to saturate the body with calcium salts. Personal cases absorbed much more cal- cium while taking laige quantities of water. Ingestion of calcium seemed to increase the quantity in the circulating blood. Specific gravity of blood was not distinctly affected by the treatment. The plasma-nitrogen, plasma-albumin, and the quantity of albumin in the plasma of 100 cubic centimetres of blood, were constant in the two cases, except at one estimation. The fibrin-nitrogen was not increased. The time of coagula- tion was reduced in one case, but was not aflected by the ingestion of calcium. In the other case the time varied, but was not shortened on the average. Influence of the treatment upon the blood seemed, therefore, entirely negative, although ■ both patients showed distinct improve- ment in their physical signs. A. E. Tay- lor (Jour. Exper. Med., May, '98). Medicinal Teeatment. — With the idea that aneurism is often due to syph- ilis, iodide of potassium has been much employed; its probable action is that of depressing the heart. The assertion that iodide of potassium has the power of lowering blood-pressure is contradicted by the sphygmomanom- eter. Alexander James (Brit. Med. Jour., June 29, '95). The cases reported in which iodide of potassium has been of benefit do not sustain the credit accorded that drug as a curative agent; still it ought to be tried in cases where there is even but a suspicion of syphilitic taint. Bristow (Brooklyn Med. Jour., Oct., '95). [It may further be said that the drug usually seems to promote the comfort of the patient: a factor of considerable im- portance in the treatment of a chronic, incurable, and often distressing disease. Whittieb and Vickery, Assoc. Eds., Annual, '96.] In cases which have a history of syph- ilis, iodide of potassium internally and mercury as an inunction recommended. For some weeks afterward the patient is kept in bed and fed chiefly with milk. Over the situation of the aneurism an ice-bag is applied several times a day for hours. The results of this treatment have, on the whole, been so favorable as 308 ANEURISM. TREATMENT. to wan-ant the use of mercurial inunc- tion in oases without a history of syph- ilis. A rapid subsidence of dyspnoea and bronchostenosis was obtained, the relief continuing sufficiently long, in some instances, to permit patients re- suming their occupation. A. Fraenkel (Deutsche med. Woch., Feb. 4, '97). Case of non-syphilitic aneurism in which 30 to 60 grains of iodide of potas- sium per day, and an ice-bag applied to the tumor, caused the pulsation to di- minish, and in five months the patient, a street-singer, was able to resume his occupation. Edouard (Revue de Med., May 10, '97). The calcium salts have been recom- mended. Four cases of aneurism in which the amount of calcium salts passed in the urine was much greater than normal; may be useful as an aid to diagnosis. E. Reale (Rivista clinica e terapeutica, Naples, Nov., '91; Brit. Med. Jour., Mar. 26, '92). Marked improvement from hydrated calcium chloride in doses of 1 drachm daily. Solomon Solis-Cohen (Philadel- phia Polyclinic, July 6, '95). Acetate of lead lias been used to "equalize the circulation," and bromide of potassium is frequently employed against the cough and pain. Gallic acid, iron sulphate, barium chlo- ride, digitalis, veratrum viride, and aco- nite have been used, but the majority of clinicians do not look upon these agents with favor. Coagulating Inj&ctions. — These have been utilized for aneurisms of the ex- tremities. Tannin, lead acetate, Monsel's solution of iron, spermaceti (Dobell), and other drugs being used. Cervical aneurisms should not be treated by these injections, lest an em- bolus be carried to the brain. To prevent emboli being carried into the circulation the arteries above and be- low the aneurism should be compressed both during the operation and for some time after it. In the opinion of Till- mann, any treatment by injection is dan- gerous. Gelatin Injections. — Injections of liq- uid gelatin have recently been advocated even in desperate cases. Operative technique of injection of gelatin for treatment of aneurism is as follows: White gelatin in a quantity of from 1 drachm to 1 V4 drachms is dis- solved in a 7-per-cent. solution of sodium chloride in measure 1 to 2 quarts. The solution is placed in a flask, which is sealed and then sterilized with its con- tents at a temperature of 120° C. For the injection a flask of the capacity of 1 pint is got ready, fitted with a cork and two tubes like a wash-bottle. The long tube is connected with a sterilized needle and the short tube with an India-rubber air-ball. The gelatin is liquefied in a water-bath at a temperature of 95° F. and poured into the flask, which is also kept in a water-bath. The injection is made slowly into the subcutaneous tis- sues of the buttock and should take fifteen minutes. It should be repeated every six or eight days until the sac is obliterated. This method, if carried out with care, gives excellent results in the most desperate eases. Lancereaux (Paris Academy of Med.; Lancet, Nov. 19, '98). Injections of gelatin in aneurism. Case of aortic aneurism in which the size of the tumor was much reduced after 10 injections (1V= ounces each) of gelatin solution. The following formula is sug- gested: — 1} White gelatin. 15 grains. Salt, 7 V; grains. Hot water, 26 ounces. This mixture is sterilized and allowed to cool. When required for use it is warmed to fluidity and injected under the skin with antiseptic precautions. The injections may be given every few days, or even every day. After the in- jections the patients should remain abso- lutely quiet in bed. Frankel (Deut. med. Presse, June 9, '99). ANEURISM. TREATMENT. 309 Nine cases treated with gelatin sug- gest the following conclusions: 1. In no case did cure of the aneurism result, and only in one was there considerable im- provement. 2. In seven cases there was an appreciable lessening of the pressure symptoms. 3. The coagulability of the blood is greatly increased. 4. The injec- tions often cause a good deal of pain. 5. The injections are sometimes followed by rigor and fever. 6. The treatment affords amelioration, and is deserving of further trial. Futcher (Jour. Amer. Med. Assoc, Jan. 27, 1900). Treatment of aneurisms with gelatin in several recent cases. Complete cure of a large aneurism by total obliteration of the sac is obtained only after a variable number of injections of gelatin, accord- ing to the ease, but approximately from 25 to 30 at the least. Lancereaux and Paulesco (Gaz. des Hop., July 17, 1900). Three cases of thoracic aneurism treated by gelatin injections. They were under observation in the Hudson Street Hospital. None of them was successful. The cases were not under observation long enough to give data for a final con- clusion, but the result seems sufficient to indicate that gelatin injections not only do no good, but cause severe pain locally and often considerable constitu- tional reaction. Lancereaux's method was to take 1 to 1 V.i drachms of gelatin and make a solution of it in 200 cubic centimetres of normal salt solution. This was kept for several days at a tempera- ture of 38° C. If no cloudiness developed nor any other sign of micro-organismal growth the liquid was injected sub- cutaneously, usually into the patient's thigh. After about a week another in- jection was made and the treatment con- tinued at regular intervals. Special di- rections were given by Lancereaux not to palpate the aneurism during the course of the treatment. At first, a 2- per-cent. solution of gelatin was used; later, however, he used a 1-per-cent. so- lution. Attention is called to the fact that, if Lancereaux's directions were followed, the patient would be given twenty injections covering a period of five months. During all this time the patient should rest in bed. Rest is suffi- cient of itself to relieve greatly the sub- jective symptoms of aneurism, and often does away with certain of the physical signs and even lessens the size of the aneurism. Lewis A. Conner (Med. News, Aug. 11, 1900). The injections are often followed by fever and pain. The possibility of ex- tensive coagulation and of embolism has not been demonstrated. The injections may cause increase of vascular pressure and involve rupture of a large-sized aneurism whose walls are thin. The clinical observations so far made do not warrant an exact estimate of the value of the gelatin treatment. Henri Grenet and G. Piquard (Archives Gfinerales de M6d., June, 1901). It has also been affirmed that the gelatin method is painful and liable to cause fever, but if the solution be gently injected into the subcutaneous tissue of the thigh, it is absolutely painless, an-d if proper antiseptic precautions are ob- served there is no fever. The authors insist upon these details, as showing that the ill success attributable to this method of treatment depend entirely on a faulty technique. Lancereaux and Paulesco (Bull. Acad, de Mgd., Paris, July 16, 1901). Suicutaneous Injections. — Langenbeck recommends subcutaneous injections of ergotine, which act in two ways: by slow- ing the action of the heart, thus favoring the deposit of fibrin, and causing con- traction of the unstriped muscular fibre entering into the composition of the middle coat of the artery, thus raising the blood-presstire. CoMPEESSiON. — Compression was used over two hundred years ago for cases of traumatic aneurism, but the first sur- geon to propose this method was Heister. In 1772 Guattani, an Italian, compressed the entire limb and the sac in cases of popliteal aneurism. Cases thus treated usually, however, ended fatally, from transformation of the circumscribed an- eurism into a diffuse aneurism, inflam- mation and suppuration of the sac, and 310 ANEURISM. TREATMENT. gangrene of the leg. The mortality was 50 per cent. John Hunter, in 1785, introduced into the treatment of aneurism the gov- erning principle that the current of the blood through the sac should not be completely suppressed, but only dimin- ished, thus allowing the elasticity of the sac to act. In this way the effect of the overpressure from the heart's action is removed. The fact that the sac in diffused and traumatic aneurism is not contractile explains why this treatment is without success in aneurisms of this variety. Advantages of compression over liga- tion: — 1. It is not so dangerous; if neces- sary, it can be discontinued and then renewed, whereas, in ligation, the danger may be great for many days following the operation. 2. In cases treated by compression only the sac consolidates, just as in spontaneous cure. The arteries, up to the point of compression, are not con- solidated, as in ligation. 3. Compression is more successful than ligation, and does not present danger of complications, such as secondary haem- orrhage, sloughing of the sac, phlebitis, gangrene, or pyaemia. 4. Ligation has been followed by a second aneurism or by suppuration in the sac. Though these complications may occur after compression, they are not likely to do so, and consequently compression is more likely to be perma- nent than ligation. Compression may be applied with the fingers or by means of various instru- ments, bags of shot, Esmarch's elastic bandage, flexion of the joints, etc. Jonathan Knight, of New Haven, Conn., first employed the finger as a means of compression in 1848, and in the same year Willard Parker and James R. Wood, of New York City, each suc- cessfully treated an aneurism in this manner. Digital pressure over the vessel, Just above the aneurism, is applied by a succession of assistants relaying one an- other. The procedure is rendered much less irksome for the operator by placing a weight upon the pressing fingers, the muscular strain being thus, in a meas- ure, relieved. It is necessary to keep up the press- ure from one to several days, until the pulsation has ceased. The average time required is three days. The pressure should then be gradually diminished, in order to prevent disintegration of the clot before it is firmly contracted. In proximal compression of the artery it is only necessary to stop the pulsation of the sac, it being unnecessary to stop the flow of blood through it. This method succeeds best in sacculated aneu- risms. In tubular aneurisms it causes gradual contraction, but not by a deposit of fibin. When the sac contains fluid blood only, the chances of success are more favorable. In an already partly-filled sac coagulation may be too sudden and imperfect. Recovery is shown, when compression above the sac has been resorted to, by cessation of pulsation in the sac when pressure is removed, by no thrill or bruit being present, and by the development of a collateral circulation. The collateral circulation which de- velops after the sac has been filled with fibrin indicates that the sac has been obliterated. Sudden enlargement of the collateral circulation, occurring both in cures hap- pening spontaneously and in those due to compression, may cause considerable ANEURISM. TREATMENT. 311 pain. The latter, therefore, may be looked upon as a favorable symptom. In aneurisms of the extremities and neck compression gives good results. This causes, wlien cure takes place, the formation of coagula in the aneurismal sac, through or alongside of which, how- ever, a canal remains through which the blood passes. The coagula shrink grad- ually and become more solid and firmly adherent to the inner wall of the aneu- rismal sac. Compression can be carried out only with intelligent patients. Bill- roth (Wiener klin. Woch., No. 50, '93). [When compression has ultimately to be abandoned, its temporary use is of advantage in so far as it prepares the way for establishment of the collateral circulation. John H. Packard, Assoc. Ed., Annual, '92.] Compression by means of the contrac- tile power of ordinary collodion, in small aneurisms; successful in three cases. Williams (Amer. Mcdieo-Surg. Bull., Apr., '93). Compression hj the Esmarch Bandage. — In this method it is sought to produce red blood-clot, such as is formed when the blood no longer circulates, and not the fibrinous, or white, blood-clot, such as is formed when the blood is in mo- tion. Such a clot contracts, but does not become organized, and acts mainly by forming a thrombus in the afferent and efferent vessels. Pressure by means of an Esmarch bandage was first successfully employed by Eeid, of the British navy, in 1875, though in 1864 Murray had already succeeded in treating an aneurism of the abdominal aorta by anesthetizing the patient and checking the circulation completely by means of an instrument. The patient should first be given an hypodermic injection of morphine, then just enough ether as an anaesthetic to prevent pain and insure quiet. After placing a piece of chamois-skin over the artery to prevent chafing, the limb is firmly wrapped in an elastic band- age from its extremity up to the tumor; the latter, however, is lightly covered over; but, as soon as it is passed, the bandage is again firmly applied, thus allowing a certain amount of fluid blood to remain in the sac. A tourniquet is then placed above the aneurism, to prevent disintegration of the clot in the sac and of the thrombi in the arteries by the circulation, and left in situ from sixteen to twenty-four hours. The pressure is then gradually decreased by unscrewing the tourniquet, while due attention is paid to the state of the circulation, to avoid gangrene by too prolonged pressure, and to avoid disturbing the clot before it is solid. A collateral circulation is soon formed. Danger may arise in some cases from the sudden rise and fall of blood-pressure or from rupture of the sac; pressure on the nerves, gangrene, and momentary renal disorders are possible sequelae. Pressure may be advantageously aided by the administration of iodides and a limited albuminous diet. The contra-indications to this treat- ment are vascular degeneration elsewhere than in the aneurism, renal disease, or inflammation of the sac. But few appropriate cases in which compression in some form has been faith- fully persevered in for a long time have been unattended with improvement. The method of applying compression preferred by Tillmann is to envelop the limb with an elastic bandage from its extremity up to near the aneurism for about an hour and a half; a tourniquet should then be applied above the aneu- rism, and removed with the bandage an hour and a half later. Digital or instru- mental compression should follow for from six to twelve hours. Compression hy Flexion. — This method, which was first employed in 312 ANEURISM. TREATMENT. 1858 by Hart, can only be used for the arm and leg. It consists in bandaging the entire extremity, and then flexing it strongly: the forearm upon the arm, the leg upon the thigh, or the thigh upon the pelvis. The effects of this method are to com- press the sac itself, to retard the circu- lation through it, and occasionally to cause a small clot to be dislodged, by means of which the mouth of the latter becomes occluded. Flexion of the joint can be used only in aneurisms of small or medium size; when the tumor is large the sac might be ruptured. It is an unsafe procedure when the sac is inflamed or when there is much cedema of the leg. Flexion is especially indicated when the tumor is of small size, the sac not inflamed, and the joint not involved. An argument in favor of flexion is that if unsuccessful no harm follows the procedure. Macewen's Method. — The object of this method is to form white thrombi within the sac, by lightly scratching the inter- nal surface of the sac with needles thrust through the previously-asepticized wall. The needles are thus left in contact with the sac xintil the entire wall has thus been lightly irritated. The position of the needle-points should be changed at intervals of ten minutes. It may be nec- essary to continue this for forty-eight hours, the sittings being repeated from time to time for weeks or even months. Besides the effect upon the aneurismal currents there occur an infiltration of the parietes with leucocytes and a seg- regation of them from the blood-stream at the point of irritation. The advantage of white thrombi over the red is in the less marked tendency of the former to shrink in volume or to undergo penetration by leucocytes or yellow softening. The object is to ob- tain an adhesion of leucocytes to the vessel-wall, and to promote successive accretions of these bodies (a parietal thrombus) until complete occlusion oc- curs. For this purpose a slender pin of sufficient length is employed to transfix the aneurism and to permit manipula- tion, in order to scratch the inner sur- face of the opposite wall at various points over its entire extent. Sometimes this can be accomplished by one inser- tion, but it may be necessary to thrust the pin in at several points. Antiseptic precautions are, of course, to be observed. The length of time during which the pin is to be kept in place varies, but should never exceed forty-eight hours, and may be much less. In the case of a very large aneurism several pins may be introduced at various points, but they should not be too close together. Every aneurism contains within itself a potential cure as the essential matter, whatever may be the method devised for inducing its action. Macewen (Lancet, Nov. 22, '90). An antiseptic gauze dressing should be applied to the neighboring region while the needle is left in the sac. One needle usually suffices, but it may be necessary to use two or three. Any superficial ulceration, inflamma- tion of the sac, or erysipelatous indura- tion is a contra-indication. Needles may also be used to transfix the aneurism or for the purpose of caus- ing coagulation, as in electrolysis. In acupuncture very fine gilded nee- dles are introduced into the sac, crossing one another, and thus forming a centre around which the blood coagulates. They are removed several days later. This method is seldom, if ever, successful. In galvano puncture two insulated nee- dles are introduced into the sac at about an inch apart, and being brought into contact by their internal extremities a galvanic current is passed through them. This method was proposed by Phillips in 1829. It exposes to embolism, suppura- ANEURISM. TREATMENT. 313 tion in the sac, and hasmorrhage through the needle-punctures. Electrolysis Through Introduced Wire. —The introduction into the sac of fili- form material, especially wire, as recom- mended by Moore (see below) having given evidences of value, D. D. Stewart, of Philadelphia, showed the great advan- tage of combining electrolysis with the introduction of wire in sacculated aneu- risms, and has published cases in which satisfactory results were obtained. The aneurisms treated were not susceptible of cure by medical or surgical means. The procedure is a distinct advance in curative means. Final report of a ease of a very large innominate aneurism completely cured by the employment of electrolysis through ten feet of snarled, coiled, fine, gold wire, introduced into the sac; death at the expiration of three and a half years from cerebral thrombosis. The newer method consists in introduc- ing into the sac, under the strictest anti- septic precautions, a fine silver or gold, coiled wire, previously so drawn that it may be readily passed through a thor- oughly insulated needle of somewhat larger calibre than the wire and, after introduction, assume snarled spiral coils, that, with a moderate amount of wire, the entire calibre of the sac will be reached, unless the cavity be already filled with coagula or the sac be of un- usual size (as was the case with one aneurism so treated) . The wire must be neither, in amount or calibre, too great nor too bulky or highly drawn that the results to be de- sired be interfered with. Nor should the wire be of a material so brittle as steel nor of hard-drawn iron, lest fracture occur in process of contraction of sac, with danger of rupture. Nor should it be of soft iron, as was recommended on theoretical grounds by Stevenson; for, with the last, so great a quantity of detritus will result, due to the decom- position of the iron and the formation of insolub'e salts under the current's in- fluence, even with low amp6rage, that danger of emboli result. Silver or gold wire is undoubtedly preferable material. The amount of wire required depends necessarily upon the calibre of the aneu- rismal sac, and must be decided upon with the greatest nicety of judgment, since with too small an amount little or no result will be obtained, and, with too great a quantity, permanent cure through obliteration of sac by contrac- Case of aortic and innominate aneurism, with erosion of the clavicle and ribs. Photograph was taken thirty-five months after Dr. D. D. Stewart had caused an arrest of the growth of the aneurism by electrolysis. tion of clot cannot be expected. For a globular sac of approximately three inches in diameter, three to five feet are sufficient ; for a sac of four to five inches, eight to ten feet. The anode, or positive pole, should in- variably be the active electrode. This is connected with the wire and the nega- tive rheophore — a large clay plate, or an absorbent cotton pad of equal dimensions made after the method of Massey — is placed upon the abdomen or the back. The current is slowly brought into cir- cuit and its strength noted by an accu- rate niilliamp6remeter. The increase is 314 ANEURISM. TREATMENT. gradual for a few moments until the maximum strength supposed to be re- quired is reached. It is maintained at this until the approach of the end of the session, and then gradually diminished to zerOj after which the wire is sepa- rated from the battery, the needle care- fully withdrawn by rotation and counter- pressure, and the released external por- tion of the wire gently pulled upon and cut close to the skin, the cut end being then pushed beneath the surface. This latter procedure is facilitated by using care in the introduction of the needle to first draw the skin at the site of punct- ure a trifle to one side, in order to pro- cure a somewhat valve-like opening. Experience has shown that the cur- rent-strength must be rather high — from 40 to 80 milliamperes — and the sitting long — from three-fourths of an hour to one and a half hours. Thus used, the following effects may be expected: The mere introduction of coiled, snarled wire without the conjoint use of galvanism, if practiced judiciously, is in itself a method of value, since the presence of wire, if engaging all parts of the sac, acts both as an impediment to the blood- stream and at the same time offers to the eddies set up multiple surfaces for clot-formation. Hence this method has more to commend it than that by mere galvanopuncture with needles. By gal- vanopuncture, although firm coagula are produced, they are of such trifling dimensions and engage such small areas of sac- wall that, without impeding in the least the blood-current, their dissolution rather than their accretion quickly fol- lows. By the application of a strong gal- vanic current through coils of wire so disposed that all areas of the sac are reached, it follows without exception, as has been noted in all recorded cases, that consolidation by virtue of clot-formation is promptly and invariably produced. The solidification is rapid, and is gen- erally manifest before the end of the electrical session, through changes ap- parent to the eye and hand, in the pulsa- tion and in the degree of consistence of the sac-wall. These changes become more decided in the course of a few days, until, after a time, in the most favorable cases a hard nodule, with a communi- cated pulsation only, replaces the pre- vious expansible tumor. This was the history of four of the ten cases now recorded, — that of Kerr, that of Rosen- stein, the second case of author's, and the case of Hershey, — and partially so in the case of Barwell, of Roosevelt, and in the first of the author's, all of which latter cases were totally beyond the slightest hope of cure at the time of treatment, as was also the case of Abbe. D. D. Stewart (Brit. Med. Jour., Aug. 14, '97). Treatment of abdominal aortic aneu- risms by a preliminary exploratory cceliotomy and peritoneal exclusion of the sac followed later by wiring and electrolj'sis. The main difficulty lies in the fact that a determination of the situation of the aneurism, even when a cceliotomy is performed, is very great. The objections to the method are as fol- low: 1. The cure of the aneurism may lead to tne death of the patient by ob- literating the orifice of important vis- ceral arteries; this is most likely to oc- cur in dealing with aneurisms of the upper or eoeliac division of the abdom- inal aortic tract: i.e., in about 50 per cent, of the cases. 2. Secondary rupture of the sac from the strain put upon weak portions of the sac in multilocular aneurisms, after partial coagulation of the contents nas taken place (particu- larly likely to occur in subjects of gen- eral endarteritis with atheroma). 3. Escape of wire through a large aneu- rismal orifice into the lumen of the aorta, with migration upward into the heart, leading to perforation, traumatic endarteritis, endocarditis, with the for- mation of secondary thrombi and em- boli. 4. Danger of perforating the sac by stiff wire or by overcrowding the sac with too much wire. 5. Danger of ex- tension of clot from the coagulum in the aneurism to the main artery, lead- ing to fatal blockade at the bifurcation, with gangrene of the lower extremities. 6. Danger of rupture of sac from sudden withdrawal of abdominal support and displacement of adherent organs in the course of the exploratory laparotomy. 7. Danger of mistaking a fusiform for a ANEURISM. TREATMENT. 315 sacciform aneurism. 8. Danger from emboli and thrombi following incom- plete coagulation of the blood in the sac (a very rare and practically un- known occurrence in abdominal cases). 9. Danger of shock. 10. Danger of sep- sis. Rudolph Matas (Amer. Medicine, June 22, 1901). Case of aneurism in which temporary improvement by wiring and electrolysis obtained, the patient dying later as a result of rupture of the sac. From an experience of eight operations of this character he concludes that electrolysis in properly selected cases of aneurism is a valuable measure and prolongs life. The operation itself is neither dangerous nor painful. The failure of permanent cure does not depend so much upon the failure of the operation to limit the disease locally as to the fact that the adjacent parts of the blood-vessel are weak, and, when the bulging area is solidified by the clot, these lateral areas may later on give way. Even in these cases life is prolonged by the closing of the weakest area, and it is not to be forgotten that in at least one case (Stewart's) life was prolonged three years, death taking place from an alco- holic debauch. Hare (Therap. Gaz., Jan. 15, 1903). Introduction of Foreign Bodies into the Sac. — Catgut, silk, horse-hair, fine wire, especially, have been introduced into the sac to promote coagulation, but this measure does not meet with the approval of the profession. Antyllus's Operation. — The oldest op- eration is that of Antyllus (fourth cent- ury), which was at first emjiloyed only for small traumatic aneurisms of the elbow. It consisted in tying the artery above and below the sac, opening the latter, and removing its contents. It was often attended by suppuration, secondary hemorrhage, and ankylosis, owing to the fact that the artery was tied immediately above and below the sac, the artery being itself diseased in these regions. In 1710, Anel, believing that the sac would collapse, tied the artery above the aneurism, but the true cause of success in such cases was not discovered until, in 1875, John Hunter proved experi- mentally that aneurism was not due to localized weakness in the vessel, but to a pathological condition of the arterial wall, extending beyond the sac. The Antyllus modified operation may be exceedingly difficult, on account of branches springing from the sac, and from the artery above and below the sac being so thickened as to make it almost impossible to tie them. After emptying the sac a probe should, therefore, be passed into the arteries above and below, and the latter only then tied. When it is too difficult to remove the sac entirely a portion may be left behind. Hunter's Operation. — In the Anel method the artery was tied too near the sac, where the diseased arterial wall did not allow the ligatures to hold firmly; by Hunter's method the artery is tied at some distance above the sac, where it is healthy. The sac does not collapse; the force of the circulation is simply dimin- ished, allowing the sac and its contents to be absorbed. Slight oedema of the limb is not a contra-indication for Hunter's opera- tion, but the aneurism should be of slow growth, of moderate size, and the sac not infiamed. It should not be per- formed in multiple aneurism, except if there are only two, and these can be operated on simultaneously. This operation may be followed by return of pulsation in the sac, and re- currence, secondary liEemorrhage, in- flammation and suppuration of the sac, gangrene, pyssmia, and septicEemia. In performing Hunter's operation it is advisable to make distal compression for a few seconds before tightening the ligature, so as to distend the sac, and to 316 ANEURISM. TREATMENT. ascertain, by digital compression, that the pulsation can be entirely arrested. A rise in the temperature of the limb is observed after the operation, accord- ing to Holmes and Ashhurst. Accord- ing to the majority of writers, however, the temperature first falls, rising only when the collateral circulation is estab- lished. After the operation two sets of vessels are formed for the collateral circulation: one around the point tied, the other around the aneurism. In a very few cases the sac will be ob- literated, but a narrow channel will still be left for the passage of the blood. As the aneurism itself has caused previous dilatation of the neighboring vessels, those forming the collateral circulation around the sac develop earlier in cases where two sets develop. If the aneu- rism be tied near the sac, but one set of collateral vessels is formed. Secondary aneurism, or pulsation, maj' occur in from a few hours to several months after consolidation and contrac- tion of an aneurismal sac; but in most cases it forms about twenty-four hoiirs after the new sac, being generally slightly higher up on the artery than the old sac. Eecurrent pulsation is due to the upper anastomotic arch allowing too much blood to ilow into the artery be- tween the point of ligation and the sac. Though in some cases as distinct as be- fore the operation, it usually consists in a mere thrill, without iruit. Pulsation in the sac may also be caused by too rapid collateral circulation being re-established above the sac. Eecurrent pulsation is best treated by raising the limb, compressing the sac moderately, and using cold with care. If this is unsiTccessful, the artery may be tied lower down. But, if there is danger of sloughing of the sac, amputa- tion should be performed in axillary or popliteal aneurism, and Antyllus's modi- fied operation in cervical or inguinal aneurism. The prognosis of cases of re- current pulsation is usually favorable, as it will usually disappear when the sac consolidates. (Ashhurst.) Secondary haemorrhage is most likely to take place from the seventh to the fifteenth day, and on the upper than on the lower limb, owing to the more abundant arterial anastomosis on the former. It is favored by the presence of large branches given off close to the point of ligation. Strong, well-prepared, chromicized catgut is less likely to be followed by secondary hsemorrhage than silk. If after ligation the tumor enlarges, but without pulsation, it is due to blood coming from the artery beyond the sac. The obstruction of the venous circula- tion caused by this may give rise to gan- grene. However, in most cases the blood coagulates, and the aneurism forms a solid fibrinous tumor. Suppuration and sloughing of the sac after Hunter's operation may be due to recurrent pulsation from want of con- solidation due to an imperfectly devel- oped lower collateral circulation, or to total sudden coagulation of the blood in the sac, from complete arrest of the cir- culation, from violence or handling of the tumor. Death results in about 35 per cent, of cases where the sac Ijursts. Hssmorrhage is most common in cases where recurrent pulsation has occurred; if suppuration is delayed, no hemor- rhage may occur, owing to the arteries communicating with the sac having be- come sufficiently occluded. Gangrene occurs usually from the third to the tenth day. It is always moist gan- grene, and is most frequent in the lower limb. In some cases it may be prevented ANEURISM. TREATMENT. 317 by opening the sac and removing its con- tents in order to relieve the pressure on the veins. When gangrene is really pres- ent, the upper limb should be removed at the shoulder-joint, in most cases, and amputation at the junction of the upper and the middle thirds of the thigh, in the lower limb. (Ashhurst.) Ligation Below the Sac. — Among the methods best known are Brasdor's, in which the artery is tied below the sac, thus completely arresting the circula- tion, and Wardrop's operation, in which the artery or a branch is tied below the aneurism, so as to allow the passage of the blood throiTgh another branch or branches, thus only partially arresting the circulation. Brasdor's operation is used in aneurism of the carotid, external iliac, etc., and Wardrop's operation in aneurism of the innominate artery or of the arch of the aorta, where the carotid or subclavian or both may be tied. Liga- tion below the sac is considered as very unreliable. The sac is likely to increase in size, being still subject to the imprdse of the heart. Extirpation was first proposed in the fourth century by Philagrius, of Mace- don. After cutting down freely upon the an- eurism, two ligatures are placed around the artery above the sac, and the artery is divided between them. The sac, with its contents, is then dissected out, and a double ligature is applied to the artery below the sac. The vessel is divided be- tween these two ligatures. This operation presents certain special advantages over compression, proximal ligation, or other methods, namely: the permanence of the cure, the absence of secondary haemorrhage, and the absence of danger of emboli or of infection. Its mortality, too, is lessened, having been estimated by Delbet at 11 per cent., whereas that of proximal ligation is 18 per cent. Again, gangrene occurs in but 3 per cent, after total extirpation, against about 8 per cent, after proximal ligation. Extirpation is indicated when the sac has ruptured, when other methods have been unsuccessfully tried, and, above all, in traumatic aneurisms, especially those of the extremities. It is especially in- dicated in all aneurisms of the forearm and leg, where the sac has ruptured and caused sudden enlargement, and where rupture is impending. It is also recom- mended in recent traumatic aneurisms, and in arterio-venous aneurisms where operation is indicated. Statistics of treatment by extirpation: In 1S8S the mortality was between H and 12 per cent., but in the 76 cases since reported there is not a single death. Of 109 cases treated by simple ligature, 12 had gangrene, while, of the 76 cases extirpated, there were only 7 instances of this accident, and in 4 of these the gangrene existed before the operation. Recurrence is also one of the dangers of ligation, but it is much less apt to take place with extirpation — if, indeed, it is possible. Delbet (La Semaine Med., Oct. 30, '95). Results of 86 cases treated by extir- pation. Of these, 27 were idiopathic, 59 traumatic, 29 occurred in the popliteal artery, 14 in the femoral, and the others were distributed tolerably equally over the remainder of the arterial system. Only 3 deaths ensued: 1 from haemor- rhage during the operation, 1 from sec- ondary hemorrhage, and 1 after amputa- tion for gangrene. Gangrene occurred in only 2 cases (2.3 per cent.), and second- ary hasmorrhage in but 1 (l.I per cent.). In contrasting this method with others, it becomes evident that the percentage of cases in which gangrene occurs is less than after ligature of the main trunk above, while there is here no possi- bility of local relapses. The advantages claimed over the old-fashioned method of Antyllus are the following: 1. The length of the after-treatment is im- mensely diminished, since in many cases 318 ANEURISM. AORTIC. SYMPTOMS. it is possible to obtain primary union. 2. The risk of subsequent bleeding is greatly lessened, since all the collateral branches are secured, and it was from these that it usuaUy arose, and not so much from the main trunk. 3. The presence of a thickened cicatrix, which included the doubled-up and wrinkled sac-wall, was likely to lead to interfer- ence with the utility of the part, when, as at the knee, the aneurism occurred in the flexure of a limb. Kopf stein (Wiener klin. Rund., Nos. 11-16, '96). Advantages of the treatment of aneu- risms by excision: 1. If the operation can be successfully performed the result is a complete cure of the aneurism. 2. The ligatures have the advantage of be- ing applied to the ends of the divided vessels, and not to them in their con- tinuity. 3. Even if the corresponding vein is divided and a portion of it re- moved the risk of gangrene is not great. 4. That in this method all the advan- tages of the antiseptic treatment can be obtained, in connection with the success- ful healing of the wound and closure of the vessels where divided. 5. Inflamma- tion and suppuration of the sac or rupt- ure of it cannot occur in connection with this method. 6. Although as yet more experience is required, it seems likely that certain aneurisms, such as the sub- clavian, Avill in the future be treated more successfully by this method. T. Annandale (Scottish Med. and Surg. Jour., Oct., 1900). Aortic Aneurism. Symptoms. — Aneurisms may be di- vided into three groups: (1) those which are entirely latent, giving no physical signs; (2) those giving signs of intra- thoracic pressure, but in which the na- ture of the cause cannot be ascertained; (3) aneurisms which form distinct tu- mors and give well-marked pressure symptoms and external signs. (Bram- well.) Aneurisms of the ascending portion of the arch are those most liable to affect the sympathetic. Eeflex dilatation of the pupil may thus be caused; the face may be pale. When the cilio-spinal branches are destroyed the pi-Lpil is contracted; the vessels of the side of the head may be dilated. Congestion and unilateral perspiration are also, though less fre- quently, observed. Tugging on the trachea is a valuable symptom, and may be detected in the following manner: The patient's head being inclined forward to relax the neck, and the cricoid cartilage being grasped between the index and the thumb, the trachea is drawn upward. If an aneu- rism is present a well-marked ascending motion will be felt at each pulsation. Olivier's symptom for diagnosis of aneu- rism of thoracic aorta, systolic pulsation of the larynx and trachea, is not to be expected in all aneurisms of the aortic arch, but is especially to be observed, either when the aneurism is situated ex- actly at the intersection of the aortic arch and bronchus or when, if the aneu- rism is situated at the beginning of the arch, it is adherent to the anterior wall of the trachea. The only other patho- logical condition which one might expect to produce similar symptoms is a tumor in the anterior mediastinum. This must hold certain relations to the aortic arch, either through pressure exerted by the arch, the tumor is pressed against the bronchus, or it must be adherent to the convexity of the arch and to the trachea. A. Fraenkel (Deutsche med. Woeh., Jan. 5, '99). At times a systolic murmur is caused in the trachea by the air being forced out of it during the systole. The sound, however, may also be caused by the sac. It may be heard at the patient's moitth when the latter is well opened. Trac- tion of the tongue causes this symptom to become more distinct. In two oases a rhythmical shake of the head observed, synchronous with the car- diac systole and due to downward trac- tion of left bronchial tube and trachea by the aneurism at each diastole. Feletti (La Semaine Med., Nov. 6, '95). ANEURISM. AORTIC. SYMPTOMS. 319 Pain is especially marked in deep- seated tumors. Angina pectoris fre- quently occurs in aneurisms situated at the root of the aorta. Cough in thoracic aneurism may be due to bronchitis, or it may be caused by pressure on the trachea. The expectora- tion is at first abundant and watery; later on it is thick and turbid. On percussion large aneurisms pre- sent abnormal dullness. This dullness is toward the right when an aneurism of the ascending arch is present, and more to the centre and left in those of the transverse arch. Aneurisms of the de- scending portion of the arch show dull- ness in the left interscapular region: i.e., in the space between the spinal column and the scapular border. A ringing, accentuated, second sound, heard over a dull region, is frequent in large aneurisms of the arch. Absence of pulse in the abdominal aorta and its branches is observed in cases of large thoracic aneurism. Case of aneurism of the aortic arch in which the pulse of the carotids and right radial arteries had the reversed character of the pulsus paradoxus. There was a very marked diminution in the volume of the pulse during expiration, and with the respiratory variations there was a definite ana- crotic wave. Post-mortem examination showed an aneui'ism involving chiefly the posterior portion of the aorta in the region of the transverse arch. The left carotid and innominate arteries sprang from the anterior surface of the arch instead of from the convexity, on ac- count of the distension of the aorta. With each expiratory excurse these blood-vessels were compressed against the bony thorax-walls. J. Hay (Lancet, Apr. 27, 1901). Inspection is negative in many cases of aneurism of the aorta, but in some abnormal pulsation or a diffuse heaving impulse may be perceived, usually in the first or second right interspace. Throb- bing may be seen at the sternal notch or in the neck when the innominate artery is involved. A tumor may be visible in front or in the rear, usually in the left scapular region. Dyspnoea may be due to compression of the recurrent laryngeal nerves, of the trachea, or of the left bronchus. Pressure on this nerve, especially on the left one, causes hoarseness and loss of voice. This may be due either to spasm or paralysis of the muscles of the left vocal cord. Abductor paralysis may be the only symptom of aneurism. In the early diagnosis of aneurism of the arch of the aorta, attention is called to the fact that pressure upon the recur- rent nerve from aneurism or thoracic tumor does not necessarily produce aphonia. The only subjective symptom of this stage may be a more or less con- stant laryngeal cough. There may also be dyspncea from pressure on the bra- chial plexus with consequent bron- chial spasm. A frequent indication of aneurism of the aorta is pain in the region of the fifth or sixth dorsal verte- bra. Auscultation of the left interscapu- lar space may reveal an arteriodiastolic murmur not heard elsewhere, or else a systolic murmur due to the beating of the aneurismal sac against the left bronchus. Another auscultatory phe- nomenon is the presence of the systolic sound or thud in the brachial artery sim- ilar to that observed in aortic insuffi- ciency. W. Porter (N. Y. Med. Jour., Dec. 9, '99). Early diagnosis of aortic aneurism. Series of 54 cases in which 38 had paral- ysis of the left recurrent laryngeal nerve, 5 of the right nerve, and only 1 of both nerves. In all these cases the patients first consulted the author on account of hoarseness. Tracheal buzzing was pres- ent in 19 out of 31 cases. It is best felt when the cricoid cartilage is pushed up- ward with the index and middle finger of the right hand, the head of the patient 320 ANEURISM. AORTIC. SYMPTOMS. being bent a little backward. A pulsa- tion downward is felt which ought not to be confused with the general pulsatory vibration of the larynx that occurs not infrequently in excited patients. Moritz Schmidt (Med. Chronicle, Mar., 1900). Haamorrhage from the air-passages may be produced in three ways: (a) by the formation of granulation tissue in the trachea where it is compressed, in which case the bleeding is not abundant; (6) by the sac breaking into the trachea or bronchi; (c) by the lung-tissue being eroded or perforated. A patient may re- cover and live for years even after pro- \ Aneurism possibly arising from one of the pulmonary sinuses of Valsalva. [Shoier.) fuse hasmorrhage occurring as the result -of aneurism. A relatively frequent phenomenon is repeated occurrence of hsemoptysis pre- ceding the opening of the sac into the bronchial tubes, due to the existence of a small communication between the aneurism and the latter. Hampeln (Ber- liner Idin. Woeh., Dec. 24, '94). Dysphagia may be due to spasm of the oesophagus or to compression. Perfora- tion may be induced by the passage of an oesophageal bougie. This instrument therefore should not be used. Ascending Portion of the Arch. — Aneu- risms in this region may be situated just above the sinuses of Valsalva, or some- what higher, on the convex border of the ascending arch. In the former case they may be small and latent, and their rupture into the pericardium (usually causing instant death) be the first in- dication of their existence. "When this does not occur aneurisms in this region may become exceedingly large and pro- ject into the right pleural cavity or for- ward, after destroying the sternum and ribs. [I witnessed and reported a case in \yhich aneurism of the innominate artery was suspected and in which ligation of the carotid artery was practiced as a last resort, following the use of iodide of potash, digitalis, and continued digi- tal pressure for thirty-six hours and mechanical pressure for one hundred and twenty hours. The patient died immediately upon the ligation of the carotid artery. A post-mortem exami- nation showed that the aneurism was one involving the arch of the aorta and that coagulation had resulted from the pressure, but not sufficient to occlude the vessel. J. McFadden Gaston.] Aneurism probably arising from one of the pulmonary sinuses of Valsalva. Peculiar features noted: Development of the sac anterior and to the left of the sternum; the sac fills up a large portion of the upper half of the left thorax; absence of involvement of the vagus and recurrent laryngeal and of the sympathetic nerves; peculiar and unusual murmurs; absence of irregular and asynchronous action of the radial pulses; absence of tracheal tugging. Points of unusual interest: 1. Two years since the first symptoms appeared; the patient has, during the greater part of the time, been able to be about on her feet, doing light work. 2. Almost entire absence of the usual pressure symptoms. 3. Remarkable result of the therapeutic measures: iodide of potas- sium, mercurial inunctions, and repeated venesection. 4. Decided benefit gained from venesection. On one occasion, at ANEURISM. AORTIC. SYMPTOMS. 321 least, the patient's life was undoubtedly saved by the prompt opening of a vein and the withdrawal of twenty-eight ounces of blood. J. B. Shober {Amer. Jour. Med. Sciences, Feb., '97). Remarkable case of aneurism of one of the sinuses of Valsalva met with in a man, aged about 45, found dead. The aneurism bulged into the right auricle and ruptured at a point just above the attachment of the posterior tricuspid In 1840 Thurman collected 22 cases where aneurism of the aortic sinuses was present. Twenty further cases given. Cottell and Steele (Inter. Med. Mag., pp. 258-263, '97). The situation of the aneurism with reference to the stiperior vena cava and subclavian vein causes various accidents. The aneurism may burst into the supe- rior vena cava, or may compress it, caus- ing engorgement of the vessels of the head and arm; or it may compress the subclavian vein, when the right arm is enlarged. Aneurism of the ascending portion of the aortic arch that lead to external rupture. External rupture is one of the more uncommon terminations of a tho- racic aneurism. According to Crisp's tables, this occurred six times in one hundred and thirty-six cases of aneu- rism of the ascending arch which he found recorded. Stewart and Adami (Montreal Med. Jour., Nov., '96). Case of large aneurism of the arch of the aorta was treated by Macewen's method. The tumor occupied third right intercostal space and was six and one- half centimetres across at its base. At five different times two needles were inserted, and at two other times one needle. The needles were removed one or two days later. The treatment re- quired about two months. No swelling could then be perceived at the level of the tumor. It was almost as hard as bone; percussion gave dullness over the manubrium of the sternum and extend- ing somewhat to its right. A. Gignane (Gaz. degli Osp. e d. Clinic, No. 62, '96). These aneurisms may affect the right 1 recurrent laryngeal nerve; and also com- press the inferior vena cava, which is fol- lowed by ascites and oedema of the feet. Point in aortic aneurism emphasized of recent years: the comparatively fre- quent latency of aortic aneurism, the disease then giving rise to very few or indefinite symptoms. A paralysis of the left vocal cord may constitute, the first means of recognizing the aneurism. Auscultation of the upper part of the left interscapular space may reveal an arterio-diastolic murmur not heard else- where, or there may be here, or in the neighborhood, a systolic murmur due to the beating of aneurismal sac on the left bronchus. Gerhardt (Deutsche med. Woch., June 10, '97). The heart may be pushed down to the left. Eupture into the pleura or superior vena cava is the usual cause of death, but this may be due to heart-failure or to external rupture. Transverse Arch. — Three varieties of aneurism are observed in this location. In the first and most common form the aneurism is small and not visible exter- nally. The growth is directed backward or downward and may involve the oesoph- agus, causing dysphagia. The trachea may also be pressed upon, giving rise to cough, which is often paroxysmal. The left recurrent laryngeal nerve may also be compressed as it passes around the arch of the aorta or a bronchus. In the latter case bronchiectasis, bronchorrhoea, and suppuration into the lung, not un- commonly the cause of death, may result. The second variety of aneurism of this class is that in which the mass may pro- ject forward and simulate a large tumor. It may destroy the sternum and pene- trate the opening thus created. In the third class the aneurism may grow on both sides into the pleura be- tween the sternum and vertebral column. This form may last for years. The ca- 21 322 ANEURISM. AORTIC. DIFFERENTIAL DIAGNOSIS. rotid (radial pulse) may be affected by the involvement by the sac of the innom- inate artery, or more rarely the carotid and subclavian arteries. Compression of the thoracic duct, an occasional complication, may finally in- duce inanition. When the compression includes the sympathetic nerve, there is, at first, dilatation of the pupil; this may be followed by paralysis, with contrac- tion of the pupil. Pressure of the ver- tebrae may cause severe pain; of the oesophagus, dysphagia; of the lungs or bronchi, bronchiectasis, the retention of pulmonary secretions giving rise to fever. Most are saccular; some are small and spring from the aorta just above the aortic ring. Another variety springs from the anterior and upper aspect of the aorta in the form of large tumors, or from the descending aorta and the lower surface of the arch, compressing the trachea or bronchi. In intrathoracic aneurism clubbing of the fingers and incurving of the nails of one hand may also be observed, even when no venous engorgement is present. Sudden death may be induced by rupt- ure into the pleura or a small and latent aneurism bursting into the oesophagus. The spinal cord may be compressed and give rise to disorders of locomotion. Differential Diagnosis. — When the an- eurism is in the thorax, the conditions with which it may be confounded are: — 1. Violent throbbing of the arch through marked aortic insufficiency. 2. Displacement of the heart through the deformity caused by spinal curvature. 3. Pulsating pleurisy can be differ- entiated by means of a fine, hypodermic needle. In pulsating pleurisy the throb- bing is usually wide-spread and diffuse; in aneurism there is a firm, heaving dis- tension and a diastolic shock. 4. Tumors. In deep tumors the pain is likely to be more severe. Pressure phenomena are most common in aneu- rism. When the abdominal aorta is in- volved, neurotic pulsation of the latter shoi;ld be suspected. ' Almost none of the symptoms are due to the aneurism itself, but most are produced by the influence of the tumor upon neighboring structures. A certain amount of dull pain may be due to the distension of the sac-wall itself; but this is usually entirely overshadowed by that produced by alterations in parts in the neighborhood. For our diagnosis we must depend not so much upon the physical signs of an arterial tumor as upon those due to an abnormal growth of whatever nature. The typical signs of aneurism may be said to be tumor, expansile pulsation, thrill, bruit, and shock. Tumor is fre- quently absent; expansile pulsation is, in many situations, impossible of detec- tion; thrill is a very uncertain signj bruit is as often absent as present; while shock, Avhether diastolic or systolic, is frequently absent. F. A. Packard (Mass. Med. Jour., Oct., '97). Radioscopy is of value in the study of aneurisms of the arch of the aorta, but of little use in case the descending aorta is affected, as under the latter conditions the shadow of the heart overlies that of the aneurism. G. R. Murray (Prac- titioner, Feb., '98). The fluoroscope in diagnosing anei? risms of the aorta. While aneurisms usually throw a shadow beside the heart, which can be seen to enlarge in all di- rections with each heart-beat, this must not, however, be regarded as pathogno- monic. Case in which, although the shadow was well defined and the pulsa- tion marked, necropsy showed carcinoma of the cardia with extreme dilatation of the oesophagus above, thus simulating aneurism. G. Kirchgaesser (Munchener mcd. Woch., May 8, 1900). Case of aneurism of the aorta in which pain along the intercostal nerves, on both sides, with marked disturbances ANEURISM. AORTIC. ETIOLOGY. TREATMENT. 323 of sensibility, — i.e., intercostal neuritis, due to pressure, — was the main symp- tom of the aneurism for months. Sub- jective symptoms were entirely absent. Frick (Wiener klin. Woch., June 20, 1901). The diagnosis of aortic aneurism still remains, in obscure eases, a difficult one, and even the x-ray examination may be misleading. Attention called to the frequency with which, in aneurism of the arch, the left supraclavicular groove is obliterated or even bulges, and the left external jugular is obviously fuller than the right. The anatomical reason lies simply in the compression of the left innominate vein as a result of the dilated arch. A mediastinal tumor may have the same effect, but dilatation in cases of aortic insufficiency is appar- ently seldom sufficient to effect com- pression. Dorendorff (Deutsche med. Woch., Nov. 31, 1902). Etiology. — Aortic aneurism is espe- cially due to alcohol, syphilis, and over- work. Sudden muscular exertion may lacerate the media. The etiological fac- tors of aneurisms in general may all be considered as capable of promoting aneu- rism of the aorta. Treatment. — All methods shoiild be aided by rest in bed and proper diet. It is unnecessary to give large doses of potassium iodide, viz.: from 10 to 20 grains thrice daily. This drug relieves pain, causes thickening and contraction of the sac, and lowers the blood-press- ure. Pain may sometimes be relieved by anodyne plasters or embrocations, but morphine may be necessary in the final stages. Ice poultices, recommended by some to relieve pain, are liable to cause gangrene of the skin, owing to deficient circulation. Chloroform may be used in dyspnoea. Small, but repeated, venesec- tions are highly recommended for the latter symptom. Venesection — removal of from 27 to 30 ounces — followed by great relief from paroxysmal dyspnoea and from pain, lasting nine months in one case. One copious venesection recommended. Davi- son (Lancet, May 19, '94). Tracheotomy may be useful when dyspnoea is due to bilateral abductor paralysis, but not when it is due to compression at the bifurcation, which is almost always the case. Where external rupture of an aneu- rism is feared hemlock or lead plaster may be used as a support. (Ashhurst.) Laceration of the media frequently occurs in the ascending portion of the arch previous to the occurrence of com- pensatory thickening. (Osier.) TufEnell's treatment of restricted diet and rest in bed has given satisfactory results. If the milder methods do not succeed needling should be tried, aided by distal compression, when feasible, during the use of the needles; if this fail, distal ligation should be resorted to. (Nan- crede.) In treatment of aneurism of aortic arch following conclusions reached: I. The remedy lies within the domain of surgery. 2. There are but two such methods at the present time to be con- sidered: (o) obstruction of the right subclavian and common carotid arteries; (6) introduction of wire or needles into the sac, with or without galvanism. 3. Either one or both of the operations should be applied in all cases after a thorough saturation with the iodides. 4. Ligation is attended by less danger, less mortality, greater and more permanent and universal benefit. B. Merrill Ricketts (Jour. Amer. Med. Assoc, Aug. 13, '98). Discussion on treatment of aneurism of the aorta. Golubinin, of Moscow, had employed in 8 cases the method of treating aortic aneurisms by injection of gelatinized serum recommended by Lan- eereaux and Paulesco. The number of injections varied according to the case 324 ANEURISM. AORTIC. TREATMENT. from 2 to 15. Of the 8 patients, 4 died in a short time and the other 4 were lost sight of; in 3 of the cases belonging to the latter group the injections produced no effect. In the remaining 1 they were followed by slight improvement in the subjective symptoms without modifica- tion of the objective signs. Golubinin had come to the conclusion that the method did not fulfill the expectations that had been founded on it. In the treatment of aortic aneurism. Huehard says it is a mistake to allow one's self to be hypnotized by the changes to be brought about in the content of the sac, — that is to say, in the blood, — and to take no account of the containing structure. The method of gelatinized injections, which is useful, although in- sufficient, is open to this criticism. To complete its action, especially in persons with large heart and increased arterial tension, — they are almost always at the same time subjects of Bright's disease, — medicaments should be chosen which di- minish arterial tension, such as potas- sium iodide, trinitrin, nitrite of amyl, and especially tetranitrate of erythrol, or tetranitrol, which Huehard has now used for a considerable time and which, as compared with trinitrin, has the ad- vantage of a more durable action. More- over, an essential point is to supervise the diet not in regard to quantity, as in Valsalva's method, but in regard to quality. Meat, which holds too large a place in our food, contains toxins, which have an excessively powerful vasocon- strictor action. The best treatment of aortic aneurism is still absolute milk diet regularly adhered to. (Section of Therap., Inter. Congress of Med., 1900; Brit. Med. Jour., Oct. 13, 1900). Remark on treatment of aneurism of the aorta by the insertion of a perma- nent wire and galvanism based on a re- port of 5 cases. A black varnish or lacquer makes the best insulation for the needle. The disposition of the wire in the lumen of the sac is an important factor in the amount and the effective- ness of the fibrin whipped out. A small quantity of wire possessing a good spring should be selected. Cure of the aneurism demands as complete contraction as pos- sible of the sac-wall upon the clot formed at or soon after the operation. The wire should be of such amount and material as not to interfere seriously with this contraction. The corrosion of the wire by the electric cuiTcnt makes a rough surface very conducive to the rapid whipping out of fibrin. Within certain limits, the wire most easily corroded is to be preferred. The sac should never receive both poles, and the negative elec- trode should never be in the sac. Sepsis is an omnipresent danger. Another danger is that of the development and rupture of a secondary sac due to the rapid filling up of the main sac by coag- ulum, and the shunting of the blood- stream against a portion not receiving a special strain before. Thirty-nine per cent, of successful results reported in the 23 eases, including the author's 5, found in literature. G. L. Hunner (Johns Hop- kins Hosp. Bull., Nov., 1900). In these cases graduated exercise, baths, and the Schott method, with a suitable dietarj', sometimes afford marked relief. Case of aneurism of the aorta treated by mineral baths and graduated walking exercise, with a liberal nitrogenous di- etary and free ingestion of fiuids to eliminate uric acid, etc. After six weeks the patient could walk with comfort during three hours a day. A sciagraph showed that there was no increase in the size of the aneurism in spite of the exercise. Recurrence of the symptoms promptly yielded to the same treatment. Bezly Thorne (Brit. Med. Jour., Mar. 6, '97)." In this form of aneurism favorable results are sometimes obtained by the introduction of foreign bodies. Fifteen cases of aortic aneurism in which, when practicable, introduction of silk-worm gut was resorted to. In one case the gut-fibres were absorbed after the desired effect had been produced. Von Schi-otter (Inter, klin. Rund., Nov. 26, '93). In 1895 Dastre demonstrated that the injection of a solution of gelatin into the ANEURISM. CAROTID. SYMPTOMS. 335 veins of a clog rendered the blood more coagulable. This discovery has recently been utilized in the treatment of aneu- rism of the first portion of the arch of the aorta. Case of a man, aged 46 years, who had a large aneurism undoubtedly due to a malarial aortitis, which had eroded the second, third, and fourth right cartilages, the extremities of the corresponding ribs, and a large portion of the sternum. On the surface of the tumor there were patches of ecchymosis which were soft and depressible, and in the neighborhood of which the blood was directly in con- tact with the very thin skin. On Janu- ary 20th 13 drachms of a 1-per-cent. sterilized solution of gelatin in a 0.1-per- cent, solution of sodium chloride was injected into the subcutaneous tissue of the left buttock. The solution was in- jected at a temperature of 98.4° F. There was a slight reaction following this injection. During the following days the tumor became somewhat dimin- ished in volume and the pains completely disappeared; but soon the tumor re- turned to its former dimensions, the walls again became soft, and the inter- costal pains returned. On February 10th a second injection of 5 ounces of a solu- tion similar to that first employed was given. This solution was followed by results similar to those which followed the first injection, except that there was no reaction. Since that time twelve in- jections similar to the second have been made at intervals of from two to five days. The tumor diminished in volume (one inch in the vertical and one-half inch in the transverse diameter). It is very firm, and, although on palpation a pulsation can be felt, that pulsation is not expansile, but is transmitted from the aorta. The pain entirely disappeared. Laneereaux (Gaz. des Hop., June 24, '97). Case of aortic aneurism in which the tumor extended over the sternum, the sternal portions of the clavicles, and the whole anterior surface of the neck, its diameter being seven and one-half inches. Injections in the vicinity of the tumor of 75 minims of gelatin, suspended in 10 drachms of sterilized normal saline solu- tion, were given every four days. Under this treatment its size has decreased, the hoarseness has disappeared, and the general condition is improved. Carl Beck (N. Y. Med. Jour., Apr. 15, '99). Gelatin Injections in aortic aneurism. The first indication is to eradicate, if pos- sible, the cause. By increasing the co- agulability of the blood the sac may now be obliterated. This is most efficiently accomplished by gelatin. Gelatin injec- tions (15 grains of gelatin in 2V3 drachms of sodium-chloride solution once a week) may then be resorted to. Re- markable results on personal case in which five weeks of this treatment prac- ticallj' freed the patient from symptoms both subjective and objective. In this case the iodides had produced no eflfect. N. Kalendern (Klin, therap. Woch., Jan. 28, 1900). Case of very large aneurism of the ascending aorta, treated by gelatin and electrolysis. Coagulation of most of the contained blood occurred. The opera- tion was comparatively painless except at the beginning. A few weeks later the patient had an attack of intermittent fever. Several large blebs formed near the sternal margin of the aneurism, which finally ulcerated and revealed ne- crosed fragments. The patient died suddenly from haemorrhage, the blood poviring from the point of successful puncture. Autopsy showed evidences of recent coagulation. W. W. Johnston (Amer. Medicine, May 11, 1901). Carotid Aneurism (in the cervical region). Symptoms. — Aneurism of the carotid artery usually occurs where the common carotid bifurcates into the internal and external carotid arteries. On the right side it most frequently appears where the artery springs from the innominate artery. Its special symptoms are dysp- noea, difficulty in swallowing, hoarseness, a brassy cough, vertigo, and tinnitus aurium. 326 ANEURISM. CAROTID. DIFFERENTIAL DIAGNOSIS. TREATMENT. Carotid aneurism first appears as a small tumor, which may grow very rapidly. Case of aneurism of the internal ca- rotid following scarlet fever in a girl, aged 18 years, severe inflammation of the throat being a prominent symptom. A month after the onset the aneurism appeared in the left sterno-mastoid re- gion, immediately below the mastoid. It was the size of a walnut, reducible, and pulsating energetically. On explor- atory puncture with a Rravaz syringe blood was obtained. No treatment was employed. Gradual improvement took place, and the patient spontaneously re- covered in three months. Lyot and Retit (Revue des Sciences Med., July, '97). Case of aneurism of the internal ca- rotid artery following tonsillar abscess in a girl 8 years old. The left tonsil and the wall of the pharynx were markedly protruded; this, with the enlarged sub- ma.xillai-y glands, closely resembled post- pharyngeal abscess. The tumor, how- ever, showed marked expansile pulsation, and aspiration brought away nothing but pure blood. During the opening of a tonsillar abscess the carotid artery had been wounded, causing the loss of a pint or more of blood. The child recovered and an aneurism gradually developed. The common carotid was ligated just below its bifurcation. The aneurism ceased and did not return. The clot in the sac, however, suppurated and was opened, and a discharge came from the left ear, which, however, finally disap- peared. The throat returned to its nor- mal size and complete recovery ensued. P. Wulff (Miinchener med. Woch., May 15, 1900). Differential Diagnosis. — At the root of the neck it is sometimes difficult to ascertain whether the carotid alone is involved. Aneurisms of the subclavian, the innominate, and the aortic arch may simulate those of the carotid when these are close to the clavicles. Enlarged cervical glands may be taken for aneurism; but, as these are iTsually multiple and not endowed with powers of auto-expansion, their diagnosis is easily established. Cysts and vascular growths of the thyroid resemble aneu- risms in some cases. Cysts in the cer- vical region are very rare, while any growth connected with the thyroid gland follows the movements of the latter dur- ing deglutition. Abscess may be taken for aneurism, especially cold abscess, but the cachectic facies is different, and the growth, though pulsatile through the pressure upon the underlying large vessels, is not expansile. An ordinary abscess can easily be recognized by its characteris- tics, which differ entirely from those of aneurism. Prognosis. — Spontaneous cure is rarely observed. The usual course of an aneu- rism is to progress until rupture into the pharynx or trachea or externally takes place. Some cases remain dormant for a long while, and suddenly undergo the process of development. Treatment. — All methods should be supplemented by recumbency and diet. Proximal compression, when feasible, should always be tried, and, where the arterial coats are seriously diseased, should supersede ligation. Needling should supplement pressure when the case is progressing rapidly. Possibly it is advisable in all cases suitable for com- pression, and is certainly to be employed where this method fails in cases with highly atheromatous vessels. Proximal ligation, having been rendered much safer of late by the use of aseptic pre- cautions, less-absorbent ligatures, and the avoidance of all injury to the arte- rial walls by employing the stay-knot, is permissible when the arterial walls are relatively sound, until experience decides whether or not needling is clearly indi- cated. Since recurrence after proximal ligation almost certainlv results from ANEURISM. SUBCLAVIAN. SYMPTOJIS. DIAGNOSIS. 337 non-deposition of white thrombi and their maintenance in contact with the aneurismal wall from lack of proper changes of its lining, needling is clearly indicated. Where the location prevents proximal arrest of the blood-current, needling is the best operation; possibl}' distal compression — rarely feasible — might aid in the deposition of thrombi. For the reasons already given, although occasionally successful, the indications for the permanent introduction of such foreign bodies as wire, horse-hair, etc., into aneurismal sacs are so much better met by needling that such procedures had better not be adopted. The modern revival of the older method of extir- pation of aneurisms should not be at- tempted for spontaneous cervical aneu- risms. (Nancrede.) Extirpation of an aneurism of the carotid may, however, be followed by good resiilts, even when the common carotid is involved. The treatment most generally em- ployed, if there is room, i« to tie the artery between the sac and the heart, and, if there is not room enough, beyond the sac. This may, however, be followed by embolism, cerebral softening, hemi- plegia, syncope, or by secondary hemor- rhage or suppuration. More than one-third of the deaths following ligation of the common carotid are due to subsequent cerebral disease. Cerebral softening following ligation of the common earotidj due to embolus, is mainly caused by the arrest of the blood-current. Besides the trunk of the common carotid, the internal carotid should also be ligated, to prevent the return-current, which takes place from the internal to the external carotid. Lampiasi (La Semaine Mgd., Nov. 11, '91). Ligation of both common carotid ar- teries, at a year's interval; neither oper- ation followed by brain symptoms. Gay (Boston Med. and Surg. Jour., Mar. 8, '94). When both carotid arteries must be tied, it should not be done at the same timej as fatal coma has followed a simul- taneous operation. Gentle handling of cervical aneurisms recommended to avoid the dislodgment of coagula through the internal carotid. Case in which a rough manipulation was followed by immediate paralysis. Hulke (Inter. Med. Mag., Dec, '92). Subclavian Aneurism. Symptoms. — Aneurism of the sub- clavian attacks more especially the third portion of the artery, appearing as an Extirpated aneuusm of the external carotid. (Delag^niere.) (Archives Provinciales de Chirurgie.) elongated tumor beneath the clavicular insertion of the sterno-cleido-mastoid. The special signs of subclavian an- eurism are a varicose condition of the jugular veins, a retarded pulse at the wrist, oedema of the arm and hand, pain in the nerves of the brachial plexus, and, if the aneurism is on the right side, a brassy cough from irritation of the re- current laryngeal nerve. Two-fifths of the deaths following ligation of the third part of the subclavian are due to intra- thoracic inflammation. Diagnosis. — Aneurism of the sub- clavian artery in its third portion is to 328 ANEURISM. AXILLARY. be distinguished from carotid aneurism. In the former the pulse at the wrist is found delayed when compared to the pulsation of the carotids. When both the carotid and radial pulse on the right side are delayed as compared to the left carotid artery, an- eurism of the innominate artery is to be suspected. Treatment. — Medical treatment of subclavian aneurism should precede all other methods. Ligature of the innom- inate, when supplemented with simul- taneous and consecutive ligature of the associated contiguous arteries, or by other expedients equally well intended to aid the cure, is worthy of favorable consid- eration. (J. D. Bryant.) Pressure applied by the finger be- tween the aneurism and the heart, sup- plemented with general measures, has been tried in cases in which the tumor was small. This procedure is not easy, however, on account of the anatomical constitution of the region and has been replaced by direct pressure upon the sac proper. When compression is unsuccessful the artery may be tied beyond the aneurism. Ligation between the latter and the heart has rarely succeeded. Method of controlling the circulation in the upper extremity by elastic com- pression. A wooden pad is placed over subclavian and held in place by the rubber bandage of the Esmaroh appara- tus; the bandage carried from the chest over the back and then alternately be- tween the thighs and under the opposite axilla. W. W. Keen (Med. and Surg. Reporter, June 27, '91). Successful ligation of the first portion of the left subclavian artery and excision of a large subclavio-axillary aneurism, probably the only successful case of this kind and the first one of complete extir- pation of a subclavio-axillary aneurism. Halsted (.Johns Hopkins Hospital Bulle- tin, July, Aug., '92). Simultaneous ligation of the common carotid and subclavian arteries recom- mended. The larger the aneurism, the greater the development of collateral circulation. Guinard (Bull. G6n. de Ther., Jan. 13, Feb. 15, 28, '94). Simultaneous ligation of the right common carotid and right subclavian or axillary artery appears to be the opera- tion of choice. Statistics showing six cures and twenty-two improvements out of fifty-six cases. Toivet (Revue de3 Sciences Medicales en France et 9. I'etranger, Jan. 15, '94). Study of one hundred and fifteen oper- ated cases of subclavian aneurisms. De- ductions as to treatment: Strict asepsis the sheet-anchor. The best plan is to ligate the first portion of the subclavian with a double or, better, triple, non- contiguous, absorbable ligature, without rupturing the coats. When it is decided to ligate the subclavian and the common carotid in one operation, it is best to first ligate the subclavian. In idiopathic aneurisms the defective general condi- tion of the patient should be borne in mind. Souchon (Annals of Surg., Nov., '95). Case of left subclavio-axillary trau- matic aneurism; ligation of subclavian artery in its second part; recovery, with perfect use of arm. Croly (Med. Press and Circ, Feb. 16, '98). Axillary Aneurism. A peculiarity of this form is its rapid growth. Being surrounded by lax tis- sues, it develops very quickly and is soon of considerable size. The same anatom- ical feature causes the sac to be easily inflamed, its location tending to assist this by the exposure to traumatism, press- ure, etc. Pain is usually a prominent symptom, owing to pressure on the nerves of the brachial plexus. (Edema of the forearm usually follows the venous obstruction induced by pressure of the aneiirism on the venous trunks. The pulse at the wrist is slower than that of the opposite side. ANEURISM. BRACHIAL. ABDOMINAL AORTA. 329 An axillary aneurism may compress the lung, causing dry pleurisy or hyper- plastic pneumonia, or may erode the ribs. It may invade the shoulder- joint, inter- fere with the motion of the arm, and cause ankylosis. Traumatic axillary aneurisms are caused by a wound, an attempt to re- duce an old dislocation, etc. Etiology. — Aneurism of the axillary artery is sometimes traumatic. At other times it may be due to elongation of the artery by too free motion of the shoul- der-joint, or to stretching during the re- duction of an old dislocation, especially when the vessels are atheromatous. Case of axillary aneurism caused by the pressure of a crutch. Bardeleben (Berliner klin. Woch., Deo. 16, '89). Case of axillary traumatic aneurism caused by the jamming of a pair of scis- sors up into the axilla, making a punct- ured wound about 1 inch in depth. The aneurism consolidated spontaneously and was almost entirely absorbed. This re- sult was probably induced by elevation of the arm, with the patient in the re- cumbent position. Willett (Practitioner, Dec, '98). Prognosis. — Spontaneous cure of these aneurisms is very rare. The sac, if al- lowed to do so, rapidly becomes larger and ruptures into the surrounding cell- ular tissue, the shoulder-joint, or the thorax. Treatment. — Compression of the third portion of the subclavian may be first tried, with or without an elastic band- age applied to the arm. Compression is usually very painful. Should these methods fail, the third portion of the subclavian may be tied. The most satisfactory treatment in general is to ligate the subclavian as far away as possible, dividing the scalenus anticus. When the incision involves considerable tissue the phrenic nerve should be watched for, and pushed aside if met. Collateral branches of the artery should also be tied to diminish the risk of secondary hemorrhage. Cases of axillary aneurism, with suc- cessful ligation of subclavian artery. Neugebauer (Centralb. fiir Chi., Aug. 17, ■95) ; Horwitz (Ther. Gaz., May 15, '95) ; W. E. Waters (Medical Record, May 25, '95). The treatment of traumatic aneurism should consist in arresting the circula- tion by pressure on the third portion of the subclavian, opening the sac, and re- moving its contents. The wound in the artery should then be found and the artery divided at that point, both ex- tremities being tied. Brachial. Brachial aneurism is usually traumatic in origin. Venesection, carelessly per- formed, occasionally causes aneurismal varix or varicose aneurism at the bend of the elbow. Aneurism half the size of an orange in the bend of the elbow, subsequent to venesection, cured by ligature of the brachial artery in middle third. Gallo (Le Dauphine Med., Mar., '94). Case diagnosed as a neuroma of me- dian ner\'e found, on exposing swelling, to be a cured traumatic aneurism of the brachial artery. On account of excru- ciating pain artery cut above and below aneurism and sac dissected out. Bland Sutton (Med. Press and Circular, Sept. 26, '94). Idiopathic brachial aneurism may be treated by Hunter's method, by the modified method of Antyllus, or by com- pression. In either of these, however, gangrene of the forearm is a possibility. When this complication occurs, amputa- tion becomes necessary. Abdominal Aorta. Symptoms. — Aneurism of the abdom- inal aorta is uncommon, as compared to that of the thoracic aorta. It usually occurs near the coeliae axis, where it may form a fusiform, sacculated, or 330 ANEURISM. ABDOMINAL AORTA. DIAGNOSIS. TREATMENT. multiple tumor; this may project back- ward, and either erode the vertebrse, causing subsequent numbness and tin- gling in the legs, which may be followed by paraplegia, or it may burst into the pleura. This form of aneurism, however, usu- ally projects forward either in the middle line of the abdomen or somewhat to the left. If it is located high up, and under the pillar of the diaphragm, it may be beyond the reach of the hand in palpa- tion. There usually are disorders of diges- tion, especially vomiting and pain, the latter frequently simulating cardialgia. It may be located either in the back or resemble girdle pains, passing around the sides to the back. Case of aneurism of the abdominal aorta, with symptoms of renal colic. Cheadle (Lancet, Nov. 20, '97). A distinct tumor is generally visible in the epigastric region. Locally, pulsa- tion may be detected, while a thrill may frequently be observed when the hand is applied over it. Palpation usually reveals the presence of a definite tumor, showing a strong expansile eifort; the pulsations may be double in character when the aneurism is large and brought in contact with the pericardium. Percussion may elicit a certain amount of dullness, usually intermingling with the dullness of the left lobe of the liver. Auscultation will usually reveal a sys- tolic murmur, and at times a very soft diastolic murmur. The former is fre- quently best heard by auscultating be- hind, near the spinal column. Differential Diagnosis. — A throbbing aorta is frequently mistaken for an an- eurism. An abdominal aneurism should not be declared present unless a definite expansile, pulsatile, and graspable tumor can be felt, notwithstanding the presence of a forcible pulsation, a thrill, or a sys- tolic murmur. Tumors of the left lobe of the liver, of the pancreas, and of the pylorus may all be infiuenced by the movement of the aorta and suggest aneurism, but there is no expansile action in tumors, and, if the patient be placed in the knee-elbow posi- tion, the pulsation will usually not be felt, owing to the tumor falling forward by its weight and thus being no longer in contact with the aorta. Prognosis. — The prognosis is unfavor- able, although a few cases of spontaneous recovery have been observed. Death may be due to compression of the spinal cord; paraplegia and its re- sults; to embolism of the superior mes- enteric artery followed by infarction of the bowela; to the aneurism bursting into the retroperitoneal tissues, the peri- toneum, or the intestine, usually the duodenum, or into the pleura; or finally to the abdominal aorta becoming oblit- erated by clots. (Osier.) Treatment. • — The treatment of ab- dominal aneurism is the same as that of aneurism of the thoracic aorta. Pressure of the aorta above the sac has been successfully tried in a case where the aneurism was localized low down; but it should be remembered that trau- matism of the sac has caused death in similar cases. Should this treatment be selected the pressure should be continued for many hours, under chloroform. Case of aneurism of the abdominal aorta causing death by rupture into the stomach. Great danger of the adminis- tration of ergot in aneurisms, greatest in cases where the walls of the sac were more than ordinarily attenuated, or where the tendency to atheroma was marked. Ridley-Bailey (Brit. Med. Jour., July 11, '91). The introduction of gold or silver wire. ANEURISM. ABDOMINAL AORTA. TREATMENT. 331 -vvitli or without the assistance of electric- ity, have been used witli success. Case in which aneurism of abdominal aorta was exposed by a free abdominal incision, and a hollow, gold-tipped needle inserted into the sac. Through this was passed eight and one-half feet of No. 30 gold wire, which was connected with the positive pole of the battery ; a clay plate placed under the buttocks was connected with the negative pole. The current was gradually increased to 70 milliamperes during half an hour. The pulsation in the tumor lessened, but the patient be came collapsed and cyanosed, reviving, however, later under stimulant treat ment. The wire was left in the sac and the wound closed. Patient died six months later from some other aflfection, but there was no recurrence of the aneu rism. Of 11 other cases treated in this way by other surgeons, 4 resulted in ap parent cure and 6 improved. W. H, Noble (Phila. Med. Jour., June 25, '98) Aneurism of the abdominal aorta sue cessfully treated by introduction of silver wire into the sac. A trocar was intro- duced into the sac, and not much blood issued. Five feet of silver wire were in- troduced without difficulty. The punct- ure was secured with a silk ligature. There was some vomiting and a good deal of restlessness after the operation. A month later consolidation was occur- ring. The after-progress was uneventful. There is at the present time a hard mass in the middle line much smaller than before the operation, and the thrill and bruit have disappeared. Her health was excellent. John Langton (Treatment, May 25, '99). Case of ligature of the abdominal aorta just below the diaphragm in aneu- rism of the upper part of that vessel, the patient surviving forty-eight days. The patient was a laboring man, 52 years old, probably with a syphilitic history, for whom it was first proposed to employ wiring and electrolysis, should an ex- ploratory section show its feasibility. The patient, however, left the hospital, only to return five days later with the symptoms of a severe internal haemor- rhage. An exploratory section revealed an enormous retroperitoneal hasmatoma communicating ^^■ith the aneurism, and the incision was closed. Repeated injec- tions of a 2-per-cent. solution of gelatin were given, and, the patient's condition improving, a second operation was per- formed thirteen days later. The omen- tum was torn through, and with a long- handled pedicle needle four strands of floss silk were carried from left to right under the aorta and near the diaphragm. The silk was disengaged from the eye of the needle with great difficulty and- was tied. Immediately the head, face, and neck became livid, but this lividity subsided after a few hours. The aneu- rism shi-unk to one-half its original size within a few minutes. Seven days later the femorals were found to be pulsating slightly, and the legs had regained their warmth. The amount of uri- e excreted after the operation gradually reached the usual pre-operative amount. Forty- eight days after the operation the patient died suddenly from haemorrhage due to ulceration of the aorta at the seat of ligation. Personal opinion that this re- sult will almost certainly follow in any case of ligation of the aorta in which death does not result from other causes, and a removable clamp (devised by the author) to be placed upon the aorta through an abdominal incision and capa- ble of being loosened, tightened, or re- moved, at will, becomes necessary. Keen (Amer. Jour, of Med. Sciences, Sept., 1900). The case of an abdominal aortic aneu- rism in a woman noted. There was a systolic "bruit" over the area, but the heart was normal. Gelatin was given per mouth. Twenty grammes dissolved in normal saline were given daily. The recumbent position was maintained and ice-bags continuously applied to the ab- domen. Two months afterward the tumor was less resistant and smaller. The ice-bag was then used during two hours daily, and the gelatin given every other day. Four weeks later the aneu- rism could only be felt as a slight thick- ening. The ice applications were now suspended, and a solution of ichthyol in CHCI3 and camphor spirit was rubbed over the painful places. The gelatin was continued for four weeks, and the patient 333 ANEURISM. ILIAC. SYMPTOMS. DIAGNOSIS. TREATMENT. allowed to gradually resume ordinary duties. Buchholz (Norsk Mag. f. Laege- vidensk., p. 185, 1900). Iliac Aneurism. An aneurism may form on either the common, internal, or external iliac arter- ies or one of their branches, and be, as in other regions, idiopathic or traumatic. In the latter case, however, the external iliac is almost always the portion in- volved. Symptoms. — The enlargement appears as a circumscribed swelling in the line of the vessel, presenting the characteristic expansive pulsation and bruit along its course. If the genito-crural is pressed upon, pain may be a prominent feature of the ease. Owing to the ease with which the surrounding organs may grad- ually be displaced, however, the aneu- rism attains a large size before it is dis- covered. (Edema and gangrene some- times result from the pressure induced on venous trunks. If left to itself an iliac aneurism usually ruptures. Differential Diagnosis. — Enlarged glands near Poupart's ligament may sim- ulate an iliac aneurism. The glands are not pulsatile and cannot be emptied by pressure, while no bruit can be detected. Tumors and abscesses may be differen- tiated in the same way. Treatment. — Aneurism of the common iliac artery is best treated by compression above the aneurism, as little as possible over the sac. A mortality of almost 75 per cent, is found as a result of ligation of the common iliac for aneurism. If the aneurism be one of the internal iliac and idiopathic, pressure may be ap- plied above it, and, in non-success, co- agulating injections, or even ligation by a median laparotomy may be resorted to. If the aneurism is traumatic, the artery should be compressed above the aneu- rism, the sac incised, and the artery tied above and below the wound. When dealing with the external iliac artery and the aneurism is idiopathic, compression should be first tried, fol- lowed in case of failure by ligation above the sac. This operation may be per- formed by a median laparotomy. The modified operation of Antyllus should be used if the aneurism is traumatic. Case of successful extirpation of an aneurism of the right external iliac ar- tei-y, occupying whole right iliac fossa and as large as the head of a child at term. Recovery uneventful, and patient following his occupation as a clown. Qu6nu (Le Bull. Med., Dec, '94). Case of large ilio-femoral aneurism. Ligation of external iliac artery. Pa- tient up by the forty-seventh day. Three months later aneurism in opposite groin. Operation repeated: recovery much more rapid than on first occasion, collateral circulation being established more promptly. Patient a carpenter. Makins (Brit. Med. Jour., Nov. 30, '95). Case in which transperitoneal ligation of the external iliac artery for femoral aneurism was performed with subse- quent dissection of the sac. Recovery, but with complete paralysis of sensation over the anterior aspect of the thigh and inability to extend the leg on the thigh, probably due to section of some branches of the anterior spinal nerve while laying the sac open. N. P. Dandridge (Med. News, Apr. 3, '97). Two cases of ligature of the external iliac artery for aneurism by the trans- peritoneal method. The transperitoneal operation has many advantages over the older operation, provided strict cleanli- ness is maintained. In both cases the ordinary operation would have been diffi- cult, if not Impossible, owing to the position of the swelling. W. H. Brown (Lancet, Oct. 23, '97). The following conclusions offered as fundamental rules to be observed in the treatment of ilio-femoral aneurism: Whenever possible, compression should be given a trial before resort to more ANEURISM. FEilOEAL. SYMPTOMS. DIFFERENTIAL DIAGNOSIS. 333 severe measure. If compression fails, operative procedures are then indicated, and, when feasible, total extirpation of the sac should be chosen as the surest. These rules are especially applicable to ilio-fenioral aneurism, but they are equally so to aneurisms of other portions of the body, if they are so situated as to allow of operative treatment. F. Schops (Wiener klin. Woch., Nov. 24, '98). Case of aneurism of uterine artery cured by ligation of internal iliac artery. Patient was originally operated on for a pelvic abscess, which was opened through the vagina. The incision was followed by copious venous haemorrhage. On ex- amination there was found "a softly elastic, strongly pulsating, and thrilling tumor of about the size of a hen's egg, projecting into the left vaginal vault, close to the cervix and extending slightly down on the left vaginal wall." An in- cision was made in the left semilunar line and the internal iliac artery was isolated and tied. Pulsation, all but a slight transmitted movement, entirely stopped in aneurism and the patient made a good recovery. In order to doubly insure a cure galvanopuncture was practiced twice, with noticeable benefit. Paul F. Mundg (Med. Rec, Dee. 31, '98). Femoral Aneurism. Symptoms. — The femoral artery is fre- quently the seat of traumatic aneurism on account of its exposed position. It may involve the common, the superficial, or the deep. It is generally sacculated. In some cases it is fusiform or flattened, as in Hunter's canal. Differential Diagnosis. — The difficulty here lies in recognizing whether the dila- tation is on the superficial or the deep branch, the other characters peculiar to an aneurism being easily determined. The sriperficial branch is that most fre- quently affected, and the arterial pulsa- tions below are more affected by it than by an aneurism of the superficial branch. The bruit of aneurism in cases where the femoral or popliteal artery is the seat of the lesion may frequently be made more distinct by placing the patient in the re- cumbent position and elevating the limb. Case of multiple aneurism. Vo. 1, "In- guinal" aneurism; No. 2, Femoral aneurism; No. Z, Small aneurism, which had not been discovered during the patient's life; No. 4, Popliteal an- eurism, which ruptured; A, Orifice of femoral artery; B, Inferior orifice of same; C, Continuation of poplit- eal; E, Aneurismal sae. (Monro.) Case of double aneurism of left thigh: one, the size of an egg, at Scarpa's tri- angle; the other, as large as a cocoa-nut, at the opening through the abductor 334 ANEURISM. FEMORAL. TREATMENT. ■ magnus. Superficial femoral ligated in middle of Scarpa's triangle, suppuration and two secondary haemorrhages ensu- ing; wound enlarged and bleeding ends tied. Only one case on record of cure of double aneurism of superficial femoral artery by operative procedure. Souchon (N. Y. Med. Jour., Nov. 2, '95). Treatment, — In idiopathic aneurism of this artery digital or instrumental com- pression above the sac is to be preferred. If this proves unsuccessful, ligation is to be resorted to. If the aneurism is in Hunter's canal, the artery should be li- gated above; if it is in Scarpa's triangle, ligation of the common femoral gives the best results, although ligation of the ex- ternal iliac is usually preferred, owing to the absence of branches where the liga- ture is usually applied. The favorable statistics of the last decade may be greatly increased by adoption of this method of suture: an obliteration of the sac, instead of the classical ligation of the arteries, with or without extirpation; the closure of the arterial orifice, supplying the sac, whether single or multiple, by sutures; and within the sac simplified technique of the other operation. A favorable case — namely: saccular aneurism, with one orifice into the trunk is best. It is possible, by these sutures, to close the limien without narrowing the main channel. In fusiform, traumatic aneu- risms, and in all with a healthy, friable sac, lost continuity of the arteries may be renewed by building a new channel and connecting the main orifices of communication. The fear that atheroma and degeneration will interfere with healing has been exaggerated, especially since it has been shown that amputa- tions in aged patients with sclerosed arteries may well succeed. The failure and danger of the old operation of Antyllus lie in the fact that ligation of the main artery, above and below the sac, will not always control the bleeding from collateral vessels opening into the aneurism, or into the main trunk between the arteries of the sac and the seat of ligation. The cutting of the sac away has the danger of in- terfering with collateral circulation. The operation of Antyllus, moreover, leaves the sac as an open cavity in the bottom of the wound, which heals by granulation, and induces infection, suppuration, and secondary haemor- rhage. All these difliculties are in- creased by the extirpation. R. Matas (Annals of Surgery, Feb., 1903). In traumatic aneurism of the femoral the artery should be compressed on the edge of the pelvis by means of a tourni- quet, the sac opened, and both ends of the divided artery tied. Aneurism in Scarpa's triangle, in which instrumental compression above was em- ployed for eighteen days, but had to be abandoned on account of the irritation of the skin which it caused. The aneu- rism gradually diminished in size and recovery followed. MoUoy (Med. and Surg. Reporter, Apr. 22, '93) . Case of extirpation of a femoral aneu- rism, in a little girl of 11, extending from near Poupart's ligament to the lower part of Hunter's canal; it had been growing for fifteen months, and was not attributable to injury. The main trunk was first secured above the sac, and the whole mass enucleated; thirty-five dilated arterial twigs required ligature, and about five and a half inches of the femoral vein were also removed. The patient made a good recovery. Heurtaux (Bull, et Mem. de la Soc. de Chir., Nos. 9, 10, '95). Two cases of femoral aneurism treated by excision. The vessel is li- gated at its end instead of in its con- tinuity and by removal of the sac. Pro- vision is made against relapse through diseased or injured vessel, while the presence of more branches for recurrent circulation is insured. The first case was still well three years after the last operation. The second case died the second day from pulmonary congestion and oedema. G. R. Fowler (Med. Record, Mar. 23, 1901). Popliteal Aneurism. The popliteal artery being peculiarly liable to atheroma, it is the most com- ANEURISM. POPLITEAL. SYMPTOMS. DIAGNOSIS. PROGNOSIS. 335 mon seat of aneurism after the aorta. Flexion and extension of the knee, if exaggerated but slightly when the vessel is diseased, act as exciting causes. The aneurism sometimes develops in this re- gion without any apparent mechanical cause, and may present itself on either side. It usually grows posteriorly, rap- idly penetrating the surrounding alveolar tissue and assuming large proportions. At other times it forms anteriorly, and presses against the bone or the posterior ligaments. Supported by these hard sur- faces its growth is much slower. Case of diflfuse popliteal aneurism caused by an exostosis due to ossifiea- tion of the tendon of the adductor mag- nus muscle. Similar case reported by Boling quoted in which rupture of the artery was caused by two epiphyseal exostoses. Terrier and Hartmann (Lon- don Lancet, May 20, '93). Symptoms. — Although a sudden pain may reveal the presence of the aneurism, rheumatism of the knee is the usual complaint at the start. The joint then becomes weak and stiff, and examination finally reveals a growing tumor, pre- senting all the characteristics already de- scribed: expansive pulsations and bruit extending down the leg. The aneurismal tumor can usually be emptied, but in some cases all the subjective symptoms have to be very carefully sought after to be discovered. The tibial pulses usually show a marked difference. Complica- tions frequently followed popliteal aneu- rism. Posteriorly, it may compress the veins and cause oedema, or give rise to severe neuralgia by pressing on the pop- liteal nerve anteriorly; synovitis may be induced, causing severe pain. Case of pulsating tumor of the pop- liteal space simulating aneurism; illus- trates importance of using exploring- needle in deep-seated fluctuating tumors. Marmaduke Shield (London Lancet, Oct. 6, '94). Case of popliteal aneurism showing, as only symptom, cramp-like pain in the leg. J. Hutchinson, Jr. (Med. Press and Circ, Oct. 16, '95). Differential Diagnosis. — Arterial hsem- atoma presents the characteristics of pop- liteal aneurism even when no trauma is found. The bruit may be present, but the pulsation along the course of the vessel is weaker. Osteosarcoma, glandu- lar enlargements, abscess, cysts, may also- simulate a popliteal aneurism, but the- expansile nature of the latter, and the possibility of emptying the sac, make it impossible to readily establish the nature- of the case. When the femoral artery above does, not feel rigid, the aneurism is not due to. atheroma and there is no atheromatous^ degeneration in the vicinity of the sac. Billroth (Wiener klin. Woch., No. 50, '93). Prognosis. — Popliteal aneurisms occa- sionally undergo spontaneous cure. Usu- ally, however, it progresses more or less- rapidly according to its location; begins to leak; and finally ruptures into the surrounding cellular tissue, the blood ex- tending along the tissues of the leg. The- popliteal space becomes at once greatly distended. Considerable pain and faint- ness are experienced. The typical local symptoms do not cease, however, al- though considerably reduced in intensity. The limb below becomes livid and cold,, and gangrene soon follows, if an inflam- matory process does not come on. In the- latter there is redness of the skin, local cedema, and severe pain. Suppuration of the joint is then probable. [Two cases of this kind witnessed by me were cured by means of the iodide of' potassium and compression. Both pa- tients are now strong and healthy. J.. McFadden Gaston.] 336 ANEURISM. TRAUMATIC. Treatment. — If there is evidence of atheroma digital corapression should be preferred, provided there is no fear of impending rupture. Esmarch's bandage may also be employed. Flexion is useful if the aneurism is small. If these fail, ligation of the femoral artery at the apex of Scarpa's triangle gives the best results. The limb should be carefully wrapped in cotton wadding and raised somewhat. This is especially indicated when the sac is large, if it is inflamed, when leaking has begun, or when, through pressure on the popliteal vein, there is oedema of the foot. Amputation is indicated when gan- grene follows ligature, when the sac has ruptured, or if there is caries of the osseous tissues or suppuration around the sac. Case in which total extirpation of the sac was followed by speedy recovery. Statistics of forty eases confirming this opinion, twenty-eight being cases of arterial aneurism and twelve arterio- venous. Kubler (Beitrilge zur klin. Chi., B. 9, H. 1, '92). Case of bilateral popliteal aneurism; sacs extirpated in two sittings with com- plete success. Ten cases of this affection reported, with nine recoveries and one death from sepsis. Schmidt (Archiv f. klin. Chi., vol. xliv, p. 809). Popliteal aneurisms, if not too large, permit of the radical operation. The portion of the artery within the aneu- rism al sac is denuded and its walls are softened. Secondary hfemorrhage is likely to follow ligation at this point. The ligature should be applied outside of the sac or at a distance from the open- ing in the wall of the artery into the sac. Primary union of the walls of the sac is not to be expected. The inner portion of the sac becomes detached by necrosis. Extirpation of the wall of the sac is not necessary. The wound should not be entirely closed by sutures: the cavity should be loosely packed with iodoform gauze. In the after-treatment iodoform- and-glycerin emulsion is recommended. The cavity heals without trouble. Bill- roth (Wiener klin. Woch., No. 50, '93). Three cases successfully treated by ligation of the femoral artery after com- pression and flexion had been tried with- out success. Leutaigne (Dublin Jour, of Med. Sci., July, '94). Case of double popliteal aneurism treated by compression; three months later both sacs consolidated. Iodide of potassium, administered from the start, still continued. Golding-Bird (Brit. Med. Jour., Jan. 12, '95). Case of popliteal aneurism cured by forced flexion of the knee. Treatment begun by half-flexion, which is much less painful. Alessandro (Riforma Medica, p. 5, '95). Hypodermic injections of ergotin in aneurism recommended, the following mixture being employed: — IJ Ergotin (Bonjean), 40 grains. Spiritus vini rectificati, 80 minims. Glycerini, 80 minims. M. et ft. sol. Inject 3 centigrammes under the skin over the tumor. Lang- enbeck (Phila. Med. Jour., Feb. 14, 1903). Traumatic Aneurism. Traumatic aneurism is not due, like other aneurisms, to an anterior patho- logical condition of the artery-wall, but to a direct injury to the vessel, resulting in an arterial hsematoma. Traumatic aneurism may be caused by a shot or stab wound of an artery, by which the blood is extravasated into the neighboring cellular tissue, until it is arrested. There are three varieties of traumatic aneurism. The true traumatic aneurism is the form in which the artery, generally a large one, has received a punctured wound, which has healed and the cicatrix afterward yields. In this case the external coat of the artery and its sheath form a true sac. A circumscribed traumatic aneurism is a variety wherein condensation of the surrounding cellular tissue has formed an adventitious sac for the blood. Cir- cumscribed traumatic aneurism is usu- ANEURISM. CIRSOID. 337 ally due to punctured wounds of small arteries. A diffused traumatic aneurism may be caused in three ways: (1) by healing of the cutaneous woimd before the arterial wound heals; (2) by a subcutaneous in- jury to the artery without a skin wound; (3) later on, due to a bruise caused by a projectile or instrument, the bruised spot yielding when the remainder of the in- jury was healed. A diffused traumatic aneurism should not be considered an aneurism; it is, in realitjf, but a collection of arterial blood in the tissues, not in communication with the exterior, like an ordinary wounded artery. Protrusion of the inner coats of an artery through a wound oi the outer coat is called a hernial aneurism. It is ex- ceedingly uncommon. Diagnosis. — That a traumatic aneu- rism may cause an abscess should be borne in mind; on the other hand, an imcomplicated traumatic aneurism may resemble an abscess. A positive diag- nosis may be arrived at by the history of the case, and by withdrawing some of the contents with an asepticized hypo- dermic needle. Pus will be found if an abscess is present, and fluid blood if an aneurism. Treatment. — The treatment of trau- matic aneurism varies according to its location. It should be treated like a primary wound of an artery. Where possible, as on a limb, an Es- march bandage should be applied, the injured artery exposed by incision, com- pletely divided. Both ends of the vessel are then tied. Every effort should be made to obtain primary union. When the aneurism is located in a region where Esmarch's bandage cannot be used, as on the neck, the tumor should be exposed, and an opening made just large enough to introduce one finger, which, guided by the current of warm arterial blood, should be carried to the artery leading to the aneurism. Six cases in which aneurism of the arch of the aorta and of the base of the neck by the simultaneous ligation of the right carotid and subclavian arteries. But one death occurred: due to hemiplegia. In this case the arteries on the left side were not permeable, and so could not furnish blood to the brain. Thiombosis occurred. Ligation of the right carotid should never be performed when the left carotid and its branches no longer pulsate. The operation is not dangerous, pro- vided a completely aseptic ligature is used. Blacque and A. Guinard (Ann. Mai. de I'Or., Nov., '96). Traumatic aneurism of the ulnar artery in the palm cured by tying the ulnar artery above the wrist. William Robertson (Brit. Med. Jour., Dee. 4, '97). Two cases of traumatic aneurism of the radial artery, treated by excision of the sac. Recovery. Elevation of the limb, combined with pressure on the sac, will sometimes effect a cure, but at best it is tedious in its application and un- certain in its results. Simple ligation of the vessel above and below the sac is more likely to prove successful. Ex- cision effectually cures the disease, and is easily performed if the sac be of small size. Non-removal of the tourniquet, until the dressing and bandaging of the Mound are completed, is a valuable detail. J. E. Piatt (Med. Chronicle, Dec, '97). Cirsoid Aneurism. As compared to the forms of aneurism already described, this variety is very rarely met with. It should be classed with tumors, being, in reality, an arterial angioma. Varieties. — Where a single vessel is involved, it is usually called an arterial varix; when a number of vessels are included in the mass, it is termed cirsoid aneurism; and, when the surroimding veins and capillaries are also dilated, the 338 ANEURISM. CIRSOID. SYMPTOMS. TREATMENT. name aneurism by anastomosis is applied to the irregular mass thus formed. Symptoms. — Although cirsoid aneu- risms may be met with in any part of the body, their site of predilection is the head especially, and more particularly the temporo-parietal region. The hands come next in the order of frequency. A cirsoid aneurism appears as an irregu- larly-shaped, bluish, and flattened mass of dilated blood-vessels, twisted inextri- cably together, from which project am- pulla, or bags. The skin over this is extremely thin, soft, and doughy to the touch, and is in imminent danger of rupture. Manual examination shows that it is connected with the arterial system, synchronous pulsation with the heart be- ing evident. Its temperature is generally higher than that of the surface of the body, owing to the increased rapidity of the circulation through the tortuous an- eurismal channels. It is easily emptied by pressure, but immediately fills as soon as released. A distinct thrill may gener- ally be heard over it, which can be traced along its branches. It does not give rise to pain imless a nerve is involved in the absorptive process which cirsoid aneu- risms give rise to in the surrounding structures. To this process is due the grooves found in bone underlying them and the thinness of the skin covering them. Diagnosis. — When the discoloration and the general outline of the growth present does not at once establish its identity, a true aneurism may be simu- lated. True aneurism, however, is usu- ally found upon an artery of considerable size, such as the carotid, the tracheal, and the popliteal, and does not yield so readily to pressure. The bosselated out- line of cirsoid is replaced by a regular globular mass. The peculiar doughy sen- sation communicated to the hand during palpation is peculiar to cirsoid growths. Again, these are habitually situated in the extremities where medium or small arteries are to be found. Pathology. — Cirsoid aneurisms usually occur as the result of traumatism. This is thought to give rise to paralysis of the vasomotor nerves supplying the region affected, and thus allowing the blood- vessels to be dilated. It has been known to start from a nsevus, and it has been traced to an arteritis. In the majority of cases, however, its origin cannot be ascertained. As already stated, it be- longs more properly to true tumors, and should be termed, according to Tillmann, "angioma arteriate racemosa." Cirsoid aneurisms believed to be due to arteritis, whicli weakens the vessel- walls and allows their dilatation. Ar- teritis explains all cases of cirsoid aneu- rism following an injury; those follow- ing nsevi can be explained by a congeni- tal defect of nutrition of the walls of the vessels. J. L. Reverdin (Rev. Med. de la Suisse, Feb. 20, '98). Cirsoid aneurism is most frequently found on the scalp and face, but it may likewise be found in the tongue, extrem- ities, internal viscera, and bones. Prognosis. — Although a cirsoid aneu- rism may not grow or change for many years, it may also steadily develop in size and spread by invading the vessels of the surrounding tissues. The thinness of the overlying skin presents constant danger, and rupture of one of the ampullaa may give rise to uncontrollable hemorrhage. Treatment. — Eemoval by excision is,, by far, the best procedure to use, with complete arrest of the hemorrhage by ligation of the afferent and efferent ves- sels. Among the other measures recom- mended have been ligation of the various afferent arteries, coagulation of the blood by means of various injections, the gal- vanocautery, electropuncture, and acu- ANEUEISM. ARTERIO-VENOUS. 339 pressure. But none of these afford satis- factory results in the great majority of cases. In multiple cirsoid of the hand or other extremities, amputation some- times becomes necessary. Case of extensive cirsoid aneurism of the scalp, cured by multiple ligatures. Mynter (Annals of Surg., Feb., '90). Case of cirsoid aneurism with liga- ture of the common carotid artery. Decided improvement, notwithstanding heavy work. W. D. Hamilton (N. Y. Med. Jour., Kov. 3, '94). Fig. 1. — Diagi-am of aneurismal varix. a, Artery; v, Vein. Successful result in a case of large cirsoid aneurism of the scalp. Blood- supply controlled by acupressui'e-pins applied to external terminal branches of nutrient arteries. Subsequent crucial in- cision and vascular tissue entirely re- moved between the skin and periosteum of flat bones. Compression applied; complete recovery. W. S. Forbes (Med. News, June 15, "95). Case of cirsoid aneurism of the scalp; ligature and acupressure followed by im- mediate and complete excision; recovery. J. J. Pratt (Lancet, .July 3, '97). Cirsoid aneurism of the scalp follow- ing a fall against a curb. In spite of the probable haemorrhage, the best treatment in this location is excision of the aneurism entire. The child was well in a week. Broca (Jour, de Chir., Apr.- May, 1901). Arterio-venous Aneurism. Varieties. — An artery and a vein may intercommunicate in two ways: (1) when the one vessel opens into the other by a short channel — the so-called aneurismal varix — and (2) when between the two Fig. 2. — Diagram of varicose aneurism. a, Artery ; v. Vein ; s. Sac, containing- a laminated clot on each side of the channel; *, Intervaseular tissues. vessels there is an adventitious sac: the so-called varicose aneurism. Although both terms are incorrect and misleading, they serve to establish a distinction which becomes important when the treatment is considered, the measures indicated in aneurismal varix being dangerous in vari- cose aneurism. The difference between the two varie- ties is illustrated in the wood-cuts printed above. 340 ANEUPaSM. ARTERIOVENOUS. SYMPTOMS. ETIOLOGY. Symptoms. — The receipt of the injury may be attended by syncope if internal vessels are woimded, but superficial ves- sels are by far those most frequently in- volved, and aneurismal varix may last for years without serious disturbance. The most common situation of this variety is the bend of the elbow, the result of punctured wounds which penetrate both vessels. A whirring sound, like the purring of a kitten, is produced by the current passing from the artery into the vein. This sound was compared by Spence to the noise made by a fly in a paper bag. It is more distinct above than below the tumor, and the limb is usually somewhat weaker and colder than is natural. A thrill is felt when the hand is applied over the tumor. In varicose aneurism there exists, as already stated, a sac between the two vessels; but it is important to remember that this sac is not constituted of the coats of the vessels involved; it is an artificial formation at the expense of the tissues between the vessels. These having been simultaneously wounded, the lymph effused in the course of the inflammatory process forms a partition to limit the extravasation. This extrav- asation differs from that of a false aneu- rism in that it communicates with a vein. The difference between aneurismal varix and varicose aneurism consists, besides the presence of the adventitious sac, of a greater length of the interven- ing canal in varicose aneurism. A lami- nated clot on each side of this canal con- tributing also to reduce its diameter to that of the canal in aneurismal varices, taken as a whole, the symptoms of both conditions are about similar. Palpation sometimes makes it possible to detect the presence of the intervening sac, and also, in addition to the thrill and buzzing sound of aneurismal varix, a distinct im- pulse. An aneurismal murmur or soft bruit may frequently be elicited. The conformation of varicose aneurism is not such as to tend toward much enlarge- ment. If, according to Tillmann, the point of communication between the artery and vein be compressed, the pulsation in the dilated and tortuous vessels ceases, and they collapse. The limb is generally wasted below the varix if the case is one of long standing; it may also be cedematous, hard, and en- larged. In twenty-nine cases of aneurism of the ascending arch of the aorta opening into the vena cava analyzed by Pepper and Griffith, a thrill was observed in some cases; in others a continuous mur- mur with systolic increase, with sudden development of cyanosis, oedema, and en- gorgement of the veins of the upper part of the body. Case of traumatic arterio-venous an- eurism of the arch of the aorta and the innominate vein. The thrill was most distinct over the manubrium sterni, and could be follo\yed down the internal jugular and left brachial veins and over the skull in the course of the sinuses. The autopsy showed an opening in the arch of the aorta between the points of origin of the carotid and the innominate arteries, which communicated directly with the left innominate vein: dilated at this point to the size of an orange. Long survival after the accident is worthy of notice. Colzi (Lo Speri- mentale, Feb., '95). Etiology. — Both varieties are caused by traumatisms by which an artery and vein in juxtaposition are wounded simul- taneously from a stab or in phlebotomy. Arterio-venous aneurisms were much more frequent when venesection was in vogue than they are now that this procedure is rarely resorted to. ANEURISM. ARTERIO-VENOUS. PATHOLOGY. TREATMENT. 341 A true aneurism may gradually ad- here to a vein, and give rise to an arterio- venous aneurism. Case of spontaneous, probably eon- genital, arterlo-venous aneurism of the arm and hand, caused by an abnormal communication between the common in- terosseous artery and a deep branch of the cephalic vein. Ligature of the bra- chial artery followed by gangrene of the forearm and hand; amputation; recov- ery. Weidemann {Beitriige zur klin. Chir., Sept. 15, '93). Pathology. — Besides the features al- ready noted is the fact that the wound between the vessels does not heal, so that at each pulsation a certain amount of blood is forced through from the artery into the vein. The latter pulsates strongly and becomes tortuous and di- lated; the veins beyond the aneurismal varix on the limb are likewise dilated. The artery is more or less dilated above, but much contracted below, the lesion. Prognosis. — An aneurismal varix may, as already stated, cause no very serious disturbance, and is not, therefore, re- garded as a dangerous condition. This is not the case, however, with varicose aneurism, as the intervening sac may at any moment become disorganized and give rise to a diffuse aneurism. The varicose veins may also become greatly enlarged, and be followed by cedema and perhaps gangrene. Case of fourteen years' standing, caused by a punctured wound of the axilla. Arm normal, veins not dis- tended, function perfect, but all over the arm the characteristic bruit could be heard; operation contra-indicated. Osier (Annals of Surgery, Jan., '92). Case of aneurismal varix of the left in- ternal carotid artery and the cavernous sinus. It has remained unaltered for twenty-three years. C. E. Williamson (Brit. Med. -lour., Oct. 13, "94). Fourteen cases of arterio-venous aneu- rism of subclavian published. Case in which there was no syncope at the time of accident and seven months after de- velopment of aneurism no functional trouble. Wedenkind (Deutsche med. Woch., No. 16, '95). Treatment. — In the majority of cases aneurismal varix requires no treatment, or no more than the application of an elastic bandage to prevent its growth. Where extension of the affection causes pain and disturbance in the cir- culation, compression may be applied above and below and upon the tumor itself; should this not succeed, the artery and vein can be tied above and below the opening, and the aneurism removed. It is only when absolutely necessary that aneurismal varix of the femoral vessels or of the carotid and internal jugular should be submitted to operative pro- cedures. Unlike aneurismal varix, varicose an- eurisms, as stated, present an element of danger: the intermediate sac, owing to its histological composition, tending to ulcerate at any moment and to give rise to a difiuse aneurism. Pressure is ob- viously contra-indicated; it would cause enlargement of the already dilated veins and probably give rise to cedema and gangrene. The best treatment, especially when the aneurism is small, is to tie both vessels above and below the aneurism, and to remove the latter. Case in which arterio-venous aneurism followed a wound of the popliteal artery and vein by a spicule of glass. Operation was performed four and one-half weeks after the accident. The sac was opened, both vessels discovered to be injured, and, after an unsuccessful attempt to close the vein by suturing, both were ligated. Of 7 cases of simultaneous ligation of the popliteal artery and vein, in 6 of which these vessels had been Avounded, all recovered, 1 after amputation for gan- grene. In 8 other cases the results Avere 342 AifEURISM. ANGINA PECTORIS. entirely favorable. G. P. Newboldt (Lancet, Apr. 23, '98). In varicose aneurism of tlae neck or femoral vessels, it is best to cut down upon the artery below and above the sac and ligate without touching the vein or the sac. This method was suggested by Spence, of Edinburgh. In cutting down upon a varicose an- eurism, the incision intended to open the enlarged vein should be followed by one opening the sac, so as to bring the aperture within the artery into the field of operation. Hunter's method of ligating the artery above the sac is not successful, as the unimpeded circulation of blood into the sac through the vein prevents coagiila- tion of the fibrin. In a general way, it may be said that all small aneurisms, not involving the larger vessels of a limb, should be extirpated, unless important nerves are jeoparded by the dissection, or, as on the face, where it is important to not leave a scar. The treatment se- lected for larger aneurisms depends upon their situation. Those of the neck which involve the external jugular vein will rarely require treatment, but, should it be necessary, such cases are best treated by double ligation of both vessels. In other situations the simple ligature of the vessels should not be chosen, for it will, in most cases, require as much dis- section as will incision or extirpation, while not giving the same immunity from relapse. The surgeon should make an incision down upon the sac in its entire length, and attempt to dissect it from its bed. If this prove difficult or impossible because of inflammatory thick- ening or intimate connection with impor- tant parts, the sac should be incised, for it is often easier to secure the vessels when the sac is freely opened. The sac could then be left entirely in place or it could be partly removed. Suture and simple drainage of the sac have been found sufficient, and it is unnecessary to resort to packing. (Farquhar Curtis.) J. McFadden Gaston, J. McFadden Gaston, Je., Atlanta. ANGINA PECTOEIS. Definition. — Angina pectoris (steno- cardia, breast-pang) is the name given to a group of symptoms which usually depends upon organic disease of the heart or aorta. An attack consists in the sudden onset of agonizing pain in the praecordial or sternal regions, accom- panied by a feeling of constriction and in severe cases by a sense of impending death. The pain radiates into the back, the shoulders, and the arms, particularly the left. The patient is pale, haggard, motionless, and often bathed with cold perspiration. Symptoms. — Suddenly, after exertion, excitement, or a hearty meal, the patient feels an excruciating, burning, or tearing pain in the heart or beneath the sternum, accompanied with a sense of constriction {angere, to throttle), as if the heart were in a vise. The pain radiates into the back, upward into the shoulders, and down the left arm, often even to the finger-tips. It may be felt in both arms, in the neck and head, and even in the trunk and lower extremities. "In true angina the seat of the pain may be en- tirely way from the chest, and may be, as in Lord Clarendon's father, at the inner aspect of the arm, or about the wrist, or in rare instances confined to the side of the neck, or even to one testis." (Osier.) Attacks occur in which pain is slight or absent (angina sine dolore). Early attacks are often of this sort. At a later ANGINA PECTORIS. SYMPTOMS. 343 period there may still be no pain, or the paroxysms may sometimes be painful and at other times not. A feeling of numbness accompanies the pain. There is a sense of impending dissolntion. The sufferer sits or stands immobile and hardly dares to breathe. Yet there is no real dyspnoea. The face is pale or livid, the forehead wet with perspiration. The pulse may remain strong and regular. Usually it is accel- erated and of increased tension. It may intermit or vary. Exceptionally it is slowed. The paroxysm lasts a few sec- onds or minutes, — sometimes half an hour or even several hours. At the end of it the patient often belches gas or vomits or has a movement of the bowels, with great relief. The attack may prove immediately fatal. If not, the patient is left exhausted, but regains his usual condition in a few hours or days. Study of twenty-one cases. The at- tacks usually came on after a meal. In every case exertion increased the pain, and the sense of fullness was relieved by the eructation of gas. Most of the patients attributed their trouble to in- digestion. In all there was shallow respiration with an occasional deep in- spiration. The heart was usually slow, occasionally palpitating or irregular, and the pulse was generally tense and sustained. In all arterial fibrosis could be recognized by a thickening of the palpable arteries; cardiac disease — manifested by accentuation of the sec- ond aortic tone, feebleness of the first sound, cardiac murmurs, etc. — was pres- ent at some time in nearly all cases. During the attacks the second aortic sound was always much accentuated, while the first sound could be heard very indistinctly. Frank Billings (Chi- cago Med. Recorder, Feb., 1901). The attack is almost sure to be re- peated. This may happen in an hour or not for weeks or months. The lensrth of the interval depends greatly upon the persistence of the patient in avoiding the exciting causes. Successive paroxysms occur with gradually increasing readi- ness. Angina pectoris is probably due to increased intravascular pressure. We can reasonably infer the presence of dilata- tion of the heart by the physical signs of displaced apex-beat; gallop-rhythm; a soft, regurgitant murmur in the tricuspid or mitral area; by venous phenomena; and by the congestions, cyanosis, and dropsy that attend this affection. The results of cardiac percussion may be con- firmatory, but are not looked upon as essential in the diagnosis of cardiac dila- tation. Five cases to illustrate the fol- lowing propositions: — 1. Wben dilatation of the heart super- venes in a patient the subject of an attack or attacks of angina pectoris, the subjective symptoms may subside. At the same time the physical type of the individual changes. 2. Angina pectoris may occur in a patient who has had dilatation of the heart when the organic condition (dila- tation) is removed by treatment. J. H. Musser (Amer. Jour, of Med. Sciences, Sept., '97). Attention drawn to that form which is found in association with dry pericar- ditis: the pain in these cases is situated at the base or middle of the sternum; It may also be in the epigastrium and over the cardiac area. It radiates outward toward the arms. These signs, in truth, afford no differentiating clue. On careful auscultation, however, to-and-fro friction may be heard coincidently with the car- diac movements, with hyperfesthesia in the prEecordial region; and the facts of its frequently following tonsillitis and rheumatic ailments, and not being amen- able to the operation of vasodilators and stimulants, serve to distinguish it from most cases of coronary angina: it is an exocardial angina. The treatment of the condition is, naturally, that of pericar- ditis. M. Pawinski (La Semaine M6d., Oct. 6, '97). Special variety of musical heart-mur- 344 ANGINA PECTORIS. DIAGNOSIS. mur, resembling a feeble groan or chirp- ing of chickens. Similar cases described by Capozzi, in which a constant lesion was found, namely: a regular perfora- tion of a free valve. Case of a man, aged 30, suffering from anginal attacks. Double aortic murmur, the diastolic part of the murmur being musical. The apex- beat was in the fifth space, outside the nipple-line. No history of rheumatism. History of syphilis. Death in one of the attacks of angina. At autopsy mitral valves found normal; aortic valves thickened, two cusps being adherent; the third was perforated near the aortic parietes, but not adherent. Coronary arteries healthy. Tecce (La Eif. Med., Apr. 2, '97). Diagnosis. — In true angina pectoris skilled observers almost invariably find evidence of organic cardiac or aortic le- sion. In a supposed case these should be sought most carefully. Particularly to be looked for are arteriosclerosis, hyper- trophy or dilatation of the left ventricle, aortic regurgitation, and feebleness of the muscular power of the heart. True angina always associated with cardiac lesions, especially of the coronary arteries; but the absence of physical signs do not always affect the diagnosis, as it frequently occurs that the lesions are only discovered after death. Pre- sumptive signs which deserve atten- tion: — The age of the patient; true angina is very rare before forty. The pain commences always in the heart, while in pseudo-angina it is as- cribed to the arm and radiates in several directions. The infrequency of the attacks in true angina, the patient being liable to suc- cumb in the second or third attack. True angina is provoked by effort, emotion, and disorders of digestion. It occurs in the day-time, while in false angina the attacks are generally nocturnal. Patients suffering from true angina are pale and can neither stir nor breathe. In the false angina he is agitated, gets up from bed, and runs to the window for fresh air. Rendu (Med. Press and Cir- cular, July 22, '96). Diagnosis of angina pectoris due to disease of the coronary arteries, based upon retrosternal pain, with tendency to radiate; a sensation of anguish and fear of imminent death; the tendency of the attack to be excited by exertion, by emotion, or by exposure to cold. The pain is similar to that experienced in a limb the main artery of which is, by atheroma,' diminished in calibre. Owing to the defective supply of arterial blood, the heart contracts in a manner painful to the patient, the peripheral nerve dis- tributions wanting a due supply of oxy- gen. P. Merklen (La Semaine Med., Aug. 9, 1900). Intebcostal neuealgia causes pain along an intercostal nerve, not radiating as in angina pectoris. It presents points tender to pressure near the vertebrae and sternum and in the axilla. It is not asso- ciated with disordered circulation. Gastealgia is apt to occur when the stomach is empty. The pain does not stream into the shoulder and arm. While there may be collapse and a sense of im- pending death, there is no evidence of heart disease. Both gastralgia and in- tercostal neuralgia are likely to occur in anemic young women, rather than in middle-aged men. On the other hand, the pain of true angina pectoris may be felt lower down than the prtecordia. As already stated, the termination of an attack may be marked by the dis- charge of gas. Particularly if there is no extreme cardiac pain, this may lead the patient, and in some instances has led his physician, astray. It is important to bear in mind that symptoms of cardiac embarrassment as- suming the character of "angina sine doTore" may be described by the patient as arising from dyspepsia. These pa- tients ascribe their discomfort to flatu- lent distension, and they do so from the ANGINA PECTORIS. ETIOLOGY. 345 well-known fact that a discharge of flatus gives relief to the uncomfortable sensation. It is well, in advanced middle life, to pay rather more than ordinary attention to flatulent discomfort coming on after food or exertion. A careful e.\- amination will often solve the problem and will conclusively prove that the symptoms are rather those of cardiac inefficiency than of stomach trouble. D. W. C. Hood (London Lancet, Sept. 26, '96). Cardiac asthma is dyspnoea due to a weak heart and occurring more or less paroxysmally. Pain is not prominent. The picture is apt to include pulmonary cedema, enlarged liver, and dropsy, and it could hardly be mistaken for angina pectoris. It should be remembered, how- ever, that angina may attack a person who is already suffering from failing compensation. Pseudo-angina pectoris, or hysterical angina, occurs in females or neurasthenic men, usually under the age of 40, with- out evidence of organic cardio-vascular changes. There are low tension, feeble second sound, and soft arteries. The attacks are spontaneous and are apt to be nocturnal and periodic (menstrual). They last an hour or two, being more prolonged than the true paroxysms. The patient is agitated, writhes, or walks about the room, and talks. The heart feels, not constricted, but distended. The pain is not apt to be so severe as in true angina pectoris. Parssthesiae and vasomotor symptoms are prominent. Death never occurs. Hysteria. — It should, of course, be remembered that hysteria may be com- bined with organic disease, and that a careful physical examination should be made in any suspected case; but the dis- covery of mitral disease would not be inconsistent with a diagnosis of pseudo- angina. Syphilis. — A history of syphilis in a man, even if under 40 years of age, renders the occurrence of true angina pectoris less improbable than it other- wise would be, for there is a possibility of syphilitic aortitis obstructing the ori- fices of the coronaries. Tobacco, Tea, etc. — Excess in to- bacco (less often alcohol, tea, and cofEee) and lead poisoning may occasion spurious angina, or again they may aggravate a genuine paroxysm depending on organic lesions. While certain cases are evidently true angina and others equally obviously pseudo-angina, some are extremely puz- zling. Etiology. — j\Iales over 40 years of age in comfortable worldly circumstances make up the majority of sufferers from angina pectoris. Predisposing causes are: alcohol, syphilis (arteriosclerosis, tabes dosalis), rheumatism, gout, diabetes, chronic nephritis, and influenza. Some- times attacks are hereditary. As exciting causes may be named : physical exertion, mental strain, pro- found emotion, and digestive disturb- ances. The attacks may come in the day-time, especially at first; but some of the worst occur at night; so that finally they may make the patient dread going to sleep. Angina pectoris due in part to the attitude of writing in haste, in part to nervous overexcitement. The attitude hampers respiration, and by compressing the abdomen interferes with the move- ment of the diaphragm; in addition, there is a kind of spasmodic contraction of the fingers which is communicated to the muscles of the forearm, arm, and chest. The action of the whole heart, and particularly of the right ventricle, is impeded, and this leads to some degree of venous stasis, which would provoke a spasm of the coronary vessels simulat- 346 ANGINA PECTORIS. PATHOLOGY. ing an attack of true angina. Musgrave (Semaine Med., Jan. 25, '99). Angina pectoris and the menopause. Attacks of angina pectoris observed for the first time at the menopause may be dependent upon the changes occurring at this period, or they may accidentally begin at this time from other and unas- sociated causes. In the former ease the attacks may be purely neurasthenic or hysterical, or they may be of vasomotor origin (spasm of the coronary arteries), giving the picture of severe organic an- gina pectoris. These two forms may, of course, be combined. Th. K. Geisler (Vratch, Feb. 12, 1900). While, in general, the vascular origin of angina pectoris cannot be denied, eases occur which undoubtedly are due to lesions of the aortic or coronary plexus, and the cases cited are thought to justify the belief that in syphilitic angina pectoris, in which a coronary stenocardia might be considered prob- able, there exist changes in the aortic plexus and in the nerves of the heart. This alteration of aortic or cardiac plexus may be in the nature of a neu- ritis, or may be due to changes in the vessels of the nerves, the functional efTeets of which would be equivalent to a lesion of the nerve proper. Such changes in the nerves or vasa nervorum are caused by a terminal obliterating endarteritis, pericellular infiltration, or embryonic gummata which irritate the vessels. These changes can, in the large majority of cases, be controlled by energetic specific treatment; hence the importance of early etiological diag- nosis. XJ. Benenati (La Riforma Medica, May 3, 5, 6, and 7, 1902). Pathology. — It is exceptional for at- tacks of tnie angina pectoris to be observed in persons presenting no evi- dence of organic circulatory lesion. The commonest underlying conditions are sclerosis of the coronary arteries, degen- eration of the myocardium, cardiac hy- pertrophy, atheroma of the aorta, aneiT- rism of that vessel near its origin, and aortic regurgitation. There is, however, "hardly an affection of the walls or cavi- ties of the heart, scarcely a morbid con- dition of the arteries that nourish it or spring from it, with which the distress- ing malady has not been observed to be associated." (Da Costa.) Eecent writers lay stress on oblitera- tion of the lumen of the coronary arter- ies as the essential basis of true angina pectoris, which obliteration may be oc- casioned either by sclerosis of the vessels or by changes in the aorta at their origin. "So intimately associated is the true paroxysm with sclerotic conditions of the coronary arteries that it is extremely rare apart from them." (Osier.) (Same view. Whittaker.) Case of angina pectoris without lesions of the coronaries in which death oc- curred during a paroxysm. Aortic and mitral endocarditis wa-s found post- mortem, but no lesion whatever of the coronaries. Numerous personal autop- sies on the bodies of old people, at the Bicetre Hospital, where there had been no complaint of angina during life, and yet the coronaries were found to be al- most occluded by atheromatous plaques. Pilliet confirmed these observations. He had found a large number of obstructed coronary arteries which had never caused angina. Auseher (Bull, de la See. Anat., Oct. 9, '91. The immediate, precipitating condi- tions of a paroxysm are not known, but they are supposed to be connected with disturbances of the vagus, or, perhaps, the sympathetic nerves. Nothnagel re- ported a series of cases under the title "Angina Pectoris Vasomotoria" which seemed to be due to a pure neurosis. They followed exposure to cold, and were ushered in by spasm of the peripheral arterioles, which presumably produced the cardiac disturbance because of the in- creased exertion demanded of the heart in order to propel the blood through nar- AXGIXA PECTORIS. PATHOLOGY. 347 rowed channels. Cases of this sort must be rare. Authors quote Nothnagel with- out mentioning similar personal observa- tions. From a neuralgia or a neurosis true angina pectoris differs in being usually fatal, in attacking men ten times as often as women, and in being associated with organic changes in the neighboring structures, viz.: the heart and aorta. Lesions of the cardiac plexus and the branches of the vagus have been found in repeated instances of angina pectoris, but that such lesions are invariably pres- ent and essential to the disorder has not yet been proved. "The cardiac nerves may be seriously implicated in aneurism, in mediastinal tumors, in adherent peri- cardium, and in the exudate of acute pericarditis, without causing the slight- est pain." (Osier.) The late Sir Benjamin W. Richardson regarded angina pectoris as an actual disease analogous (as Trousseau held) to epilepsy, and due to a disturbance in the sympathetic nervous system. Debove says that in tabetic angina pectoris there is no organic lesion of the heart or large vessels and that the at- tack must be regarded as a visceral crisis. Dana refers cardiac crises in tabes to a degenerative irritation of the vagus. [It should, however, be remembered that aortic disease is rather frequent in tabetic patients. H. F. Vickbey.] In regard to the causation of attacks of angina pectoris in the graver cases which are associated with serious struct- ural disease of the heart and vessels, J. Burney Yeo states that in by far the greater number of deaths from organic disease of the heart all the various lesions may be present which have been found in fatal cases of angina and yet no true anginal attacks have ever been com- plained of. In his opinion there is some additional circumstance needed to ac- count for the angina. The most serious forms of angina seem to have a complex causation. First, there must be a neu- rosal element; the nerves of the cardiac plexus suffer irritation, and an intense cardiac nerve-pain is excited; this acts as a shock to the motor nerves of the heart, and thus reacts on the heart-mus- cle, which, in fatal cases, is already on the verge of failure from organic causes; and, if there should be excited at the same time some reflex arterial spasm, the heart will have to encounter an increased peripheral resistance as well. In such cases the rapidity of the fatal issue is no argument against the neuralgic nature of the angina. In certain conditions, espe- cially in habitual high arterial tension, strain is apt to fall (when the aortic valves are competent) rather on the first part of the aorta than on the ventriciilar surface, and anginal attacks are more prone to occur in these cases, as this part of the aorta is in such close relation with the nerves of the cardiac plexus, rather than in those cases in which the strain is felt on the interior of the cardiac cavi- ties. The causation of the less grave and more remediable forms of angina is also, in many instances, complex. A cardio- vascular system, feeble and poorly nour- ished, on account of anemia, may be submitted to undue strain; or there may be some intoxication — such as that of tea, tobacco, alcohol, gout, or some intes- tinal toxin — irritating the cardiac and vasomotor nerves, increasing peripheral resistance, and so exciting anginal at- tacks, which may altogether pass away and be completely recovered from. Va- somotor spasm, as a unique cause of at- tacks of angina, must be set aside as inconsistent with extended clinical ex- perience. Cases of angina pectoris, both of the milder and graver forms, occur 348 ANGINA PECTORIS. PROGNOSIS. TREATMENT. without any evidence of vasomotor spasm or of heightened arterial tension; and the conditions of heightened arterial ten- sion, together with a feeble cardiac mus- cle, very commonly co-exist, without any tendency whatever to the development of anginal attacks. The argument in favor of a vasomotor causation has been inferred from therapeutic experiment and the relief to the paroxysm which has attended the use of agents which cause arterial relaxation. But most, if not all, of these vasodilators are also anesthetics, and, as Balfour has pointed out, it is probably to their anodyne action on the sensory cardiac nerves that they owe their chief eiiicacy; Grainger Stewart has also pointed out that nitrite of amyl has a direct effect on nervous structures, and that it relieves other forms of neuralgia. Angina pectoris is due, not to an in- crease, but to a further reduction, of tlie muscular energy of a heart already en- feebled: the Stokes-Parry theory. The associated pathological processes are sclerosis of the coronary vessels, altera- tions of the aortic valves, and ectasic aortitis, which latter has a special stenotic effect upon the origin of the coronary vessels. These conditions, together with the resistance of the contracted arterial system, induce weakening of the heart. A moderate distension of the heart may lead to a temporary occlusion of the coronary vessels at the point of an al- ready existing constriction, and so bring on an attack of angina pectoris. In other cases a thrombus or embolus may be the cause of the block. T. Sehott (Lancet, Sept. 8, 1900). Prognosis. — The underlying condition is apt to prove fatal eventually, and it may end life in the first paroxysm; but a careful regimen may prolong existence for years; and Flint, Bendel, and Labol- bary have each reported cases of recovery. The signs of danger during any par- ticitlar attack are the subjective sense of impending death and the feebleness and irregularity of the pulse. The general prognosis is, of course, influenced by the stage which the organic circrilatory changes have already reached. The pseudo-attacks are apt to be re- peated oftener than are the genuine, but the prognosis is good both as to life and to the final disappearance of the trouble. True angina, when it occurs in dila- tation of the heart, admits of a prognosis more favorable than when it occurs with other mural conditions, as myocarditis or hypertrophy, without dilatation. Grave cases of dilatation of the heart, conversely to the above, may be looked upon as amenable to successful treat- ment if the patient should have par- oxysms of true angina pectoris. J. H. Musser (Amer. Jour, of Med. Sciences, Sept., '97). The majority of writers hold that true angina pectoris (that is, combined with anatomical lesion of the heart, fatty de- generation sclerosis of the coronary arteries, etc.), generally ends sooner or later in sudden death, and that recovery is a rare exception. Personal experience in seventy-three cases has shown that this statement holds good only of pa- tients in whom angina is combined with aortic insufficiency. Among the other eases there was only a single patient who died suddenly after the disease had lasted tliree years. Most of them after treatment recovered sufficiently to under- take laborious work; a few were com- pletely cured, and in only three eases did no improvement take place. Of these one was a drinker and a great smoker, another suffered from pleurisy, while in the third arteriosclerosis went on de- veloping, aortic insufficiency was pro- duced, and the patient died suddenly. Fr. Somberger (Sbornik Klinicky, vol. i, Fasc. 1, '99). Treatment. — During a paroxysm the first remedies to employ are such as will dilate the arterioles. Nitrite of amyl is the best because it acts with the greatest rapidity. A "pearl" of this drug may be crushed in a handkerchief or in cotton placed in the bottom of a glass tumbler, ANGINA PECTORIS. TREATJIEXT. 349 and inhaled. Nitroglycerin may be injected subcutaneously (^/loo to V50 grain), or a tablet of this substance may be masticated. It is readily absorbed from the mouth and acts almost as quickly as when given hypodermicaUy. For treatment of attack itself, rest, the inhalation of 5 or 6 drops of nitrite of amyl and an hypodermic injection of '/loo grain of nitroglycerin are to be resorted to. To overcome the syncope ether, caf- feine, or camphorated oil, the latter in 10-per-cent. strength, are to be employed. Friction should also be applied to the limbs and, should there be evidences of pulmonary involvement, venesection must be practiced, while, if respiration fails, rhythmical tractions of the tongue must be performed. Fifteen- to 45-grain doses of antipyrine may be given by the stom- ach or by rectal mjection, or smaller amounts of phenacetin may be used; to the point of pain chloride-of-ethyl spray may be applied. Lyon (Revue de Ther. Med.-chir.; Ther. Gaz., Oct. 15, "OS). In angina pectoris pearls of amyl-nitrite recommended, especially in the beginning of the attack. The dose is from 5 to 10 drops. Should the attack last for any length of time injections of nitroglycerin advised. A good formula is as follows: — 1} Spirit of nitroglycerin, 10 minims. Cherry-laurel water, 3 drachms. M. Twenty minims to be injected sub- cutaneously. Small blisters to the prsecordium are often useful. Between attacks the diet should be very limited and the use of alcohol and tobacco be forbidden. Iodides should be given for at least from two to four years following an attack, and it is well to alternate the sodium and potas- sium salts and combine them with digi- talis or caffeine. Huguenin (Allgemeine med. Central-zeit., No. 14, '98). Eelief by these means is often im- mediate; but, if not, ether should be inhaled. Chloroform is also advised by excellent authorities. Flint thinks it not without danger, if the heart is weak; ether, on the other hand, is a stimulant. Morphine, subcutaneoiisly, is a valuable and sometimes an indispensable remedy. Whittaker suggests that it be given with caution in a condition which may any- way terminate in sudden death. The morphine (V^ grain) may he guarded by atropine (V150 grain), and in case of alarm also by strychnine (^/ao to V2» grain). Electricity has also been recom- mended. Electricity is generally unreliable or dangerous, and faradization should be used only in threatening syncope. Huchard (Univ. Med. Mag., May, '92). The application of the continuous electric current along the course of the vagus in the neck and down the arm, in cases where a distinctly painful aura is experienced in the hand, has been found useful in warding off attacks. Burney Yeo (Practitioner, May, '93). Electricity certainly seems to exercise its best effects in those cases in which the pain is of a very positive neuralgic character, with no co-existing organic disease, although the presence of struct- ural changes in the heart and blood- vessels does not contra-indicate the judi- cious use of either form of current. Rockwell (Hare's "System of Practical Therap.," vol. i, p. 394). . Hot and stimulating applications over the prseeordia, such as a strong mustard poultice, are appropriate, as are also heat and friction for the extremities. Some- times an ice-bag is put over the heart. Alcohol and aromatic spirit of ammonia are of benefit in case the cardiac action is feeble. Syncope demands such drugs as digitalis, digitaline, caffeine, strych- nine, and camphor, employed hypoder- micaUy. I have known oxygen to con- tribute to a favorable result in collapse due to chronic myocarditis with dilata- tion of the left ventricle, and cannot see why it might not be well for a subject of angina pectoris to keep some ready in his house. Between attacks it is of vital impor- tance to avoid the predisposing and ex- 350 ANGINA PECTORIS. TREATMENT. citing causes. Best and moderation are demanded. As for drugs, nitroglycerin, taken after meals in doses just short of causing headache, has a distinct inhibi- tory effect upon the paroxysms. In some instances it might be better to order it every three hours, as its influence is not long continued. Nitrite of sodium (2 to 5 grains) may replace nitroglycerin. A new remedy is erythrol-tetranitrate in grain doses four times in the twenty- four hours. If this drug is given in spirit and water (1 grain in 1 drachm of alcohol and 7 drachms of water) the tension begins to fall in two or three minutes; if given in a pill, the time is twenty to forty minutes; if given in tabloid form and chewed, the time lies somewhere between the two. The drug was not introduced to replace amyl- nitrite and nitroglycerin in cutting short attacks, but only to replace them in pre- venting the onset of the attacks. J. B. Bradbury thinks the tablet imdoubtedly the best form of administration. Severe case in a physician, in which erythrol-tetranitrate (1-grain closes) was taken steadily, at eight hours' interval, as a prophylactic. For three weeks there was immunity from attacks, al- though some weariness and oppression came on after six or seven hours from taking the tablets. Now taken four times in the twenty-four hours with marked relief. The initial fall of the pulse-tension de- pends on the mode of administration. If the drug is given in spirit and water (1 grain in 1 drachm of alcohol and 7 drachms of water) the tension begins to fall in from two to three minutes; if given in a pill and swallowed, the time is from twenty to forty minutes; if taken in tablet form and masticated the time lies somewhere between the two. The best form of administration is un- doubtedly the tablet. The alcoholic solu- tion sometimes irritates the stomach. Bradbury (Brit. Med. .Jour., Apr. 10, '97). Erythrol-tetranitrate in angina pec- toris. Case in which glycerin soon lost its effect, and its administration was attended by severe headaches. Erythrol- tetranitrate was substituted in tablets of Vo grain, each, two to three times a day. This produced a cessation of the attacks, tlie administration of the remedy being attended by the same vasodilator effect noted in the use of the nitrites and glonoin, but the action was much more sustained. Houghton Addy (Brit. Med. Jour., May 6, '99). The persistent use of potassic iodide is very effective. Ten or 15 grains may be given thrice daily before meals in half a glass of water; or 20 grains three times a day for twenty days, followed by nitro- glycerin for ten days. The iodide is be- lieved to dilate the arterioles and to pro- mote arterial nutrition. See supposed that also by enlarging the calibre of the coronary arteries it invigorated the myo- cardium. Arsenic in small doses also tends to avert the paroxysms. In case of fatty degeneration of the heart it would be contra-indicated. Quinine and methylene-blue have also been recommended. The treatment by saline baths and by the Schott method of exercises has a most potent effect in improving the con- dition of the cardiac muscle and vessels, and appears to have a direct effect in making the attacks less numerous and severe, and even in causing them to cease during a period of months or years. The movements must be made with es- pecial care and caution in these cases, and the resistance at the onset must be at a minimum. The artificial saline baths should contain from 1 to 3 per cent, of salt, and from V4 to 1 per cent, of chloride of calcium, and should grad- ually be strengthened by the addition of carbonic acid. (H. N. Heineman.) AXGINA PECTORIS. TREATMENT. 351 Angina jjectoi'is "with pseudcsteno- crtidia. The angina is due to probable endo-aortitis, and is relieved by an ex- clusive milk diet and theobromine for two weeks. Then, one week every month, milk diet and sodium iodide. During the balance of the month, spe- cial diet, with the theobromine con- tinued. H. Huchard (Jour, des Prati- ciens, Feb. 23, 1901). The writer confirms the remarkable benefit to be derived from theobromine in these conditions as announced by Askanazy in 1895. The diuretic influ- ence of this drug is familiar, but its property of promptly arresting the pains of angina pectoris, cardial asthma, and allied conditions is less generally known, and yet the writer considers it one of the most blessed facts in modern therapeutics. He describes over a dozen cases in detail, showing its rapidly beneficial influence in all pains of arte- rial origin. They form a series rang- ing from pure angina pectoris to attacks of pain attributed by the patients to the head, stomach, shoulder, kidney, or intestines, and apparently with no feat- ures in common with angina pectoris ; yet all show by the prompt response to theobromine that they have a com- mon origin in the arteries and that theobromine has a specific action on the latter. Arteriosclerosis and certain other affections of the arteries are li- able to cause constant pains in the ves- sels which may radiate to remote re- gions. The pains may be due to in- creased blood-pressure and distension, but they are also liable to be caused by spasmodic contraction of the ar- teries. These contractions occur by preference in the smaller arteries and are the result of pathological or path- ologically exaggerated reflexes originat- ing in the diseased vascular wall. They are set in motion by various causes which raise the blood-pressure, emotions, muscular exertion, the horizontal posi- tion in sleeping, etc. They are especially liable to occur in the organs which re- quire the largest supply of arterial blood, such as the digestive tract, heart, and muscles. The arterial fluxion in- duced by increased function starts the attack of pain. The spasmodic contrac- tion of the arteries causes symptoms of ischtemia as the arterial supply is cut ofl' from muscular organs. In the ex- tremities it becomes evident as inter- mittent claudication; in the digestive tract as paresis and meteorism; in the heart, as sudden inadequacj' and paral- ysis. Sensory phenomena may be super- added to these and it becomes diflioult to decide whether the pains are due to the vascular spasm or to the ischse- mie parenchyma. When the vessels of the heart are directly or indirectly in- volved the specific angor cordis devel- ops. The lesions of the heart arteries may radiate the pain to remote regions. The spasm of the heart arteries is peculiarly intense when it is not the result of the usual causes, but is due to direct irritation of the intima by a thrombus or embolus. This explains the sudden death that may occur from a small embolus in one of the terminal ramifications of a coronary, as well os in case of obstruction of a large artery from this cause. Theobromine has evi- dently some action on the spasmodic contraction of the arteries, and when this is controlled the pain ceases. It may also act by diminishing the refle.x excitability or by reducing the arterial pressure. Be this as it may, the fact is established that theobromine is a powerful and harmless remedy for pain* on an arterial basis. The writer always gave it in the form of diuretin (Elnoll), in doses of 0.5 gramme four or five times a day, and in the severest cases 3 to 4 grammes a day. The only ob- jection to its use is the high price charged for the preparations of theo- bromine. R. Breuer (Miinchener med. Woch., Oct. 14, 1902; Jour. Amer. Med. Assoc, Nov. 15, 1902). The cardiac tonics — sparteine, stro- phanthus, strychnine, valerian, and in suitable cases digitalis — are of the great- est utility. Digitalis is of doubtful utility. It should not be given unless there is an excess of dilatation. J. H. Musser (Amer. Jour. Med. Sciences, Sept., '97). The general tendency to anaemia and defective oxygenation must never be lost 352 ANGINA PECTORIS. ANIIALONIUM LEWINII. sight of, and general tonics, including the use of oxygen-gas, will be of excellent service. Angina pectoris is due to a simple liyperaemia of the spinal sensory centres. A spinal ice-bag from the fourth dorsal to the third lumbar vertebra, applied once or twice a day for from forty min- utes to an hour, will not only relieve the attacks, but will completely eradicate the trouble. Amyl-nitrite is useful. An- other remedy recommended very highly is oxygen by inhalation. Oxygen alone will relieve an attack of angina, but in combination with cold over the spine and heat to the extremities it is the speediest method of relief at our command. Most efficient formula of oxygen for adminis- tration consists of 2 parts of pure oxygen, 1 part nitrous monoxide, and 1 per cent, of ozone. B. Kinnear (Med. Record, July 16, 'OS). Attacks of pseudo-angina may be treated with asafoetida, ammoniated tincture of valerian, or compound spirit of ether, and the outward employment of heat-friction and rubefacients. Some- times recourse must be had, however reluctantly, to morphine. The statement in clear and decided language of a favor- able prognostic prospect is of great bene- fit. Between attacks the underlying con- dition should be cared for. (Heineman.) The fact of the pain itself being capa- ble of acting as a vasoconstrictor has been too much overlooked. Certainly morphine is the great remedy that we have usually to fall back upon when vasodilators have spent their powers of affording relief. Graham Steell ("The Sphygmograph in Clinical Medicine," '99; Phila. Med. Jour., Feb. 24, 1900). Herman F. Vickeht, Boston. ANHALONIUM LEWINII (MESCAL BUTTON). — The mescal button is ob- tained from a plant which grows in a valley of the Eio Grande, in Mexico. The tops of the plant when dried consti- tute the commercial form of Anlialonium Lewinii, first described by Lewin. They are brownish in color, circular, and from one to one and a half inches in diameter. The button is hard and can be pulverized in the mortar with difficulty. In the mouth, however, under the action of the saliva, it swells and rapidly becomes soft, giving a nauseous and bitter taste, with a marked sensation of tingling in the fauces. An alkaloid (anhalonine) has been extracted from anhalonium. It is a glucoside, with an action somewhat like that of strychnine, and is very poisonous. Dose." — The following preparations may be used: A tincture (10 per cent.). Dose, 1 to 3 teaspoonfuls. An extract of leaves (100 per cent.). Dose, 7 ^/^ to 15 minims. Powdered leaves, 7 ^/g to 15 grains. The tincture and extract should be made according to the processes pre- scribed in the United States Pharma- copoeia for such preparations. Physiological Action. — Lewin found anhalonium to be an intensely poisonous drug, and that a few drops of a decoc- tion used by him in the frog sufficed to produce almost instantly very marked changes, chiefly consisting in the appear- ance of skrinking of the body, so that the batrachian seemed to pass into a mummified condition. Simultaneously with these appearances, the animal raised itself iipon its fore-extremities and re- mained standing in this position like an ordinary quadruped, or crawled about. After fifteen minutes this spastic condi- tion passed off and he rapidly returned to his normal condition. When larger amounts were given, death occurred in tetanic rigidity. It would seem that the symptoms produced by it are closely allied to those of strychnia, for Lewin noted that even after the spinal cord was severed peripheral irritation caused tetanus. On pigeons it was found that the drug produced convulsive vomiting ANHALONIUM LEWINII. THERAPEUTICS. 353 in a few moments when given hypoder- mieally. The bird spread its wings, crouched down to the ground, and if disturbed would twitch convulsively. Later the head was drawn sharply back, the mouth opened widely, and general convulsions asserted themselves. When death occurred the heart was always found in diastole. In rabbits the symp- toms were those of strychnia poison. The taste of the liquid preparations is some- what disagreeable, unless it be disguised by a suitable vehicle, such as a mixture of fluid extract of licorice and elixir of yerba santa. The powdered drug is best administered in wafer-paper, cachets, or capsules. (Lewin.) It seems to produce an effect in the human subject resembling that of Indian hemp: visions ranging from flashes of color to beautiful landscapes, figures, etc. It depresses the muscular system without having, however, produced intoxication, as would be the case with alcohol. An- halonium is not hypnotic and sometimes induces wakefulness. The principal feature of the visions is the eolor-eflfeot. Tlie power of the drug seemed to be mainly due to the develop- ment of these entrancing visions. Pren- tiss and Morgan (Ther. Gaz., Sept. 15, '95). Personal experience in the use of the drug. The principal phenomena were extraordinary color-visions, and also brilliant form-illusions. After-effects of the drug quite unpleasant, producing nausea and headache for several hours afterward. Symptoms produced resem- bling the visual phenomena of ophthal- mic migraine, suggesting that possibly the drug might be found useful in this affection. S. Weir Mitchell (Jour. Nerv- ous and Mental Dis., Sept., '9fl). The important effect of the alkaloid of the mescal plant in therapeutic doses would appear to be: 1. A direct stimula- tion of the intracardiac ganglia. 2. An initial slowing of the heart. ?,. An ele- vation of arterial tension. 4. A direct 1- stimulation of the brain-centres and motor-centres of the cord, as shown by the increase in reflex excitability. Dixon {Brit. Med. Jour., Oct. 8, '98). Investigations carried out on writer himself were made to determine the active ingredient producing the peculiar visual hallucinations described by Pren- tiss and Morgan, Weir Mitchell, and others. In the first place, an alcoholic extract of mescal buttons corresponding to 4V2 drachms was taken, and after- ward an amount of the individual alka- loids corresponding to the quantity in the extract. The active ingredient was found to be mescaline. The symptoms produced, both by the alcoholic extract and mescaline {IV: grains), were colored visual hallucinations, slowing of the pulse, dilatation of the pupil, loss of time-relations, heaviness of the limbs, nausea, and headache. After anhaloni- dine (1 '/, to 3 Vi grains) some sleepiness and heaviness of the head were observed, but no visions or change in the pulse. Anhalonine (IV2 grains) only produced slight sleepiness, while lophophorine (^%oo grain) induced a painful feeling at the back of the head and burning and redness of the face. The pulse fell from 78 to 70 per minute, but all the symp- toms were transient. After a resin ob- tained from the plant no visions or other typical symptoms, except heaviness of the limbs, were obtained; thus the theory that this is the active ingredient is dis- posed of. Heffter (Arehiv f. Exp. Path, u. Pharm., xl, 385, '98). Anhalonium, in drop doses, a sustainer of the respiration and a cardiac stimu- lant. Seminal emissions may occur from "its use without erection. A valuable ad- juvant to digitalis, according to Landry. Therapeutics. — The use of mescal but- tons is credited with beneficial results in general "nervousness," nervous headache, nervous irritable cough, abdominal pain due to colic or griping of the intestine, hysterical manifestations, and in other similar afEections where an antispasmodic is indicated; as a cerebral stimulant in depressed conditions of the mind, — hypo- 35-t ANIMAL EXTRACTS. THYROID. PHYSIOLOGICAL ACTION. chondriasis, melancholia, and allied con- ditions; as a substitute for opium and chloral in conditions of great nervous irritability or restlessness, active delirium and mania, and in insomnia caused by pain, in color-blindness. ANIMAL EXTRACTS. — Under this heading are included not only the ex- tracts of various tissues at present util- ized in therapeutics, but, likewise, the tissues themselves, and all the prepara- tions, active principles, etc., that are obtained from them. Of the animal tissues, and the products obtained from them, employed therapeu- tically, the ductless glands, whose func- tions are now known to be intimately associated with metabolism, have by far taken the lead over all other portions of the animal organism utilized. Indeed, if they continue to increasingly engage attention as they have of late, the time is not far ofE when antitoxins will find in them a potent rival. On this account, considerable space has been devoted to the subject as a whole; but, as the pre- vailing views still belong to the domain of conjecture, the purpose of this article vnll be to present what evidence clini- cians have furnished. Our personal views will only be in- corporated in this article after the pro- fession at large will have recognized their merit, if such exist. This work is only intended to portray generally-accepted doctrines. The ductless glands and their prepa- rations will first be considered in the cr- der of their importance in therapeutics. A few pages will then be devoted to the various other organs and products at present being tried, the so-called "organic extracts," some of which are rapidly losing their claim to recognition. Thyroid Gland. In the latter part of the last century. King, of London, showed experimentally that the colloid substance of the thyroid gland passed directly into the lymphat- ics; and Schiff, in 1859, reviving views previously held by many, showed that this organ played an important part in the economy, through some substance which it secreted, and that intraperi- toneal transplantation of the healthy gland in a dog shortly after thyroidec- tomy had been performed prevented cachexia strumipriva, which follows this operation. Then followed, in 18S3, the experiments of Kocher and Reverdin, demonstrating that, in man as well as in animals, the same phenomena occurred under identical circumstances. This led the way to the investigations of Murray and Ord, who, followed by many observ- ers, then showed that myxcedema could be counteracted by the internal adminis- tration of thyroid gland. Since then this organ has been used as a remedy in a large number of disorders and with marked success in some, the best results being obtained in conditions more or less distinctly associated with myxcedema. Physiological Action. — Under the in- fluence of a preparation of thyroid gland the body-weight diminishes and the ex- cretion of nitrogen, water, carbonic acid, sodium chloride, and phosphoric acid increases, indicating a decided influence upon general metabolism. Increased metabolism, shown by (1) elevation of temperature; (2) increased appetite, 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- provement in body -nutrition generally; (6) increased activity of mucous mem- branes, skin, and kidneys. The rheu- matic symptoms and the anaemia are not ANIMAL EXTRACTS. THYROID. PHYSIOLOGICAL ACTION. 355 only not relievedj but are frequently aggravated. G. W. Crary (Amer. Jour. Med. Sciences, May, '94). Appearance of glycosuria as a result of the administration of tablets of thy- roid gland. Ewald (La Sera. Med., p. 357, '94). Metabolism during thj-roid treatment studied in three goitrous patients, aged, respectively, 19, 24, and 27 years, their usual diet being given. 1. The goitre diminished in size in all the cases. 2. The body-weight decreased one kilo- gramme in one case, and two kilo- grammes in the other two cases. The diminution in \\eight depended on the duration of the treatment. 3. The amount of urine was increased. 4. The nitrogenous excretion appeared to be increased, chiefly through the urine. 5. The increase in nitrogenous excretion caused a negative nitrogenous balance of 5.46, 5.2, and 4.34, respectively. 6. The uric-acid excretion was increased in two of the cases examined. 7. The excretion of solid chloride and phosphoric acid was increased. The considerable increase in phosphoric-acid metabolism, mentioned by Eoos, not confirmed, but only phosphoric acid in the urine, and not in the faeces, was estimated. Irsai, Vas, and Gara (Deutsche med. Woch., July 9, '96). Experiments to ascertain whether the loss of the weight takes place at the expense of the fat of the body or of the protoplasmic tissues, such as the muscles. Conclusions: that fresh thyroid acts en- ergetically on albuminous decomposition, but that some of the eflSciency is lost to the thyroid substance in the process of making tablets or in keeping it too long. The administration of the artificial prod- ucts over long periods of time is, how- ever, not without action on albuminous substances. Gluzinski and Lemberger (Centralb. f. inn. Med., Jan. 30, '97). Under the effect of thyroid there is an increased rapidity of combustion through- out the body, while the increased urinary flow which follows its use decreases the patient's weight considerably as well. Another important effect of the thyroid gland is to hasten cell-activity. Robert Hutchinson (Brit. Med. Jour., July 16, ■98). Following conclusions deducted from a series of investigations on thyroid treat- ment: 1. The loss of weight after the ingestion of thyroid is not due con- clusively to loss of water and albumin, but in part, in some cases, to loss of fat. Thyroid causes, therefore, a genu- ine reduction of fat. 2. So far as this is due to increase of normal tissue-change it is moderate, except in my.xoedema. 3. Increase of metabolism does not occur in all persons who take thyroid. It is most marked in myxoedema. 4. The proteid deficit in thyroid feeding may continue even in case of superalimentation, and is, therefore, a specific, toxicogenic effect of the substance. 5. Thyroidin shows efi'ects on metabolism like those of the extract of the glands, but thyreotoxin and potassium iodide give no such re- sults. 6. Absence of thyroid function causes not only defective growth and serious bodily and psychical degeneration, but also a distinct decrease of gaseous interchange, of heat-production, and of total metabolism. The excessive and ab- normal function causes increased metab- olism and emaciation. Administration oi the gland in such cases is followed by in- creased metabolism and improvement of symptoms. 7. The loss of fat and albu- min in thyroid feeding shows a plain analogy with the same process in Base- dow's disease and is toxic when it reaches a high grade. Thyroid preparations must, therefore, be used cautiously in the treatment of obesity. A. Magnus Levy (Zeit. f. klin. Med., B. 33, p. 258, '98). In rabbits thyroid substance produced a lowering of the blood-pressure, begin- ning a few seconds after the injection and persisting, with an unchanged heart- action. The fall in pressure is due to dilatation of the vessels. As substances having a similar action are found in the hypophysis extract and adrenal extract, and since, moreover, peptones have the same influence, no final conclusions can be drawn from the action of the thyroid extract upon the tone of the vessels. Bela V. Fenyvessy (Wiener klin. Woch., Feb. 8, 1900). 356 ANIMAL EXTRACTS. THYROID. PHYSIOLOGICAL ACTION. It seems exceedingly probable that the iTntoward phenomena resulting from thyroid extirpation are due to an in- toxication, to some kind of an autoin- fection, whose harmful influence is no longer counteracted by the normal ac- tion of the thyroid gland. The efEect of thyroid transplantation or implanta- tion, together with the positive results produced by thyroid feeding or by the use of extracts, speaks for the action of the gland by means of a secretion, — that is, at ,a distance from the gland; and this is against the view that some have suggested, that the toxic substances are brought to the gland and there trans- formed or rendered innocuous. The gland acts, therefore, not by virtue of storage or of direct blood purification. (J. W. Warren.) Substances which diminish the excita- bility of the nervous system, bromide of potassium and antipyrine in particular, will diminish or suppress the convul- sive symptoms following thyroidectomy. Gley (La Sem. Med., Apr. 13, '92). In dogs the symptoms of tetanus caused by thyroidectomy can be over- come by large doses of potassium bro- mide. Fifty dogs thus kept alive two years and two six years after the opera- tion. Same results obtained with hypo- dermic injections of a concentrated solu- tion of the substance of the thyroid gland, and with a solution of the gray matter of the brain of healthy dogs. Canizzaro (Deutsche med. Woch., No. 184, '92). Intravenous injections of solutions of brain, testicle, or blood-serum have no such effects as the thyroid juice. Ex- periments favoring the belief that the thyroid gland has the function of pre- venting autointoxication, by transform- ing the toxic products of tissue-change into substances easily eliminated, or by directly neutralizing them by its own secretion. Vassale (Review of Insanity and Nervous Dis., June, '92) . In Bright's disease two to six thyroid glands of the sheep per week increase the density of the urine and the quantity of urea is augmented very sensibly. Gif- ford (Brit. Med. Jour., Mar. 31, '94). Study of sixty cases. The action of thyroid extract is complex. It undoubt- edly produces a mild, feverish condition, the action and reaction of which are often of considerable benefit. It is a direct cerebral stimulant. There is a strong probability that at some periods of life the administration of the thyroid supplies some substance necessai"y to the bodily economy. Bruce (Jour, of Mental Science, Oct., '94). Experiments on dogs showing that after removal of the thyroid the urotoxic coefficient rose to nearly double. The toxicity of the blood-serum also increased after thyroidectomy. The thyro-iodine of Baumann, when given to athyroidized dogs, caused the urotoxic coefficient to return almost to the normal, and re- lieved most of the nervous symptoms. Spoto (Gior. dell Assoc, di Napoli, p. 526, '96). Five mice and three guinea-pigs were treated with thyroid extract. Swelling of the face, emaciation, and loss of strength. In all cases the administra- tion was continued till the animal died. No lesion found of either nerve-elements or neuroglia; no varicose or atrophied dendrites or loss of gemmulae. The cor- pora showed no loss of angularity, and the axons and appendages were all healthy. No nuclear change in the cells ascertained; the blood-vessels were care- fully examined without the discovery of any lesion. It would seem from these investigations, so far as they go, that the toxic action of thyroid is of a different nature from that of other conditions, and one which we are not, therefore, in a position to understand. Berkley (Bulle- tin of the Johns Hopkins Hospital, July, '97). Two main hypotheses have been ad- vanced as to how the secretion of the thyroid acts on the tissue of the body: First, that the tissue forms toxic sub- stances which are neutralized by the thy- roid secretion; this is the antitoxic theorv. Second, that the thyroid secre- ANIJL4.L EXTRACTS. THYROID. ACTIVE PRINCIPLES. 357 tion promotes or regulates normal metab- olism; this is the trophic hypothesis. All the newer evidence seems to point to the latter as the more probable one. H. Sneve (Columbus Med. Jour., Dee. 20, '98). The thyroid gland is not to be re- garded as an organ pouring a useful in- ternal secretion into the circulation; the lymph leaving it, and the lymphatic glands in the vicinity, do not contain iodine; and the blood and central nerv- ous system in healthj' animals are also free from iodine. Removal of the thyroid is followed by disease and death, because the organ which removes poisonous sub- stances from the blood can no longer pro- tect the animal. It is the central nervous system which principally suilers, and by Nissl's method great changes (ehroma- tolysis) can be demonstrated in the ganglion-cells. The thyroid, therefore, appears to be the great protective organ to the central nervous system. The poisonous substances are destroyed by oxidation, and this appears to be assisted by combinations with the iodine. F. Blum (Pflueger's Archiv, 70, '99). Iodine-holding proteid compounds are almost wholly separable from the gland by water. The total iodine of the gland is so distributed that about 96 per cent, can be separated by alcohol, acids, etc., as iodo-albumin compounds in firmly bound form. Thyroidin does not occur free in the gland. R. Tambach (Zeit. f. Biol., xxxvi, No. 4. p. 549, '99). Removal of the thyroid alone invari- ably causes myxedema, W'hile removal of the fonr parathyroids produces the acute tetanic symptoms observed after so-called experimental "thyroidectomy." The partial tetany sometimes observed after apparent removal of the thyroid in man is most likely really due to the inadvertent removal of some of the parathyroids along with the thyroid proper. The symptoms of myxcedema can be fully explained by the absence of iodothyrin from the blood which such removal entails, and the symptoms of parathyroidectomy are not yet sus- ceptible of any satisfactory explana- tion. Robert Hutchison (Practitioner Apr., 1901). Active Principles of Thyroid. — It is quite clear that the thjToid gland is es- pecially characterized by the presence of a compound proteid of peculiar consti- tution, and that this substance, which Eobert Hutchinson calls "colloid matter," is the active constituent of the gland There is also present another proteid, a nucleo-albumin, in small amount, which Hutchinson considers as probably con- tained in the cells of the acini. In addition there are certain extractives to be found, — viz., xanthin, hypoxanthin, inosite, volatile fatty acids, paralactic acid, succinic acid, and calcium oxalate, — bodies, however, of no special physio- logical significance. (E. H. Chittenden.) Iodine has recently been shown by Baumann to be a normal constituent of the thyroid gland. Thyro-iodine — the name given by him to the product obtained — contains over 9 per cent, of iodine, and it becomes inert when the latter agent is removed from it. Bau- mann has also shown that the amount of iodine in the gland is much greater when the organ is normal than when it is goitrous. Thyro-iodine is best prepared by treat- ing the gland with a solution of sodium chloride. The globulin is precipitated by a current of carbonic acid, and the solu- tion acidified and boiled, when a pre- cipitate of albumin and thyro-iodine falls. The latter is an organic substance combined with nitrogen and iodine (10 per cent.). Clinical observations show that thyro-iodine is very active, patients suffering from goitre and myxcedema having been cured by it. Baumann main- tains that the entire active substance re- mains on the filter after coagulation of the albumin. Baumann (Zeit. f. physiol. Chem., B. 21, pp. 319 and 481, '96). The colloid material, believed by Hiitchinson to be the active ingredient of the thyroid gland, has been found to contain iodine in organic combination, 358 ANIMAL EXTRACTS. THYROID. PREPARATIONS. the colloid matter owing its activity to the presence of this organic compound of iodine. The proteids of the gland are two in number: 1. A nueleo-albumin pi-esent in small amount and probably derived from the cells lining the acini. 2. The colloid matter, made up of a proteid and a non-proteid part, the latter containing, in all probability, Baumann's throidin. Certain extractives are also obtained from the gland, as creatin, xanthin, etc., which have been found absolutely inert when administered either to healthy persons or to cases of myxcedema. The same result obtained on giving the nu- eleo-albumin. The pure colloid matter gave the ordinary signs of thyroid ac- tivity in healthy individuals, and in large doses distinct thyroidism resulted. Marked beneficial results were obtained on administering it to a patient with myxcedema. The proteid and the non- proteid constituents of the colloid were then given separately, and although benefit resulted from the former, yet the most favorable results were obtained from the administration of the latter. Robert Hutchinson (Brit. Med. Jour., Jan. 23, '97). The colloid substance is the active se- cretion of the thyroid gland, and is made up of thyreoglobulin and nucleoproteid. Experiments were undertaken to show the influence which thyreoglobulin and mucleoproteid exercised upon general metabolism. Results showed that in the ■case of dogs the excretion of nitrogen Avas considerably increased when thyreo- globulin was given, whereas nucleopro- teid had no efTect upon the output of nitrogen. Thyreoglobulin is the most active body in the thyroid gland; it contains all the iodine, and the amount of iodine in- creases pari passu with the increased col- loid material; it therefore follows that thyreoglobulin is contained in the col- loid material. Oswald (Hoppe-Seyler's Zeit. f. physiol. Chemie, vol. xxvii. Parts 1 and 2, '99). Thyro-antitoxin is the provisional name of another active principle, ob- tained by Fraenkel, from the thyroid gland of the sheep. It exerts no influ- ence on nutrition comparable with that of fresh thyroid or thyro-iodine. The albuminous bodies were precipi- tated by acetic acid, and by feeding ex- periments it was ascertained that the precipitate had no marked effect, while the filtrate that was obtained possessed the well-known properties of the thyroid gland, or, in other words, contained the physiological active principle. Fraenkel (Wiener med. Bl., S. 48, '95). In the tetanic condition toxins are found in the blood which are rendered innocuous by the thyro-antitoxin of Fraenkel, formed in the gland-alveoli. In the myxoedeniatous condition, on the con- trary, a "thyroproteid" is formed in the tissues, passes into the blood, and is fixed by the thyroid. Here it is ren- dered innocuous by an enzyme which splits it up into two parts: a proteid constituent, which unites with thyro- iodine, and the other a carbohydrate. Notkin (Virchow's Archiv, Suppl., B. 144, '96) . Preparations, — The implantation of a portion of the thyroid gland beneath the skin was soon superseded by the hypo- dermic method, bitt the latter presented another drawback, that of requiring the constant attendance of the physician. Besides this the preparations often pro- duced suppuration. The gland itself, therefore, administered in the form of desiccated powder in tablets or capsules, is preferred by the majority of practi- tioners. It seems evident, all in all, that the entirely unobjectionable whole gland pre- pared in desiccated powder or capsule or in compressed tablet is the only means by which we ought to attempt to treat conditions in which this animal sub- stance has been found useful. Editorial (Ther. Gaz., May 15, '97). The glands of young sheep have given the best results. When the glands them- selves are to be administered, considerable ANIMAL EXTRACTS. THYROID. PREPARATIONS. 359 care should be taken, and they should be obtained through a veterinary surgeon. Again, the glands should be carefully examined to ascertain that they are not diseased. Over 50 per cent, of sheep's thyroids e.xamined showed more or less evident indications of deviation from the normal. Emphasis on the need of care in the selection of glands for administration. A. Napier (London Lancet, Feb. 4, '93). It is usually advisable for the doctor himself to get the thyroid lobes. If it is left to the butcher quite other sub- stances may be supplied. The glands of sheep, and. especially of young sheep, are to be preferred, tuberculosis being ex- tremely rare in this animal. The sheep has two thyroid bodies, one on each side of the trachea. The upper part of each thyroid corresponds exactly to the track of the butcher's knife in bleeding the animal; the top of the gland is almost always cut by the knife, and this forms a good guiding mark for finding the gland at once. Gabriel Gauthier (Lyon Mgd., June 27, July 11, '97). The thyroids should be removed as quickly as possible after the animal is killed. After careful antiseptic prepara- tion of the field of operation, the glands should be dissected out with aseptic in- struments, and after removing all the fat and connective tissue they should be put into a sterilized, covered glass dish which has been previously weighed. The organs, as soon as secured, should also be taken to the laboratory and weighed. They are then cut into small pieces with aseptic scissors and double their weight is added of a mixture con- taining 2 parts of glycerin and 1 part of sterilized water. After standing in this for twenty-four hours, they are poured into a suitable bottle, which is stoppered with cotton and sterilized. The extract thus obtained is poured into small ster- ilized bottles and will keep for a consid- erable time. Of the extracts containing 20 per cent, of the thyroid gland, 1 drachm per week may be given, and of the thyroid glands themselves 1 lobe: that is, one-half of the entire gland. The latter may be administered chopped finely and cooked, or it may be macerated after chopping in a small quantity of water, and the extract thus obtained given in beef-tea without cooking. Broiled slightly, the natural juices of the thyroid are less altered when administered. A powder may be made by separating the gland from all foreign tissues and, after chopping finely, desiccating at a low temperature to avoid cooking. The objection to this method is that the powder has an unpleasant odor, which, however, may be disguised by mixing with cacao and administering in pill form; 8 pills, of ^/^ of a grain each, are given daily. This amount is nearly equivalent to one lobe of the thyroid. This powder may also be dispensed in tablets or inclosed in gelatin capsules. If small quantities have to be admin- istered, owing to antagonism on the part of the patient, etc., Murray's method may be used. The gland is cut into small pieces, and macerated in an equal amount of glycerin, the extract being obtained by pressure and filtration and administered in drop doses. The dose is four times that employed in hypodermic medication. The action of the thyroid gland is to convert the salts of iodine, which are present in the blood, into iodothyrin. It would therefore seem advantageous to administer iodothyrin in place of thyroid extracts. De Cyon (Med. News, Oct. 1, '98). Aiodine is a new preparation obtained by precipitating with tannin the iodo- albuminates: the bases and the mucous substance of the thyroid gland. Fifteen grains of aiodine correspond to one hun- 360 ANIMAL EXTRACTS. THYROID. UNTOWARD EFFECTS. dred and fifty grains of fresh, or three hundred grains of desiccated, thyroid gland. Schoerges (Nouveaux Remedes, Aug. 24, '98). New preparation, aiden, a precipitate from a solution of thyroid in normal salt by means of tannin. It contains a greater number of the extractive prin- ciples of the gland than have hitherto been obtained, as shown by experiments on animals. Jaquet (Correspondenz- blatt f. Sehweizer Aerzte; Med. News, June 10, '99). The fresh gland furnishes 20 per cent, of extract or 27 to 28 per cent, of dry powder. The powder is employed in tablet form, in the dose of Ve of a grain. A powder that will keep for a long time may be prepared in the following manner: After an aseptic removal of the glands, and removing all foreign tis- sues, pulpify and mix them with the bibcrate of soda and powdered charcoal. In this manner is obtained a dry powder, which is put in capsules, each contain- ing 1 Vs grains of the extract. This preparation, when not exposed to heat, is not altered. Vigier (Archives de Neurol., Mar., '96). A preparation that will also keep a long time is the following: Immediately after the death of the animal the gland is excised under all aseptic precautions, all extraneous tissues are removed, and the gland is powdered with boric acid. When a sufficient number have been prepared they are taken to the laboratory, cut up, and triturated with sugar and an addi- tional amount of boric acid. The sugar absorbs the juices, and the resulting mixture is almost free from liquid. This mixture is desiccated at a temperature of 86° C, and divided into small masses, which are coated with gelatin, each mass containing about 1 ^/j grains. Each lobe of the thyroid produces about 26.8 per cent, of powder; three capsules are therefore equivalent to one lobe of the gland, or the therapeutic unit. (Yvon.) The thyroid extracts prepared by the pharmaceutical chemists of the United States offer a convenient form of admin- istration. TJntoward Effects and their Preven- tion. — The dangers attending the use of thyroid preparations depend, to a degree, upon the manner in which the remedy is administered. When the pure gland is used, the j)hysiological phenomena caused by an overdose will show them- selves, — namely: a weak, rapid pulse and shortness of breath; vomiting, cardiac oppression, a feeling of tightness around the chest, vertigo, and coma. When dried powder or compressed tablets are used symptoms of ptomaine poisoning may be added to those mentioned. Too great an increase in the pulse-rate and vomiting are signs that the patient is getting too much. H. W. G. Macken- zie (Centralb. f. Nerv. Psy., July, '93). In giving thyroid preparations, the best guide is the pulse. Any consider- able quickening or palpitation should lead us to discontinue the drug until the cardiac action is again normal. There are no dangers in the use of the drug, provided we begin with small doses, from 1 to 2 grains of Ameri- can extracts, and gradually increase, watching the pulse. It should never be given to a patient who cannot be closely watched. R. C. Cabot (Med. News, Sept. 12, '96). Case in which a man took for obesity nearly 1000 5-grain tablets of thyroid extract within five weeks. After the first three weeks he began rapidly to develop the symptoms of acute Graves's disease. When thyroid was stopped and patient was put upon arsenic all the symptoms disappeared quickly, excepting the eye changes and the goitre, which were still notable for about six months. A. V. Notthaft (Centralb. f. innere Med., Apr. 16, '98). ANIMAL EXTRACTS. THYKOID. UNTOWARD EFFECTS. 361 Among the less active symptoms are anorexia, diarrhoea, malaise, lassitude, and pain in the extremities; headache, increase of urine, rise of temperature, various eruptions, urticaria, transient and papular erythema and eczema, and, in some eases, nervous manifestations: neuralgia, delirium, convulsions, delir- ixim of persecution, aphasia, monoplegia, etc. Some of the discomforts of treatment are a feeling of tightness in the chest, with itching, burning, and otlier ab- normal sensations in the skin, and a sense of Aveakness. G. Stewart (Practi- tioner, July, '93). Thyroid powder, when given subeu- taneously, also produces a rise of tem- perature. It is a pyrogenic agent. This action of the thyroid shows that we should be careful in its administration to persons affected with heart disease. Isaac Ott (Med. Bull., Oct., '97). The drug is badly tolerated by general paralytic and tuberculous patients, still worse by patients over 60 years of age, and worst of all by fat patients, espe- cially those in whom there is reason to suspect fatty degeneration of the heart. C. C. Easterbrook (Lancet, Aug. 27, '98). Among the early warnings obtainable when large doses are being administered is undue loss of weight. Loss of weight is an early sign of im- provement, which sometimes goes beyond the requirements of health. Rise of tem- perature and pulse, increase of urine, faintness, headache, prostration, cardiac weakness, and neuralgic pains have been observed during treatment. J. J. Put- nam (Amer. Jour. Med. Sci., Aug., '93). It is a powerful remedy, and must be used with caution. A daily dose or one every second day may be sufficient. One-half to 1 grain to children and 5 to 10 grains to adults personally given. J. H. Musser (Inter. Med. Mag., Nov., 1900). When the preparation of thyroid first employed tends to give rise to untoward effects, a change of preparation is some- times suffi-cient. Case in which the glycerin extract of thyroid could not be taken, even in small doseSj without the production of very distressing symptoms, while the powdered extract was well borne. J. M. Anders (Med. News, June 12, '97). If even then the preparations are not borne, portions of the gland or glandular extract may be administered by the rec- tum. The extract, as shown by Lepine, can also be injected into the rectum. According to Mackenzie, inunctions of a thyroidin ointment prepared as shown below may be employed. When patients cannot bear even very small doses of thyroid, twice a day, after hot sponging and vigorous rubbing, the body is well anointed with the following mixture: — • B Thyroidin, 10 parts. Ether, 60 parts. Lanolin, 480 parts. — M. A rise of temperature of one degree followed the Inunction. The process was well borne and followed by satisfactory results. E. Blake (Prov. Med. Jour., Sept, 1, '94). Arsenical preparations antagonize thy- roidal intoxication through the energetic restraining influences of arsenic upon oxidation processes. They diminish the palpitation of the heart without in any Avay interfering with the other good in- fluences of the thyroid gland. Experi- ments upon dogs and rabbits to which were administered thyroid gland and Fowler's solution and several cases showed that it was possible to push the thyroid gland in ascending doses more rapidly and with better effect when arsenic was given than without it. Ma- bille (Les Nouveaux Remedes, May 8, '99). Mabille's observation confirmed that arsenic obviates the unpleasant symptom excited by thyroid preparations. In 5 cases of idiopathic goitre, in a case of obesity, and 1 of infantile myxoedema, iodothyrin was given in progressive doses 362 ANIMAL EXTRACTS. THYROID. UNTOWARD EFFECTS. of from 3 Vb to 30 or 38 V2 grains daily. At the same time arsenic was given, either in pills or as Fowler's solution, in doses increasing proportionately to the iodothyrin of Voi to Vio or even Vs grain daily. The results fully confirmed Ma- bille's experience, for, though the 7 cases took respectively 231, 111, 86, 320, 108, 296, and 125 iodothyrin tabloids, con- taining nearly 4 grains each, beyond oc- casional increased frequency of the pulse no symptoms of thyroidism appeared, so that the course could be continued unin- terruptedly. Arsenic, therefore, appears to suppress thyroidism with greater cer- tainty than atropine does iodism, and it is now possible to giv'e iodothyrin safely in doses and for a period capable of producing definite therapeutic effects. Ewald (Die Therapie der Gegenwart, Sept., '99, and Med. Review, Dec, '99). As noted in cases treated by Stabel, thyroid gland is likely to canse gastric disturbance most frequently during warm weather. He found that this could be avoided by preserving the glands or their preparations on ice, when th€y were not to be used at once. According to Lanz, the danger con- sists more in the extreme alterability of the products than in the toxicity of their active principles. A series of experi- ments showed that 9 grains of the English thyroidin, dried by the ordinary procedures, gave rise to tachycardia, whereas the absorption of from 5 drachms to 1 ounce of raw fresh thy- roid gland did not give rise to any disturbance. Examination of pastilles, tablets, tabloids, capsules, etc., revealed bacteria, including even the septic vib- rio, ptomaines, etc. Gastric digestion, as shown by Howitz, in no way modifies the properties of the glands. Maurange has obtained a peptone which can be kept indefinitely either in the dry state or in a syrupy condition with the addition of an equal quantity of glycerin and alcohol. It may be given in wine or sweetmeats contain- ing 50 per cent, of sugar. The author has used these peptones, named by him peptothyroidin, peptovarin, peptomedul- lin, etc., for fifteen months and though still very imperfect and prepared only as needed, they have been perfectly tole- rated even by confirmed dyspeptics. As to the use of any of the active principles described, clinical results have not sufficiently sustained the theoretical views concerning their actual worth to warrant a wholesale recommendation of them. Again, physiological investiga- tions have seemed to suggest that their influence upon general metabolism is dif- ferent from that exercised by the com- plete gland. Still, in a few instances, excellent results have been obtained from them and further study will doubtless make it possible to isolate an active prin- ciple devoid of useless and perhaps harm- ful elements. For the present, therefore, the gland itself or prepared in desiccated powder or capsule or in compressed tab- let should only be employed. A promising agent is Eobert Hutch- inson's colloid. Here, however, the in- ert extractives removed are mere foreign bodies, the colloid itself being a compos- ite proteid containing various active ele- ments, including, probabl_y, Baumann's thyroidin. We are not dealing, there- fore, with an active principle per se, but, in reality, with the active part of the gland. The advantages claimed for col- loid are: 1. A constancy of dose is in- sured. The quantity of colloid in differ- ent glands varies considerably; hence the amount of active substance in dried preparations of the whole gland is really not constant. 2. The drug is quite pure. 3. The pure colloid is free from taste and odor, and keeps indefinitely. 4. A very small dose is required. 5. The col- loid is absorbed with great ease and ra- ANIJIAL EXTRACTS. THYROID. THERAPEUTICS. 363 pidity. 6. The administration of the col- \ loid matter is really the most economical way of giving the thyroid. There is no waste of active material, as occurs in the preparations of thyroidin. Therapeutics. — The diseases in which thyroid gland and its preparations are utilized are so numerous that a general review of the results obtained would af- ford hut little information. The various disorders, including the clinical data collated upon each, are therefore pre- sented separately, and in alphabetical order. The thyroid extract is a powerful al- terative. Its use is likely to be of service, however, only in those diseases which are in some way related to par- tial or total suspension of the thyroid function. Its action is almost specific in mj'xoedema, sporadic cretinism, and the cachexia which follows the e.xtirpa- tion of the thyroid gland. Its use in insanity is in some degree justified rationally on the ground that in that disease altered glandular action and disordered metabolism are almost uni- versally found. Thyroid is a constant ingredient in antifat remedies, and M. Porges has made extensive experimentation in this regard. He finds that the majority of eases show no improvement whatever, while the few, and those are those cases which readily show the physiolog- ical action of the remedy, experience some benefit. He thinks that in these cases the fatness, in some measure at least, is due to the defective action of the thyroid gland, and hence the ex- hibition of the thyroid extract is highly rational. On the whole, he condemns its use in this class of patients, as the benefits derived are not worth the haz- ard undergone while taking the treat- ment. It has been tried in many forms of skin diseases, both internally and as a local application. The results reported are variable. Scleroderma, psoriasis, eczema, and ichthyosis are said to do well occasionalh', and of late very en- couraging reports of it have been noted in st'ubborn eases of diffuse eczema. Externally, it has been tried in various forms of chronic ulcer, but the reports of results have not been such as to show that it had any special value for this purpose. De Lace reports a case of severe purpura in which thyroid eft'ected a complete cure. As an emmenagogue it has repeatedly succeeded when other means had failed, but, when given for this purpose solely, it seems to be useless. In cases of in- sanity where the menstrual function was in abeyance, when the remedy ameliorated the patient's general mental and physical condition, return of the menses was among the other signs of improvement, but in no case was men- struation re-established as the only apparent result of the treatment. In exophthalmic goitre, with or without mental symptoms, it seems to be posi- tively harmful. Hiram Elliott (Brook- lyn Med. Jour., April, 1901). Arrested Growth. • — In the treat- ment of dwarfing thyroid extract has been found to be of great value, whether the condition be associated with idiocy or not. The observations of Virchow, in 1883 — to the effect that rachitis, cretin- ism, and dwarfing were dependent upon disease of the thyroid gland, fully sup- ported by experiments showing that thy- roid feeding was capable of restoring normal growth when the latter had been arrested by thyroidectomy — pointed dis- tinctly to thyroid as a valuable remedial agent. More recent experiments have further sustained this view and shown that the leanness attending rapid growth in yoitths could be attributed to an ex- aggerated activity of the thyroid gland. Effect of thyroid in children and youths who, although not cretins, were backward in growth. In 6 of these cases, in which the arrest of growth was due either to chronic albuminuria (2), rickets (2), masturbation (1), or congenital de- bility ( 1 ) , there was a renewal of active growth, — in some very considerable. E. Hertoghe (Bull, de I'Acad. Royale de Med. de Belgique, '9.5). 364 ANIMAL EXTKACTS. THYROID. CRETINISM. In three cases of myxcedematous idiots, aged from 14 to 30 years, the striking points were growth and a loss of weight. In three other cases of obesity in idiots the growth under treatment was pro- portionately more in four, five, or six months than the average growth of the eigliteen untreated imbeciles or epileptics during their tenth, eleventh, and twelfth years, which were taken as more nearly approaching normal children to control these experiments. Bourneville (Progres M«d., Feb. 1, '96). The rate and amount of the increase in height is in inverse ratio to the age of the patient and to the stage of the treatment. Thus, children grow more than adolescents, and adolescents more than adults; the rate of growth is at first very rapid, but becomes slower as the height approaches that of the nor- mal for the age. John Thomson (Brit. Med. Jour., ii, 615, '96). Number of recorded examples of dwarf- ing associated with atrophy of the thy- roid gland cited. Experiments on ani- mals corroborate the idea of a direct connection between the tAvo conditions. Four cases in which thyroid treatment was resorted to to overcome dwarfing in children, in which normal height was reached. J. J. Schmidt (Therap. Woch., Nov. 15, '96). In nine cases, including four idiots, large doses of sheep's thyroid (half a lobe every day or every second day) given. The way most of them gained in height was most remarkable. In one the gain amounted to 2 Vs inches in five months. Eoullenger (Pediatrics, Mar. 15, '97). Case of cretinism in which patient was 30 years of age, and resembled a child of 7 or 8 years as to height. Under thyroid extract improvement was marked, in 2 V: years the increase in height being 7 centimetres. W. Sinkler (Phila. Med. Jour., May 7, '98). Cretinism. — Clinical and experimen- tal evidence have demonstrated that ah- sence or impotence of the th^Toid gland, as a result of insuffieient development, removal, or neoplastic overgrowth, leads to a general condition at least closely allied to that witnessed in cretinism, while symptoms of myxoedema are pre- eminent in the majority of cases. That much was expected from thyroid as a remedial agent need hardly be empha- sized. It may be said that the hopes enter- tained have been fully realized. The mental condition is greatly improved and the stunted growth is counteracted. As the patient approaches the height normal to his age the growth continues at the normal ratio. The myxoedema- tous symptoms are rapidly removed, the abnormal appearance being thus in great part corrected. If begun early in the disease and continued systematically, the , treatment seems capable of finally re- storing the patient to a comparatively normal condition. In a recent paper Osier was able to collect sixty cases of sporadic cretinism which had been observed in America, demonstrating that the disease is not limited to European countries, as thought by many. Case of cretinism in which mental as well as physical condition improved. Immediately upon the exhibition of the remedy and at the close of the first week a decided decrease in weight was ob- served. At the end of the first two months he had lost twenty-two pounds and gained over an inch in height. Gen- eral condition, physical as well as mental, has considerably improved. H. H. Vinke (Med. News, Mar. 21, '96). Cretin child under treatment by thy- roid about two years in an intermittent and rather unsatisfactory manner, af- forded clear proof of the value and potency of the treatment. Every time it was begun the child underwent a rapid and striking improvement; every time the treatment was neglected the child relapsed into its former cretinoid appear- ance, although it never became so bad as it was at first. Finlayson (Glasgow Med. Jour., May, '96). ANIMAL EXTRACTS. THYROID. CRETINISM. 365 Table of Published Cases of Cretinism Treated by Thyroid Administration. Found in Literature up to May 1, 1896, by Fieflerick Peterson and Pearce Bailey (Pediatrics, May 1, '96). Author and Reference. Symptoms. 2 H D Ed Character OF Treatment. Results. Robin. Lyon Med., 1892, Ixx, p. 405. F. 7 yrs. Con- genital. Characteristic. Unable to walk or talk. Not stated. Extract fol- lowed by implantation. Complete change in ap- pearance. Walks. Carinicliael. Lancet. 1893, i, p. 580. F. 8K yrs. Con- genital (?). Characteristic appearance. Intelligence limited. Unable to walk or talk. 9 mos. Hyp. inject, of extract and feeding of raw gland. Skin became normal. Learned to walk and run. Intelligence im- proved. Evans. Br. Med. Jour., 1893, i, p. 767. M. 8 yrs. Not stated. Not stated. 6 weeks. One lobe of sheep's thyroid twice a week. No improvement. Hellier. Lancet. 1893, ii, p. 1117. F. 2^3 yi's. 1-2 yrs. Characteristic appearance. Unable to walk or talk. Idiotic. i]4 mos. Extract. CEdematous symptoms gone. More intelli- gent. Cannot walk or talk. lAinn. Br. Med. Jour., 1893, p. 1273. F. 26 yrs. Not stated. Idiotic. No other details. Not stated. Not stated. Became relatively in- telligent and men- struation was re- sumed. Ord. Lancet. 1893, ii, p. 1113. F. 6% yrs. Con- genital Characteristic appearance. Could not walk or talk. 8 mos. Had been grafted previously with temporary benefit. Raw gland and extract. Great improvement. Learned to walk in three months. Can talk. Ibid. M. 3 yrs. Con- genital Could not talk. Always dwarfed and bow-legged. Skin dry. 8 mos. Raw gland, dried gland, and extract. Marked. Learned to talk. Growing rap- idly. Ibid. M. 9inos. Not stated. Typical. Improved rapidly, but died of intercurrent diphtheria. Ibid. M. 9Myrs. In infancy. Characteristic physically, but intelligent. Height, 34 in. Could walk. 8 mos. Compressed extract. Grew 1)4 inches in four months. Improve- ment in other respects not so marked. F. 26 yrs. In infancy. Characteristic. Tabloids. Injprovement. Br Med. Jour., 1893. p. 1273. Height, 40J^ in. Patterson. Lancet. 1893, ii, p. 11 16. M. 19 mos. 12 mos. (V). Char.acteristic. 8 mos. Extract. CEdematous symptoms gone. Can stand. Learning to talk. Has sixteen teeth. Veinieliren. Dent. med. Wodi.. 1893, ji. 2.58. F. 29 yrs. 24 yrs. Characteristic. 3 weeks. Thyroidin. Marked improvement. Wood F. lyr. 11 mos. 1 mo. Had been grafted. Raw gland. One month's feeding without benefit. Anst. Med.Jr., 1893, p. 166. 366 ANIMAL EXTRACTS. THYROID. CRETINISM. Table of Published Cases of Cretinism Treated by Thyroid Administration. { Continued. ) Author and Reference. Character of Treatment. Rehn. Ver. der XII Cong., 1893, p. 224. Ibid. Anson. Lancet, 1S94, i, p. 1063. Bramwell. Br. Med. Jour., 1894, i, p. 6. Coniby. Med. Enfant., 1894, i, p. 578. Crary. Am. Journal Meel. Sciences, 1894, p. 529. Garrod, Br. Med. Jour., 1894, ii, p. 1112. Lendou. Aust. M. Gaz. 1894, p. 154. Korthrup. N. Y. Medical Jour., 1894, 60, p. 505. Osier. N. Y. Medical Jour., 1894, 60, p. 505. Railton. Br. Med. Jour. 1894, i, p. 1180. m yrs. 6% yrs. 16}^ yrs. 5 yrs. 12 yrs. 3 yrs. Con- genital. Characteristic. Characteristic. Cliaracteristic appearance. Could walk clumsily. Mental process slow. Typical. Idiotic. Height, 29M in- Characteristic appearance. Cainiot walli or talk. Dwarfed, lor- dosis, impaired intelligence. Characteristic. Heiglit, 32 in. Weight, 25 lbs. Loss of sphincteric control. Height. 3 ft., 3% in. Growth in six years only 2^ in. Characteristic. Characteristic. Could not walk or talk. Characteristic. Idiotic. Height, 33 in. 2}^ mos. Raw gland and glycerin extract. Raw gland. Hypodermic injections of extract. 9 mos. Not stated. 80 days. Extract. Not stated. Not stated. Treatment not systematically carried out. 11 mos. Raw gland and tahlo.ds. Marked improvement. Marked improvement. CEdematous symptoms gone. Intelligence improved. Grew 4 in. (For three years pre- viously lia'd grown only 2 inches.) (Edematous symptoms disappeared. More intelligent. Grew 6^ inches. Great improvement mentally and physic- ally. Improveme n t — then fever, bronchitis, and death. Grew 4% inches. Much improved. Results not marked. CEdematous symptoms all disappeared. Walks and talks. Grew 4 inches. No material gain. CEdematous symptoms d.sappeared. Cannot ta.k well. Grew 3 inches. ANIMAL EXTEACTS. THYROID. CEETINISM. 367 Table of Published Cases of Cretinism Treated by Thyroid Administration. {Concluded.) Author AND Reference. a to Age at Beginning OP Treatment. Symptom.s. Character OF Treatment. Results. Smith. Br. Med. Jour., 1894, i, p. 1178. M. 9 yrs. 7 yrs. Not a severe case. 9 mos. Raw gland and tabloids. Improvement. Thomson. Edin. Medical Jour., 1894, Feb., p. 720. M. 18 yrs. 16 yrs. Characteristic. Mind that of a child of 3 years. Height, 331^ in. Waddling gait. 12 mos. Raw gland. Some toxic symptoms. Skin grew softer and mind became brighter. Grew 4^ inches. Most im- provement at first. Esclierich. Wien. med. Woch., 1895, p. 350. F. 6M y>-s. m yrs. Myxoedema- tous symptoms not marked. "A backward child." 6 mos. Raw glaud of calf. Grew 13 centimetres. Lebreton. Gaz. Med. de Paris, 1895, No. 1, p. 8. M. 13 yrs. 12 yrs. Characteristic. Idiotic. Not stated. Raw gland, sligTitly browned. Dentition appeared. Growth resumed. Nothing said of intel- ligence. Lebreton. Gaz. Med. de Paris, 1895. No. 3, p. 31. M. 3 yrs. lyr. Cliaracteristic. 1 yr. Dried gland. Improved. Sinkler. Int. Medical Mag., 1894-'95, iii, p. 785. F. 4 yrs. S]4 yrs. Characteristic. Unable to walk, talk, or understand. Height, 301^ in. 3 mos. Extract. OEdematous symptoms mostly disappeared. Became more intel- ligent and began to talk. Grew 214 inches. West. Arch, of Ped., 1895, p. 348. F. 17 mos. Con- genital. Stupid. Height, 2314 in. Weight, 14J^ lbs. No teeth. 6 mos. Desiccated extract. Glycerin extract. CEdematous symptoms disappeared. Eight teeth. Grew 4 inches. Intelligent. Fruitnight. Arch, of Ped., 1896, p. 143. M. 4 yrs. 3 yrs. Cannot walk or talk. Height, 25 in. Weight, 16K lbs. Imo. Dried gland. Grew thinner and more intelligent. Noyes. N. Y. Medical Jour., 1896, 68, p. 334. F. 2 yrs. 1 yr., 10 inos. Characteristic. Height, 24 in. 4K mos. Tablets. CEdematous symptoms gone. Intelligence improves. Begun to creep. Grew 8 inches. Parker. Br. Med. Jour., 1896, i, p. 333. F. 6J^ yrs. Con- genital Typical. 12 mos. Tabloids. CEdematous symptoms disappeared. Learned to walk. Did not learn to talk. F Peterson M. 18 mos. (?) 10 mos. One grain extract daily. Probably cured. and P. Baile.v, Ped.,Mayl,'96. Jbid. F. 15 yrs. (?) 3 mos. One giain extract daily. Great improvement. Vinke. Med. News, 1896, 68, p. 309. M. 6 yrs. Con- genital. Characteristic appearance. Can walk and talk a little. 5 mos. Tablets. Marked improvement in all symptoms. 368 ANIMAL EXTRACTS. THYROID. CRETINISM. Case of a cretiiij nearly 18 years old, so stunted as to be easily mistaken for a child aged 2 or 3 years; she could not stand or walk or speak. On October 15th she began taking half of a 5-grain thyroid tabloid daily, and within the first week she became much brighter and quicker in noticing things; she also lost one and three-fourths pounds. During the second week she lost two pounds more; made very ill, hot, feverish, rest- and three-fourths inches in the first year of treatment^ four and one-fourth inches in the second year, and two and one-half inches in the third year. In two adult cretins, 36 and 39 years of age, the growth in one was three-fourths of an inch and five-eighths of an inch in the first and second years, and none in the third. J. Thomson (Brit. Med. Jour., vol. ii, p. 618, '96). Cretins whose bones show signs of Case of typical sporadic cretinism. Appearance Avheu treatment was begun. After eighteen months' treatment he had grown nine inches and the mental condition had improved correspondingly. ( Vinke. ) less, parched, and thirsty. During the third week she lost one and one-half pounds more, and became still brighter and quicker. Both physical and mental improvement during the first six months. W. Rushton Parker (Brit. Med. Jour., June 27, '96). Case of a child, 5 years of age, seven inches below the normal height at the beginning of treatment, who grew five softening should be kept lying down as they would be in ordinary rickets. Victor Horsley (Brit. Med. Jour., Sept. 25, '96). During thyroid treatment the rapid growth of the skeleton leads to a soft- ened condition of the bones, which re- sults in a yielding and bending of those which have to bear weight; as cretins under treatment become more active and inclined to run about, this tendency to ANIMAL EXTRACTS. THYROID. CRETINISM. 369 bending has to be guarded against. If any bending of the bones of the legs appears, the child should not be allowed to walk for a time, or the legs should be supported by light splints. The diet should be generous, and the child should get plenty of sunlight and open air. The administration of codliver-oil and Par- rish's food would probably prove bene- ficial at the same time. T. Telford- Smith (Lancet, Oct. 2, '97). Case in which all the symptoms of in- fantile myxoedema were present: idiocy, tins. M. H. Fussell (Med. and Surg. Reporter, Feb. 20, '97). Three cases in two brothers and sis- ter. The two older marked cretins, tlie younger being quite a typical case, ■while the baby has the cretinoid tend- ency well marked. Thyroid treatment instituted. The baby's present condition is quite that of a normal child. The cases of the two older are less promising as to final results, although they have shown improvement in many ways. C. S. Caverly (Med. Record, Apr. 10, '97). I ^£ ^C' - 1 Li 1 Fig. 1 Fis. 2. Cretin nearly 18 years of age. Fig. 1. Before treatment. Fig. 2. Sis months after treatment by thyroid extract. {Ruslitnn Parker.) dwarfism, absence of the thyroid gland, retarded dentition, pachydermic denti- tion, etc. Effects of thyroid treatment remarkable. Suspension of treatment: reappearance of almost all symptoms. Treatment was resumed and child trans- formed physically and intellectually. Rourneville (Le Prog. Med., Mar. 6, '97). Three cases improved markedly after taking thyroid three times a day in 1-graJn doses; they could be classed with those mentioned by Horsley as being ■bom with but few, if any, signs of the ■disease, and who gradually become cre- 1—24 Four cases of cretinoid myxcedema in which thyroid extract in small doses (2 V:: grains twice a week) was used with success. It is a great deal better to begin with small doses two or three times a week, even if the desired results are obtained more slowly, than to deluge the patient with it. J. C. Shaw (Brook- lyn Med. Jour., -Jan.. '97). Case of a child, nearly 8 years old, typical of cretinism, put under desic- cated thyroid 1 'A grains t. i. d., but, the remedy being administered irregu- larly, the patient was taken into a hos- 370 ANIMAL EXTRACTS. THYROID. CRETINISM. pital. It was then found that 6 grains daily was her maximum dose, and on this amount she very rapidly improved. At the end of four months (seven from the beginning of treatment) she had gained four inches in height, four pounds in weight, and had begun to act like a normal child. Dickson L. Moore (Colum- bus Med. Jour., Apr. 13, '97). Case of advanced cretinism in Hindoo boy treated by thyroid extract. Thyroid treatment was begun by administration as the thyroid extract. After a fort- night signs of the reflex returned; pa- tient became much stronger on his legs. H. E. Drake-Brockman (Lancet, Oct. 2, '97). 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-graiD tabloid of thyroid extract (Burroughs, Wellcome & Co.) daily, which raised the temperature to 102° F. ; dose reduced to Case of cretinism. Result of four months' treatment. Growth, 4 inches, approaching normal. (Moore.) of 3 grains of the dry extract by the mouth daily. Thyroid enlargement di- minished fully two inches in the space of one month; the lad, both physically and mentally, had shown marked im- provement. Dose increased to 5 grains daily. Marked and steady improvement continued, but marked absence of patel- lar reflex: a prominent symptom in tabes dorsalis, in which Brown-Sfiquard has used orchitie fluid. Administered to patient 5 grains of didymin daily, as well one-half. Gradual improvement. Weight fell at first to twenty pounds, and then slowly increased, the cretinoid aspect dis- appeared, 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). ANIMAL EXTRACTS. THYROID. CRETINISM. 371 Case of a girl, aged 10 years, who first came under observation in June, 1897, and had not previously been ti'eated with thyroid gland. She was then 9 Va years old, weighed thirty pounds, and was two feet and ten inches in height; legs short, with lordosis and prominence of the ab- domen. She was in the second standard at school. During four months of thy- roid treatment grew two and one-half inches, fatty masses disappearing from her neck. Expression lively and intelli- gent. W. S. Coleman (Brit. Med. .Jour., Nov. 13, '97). Case with numerous abscesses which healed as soon as the child was put under the thj'roid treatment. Hgemoglobin in- creased from 25 to 75 per cent., child not haying done well on the daily doses of from V4 to V2 grain of the thyroid ex- tract, this attributable not only to the small doses of the thyroid, but to the use of a bad preparation. Case, in which cold hands showed weak circulation, greatly improved when the preparation was changed. It seemed that the dose must be increased as the child grew older. These children should be kept upon the largest doses of thy- roid they will stand without having an elevation of temperature. H. Koplik (Pediatrics, Nov. 15, '97). Case of cretinism, after two years of treatment, very remarkably improved. During the first year of treatment an attempt was made to keep the child on as large a dose of the thyroid extract as possible. It was found after trial that the child did best on 1 grain a day. After nine months 1 ^U grains (Parke, Davis & Co.), twice a day. During the first year of treatment she grew eight and one-fourth inches and gained four- teen pounds: i.e., nearly doubled her weight. After she had been under treat- ment a year the thyroid was stopped, and during that time the peculiar ap- pearance of the cretin returned and she became much more stupid. She was then put back on 1 V, grains a day, and this was kept up until the first of this year. Since then she has had 1 'A grains twice a week, on alternate weeks. J. P. West (Pediatrics, Nov. 15, '97). In sporadic cretinism the fresh thyroid gland, the desiccated gland, and even the colloid substances have been found al- most equally efficacious. The preparation used should be free from decomposition- products. Half a grain of the desiccated gland may be at first given two or three times a day, the dose increased in a week or two to 1 grain, and later this may be increased if improvement is not satis- factory. If unpleasant effects result, the dose should be lessened or a fresh prepa- ration tried. A. McPhedran (Canadian Jour, of Med. and Surg., vol. iv, p. 275, '98). Mental Development Following Treat- ment with Thyroid. — The alteration in the mental condition is noticed within a couple of months. The patients look much brighter and the face is not ab- solutely expressionless. As a rule, ihe younger the case, the more marked is the mental change. Young cretins who have not learned to speak a word soon begin to talk in their play. In children between six and ten the effects are even more remarkable, and with the loss of the myxoedematous condition there is a corresponding awakening of the mental faculties. In older patients the treat- ment is not so etficacious. (Osier.) A grain of the desiccated gland three times a day in young cretins is the dose preferred by Osier, but, as already stated, its effects should be carefully watched and the amoxmt reduced if the pulse becomes more rapid or if there is fever. Older patients may take as much as 5 grains in the day, and the amount may be diminished as the symptoms indicate. Young patients bear the remedy very well, and in a few months, if no im- provement is noted, larger doses must be tried, without, however, relinquishing watchful care. 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. 372 ANIMAL EXTRACTS. THYROID. CUTANEOUS DISEASES. After undergoing the treatment at ir- regular periods during about nineteen montlis, her temperature suddenly rose to 104° ¥., 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. Medi- cation 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 one o'clock in the afternoon, she died. S. H. Friend (Med. News, Dec. 4, '97). Case of cretinism; after the age of 30 years the patient's height increased nearly three inches through the adminis- tration of thyroid (3 grains three times a day) only; menstruation, which had not appeared until the age of 26, then occurred scantily at intervals of three or four months, became regular and normal; four additional teeth were cut, and her intelligence was much improved. Whar- ton Sinkler (Phila. Med. Jour.; Alienist and Neurol., Oct., '99). Unpleasant effects are less commonly seen than in the myxcBdema of adults. After the disappearance of the myxce- dema and the establishment of the proc- esses of growth and development, a very moderate dose seems sufficient: 1 or 2 5-gTain tablets a week. Osier has noticed that an intermission for a month or six weeks does not seem to be followed by any striking change, but an intermission for a longer period is followed by symp- toms indicating a relapse. This is clearly shown in the eases quoted above. Thyroidin has proven of value and might be used instead if, for any reason, the more reliable preparations cannot be employed. Case of cretinism successfully treated with thyroidin, in a girl of 11 years, who first manifested symptoms of her condi- tion at the age of three years. Her men- tal condition was of a very low type. Two and one-half grains of thyroidin were given every other day, increased to 5, and still later to 7 'A grains every day. The improvement was rapid from the be- ginning of the treatment, growth and mental development keeping up with the general progress. C. M. Anderson (Lan- cet, Oct. 2, '97). Prevention of Cretinism. ■ — The cases observed by Gordon Paterson would tend to demonstrate that the administration of thyroid extract during pregnancy to a woman who had previously given birth to cretins would so modify her phj'sio- logical functions as to render her capable of bringing forth normal children. Treatment of a mother in her third pregnancy, from the beginning of the third month, who had given birth to two cretins in successive pregnancies. One tabloid taken every day during the re- maining seven months of the pregnancy. At no time did she suffer from any dis- comfort; on the contrary, was much better throughout than she had been in the previous pregnancies. The child was a fine, healthy female, indistinguishable from any other infant in appearance. At the age of 5 months, the infant is re- markably fine and intelligent and can sit up finely. She is now able to stand and to say several words and is 11 months old. A. Gordon Paterson (Lan- cet, Oct. 2, '97). Cutaneous Diseases. — The hopes at first entertained have been, to a great degree, dispelled by the results obtained. In psoriasis thyroid extract has not shown itself as effective as other forms of treat- ment. In lupus and leprosy indications would seem to warrant further trial. The same might be said of keloid. According to Don, who used thyroid gland with advantage in cases of ichthy- osis, there is no doubt that it is strongly stimulating by directly increasing the cutaneous circulation, as evidenced in sensations of flushing, hot tingling, and congestive irritation, frequently felt as a precursor to ordinary perspiration. The increased cutaneous vascular supply ap- parently results in: 1. Increased nutri- AXIMAL EXTRACTS. THYROID. PSORIASIS. 373 tion of the skin; hence its probable re- medial action in ichthj'otic conditions: an effect produced without any necessary abnormal perspiration. 2. Increased ac- tion of the cutaneous glands, accelerating excretion of waste-products, thus keep- ing the surface in a supple condition. 3. Eegrowth of hair, as shown in myxoe- dema and some cases of general alopecia. 4. Increased activity of the epidermal layers, cavising desquamation of un- healthy epidermis and reproduction of a new covering, as observed in ichthyosis, psoriasis, dry chronic eczema, and also in some cases of myxoedema and cretinism. In other diseases, however, in which the remedy was employed the results have been such as not to warrant fur- ther trial. Indeed, the untoward effects sometimes attending its administration and the imcertainty of the results have caused many dermatologists to abandon its use altogether. 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 (Arehiv f. Dermat. u. Syph., B. 37, H. 3, "96). The thyroid extract has certain!}' no specific action in scleroderma, as it has in myxcedema. In no case did the skin of the affected regions become softer or regain its natural appearance. In two cases the disease did not progress under its use. Two of the cases — one with tacliycardia — took it for eighteen months, and another for nineteen months, with- out any ill effects; the latter case gained weight. AV. Osier (Jour, of Gut. and Genito-Urin. Dis., Mar., '98). Curative effects observed in urticaria. The extract was being used for obesity with chronic and persistent constipa- tion. The patient for several years had been a victim of urticaria. She had been treated at various times with no results. Two hundred 5-grain tablets of the extract were taken at the rate of three per day. From the third day (eight months ago) she has not been troubled either with the constipation or the urticaria, though the obesity was not influenced. J. N. Roussel (New Orleans Med. and Surg. Jour., April, 1902). Psoriasis. — Of all the skin afEections psoriasis is the only one in which thy- roid extract seems to have proved bene- ticial in a reasonable proportion of the cases in which it was used. But at best its effects are not to be relied upon, and it should only be tried after arsenic and other standard measures have been fully tried. Four cases of psoriasis treated by thy- roid extract, in the form of pastilles. Two daily, equivalent to one thyroid gland, were given. One of the patients took thyroid gland daily. In none of the ca.ses did any improvement result from the use of the medicament. The inges- tion of a thyroid gland in one case pro- duced a febrile condition, nausea, and diarrhoea, without any manifestations of acute dermatitis. Menau (I'Encephale, June 10, '94). Results in twenty cases of psoriasis: In a very considerable proportion of cases the thyroid treatment produces a tempo- rary cure, the eruption entirely disap- pearing and the skin being left in an absolutely healthy condition. In excep- tional cases small doses produce a rapid improvement, while in others improve- ment is only produced after distinct symptoms of thyroidism. Some obstinate eases ultimately yield to very large doses, continued for a long time. Xo case should be regarded as hopeless unless thyroidism has been produced, the largest dose which the patient can take having been continiied for at least two months. In several cases the first effect of the remedy is to produce an extension of the eruption, this being most marked in cases in which the treatment is most successful. In some cases the treatment produces no effect. Relapses are not prevented. Long-standing, chronic cases are more readily cured than the more recent ones. Treatment begun with small 374 ANIMAL EXTRACTS. THYROID. LUPUS. doses and increased until distinct symp- toms of thyroidism are produced. Byrom Bramwell (Jour, of Dermatology, July, '94). Disappointed with the effect of thy- roid in psoriasis. Although some of the cases treated had been benefited in a marked manner, the majority had not. Even in the cases that had been improved equally good results, with much less dis- turbance of the patient's health, would have been achieved by the vigorous use of external remedies, such as ointments and baths. P. S. Abraham (Med. Press and Circular, Jan. 2, '95). Thyroid treatment has a limited sphere of usefulness ; unsuited for elderly patients with weak hearts. Radoliffe- Crocker (Lancet, June 8, '95). Twenty-four cases of psoriasis, eleven of which were cured and seven were im- proved by the treatment. In a few cases even tolerably large doses seemed to have hardly any effect. It does not seem at present possible to distinguish before- hand those cases of psoriasis which are benefited by the treatment from those which derive no benefit. Zum Busch (Derm. Zeit., Sept., '95). Cases successfully treated by thyroid extract. Wilson (Brit. Med. Jour., Feb. 16, '95) ; Preeee (Brit. Med. Jour., Mar. 30, '95) ; see Annual, '96. Thyroid extract used in psoriasis in six cases, in only one of which it was successful in curing the disease. H. S. Purdon (Dublin Jour. Med. Sciences, Nov. 2, '96). Case of psoriasis with insanity. The patient was depressed, suspicious, and his memory was impaired. He was put to bed and thyroid tablets, in 15-grain doses three times a day, were admin- istered. On the third day a marked change in the mental condition was ob- served. He woke up from his confused lethargy, appeared quite collected, read a newspaper, and took an interest in his surroundings. His improvement was steady. The thyroid was reduced to 5 grains a day on the eighth day, and this amount was given daily for an- other week. The psoriasis had entirely disappeared by the end of the fourth week, leaving very little scarring. He had lost sixteen pounds in weight dur- ing the treatment, but he soon regained his lost flesh. He was discharged cured two months after admission, and eight- een months later had had no return of the skin or mental affection. H. de Maine Alexander (Lancet, Dec. 8, 1900). Lupus. — In lupus vulgaris thyroid has not been extensively tried, but the bene- fit derived in a number of cases, and the unfavorable results attending other forms of treatment, warrant further investiga- tions. Large doses are required. Two cases in which thyroid extract was used : In the first, a girl aged 16 '/- years, whose disease had persisted for nine years, covering the nose, left cheek, and upper lip, and extending from each corner of the mouth to the chin, admin- istration of the extract was continued, with a few intervals, during six months. At the latter date the improvement was marked. In an intermission the disease retrograded, but improved again on the resumption of the thyroid treatment. After a year the patient was much im- proved, not cured. The second was a girl, aged 18 years, whose nose, moutn, and right eyelid were affected. Notice- able improvement was made within a month. Byrom Bramwell (Brit. Med. Jour., Apr. 14, '94). Case of lupus vulgaris treated with thyroid extract and linear scarification. Face wonderfully improved. On passing the finger over the lupus it is found to be perfectly smooth and the ulceration apparently healed. G. G. Stopford Tay- lor (Med. Press and Circular, Oct. 3, '94). Cases in which treatment by thyroid extract proved beneficial, but not cura- tive. Abraham (Brit. Jour, of Derm., Aug., '94) ; Lake (-Jour, of Laryn., Feb., '95). Fovu- eases where the results had been extremely good. P. S. Abraham (Med. Press and Circular, Jan. 2, '95). Thyroidin appears to cause local re- action somewhat resembling that caused by tuberculin. Zum Busch (Derm. Zeit., Sept., '95). Duration of treatment necessary to insure permanent cure, even with full ANIMAL EXTRACTS. THYROID. EXOPHTHALMIC GOITRE. 375 doses given regularly and continuously, not shorter than one year. The dose in lupus, as in psoriasis, requires to be larger than what is found sufficient for myxcedema. The older the patient, the more cautious ought we to be with the quantity prescribed. J. Barclay (Brit. Med. Jour., Oct. 24, '96). Two cases of lupus in which the re- sults were very successful. In both cases there was no bad symptom. The points to be noted are preliminary scraping, the gradual increase in the amount of the drug, and the large quantity taken, as much as 90 grains a day in one case. Seen eight months later: in one case there was a tiny focus in the interior of the nose, and in the other there was no return whatsoever. F. G. Proudfoot (Brit. Med. Jour., Jan. 2, '97). Leprosy. — Closely associated with lupus is leprosy, in a few eases of which thyroid gland has been tried. The re- sults, though promising, do not warrant even an estimate of its value, and it is hoped that its merits will be further in- vestigated. Tried tabloids on the Trinidad Leper Asylum patients. Results not encour- aging. The most powerful preparation of the drug had been pushed as far as safety would allow in leprosy. Bevan Rake (Med. Press and Circular, Jan. 2, '95). Two cases of leprosy treated by thy- roid gland; beneficial influence on both. Patients seen two years later and found apparently well and able to earn their living. The disease had not advanced. C. B. Maitland (Lancet, Oct. 31, '96). Keloid. ■ — Thyroid extract has caused disappearance of the hypertrophic tis- sues in a case reported by J. W. White. Case following cut in which absorbent ointments, pressure by means of plaster, and other means of local treatment hav- ing been tried to no purpose, put upon thyroid extract, from 2 to 4 tablets — each tablet containing 5 grains — being given daily. All local treatment discon- tinued, the scar covered with a film of collodion to prevent abrasion of irrita- tion and to keep up gentle pressure. In a few weeks a perceptible change noted; in six weeks the scar had, in almost its entire extent, come down to the level of the surrounding skin and the dense base had disappeared. J. W. White (Univ. Med. Mag., Aug., '95). Epilepsy. — The four cases given be- low would tend to show that thyroid gland is of no value in this disorder. Cases selected for trial those in which many congenital defects were noticeable, and in which epilepsy had been a promi- nent feature of the patient's life since early infancy. The administration of thyroid not attended with very good re- sults. While all seemed to be benefited for the time being, permanent improve- ment doubtful. Trial subjects lost from three to ten pounds in weight. The results would not seem to justify its continued use in epilepsy, and its further administration was not attempted. L. P. Clark (Med. Record, Oct. 24, '96). Exophthalmic Goithe. — In the treat- ment of this condition the various prepa- rations of thyroid have been found more harmful than beneficial in many cases. This would seem to sustain the opin- ion expressed by M. Allen Starr, that if exophthalmic goitre is due to hyper- activity of the thyroid gland — a theory first proposed in 1886, and which has gradually gained ground since then — there is every reason why the thyroid treatment should be avoided. The few cases of reported improvement from this treatment would not, in his opinion, bear critical investigation. It is probable, however, that in certain cases thyroid gland may prove of value, as shown in some of the instances re- ported below, and that we are as yet in- sufficiently informed to determine just where the remedy is applicable. It should certainly not be employed indis- criminately, and judging from a review of recent reports as a whole the condi- tion of the heart would seem to infl[uence the action of the remedy. 376 ANIMAL EXTRACTS. THYROID. EXOPHTHALMIC GOITRE. Case bj' thyroid extract, with improve- ment at first, followed later by deterio- ration. The thyroid extract was reduced, then stopped, but the patient died three weeks later. There was great prolifera- tion of the thyroid epithelium. H. Power (N. Y. Med. Record, Aug. 11, '94). Nine eases, all markedly improved. In the majority the improvement wag slow, though steady, but in only one did the exophthalmos disappear. Bogroff (Gaz. Heb. de la Russie Merid., Jan., Feb., '95). In Graves's disease thyroid treatment contra-indicated. It is possible, however, that when the goitre seems to be the primary trouble some . benefit may be derived from this agent. Senator and Mendel (Berliner klin. Woch., Feb. 3, '95). Thyroid has no favorable influence, and is, indeed, likely to increase the dis- comfort, or, where the sj'mptoms had abated, to light them up again. Stabel (Berliner klin. Woch., Feb. 3, '95). Successful ease after the use of a quarter of a lobe eaten raw twice a day. Fergusson (Brit. Med. Jour., Oct. 20, '95). Case in which 1 '/~ to 2 drachms of sheep's thyroid daily before meals, small amounts of gland daily, then omitting use for ten daj's every three weeks, caused all symptoms to disappear except slight swelling and slight exophthalmos. Voisin (La Sem. MSd., Oct. 24, '95). Cases in which the remedj' aggravated the active symptoms. Dreyfus-Brisac and Beclere (La Sem. Med., Oct. 24, '95). Three cases in which good results were obtained. Voisin (Revue de Thfirap., p. 728, '95). Patients who have been treated with thyroid extract prior to operation seem to be more liable to heart-failure both during and after this proceeding, and one or two deaths have been attributed to this cause. Angerer (Miinchener med. Woch., 21, '96). Case of woman. 40 years old, who had been treated unsuccessfully with arsenic. The action of the heart was tumultuous and the pulse-rate was 160. The tremor in the hands Avas so pronounced as to prevent the patient's continuance of work as a sewing-machine operator. The woman received from a friend 120 tablets of thvroid extract, each of 10 grains, and took six of these daily. After the lapse of three months the patient appeared almost entirely well. Slight struma was still discernible, but exophthalmos and Graefe's sign had dis- appeared; the pulse ranged from 90 to 96; the tremor in the hands was absent; and the roaring over the heart was no longer apparent. The patient herself felt perfectly well. Silex (Berliner klin. Woch., No. 6, '96). Case apparently much benefited by the administration of thyroid extract. The case had existed for a number of years, and thyroid enlargement has been quite distinct. After the thyroid extract had been given for about a week, the pulse had dropped from 110 to 80, and ever since then the patient has been much more comfortable. It was necessary, however, to take thyroid every few months. There had been no return of the enlargement except for a few days, while the patient had had a cold. Hal- lock (Jour. Nerv. and Mental Dis., June, '96). In fiftj'-one cases of exophthalmic goitre, treated by the thyroid extract, the size of the gland has been dimin- ished, but the other symptoms have not been relieved. Crary (Jour. Nerv. and Mental Dis., June, '96). Case made very much worse by the thyroid extract. Leszynsky (Jour. Nerv. and Mental Dis., June, '96). Four cases showing that, while thyroid extract has certainlj' accomplished a cure in two of the eases, the indications are strongly against its indiscriminate use in exophthalmic goitre. It acted bene- ficially in the two cases and injuriously in the two others. Its cautious exhibi- tion, in proper cases, however, is not to be discouraged. Henry L. Winter (Araer. Medieo-Surg. Bull., July 11, '96). A case of exophthalmic goitre success- fully treated by thyroidin. Owing to anorexia and nausea, was obliged to sus- pend the treatment three times, and to reduce the dose, but after about sixty days all signs of the disease had disap- peared. A year later the patient was ANIMAL EXTRACTS. THYROID. GOITRE. 377 well, cheerful, and bright, and her men- strual functions are regular. R. M. Whitefoot (Med. News, Get. 3, '96). Case of a girl of 13 years whose father had been an epileptic and whose sister had died of tubercular meningitis. Marked exophthalmos; pulse, 140; thy- roid gland perceptibly enlarged. Usual means having failed, resort had to desic- cated thyroid, 5 grains after meals. After two days considerable relief. On the ninth day the powders gave out and in two days the pain returned. After five months of treatment, exophthalmos and thyroid enlargement greatly reduced, and patient comparatively well. Kerley (Pediatrics, June 1, '97). Thyroid extract given in case of ex- ophthalmic goitre in which sudden swell- ing of the gland was so severe as to in- terfere with breathing; also in a case of acute thyroiditis. In both cases the swelling subsided and symptoms were relieved. J. Eliot (Va. Medical Semi- monthly, June 28, '98). Goitre. — In simple goitre the prepa- rations of thyroid prove effective in about two-thirds of the cases, the results rang- ing from total disappearance of the goitre to a noticeable reduction in its size. Children and young adults are benefited in the great majority of instances. A favorable result is seldom obtained in adults. Increasing doses seem to procure the most satisfactory effects. The influ- ence of the remedy is felt after the first three or four da3's in successful cases, and, in a month or so, the reduction of an average tumor will generally have been effected. In order to keep the goitre from returning, the administra- tion of the remedy must be continued, the preparation being given in reduced quantities and at longer intervals. The results have been practically the same whether fresh or desiccated glands or extract were employed. Its admin- istration should be carefully watched, however, and the dose reduced upon the appearance of any untoward symptom. Six insane patients with goitre treated surreptitiously, using raw thyroid from the sheep, 1 V2 or 1 V, drachms concealed in slices of sausage in a sandwich, re- peated in ten or fifteen days. In five cases there was an appreciable diminu- tion in the size of the goitre after each ingestion of thyroid. No untoward symptoms. Emminghaus and Reinhold (Les Nouveaux RemSdes, No. 18, '94). Nineteen patients treated with tablets, but in no case did the goitre disappear entirely. The gland sometimes became smaller, but not unless the patient was young, and the effect was only tempo- rary. Ewald (Berliner klin. Woch., Feb. 3, '95). Ninety-three patients treated partly with an extract of fresh thyroid glands of wethers and partly with thyroid tab- lets. In twenty-five cases glands of freshly slaughtered animals reduced to a pulp and mixed with water were used exclusively, the average quantity taken by a patient in a week being 5 drachms, although in some cases it rose to 9 drachms. In the hot season the patient complained of slight gastric troubles, which, however, disappeared as soon as the thyroid preparation was preserved in ice. There was only one instance in which the treatment had to be discon- tinued on account of its disagreeing with the patient. The thyroid gland regained its normal dimensions in only four of the twenty-five patients treated in this way, and in only two of these four was the good effect permanent, for the other two had a relapse after the expiration of a month. In all the other cases there was an obvious reduction in the size of the gland, and with two of the patients this was permanent, but it generally began to swell again whenever the treatment was stopped. The frequency of the pulse was a little augmented, but never so much as to make an interruption of the treatment necessary. A number of pa- tients after having taken the fresh glands for several weeks were then treated by tablets. In another series these tablets were used from the beginning of the treatment. The results were much less satisfactory. Stabel (Berliner klin. Woch., Feb. 3, '95). 378 ANIMAL EXTRACTS. THYROID. GOITRE. Sixty cases of benign parenchymatous goitre, without selection, treated with thyroid tabloids^ 2 daily to adults, 1 to children. Duration of treatment from three to four weeks, on the average. In young children complete recovery the rule. In adults recovery rare and less common in proportion to age. Complete return of thyroid to normal size not to be expected later than twentieth year. Bruns (Anier. Jour. Med. Sciences, May, '95). Warning against too sanguine views as to success of thyroid treatment. Kocher (London Lancet, July 20, '95). Cases treated by desiccated thyroids. Size rapidly reduced, though treatment not maintained for a sufficient time to establish final recovery. Remedy not free from danger if given in unlimited quan- tities and over too great a length of time. Illustrative case. E. Fletcher In- gals (Medicine, Aug., '95). Among twenty-one cases of goitre, in eleven, of from 2 to 17 years of age, there was considerable diminution, but not complete disappearance, of the tumor; in five, from 12 to 21 years of age, the amel- ioration was slight, and in five cases there was no result. Knopfelmacher (Wiener klin. Woch., Oct. 10, '95). [In a case of goitre under my care, in which thyroid tablets were given, the latter had to be discontinued on account of untoward symptoms: accelerated and weak pulse with tendency to syncope, accelerated respiration with dyspnoea, increased diuresis, and, also, pronounced anorexia, which disappeared upon the withdrawal of the thyroid extract. C. Sumner Wtthebstine, Assoc. Ed., An- nual, '96.] Nine children suflering from parenchy- matous goitre healed with Merck's tab- loids containing 5 grains of thyroidin. Children under two had from Vs to I tabloid daily during the first week, and from 1 to 2 tabloids daily afterward; older children, after the first week, as many as 4 or 5 tabloids allowed daily. Marked diminution in the size of the gland, the improvement commencing after about three days' treatment and reaching its maximum in three weeks. In all the eases treated the rapidity of the heart's action was increased; but, on the discontinuance of treatment, the action again became normal. Cautious use of the drug advised, beginning with small doses, and gradually increasing them. If the heart's action becomes irregular, suspension of treatment. Do- browsky (Arch. f. Kinderh., B. 26, '96). Seventy-eight cases treated with thy- roid. In all the cases in which the treat- ment was tolerated and continued for several weeks, diminution of the goitre was attained. Best results noticed in the soft, simple, hyperplastic goitres, espe- cially in those occurring about the age of puberty. Cystic goitres became more superficial through the atrophy of the hyperplastic tissues, and their enuclea- tion was facilitated. Angerer (Mun- chener med. Woch., p. 93, '96). Thyroid gland is best adapted for the form known as struma parenehymatosa. Definite cure is rarely observed and only in young subjects. The results are satis- factory in 63 per cent, of cases, the goitre lessening in size. In 30 per cent, of the eases the treatment is absolutely value- less. When goitre has undergone sec- ondary degenerations, such as colloid or cyst- formation, the treatment is useless. Serafine (Revue de Ther., July 15, '97). Case of weak, cachectic newborn infant presenting a marked bilobed goitre. The mother, herself goitrous, was in excellent health, but mentally weak. The treat- ment of the mother consisted in daily administration of 22 ^/j grains of thyroid body. At the end of one month and a half her goitre had almost totally dis- appeared, and in the infant the cure was complete. MossS (Revue Men. des Mai. de I'Enfance, June, '98). Thyroidism in an infant from adminis- tration of thyroid extract to the mother, a woman, aged 34, who had exophthalmic goitre. On December 24th thyroid ex- tract (two 5-grain tabloids daily) was administered to the mother. On January 1st the child had been sweating profusely for several nights. It was looking ill and was sleepless. It had vomited every morning for three days. The extract was consequently stopped for five days. The child immediately improved, and on January 4th was quite well. On the ANIAL-VL EXTRACTS. THYROID. INSANITY. 379 ninth thyroid extract was again given to the mother. The next day the child vomited, was again restless, did not look well, and sweated profusely, etc. The child was weaned and after this remained perfectly well. Byrom Bramwell (Lan- cet, Mar. 18, '99). Insanity. — It is in melancholia and the mental disorders connected with the menopause that thyroid extract finds its greatest usefulness. In recurrent mania, delusional insanity, excellent results have also been reported. MacPhail and Bruce consider its itse dangerous in cases of acute mania and melancholia where there are rapid loss of body-weight and mal- assimilation of food; also in cases where there is active phthisis or valvular disease of the heart. The profoimd effects of the drug on the circulatory system render it imperative that during treatment, and for at least a week afterward, the patient should be rigorously confined to bed. Oskr is of the opinion that the cases of insanity in which thyroid extract proved beneficial were probably cases in which there was some derangement of the thyroid gland. The pulse ran up under its influence in some cases to 160, but in none had it caused any serious results. Kinnicutt, in sustaining this view, thinks that the very fact that in a large majority of the cases the treatment is without effect, while now and then it is so strikingly successful, would indicate that in the latter the trouble was prob- ably connected with diminished or per- Terted secretion or function of the thy- roid gland. As in other disorders, the use of thyroid has to be continued after recovery to prevent relapse. In twenty-five cases internal adminis- tration of thyroid induced true febrile process; resulting action beneficial. Spe- cially useful in insanity of adolescent, climacteric, and puerperal periods, and frequently so in cases where recovery is protracted and tendency is to drift into dementia. Bruce (Jour, of Mental Science, Jan., '95). Four cases of insanity with well- marked stupor where the outlook had become unfavorable, if not hopeless. A decided reaction sought for, and the dose of thyroid regulated by the tolerance of each patient. No benefit in one case; two sufficiently benefited to be dis- charged from the asylum, and a fourth materially improved. Cell-nutrition is undoubtedly afl'ected in a striking man- ner, and increased metabolism occurs as the result of quickened circulation. The autotoxie process, so frequently present in cases of mental disease, is interfered with in a way that may be beneficial. C. K. Clark (Canadian Pract., Oct., '95). Cases of post-melancholic hebetude fol- lowing a lengthy period of depression offer the best prospect of improvement and are more or less influenced in the majority of instances. Cases of stuporous melancholia of long duration are usually improved by thy- roid. Cases which recover appear to have a special predilection to relapse. Maniacal cases Avhose attacks have been unduly prolonged give a very en- couraging prognosis. Cases of cerebral exhaustion following acute delirium or stupor whose elimina- tion of urea and other nitrogenous com- pounds is greatly reduced, offer a fair chance of improvement. Many cases of chronic mania without fixed delusions may be benefited by a course of thyroid treatment. In doubtful cases thyroid may assist in clearing up the diagnosis. It will early differentiate between true stupor and dementia. In delusional cases of a doubtful nature a course of treatment will usually show whether delusions are fixed or temporary, as the latter will vary in character or entirely disappear during treatment, while the former un- dergo no change whatever. W. L. Bab- cock (State Hosp. Bull., Utiea, K. Y., Jan., '96). The early use of the thyroid and treat- ment of forms of insanity not associated with myxoedema appears to have been 380 ANIJIAL EXTRACTS. THYROID. INSANITY. based upon observations made in the use of thyroid in other conditions, showing that a mild febrile reaction follows the employment of the gland. It was to induce this febrile reaction that first sug- gested the employment of the thyroid in non-myxoeaematous cases of insanity. Case characterized by delusions of doubt and fear, especially of fear of con- tamination, improved. Better control over most of the ideas of contamination. Case of chronic delusional insanity, violent, untidy, destructive, with rough skin and scanty hair, rapidly improved. Case of a mild case of simple melan- cholia with slight enlargement of the thyroid gland; at first more depressed, but now convalescent. Case with attacks of recurrent mani- acal excitement. At first evident eleva- tion of temperature, flushed face, free perspiration, and slight nausea. Patient practically convalescent. Two cases of chronic melancholia in men in which no improvement was mani- fest. Inclined to indorse the views of Bruce, that the thyroid undoubtedly produced a more or less feverish condition, the action and reaction to which are of con- siderable benefit to the patient. Thyroid is a direct cerebral stimulant, and there is a strong probability that at some periods of life the administration of thy- roid supplies some substances necessary to the bodily economy. E. N. Brush Jour, of Nerv. and Mental Dis., Apr., '96). One very important function of the thyroid is to stimulate brain-metabolism. We must regard the thyroid extract as containing a most potent cerebral stim- ulant which does alter, in some way, the metabolism of the nerve-centres and stimulates them in a most extraordinary manner. William Osier (Jour, of Nerv. and Mental Dis., Apr., '96). Forty cases, consisting chiefly of com- mencing senile dementia, acute mania, and melancholia, treated with thyroid. Of these, eight were unaffected by the treatment, twelve were somewhat and fourteen were much improved, five cured, and one died. The drug had an alto- gether extraordinary influence on the mental condition of the patients. Among clinical symptoms during the use of the remedy, rise of temperature and pulse- rate, gastric disturbances, increased per- spiration and quantity of urine, transient albuminuria in 10 per cent., cedema of face and extremities, cyanosis, desquama- tion of the skin^ sexual excitement, — so that masturbation in three cases necessi- tated the discontinuance of the thyroid extract, — were observed. C. G. Hill (Trans. Med. and Chir. Fac, Maryland, p. 30, '96). Thyroid treatment of great value in a form of mental disturbance occurring at the climacteric: a mental depression with anxiety and morbid fears, but with- out delusions of insomnia. Allen Starr (Amer. Jour. Med. Sci., vol. cxiv. No. 1, '97). Insane cases in which a pill containing 5 grains of fresh sheep's gland was ad- ministered daily, and subsequently in- creased to two or three according to re- sults. Besides the usual symptoms there ^^■as more or less mental or motor excite- ment in all cases no matter how de- pressed or demented the patients had been previous to the administration. In some instances there was considerable mental improvement. Berkley (Johns Hopkins Hos. Bull., July, '97). In conditions marked by inhibition of sensory, motor, and mental activity, without gross organic lesion, such as obtain in catatonia and in certain types of stuporous insanity and melancholia, we may expect beneflt from thyroid med- ication, judiciously used. Results of thyroid feeding in twenty patients. The extract, in tabloids of 5 grains each, administered. 1. Melan- cholia agitata. Four females and one male. The four females were unim- proved, the male greatly benefited. 2. Melancholia. Three females and four males. The females and all but one of the males Avere unimproved. 3. Senile dementia. One female. No improvement under treatment. 4. Chronic mania. Two females. No improvement under treatment. 5. Mental enfeeblement. One female and two males. No improvement ANIMAL EXTllACTS. THYROID. INSANITY. 381 under treatment. 6. Dementia. One female and one male. No improvement under treatment. In all cases the pulse was the first to show any change, and was most affected by the drug. Robert Cross (Edinburgh Med. Jour., Nov., '97). Results of administration of thyroid extract on the red and white corpuscles and haemoglobin in cases of anaemia as- sociated with melancholia. In 9 eases thyroid medication was employed and in 5 cases there was a marked change for the better; in the other no favorable in- fluence was noted. In 3 of the 5 in which improvement took place there was increase of weight during the treatment, and in 2 subsequently. The psycholog- ical effect was observed almost from the beginning in those in which permanent improvement took place. Samuel Bell (Phila. Med. Jour.; Brit. Med. Jour., July 9, '98). As a result of thyroid treatment in 1032 collected cases of insanity, the fol- lowing conclusions reached: 1. The dose of the extract depends entirely on the individual case. In some eases 25 gi'ains three times a day will be necessary to bring abOut a circulatory or temperature reaction, while in others the same results may- be had with the use of 5 grains t. i. d. Each case must be a law unto itself. 2. It is essential that the patient should be placed in bed to obtain the best results, and he should be continued there during the entire treatment and for a week following its discontinuance. 3. The treatment should be continued for at least thirty days. 4. We should not be discouraged by failure in the first ad- ministration, but should resort to two, three, or more trials, if necessary. 5. The most gratifying results in thyroid treatment are to be obtained in eases of acute mania and melancholia with pro- longed attacks, puerperal and climacteric insanities, stuporous states and primary dementia, particularly where these forms of mental alienation do not respond to the usual methods of treatment. 6. A high temperature reaction is not essen- tial, as the average maximum tempera- ture in the recovered cases among men was 99.6°. 7. Physical improvement is the outcome in most cases whether men- tal improvement takes place or not. 8. The proportion of individuals who re- cover under thyroid treatment and then relapse is less than the proportion that relapse after recovery from other meth- ods of treatment. In personal series of cases only one patient who recovered has relapsed. William ilabon and Warren L. Babcock (Amer. Jour, of Insanity, Oct., '99). Trial of thyroid in 130 patients whose insanity was definitely making no prog- ress toward recovery under the methods adopted in the asylum, or whose insanity was becoming chronic or incurable. Each patient was put to bed during the period of experiment, and was given a staple diet sufficient to maintain body-weight at its usual level, the administration of the extract beginning on the fifth day. The patient was weighed weekly during treatment and for a month after. The urine was regularly examined and the urea was estimated by the hypobromite method. The phosphates in the urine were determined by the uranium method. The thyroid extract was administered in 130 cases of insanity (45 males and 85 females) with the following results: T^Tiere large doses were given there fol- lowed pyrexia in most of the cases to a slight or moderate degree. Loss of weight was a constant symptom, also increased sweating, pains, and tinglings in various parts of the body, and a slight or moderate degree of exaltation, or rest- lessness. There was tachycardia in most cases, and the respirations were increased by about six per minute. Appetite and thirst increased, and in females menstru- ation was made more profuse than usual. Urea and nitrogenous products were in- creased in the urine, showing an en- hanced metabolic activity. Slight transi- tory albuminuria was found in 10 per cent, of the cases. In moderate and small doses the above results were pres- ent in a correspondingly less degree, and it was concluded that the thyroid ex- tract acted as a powerful metabolic (katabolic) stimulant. The patients in- cluded five idiots and imbeciles, seven pubescent or adolescent cases, and cases of mania, melancholia, myxoedema, alco- holic and general paralytic insanity, etc. 382 ANIMAL EXTRACTS. THYROID. MYXOEDEMA. Of a total of 130 patients, 12 recovered, 29 were improved, and 89 were unim- proved. The recoveries included 4 eases of stupor, 3 of puerperal mania, 1 of lac- tational melancholia, 1 of myxoedema, 1 of simple melancholia, and 2 of climac- teric melancholia. These patients also improved physically. The threatened attacks of foUe ciroulaire were aborted by thyroid administration. C. C. Easter- brook (Lancet, Aug. 25, 1900). Myxcedbma. — With very few excep- tions, cases of myxcedema are always attended by well-marked atrophy of the thyroid gland. That the disease is a result of the absence from the blood of the secretion of the thyroid is a logical conclusion which the use of the gland as a remedy has amply verified. Again, the fact that absence of the gland is the primary factor in the etiology of the disease also makes it plain that unless the secretion which it furnishes the sys- tem is replaced continuously the disease will recur after recovery: another fact verified by practical experience, which has shown that small doses of the gland must be administered for years if the recurrence of the myxredemic symptoms is to be prevented. As originally recommended by Mur- ray, the treatment should be divided into two stages: (1) removing the symptoms of the disease; (2) maintaining the con- dition of health attained. The first stage must be carried on gradually, and with care, as the alteration in the patient's condition is so great that, in many cases, it is not safe to bring it about rapidly. This caution applies especially to cases which show signs of cardiac or vascular degeneration. Several such patients have died of syncope brought on by overexer- tion, after the symptoms of myxoedema had been much improved. Ten to 15 minims of the extract, twice or thrice a week, may be slowly injected. If flush- ing of the face or pain in the lumbar region occur, the injection should be stopped. When taken by the mouth from the beginning, daily doses of 5 to ]5 minims two or three hours after breakfast have been found best. The changes which take place in the tem- perature, pulse, weight, appearance, and sensations of the patient are all impor- tant in governing the dose. In the sec- ond stage, the smallest dose which keeps the temperature up to the normal, or above 97° F., is sufficient. The remedy is given preferably by the mouth in this stage. AVhen cardiac disorders are present, the dose should be small and the patient kept in the recumbent position, as ad- vised by Bramwell. Two deaths, under treatment, of pa- tients with weak heart. F. Vermehren (Centralb. f. Nerv. Psy., etc., July, '93). The dose should be much smaller when cardiac disorders are present than the usual one. Complete rest in the recum- bent position should be enforced from the commencement of the treatment. B. Bramwell (Practitioner, July, '93). Effect of thyroid extract in myxoe- dema complicated by angina pectoris beneficial. No discomfort until the twelfth day, when extract discontinued. H. C. L. Morris (Lancet, Sept. 28, '95). Statistics of one hundred and sixteen cases, with absolute failure to secure im- provement in only three, show the value of the thyroid treatment. Eeports vary in regard to the degree of improvement from "cure" to "slight improvement." The latter cases, however, were few in number. (Eskridge.) Case of myxoedema placed on a diet regulated so that its different elements should be, as far as possible, the same each day. At the end of a week treat- ment with thyroid extract was begun, the diet remaining the same. During treatment the urine was increased in volume; the nitrogen excreted in the urine exceeded the total quantity of ANIMAL EXTRACTS. THYROID. MYXCEDEMA. 383 nitrogen in the food, and appeared in the urine chiefly in the form of urea. Phosphoric acid and chlorine elimination was practically unafl'ected. The body- weight was diminished rapidly and the temperature raised. Mental improve- ment in myxcedematous patients under the thyroid treatment has generally been as marked as the physical. W. M. Ord and E. White (Brit. Med. Jour., July 29, '93). Eleven cases of myxoedema treated by thyroid grafting. Improvement in six and failure in five cases. Kinnicutt (Med. Record, Oct. 7, '93). Case of a boy, about 5 years of age, who, in the early part of the treatment, took one-fourth of the thyroid gland of a sheep each twenty-four hours. Later on the gland was given him in a desic- cated form. In fourteen months the boy grew four inches: an unusual increase. At the time of the report he walked and ran about, and had gained so much men- tally that few would think him abnor- mal in this particular. Osier (Med. Record, July 21, '94). Three cases of myxoedema in which fresh thyroid gland was given. Results excellent, but temporary. If moderate doses be given, the symptoms character- istic of goitre can be made to disappear gradually. W. Pasteur (Rev. Med. de la Suisse Rom., p. 35, '94). Unmistakable improvement in three eases of myxoedema. Good results from the use of the tabloids containing, each, 5 grains of the extract. Starr (Boston Med. and Surg. Jour., Sept. 27, '94) . Two cases of myxoedema in children, one a girl 9 years old, the other a boy 12 years old, treated with glycerin ex- tract of sheep's thyroid. Improvement. Northrup (Archives of Pediatrics, Nov., '94). In a ease of congenital myxoedema treated with thyroid, diameter of red corpuscles before treatment began was 3.13 microns; after, it was 7.5 microns. Nucleated red corpuscles disappeared under treatment. Persistence of a foetal state of blood seems to coincide with a tardy development of the body. Lebre- ton and Vaquez (La France M6d. et Paris M6d., Jan. 18, '95). The treatment of acquired myxoedema in the adult is almost universally suc- cessful. When failure occurs, it is gener- ally in experienced hands or the thyroid itself is not good. For a continuous good result treatment must be maintained, but, as the action of thyroid is cumu- lative, intervals of . cessation, varying in different cases, are necessary. In winter larger doses and shorter intervals are necessary than in summer. Feeling of cold an indication to renew treatment. One grain of powder cautiously increased. Meltzer (Amer. Medico-Surg. Bull., July 1, '95). Several children suffering from myxce- dematous idiocy, in whom physical and intellectual conditions were greatly bene- fited by thyroid alimentation. Bourne- ville (Revue de Ther. Medico-Chir., Nov. 1, '95). Sixteen cases of myxoedema treated with thyroid gland, in two of which exact estimates of metabolic processes- made, metabolism of proteids found to be excessively small, proteids of food digested in a defective manner; when thyroid ingested, more nitrogen excreted, and whole metabolism improved. Ver- mehren (Univ. Med. Jour., Nov., '95). After-history of the first case of myx- osdema treated by thyroid extract. The patient, a woman aged 46, who had suf- fered from myxoedema four or five years- before the treatment was commenced in April, 1891, is still quite free from the disease. On two occasions, when the remedy was discontinued for some time,, the symptoms partly returned. She still takes 1 drachm of thyroid extract each week. C. R. Murray (Brit. Med. Jour.^ Feb. 8, '96). Series of cases, some of which had beea under continual and regular treatment, others in which the treatment by thyroid extract had been irregular and intermit- tent. The cases in which the treatment, had been continual had lost all the char- acteristic features of my.xoedema, and: could no longer be recognized as in- stances of that disease. Other cases in which the treatment had only been irregularly carried out still presented characteristic features of myxoedema. Myxoedemic patients taking thyroid 384 ANIMAL EXTRACTS. THYROID. MIDDLE-EAR DISORDERS. preparations complained of a great deal of pain in tlie baclt or limbs, and that it was worthy of consideration whether those pains might not be of a gouty nature. Thomas Harris (Brit. Med. Jour., Feb. 15/96). Priority claimed, as regards giving the thyroid* gland by the mouth, for Dr. Howitz, of Copenhagen. Polyuria, rise of temperature, insomnia, and pains in the limbs are signs warning that the remedy should be suspended. Dupaquier (New Orleans Med. Jour., Mar., '96). Case in which, after treatment by ex- tract of thyroid for six weeks, all symp- toms had disappeared and the reduction of the weight was forty pounds. This method of treatment does not influence favorably cases of ordinary obesity. All cases must be carefully studied and selected before this powerful agent is to be administered. J. M. Anders (Med. and Surg. Reporter, June 12, '97). (See Myxcedejia.) Where the total removal of the thy- roid has been practiced, Billroth observed no onset of tetany in 109 cases. Weiss found 23 per cent, among 53 cases, Roux none in 118. Eiselsberg, Schiflf, Wagner, and Horsley saw symptoms of tetany and of chronic convulsions in animals de- prived of a more or less large portion of the thyroid gland. Tetanus com- mences with trismus, and thereafter af- fects the more peripheral muscles, and is remittent, not intermittent; while tetany first affects the muscles of the extremi- ties, never beginning in the masseters, and is always of an intermittent type. Schilling (Miinchener med. Woch., Feb. 21, '99). Case of myxcedema complicated by mental symptoms in w-hich thyroid ex- tract was used Avithout effect for two months; after this marked and con- tinued improvement occurred. R. R. Deeper (Brit. Med. Jour., Jan. 27, 1900). Lactation. — In the various disorders of lactation the thyroid preparations have been found of signal service, espe- cially as galactagogues. Because of its specific action upon the mammary glands, thyroidin is of great value to women in whom lactation is im- perfect. Hertoghe (Rev. M6d-Chir. des Maladies des Femmes, June 25, '96). Thyroid extract is a valuable galac- tagogue; it stimulates the mammary secretion, w'hile it lessens functional activity of the uterus. Cheron (Revue Medico-Chir. des Mai. des Femmes, Nov. 25, Dec. 25, '96). Two cases in which deficiency of milk was counteracted by tabloids of thyroid gland. In one of these the milk became free while tablets were being taken, and failed as soon as they Avere neglected. Stawell (Intercolonial Med. Jour, of Australasia, Apr. 20, '97). Extract of thyroid gland found to be an efficient galactagogue in certain cases, and the milk secreted under this influ- ence found to be of good nutritive qual- ity. Stawell (Intercolonial Med. Jour, of Aus.; Ther. Gaz., Jan. 15, '98). Middle-Eae Disorders. — A few myxcedematous patients, suffering from deafness, having improved in hearing during the administration of thyroid ex- tract, several observers gave this drug a trial in chronic adhesive processes of the middle ear uncomplicated with myxce- dema. Various results have been ob- tained, success or non-success evidently depending in a marked way upon the degree of thickening and ankylosis that may be present. On the whole, thyroid is not of much value in aural diseases. Results obtained in a number of pa- tients in Politzer's clinic, commencing with 1 tabloid daily, and increasing them in a fortnight's time to 3 per diem. After four weeks of treatment the drug was discontinued for a week, and again resumed. No bad symptoms observed. At first marked impairment in hearing, both to loud speech and to whisper, while tuning-fork vibrations were better heard through the bone. Sixteen cases remained under treatment and observa- tion from six to eight weeks. Eight re- mained subjectively and objectively un- changed. Of the remaining eight, two showed evident improvement; four gave a satisfactory result; while in two there was a marked and continued improve- ANIMAL EXTRACTS. THYROID. MUSCULAR ATROPHY. ACROMEGALY. 385 ment in hearing. Briihl (Monat. f. Ohren., Jan., '97). Eight cases of sclerosis of the middle ear treated with thyroid tablets, about 5 grains given daily for periods varying from thirty to eighty days. In none of the cases were there any bad results, either in the ears or general system. A permanent improvement in hearing was obtained in three of the eight cases. A. Eitelberg (Archiv f. Ohren., vol. xliii. Part 1, '97). Trial of thyroidin in fourteen cases of deafness — due in eight cases to adhesive processes, in six to sclerosis. All the cases had previously undergone other treatment without success. Treatment terminated at the end of three weeks where no improvement had occurred. Nine cases showed no improvement. Two had some diminution of tinnitus. In two a marked gain in hearing was experi- enced. Morpurgo (Rev. Hebd. de Lar., Apr. 23, '98). Results arrived at by careful treat- ment, after the manner of Briihl, of 21 cases of middle-ear disease with thyroid. Duration of disease varied from one to twenty years. There were 15 cases of sclerosis, 3 of middle-ear catarrh with ossicular ankylosis, and 3 of ossicular ankylosis following suppurative disease. Nearly all the cases had already been treated in other ways. In no single case did any benefit result from the thyroid, although several cases were benefited by being treated by other methods. Mac- leod Yearsley (Jour, of Laryng., Rhin., and Otol., Sept., '98). Muscular and Osseous Dtsteo- PHIES. — Muscular Atrophy. — The fact that two cases of mtiscular atrophy were greatly improTed and reported as such by so reliahk an observer as Lepine would indicate that a portion, at least, of these cases can be benefited. Thyroid gland employed in two cases of muscular atrophy and successful re- sults obtained. In one case — a man, 44 years of age, who had suffered for eight years — 2 ounces daily had been admin- istered for about two months. Improve- ment had taken place in about two 1- weeks after the beginning of the treat- ment. The patient felt stronger and had been able to walk alone, which he had not been able to do for some time. L6- pine (Revue Inter, de M6d. et de Chir., Aug. 10, '96). Acromegaly. — The reports of cases of this disease treated with thyroid have been insufficient to warrant a conclusion, but it would seem probable that con- ditions due to disorders associated with myxosdema or goitre could alone be ex- pected, the osseous hypertrophy being beyond the remedial process. Case illustrating the association of acro- megaly and goitre. (G. R. Murray.) Case of acromegaly treated with dried thyroid extract in gradually increasing doses until 12 grains a day were taken, besides galvanism and tonics. Three months later she was feeling very much better, her memory had improved, and she spoke and moved more rapidly. She had lost over twenty pounds in weight, but felt stronger. General condition practically the same. The history of the case and the marked physical changes leave little doubt that it was a case of acromegaly, but certain anomalous symp- toms — such as the puffy conditions of the eyelids, which may, however, have been simply the result of anaemia, though its appearance was somewhat different: the 386 ANIMAL EXTRACTS. THYROID. OBESITY. slow speech, and the altered mental state — suggested that her condition was also associated with a loss of function of the thyroid gland. G. G. Sears (Boston Med. and Surg. Jour., July 2, '96). Case of a woman, 26 years old, who had suffered from acromegaly for upward of two years, and who for a period of five months had been treated with mixed pituitary and thyroid extracts, with great improvement. The superficial re- semblance between acromegaly and myx- ffidema seemed to justify the administra- tion of thyroid extract, especially as, in several cases of acromegaly, treatment with pituitary extract alone had failed to effect any improvement. RoUeston (Brit. Med. Jour., Apr. 17, 97). Obesity. • — The selective action on adipose tissues shown to attend the in- creased metabolism brought about by thyroid, and the decided increase in the nitrogen excretion sustain the use of this agent in obesity. The effects have been irregular, hov?ever, some patients re- sponding readily to the influence of the remedy, but others not doing so. The views of the French authors in this par- ticular perhaps afford an explanation, namely: young, vigorous, and plethoric individitals, who are good livers, receive little or no benefit from thyroid treat- ment, but are benefited by a dietetic regimen. On the other hand, fat per- sons that are pale, soft, and flabby, and inclined .to oedema, receive benefit from the ingestion of the thyroid gland. They lose weight rapidly, oxidation is in- creased, and nutrition is improved. We are again brought face to face with con- ditions showing some of the elements of myxoedema. Besides the dangers attending the use of thyroid in any case, the only source of untoward effects is the giving of large doses at first, the organs, especially the heart, being thus exposed to the effects of undue reaction. In appropriate eases the remedy is taken without trouble, and the effects soon show themselves. After a time the reduction in weight is propor- tionately smaller, and discontinuance of the treatment is followed by recurrence, in the great majority of cases, until the former weight is reached. To maintain the advantage gained, however, dieting and small doses of thyroid at longer in- tervals may be utilized with advantage. Case of obesity treated by thyroid juice, 15^/2 minims daiV, either by sub- cutaneous injection or by the mouth. In three months weight fell from 292 to 253 pounds. As soon as the treatment was discontinued the loss of flesh also ceased, and when the thyroid extract was re- sumed a daily loss of 1 "/j to 4 Vs ounces was observed, this becoming less after a time. A second case treated showed sim- ilar, but less marked, results, while in a third no effect could be noted. The in- constancy of results perhaps depended upon the different forms of obesity, upon the insufficiency of the treatment, or upon the extract used, which may not have been genuine. Charrin (La Sem. M6d., Jan. 2, '95). The thyroid gland of the sheep a spe- cific in obesity; free from danger and injurious after-effects, and the beneficial results of which appear within a few months from beginning of treatment. The sole risk is in beginning with large doses, as palpitations and fainting fits are possible until the patient is well ac- customed to the drug. Frederick Gutt- mann (Amer. Medico-Surg. Bull., May 15, '95). Case of a man who took a large quan- tity of tablets in the hope of reducing his obesity and became maniacal within a few days; oedema of the brain was found at the necropsy. Stabel (Lancet, Mar. 28, '96). In excessive obesity with tendency to weakness and anaemia, in which exercise and diet fail, thyroid extract should be tried. H. C. Wood (Univ. Med. Mag., Apr., '96). Of considerable value to reduce weight in obesity, especially in the ansemic, flabby types, and provided the relapse is ANIMAL EXTRACTS. THYROID. SYPHILIS. TETANY. 387 prevented by diet and exercise. Cabot (Medical News, Sept. 12, '96). Tabloids of the whole gland-substance , disagree in some instances, owing, no doubt, to the fatty matter they contain. Colloid tablets not prepared according to the method advocated by Dr. Hutch- inson decidedly disappointing. Of the three sorts of tabloids used, those pre- pared according to Dr. Hutchinson's process the most efficacious. P. .Jervis (Brit. Med. Jour., Oct. 2, '97). Unpleasant and even serious symptoms observed after the administration of thy- roid extracts; attributed to the presence of toxic decomposition products. By the employment of iodothyrin — an active principle of the gland — these unfavorable symptoms can be practically obviated. Used in seventeen cases of simple obesity, it brought about a reduction of Aveight without the aid of other treatment. In five cases there was diminution in Aveight after fifteen days' treatment. Lutaud (Coll. and Clin. Eec, Dec, '97). Three cases of obesity in which was used a new preparation of thyroid gland known as thyroglandin. One grain was given three times daily for a few days. Dose was then rapidly increased until 9 grains Avere taken in the course of the day. Decrease in Aveight Avas rapid and persistent in all cases and Avas unaccom- panied by the unpleasant symptoms so commonly experienced Avith other prepa- rations used for this purpose. MacLen- nan (Brit. Med. Jour., July 9, '98). The most serious disadvantage lies in the lack of permanency of its action. The most marked results are to be ob- served in the first Aveeks of the treat- ment, Avhile after a feAv months the system may become so accustomed to the remedy that the patient not only ceases to lose his superfluous avoir- dupois, but may actually regain much of the flesh lost. After cessation of the treatment there is quite com- monly a strong tendency of the body to return to its previous condition. If we wish our treatment of obesity, either by the thyroid or diet, to be permanent, Ave must insist on a continuance of abstemi- ous habits: a point on Avhich the origi- nator of the thyroid method, Yorke- Davies, lays especial stress. H. B. Wood, Jr. (Merck's Archives, July, '99). Four cases of juvenile obesity treated Avith the thyroid extract. One a boy, aged 8 years, Aveighed before treatment 131 pounds. With purgation, diet, and exercise he Avas ordered 2 '/, grains of thyroid extract three times a day, Avith a gradual increase until a 5-grain tablet Avas taken four times a day. After fourteen months' treatment he Aveighs 106 pounds and he has developed muscle to a considerable degree. I. N. Love (Jour. Amer. Med. Assoc., Apr. 21, 1900). Syphilis. — Thyroid extract has not been extensively tried in this affection, but the few cases reported would seem to indicate that it assists alteratives, mer- curials, etc., by stimulating metabolism. In a few cases thyroid extract apparently modified the syphilitic process independ- ently of the usual remedies employed. Case of syphilitic psoriasis. After five Aveeks' treatment by mercury and ar- senic there was considerable improve- ment, but this line Avas stopped and the patient placed on thyroid. In three Aveeks the disease had disappeared, leav- ing only the usual pigmentation. John Gordon (Brit. Med. Jour., Jan. 27, '94). Cases of malignant syphilis treated Avitli thyroidin: cachectics, presenting squamous, ulcerous, osseous lesions, Avhich had previously been treated in vain Avith mercurials and iodides. Thyroidin (dry extract of thyroid glands), 4 to 7 V4 grains daily, in tablets, administered, suspending specific medication. Cutane- ous and osseous lesions healed in part; even the pigmented spots of the skin Avere seen to disappear. Menzies (Brit. Med. Jour., July 7, '94). Case of severe syphilis cured by inges- tion of thyroid gland. Thirty grains progressively increased by same amount until 3 V2 drachms taken at a dose. Every second day treatment interrupted twenty-four hours. Guladze (Wratsch, No. 30, '95). Tetany. — The fact that tetany, as well as myxoedema, has not rarely been observed after extirpation of the thy- 388 ANIMAL EXTRACTS. THYROID. TORTICOLLIS. UTERINE DISORDERS. roid gland has suggested the use of this remedy. It has seemed to be of value, especially in the idiopathic tetany of children. Form following total removal of thy- roid gland a manifestation of acute myx- oedema, and due to complete arrest of thyroid secretion. Thyroid extract cura- tive. Common tetany may be due to lack of thyroid secretion. Thyroid treat- ment should be tried. Bramwell (Brit. Med. Jour., June 1, '95). Case which presented none of the symptoms of myxoedema and possessed an apparently healthy thyroid gland. Tablets, 1 to 3 daily, consisting of 4 grains of thyroidin, used for about a month; the symptoms entirely disap- peared. Four months later there had been no recurrence; hence it may be as- sumed that the cure was perfect. Max Levy-Dorn (Ther. Monat., H. 2, S. 63, '96). 1. In the idiopathic tetany of children the administration of the thyroid gland is extremely useful; it always dimin- ishes the intensity and the frequency of the attacks, and shortens the duration of the disease; it also notably hastens the arrival of the latent period which precedes recovery. 2. The treatment is well tolerated. 3. The organic exchanges, the digestive function, and diuresis are not notably influenced. 4. The circu- latory and respiratory functions are ac- complished normally. 5. In very young children, on account of their perfect tolerance, it is useful to administer the thyroid gland, raw or slightly cooked, internally. 6. With the exception of cer- tain peculiar cases, it is not necessary to suspend the treatment from time to time. 7. The daily dose is from 30 to 60 gi-ains. 8. This treatment is not op- posed to the symptomatic treatment, as it does not present any incompatibility with the methods ordinarily employed. Leone Maestro (Riforma Medica. Xo. 116, '96). ToETicoLLis. — Spasmodic torticollis would also seem to enter within the field of thvroid-gland treatment, although a single case can do but little more than suggest its further trial. Case of spasmodic torticollis in which thyroid extract was used. History of four attacks of influenza. On leaving his bed after the third attack, neuralgic pains on the right side of the neck, right shoulder, upper arm and side; slight numbness in the legs. A few days later violent attack of pain, during which his head was drawn down toward the right shoulder. These attacks became fre- quent, eventually occurring as often as three or four times in an hour. The sterno-mastoid was slightly hypertro- phied. Ordered 10-mii.im doses of thy- roid extract to be taken three times in the day: equal to about one average- sized gland. After having taken 2 drachms of the extract, the attacks be- came less frequent, and were attended with less pain, and after taking about 2 ounces of it he suffered so little in- convenience that he discontinued the treatment. On a subsequent occasion, he was kicked by a horse on the outer right thigh; great tonic muscular spasm; con- siderable shock. For two days the spasm continued unabated. Thyroid extract renewed; after taking 30 minims the spasm became gradually less, and on taking the drug for two more days it completely subsided. H. H. P. Cotton (Brit. Med. Jour., July 24, '97). Uteeine Disoedees. — Certain condi- tions influencing the genital apparatus — such as puberty, pregnancy, fibroid tumor, which cause a distinct change in the metabolism of the entire organism — very frequently cause an enlargement of the thyroid gland. Again, the deficiency of the normal thyroid secretion follow- ing thyroidectomy in myxoedema, cre- tinism, etc., is often associated with atrophic changes in the genital appa- ratus, as shown by Fisher, of Vienna. This suiSciently indicates direct associa- tion between the thyroid and the genital system to warrant careful investigation into the uses to which thyroid extract ANIMAL EXTRACTS. THYHOID. UTERINE DISORDERS. 389 might be put in the treatment of diseases of the reproductiYe tract. The deficiency of glandular substances in the economy experienced at the meno- pause seems to suggest that there is some lost principle which we may thera- peutically supply until the system has gradually become accustomed to effect the necessaiy metabolism independently. Quite recently it has been claimed that iodine salts are always present in thyroid extract, ■\\hieh may partly explain the efi'ect. Leith Napier (Brit. Gynaec. Jour., Aug., '96). The administration of thyroid extract as a palliative of uterine fibroids caused improvement, especially in cases that took the remedy longest. The mani- festations were: (a) control of the menstrual flow; (b) arrest of the growth, and, in some cases, diminution in the size and apparently softening of the tumor; (r) disappearance of pain and diminution of tenderness in the growth, and also of the sense of abdom- inal and pelvic distension, with increase in muscular and nervous energy; (d) betterment of the general nutrition, manifested at first by slight loss and then by return of flesh; improved state of the skin, hair, and nails, and in the substitution of a good color for the ap- pearance of anaemia. The nearer the growth approaches the type of pure myoma as distinct from fibromyoma, the better the ultimate result. William M. Polk (Med. News, Jan. 14, '99). 1. The thyroid gland, in addition to its general effect upon the metabolism of the body, exerts an inhibitory action upon the pelvic genital organs, and upon the uterus in particular. This ac- tion seems to be especially marked upon the epithelial elements of the endo- metrium. 2. As a result of this inhibi- tory, or vasoconstrictor, action there fol- lows a retardation of hsemorrhages from the uterine mucosa. 3. This action is directly antagonistic to that exerted upon the uterus by the ovarian secretion. 4. In cases in which this conservative influence is deficient or absent it may be restored by the ingestion of fresh thyroid gland or desiccations or extracts of that organ. 5. In gynaecology thyroid therapy is especially indicated in haemorrhagic affections of the uterus and in all forms of pelvic congestion, notably in uterine fibromata, haemorrhagic endometritis, menopausal haemorrhages, and chronic tubal diseases. 6. The best results are to be expected in fibromata and patho- logical conditions of recent development. The more chronic the case, the more re- bellious will it prove to thyroidization. 7. The thyroid influence is also found to cause an increase in the metabolism of the mammary gland, and the treatment is therefore indicated in all cases of in- sufficient lactation. W. A. Newman (Ther. Gaz., July 15, '99). So far, thyroid extract has furnished marked eyidence of its value for the pur- pose of arresting haemorrhage whether this occur in connection with abortion, the menopause, tumors, or uterine mal- positions. A remarkable case of metror- rhagia due to hfemophilia successfully treated with thyroid extract is reported by Dejace. Thyroid extract an excellent remedy in threatened abortion with haemorrhage, and is valuable in preventing the arrest of uterine involution after childbirth. Ch6i-on (Revue iledico-Chir. des Mai. des Femmes, Nov. 25, Dec. 25, '96) . Thyroid extract is particularly favor- able in cases of uterine haemorrhage. In purely functional cases the results had been a complete and lasting cure, also in the hsemorrhages of menopause or de- pendent on uterine malpositions. The growth of fibrous tumors is also checked by retrogression, and cure has followed its use early in the history of the eases. Jouin (Gyngcologie. Oct., '97). Case of hfemophilia treated by the thyroid substance. Face and mucous membrane absolutely colorless; the gums bled profusely at the least touch. The legs, arms, and the body were covered with spots of purpura. During each menstrual period the blood was dis- charged in an alarming abundance, and the menses lasted, on an average, from twelve to fourteen days. She had used all the haemostatics without avail. Thy- 390 ANIMAL EXTRACTS. THYROID. CANCER. roid substance, three capsules a day. was begun ou the 9th of October. On the I2th the menses appeared, and instead of continuing for twelve days, as before, lasted but four days and were moderate in quantity. On the 18th the loss of blood from the gums disappeared. Till the 27th the patient had had no haemor- rhage since the last menstrual period. The purpuric spots had disappeared and the gums and face had regained a rosy color. The thyroid substance exercises an action as yet unknown on the plas- ticity of the blood. M. L. Dejace (In- dependance Med., Nov. 24, '97). Case in which hasmophilic epistaxis was absolutely unaffected by ordinary therapeutic agents, and the epistaxis became so persistent and exhausting that permanent blocking of the nasal fossa was necessary. Treatment by thy- roid extract exerted an immediate and benefieial effect, and was followed by cure. In three days the violent and per- sistent epistaxis had practically stopped. In six days, about 8 gi'ains of thyroid extract having been given daily, the purpuric eruption ceased and the old spots began to disappear. Scheffler (Archives de iled. et de Pliarm. Mil, March, 1901). Cancee. — Thyroid has recently been tried in tliis afifection, hut the cases re- ported have been too few to warrant any conclusion as to its merits. Thus, D. McMcol, of Glasgow (Brit. Med. Jour., ISTov. 9, 1901), after referring to an analysis of forty-nine eases thus treated, tried thyroid extract in four personal cases, and reached the conclusion that it did not even prolong life. In our opin- ion, the concomitant use of hypoder- moclysis would have insured a better re- sult. Case of a woman who had a mammary tumor which was at first thought to be malignant. Thyroidin was given, and there was a rapid decrease in the size of the tumor, and it idtimately praeticallj' disappeared. Similar effects were observed in two cases in which there were large lyniphomata and also in three cases of marked splenic en- largement without increase of leuco- cytes. Arthur Jaenieke (Centralb. f. innere Med., Jan. 12, 1901). Case of widespread carcinoma in a woman, aged 44 years, in whom thyroid extract, in 5-grain doses varying from two to four times daily, given for six months, produced great amelioration of the symptoms. The symptoms returned, however, in spite of persistence of the treatment. P. B. Smith (Brit. Med. Jour., Feb. 16, 1901). Case of uterine cancer in which the improvement followed so quickly upon the emploj'ment of the remedy, and was so striking, that in his own mind the author has not the slightest doubt that it was entirely due to its use, and he is certain that thyroid extract should always be given a trial in this class of cases before more heroic measures are adopted. H. A. Beaver (Brit. Med. Jour., Feb. 1, 1902). The removal of the ovaries, provided they are actively functionating, fre- quently causes an arrest of the malig- nant mammary growths, and sometimes their complete cure. This action is materially aided by excision of as much as possible of the neoplasm, supple- mented by the administration of thyroid extract in full doses. In women past the menopause, the excision of these organs is not so effective, while in others relief appears within twenty-four to forty-eight hours, and in favorable cases is rapidly progressive. The dose of thj'roid extract that can be safely employed varies from 10 to 15 grains daily. Though this method should not result in perfect cure, it is the best palliative operative pro- cedure yet devised. (Borland.) Two cases in which oophorectomj' plus the administration of thyroid gland had given successful results. In one case the treatment brought about the healing of a large carcinomatous ulcer of the right breast which had recurred after two operations for removal by surgical means, and had determined the disappearance of ANIMAL EXTRACTS. THYMUS. GOITRE. 391 a large tumor in the other breast, the nature of which was shown by the en- largement of the corresponding axillary glands, which glands also had ceased to be perceptible to the touch. G. Herman (Med. Press and Circ, Apr. 22, '99). Dr. Herman's first case remains well twenty-five months after the operation and his second nine months after. Six other cases (treated by Dr. Beatson, Dr. Cheyne, and self) were disappointing failures. Perhaps thyroid was not stead- ily persisted in throughout all these cases, but it Avas given at first and would doubtless have been continued had it seemed to do good. Such facts as we have before us support (not establish) the view that oophorectomy is by far the most important factor in the treatment, and that it may be the only one. Stan- ley Body (Lancet, Apr. 29, '99). Thymus Gland. This organ having been accidentally substituted for thyroid in a case of Owen's and benefit procured, it was found to produce analogous effects in other cases. This led Svehla to under- take a series of experiments to determine its physiological action. Injected into the femoral vein, thymus extract gave rise to a fall of blood-pressure, due to weakening or paralysis of the vasocon- strictors, and increase of pulse-rate, due to direct influence on the heart. Wlien large doses were given there was excite- ment, followed by dyspnoea and collapse, ending in death, with post-mortem evi- dences of asphyxia. A certain analogy was thus shown to exist with the physi- ological action of thyroid, and this was further emphasized by the observations of Baumann, who found that the thymus contained iodine, as does thyroid, al- though in comparatively small quantities. In the urine of dogs fed with thymus gland has been found a peculiar sub- stance that has the formula approxi- mately of CsNjHjOj and which is believed possibly to be an imidopseudouric acid: that is, an oxidation-product of imido- hypoxanthin. It is also possible that It is allantoin, and this seems to agree with some of its chemical reactions. It is important as perhaps contributing to the explanation of the form of uric acid derived from nucleinic acid. Minkowski (Centralb. f. innere Med., May 14, '98). Dose. — The doses of thymus adminis- tered have been much larger than would be prudent in the case of thyroid. Of the gland proper the doses have ranged from 2 ^/j drachms to 1 ounce, given three to five times a week; while the extract has been given in doses ranging from 30 to 60 grains. Therapeutics. — Young sheep's glands should invariably be used; the glands of older sheep, having undergone fatty transformation, are, therefore, worthless. GoiTEE. — In this disease thymus seems to produce the same effects as thyroid gland, when administered in suf&ciently large doses. In fact, from the results obtained it would appear that the thymus is but a thyroid six times weaker in cura- tive activity. Three cases in which diet of thymus produced good results: 12 to 15 (3 grains) tabloids given daily. Cunning- ham (N. Y. Med. Record, June 15, '95). In the majority of the cases observed, a reduction in the size of the goitre and an amelioration or removal of unpleasant symptoms has taken place. Thymus is to be preferred to thyroid feeding. G. Reinbach (Mittheilungen aus den Grenz- gebeiten der Med. u. Chir., B. 1, H. 2). Ten cases of goitre treated with thy- mus gland, the ages ranging between 13 and 28 years. From 2 Va drachms to ^7, ounce of raw sheep-thymus were given on bread three times a week and in- creased to 7 drachms. In one case of small goitre complete recovery was ef- fected within two weeks. In six cases there was a marked reduction. In two cases there was slight improvement; one was not benefited. Mikulicz (Berliner klin. Woch., Apr. 22, '95). Thirty cases of goitre treated with thvmus extract. In twentv decided re- 392 ANIMAL EXTEACTS. THYMUS. EXOPHTHALMIC GOITRE. duetion followed, and the general symp- toms were improved. Among these were a number of cases but slightly improved or aggravated by thyroid treatment. A complete cure was obtained in but two cases. Mikulicz (Centralb. f. Chir., p. 929, '96). Exophthalmic Goitee. — In exoph- thalmic goitre improvement is reported to have been obtained in about one- half of the cases treated, but there is a striking lack of concordance between the various reports, some authors reporting series of cases in which all cases were materially benefited, others reporting failures on all sides. In a recent paper Hector Mackenzie described a series of experiments having for their object to determine the actual status of the ques- tion. He compared results obtained in 15 cases in which thymus was used by other phj'sicians to 20 cases tinder his own charge. In the 15 cases from other sources there was marked general im- provement in no less than 14; in 7 the pulse-rate was markedly diminished; in 3 there was complete and in 4 partial disappearance of exophthalmos. Of the 20 personal cases, 1 died; in 6 there was no improvement; in 13 slight im- provement. As to the pulse-rate, in 12 there was no change; in 2 it was in- creased; in 5 it was slightly and in 1 markedly diminished; but in this 1 the improvement was merely transitory. Of 20 other cases in which remedies other than thymus were employed, in 11 there was no change, in 2 slight increase, in 4 markedly and in 3 slightly dimin- ished pulse-rate; so that, from the side of the heart, there was no special bene- fit from the thymus. As to the goitre, in 3 cases there was material diminution in size, and in 3 enlargement from thy- mus. Of the 20 contrast cases: in 13 there was no change, in 4 cases more or less diminution, in 1 complete disap- pearance, and in 1 enlargement. The balance, therefore, is against the thymus treatment. As to the exophthalmos, diminution occurred in only 1 case, and this commenced before thymus was tried. In the 20 contrast cases, 3 lost the ex- ophthalmos. In the matter of general nutrition there was a slight weight in favor of the cases under treatment by thymus. Williams reported a case in which the symptoms were perceptibly aggravated and Kinnicutt, in two test- cases carefully watched, could observe no improvement. Case treated by raw sheep's thymus in doses of 2 V2 drachms to 7 drachms in gradually increasing doses about three times weekly. The subjective symptoms — the exophthalmos and tachycardia — were all diminished, but the goitre and tremor remained unchanged. Mikulicz (Berliner klin. Woch., Apr. 22, '95). Case treated with capsules of dried thyroid, continued nearly two months without any perceptible influence upon her condition or upon the secretions, urea and uric acid being quantitively exam- ined. After trying potassium bromide, nuclein, and an extract of spleen without favorable result, the patient, on July 15th, began to take capsules of dried aqueo-glycerin extract of the thymus gland, 3 a day, each of which contained 1 V: grains. On August 5th feeling much better, although there were no obvious changes in the symptoms; on September 7th she was discharged re- lieved. After having stopped the use of the thymus, in about four weeks after leaving the hospital, she was again pro- vided with capsules to take twice a day On December 6th the pulse was 92. Im- provement; swelling of the thyroid less, and patient able to work. R. T. Edes (Boston Med. and Surg. Jour., Jan. 23, '96). Case of exophthalmic goitre which, in spite of all treatment, became steadily worse. Thymus-gland medication was begun and continued with the best re- sults. The patient felt so well that, the supply of tabloids being finished, she ANIMAL EXTRACTS. THYMUS. EXOPHTHALMIC GOITRE. 393 stopped the treatment, and in a few weeks the exophthalmos was back again to a considerable extent. The tabloids were resumed, and in a short time their benefit was noticeable. N. J. McKie (Brit. Med. Jour., Mar. 14, '96). Four cases treated by thymus. It cer- tainly does improve the deranged heart- action, but it seems more pai-ticularly to lessen the gastro-intestinal symptoms and the tremor and general muscular weakness. Three of the cases had pre- sented great psychical alteration; in all of them the mental state has improved readily. A. Maude (Lancet, July 18, '96). Case of exophthalmic goitre in a girl of 22. Pulse, 156 and very irregular, both in force and frequency. Thirty grains of dried thymus in the form of tabloids given daily, and on the third day the pulse had fallen to 130 and Avas quite regular. The amount of thymus was gradually increased to 100 grains daily; at the end of three weeks the pulse had fallen to 73 and was regular. The size of the thyroid was not dimin- ished, but the exophthalmos was less marked. C. Todd (Brit. Med. Jour., July 25, '96). Three eases of exophthalmic goitre treated with thymus gland. All three were restored to health by the treat- ment. The dose of the raw gland was from half an ounce to an ounce three or four times a week. In one of the cases discontinuance of the gland was followed by relapse, but on resuming it the patient again improved. Upon one occasion a patient who always had been benefited by the treatment failed to re- spond to the glands. This was found to be due to their having been taken from full-grown sheep. On giving calves' thy- mus most urgent symptoms were at once relieved, especially dyspncea, palpitation, and tremors. David Owen (Lancet, Aug. 22, '96). Case of twenty years' duration in which ordinary remedies were tried with- out benefit. Raw thymus obtained from the lamb, in doses of 2 drachms daily for three months, caused the cardinal symptoms to disappear. The treatment was discontinued after seven months. Three months later there was a return of goitre, tachycardia, and slight exophthal- mos. He resumed the thymus, taking 'A ounce or more cf the raw gland three or four times a week. After three months the exophthalmos and goitre had quite disappeared, the pulse, instead of 120 and over, was 72. The following autumn the patient was unable to take the gland any longer, on account of its nauseating effects. At the end of three months the old disease was returning. He again resorted to the thymus, but took it for two months without any eS'ect whatever. Lambing season cor- responding to the spring, however, the failure of the glands doubtless due to the fact that the glands had been taken from older sheep than before. Calf's thy- mus tried, lamb's not being obtainable. For some time the patient was worse; but, during severe suffering he took about "A ounce of calf s thymus, and re- peated the dose in the morning. During the following week he improved remark- ably. The improvement continued dur- ing the winter, but there was a return of symptoms this summer. Now suffers from occasional palpitation, sense of weakness, and low spirits, and some prominence of the eyes. David Owen (Brit. Med. Jour., Oct. 10, '96). Case of a girl, 21 years of age, who had applied for treatment for palpitation of the heart, prominence of the eyes, and swelling in the neck, first been observed two years ago. All three symptoms were less striking than before the use of thy- mus gland, begun two months before re- port. C. E. Nammack (Med. Record, Apr. 17, '97). Improvement in six out of twelve cases of exophthalmic goitre. The goitre, ex- ophthalmos, and palpitation were im- proved, and nervousness, insomnia, and tremor very much relieved. Solomon Solis-Cohen (Amer. Jour. Med. Sciences, p. 132, '97). The best results in the treatment of exophthalmic goitre can be obtained from the joint administration of thymus and suprarenal substances. Solomon Solis-Cohen (Phila. Polyclinic, Sept. 7, '98). Marked case of Graves's disease, rebell- 394 ANIMAL EXTRACTS. SUPRARENAL EXTRACT. ious to other treatment for three years and threatening melancholia, improved in a week and practically cured in three months, with 15 to 25 grains of extract of lamb-thymus a day. The only symp- tom left was a slight enlargement of the thyroid. C. E. Boisvert (Revue Med. de Montreal, June 21, '99). Four cases of exophthalmic goitre treated with thymus extract. In two no perceptible effect was obtained. In the two others there was considerable im- provement amounting practically to a cure in one case. W. R. Parker (Brit. Med. Jour., Jan. 7, '99). From the cases narrated, there is reason to believe that furtlier use of thymus or its preparations will demonstrate that it is superior to thyroid in exophthalmic goitre, although it may not prove more ef&eaeious than the remedies usually em- ployed in the treatment of this disease. Suprarenal Extract. To try to establish the therapeutic application of suprarenal gland or its preparations upon a solid foimdation for the present would be a futile effort, physiologists having not, as yet, ivlly determined any of the purposes of the organs themselves in the human econ- omy. Quoting Horatio C. Wood (1896), "The functions of the suprarenal cap- sules still remain a mystery. This only is certain: that disease of these cap- sules is followed by a progressive asthe- nia, a peculiar bronzing of the skin, and loss of digestive power with excessive vomiting," while Stockman, referring to its secretion, wonders whether its absence leads to a toxic condition of the blood which poisons the other tissues, or whether the want of it leads directly to an atonic state of the whole muscular system. These, he thinks, are questions which, for the present, must be left open, along with many other important points, such as the origin of the pigment, etc., which are still very obscure. As previously stated, this work is in- tended to portray the prevailing viev/s of the profession, and not our own doc- trines, pending confirmation of the lat- ter. The interpretation of Auld (Brit. Med. Jour., June 3, 1899) presents, in the aggregate, the conclusions to^ which other investigators have been led: — "The available evidence goes to show that the suprarenal acts by destroying deleterious substances, and also by ftir- nishing a material to the blood. As the work seems to be done by the medulla, there is considerable ground for regard- ing the vasoconstricting substance as evi- dence of the former function." Physiological Action. — There is good ground for the belief, however, especially since the experimental investigations of Brown-Sequard, Abelous, Langlois, and Dubois, that the physiological function of the suprarenal capsules is to transform or to destroy the toxic substances which are produced in the organism under the influence of muscular activity and of the nervous system. The destruction of these organs is thought to be capable of causing in the organism an accumulation of toxic agents which is the principal cause of the sensation of extreme fatigue and of the profound and generalized asthenia experienced by patients who suffer from Addison's disease. The evidence that the suprarenal cap- sules contain a toxic substance of great activity, much more active than that of any other gland, seems quite con- clusive. Extracts made from the suprarenal glands of the calf, sheep, guinea-pig, cat, dog, and man have a similar action. Dis- eased glands from cases of Addison's disease were found by them to be inert. The active principle, whatever it is, must therefore be recognized as an ex- ceedinglj' powerful body, if we reflect ANIMAL EXTRACTS. SUPRARENAL EXTRACT. 395 that of this Vi grain about 80 per cent, io water^ and another very large pro- portion must consist of the proteids, etc., of tlie gland-substance. Oliver and Schilfer (Jour. Physiol., vol. xviii, pp. 230-276). The experiments of Dubois would tend to show tliat the toxic substance isolated is identical to muscle-toxin: e.g., orig- inating in the muscles. Being foreign to the capsules themselves, these organs would have the destruction of the toxic products as their physiological function. Several albumoses found in the capsules which in themselves seem to possess no well-marked toxic properties would, ac- cording to Dubois, possess the properties presented by the organ when used as a remedy. Suprarenal extract is much more toxic than the extracts of other glands. In- travenous injections of 30 centigrammes to 1 gramme of a 25-per-cent. solution in glycerin and water killed a rabbit of 1500 grammes in a few moments, while 6 to 12 grammes of other extracts did not produce death. The injection was followed at once by paraplegia, later by convulsions and opisthotonos. If only injected under the skin the animals sur- vived several daj's, while after death nothing but parenchymatous nephritis could be found. Immediately after each injection a very marked increase in the blood-pressure was observed. Gluzinsky (Wiener klin. Woch., '95). Toxic substance separated from the gland, soluble in alcohol, which caused death in rabbits from respiratory failure. It had no paralytic action, but seemed to act on the central nervous system. Gourfein (Bull, de I'Acad. de Med., p. 331, '95). If suprarenal bodies of the calf, sheep, or dog were injected, even in very small quantities, into a vein in a dog or a rabbit the following pronounced physi- ological effects were produced: 1. Ex- treme contraction of the arteries, which was shown to be of peripheral origin. 2. A remarkable and rapid rise of the arte- rial blood-pressure, which took place in spite of powerful cardiac inhibition, and became further augmented when the vagi were cut. 3. Central vagus stimulation so pronounced that the auricles came to a complete stand-still for a time, al- though the ventricles continued to con- tract, but with a slow, independent rhythm. 4. Great acceleration and aug- mentation of the contraction of the auricles and ventricles after section of the vagi, — the auricular augmentation being especially marked. 5. Respiration only slightly affected, becoming shal- lower. G. Oliver and E. A. Schafer (Jour, of Physiology, Apr., '95). The active principles of adrenal divided into two classes: (1) several albumoses which are precipitated Avith alcohol and redissolved in water and which when isolated have no well-marked toxic effect, but which alone possess the property of destroying toxins, especially those origi- nating in muscular tissues; (2) a class composed of bodies which resemble in their constitution and reactions the alka- loids, having a marked degree of l.oxic effect resembling muscle-toxins. Dubois (Arch, de Phys. Norm, et Path., vol. viii, p. 412, '90). The active substance contained in the medullary portion of the capsule and the activity of the extract shown to run parallel with the distinctness of certain color-reactions (e.g., a green with ferric chloride), which are due to a substance which has not yet been isolated in a pure state. Fraenkel (Wiener med. Bl., '9G). Experiments showing that after sec- tion of the medulla and extirpation of the spinal cord, the injection of suprar- enal extract is capable of prolonging life of the animal, which would otherwise quickly succumb. Strickler, in 1877, proved that extirpation of both the cer- vical and thoracic parts of the spinal cord caused instantaneous stoppage of the heart's action. Biedl (Lancet, Mar. 21, '96). The marked stimulation of the heart and arterioles is probably due to an action on their intrinsic nervous ganglia rather than to a direct action on the muscular fibres. As previously observed by Cybulski, administration of the ex- tract by the mouth or subcutaneously 396 ANIMAL EXTRACTS. SUPRARENAL EXTRACT. has very little effect on the circulation as compared to what is observed after intravenous injection. Obviouslj', the active principle is destroyed by the tis- sues. Gottlieb (Arch. f. Exper. Path. u. Pharm., B. 38, '96). Researches into the constitution of the blood-pressure-raising constituent of the suprarenal capsule showing that it is to be classed with the pyridine bases or alkaloids, and that it is not possible to split off pyrocatechin from the isolated active principle. This view is the op- posite of that of Mtihlmann, who sup- posed that the blood-pressure-raising constituent was pyrocatechin joined to some other substance, probably an acid. Abel and Crawford (Johns Hopkins Hosp. Bull., vol. viii, p. 151, '97). The extraordinary rise in the blood- pressure after intravenous injection of suprarenal extract is due to stimulation of the vasoconstrictor nerves : the centres in the brain as well as the ganglia in the blood-vessels. The suprarenal extract paralyzes the vagus nerve and the car- diac depressor. It, on the other hand, stimulates the central as well as periph- eral ends of the accelerators. The tem- porary retardation of the heart-beat is produced by the momentary stimulation of the pituitary body, which is brought about by the sudden rise of the blood- pressure in the skull. Cyon (Pflueger's Arch, of Phys., vol. Ixii, p. 370, '98). The two drugs which most promote contraction of the arteries, and in conse- quence must antagonize the dangerous fall of blood-pressure produced by chloro- form, are atropine and extract of supra- renal capsule. Extract of suprarenal cap- sule remarkably increases the rate and the force of the heart-beat. Schafer (Lancet, Feb. 5, '98). The most useful application of the suprarenal extract will be in cases of cardiac weakness and threatening col- lapse. Mankovsky (Russian Arch, of Path. Clin. Med. and Bact., Mar., '98). The medulla of suprarenal capsules contains a chromogen, possibly allied to tannin in coffee, and an active principle which chemically appears to be closely connected with piperidine. This latter has a remarkable effect upon the mus- cular tissues, generally increasing their tone, and producing, when injected in- travenously, an enormous rise in blood- pressure. Swale Vincent (Birmingham Med. Rev., vol. xliii. No. 236). Experiments of Biedl and of Gottlieb repeated. Conclusion that the use of suprarenal gland in the lower animals does much toward preventing accidents during the administration of chloroform, probably through its powerful influence on the vascular system. Minkowsky (Revue de Ther. Med.-chir.; Ther. Gaz., Dec. 15, '98). Suprarenal extract in dogs stimulates the vagus centre, thus inhibiting the heart. It produces also a direct stimula- tion of the heart-muscle, resulting, when the vagus influence is removed, in an in- crease in the force and frequency of its beat. Accompanying the heart-action there occurs a rise in the systemic blood- pressure due to the contraction of the arterioles. The pressure in the pulmo- nary arteries, however, is not raised, these vessels not being acted upon as are tlie others. Wallace and Mogt (Boston Med. and Surg. Jour., Jan. 26, '99). Epinephrin, the active principle of the adrenals and the commercial adrenalin, may practically be considered alike. Injected subcutaneously, intravenously, intraperitoneally, or into the spinal canal, epinephrin in large doses causes repeated vomiting, excitement, and gen- eral weakness, which may end in com- plete prostration, bloody diarrhoea, and death. The findings at autopsy are characteristic. Death may be caused by cardiac or respiratory paralysis or by both. The lethal dose lies between 1 and 2 milligrammes, per kilogramme, intravenously. The subcutaneous lethal dose lies between 5 and 6 milligrammes, the intraperitoneal between 0.5 and O.S milligramme. S. Amberg (Arch. In- ternat. de Pharmacodj^n., vol. xi, fase. 1 and 2, 1902). Prolonged contact of the blood with the extract does not deprive the latter of its effect on the blood-pressure. In- travenous injections of adrenalin in rab- bits in which the blood-vessels of one ear were deprived of the vasomotors showed a blanching of the ear of the ANIMAL EXTRACTS. SUPRARENAL EXTRACT. 397 operated side which lasted longer than that on the normal side. Following this the normal ear became perceptibly more congested than before the injec- tion. This seems to show that the ex- tract favors vasodilation when the cen- tral nervous influence is intact; when the latter is absent, constriction results. The authors also demonstrated that sub- cutaneous injection in the normal animal had no effect on the pupil and very little constricting effect on the blood-vessels, but when the sympathetic nerve was cut the pupil remained dilated for a considerable time, and vascular constriction also lasted for an equal period. S. J. and C. Meltzer (Amer. Med., Feb. 7, 1903). Therapeutics. — Suprarenal therapy has now exceeded thyroid therapy in far- reaching application. Indeed, supra- renal extractives seem endowed with properties which Bates summarizes by the word ''marvelous." Unlike other po- tent agents, they are devoid of pernicious, after-effects. The author just named states, for example, that, while we expect great dilatation of blood-vessels to follow powerful contraction, "in 2000 cases noted in which the suprarenal produced this contraction the expected dilatation did not occur.'"' Again, though a drug which, in minute doses, produced power- ful effects is deemed a poison, such can- not be said of pure adrenal products. "No untoward effect," he writes, "has ever followed the local or internal ad- ministration of the untainted gland. Two pounds of the fresh suprarenal cap- sule in the form of an aqueous extract has been swallowed without any apparent ill effects." Its application to the eye does not cause irritation, and it does not cause dilatation or contraction of the pupil. It is not cumulative when taken internally, and it does not possess at- tributes which involve the danger of a "habit," as do cocaine, alcohol, etc. We cannot agree with Dr. Bates when he states that no untoward effects ever follow the local use of adrenal extract. There sometimes occurs overdistension of the sinuses of the turbinals, for in- stance, as noted by Kyle and others, and secondary haemorrhage is more likely to follow its use. The extract, applied locally, reduces congestion and is of especial benefit in rhinitis and hay fever. Eye: Local ap- plication lessens congestion in conjuncti- vitis, keratitis, and iritis, and hastens the absorption of inflammatory tissue. In lacrymal stricture and abscess the writer injects a solution of the extract through the "puncta." The vascularity is rapidly diminished, and any pus present may be expressed via the canal. Ear: Locally applied to the Eustachian tube, the con- gestion is reduced and deafness and tin- nitus disappear. Its haemostatic proper- ties are well known, and it can be used thus with confidence, as no clots are formed. In Addison's disease and asthma it has given good results, and 2 grains of the dried extract internally in exophthalmic goitre will lessen the heart- rate and decrease the size of the thyroid. The normal heart is not affected when •given internally, neither the normal blood-pressure nor pulse, but an inter- mittent pulse becomes regular, a weak pulse stronger, and feeble cardiac muscle remarkably stimulated. All the effects produced are only temporary, so that re- peated applications are necessary. But in all forms of inflammation it is very useful in reducing tension and allaying pain. Bates (Med. News, p. 441, Mar., 1900). After the use of suprarenal extract there is danger of secondary haemor- rhages, which come on several hours after the operations, and are often so pro- fuse as to alarm the patient. Conclu- sions are that there is a likelihood of having more profuse secondary haemor- rhages after the use of cocaine and suprarenal extract than after the use of cocaine alone. F. E. Hopkins (Phila. Med. Jour., May 5, 1900). This does not, however, reduce the therapeutic value of adrenal extractives. 398 ANIMAL EXTRACTS. SUPRARENAL EXTRACT. ADDISON'S DISEASE. Solutions of adrenal extract, or of its more conyenient preparations on the market (epinephrin, adrenalin, etc.), in 1 to 1000 or 1 to 5000 solution arrest epistaxis and limit haemorrhage during intranasal operations, while greatly in- creasing the operative field by contract- ing the tissues. The solution is to be ap- plied with a pledget of cotton and left in situ about five minutes, when the tis- sues are blanched and ready for operative work. It may also b* applied in the form of a spray in hay fever and local in- flammatory disorders, 1 part of adrenalin in 6 of the normal salt solution is to be preferred in the latter. Thirtj'-five cases in tabulated form, showing that the useful effects of the suprarenal gland were obtained. In two eases the nose was not packed, but the patients were placed in bed and kept quiet for two days and adrenalin, 1 to 10,000, was applied by means of spray every two hours. There was no sub- sequent haemorrhage in either of these cases. The author has employed no suprarenal extract since taking up the use of adrenalin. Emil Mayer (Phila. Med. Jour., April 27, 1901). Great relief and almost complete com- fort from the topical use of adrenalin solution applied on a cotton wad, or as a spray in the proportion of 1 to 5000. S. Solis-Cohen (Amer. Med., Sept. 7, 1901). The following solution is a valuable local application in hay fever, and is also remarkably efficient in controlling inflammation or bleeding and in produc- ing anaesthesia of the mucous mem- brane: — IJ Adrenal, 20 grains. Phenic acid, 2 grains. Eucaine-B, 5 grains. Distilled water, 2 drachms. Macerate ten minutes; filter. This solution is permanent, will not decompose nor lose its physiological activity for several months. Somers (Merck's Archives, June, 1900). The best way of applying solution adrenalin chloride is in conjimction with a 2-per-eent. solution of cocaine. In the nose a pledget of cotton saturated with a 2-per-cent. solution of cocaine should be allowed to remain in contact with the tissues not longer than two minutes, and its use .should be imme- diately followed by the similar applica- tion of solution adrenalin chloride. Prior to operative procedures the 1 to 1000 or the 1 to 2000 solution should be employed ; for the relief of local con- gestion the 1 to 10,000 will give the most satisfactory results. The adre- nalin pledget should be left in contact Avith the tissues for ten to fifteen minutes, depending upon the result de- sired, as well as the amount of swelling to be reduced. D. Braden Kyle (Therap. Gaz., .July 1.5, 1902). In cases of obstruction from any cause the nasal passage is packed with cot- ton-wool saturated with adrenalin- chloride solution. When the swelling- lias been reduced the membrane should be cocainized and the passages explored, until the cause of the trouble is located, when the operation may be performed with safety. D. S. Reynolds (Med. Mirror, Aug., 1902). In pharyngeal and laryngeal inflam- mations a solution of 1 to 10,000, grad- ually increased to a 1 to 2000, is often of advantage applied in the form of a fine spray. It may also be painted over inflamed tonsils with a camel's-hair pen- cil or a pledget of absorbent cotton. Case of chronic laryngitis in which 1 to 10,000 normal salt solution of ad- renalin chloride was applied two or three times. In the course of five minutes the congestion had been con- siderably reduced ; the blanching process did not extend at all beyond the parts actually touched. Case of acute laryngitis with oedema of the glottis, in which there was great swelling and redness of the epiglottis, with difficult respiration, which seemed likely to necessitate a speedy trache- otomy. The interne was directed to apply to the larynx, every tlu'ee or four hours, a spray of 1 part of adrenalin to 10,000 normal salt solution. This was done, with the effect of giving the ANIMAL EXTRACTS. SUPRARENAL EXTRACT. ADDISON'S DISEASE. 399 patient speedy relief. He said that he felt as though the parts had been con- tracted. In addition to this treatment the patient was given i / grain of ni- trate of pilocarpine, which caused free salivation and profuse sweating. This was repeated twice a day for two days; therefore it cannot be said just what the influence of the adrenalin was; how- ever, its immediate effects were good, as demonstrated several times. The pa- tient made a speedy recovery. E. Fletcher Ingals (Jour. Amer. Med. As- soc., April 27, 1901). A few minutes' application of a solu- tion of adrenalin chloride (1 to 1000) to tlie mucosa of the respiratory tract makes possible an absolutely bloodless operation; its value as an adjunct in operative procedures cannot be over- estimated. It has a wide field of use- fulness as a therapeutic agent because of its rapid and safe contraction of the superficial capillaries. The author has found the 1 to 1000 solution useful iii acute and subacute laryngitis, especially in the ease of vocalists. A simple con- gestion of the larynx may be reduced readily and vocalization restored with- out discomfort or irritation. il. A. . Goldstein (St. Louis Med. Rev., Aug. 10, 1902). Internal Administration. — Suprarenal substance and extractives have been nsecl internally witli more or less advantage in inflammatorj' disorders of the respiratory and cardiac systems, inclnding asthma, bronchitis, hemoptysis, and in exoph- thalmic goitre, malaria, diabetes, and mental disorders. As is the case with thyroid substance and its extractives, su- prarenal substance and its extracts are not destroyed in the digestive process. The use of suprarenal powder in dis- eases of the heart in one hundred cases warranted the following conclusions: After the administration of the supra- renal powder the following was ob- served: 1. A weak and irregular acting heart became stronger and more regu- lar. 2. A dilated heart was contracted. 3. A diffused apex-beat became localized. 4. A diffused, loud, and rough mitral regurgitant murmur became localized, smoother, and lessened in intensity, while in some cases the murmur disap- peared. 5. A murmur which, owing to the extreme weakness of the heart, could scarcel}' be heard, became more distinct, thus aiding in the diagnosis. 6. The normal cardiac sounds, when dis- tinct, became clearer and more easily distinguished. 7. In some cases a rapid pulse became less rapid; in other cases a slow pulse became faster. 8. Patients who were very weak, with organic heart disease, were improved. 9. No effect was observed in organic heart disease when the pulse was strong and regular. Three grains of the powder were found effective, but larger doses proved harm- less. Samuel Floersheim (New York Med. Jour., May 4, 1901). Two cases in which suprarenal extract proved effective when other remedies had failed. One patient was a woman aged 82, suffering from mitral insuffi- ciency with swollen extremities, gastric- irritability, and other symptoms of car- diac failure. She had received digitalis, caffeine, strophanthus, etc., with unsat- isfactory results. Suprarenal extract was given in 3-grain doses, thrice daily after meals. Prompt and continuous improvement followed, the cedema disap- peared, vomiting ceased, and the patient could soon resume her walks. The sec- ond case, a man of 76, had swollen feet, and a cardiac lesion was suspected. The usual heart-tonics failed to give re- lief, until suprarenal extract was tried, and almost immediate amelioration resulted. Six weeks later all oedema Avas gone. The tonic influence of the remedy on the vascular system was marked. W. E. Decks (Montreal Med. •Jour., Nov., 1901). The chief physiological action of suprarenal-gland extracts is increase of arterial pressure, but they also produce a tonic effect upon the heart and on muscle generally and possibly some diminution of metabolism. Owing to the transitory nature of the effects pro- duced by intravenous injection of the extracts, they must be given by the mouth if any prolonged action is to be 400 ANIMAL EXTRACTS. SUPRARENAL EXTRACT. OPHTHALMOLOGY. obtained. Digestion is not impaired by moderate doses. Both for a •priori rea- sons and as a matter of experience they appear to be indicated in conditions of excitement and exaltation, in which state the blood-pressure is usually low- ered. In mental diseases administration for a certain length of time will be found necessary in most cases to pro- duce marked effect where excitement is violent. Although the state oi the blood- pressure, as a rule, forms a conven- ient indication for their use, high press- ure does not absolutely contra-indicate them, if there is some reason to think that it is not associated with the mental state, as an abnormally high pressure may still be lower than the average of an individual case. Suprarenal extracts seem unlikely to be of benefit in eases of melancholia and where there is much stupor. It therefore seems probable, on the whole, that the psychoses in which this will be found most useful is in acute mania of fairly recent origin uncom- plicated by stupor. W. R. Dawson (.Jour. Mental Science, Oct., 1901). Addison's Disease. — • Imperfect ac- tion of the suprarenal capsiiles implying, in the light of our present knowledge, a gradual toxemia by the products of metabolism; it was thought that the in- gestion of the organ or its extracts would prove curative. So far, no cases of final cure can be said to have been witnessed, but several cases have remained well un- der the continued use of the remedy for a considerable time; some of these, how- ever, have had sudden recurrences, ter- minating fatally. It is quite evident that the entire question is still very obscure, but it is also certain that the use of adrenal or its preparation merits further trial, especially in the earlier stages of the disease and when the presence of a tubercular process cannot be absolutely recognized. Ophthalmology. — In inflammatory diseases of the eye, the active principles of suprarenal have the power of suddenly stimulating the vasomotors, thus deplet- ing the engorged vessels. In a method recommended by Barraud, sheep-capsules are used, and with the product of evapo- ration a solution is prepared with equal quantities of sterilized water; this is done, as much as possible, at the time of using, for the solution becomes rapidly altered. One drop of Barraud's suprar- enal solution instilled into the eye pro- duces an energetic vasoconstriction of the conjunctiva at the end of thirty to forty seconds. In a few minutes this action is sufficiently marked to cause pallor of the mucous membranes, and continues about twenty minutes, after which the vessels return to their former condition. In an inflamed conjunctiva, the pain and redness completely disappear for the time being. Its application causes no pain even when the congestion of the eye renders it hyperassthetic. In ophthalmology, therefore, the aque- ous extract of suprarenal capsules flnds its application as follows: 1. In con- junctivitis, kerato-conjunctivitis, vascu- lar keratitis, episcleritis, and glaucoma as an aid to the usual medication. 2. In cases in which extreme inflammation of the tissues and intense congestion of the media of the eye limit the action of cocaine, it regains its analgesic power, owing to the ischsemia previously pro- duced by the suprarenal extract. 3. Finally, whenever there is reason to fear a hsemorrhage during surgical interven- tion on the eye, the extract acts either as a preventive or as a radical htemo- static agent. (Maurange.) Dor was first to recommend the ap- plication of suprarenal extract in cases where, an operation being urgent, it was difficult to obtain local anesthesia with cocaine alone, owing to hyperemia of the conjunctiva. (Darier.) ANIMAL EXTRACTS. SUPRARENAL EXTRACT. NEURASTHENIA. 401 The method for preservation of suprar- enal solutions employed for over a year now in Buffalo with excellent satisfac- tion is as follows: One-half gramme of the extract of suprarenal capsule is rubbed to a paste, the water is added gradually until there is a solution of 1 ounce. This is then heated for some time to 160° F. Water being constantly added as the solution evaporates so as to keep the amount of liquid always up to 1 ounce. Fifteen grains of boric acid are then added and the solution is ready. It will keep for weeks. The suprarenal ex- tract is used in the eye in the shape of small wafers. To make these the extract is rubbed up into a paste and then mu- cilage added to give it consistency. These feel somewhat rough, but are un- irritating when moistened. The addition of formalin, 1 to 10,000 or the employ- ment of a concentrated extract in glyc- erin diluted as required are good methods for preserving the substance. But both the formalin and the glycerin have proved irritating to some eyes. Lucien Howe (Med. News, Mar. 24, 1900). Adrenalin may be employed in very ailute solutions in the form of a collyr- iiun with boric acid. One drachm of the 1 to 1000 solution in 2 ounces of distilled water, with 10 grains of boric acid, is effectual when frequently used. To relieve the congestion, irritation, and lacrymation caused by ordinary con- junctivitis, and to combat blepharo- spasms. To relieve trachomatous pan- nus. To enhance the action of cocaine, atropine, eserine, and pilocarpine, by promoting their absorption. Adrenalin is first used, followed during the period of blanching by the drugs named. To re- duce the tension in trachoma. To facil- itate the introduction of lacrymal sounds, the solution being first injected into the ductus ad nasum. To relieve ciliary pain in keratitis, iritis, and cy- clitis with glaucoma. To modify opac- ities of the cornea. To produce cosmetic effect. G. E. de Schweinitz (Therap. Gaz., July 15, 1902). Genito-itrinaey Diseases. — In dis- orders of the urethra and Tulva supra- renal extract has recently been found of 1- considerable value. Its effects are sim- ilar to those produced upon the tissues of the upper respiratory tract. A 1 to 10,000 solution was also found by Fritsch greatly to facilitate cystoscopy and op- erative procedures in the bladder. In chronic urethritis involving the glands and follicles in the anterior urethra the extract of suprarenal gland is of marked therapeutic value. It acts not as an astringent, but as a direct stimulant to the muscular coats of the blood-vessels. Absorption of embryonic tissue is thus brought about, and im- provement of the general tone takes place. Three cases are reported in which chronic urethritis was cured by the use of a solution containing the extract. In one ease of chronic posterior urethritis local applications through the endo- scopic tube of a 10-per-cent. solution, daily are said to have practically cured the disease after fifteen days of this treatment. In the ordinary cases of chronic anterior urethritis the remedy was applied by means of a hand-syringe. Eaton (Occid. Med. Times, March, 1902). Adrenalin is indicated in cases of mucous or muco-purulent discharge; when the urine shows mucus or flat, scaly shreds and mucous shreds; when endoscopical examination shows gran- iilar patches or superficial scleroses; when pus-cells, epithelium, mucous gon- ococei, or other micro-organisms are present. Series of cases of urethritis which had resisted other drugs, and which were, with few exceptions, bene- fited by instillations of adrenalin chlo- ride, 1 to 1000. The field of usefulness of this drug in urethral work is limited to the same indications as for mucous membranes in other localities. It is painless to apply, and causes a cessa- tion of secretion by contraction of the blood-vessels for a varying time. It will only act, however, on superficial lesions, and will bear watching for untoward action. S. E. Gans (Phila. Med. Jour., Dec. 13, 1902). In two cases of pudendal irritation, attended with marked pruritus, supra- renal extract gave marked relief. In the one, a young woman 18 years of 403 ANIMAL EXTRACTS. PITUITARY EXTRACT. age, violent itching of the vulva and anus had come on ten days before. Not- withstanding usual methods of treat- ment, there was no relief, and in the meantime the condition had become so severe that she was unable to leave the house. A local examination showed an intensely congested condition of the vulva and the lower part of the vagina, with increased secretion. A strong solu- tion of suprarenal extract was applied to the part, which was followed by a rapid blanching of the mucous mem- brane. Momentarily the itching was in- creased, and then gave way to a slight burning sensation, which passed oflf in a few minutes. The effect of this appli- cation lasted for fourteen hours, when the itching recurred. A second applica- tion cured the case. F. S. Meara (Merck's Archives, May, 1902). Pituitary Extract. Lesions of the pituitary body having been found in almost all autopsies in cases of acromegaly, a close connection between this organ and the symptoms of the disease could but be inferred; it also suggested the use of the gland as a remedial agent soon after the animal extracts entered the field of therapeutics. Physiological Action. — Although Mairet and Bosc found that triturated or macerated gland was practically inert in man as well as animals, producing rise of temperature and emaciation, Schafer and Oliver found, to the contrary, that it was quite active, affecting mainly the arterioles and heart-muscle. It is thought to bear some undetermined relation to the nutrition of bone or dermal tissues. Rapid and great rise of blood-pressure observed, bearing directly upon the arterioles and probably upon the heart- muscles. The pituitary body furnishes a secretion to the blood which serves to increase the contractile power of the heart and arteries and to influence the nvitrition of certain tissues. Schafer and Oliver (Jour, of Phys., p. 277, '95). In animals (rabbits), excepting dis- turbances evidently due to local infec- tion produced by the subcutaneous in- jections, very slight effects were ob- tained: a transient elevation of tempera- ture, most marked two hours after the injection. Injected into the veins it produced disturbances similar to those obtained after injection of blood, namely: death from coagulation. If treated by sodium chloride or by heat it produces results similar to those of blood-serum when similarly treated, but it is dis- tinguished only by a more marked my- osis; and given by the mouth, macerated or triturated pituitary gland causes, besides a slight elevation of temperature, a noticeable gastro-intestinal disturbance and a temporary albuminuria, showing that this substance possesses only a slight degree of toxicity. With dogs nothing of impoi-tance is noticed: slight emaciation and slight elevation of tem- perature. With healthy men the same results were reached. Mairet and Boso (Arch, de Phys., No. 3, p. 600, '96). It is probable that the pituitary gland bears some unascertained relation to the nutrition of bony and dermal tissues, as a result of which an overgrowth of them accompanies changes in the gland which presumably affect its functions. Whether or not these changes are pri- mary is yet unknown. F. P. Kinnicutt (Amer. Jour. Med. Sciences, July, '97). The pituitary gland is a functional organ, disturbances of the metabolism of which are the principal factors in both acromegaly and giantism, the differences between the results being due to the stage of individual development at which the disturbance of function begins. Woods Hutchinson (N. Y. Med. Jour.,, July 21 and 28, 1900). Therapeutics. — In acromegaly it can- not be said to have done much more than to relieve some of the active symptoms and to have contributed to the patient's comfort. This means considerable in these cases, which sometimes suffer greatly from neuralgic pains, violent headaches, etc. Statistics of 13 cases of acromegaly treated with pituitary preparations: In ANIMAL EXTRACTS. SPLENIC EXTRACT. 403 7 cases varying degrees of improvement were noted. In 1 of these the improve- ment occurred under the combined use of pituitary and thyroid preparations. In 5 eases no eflfect wr.s obtained; and in 1 case the patient was made worse by the treatment. F. P. Kinnicutt (Amer. Jour. Med. Sciences, July, '97). Administration of tlie tablets for months at a time having failed to amelio- rate the symptoms of acromegaly in per- sonal cases, and the fact that extirpation of the pituitary gland in dogs and in man (when the hypophysis cerebri has been the seat of a destructive process, such as sarcoma) is not followed by any of the pathognomonic symptoms of acro- megaly, Avould seem to prove that acro- megaly is not due to obliteration of the glandular structure of the hypophysis, and that this alleged remedy has been used only empirically and is absolutely inefficacious. W. M. Lesz}'nslcy (Med. Record, June 30, 1900). Organic Extracts. Preparations of the various organs, the spleen, the ovaries, hone-marrow, the tes- ticles, the brain and nerves, the kidneys, the lungs, the liver, and the pancreas have all been tried as remedial agents; but it may be said that, while only the products of the first five have attracted wide-spread attention, those of the spleen and ovaries alone seem to present suffi- cient value over other means at our dis- posal to still merit the confidence of the profession. The preparations of the first five or- gans mentioned in the list will be re- viewed in this article. The literature of the others is so scanty that no adequate idea could be conveyed of their actual worth. Strength of organic extracts may be tested by adding to them Biondi's stain- ing-fluid. If nuclein is present in large amount and the extracts therefore are of good quality, they will turn a distinct green. Posner (Berliner klin. Woch., Mar. 14, '98). Splenic Extract. The use of spleen was suggested mainly by the fact that enlargement of that organ occurs in some cases of cretinism and myxosdema and after removal of the thyroid gland. This was further sub- stantiated by the experiments of Oliver and Schiifer, who obtained a fall of arte- rial pressure followed by a gradual, but steady, rise, by means of intravenous in- jections of splenic extract, thus demon- strating that it was not inert. Kriiger found that it increased the excretion of uric acid and of the xanthin bases. Effect of spleen substance administered to a number of patients in the Lanark County Asylum, Hartwood, investigated for a period of two years. It Avas found to aid digestion and nutrition, to increase the cutaneous circulation, to stimulate the glandular activity of the skin, and in some cases to produce a favorable change in the mental condition. A. C. Clark (Edinburgh Med. Jour., Feb., '98). Results of investigation of therapeutic value of spleen extract. Treatment was begun with three capsules of desiccated spleen representing 100 grains each of fresh spleen; this was increased to 6 cap- sules a week later. Capsules of liquid extract, each containing 20 grains of fresh spleen, were tried some weeks later, and W'ith more distinct benefit. Conclu- sions are: — 1. That the most general result of this treatment is physical improvement. 2. That its action on the mental state is undoubtedly evident in a fair propor- tion of cases, especially of adolescents, sometimes direct, at other times owing to improved physical conditions. 3. That it materially assists in render- ing thyroid treatment efficacious, the pa- tient, after a course of spleen treatment, being more susceptible to the action of thyroid. 4. That where it fails there may be a defect in the preparation of the extract. Vile have found that capsules of the liquid extract are best. They have been made for us by Duncan, Flockhart & Co. The desiccated spleen, which is usually 404 ANIMAL EXTRACTS. SPLENIC EXTRACT. employed for tablets, must necessarily lose some of its active properties. 5. It is best given at least half an hour before meals. Charles A. Bois and Neil T. Kerr (Brit. Med. Jour., Sept. 10, '98). Administration. — Two practical dif- ficulties ar« met with in administering splenic extract: it produces gastric pain and derangement of the digestion when given by mouth, and great local irritation and even abscesses when administered hypodermically, although, of course, this does not always follow. A splenic ex- tract employed by Cohnstein is known by the trade-name of "eurythrol." It is a watery extract to which salt has been added, partly to preserve it and partly to give it a better flavor. It is described as resembling Liebig's beef-extract. The amount to be given daily is from 1 to 2 teaspoonfuls, dissolved in hot water. It does not seem to occasion distress. Exophthalmic Goitre. — H. C. Wood observed three cases in which spleen ex- tract produced very satisfactory results. One was cured and the other two were greatly improved. The advisability of trying this remedy is thus greatly em- phasized. Case of severe chronic exophthalmic goitre treated some years ago, in which an acute splenitis developed in a manner which was altogether inexplicable; no cause for the attack could be made out. Deep in the parenchyma of the organ there was formed an abscess whose open- ing and discharge were, after many months of severe sepsis and desperate illness, followed by return to health. In the second or third week of the splenitis the enlarged thyroid began to diminish, and in a short time regained the normal size. The result was a permanent cure of the exophthalmic goitre, no symptoms of the disease returning. In a private case the disease was of six years' duration; the exophthalmos was very pronounced; the action of the heart extremely rapid and irregular: about 180. The enlargement of the thyroid was very great. The breathless- ness \Nas marked^ and the general nei-v- ous erethism such that the patient was on the verge of insanity. A teaspoonful of the glycerin extract of spleen produced at once violent gastric distress, with local pain, lasting for some hours, and com- plete disgust for food. Other doses gave similar results. Following this, 10 minims were injected twice a day hypo- dermically into diiferent portions of the body; they produced much local pain and hardening Of tissue, but no abscess. This was kept up for si.x months, when 10 drops of the spleen extract with 10 drops of digitalis were administered three times a day. The improvement began not a great while after the commence- ment, and gradually increased. Before the treatment there was extreme breath- lessness; now she walks comfortably for a long distance. H. C. Wood (Amer. Jour. Med. Sciences, May, '97). Blood Disorders. — The physiolog- ical functions of the spleen promptly suggested the use of spleen extract in diseases of the blood, and encouraging results were obtained by Danilewski and Cohnstein. The former had found that the use of a watery extract of the ox's spleen, whether given by the mouth or subcutaneously, gave rise to a notable increase in the number of the red blood- corpuscles in dogs and rabbits. Case of leukaemia treated by injections of splenic extract. There was very little pain, but copious sweating and fear, with which dyspnoea was sometimes associ- ated. The effect on the blood was a decided increase of the number of leuco- cytes immediately after the injection, followed later by an increase, not suffi- cient, however, to restore the number to that previously present. This result is not interpreted as an evidence of real improvement in the disease, but rather as an apparent change due to retention of the leucocytes in the capillaries of the lungs. Paul Jacob (Deutsche med. Woch., Aug. 9, '94). Statistics of twenty-three cases in which a watery extract (eurythrol) was employed. In one case the disease was ANIMAL EXTKACTS. OVAMAN EXTRACT. 405 leukaemia; the others were examples of antemia or chlorosis. In the case of leukfemia there was only a transitory efl'ect observed, not really therapeutical. On the other hand, in the majority of the cases of antemia and chlorosis the action of the extract was very striking. The first signs of improvement were seen in the subjective symptoms of debility, loss of appetite, constipation, headache, and dysmenorrhoea. Objectively, the pallor disappeared, and often there was an increase of the hEemoglobin or of the number of the red blood-corpuscles. In many cases the patients gained flesh notably. In many others there were no objective signs of improvement. In no instance was any unpleasant effect ob- served. W. Cohnstein (Allgem. med. Central-Zeit., No. 43, '96). Extract of the spleen, by producing a decided leucocytosis, has a most gratify- ing effect upon the course of typhoid fever. In doses of 5 grains, three times a daj', it rapidly and steadily reduces the temperature, ameliorates all the symp- toms, and quickly restores the patient to the normal condition. To obtain the best efi'ects from this remedy, however, the percentage of haemoglobin and the number of red coi-puscles muse be kept up to normal. Carpenter (Med. Record, Feb. 17, 1900). Ovarian Extract. Four well-known facts are given by Muret as fundamental reasons for the use of ovarian extract as a remedy,- — namely, that (1) without ovaries there is no uterine development or menstrua- tion; (2) ablation of ovaries in young children causes them to grow up with- out any feminine attributes: (3) after puberty loss of ovaries entails cessation of menstruation and atrophy of genital organs; (4) osteomalacia is cured by oophorectomy, — all generally explained by some indefinite action of the nervous system. But the active principle giving rise to these effects is not defined. The following statements may be for- mulated in regard to the use of ovarian extract: — 1. The ovaries, in common with otlier glandular organs in the body, exert an occult, but very positive, influence upon the general organism. 2. When this influence is removed, either by the natural atrophy of the glands at the climacteric, by destruction of the ovarian stroma from pathological processes, or by extirpation of the organs, there results a series of distressing phe- nomena, including hot and cold spells, nervous and mental manifestations, and neuralgic attacks. 3. The administration of ovarian sub- stance or of the extract of ovarian tis- sue is promptly and very generally fol- lowed by a marked amelioration of these symptoms. 4. The average dose required varies from 2 to 5 grains of the extract adminis- tered thrice daily. 5. Excessive doses of the remedy will be followed by cardiac and nervous mani- festations, necessitating a diminution in the dose administered or a complete, though temporary, change of treatment. 6. In some cases there appears to be developed a tolerance to the remedy whereby its effects are diminished in in- tensity. For this reason it is better to begin with, small doses and gradually in- crease the amount given. W. A. New- man Borland (Ther. Gaz., Apr. 1.5, '99). Preparations and Dose. — The ther- apeutic uses of ovarian substance were studied by Touvenaint. Heifers' ovaries can be reduced to powder by desicca- tion at a temperature of 25° C. Pills containing 1^/^ grains of the dry powder can be used, corresponding to 12 grains of fresh ovary. Three of these may be taken daily a quarter of an hour before meals. The average dose of dried ovary powder should not exceed 4 to 5 grains daily. Liquid ovarian extract is another form: a glycerin extract of ovaries of young cows, containing 15 grains of ovarian tissue in 7 ^/, minims of glycerin, which is injected into the buttocks daily in doses of 7 to 15 minims. 406 ANIMAL EXTRACTS. OVARIAN EXTRACT. Compressed tabloids, containing 4 to 5 grains of dried gland, proved quite as efficacious as the injections, when two or three a day were given, and were finally used in place of the injections. The treatment can be continued for a month or more and is always well borne. (Muret.) Therapeutics. — In disturbances fol- lowing removal of the ovaries or uterus, or in the nervous phenomena attending the menopause, ovarian tissue has given considerable relief. Lissac first tried crude ovarian tissue and ovarin by the mouth, and hypodermic injections of ovarian liquid; but ovarin was found to be most convenient, though it sometimes caused indigestion. The insomnia from which the patients all suffered was promptly relieved; cephalalgia generally disappeared and many psychical symp- toms, mental depression especially, were ameliorated. In four of his cases uterine hjemorrhages ceased under treatment. The treatment should be continuous, however, if the relief is to be maintained. He mentions sixteen cases treated by Jayle in the same manner in which the flushing was more or less relieved, but returned after cessation of the treatment. In exaggerated symptoms of the natu- ral or induced menopause the ovarian treatment may be applied in two ways: (1) through transplantation of ovarian tissue, and (2) administration by the mouth. In case of induced menopause through hysterectomy no effect was ob- tained; but, of cases presenting severe sj'mptoms during the natural menopause, three very much improved. Chrobak (Centralb. f. Gyn., No. 20, '95). Tablets of 3 '/= grains (Merck) of the entire ovarian substances, of the precipi- tate of the follicle-contents, or of cortical substance of the ovary of the cow, used in eleven patients, where either part or all of the internal genital organs had been removed; or where the patient complained of symptoms of the natural menopause: amenorrhoea, the result of atrophy of the genitalia, etc. The re- sults were, as a rule, very encouraging, the symptoms being very much relieved. Mond (Mtinchener med. Woch., No. 14, '96). Ovarian substance used in patients who had reached the climacteric age, who complained principally of sensations of fullness in the head, occurring many times during the day, pains in the back and legs, etc. The dose varied from 15 to 22 grains, administered in tablets con- taining each 7 Vi grains of the ovaries of sows or cows. The sensations of full- ness in the head had practically disap- peared in two Aveeks. To avoid the in- fluence of suggestion tablets containing none of the substance were given from time to time, but the symptoms immedi- atel}' reappeared and the patients felt worse. The effect lasted only while the ovarian substance was being taken. Lan- dau and Mainzer (Lancet, July 4, '96). Ovarian extract tried in 21 cases, 9 nervous disorder due to menopause and of usual vasomotor origin, insomnia, lumbar pain, visceral troubles, flatulence, anorexia, etc. All cured or much im- proved. Three cases of climacteric irreg- ularity of menstruation: 2 were cured and 1 improved. Muret (Rev. Med. de la Suisse Rom., July 20, '96). Ovarian extract appears to be par- ticularly indicated in amenorrhea and ehloransemia, in which the results are excellent. It is very useful in all cases of artificial menopause due to removal of the genital apparatus. It can also be tried with advantage for the removal of symptoms due to natural menopause. Touvenaint (M6d. Mod., Oct. 17, '96). Results obtained from the use of ovary- juice in various diseases of women, especially those peculiar to the meno- pause. In 51 cases, 34 of which were personal, the results warrant the follow- ing conclusions: I. The troublesome symptoms of the natural menopause dis- appeared or were greatly diminished by the use of the ovarian extract without any other medication. 2. Similar effects were produced by the administration of ANIMAL EXTRACTS. BONE-MARROW. 407 that substance in the relief of symptoms — for instance, irritability of the blad- der — that follow surgical operations which have for their result the suppres- sion of the menstrual flow. 3. Rapid improvement is constantlj' seen in chlo- rosis and dysmenorrhoea. 4. The influ- ence of extract of ovary on the psychical disturbances which accompany or are dependent on genital lesions are unde- niable. 5. Rapid and permanent im- provement in the general state. 6. Cli- macteric metrorrhagia without neoplastic lesions yield rapidly to the administra- tion of the remedy. 7. Its therapeutic action on the nervous system is manifest from the first day of its administration. Author states that he will shortly pub- lish the results of laboratory researches as to the chemical constitution of the substance which he prescribes. C. Jacobs (La Policlinique, Dee. 1, '96). Ovarian extracts act directly for the relief of the distui'banees attending the menopause, either natural or artificial. Its use is also valuable in amenorrhcea, dysmenorrhoea, and in anaemia of ovarian 'origin. Good results have also been noted in some eases of simple oophoritis. Jayle (Revue de Gynec. et de Chir., No. 4, '98). Oophorin preparations given to women suffering from acne rosacea and cutane- ous disorders at the menopause, with satisfactory results. E. Saalfeld (Ber- liner klin. Woch., No. 1.3, '98). Extract of corpora lutea, to which the value of ovarian extract is due, adminis- tered to patients suffering with the sub- jective phenomena commonly following the menopause, thought to be due to ovarian insufficiency. In two eases in which this substance was used, the same results as those obtained from the ovarian extract were noted. A. Lebreton (Lancet, July 1.5, '99). The nervous disorders following re- moval of the ovaries or uterus were also found to be relieved by Landau and Mainzer, but only temporarily. Knauer has shown that in rabbits the ovaries can be removed and then trans- planted in other than their normal posi- tion. They can be attached to the peri- toneum as well as implanted between muscle-fibres. Thus implanted, the ovary is nourished and continues its function. Might this not be repeated in the human subject to antagonize the symptoms following oophorectomy or castration for hypertrophied prostate? Case in which bilateral oophorectomy was followed by flashes of heat, profuse sweating, headache, and marked sensa- tions of pressure in the occipital region preceding and during the early part of the menstrual period. Three-fourths to 5 drachms of ovarian substance admin- istered twice a day caused the attacks of flashes of heat and sweating to become less frequent and severe. This was fol- lowed by general improvement. Stachow (Monat. f. Geburtschulfe u. Gyn., B. 4, H. 1). In disorders of any kind resulting from uterine affections, it seems to merit further trial. Four cases of chlorosis treated for fourteen days with rest in bed alone, then a second period of fourteen days with ovarian extract. A relatively larger increase of hsemoglobin in the second series, and in three of these a larger in- crease in weight. The menses appeared in two after an absence of some months. Muret (Rev. Med. de la Suisse Eom., July 20, '96). Ovarian extract is harmful to chlo- roties because the influence of the ovary upon the organism is of a chemical nature. The only form of opotherapy which offers any prospect of success in chlorosis is the medullary. U. Arcangell (La Riforma Mediea, No. 91, '99). Bone-inarrow. On the assumption that the red blood- corpuscles were produced mainly from the red bone-marrow, J. Dixon Mann, of Manchester, utilized an extract of this substance in anaemia and other condi- tions dependent upon a depraved condi- tion of the blood. The cases have been numerous in which the results have ap- 408 ANIMAL EXTRACTS. BONE-MARROW. parently supported Dixon Mann's hy- pothesis, great and rapid proliferation of the red corpuscles having been noted. Case of pernicious anaemia in wliieh bone-marrow was employed in consider- able success. HEemoeytes, 1,860,000 to 1,460,000 per cubic millimetre; hsemo- globin, 28 to 30 per cent. Three ounces of uncooked bone-marrow from the ox given by the mouth daily. After twenty- seven days the hsemocytes numbered 3,900,000 per cubic millimetre and the htemoglobin amounted to 78 per cent. Eraser (Brit. Med. Jour., No. 1744, '94). The tissue-forming power of young animals being taken as a criterion, the marrow obtained from them was thought to be preferable to that of older animals. The best results were obtained from the ' marrow contained in the ribs of a young animal. The coarse marrow from the long bones contains a great deal of fat, which does not contain the specific virtues to the same extent as the finer medullary substance. Preparation. — The method of prep- aration advocated by the majority of writers is that recommended by Dan- forth, of Chicago. The anterior extrem- ities of calves' ribs are comminuted so as to expose the cancellated tissue, and the fragments are placed in a jar and covered with glycerin, to the influence of which they are exposed for three or four days, being occasionally agitated. At the end of this time the liquid is strained, and the resulting fluid presents a reddish, syrupy appearance, without pronounced odor, and with the taste of glycerin. At flrst a teaspoonful of this extract is administered thrice daily. The marrow may also be administered raw, on bread; but this method is usually repulsive to the patient. Physiological Action. — An indirect influence as to the action of bone-marrow may be obtained from recently-made ex- periments by Trambusti, which have shown that bone-marrow reacts in the course of an infective diphtheritic proc- ess in rabbits with great functional activ- ity of the cellular elements of which it is composed. This energetic functional ac- tivity of the cellular elements tends more toward the function of secretion than to that of reproduction. The increased function of secretion shows itself micro- scopically both by a greater quantity of granulations in the interior of the cell- plasma, and by a greater quantity of free gramdations. The great functional activity of the cellular elements is dimin- ished, with the progress of the infection, by the accumulation of a greater quan- tity of toxic material within the organ- ism. Although this material in small dose stimulates the above-mentioned energy, yet it here acts as a paralyzant and in producing necrosis. The results which he has obtained from the use of bone-marrow justify the belief that the leucocytes produce a substance which is bactericidal and antitoxic. Its effects have been ascribed in the presence of iron. Whether or not it is anything more than an assimilable preparation of iron is not conclusively proved. Bone-mar- row, especially red marrow, is certainly a readily assimilated, organic compound of iron, and is a valuable addition to the resources of the physician in cases of ordinary chlorosis and anaemia and in some cases of blood impoverishment of a more intractable kind. W. E. Quine (Boston Med. and Surg. Jour., Aug. 6, '96). Any action bone-marrow may have must be due to some ingredient which stimulates blood-formation, and not to iron, or to any other constituent which might be directly used to build up red blood-corpuscles. Stengel (Ther. Gaz., '96). Therapeutics. — Not much can be said in favor of bone-marrow as a therapeu- ANIMAL EXTRACTS. BONE-MARROW. 409 tic agent. In pernicious anaemia it in DO way approaches arsenic in value; in anaemia indications would seem to show that it is not as reliable as iron. In leu- cocythfemia, leukeemia, and Hodgkin's disease it seems worthy of more extended trial. Peenicious Anjjmia. — It is very doubtful whether bone-marrow can in any way be compared to arsenic as a remedial agent in pernicious ansmia. The belief that the active agent of mar- row is iron would sustain this view, iron being as useless in true pernicious ane- mia as it is useful in the benign form. There is ground for the suspicion that an erroneous diagnosis led to some of the favorable reports published. These are not included in this review. Again, in the majority of the cases of pernicious anaemia treated with bone- marrow hitherto reported, their value as therapeutic records is much diminished by the fact that other drugs were often given in addition, and also that in no case has the further history and ultimate fate of the patient been recorded. It is well known that such cases often im- prove for a time imder various forms of treatment, but they tend always to re- lapse, and ultimately to die. Case of pernicious anaemia in a man, aged 60, treated with iron, arsenic, and salol, who made no progress until 3 ounces of ox-marrow were given in ad- dition. Complete recovery followed. Eraser (Brit. Med. .Jour,, vol. i, p. 1172, '94). Bone-marrow given in one case of per- nicious ansemia, without benefit; in a second, however, occurring in a man aged 43, who had become worse under arsenic and to whom 3 ounces of fresh marrow were then given daily, the results were remarkable. In two months the blood- condition had returned to the normal in every respect. Barr (Brit. Med. Jour., ■ vol. A, p. 358, '95). Three cases of pernicious anaemia in which the red marrow did not have the least effect. In one of the cases rapid improvement was noted as soon as the patient was placed on arsenic. Bone- marrow should not be .given unless arsenic has failed. G. B. Hunt (Lancet, Feb., '96) . Case in which marked improvement was brought about by bone-marrow and in which benefit had persisted up to the date of the report. Janeway (Ther. Gaz., May 16, '96). Two cases of pernicious ansemia treated with bone-marrow. The first, a man aged 39, had various ups and downs, but ultimately succumbed. The second case occurred in a woman aged 60; but under similar treatment she also progressively sank. Stengel (Ther. Gaz., '96). The most that can be said for bone- marrow in pernicious ansemia is that it should be tried where arsenic fails. Anemia and Chloeosis. — In severe anaemia, whether primary or secondary, bone-marrow has given better results than in pernicious anaemia. Here it would find a logical application, espe- cially if, as thought by Quine, it repre- sents an assimilable preparation of iron. The marked increase of haemoglobin and the general improvement noted, espe- cially in Mann's cases, would seem to warrant further trial of the remedy. Trial in two cases of ansemia and two of chlorosis; doubtful whether the bone- marrow treatment is superior to iron. J. S. Billings, Jr. (Johns Hopkins Hosp. Bull., vol. V, No. 43). Administration of the medullary glye- eride has shown better results than that of iron or arsenic. Danforth (Amer. Med.-Surg. Bull., May 16, '96). Twenty-two insane male cases of ansemia treated with bone-marrow. The average increase in red corpuscles was 1,361,489. The percentage of hsemoglobin increased on an average of 12.5 per cent. The leucocytes, which in nearly all were abnormal at first, decreased in number at the end of the month. The whole general appearance in the majority of the 410 ANIMAL EXTRACTS. BONE-MAREOW. cases improved. Appetite was better and the action of the bowels more regular. Mentally, one case began to improve at once and soon went home recovered. Three were regarded as much improved and four others were brighter and had lost a great deal of the apathy they formerly had. In the remaining four- teen the only improvement noticed was in their physical condition. Best results obtained with an extract made at the hospital by finely-chopped ribs of sheep and adding glycerin in the proportion of one pound to twelve ribs. This was per- mitted to macerate four days. It was then strained through gauze and was ready for use. W. 0. Mann (Amer. Jour, of Insanity, Jan., '97). Ten cases of ansemia and chlorosis treated by a preparation of nucleo- albumin and bone-marrow, shown in the table. D. D. Klots (N! Y. Med. Jour., Oct. 30, '97). of marrow; it is not precipitated by boiling; it does not contain iron, and may possibly be a deuteroproteose. Fowler (Scottish Med. and Surg. Jour., Sept., '99). Malaeial Cachexia. — • In malarial cachexia bone-marrow has been tried, but, doubtless, what beneficial influence may have been obtained was due to the improvement in the condition of the blood. Bone-marrow successful in two cases of malarial cachexia. All modes of treat- ment had failed. The remedy given in daily doses of 1 V; to 3 ounces, either raw or in sandwiches. T. K. Alexeiew (Rev. Gen. de Clin, et de Ther. Jour, dea Praticiens, Nov. 16, '95). Four cases of malarial cachexia treated with the spleen and bone-marrow of cattle, with apparently favorable results. 1 Percentage of Percentage of No. Ked No. Red Weight at Weight at Disease. Haihioglobin Hsemoglobin Blood-cells at Blood-cells at Beginning End of m at Beginning at End of Besinning of End of Four of Four 6 of Treatment. Four Weeks. Treatment. Weeks. Treatm't. Weeks. 1 Chlorosis 54>^ 74 2,730,000 4,210,000 117 124 2 Chlorosis 43 fiSK 2,140,000 4,020,000 108 115 3 Chlorosis 51 75 2,340,000 4,120,000 93 99 4 Chlorosis 34 61 2,310,000 3.990,000 104 113 5 Chlorosis 44 74 2,360,000 4,030,000 117 123 6 Secondary ansemia 36 71 2,140,000 4,430,000 123 131 7 Secondary ansemia 51 62 2,420,000 3,320,000 1.33 136^ 8 Secondary ansemia 54 esx 2,430,000 3,470,000 111 117 9 Secondary ansemia 42 63 2,170,000 3,940,000 141 149 10 Secorjdary ansemia 68 79 3,620,000 4,100,000 122 129 1. Subcutaneous injections of bone- marrow have no action on the red cor- puscles or haemoglobin of a healthy ani- mal. 2. When the red corpuscles and hsemoglobin fall below their normal limits, injections of bone-marrow produce a decided rise in both. This rise is well marked, sudden, and of short duration. 3. Along with the increase in the red corpuscles there is no corresponding im- provement in the form of the cells. 4. The active principle is present in an aqueous, but not in an alcoholic, extract Gritzmann ( Allg. Wiener med.-Zeit., June 30, '96). LEUCOCTTHiEMIA AND LeUE^MIA. Extracts of the bone-marrow and of the spleen have been employed in the treat- ment of leucocythsemia, but so far there has been no great success, and the reason of the failure is obvious when we remem- ber that in leucocythsemia the bone-mar- row is hypertrophied, not atrophied. It is not probable that glycerin extracts of ANIMAL EXTRACTS. BONE-MARROW. 411 marrow will jDrove valuable, since there is already too much marrow-activity. (H. C. Wood.) Excellent results from the treatment of a case of leukajmia, in a lad of 12, with bone-marrow taken raw and spread on bread. After a few days the method was not particularly disagreeable. The improvement little short of marvelous. Rigger (London Lancet, Sept. 22, '94). Good effects apparent within a few days. A. MeLane Hamilton (N. Y. Med. Jour., Jan. 12, '95). Case of splenic myelogenous leukaemia in which bone-marrow did not prove curative. Arsenic had also been used, but its physiological effects caused it to be stopped. Beneficial effects of marrow shown, however, by reduction of spleen and blood-count. C. E. Namraaek (N. Y. Med. Rec, Dee. 14, '95). Case of leucocythsemia in which, dur- ing seventeen days' treatment under arsenic (2 to 12 minims, t. i. d., liq. potass, arsenit.), no improvement oc- curred. A dessertspoonful of ox's bone- marrow spread on toast being given three times a day with arsenic, a remarkable diminution in the number of leucocytes followed, and continued after the arsenic was stopped. At the end of eight weeks the erythrocytes numbered 4,170,000, the leucocytes 25,000 (1 to 167). The pa- tient left the hospital and subsequently ceased taking the marrow. At the end of six months she returned with the spleen larger than ever; the erythrocytes num- bering 3,670,000; leucocytes, 225,000. Again given the tabloids of bone-marrow and began to improve at once. Four weeks later the patient became very ill, breathless, pulse rapid, temperature 102" F., pulmonary congestion and pleurisy, oedema of face and upper and lower ex- tremities. The patient died a week later. At the autopsy there was a typical leuco- cythajmic spleen. 'V^Tiait (Brit. Med. .Jour., Apr. 4, '96). Hodgkin's Disease. — Eecent obser- vations tend to show that bone-marrow may become a valuable remedy in certain forms of Hodgkin's disease. Case of Hodgkin's disease at first placed on one fresh sheep's thyroid daily. Tiring of them, the patient was placed upon extract of bone-mairow and thy- roid. From this time on there was rapid amelioration in all of the symptoms. The cough and night-sweats ceased and the glands rapidly diminished in size. Six months later she reported herself as feeling quite as well as she did before her illness. The enlargement of the glands had all disappeared. M. B. Herman (Memphis Med. Monthly, Feb., '96). Well-marked case of Hodgkin's disease, erratic temperature, varying from nor- mal to 102.5° F. Patient put upon the usual arsenic treatment, beginning with 2 minims thrice daily, and gradually in- creasing the dose until she was taking 7 minims three times a day of Fowler's solution, but in spite of this she steadily and rapidly got worse, till at the end of five weeks she was a perfect skeleton, profoundly ansemic, sleepless, and the group of glands affected so agglutinated that outlines of single glands were quite obliterated. The spleen was enlarged, temperature was almost constantly about 100° F., and her digestion failed com- pletely. The case seemed rapidly mov- ing toward a fatal termination. Although bone-marrow tabloids had previously been tried in a case of the same disease in an adult without the smallest benefit, they were used in this case beginning with 1, thrice daily. The vomiting and diarrhoea soon ceased and the temperature was normal. This im- provement steadily continued. The num- ber of tabloids taken was gradually in- creased, till at the end of a fortnight she was taking 6 in the day. After two months she was apparently in good health, although the submaxillary and one of the cervical glands were still large. The tabloids were finally stopped. A fortnight afterward she was once more somewhat ansemie, and with the glands, which had subsided to normal, ap- preciably enlarged; tabloids resumed; she still continues to take 3 a day, and is now a plump, healthy child, but she still presents slight enlargement of the submaxillary and one cervical gland. J. D. L. Macalister (Brit. Med. Jour., Nov. 13, '97). Osseous Deformities. — Although 412 ANIMAL EXTEACTS. ORCHITIC EXTRACT. affording but little information as to the actual value of marrow in disorders of bone, the following cases are never- theless suggestive: — Case of rheumatoid arthritis with sym- metrical spindle-shaped joints and ulnar deviation. Under marrow, pain, creak- ing, and deformity were markedly re- duced. Case of rheumatic ankylosis of right wrist in a woman aged 43, flexion and supination being lost. Improvement. Case of lateral curvature in a girl aged 17 '/j. The point gained was increased development of both sides of the chest, but much more on the weaker side. Case of angular cuiwature in a girl aged 18. The curvature itself not re- duced in size, but its irregularities have become smoother. Extreme case of osteomalacia in a woman aged 44. The patient had not walked for twenty years. After bone- marrow treatment she could stand by holding to a chair, and could get from her bed into a chair unaided. T. M. Allison (Med. Press and Circ, Oct. 14, '96). Orehitic, or Testicular, Extract. As is well known, the removal of the testicles transforms the physical and mental attributes of an animal. Upon this is based the natural conclusion that these glands bear considerable influence upon general development and nutrition. With this undeniable fact before him, Brown-Sequard conducted investigations having for their object to determine whether the product could not be util- ized as a therapeutic agent, and, after a series of experiments upon his own per- son, he ascertained that testicular fluid was capable of increasing mental and physical vigor. As to the curative influ- ence on the various morbid conditions of the organism, he was of the opinion that, by injection under the skin, it could bring about the cure or considerable im- provement of organic or non-organic affections of the most varied character, or, at least, cause their effects to dis- appear. These actions of the liquid were thought to be brought about in two ways : the nervous system, gaining in force, became capable of ameliorating the dy- namic or organic state of the diseased parts, and, by the entrance into the blood of new material, new cells or other anatomical elements were formed, thus contributing to the cure of the morbid condition. Unfortunately clinical evidence has not sustained the hopes of the distin- guished ph)rsiologist, and the method introduced by him has, for the present, at least, practically fallen into disuse. Testicular liquid was thoitght to pos- sess such antiseptic properties that, if it should be contaminated by pathogenic germs, these germs would be rapidly killed or rendered powerless; but it was shown that the antiseptic properties were merely those possessed by any acid sub- stance over certain micro-organisms. Instances tending to show that the testicular fluid prepared at the Coll6ge de France enjoyed certain antiseptic properties. It can retard for a month the putrefaction of a piece of meat placed in it. Brown-Sequard (Archives de Phys. Normale et Path., Oct., '93). Testicular fluid always has an acid reaction, so that it is not surprising that it sterilized organisms -which could live only in an alkaline medium. If microbes which could adapt themselves to a slightly-acid medium were chosen, such as the bacillus eoli communis, the results Avere no longer the same. Sabrazes and Riviere (Jour, de M6d. de Bordeaux, Nov. 26, Dec. 3, '93). Brown-Sequard's testicular fluid con- tains two substances which, when in- jected, are useful, and substances which have a disturbing action on the metabo- lism. Hirsch (St. Petersburger med. Woch., S. 51, No. 7, '97). Preparation. — D'Arsonval and Brown- Sequard recommend the following ANIMAL EXTRACTS. OECHITIC EXTRACT. 413 method: Take the testicles of a bull, divide each into four or five portions. Macerate for twenty-four hours in glyc- erin at 86° F., in the proportion of 1 quart per kilogramme of testicle. Add 5-per-cent. salt-water, ^/^ litre to 1 kilo- gramme of glycerin. Mix and allow to macerate half an hour. Filter through Laurent paper No. 8, and sterilize the filtered liquid either by carbonic acid (sterilized filter, or an autoclave with carbonic acid without filtration through porcelain) or by filtration with alumin- ium without carbonic acid (a process inferior to the others, but simpler and within the reach of practitioners). The quantity of liquid from 1 kilogramme of testicle in the glycerin varies from 600 to 500 grammes. The quantity of glycerin is brought back by the addition of salt-water at about 15° Baume. The liquid, in flasks containing 30 grammes, well corked and previously well washed in boiling water, keeps for several months without alteration. This liquid must be injected under the skin, not pure, but one-half diluted with water recently boiled and cold. If the injection be painful, the liquid should be further diluted with water (10 to 40 drops). All vessels employed, as well as the syringe, cannula, skin of the patient, and fingers of operator should be carefully washed in 2-per-cent. car- bolized water before and after injection. At least 2 grammes of the diluted fluid should be daily injected, and even 5, 6, or 8 grammes, diluted, or else 4 to 8 grammes should be injected in several places twice a week, preferably into the abdomen, between the shoulders, or into the buttocks. The treatment shoiild be continued three weeks, and for some affections, such as myelitis and sclerosis of the cord, the time cannot be limited, but may be two or three months. Water should never be added to the liquid in the flask. The injections should be sus- pended if untoward effects are observed. The remedy may also be given per rectum, but diluted with water to avoid local irritation. Another method of preparing a steril- ized liquid is the following: The tes- ticles are macerated in glycerin for twenty-four hours, and then filtered into a second apparatus through Chardin paper, which has been sterilized in car- bon dioxide under a pressure of fifty atmospheres for three or four hours. It is not certain that the combined action of concentrated glycerin and carbon dioxide under a pressure of fifty atmos- pheres will result in perfect sterilization; therefore the use of extracts heavily charged with glycerin is persisted in. The new extracts are more active, as has been shown by experiment. The liquid should not be injected pure, but diluted with two or three times its volume of 1-per-cent. salt solution, or carbolized water, 1 per 1000. This solution should be made very slowly, so that an intimate mixture may be made. (D'Arsonval.) Physiological Action. — Beyond the fact that it is capable of acting as a stimulant of vital energy and thus, per- haps, antagonize, to some extent, the de- bilitating influence of morbid processes, it is probable that suggestion plays the most important role in the results ob- tained. This, at least, is the opinion of the great majority of clinicians. In the great majority of cases the or- ganic extracts act only by suggestion; sterilized water produced exactly the same effects as brain-substance, when injected In neurasthenia and hemiplegia. V. Negel (Bull, de la Soc. des Med. et Nat. de Jassy, Nov. 1, '92). If the injections were followed by the use of neutral glycerin an improvement took place. The same was the cage In 414 ANIMAL EXTRACTS. ORCHITIC EXTEACT. patients treated only by injections of diluted glycerin or of phosphate of soda, as well as in those to whom the broiled organs were administered at meals. Is not this the best proof that the eflfects are due to suggestion? Guelpa (Le Bull. Mgd., Apr. 16, '93). Experiments with transfusion of nerv- ous extract according to the methods of d'Arsonval and Constantin Paul, in ten patients in the asylum at Eeggio. These patients were all of the curable class, and in no case was there recovery, and in only one any permanent improvement under the treatment. The greatest effects from its use are to be looked for in those cases where a physical element comes in play, and that its action is mainly through mental suggestion: an opinion vigorously sustained by Massa- longo. C. Eossi (Eivista Sperimentale di Freniatria, etc., vol. xix, No. 4). The method acts mainly by suggestion. The cases in which benefit had been ob- tained were rare and did not prove the antidotal virtue of the medication. Sper- min is a vital principle scattered through the entire organism. The introduction of spermin into the system would be indi- cated when the elements of the economj' contained it in smaller quantity than normal. FUrbringer (Deutsche nied. Zeit, Mar. 15, '94). [Suggestion plays a considerable role in this method, when the patients to whom it addresses itself are considered. Its author is wrong in e.xaggerating its value. It has been said to cure tabes, then cholera, then cancer of the stomach, not to mention a trifling disease like diabetes. Charcot, hoAvever, waited in vain for the cure of a single case of true ataxia in his service. How could it be otherwise where such organic lesions were concerned? That which is de- stroyed is lost, and all the organic liquids are of no avail. Besides, even the exact agent of these liquids is to such a point unknown that, according to some, it is the phosphate of soda and according to others phosphorus. The truth is that injections of organic liquids have generally a tonic eiTect, but here their ambition should end. Dujaedin- Beaumetz and Dubief, Assoc. Eds., Annual, '94.] In a series of experiments upon the action of orchitic extracts registered by means of a specially devised neuro- muscular apparatus, conclusion reached that capacity for work is increased by the action of such extracts, and in the fatigue as well a diminution in the sub- jective sensations of weariness. 0. Zoth and F. Pregl (Pfliiger's Archives, vol. Ixii, p. 355). The composition of orchitic extract of all animals found practically identical. The active principles consisted chiefly of two bodies: (1) nucleo-albumin and (2) spermin. The former was very toxic, producing great cardiac inhibition re- flexly through the cardiac nerve-centres. The latter, spermin, which was also pres- ent in considerable quantity in semen, produced its effect principally by causing congestion of the abdominal viscera, in- eluding both the testes and ovaries. W. E. Dixon (Lancet, July 7, 1900). Therapeutics. — In diseases of the nervous system — the stronghold of the method — the afEection in which the greatest henefit was claimed was loco- motor ataxia. In a series of thirty-nine cases, for instance, thirty-one were re- ported as either greatly benefited or completely cnred. In much larger series the proportion of cures, etc., remained about the same; but, on the whole, the method has not in any way acquired the confidence of the profession, owing to the contradictory results obtained. In truth, Brown-Seqitard himself did not pretend to do more than counteract the symptomatic manifestations of the dis- order, and this the remedy certainly did for a time in a large number of cases. In epilepsy, however, it increased the severity and the number of paroxysms. In neurasthenia what benefit was ob- tained did not prove lasting. Experiments in patients suffering from neurasthenia, hysteria, pulmonary tuber- culosis, and locomotor ataxia. Testicular ANIMAL EXTRACTS. BRAIN AND NERVE EXTRACT. 415 juice has no physiological or therapeutic action upon the human organism; espe- cially is there no action on the dynamo- metrical forces; it may have an irri- tating local action; whatever effects are observed, ephemeral and illusory, they should be attributed to the accidental variations of the disease, and principally to the action of suggestion. Magugliani (Gazzetta Med. di Pavia, May 1, '93). In certain cases it is wrong to at- tribute the curative effects of the tes- ticular liquid to suggestion. In certain animals the physical modifications ob- served in patients, such as slackening of the pulse, increase of muscular power, etc., have also been observed. The cura- tive results are due to a special substance that gives to the nervous system a force which it lacks. As regards ataxia cured by this method, one must admit the dis- appearance of the symptoms, even if the lesion be not cured. Bouffe (Le Bull. M6d., June 4, '93). As far as locomotor ataxia is con- cerned, testicular liquid acts by sugges- tion, and that this suggestive influence is all the more manifest because, for the most part, ataxic patients are doubly hysterical. The symptoms which are cured in these ataxics are precisely those dependent on hysteria. Berillon (Le Bull. Med., June 4, '93). Twenty-eight cases of epilepsy treated by the subcutaneous injection of testic- ular fluid submitted to the treatment for a sufficient length of time to form a fair test of its value. In eight there was slight diminution of the fits. In the other twenty the fits increased. In none of them did the intellectual state show amelioration. Bourneville and Paul Cor- net (Le Progres Med., Dee. 9, 16, '93). Failure in a number of cases of ataxia, sclerosis, paralysis agitans, etc.; what- ever temporary amelioration occurred attributed to mental suggestion. G. W. Wood and A. T. Whiting (London Lan- cet, Feb. 3, '94). No improvement whatever in some cases of tabes dorsalis in which it was tried. Carter (Liverpool Medico-Chir. Jour., July, '94). Orchitic extract used in a large num- ber of cases. All cases of nervous dis- ease, without organic lesions, which are benefited by bromide of potassium, will receive marked benefit from orchitic ex- tract. H. Grey Edwards (Brit. Med. Jour., June 8, '95). Forty cases, 30 males and 10 females, suffering from locomotor ataxia, sclerotic changes in the cord, neurasthenia, and the like, treated with from 20 to 30 minims average doses of Brown-Sfiquard's fluid, frequency of injections being every other day. Nausea, vomiting, and diar- rhoea were caused by an overdose. Im- provement was noted in nervous diseases of a chi'onic nature, and consisted in a general stimulation as well as an increase in the sexual sense. F. S. Pearce (Med. News, Aug. 22, '96). Spermin has undoubted beneficial effect where other medication has failed. In the first case, after six injections, in- continence, bladder and rectal pains dis- appeared, and general tone and well- being improved considerably. After twelve injections had been given ptosis and oculomotor symptoms were cured. In the second case, one of paralysis agi- tans, the frequent insomnia, which in this patient seemed to be caused by auto- into.xieation from gastro-intestinal dis- turbances, is usually relieved by a single injection of 1 cubic centimetre of sper- min given hypodermically. M. A. H. Thelberg (Med. News, May 26, 1900). Brain and Nerve Extract. A number of observers, most promi- nent among which, are W. A. Hammond, of JSTew York; Constantin Paul, of Paris; and Dana, of New York, have employed extracts of brain-cortex and of nervous matter in various nervous diseases. D'Arsonval prepared a glycerin ex- tract made of sheep's brain and spinal cord, one part of these being emulsified with five parts of broth. Dose. — Of d'Arsonval's glycerin ex- tract 30 to 40 minims may be injected either into the abdominal wall or into the flank, the latter preferably, every day or every other day. Physiological Action. — According to 416 ANIMAL EXTRACTS. ANOREXIA NERVOSA. Althaus, extracts of brain have a two- fold action: they may be looked upon as a highly specialized pabulum of nervous matter, in consequence of their contain- ing protagon, cerebrin, and lecithin; and, in the second place, they appear to act as antitoxins, as the phosphorized bodies split up, under the influence of the alkalinity of the blood, into glycero- phosphoric acid and cholin, which have the power of stimulating intracellular oxidation and the elimination of leuco- maines. Brain and nerve extracts have also been credited with stimulating proper- ties, manifesting themselves especially upon the heart and the general nervous system. Therapeutics. — Hammond and Con- stantin Paul recorded a large number of cases of neurasthenia in which excellent results were obtained, and stray reports occasionally appear, tending to show that these extracts are occasionally used. Four cases of neurasthenia treated with subcutaneous injections of liquid extract of cerebral matter, 46 minims being injected three times weekly. In two eases marked improvement. Vet- leser (Norsk Mag. for Lsege., Mar., '95). Brain emulsion in traumatic tetanus. Case in which an emulsion of the calf's brain with a physiological salt solution was used, 233 grains of brain-aubstance being injected in three doses, with asep- tic precaution. Complete recovery oc- curred in eleven days, although abscesses at the points of injection appeared. A. Krokiewicz (Wiener klin. Woch., No. 34, '98). Case of a girl, 9 years old, in whom 240 grains of the rabbit's brain were em- ployed without giving rise to abscesses, because the brain used was perfectly fresh, calf's brain having to come from a slaughter-house. Emulsion was also filtered through thick sterilized gauze. Schramm (Przeglad Lekarski, No. 3, '99). Effects similar to those obtained from the attenuated virus of Pasteur in the treatment of hydrophobia have followed the injection of brain emulsions obtained from normal animals, while functional nervous diseases, such as neurasthenia and epilepsy, have been favorably influ- enced. V. BabSs (Klin, therap. Woch., June 17 and 24, 1900). Babes and Gibier recorded cases of epilepsy which appeared to be greatly benefited, while Moncorvo found sheep's brain extract of value in various consti- tutional affections of childhood. Dana even reported a case of bulbar paralysis apparently cured by injections of gray matter, and Montagnon mentions a ease of chorea also cured by this method. On the other hand, the negative results reported have been numerous. These, added to the active commercial enter- ■ prise which has been connected with these agents from the start, have rele- gated them to the rear, and it may be said that the prevailing opinion, at pres- ent at least, is that they are therapeutic- ally worthless. Practically every organ of the body has recently been made to contribute an "extract," but the reports are too few to warrant analysis for the present. Charles E. de M. Sajous, Philadelphia. ANOREXIA NERVOSA. — ISTervous anorexia. Definition. — Sympathetic or nervous anorexia may be defined as a manifesta- tion of hysteria in which there is total absence of hunger, a distaste for food, and leading to voluntary starvation. Symptoms. — Without apparent cause the patient expresses a repugnance for food, which gradually increases until all alimentation is persistently refused. In some cases the repugnance is so marked that tricks are resorted to by the patient to avoid swallowing any aliment that may be introduced into the mouth by ANOREXIA NERVOSA. ETIOLOGY. PATHOLOGY. DIAGNOSIS. 417 the attendants. Without showing any active manifestation indicative of a pathological process, the sufferer finally succumbs. This variety of anorexia is occasionally associated with melancholia. The number of respirations is usually reduced, and the temperature may be subnormal. Case in a girl, aged 14 years, who showed no organic lesions. Respirations, 12 to 14; pulse, 46; temperature, 97° F. Cured by light food frequently administered. The patient showed a persistent wish to be constantly on the move, notwithstanding her extreme weakness. William Gull (London Lan- cet, Mar. 31, '88). In marked cases the skin becomes dry, wrinkled, and cold, and the tongue is parched and sooty. Etiology. — Hysteria is probably a fac- tor in the majority of cases. Case in a young girl in wliom bromide of potassium caused recovery. It was learned that in the boarding-house in which the patient lived there was a girl affected with an hysterical disorder of the larynx, and that in a short time another young girl had become affected in the same manner as the patient. Schlesinger (Wien. med. Blat., No. 3, '88). Careful inquiry usually shows that the patient belongs to a more or less neurotic family. The condition usually occurs in young girls, and occasionally in children. Case of anorexia nervosa in a girl 7 Vi years old, Avho exhibited a morbid aver- sion to food, and who was reduced to a skeleton, with marked mental troubles; however, after some weeks of rational nursing and treatment she was restored to physical and mental health. Collins (London Lancet, Jan. 27, '94). Pathology. — According to Sollicr, the stomach is more sensitive than is gen- erally supposed, and its sensitiveness has a large influence on normal digestion. The organ has motor and secretory func- tions, the latter depending on two fac- tors: the condition of the glandular ele- 1- ment and the nervous system. It is therefore evident that variations in the nervous system may afEect the amount of secretion. The sensitiveness of the stomach is shown in three ways: by sen- sation of hunger, by contact of food, and by knowledge of satiety. In the anorexia of hysteria he has often found an area of cutaneous anaesthesia over the region of the stomach, which varies in intensity with the degree of altered sensation in the stomach itself; further, it is present only so long as the feeling of hunger is absent, and disappears when desire for food returns. It cannot be satisfactorily made out in the graver forms of hysteria, where cutaneous aneesthesia is extensive. If the mechanical functions are also in- volved there may be gastric atony. Case of hysterical anorexia in which, while there was no evidence of visceral disease, and no sugar in the urine, the breath smelled of acetone, and the urine gave a most marked reaction of aceto- acetic acid. There was vomiting, and the vomit also contained acetone. In the first, or comparatively fasting, period, acetone^ aceto-acetic acid, oxy- butyric acid, and ammonia were found. The amount of urine was small, and hence a considerable excretion of acetone occurred through the lungs. With suffi- cient nutrition the smell of acetone in the breath, the reaction with ferric chlo- ride in the urine, and the increased am- monia excretion disappeared. Nebelthau (Centralb. f. inn. Med., Sept. 25, '97). Diagnosis. — Cancer. — The fact that carcinoma of the stomach may be simu- lated by grave forms of hysteria seems scarcely possible, and yet cases are en- countered in which, after long observa- tion, the diagnosis is uncertain. Hyster- ical cases have even been met with in which, with all the subjective symptoms of gastric cancer, there has eventually appeared an apparently pathognomonic tumor, the growth being composed of 418 ANOREXIA NERVOSA. PROGNOSIS. TREATMENT. the patient's own hair which she had swallowed. Gastric Ulcer. — Severe pain, nausea, and vomiting, which are occasionally ob- served in anorexia nervosa, may suggest gastric ulcer, but the other symptoms — the character of the pain and the time at which it occurs — will usually serve to clear the diagnosis. Diabetes. — This condition may be suggested by the facies of a case, but the degree of wasting is far greater in ano- rexia, and the urine does not contain sugar. Eatal case of anorexia nervosa in a girl aged sixteen years. {Stephens.) Prognosis. — Anorexia nervosa but rarely proves fatal. When great debility is reached, manifested by a dry, wrinkled, cold skin; a small, rapid pulse; and a dry, sooty tongue, the likelihood is that death will ensue unless forcible means are utilized. Two eases ending in death. The dis- ease is rarely fatal of itself, death coming on through some other disease. Tuber- culosis has been known to supervene in these eases. Nothing prepares the soil better for tuberculosis than anorexia. Debove [Le Progres Mgd., Oct. 19, '95). Fatal case, in a girl of 16 years, simu- lating diabetes. Urine normal. Up to eleven months before death the patient was a fine healthy-looking girl. After death the body weighed but forty-nine pounds. The bi-ain and other organs found normal. Lockhart Stephens (Lon- don Lancet, Jan. 5, '95). Treatment. — Isolation, hypnotic sug- gestion, hydrotherapy, gastric electriza- tion, — intra and extra, — gavage, and lav- age of the stomach have all proved useful in some cases. But occasionally these- means fail. In these cases Debove in- sists on the necessity of compelling the patient to eat, by whatever means, the- appetite returning as the case improves. Anorexia nervosa in a man, aged 25- years, whose weight was seventy pounds,, in which compulsory feeding was era- ployed. The patient, who had been in bed five years, gained fourteen pounds- after a month's treatment. Drummond (London Lancet, Oct. 19, '95). Hypodermic injections of morphine- have been recommended, but the danger of producing morphinomania in such cases is very great. This method should, therefore, be used with the greatest of care, and only after all other means have failed. Three cases successfully treated in the following manner, after all other means- had failed: Morphine, about V^ grain, was injected at four-hour intervals, until three doses had been given, or until there was paralysis of the stomach-wall (in two cases three doses accomplished this- result) . Each patient was told that she would become numb, that her pains- would diminish, and that she would be able to take and retain the food that would be given to her a half-hour after the injection. The injection should be given at the same hour each day, and' be followed in a half-hour by the admin- istration of food, either with gavage or without gavage. The patient should also be assured thut the food will be retained, and that it will not give rise to pain. After having used morphine in the man- ner indicated, these patients become hypnotizable and suggestionable in a few- days. The diminution of the dose of morphine should be made progressively- ANTHRAX. DEFINITION. SYMPTOMS. 4:19 as soon as alimentation and assimilation have been sufficient to augment the bod}'- weight. S. Dubois (Le Progres Med., Feb. 22, '96). ANTHKAX.— Gr., di'dpu^, a coal. Definition. — A malignant pustule due to infection by the bacillus antliracis, by which, from an infected centre, it may spread over the body or attack the intes- tinal tract, resulting in a general infec- tion. It is also known as "wool-sorters' disease" in man and "splenic fever" in animals. Danger luiks particularly in the manes of Russian horses; so notorious is the risk that manufacturers refuse to have anything to do with them. The stuffing for chairs and sofas is another source of infection. When the material has been washed it is usually found to have di- minished by 40 per cent. Editorial (Indian Lancet, Aug. 16, '97). Death of five men in JeflFerson County, Pa., due to anthrax derived from hand- ling infected hides imported from Asia. The hides had been treated with arsenic and had been washed in a neighboring creek. The trouble maj' have been due to drinking the- water. SeA'eral cattle which drank of the water suddenly died. Editorial (Med. News, Sept. 4, '97). Seventy-two cases of anthrax met with in a factory near Paris where skins are tanned and wool prepared. Skins and fleeces coming from Turkey, Russia, Bul- garia, and Argentine are infectious. Of the 72 cases, 62 were cured, giving a death-rate of 14 per 100. Among the hands employed in treating skins there were 57 cases among 560, 15 among 160 workers engaged in preparing wool and tails. Prophylactic measures are of the greatest importance. M. le Roy des Barres (Brit. Med. Jour., Sept. 25, '97). Symptoms. — The clinical diagnosis is not always easy. The most frequent primary lesion is in the face. The first symptom is a sense of itching, followed by a red spot resembling a flea-bite; a small vesicle forms soon afterward, con- taining a bluish fluid. The surrounding skin is somewhat indurated and swelled. This changes into a black spot, which soon becomes gangrenous. If the oedema continues fresh crops of vesicles often appear, undergoing the same change, and infecting the adjacent lymphatic glands. The period of incubation is from one to three days, while the development of the local symptoms occupies from three to nine days. A line of demarkation may then form, and the slough separates. No pus is present. General disturbance be- gins only a day or two after the mani- festation of the disease. There may be no fever, bu.t in some cases, especially when the face is involved, a sudden rise of temperature may present itself, de- noting a dangerous condition. Headache, nausea, and pain in the muscles appear, with a weak and rapid heart. There is slight icterus. The prostration is great, and the last stages of the disease finds the patient almost in the algid stage of cholera. Case in which high fever (104.8° F.), with delirium, feeble pulse, and sweating, developed on the fourth day, previous to which the case had presented the char- teristics of ordinary phlegmonous cellu- litis. Recovery after excision, cauteriza- tion, and inoculation with cultures of bacillus pyocyaneus. C. E. Nammack (N. Y. Med. Jour., July 17, '97). When infection takes place through the alimentary canal, the disease begins with debility, depression of spirits, ma- laise, and probably a chill. In addition the symptoms point to the intestines- Haemorrhages occur from the mouth and' nose; vomiting is followed by a bloody diarrhoea. The diagnosis is, however,, extremely difficult, and the microscopical! examination of the blood or an inocula- tion of an animal furnishes the only con- clusive evidence. Difference between effects of the local- ization of the pneumococcus and that off 420 ANTHRAX. ETIOLOGY. the anthrax bacillus. In the former true eucephalitic phenomena are produced; in the latter, only haemorrhages. This is evidently ascribable to a difference in the metabolic products of the respective micro-organisms. E. Fraenkel (Zeit. f. Hyg. u. Infectionsk., B. 27, H. 3, '98). Etiology. — Anthrax was one of the first diseases traced to a specific micro- organism. Pollender discovered in 1849 small rod-shaped bodies in the blood of ani- mals suffering from anthrax, but Da- vaine, in 1863, proved their etiological significance. Pasteur and Koch, observ- ing that the bacilli bore spores, culti- vated them successfully outside of the body, and then produced the disease by inoculating animals with the pure cult- ures. The anthrax bacilli are large rods, with a rectangular form, caused by the very slight rounding of the corners. They measure 5 to 20 microns in length and are 1 to 1.25 microns in breadth. They form long threads, in which the single bacterium can be made out. At times isolated rods occur. In this stage granular bodies appear in the protoplasm of the bacilli. They eventually form glistening oval spores, one of which lies in each segment of the long thread, giv- ing the threads an appearance of a string of beads. The bacilli soon break up, and the spores become free. In this condi- tion the spores become highly resisting and can be preserved a very long time. If again placed under favorable circum- stances each spore will germinate into a mature cell. Spore-formation takes place only at temperatures ranging from 18° to 43° C, 37.5° C. being the most favor- able temperature. The anthrax bacilli can rapidly be stained by aqueous solutions of aniline dyes, and also by Gram's method. The spores are best stained at a high tem- perature by means of Ehrlich's aniline- water-fuchsin solution or Ziehl's solu- tion containing carbolic acid, instead of Ehrlich's fuchsin solution. The virulence of anthrax bacilli can be attenuated in various ways, such as subjecting them to a high or low tem- perature or making the cult^^re grow for a long time — twenty-four days or so — at a temperature of 42° or 43° C. By treating them in some such manner it is possible to render anthrax bacilli en- tirely innocuous (Koch, Loeffler). Pas- teur rendered sheep and cattle immune against anthrax by inoculating them with a culture which grew at a tempera- ture of 42° C. Dogs, pigs, and the majority of birds are immune from anthrax; also rats and frogs under ordinary conditions. But if a frog in whose lymph-sac are placed anthrax bacilli is put in an incubating apparatus, he will quickly die of anthrax. Birch-Hirschfeld and others have proved that anthrax bacilli can be transmitted from mother to foetus in utero. Experiments to determine the influ- ence of the serum of immunized animals. A sheep was immimized until it could bear the injection of 7 agar-agar cult- ures with but slight elevation of tem- perature. A lamb was immunized like- wise to the highest degree and blood was taken from the carotid artery of both animals in order to obtain serum. With the serum of the sheep it was actu- ally possible to save from death a rabbit in which an extremely virulent culture of anthrax was injected, either after or simultaneously with the serum. Evi- dent therapeutic results were obtained with this serum in animals that had received the anthrax bacilli previous to the injection of serum. The attenuated form of anthrax ia not microscopically different from the viru- ANTHRAX. PROGNOSIS. 421 lent foniij but it is quicker in growth and more resistant. The more virulent the growth, the more acid it is, and, vice versa, the more alkaline the blood- serum, the more difficult it becomes for the anthrax bacillus to grow. Behring (Zeit. f. Hygiene, Apr. 12, '89). E.xperiments on rabbits and sheep to ascertain relative value of serum-thera- peutics and vaccination. Intravenous in- jections of small doses of virus are not more severe than subcutaneous ones, but large quantities are far more lethal when given in the veins. A sheep vaccinated is refractory to a large dose of anthrax, but its serum has no curative power. When immunized to a very high degiee, the curative power of the serum may be- come marked from tAvo to three weeks after inoculation, after which its activity diminishes. By intensive inoculation of sheep a serum is obtainable, having dis- tinct prophylactic properties. As to the curative properties of the serum, that ob- tained from rabbits was not found strong enough to avert death. The immunity produced by this serum is evanescent ; that resulting from vaccination was, on the contrary, lasting. Marehoux (An- nales de I'lnstitut Pasteur, Nov., '95). No immunizing substances found in the blood either of animals treated with Pasteur's vaccine or of those Avho had passed through an attack of anthrax. In animals treated for weeks and months with increasing doses of virulent anthrax cultures so that an active immunity is acquired, such protective substances are present in the blood. The serum ob- tained from a sheep thus treated con- veyed a certain degree of immunity when injected into rabbits. Attempts at cure of the disease in rabbits were without effect. In 2 out of 7 sheep in which 100 to 1.50 cubic centimetres normal serum from a lamb were first injected, then small quantity of a virulent anthrax culture, both animals succumbed. Three other animals were given a single dose (.50, 100, and 200 cubic centimetres of serum) and later a virulent anthrax culture. All these animals recovered. The sixth and seventh animals were also injected with smaller virulent cultures and later with anthrax serum. Both recovered. Sobernheim (Berliner klin. Woch., Oct. 18, '97). Experiments showing the comparative value of alkaline solutions for the de- struction of spores. Cultures of anthrax bacilli rubbed up into an emulsion, the bacilli killed by exposure to a tempera- ture of 158° F., and remaining spores subjected for several days to the action of solutions containing carbolic acid alone, and other solutions containing in addition to carbolic acid in the same strength salts such as sodium chloride, sodium phosphate, and the like. The latter solutions proved much more active in preventing the gi'owth of the spores. ■\\Tien the spores were first introduced into a solution of sodium chloride and then into a mixture of a similar solution and carbolic acid, the growth of spores was much less active than when the simple salt solution was not used first. The author believes that the salts act by increasing the precipitation of proteids rather than by changing the molecular constitution of the carbolic acid. Romer (Munch, med. Woch., Mar. 8, '98). The sphalangi of Cyprus is an insect resembling an ant of medium size whose sting gives rise to anthrax. To this is ascribed the fact that anthrax is very common in Cyprus, especially among the animals, the bacillus being carried by the insect from the carcasses of such animals to human beings. G. A. Williamson (Brit. Med. Jour., Sept. 1, 1900). Case in which the source of infection was bone-dust which the patient had handled. The patient died on the fourth day after his initial symptom. The tem- perature did not rise above 100° F. The lesion was situated on the breast, where he had scratched himself, and there was an entire absence of pain, severe consti- tutional disturbance, and feeling of dis- tress. E. F. M. Neave (Lancet, Oct. 6, 1900). Prognosis. — The prognosis of anthrax in man, when infection takes place ex- ternally, depends mainly upon whether energetic surgical treatment is under- taken early enough. Lengyel and Ko- ranyi, by adopting suitable local treat- 432 ANTHRAX. PROPHYLAXIS. TKEAT.MENT. ment, lost only thirteen out of one hun- dred and forty-two cases. Patients with anthrax resulting from internal infec- tion (intestinal, pulmonary) very rarely recover. (Tillmann.) Of thirteen cases of anthrax under ob- servation, five died, in all of which the primary lesion was on the lateral aspect of the neck. In remaining cases the in- itial lesion ^\as situated on the forearm, cheek, forehead, occiput, and neck. The serious character of the lesion when it is situated in the neck ascribed to loose subcutaneous cellular tissue allowing ex- tension of the infection. Radical surgical treatment apparently aggravated the progress. Sick (Centralb. f. Chir., Sept. 9, '99). Prophylaxis. — The fact that French skins, since Pasteurian inoculation has been employed in French flocks, have been found to rarely cause anthrax speaks in favor of that method. Disin- fection, even by formol, is imcertain. Skins of French animals are never in- fectious, the result, it is believed, of an- thrax being almost stamped out among the French flocks by the practice of Pasteurian inoculation. Formol-vapor does not penetrate them sufficiently to disinfect thoroughly. The only safe- guard against anthrax infection is the Pasteurian inoculation. M. le Roy des Barres (Brit. Med. Jour., Sept. 25, '97). The present laboratory-method of pro- ducing immunity to anthrax gives rise to a very transient immunity, and in order permanently to protect animals that are spontaneously exposed it is necessary to modify the method so as to deprive the immunity of its transitory character. By combining passive im- munization (by means of serum) with active immunization a marked success observed. Sheep received mixtures of anthrax serum and attenuated anthrax cultures, and were still immune to viru- lent cultures one and one-half months afterward. A. G. Sobernheim (Berliner klin. AVoch., Mar. 27, '99). Treatment. — In man the disease re- mains localized a lons;er time than in animals. Hence it is possible to remove it more thoroughly. Complete extirpa- tion of the affected part, by means of the Paquelin thermocautery, and subse- quent cauterization with nitric acid are to be practiced. Complete excision of the pustule is the best treatment, except when vital structures are involved, in which case injection of strong solutions of the most energetic antiseptics may be used. H. L. Burrell (Annals of Surg., p. 621, '93). According to Koch, bichloride of mer- cury is the most effective poison for the anthrax bacilli, being capable of killing them when used as diluted as 1 part to 300,000 of water. Consequently it is a good plan to use, in and around the af- fected part, injections of 1 to 100 bichlo- ride or 2- to 5-per-cent. carbolic acid. General treatment has been very unsatis- factory, although Russian authors have met with success by the energetic use of carbolic acid locally and internally. Theoretical considerations should never deter one from operating, not only during the early stages, but at whatever period of the disease the cases present them- selves. There are a number of instances where success has followed excision even in the later stages. It seems that we have in the pustule a manufactory which supplies bacilli, in unlimited quantities, and, when this is removed, the phago- cytes are well able to cope successfully with the organisms which have escaped in the blood-stream. Lowe (London Lancet, Jan 23, '92). Case of anthrax of the nose in a tanner successfully treated with injections of carbolic acid and hot compresses (122° to 1.31° F., changed every ten minutes, day and night) . In the course of eighteen days more than 400 Pravaz syringefuls of 3-per-eent. solution of carbolic acid were given without signs of intoxication appearing. Alexander Strubell (Mun- chener med. Woch., Nov. 29, '98) . The fact that experiments have shown that ipecacuanha added to tubes contain- ANTIPYRINE. 433 ing 5 cubic centimetres of broth invaria- bly destroy the vitality of all the anthrax bacilli present, and no growth ensued (provided that they contained no spores) has suggested the use of this drug as a remedy. Ipecacuanha, locally, in form of pow- der and internally in doses of 5 grains every four hours advocated. Fifty cases so treated without a death. Maskett (Med. Chronicle, Aug., '91). Nucleinic acid has also given promis- ing results in the hands of Vaughan. Case of grave anthrax successfully treated with Marmorek's serum. In- cision and curetting had been of no use. A. L. Dupraz (Archives Prov. de Chir., Mar. 1, 1900). In anthrax and other septic conditions general infection must be prevented, yet no operation is indicated. Applications to the carbuncle, with fixation and in- ternal treatment, suffice. Operative in- terference may cause general infection; yet, when abscess forms, it should be thoroughly evacuated. A dry dressing is advised ; in some cases iodoform gauze and pure carbolic acid are good. In all but very slight conditions moist dress- ings are contra-indicated. E. Lexer (Die Therapie der Gegenwart, Jan., 1903). Ehitest Laplace, Philadelphia. ANTIPYRINE.— Phenazonum (Br. Ph.); antipyrinum (Ger. Ph.). Antipy- rine is an alkaloidal product from the destructive distillation of coal-tar, dis- covered by Knorr. It is known chemic- ally as dimethyl-oxy-quinizine of phe- nyl-dimethyl-pyrazole (organic base from oxyphenyl-methyl-pyrazole). It is known also as analgesine, methozine, parodyne, phenylone, and sedatine. It occurs as a fine, white, crystalline powder, and is soluble in chloroform, in an equal weight of water, in 2 parts of alcohol, and in 50 parts of ether. It melts at 105° to 113° C. (210° to 235.4° F.) according to dry- ness. It has antipyretic, analgesic, seda- tive, styptic, and antiseptic properties. The following substances incompatible with antipyrine are said to precipitate the drug from concentrated solutions: Carbolic acid in saturated solution, tannin (a white insoluble precipitate), mercuric chloride (white precipitate soluble in an excess of water), infusion and tincture of catechu; infusion, fluid extract, and tincture of cinchona-bark; infusion of rose-leaves, infusion of uva ursi, tincture of hamamelis, tincture of iodine (precipitate soluble in water), tincture of kino, tincture of rhubarb; solutions of chloral, arsenic, and mer- cury; and alkalies. In the following mixtures antipyrine is decomposed: Calomel forms with anti- pyrine a toxic combination; antipyrine in decomposed when rubbed up with betanaphthol; with chloral, antipyrine forms an oleaginous liquid; with sodium bicarbonate it disengages the odor of ether; with equal parts of sodium salicy- late it forms an oleaginous mixture. The following substances produce col- oration when added to aqueous solutions of antipyrine: Hydrocyanic acid: dilute solution — yellow; nitric acid: dilute solution — pale yellow; ammonia alum: dilute solution — dark yellow; amyl-ni- trite: acid solution — green; nitrous ether: alcoholic solution — green; fer- rous phosphate: yellow-brown; ferric sulphate: blood-red; ferric chloride: blood-red; syrup of iodide of iron: red- brown. Dose. — The usual dose for adults is 15 grains in powder or dissolved in water, syrup, or elixir, every two to six hours, or four or five times daily. The maxi- mum single dose for an adult is 20 grains. The maximum doses for children are: 6 months to 1 year, 3 grains; 1 to 3 years, 4 to 5 grains; 4 to 5 years, 4 ^/a to 6 grains; 6 to 8 years, 7 V„ to 9 grains; 10 424 ANTIPYEINE. ADMINISTRATION. to 13 years, 9 to 10 V2 grains. Gener- ally, it will be found that small doses, repeated at intervals of two hours, are attended with therapeutic effects and with less danger of untoward symptoms than larger doses given at longer inter- vals. Caution against the simultaneous use of antipyrine and calomel. Their reac- tions result in the formation of a danger- ous amount of corrosive sublimate, even when ordinary medicinal doses are given. H. Werner (Pharm. Zeit., June 10, '96). Antipyrine and sodium salicylate can- not be dispensed together in powder form; immediately, or within a short time, liquefaction takes place, and when the powders reach the patient he is likely to find no powder at all, but only thoroughly soaked pieces of paper. W. J. Eobinson (N. Y. Med. Jour., Oct. 30, '97). In giving the drug the personal idio- syncrasy of the patient should be con- sidered, as well as the integrity of the urinary and cardiac functions. A dose which would be safe for a person with healthy heart and kidneys might cause dangerous symptoms in a case where these organs are diseased. (Lepine.) Case of idiosyncrasy to antipyrine. Author suffered from migraine and used to be in the habit of taking 15 gi'ains of antipyrine during the attacks. These were followed by the occurrence of small, aphthous ulcers on the mucous mem- brane of the lips, cheeks, and tongue, which healed very slowly. Another time his lower lip became swollen and ffidema- tous, and in two hours an ulcer appeared on the tongue. Several others shortly afterward formed on the lips and cheeks, and took fourteen days to heal. In ad- dition he suffered from dermatitis about the genital region. Another ease of the same nature met with in practice. In- tolerance of the same kind gradually developed in him to all drugs of the same class, — quinine, antifebrin, phenacetin, and sodium salicylate, — which he had used to check the migraine. Steinhardt (Ther. Monat., Nov., *93). Case of a young man who had often taken antipyrine without discomfort until he was 17 years of age, when he suffered from typhoid fever, and devel- oped marked intoleranc to this drug. In the course of the following year he took it several times, once a dose of 15 grains, afterward half this dose, then only 3 or 4 grains, and finally between 1 and 2 grains. Even after the smallest dose unpleasant symptoms appeared. At first there were marked twitchings in the genital and anal regions. In a few days there appeared here numerous blebs, which burst and formed scabs. On the gums there appeared also little blisters. The remarkable fact in this case is that intolerance developed after typhoid fever. (Jour, de M6d. et de Chir., Dec. 25, '90.) A review of cases in which dangerous symptoms or death had followed sug- gests that antipyrine should not be given in antipyretic doses to fever patients, because it interferes with the action of the kidneys, and that in febrile conditions complicated by nephritis (pneumonia, typhoid fever, tuberculosis, etc.) it is contra-indicated. It must be avoided in true angina pectoris, because it acts in- juriously on the heart-muscle, and there is always danger of cardiac dilatation in this affection. In the neuralgic form of angina pectoris there is no reason for preferring its hypodermic use to that of morphine. "Weakness of the circulation, too, is a contra-indication to antipyrine. (Eloy.) Warning against its employment in all cases in which the kidneys are dis- eased, since its elimination is interfered with, and toxic effects might arise. Ar- teriosclerosis should not be treated by it, even when the kidneys are not afl'ccted. Huchard (Jour. Amer. Med. Assoc, July 7, "88). Contra-indications for the employment of antipyrine: a weak heart; diphtheria, with phenomena of myocarditis; profuse hsemorrhages ; in debilitated subjects; convalescence from chronic fevers; and the night-sweats of tuberculous patients. ANTIPYRINE. PHYSIOLOGICAL ACTION. 435 B. Martin (L'Union M6d., Oct. 20, 22, 27, ■91). Persons suffering from erysipelas seem to be peculiarly susceptible to antipyrine. It usually causes anuria and a profound fall of temperature, requiring caffeine and hot applications. Erysipelas is one of the infectious disease- in which anti- pyrine is contra-indicated. Spanoudis (L'Abeille Med., Mar. 27, '97). Antipyrine should never be prescribed for veiy old people, for subjects attacked with non-compensating cardiac lesions, or for those in an adynamic condition. In influenza and erysipelas it should always be associated with quinine, and, in convalescence, M'ith strychnine or caf- feine. In arthritic subjects, who are nearly always dyspeptics, it should be associated with an alkali (sodium bi- carbonate or sodium benzoate) and pre- scribed in solution. If it cannot be taken except in a capsule, the patient should drink a quarter or half a glass of "Vichy immediately after taking the capsule. In tuberculous subjects 12 grains at a time should not be exceeded, and the condition of defervescence should be care- fully watched. It is well, in this case, to combine alcohol and antipyrine and give the latter in solution. In diabetic subjects the association with alkalies is obligatory. In children antipj'rine may be administered without inconvenience even in amounts proportionately larger than in adults, provided it is given in divided doses. This tolerance depends as much upon the integrity of the renal function as upon the mode of adminis- tration, which should nearly always be by the solution. M. V. Clement (Gaz. Heb. de Mgd. et de Chir., Sept. 26, '97). Antipyrine intoxication after the in- gestion of 15 grains in the form of mi- grainin. The symptoms were dryness in the mouth, painful redness and swelling of the fingers, vesicles on hard palate, salivation, purpuric eruption on legs, ec- zema of scrotum, oedema and vesicles of lower lips, oedema of prepuce, fever, and rapid pulse. G. Graul (Deut. med. AVoch., Jan. 19, '99). Three cases of a remarkable eruption caused by antipyrine. This eruption con- sists of dark blotches in the skin of the penis, sometimes accompanied by oedema. In one case the eruption appeared four and a half hours after the first dose was taken. The patients were alarmed, think- ing that gangrene of the penis wag going to follow. Fournier (Ann. de Derm, et de Syph., Apr., '99). Physiological Action. — Antipyrine is excreted by the kidneys, and may be found unchanged in the urine. Perret and Givre have shown that, no matter what the age of the person may be, elimination by the urinary tract begins at the same time, varying from three- fourths of an hour to an hour. They found, however, that the elimination is finished sooner in the child than in the adult, and likewise in the adult than in old age. The conditions causing accumu- lation in the system do not influence in any manner the time of the appearance of antipyrine in the urine, but notably increases its duration. Any of the sub- stances producing coloiation when added to aqueous solutions may be used as a test to detect the presence of antipyrine in the urine, but ferric chloride is most generally employed for the purpose, de- tecting antipyrine in dilutions as high as 1 to 100,000. The elimination of antipyrine when given by the rectum occurs from the mucous membrane of the stomach, in from one-fourth to one-half hour before taking place by the kidneys. P. Kandi- doff (Wratseh, No. 13, '93). Antipyrine appears in the urine forty- minutes after its ingestion by the stom- ach and thirty minutes after its intro- duction by the rectum. Lamanski and Main (Le Bull. Med., Jan. 29, '93). Antipyrine may be excreted from the rectum, the mouth, or from the subcuta- neous connective tissue when given by hypodermic injections. When a medium dose (10 to 15 grains) is given, we notice a fall of temperature, from one to five or more degi'ees, at the 426 ANTIPYRINE. POISONING. time the temperature becomes very sub- normal. This reduction of temperature is apparently not due to the diaphoresis induced, which is sometimes small in amount, but by its inhibitory action upon the heat-regulating centres in the nerv- ous centres. This action is seen in health as well as in disease. "With the reduction in temperature is noticed an increased action of the sweat-glands, perspiration being seen first about the forehead and neck, and later upon the chest and face. Chilly sensations, which may be experi- enced if the sweating is excessive, can be removed or prevented by the exhibition of stimulants: atropine or agaricin. Stim- ulants will also prevent the depressing action upon the heart. With the calorimeter of d'Arsonval heat-dissipation found to be decreased, there being a corresponding diminution in the process of heat-production. Des- tree (Jour, de Mgd., de Chir., et de Pharm., July 20, '88). The reduction of temperature produced by antipyrine is exclusively due to in- crease of heat-dissipation, while the phenomenon of heat-production remains unaffected. Gottlieb (Arch, exper. Path, u. Pharm., vol. xxviii, H. 3, 4, '91). Antipyrine produces a decided fall of temperature in the first hour after its administration in the fevered animal; this reduction is due to a great increase in heat-dissipation, together with a fall in the heat-production. Cerna and Car- ter (Notes on New Remedies, Sept., '92). The pulse is generally reduced in fre- quency concurrently with the fall in temperature, but not in the same ratio, and sometimes not at all. The blood- pressure is usually increased with the fall of temperature, but is occasionally reduced by reason of a dilatation of the peripheral blood-vessels. The heart -beat is generally reduced and the force of the systole is lessened, at least to some ex- tent, and in this lies the great danger attached to its use: a contrary efEect to that produced by quinine, which sus- tains the heart. In regard to the influence of the drug upon the secretion of urine, experiments have shown that the quantity is dimin- ished in twenty-four hours; this is also the case as regards the amount of urea eliminated under its use. Antipyrine in doses of 30 grains causes an increase in the number of leucocytes in the blood and a decrease in the quan- tity of uric acid eliminated by the urine. J. Horbaczewski (Litzungs b. d. K. K. Wiener Akademie der Wissen., p. 101, '92). Antipyrine, in doses of 30 grains, causes a diminution in the quantity of uric acid eliminated by the urine and an increase in the number of leucocytes in the blood; unlike quinine, it does not produce atrophic changes in the spleen. J. Horbaczewski (Bull, du Comite Agric. du Dept. de I'Aube, T. C, Sec. 3, p. 101, '92). Antipyrine Poisoning. — The use of antipyrine is not always void of danger. Very unpleasant, even dangerous and fatal results are on record. The dose does not always determine the effect produced, and it would seem that some persons are extremely susceptible to its toxic action. In addition to idiosyncrasy, a diseased condition of the brain, heart, or blood-vessels, and especially of the kidneys (organs eliminating antipyrine) seems to heighten the effects of the drug on the system, so much so as to interdict its use altogether. Antipyrine is a dangerous drug. It ought to be scheduled as a poison, only to be dispensed on a written order from a qualified medical practitioner. By com- bining some preparation of ammonia with antipyrine, the latter drug can be prescribed with less fear of unpleasant sequelae. H. W. McCauUy Hayes (Brit. Med. Jour., Feb. 1, '96). The toxic effects of antipyrine when ingested are, in general, those of an irritant poison: abdominal pain, nau- ANXIPYRINE. POISONING. 427 sea, heart-burn, and in some cases vom- iting, intense colic, and diarrhosa. These effects may be avoided by rectal admin- istration of the drug. In addition to these effects upon the gastro-intestinal tract, we notice a diminution of body- heat, in some cases becoming subnormal, the skin becoming cold, cyanotic, and covered with a clammy perspiration, .sometimes followed by unconsciousness, collapse, coma, convulsions, and even death. In rare cases an elevation of tem- perature follows its use (paradoxical ac- tion), possibly due to interference with renal function and the presence of urea or leuuomaines in the blood; several cases of this action have been reported. The administration of 15 grains has been followed, in several cases reported, by violent sneezing, a copious watery dis- charge from the eyes and nose, constric- tion about the throat, loss of voice, and dyspnoea, with a sense of intense burn- ing in the nose, mouth, eyes, ears, and throat and distressing tinnitus aurium. Vertigo attended by dyspnoea, and a feeble, fluttering, and intermittent pulse are not infrequently observed. Disturb- ance of the vasomotor system is observed in some cases, resulting in cedema (some- times of the glottis, causing suifocation) of the extremities or face with a dimi- nution in temperature and a tendency to cyanosis and collapse. Case of poisoning by antipyrine. Within a quarter of an hour after tak- ing a dose of 10 grains the patient felt vei-j' ill. His face was cyancsed, his lips and nose swollen and blue^ and his eyes almost closed from swelling of the eye- lids; skin was cold and clammy; sweat- ing; pulse, 128, very weak, small, and compressible. Pupils widely dilated. Administered 5 grains of carbonate of ammonia, Vw, grain of digitaline, '/» grain of strychnine, and 'A ounce of vinum aurantii. The next quarter of an hour his condition improved as far as the symptoms of cardiac depression were concerned. Recovery. H. W. McCauUy • Hayes (Brit. Med. Jour., Feb. 1, '96). Case of an anaemic girl of 19, who took a draught containing 5 grains of anti- pyrine and 7 grains of bromide of potas- sium, with a drachm of compound spirit of ammonia. Toxic symptoms appeared about ten minutes after the draught was taken. A few minutes later the follow- ing conditions were present: Cold shiv- ers, severe and gasping dyspnoea ; the face was swollen, especially about the eyes, so much so as to prevent any possibility of opening them or of seeing, except with great difficulty, the pupil; and the body was covered with a bright-red rash, like scarlet fever, resembling that of urticaria, so that it presented wheals, which were of different sizes: from that of a small papule to some as large as five-shilling pieces. The temperature in the axilla was 97° F., and the pulse, which was very intermittent, was only 50. She complained of no pain. The tongue was very dry. The lips and gen- eral aspect were decidedly cyanotic. Stimulants, with strychnine and digitalis, were given. The shivering passed off in about three hours, but the other symp- toms continued for about eight hours. The rash did not disappear for thirty hours. E. Webster (Lancet, Jan. 30, '97). Poisoning by antipyiine in a middla- aged woman, convalescent from typho- malarial fever. After taking 10 grains of antipyrine, 20 minims of spiritus am- moniae aromaticus, and 1 ounce of water, she was very pale, but not cyanotic; no swelling of the eyelids, but almost com- plete loss of sight; rash, which disap- peared in about eighteen hours, resem- bling that of urticaria. Patient rallied well on the administration of hot coffee and whisky. Recovery. F. G. Wallace (Lancet, Feb. 6, '97). Case of a woman, aged 50 years, poi- soned by 7 grains. After an hour : swell- ing and redness of the upper lip. After three hours : pain in the eyes ; paralysis, swelling, and smarting of the tongue. Speech difficult; salivation. An hour later: chilliness, sensations of heat; and, later, syncope, vomiting, and diarrhcea. 428 ANTIPYEINE. POISONING. The next morning there was an eruption upon the face^ arms^ hands, and thighs which resembled scarlet fever, with marked burning and itching about anus and vulva that gradually extended over the whole body. These symptoms grad- ually disappeared in two weeks. Severe desquamation. Scheel (Ther. Monat., H. 3, S. 161, '97). Case showing that antipyrine may un- expectedly prove poisonous in a small dose (7^/, gi-ains, in this instance) in a person who has shown no special idiosyn- crasy toward it, after taking the drug on many previous occasions. Eisenmann (Tlier. Monat., Apr., '97). Case in which a dose of 10 grains of antipyrine caused acute pain in the ab- domen, emesis, and rapid swelling of the face, almost closing the eyes. This was followed by two periods of collapse, one lasting a half-hour. Recovery followed. The patient had taken similar doses be- fore with no ill effect. H. Blakeney (Brit. Med. Jour., July 8, '99). The toxic action of antipyrine on the blood seems to be a transformation of its oxyhasmoglobin into methEemoglobin. The action of antipj'retics on the blood when administered in toxic doses may be summed up as a transformation of oxyhaamoglobin into methsemoglobin. A phase of_ anDemia, or diminution of oxy- hfemoglobin, precedes the accumulation of methtemoglobin. In this period there is at the same time production and elimi- nation of methffimoglobin; if elimination be hindered or transformation be too rapid, phenomena of cyanosis may be produced which must be distinguished from those of the period of intoxication. Hgnocque (La Semaine Med., Mar. 27, '95). Blood of frogs and blood taken from the cyanosed lips and other parts of a rabbit, both ante- and post- mortem, ex- amined spectroscopically. The rabbit had died from toxic effects of antipyrine, yet the spectrum of methsemoglobin was certainly not present. Andres Halliday (Montreal Med. Jour.. July, '97). The poisonous effects of antipyrine upon the nervous sj'stem have been studied by Langlois and Guibaud. By graduated doses, given to animals whose spinal cord had been divided below the medulla oblongata, they discovered sev- eral stages of antipyrine poisoning. First, a cerebral stage, in which clonic epilepti- form convulsions are limited to the head; second, a cerebro-spinal stage, in which the head is still affected with clonic con- vulsions, while the trunk is attacked with one or more tonic spasms (opisthotonos); third, a cerebral stage, with spinal hyper- irritability, in which the shocks caused by the clonic convulsions of the head set up violent reflex movements of the body, comparable to the spasms of strychnine poisoning; fourth, the reflexes of the head disappear at the same time as those of the trunk. Antipyrine has, then, an elective action in the higher centres, and this explains why its sedative action is more marked in head affections than in spinal. Experiments apparently proving that the main action of the drug is upon the neiwous sj'stem, not in its peripheral por- tions, but rather upon the spinal cord and brain. Batten and Bokenham (Brit. Med. Jour., June 1, 'o9). Experiments sustaining Batten and Bokenham as to the effect of the drug upon the spinal cord, and in its local and general action as a sedative to the sensory nerves. Also in accord with most observers in the statement that antipyrine does not affect the circulation to any extent in moderate doses. Simon and Hoeh (Johns Hopkins Hosp. Bull.; Apr., '90). The deleterious effects manifested in the cutaneous system are very varied. There may be merely a sensation of great itching or burning without the appear- ance of any eruption, which disappears rapidly upon the discontinuance of the drug. If an eruption appears, it may take the form of erythema, urticaria, petechife, or papule, or resemble in ap- ANTIPYRINE. POISONING. 429 pearance one of the exanthemata: measles, scarlatina, etc. In rare cases we note discoloration of the face and of the mucous membrane of the mouth, swelling of lips, tongue, and salivary glands, with epileptoid attacks, amauro- sis, tinnitus, deafness, and delirium. In rarer cases the ingestion of anti- pyrine is followed by the appearance of albuminuria, hasmaturia, ischuria, or strangury. Urticaria produced rapidly by a single dose of 10 grains of antipyrine. E. Knight (Brit. Med. Jour., May 18, '95). Case in which entire surface of the body was covered with a copious erup- tion exactly resembling in appearance that of a severe case of measles; the face and eyelids were also swollen, after taking 10-grain powders of antipyrine twice daily for three weeks. No symp- toms of cardiac depression appeared to be produced by the drug. Webber (Lan- cet, .June 6, '96). Case of a gouty person of 65 years, who had often taken antipyrine without bad effects. One day a dose of 30 grains caused aphthous stomatitis, while an in- jection of 15 grains produced an ulcera- tive stomatitis with a purpural eruption. Dalche (Med. News, Feb. 13, '97). Case of a woman of 33 years, who, several hours after the ingestion of anti- pyrine, developed a general pemphigus- like eruption upon the skin and also upon the buccal mucous membrane. This condition lasted ten days. There was also a scanty urine, but no albu- minuria. Opinion that eruptions ai-e only likely to occur in persons with renal lesions. Lyon (L'Abeille M^d., Mar. 27, '97). Case in which there was oedema of the lower extremities and the vulva, with blebs forming under the skin after full doses. These symptoms ceased when the drug was stopped. Goldschmidt (L'Abeille M6d., Mar. 27. '97). Case of a woman who had syphilis in 1894, for which she ^^•as thoroughly treated. Near three years later syphi- litic manifestations appeared, which dis- appeared under treatment. In April, 1898, she took 7 'A grains of antipyrine on account of headache, and on following day had a crop of vesicles in the mouth, which soon disappeared. A few days later she took another dose of 7 'A grains of antipyrine. In the same evening she shivered, and was feverish, and had an urticarial eruption over the body. On the next day there were numerous ves- icles on the mucous membrane of the cheek, soft and hard palate, upper and lower lips, and also on the vaginal mu- cous membrane. Patient thought this relapse of the syphilis. In four days vesicles began to dry up, but food was taken with difficulty. Urticaria-like rash had now disappeared. Nothing but sim- ple treatment used. Immerwahr (Ber- liner klin. Woch., Aug. 22, '98). In some cases there is a marked re- semblance between antipyrine poisoning and the algid stage of cholera. Case in which there was severe col- lapse, cold extremities, vomiting, hoarse voice, and sunken eyes. The stools, how- ever, were solid, and there was a deep, rose-red rash on the patient's body. His radial pulse could not be felt. He an- swered questions slowly, complained of headache and noises in his ears, and had disturbed vision. He had taken 2 V2 drachms in 15-grain doses twice daily. Recovery under the use of stimulants. Guttmann (Ther. Monat., Oct., '92). Case of a girl of 20 years, who took 81 grains of antipyrine for the relief of headache. She did not lose conscious- ness, but the pulse became almost imper- ceptible, reaching 200 per minute. She recovered under absolute rest, strong coffee internally, and ice externally. Krysinski (Gazeta Lekarska, No. 39, '93). The dangerous and uncertain action of antipyrine in many cases renders precaution highly necessary. When the drug is known to disagree its use should be avoided. When disease of the heart, functional or organic, or of the kidneys is present, antipyrine should not be given or if necessary or expedient, it should be carefully guarded by administering stim- 430 ANTIPYRINE. LOCAL USE. ulants simultaneously. During lactation antipyrine should not be given unless we wish to control the function or cause the milk to disappear. Antipyrine in nineteen cases to sup- press the lacteal secretion. It was given every two hours in capsules containing 4 grains, and a longer interval was allowed to pass between the dose which preceded and that which followed the two meals of the day. The results in all the cases were very favorable. After the absorption of the antipyrine the breasts became empty and soft, and the lacteal secretion was completely ex- hausted. Antipyrine is one of the most inoffensive medicaments for the suppres- sion of the lacteal secretion known. Guibert (Jour, des Prat., Apr. 17, '97). Antipyrine certainly passes in a nat- ural state into the milk. Given in large doses, in two capsules each containing 15 grains, at intervals of two hours, it may be detected in the milk in from five to eight hours after its ingestion, while from nineteen to twenty-three hours afterward none can be found; hence elimination lasts eighteen hours at' the maximum. The antipyrine during this time passes into the milk only in an ex- cessively weak proportion, very much less than fifty parts in a thousand; it is only in exceptional conditions — for instance, when GO gi-ains are adminis- tered in sixteen hours — that it per- ceptibly reaches this proportion. It does not influence, in any way, the quality of the milk and, particularly, the lactose, the casein, or the fat. It seems to have no action at all on the secretion, which always remains very abundant, provided the woman continues to nurse. From the absence of general symptoms and from examinations of the weight, the in- finitesimal quantity absorbed by the nursling does not seem to have any un- favorable action. M. G. Fieux (Bull. M6d., Sept. 5, '97). Arteriosclerosis and depressed condi- iions of the system (typhoid fever asso- ciated with weak heart, typhoid pneu- monia, etc.) centra-indicate the use of antipyrine. Treatvient of Antipyrine Poisoning. — If a patient is already suffering from antipyrine poisoning our chief reliance must be placed upon stimulants: brandy, ether, ammonia, atropine, and heat ap- plied to the extremities seem best to meet the indications. As the symptoms are those of collapse, all efforts should tend toward the restoration of body-heat and normal heart-action. The presence of any renal difficulty will suggest its own appropriate treatment, in addition to that used primarily to combat the toxic effects of the antipyrine on the heart. Sodium bicarbonate is recom- mended as an antidote to antipyrine by Lepine, of Lyons, who prefers it to atropine. Local Use. — Saint-Hilaire and Cou- pard have employed antipyrine locally in affections of the throat and larynx attended with symptoms of exaggerated sensibility, and have demonstrated its anaesthetic properties. They advise a solution of 1 part of the drug to 2 V, parts of distilled water, used in an atom- izer. Cazeneuve, of Lyons, has found antipyrine serviceable in cystitis with ammoniacal urine used in a d-per-cent. solution. The pain is diminished and the character of the urine modified. For operations in the pharynx and larynx, a 10-per-cent. solution of cocaine should be applied, followed by parenchy- matous injection of 50-per-cent. anti- pyrine, the dose of the latter being 3 to 6 grains. Complete local ansesthesia en- sues in from 10 to 15 minutes and lasts 8 to 12 hours. Wroblewski (Medicine, Feb., '98). In cases of acute tonsillitis a gargle, composed of 2 V2 drachms of antipyrine, 2 V2 drachms of chlorate of potassium, 3 ounces of peppermint-water, and 8 ounces of distilled water, is useful when- ever the painful crises occur. As a substitute for cocaine in a num- ber of eases of urethrotomy, a 10-per- cent, solution of antipyine in 1-per-ceiit. ANTIPYEINE. HYPODERMIC USE. THERAPEUTICS. 431 solution of carbolic acid used. The solu- tion appears to be quite as efficacious as cocaine. The solution should be fresh, and should be allowed to remain in tlie urethra for ten minutes, as a rule. Un- like cocaine, the styptic effect of anti- pyrine is not followed by vascular re- laxation and often almost uncomfortable haemorrhage. G. Frank Lydston (Jour. Cut. and Genito-Urin. Dis., May, '98). As an anassthetic in cases of parturi- tion, antipyrine is useless for the pains of a perfectly normal labor, but finds its chief value in those cases where the pains are so excessive as to reflexly inter- fere with the proper uterine contractions. It is also useful when the liquor amnii has been discharged too early and where there is rigidity of the os. In regard to the second stage of labor, antipyrine is useless. There is evidence, however, that antipyrine has considerable ability to re- lieve the so-called after-pains. It is also seemingly a fact that antipyrine may be used with some success for the purpose of quieting a tendency to the development of pains before the full term has been reached. If it is intended to use anti- pyrine for the purpose of arresting a threatened miscarriage, then its dose must be very large: as much as 30 or 40 grains given in two or three doses of 15 grains each, at half-hour or hour in- tervals. (Misrachi, Hare.) Antipyrine has a powerful haemostatic action when applied locally. It acts by vasoconstriction and retraction of the tissues, with the formation of a minute clot, which is extremely retractile and aseptic. In epistaxis antipyrine may be employed in a 20- to 50-per-cent. solu- tion to the bleeding-point by means of a tampon. For ordinary use as an haemo- static, a 10-per-cent. solution is sufficient. Park, of Buffalo, advises a sterilized 5- per-cent. solution used as a spray, on compress, or as injection. Antipyrine is particularly indicated ia epistaxis, in a Vs or Vo solution to the- bleeding-point by means of a tampon. For ordinary use as an haemostatic a Vio solution is sufficient. It is also of value in dental, tonsillar, and uterine htemorrhages. X. Grfipin (These de- Paris, .July, '95). Hypodermic Use. — Antipyrine has been used subcutaneously in various afEections, but its use in this way is followed by ex- cruciating pain, which lasts about half a minute, and by abscess and gangrene in some cases. Such injections are believed to be particularly injurious where neu- ritis is the prominent lesion. Since the beginning of hypodermic treatment, some way of administering- quinine in this way needed, especially in severe malaria. The difficulty may be overcome by using Laveran's formula, (hydrochlcrate of quinine, 3; antipy- rine, 2; distilled water, 6), giving a oO-per-cent. solution, of Avhich the injec tion is painless. This solution, exten- sively used by Blum in 1894 during a severe malarial epidemic in Algiers, wis always found satisfactory Santesson (Deut. med. Woch., B. 2, Sept., '97). Therapeutics. — As already stated, anti- pyrine is especially useful in reducing- very high temperature when unassociated with weak heart. For this reason it is valuable in the typhoid fever of children. It not only causes the desired reduction in temperature, but also has a happy effect in calming the restlessness and dis- tress caused by the action of the toxins upon the nervous system. In the pneu- monia of children it has been found to be eqtialljf valuable, and it is a desirable remedy in the fever accompanying the exanthemata (measles, scarlatina, etc.). In healthy children antipyrine is the most active drug in causing perspiration ; next in activity is phenacetin; sodium salicylate and quinine show scarcely any influence whatever; acetanilid causes a diminution. In febrile children acetan- ilid increases the perspiration most.;. 432 ANTIPYRINE. THERAPEUTICS. antipyrine not to the same degree; while sodium salicylate, quinine, and phenac3- tin cause suppression of the secretion. Ssokolow (Wratsch, Nos. 14, 16, 21, '93). In influenza it not only controls the febrile movements, but relieves the pain and quiets the nervous system, but its depressing effects are sometimes harm- ful. In the hectic fever of tuberculosis it will sometimes be useful; but, as it influences the extension of the disease but slightly, if at all, and causes profuse diaphoresis and depression, other reme- dies are to be preferred. Nervous Disobdees. — It is in the treatment of neuralgia that antipyrine finds its best place. In hemierania, sci- atica, lumbago, the fulgurant pains of locomotor ataxia, the neuralgic pains of dysmenorrhoea when of ovarian origin, and in pains of nervous origin generally, antipyrine will be found of great value, being both efiieient and prompt in its action. Small doses, from 5 to 10 grains every four hours are generally efiieient. If ineffectual, the dose should be in- creased with caution, or the interval between the doses be shortened. In spas- modic conditions referable to the nervous system, bronchial asthma, laryngismus stridulus, pseudo-angina (not in true angina), and idiopathic epilepsy the fol- lowing combination has been recom- mended by H. C. "Wood: — ]^ Antipyrine, 6 grains. Ammonium bromide, 30 grains. — M. To be administered three times a day. Forty-three cases of idiopathic epi- lepsy, in which the most excellent re- sults were obtained by a combination of antipyrine and bromide of ammonium, as first suggested by H. C. Wood. The combination did not fail to give relief in a single one of the cases reported, and neither bromism nor the disagree- able effects often produced by antipy- rine were observed. The dose employed in adults was 6 grains of antipyrine and 20 grains of bromide of ammonium three times a day. Charles S. Potts (Univ. Med. Mag., No. 1, '90). Beneficial efi'ects in forty out of sixty cases, but in three-fifths of these cases the affection recurred. One-half to 1 V2 drachms weW tolerated for some weeks. Leroux (Revue Men. des Mai. de I'En- fance, June, '91). [Antipyrine in 15-grain doses is prob- ably the best of all drugs in systematic dysmenorrhoea, especially if accompanied by headache. E. E. Montgombby, Assoc. Ed., Annual, '94.] Tried in an obstinate case of puer- peral coccygodynia of two years' dura- tion in which extirpation of the coccyx was seriously contemplated. Immedi- ately after the first injection of a Pravaz syringeful the pain markedly decreased, while after a third it disappeared al- together and never recurred. Goenner (Corresp. f. Sehweizer Aerzte, Jan. 25, '95). Case of exophthalmic goitre with pe- culiar eye-symptoms. Under antipyrine treatment retraction of the upper lid (Stellwag's symptom) disappeared, while failure of lid to descend upon downward movement of the eye (Graefe's symp- tom) remained unchanged. J. Hinshel- wood (Brit. Med. Jour., Aug. 20, '98). Antipyrine is essentially a nervine, and acts as an analgesic and antispas- modic. In pertussis, therefore, it is plainly indicated. By diminishing the irritability of the superior laryngeal nerve, which, by reflex, produces the cough, it arrests the attacks of cough- ing and prevents secondary symptoms. This action on the nervous element of the cough is the least disputed of the effects of antipyrine in pertussis. Of eighteen patients seen by le Goff, in seventeen the number of attacks and their intensity diminished considerably, and in nine recovery occurred in less than twenty-five days, thus considerably redu.cing the duration of the disease. Antipyrine being an antiseptic, the in- ANTIPYRINE. THERAPEUTICS. 433 fectious principle of the disease is also reached. Fifteen cases treated with antipyrine with marlced success, the drug proving inefficient in only one instance. In some cases the eflects were really astonishing; this was especially the fact when treat- ment was commenced in the early stages, at a time when medication is generally useless. In may instances the disease appeared to be aborted, and in others it was rendered so mild as to be insig- nificant. J. P. C. Griffith (Ther. Gaz., Feb. 15, '88). Antipyrine employed in 300 cases of pertussis in which 196 patients were cured or benefited. The average dura- tion of the treatment was thirty-five days. From 5 to 15 grains for children up to 3 years of age, and from 30 to 60 grains for older children and adults. The only symptom observed to follow the use of antipyrine is albuminuria, which appeared in two eases; it dis- appeared, however, rapidly after the cessation of the use of the drug and the establishment of a milk diet. Le Gofl (Gaz. Heb. de Med. et de Chir., Oct. 22, '96). In mental diseases antipyrine is con- tra-indicated, its depressing influence upon the nervous system tending to aggravate the pathological process. It sometimes prevents hallucinations and other sensory disturbances of reflex origin. In most cases, however, no effect is produced or the symptoms are aggra- vated. Marandon de Montyel (Bull. G6n. de Ther., Apr. 30, '93). Antipyrine in doses of 15 grains re- newed in two hours recommended to produce sleep. One to 1 'A drachms frequently given per day for a fortnight at a time, without ill effects. J. B. Tuke (Edin. Med. Jour., Feb.-June, '94). Eheumatism. — In the treatment of iheumatism and gout antipyrine holds a well-recognized position of merit, reliev- ing the acute pains incident to those affections and controlling the fever as well. It is, however, less desirahle than 1- the salicylates in rheumatism or colchi- cum in gout, and, moreover, is not de- void of serious danger if there be any lesion of the heart or blood-vessels. It often se€ms to act specifically in acute and subacute rheumatism, after salicylic acid has failed. R. Hirsch (Ther. Monat, Oct., '88). Case in which the temperature twice rose to 106° F., and was reduced by 10- graiu doses of antipyrine. A. E. God- frey (Brit. Med. Jour., Nov. 4, '93). Antipyrine used subcutaneously : 15 minims to 30 minims, followed by mass- age at the point of injection, used in 130 cases of lumbago; 122 cured. The syringe should be carefully cleansed after use, as the antipyrine will ruin the in- strument if allowed to remain. Excru- ciating pain is produced, but it continu s but half a minute. Bergquist (Eira, vol. xiv. No. 3, '95). Diabetes. — Antipyrine has been rec- ommended in the treatment of this affection, hut its merits as regards the permanency of results have not been sustained by the experience of clinicians at large. Its continued use is likely to give rise to untoward symptoms. It is valuable in diabetes, the glyco- suria and other symptoms promptly and markedly diminishing under the use of the drug. Pousson (Jour, de Med. de Bordeaux, Oct. 11, '91). While the favorable influence exercised is not to be doubted, the gastric intoler- ance manifested by a number of cases prevented its continuance. Vergely (Jour, de M£d. de Bordeaux, Oct. 13, '91). Antipyrine, in doses of from 5 to 7 Vs grains, must not be continued more than eight to ten days. J. Mayer (Centralb. f. d. Gesammte Ther., July, '92). C. Sumner "Witheestine, Philadelphia. ANTITOXINS. See Diphtheria, Tuberculosis, and other diseases in which they are used. -28 434 APHASIA. VARIETIES. SYMPTOMS. APHASIA. — From Gr., a, priv., and ^rjiii OT <^dcj, I speak. Synonyms. — Aphrosia; alalia. Definition. — A partial or total loss of the power of expressing one's self in speech or of understanding speech, which is dependent upon cerebral disorder. Varieties. — There are two chief divi- sions of the aiiection: motor, or emissive or projective, aphasia and sensory, or receptive or subjective, aphasia. Each of these varieties includes at least two elementary forms: aphemia and agra- phia, as motor siibdivisions, and visual aphasia, or word-blindness (alexia), and auditory aphasia, or word-deafness, as subvarieties of sensory aphasia. The motor aphasia may be complete (aphe- mia) or there may be only some partial defect in the emissive mechanism of speech (dyslexia, paralexia, articulative ataxia, paraphasia, paralalia). The agra- phia may likewise be complete (agraphia) or partial (paragraphia, dysgraphia). Pantomimic speech, so called, — which is an emissive form of speech in gestures, signs, etc., — may be affected totally (amimia) or partially (paramimia) also. The more elaborate subdivisions of sen- sory aphasia are based upon qualitative rather than quantitative impairment. In the older literature all forms of sensory aphasia were referred to collectively un- der the term "amnesic aphasia," which included loss of the pictorial memory of letters and words and of the sounds of letters, words, and music. It included, also, loss of the power of understanding the meaning of figures, written music, and other symbols. In the more recent literature of the subject the term "am- nesic aphasia" has been rather arbitrarily restricted to a loss of the naming rather than the ideational functions of speech- memory. Loss of the ideational faculty is expressed by the term "apraxia" (mind- er soul- blindness). Both sensory and motor aphasia may be divided, as regards the anatomical basis, into the cortical and subcortical varieties. The terms "conceptional" and "conductive" are practically of identical significance with the terms "cortical" and "subcortical." Symptoms. — Motoe Aphasia (Aphe- mia). — In motor aphasia the voluntary act which must be carried out to give expression to thought by the phonetic co- ordination of the muscles of the larynx, tongue, soft palate, and lips is not per- formed. The patient is seldom unable to produce sound, but he can no longer produce an articulate sound. Although he understands what is said and can think, he is unable to give expression to his thought; it may be possible for him to pronounce letters or even meaning- less words, — he may even retain some words, — but these are usually interjec- tions of some kind. In some cases, nouns only or verbs only are forgotten. One language may be forgotten and another remembered. This variety of aphasia is usually encountered in persons who are afEected with right hemiplegia. In some, however, who are left-handed, there may be left hemiplegia. In some cases, al- though speech is impossible, the patient can articulate in singing,, especially if certain well-known airs are sung, the words in that case having become inti- mately connected with the notes. Case of aphasia in a child which, though unable to utter a single word as regards spontaneous speech, could articulate in singing. Knoblauch (.Jour, of Nerv. and Mental Dis., .June, '92). Case of total aphasia of articulation in which the patient Avas able to intone t'.ie voice intelligently, as one does in speech. No agraphia; woi'ds readily understood. Brissaud (I.a Semaine Med., Aug. 1, '94). Case of traumatic aphasia dependent upon sun-stroke. Three attacks have oc- curred in which the patient became un- APHASIA. SYMPTOMS. 435 conscious, and was paralyzed in the right arm, leg, and lower part of the face. While recovering consciousness he began to speak in Norwegian: a language that he had not used for many years. Later his language was a conglomeration of English and Norwegian. Eventually lie recovered completely. E. Mackey (Brit. Med. Jour., Dec. 10, '98). Aphasia may occur in iiraemia, and is at times the sole expression of that state. It is frequently associated with right-sided motor paralysis, hemiplegic or monoplegic in character. It may be the precursor of urfemic convulsions or coma. The aphasia is usually of the motor type, but it may be sensory. There may be word-blindness and word- deafness. It may be associated with agraphia, even when there is no paralysis of the limbs. It is comparatively' fre- quent in children, particularly in eases of post-scarlatinal nephritis. In adults it may occur in any form of Bright's disease. It is generally transient, dis- appearing completely. In time it is in- termittent and has a marked tendency to recur. When paralysis is present the two may disappear simultaneously, usually the aphasia first. The features of ursemic aphasia are, per se, not char- acteristic of the causal condition. The most important diagnostic features are the transitoriness of the aphasia and the presence of other ursemic symptoms and of signs of nephritis. In every case of sudden aphasia, the possibility of its being renal in origin should be consid- ered, and careful studies of the urine and of the system at large should be made with this thought m mind. D. Kiesman (Med. Record, .June 14, 1902). Ageaphia. — Agraphia consists in the loss of the memory of the necessary move- ments to write. In an uncomplicated case the patient is able to speak, hear, or read as usual, but when he tries to write he finds that he can no longer do so, though he is capable of copying letters or designs placed before him. Pure agraphia is uncommon. It is usually associated with some degree of aphemia. Agraphia can only occur in those persons whose education is sufficiently advanced to enable them to write auto- matically. In a thesis written under the direction of Dejerine the following conclusions reached: — The centi'cs of the images of language (motor centres for articulation and visual and auditory centres) are grouped in the convolution about the fissure of Sylvius, forming the zone of language. Any lesion of this zore g.ves rise to an altei-ation in the inter-.or language and consequently to manifest or latent alter- ations throughout all the modalities of language (speech, hearing, writing) with special predominance over the function of the directly destroyed images. Agraphia is always present. These form the class of true aphasias. The class of pure aphasias (motor, subcortical aphasia, pure word-blindness of Dejerine, pure word-blindness) are located outside the zone of language and leave untouched the inner language. Thej' never cause agraphia and afl^eet only one of the modalities of language. They form a group apart from the true aphasias. Nothing would tend to show the existence of a motor centre for graphic images. Both clinical observa- tion and pathological anatomy agree as to its absence. The existence of pure agraphia has not yet been established. Mirallig (Revue des Sei. MSd. en France et il I'Etranger, July 15, '96). Amimia. — Sign-language, as practiced by deaf-mutes in gestures and panto- mimic speech generally, may be affected by a cerebral lesion. Loss of pantomimic speech is often co-existent with aphemia or agraphia or both. It is rarely or ever found alone, although it is quite possible to conceive of its separate existence in one in whom this faculty had been espe- cially cultivated. (Mills.) Sensoet Aphasia. — Auditory Apha- sia. — This variety is more rarely met with than motor aphasia. Both the re- 436 APHASIA. SYMPTOMS. ceptioD and production of audible speech are deficient, the leading symptoms be- ing, on the receptive side, word-deafness and, on the productive side, word-am- nesia and articulative amnesia. Speech and separate words are dis- tinctly heard by the subject, but no meaning is attached to them. Sounds, however, — such as that of an engine- whistle, an alarm-clock, the hour, — are heard and recognized. Eight hemiplegia and a certain amount of word-blindness are frequently present. Certain cases of auditory aphasia hear as if spoken to in a foreign tongue, but they cannot under- stand what is said, although they en- deavor to do so. Other patients under- stand neither what is said to them nor what they themselves say, but can repeat words after another. They repeat like parrots (echolalia) what is said; but, if the centre of articulate voice is still par- tially connected with the sensory centres of audition and the latter are normal, the repetition of the word may suddenly give rise, in their mind, to the idea conveyed by the word. Instead of articulate speech the phenomena may show themselves in connection with music or numbers. In subcortical word-deafness the patient hears, but does not imderstand. He can, however, repeat at once whatever he hears, and write it down. While writing or speaking he may understand the words used, but not after the mechanical act is accomplished. Case of woman, aged 72 years, who had been deaf since childhood, and re- mained so until within six weeks of an apoplectic attack. Hearing during this period of six weeks had returned and remained. After the apoplexy she was found to be absolutely word-deaf. There were also motor aphasia and agraphia, with word-blindness. Shaw (Brit. Med. Jour., Feb. 27, '92). [This case presents several features of interest, among which may be noticed the return of hearing six weeks before the last stroke, to disappear again on its supervention; the remarkable picking out by the lesions of the several cortical areas, which by various observers have been associated with the faculty of lan- guage corresponding with the clinical phenomena recorded, — the second frontal convolution with the agraphia, the third frontal with the aphasia, the angular gyrus with the word-blindness, the tem- poro-sphenoidal with the word-deafness and general deafness, — and the apparent recognition by the patient of the total failure to make herself understood, this last feature being somewhat noteworthy in view of the extensive nature of the cortical lesion. L. C. Gray and W. B. Pkitchard, Assoc. Eds., Annual, '93.] Medico-legal conclusions drawn from a consideration of aphasia: — 1. Organic diseases of the brain may render a patient incapable of making a will, and that some form of aphasia may be produced also as one of the symptoms of the organic disease. 2. Some forms of aphasia may render a patient incapable of will-making. 3. Auditory aphasia, if at all well marked, incapacitates a patient from will-making. 4. Some other forms of aphasia, such as pictorial word-blindness, pictorial mo- tor aphasia, and graphic aphasia, may render a patient incapable of making a will, not necessarily from being mentally incapable, but from the difficulty of carrying out the legal formalities. 5. These difficulties in carrying out the legal formalities necessarily vary accord- ing to the law of the particular country. 6. Simple uncomplicated eases of infra- pictorial auditory, infrapictorial visual, and infrapictorial motor aphasia are capable of valid will-making. William Elder (Brit. Med. Jour., Sept. 3, '98). Case in which the patient, during the year preceding death, had nrunerous at- tacks of transient sensory aphasia. In the intervals there was no paraphasia, the language being correct, but he did not understand what was said to him. At autopsy general atrophy of the brain, with reduction of the size of the superior temporal convolutions, espe- APHASIA. DIAGNOSIS. 437 cially marked on the left side; also of the operculum and of the inferior fron- tal convolution. The ea.se demonstrates that word-deafness is essentially of cor- tical origin. 0. Veraguth (Deutsche Zeits. f. Nervenheilk., B. xvii, H. 2 and 4, 1901). Word-blindness (Alexia). — The patient sees written or printed letters and words and may be able to distinguish one from another, but they no longer have any meaning for him. Word-blindness is rarely total, however, a few words or let- ters being usually understood, nor is the disorder often found existing alone. In nearly every case there co-exists either word-deafness or motor aphasia or some other complication of speech. Word-blindness is often found in con- nection with right lateral hemianopsia, or concentric diminution of the field of vision. The patient can no longer read, but can write; as he cannot read what he has written the letters and lines are sometimes uneven and resemble those written with the eyes shiit. In the right hemianopsia found in this connection the written lines always begin on the left side of the page. The visual memory of numbers may be preserved or may also be lost (coscitas numeralis). Word-blind- ness can, therefore, he divided into two categories: in the one, the sense of the letter itself is lost (ccecitas literatis); as a consequence, persons who generally read slowly, and spell out each word, suffer the total loss of the power of read- ing. In the other, the accompanying hemianopsia prevents the general phys- iognomy of a word being rapidly taken in by the patient (cwcitas verbalis). Subcortical Word-blindness. — In sub- cortical alexia the patient can read or copy, but he does not understand what he does until the movement of his hand awakens in his mind the sense of word- hearing and of motor articulation through the muscular sense. In piTre verbal blindness the meaning of the words may be lost, but, by follow- ing with the eye the form of the letters, the patient finally may spell out the word. Four cases of word-blindness. The first occurred in a man 34 years of age. In this case the condition developed after an attack of left hemiplegia with paralysis of the left side of the face, from which he had been recovering grad- ually. The second case occurred in a man 57 years of age. The condition came on very suddenly during active exercises. It was ushered in by slight frontal headache and some mental con- fusion. The third case occurred in a man 60 years of age. The onset in this case was also abrupt. The fourth case occurred in a woman 34 years of age. In this case the onset was marked by unconsciousness, which remained for several days. Then consciousness was restored, paralysis in the right arm and right leg developed, and she was com- pletely aphasic. J. Hinshelwood {Lan- cet, Feb. 8, 1902). Apeaxia. — In apraxia (Kussmaul) the patient no longer recognizes the use of objects which he sees; a fork to him convej's no meaning of its use. Apraxia may affect other senses besides that of sight, — as, for example, hearing, taste, smell, etc., — the sound of a bell may no longer conTey a meaning or the taste of a dish. Diagnosis. — In all cases of actual or suspected aphasia the patient should be examined as to his ability: 1. {a) To speak voluntarily; (&) to speak clearly and distinctly, pronouncing properly; (c) to repeat words dictated aloud. 2. {a) To write voluntarily letters, words. Additional form of visual defect in which there is not only word-blindness, but also failure to recognize the indi- vidual letters of words. Hinshelwood (Lancet, Dec. 21, '9.5). 438 APHASIA. ETIOLOGY. numerals, and sentences; (&) to write from dictation; (c) to copy; {d) to understand what he has written. 3. (a) To vinderstand words and sentences spoken; (i) to understand or recognize vocal and instrumental music; (c) to understand the use of objects named. 4. (a) To read words, letters, numerals, and musical symbols if previously famil- iar with them; (&) to call objects by their names; (c) to recognize the use of objects exhibited; (d) to read and com- hend what is read. 5. (a) To name and recognize the use of objects felt, tasted, or smelt. WOED-DEAFNESS must be distinguished from deafness. If the patient does not suffer from aphemia, it will be at once perceived, from his ability to hear simple meaningless sounds, that he is not sim- ply deaf. When word-deafness exists in combination with aphemia and word- blindness (this latter complication is un- common) the diagnosis must be made between true word-deafness and apparent deafness with dumbness in a non-hemi- plegic, demented subject. If, however, the symptoms have fol- lowed an apoplectic stroke with right hemiplegia, the affection is probably word-deafness due to a cortical lesion. WoED-BLiNDNESS, if isolated, is easily recognized. Aphasia, ok Aphemia. — Aphasia should be diagnosticated from (1) mutism due to melancholia; (2) miitism due to hysteria; (3) the silence observed in hemi- plegic patients who speak with difficulty; (4) the silence observed in hemiplegia patients who are suffering from pseudo- bulbar paralysis of cerebral origin; (5) word-blindness associated with word- deafness. All these present individual characters which must be studied in con- nection with the general symptomatology of each affection. Agraphia arising from a lesion of the centre of writing should be distinguished from (1) the inability to write due to hemiplegia and (2) the agraphia due to a lesion of the visual centre in patients of limited education and who copy visual images; (3) the agraphia due to a lesion of the auditory centre, in which the patient writes only what is mentally heard by him. The co-existence of word-blindness or of word-deafness with agraphia should suggest that the latter might be due to a lesion of the sensory centres (visual or auditory), especially if the patient did not previously write automatically, for agraphia due to a pure lesion can arise only in cases in which automatic writing has caused the development of a special graphic centre. Infeacoetical Motor Aphasia. — A pure motor aphasia without word-blind- ness or word-deafness is likely to be of infracortical origin. Cases, however, have been reported in which an infra- cortical lesion has caused aphasia, word- blindness, and word-deafness. Etiology. — The various varieties of aphasia occur almost always as a mani- festation of cerebral lesion. The most common factor is softening; next in frequency are cerebral tumors and, es- pecially, syphilitic lesions (Fournier), cerebral haemorrhage, traumatisms, and meningo-encephalitis. Aphasia may present itself during enteric fever, small-pox, and puerperal fever. Transient aphasia — following epileptic or hysterical convulsions, mi- graine, or concussion of the brain — has been occasionally observed, and certain degrees of the affection may be tempo- rarily present and even recurrent in states of profound ansemia of the cer-j- brum. APHASIA. ETIOLOGY. 439 Case of mixed aphasia with right hemi- plegia due to meningo-encephalitis from cysticercus, affecting principally the an- terior extremity of the sphenoidal lobe. Bitot (Jour, de M6d. de Bordeaux, Dec. 15, '89). Two cases dependent upon tubercular meningitis. Picot (Gaz. Heb. des Sci. M6d. de Bordeaux, Mar. 16, Apr. 13, 27, May 11, '90). Case of mixed motor and sensory aphasia consequent on influenza. Re- covery after several weeks. T. D. Poole (Edinburgh Med. Jour., Aug., '90). Case of motor aphasia with graphla and dyslexia in conjunction with attacks of petit mal. Eye-strain. Improvement from properly adjusted glasses. Mueh- leek (Univ. Med. Mag., June, '91). Case with right facial paralysis and right Jacksonian epilepsy due to injury over base of right parietal. Recovery in few w-eeks. Symptoms supposed to be due to contusion of left centres, from counter- stroke. Ransohoff (Cincinnati Lancet-Clinic, Apr. 16, '92). Case in girl, aged 10, due to embolism. Suckling (Brit. Med. Jour., May 21, '92). Four cases occurring during puerperal period, sixteen from literature; some- times hysterical; in others, urfemic. In nearly one-half of the cases aphasia is associated with right hemiplegia and due to embolism or thrombosis. Having oc- curred in one pregnancy, it is liable to occur in the next, and usually appears about one week after delivery. Cowe (Archives de Tocol. et de Gyn., vol. xx, No. 7, '94). Several cases of ataxic aphasia during pneumonia. In every case there was pa- resis and weakness of the right face and right arm. Cause supposed to be pneu- mococcus toxins. Chantemesse (Med. Record, Feb. 3, '95). Case occurring as result of wound in left side of skull 9 centimetres from hori- zontal circumference, passing by superior border of auditory meatus and supra- orbital margins, 7 centimetres from sagittal ■ suture perpendicularly, 1 '/j centimetres in front of left auditory canal. Spherical fragment separated and pressed down 1 centimetre into the wound. As soon as removed, speech be- came normal. Dorrenberg (Berliner klin. Woch., No. 18, '95). Case of a woman, aged 20 years, who was infected, after her marriage, with gonorrhea, and who was attacked with severe convulsive movements in the right side of the face and tongue and in the right forearm. The following morning there were present right hemiplegia and complete motor aphasia. Sensitiveness was preserved. The hemiplegia persisted and typical contracture occurring, but the paralysis of the facial and pharyngeal muscles improved. The aphasia im- proved slowly. After six months it was found that understanding of words was completely restored, that both writing and print could be read, only some mutilation of words remained after a cer- tain time. Repetition of words was per- fect. The left hand could be used to write grammatically with good orthog- raphy. Since the patient suffered from salpingitis due to gonorrhoea, the troubles described are undoubtedly due to a thrombosis. L. Bruns (Schmidt's Jahr- bucher, B. 250, p. 236, '96). In polyglottic patients suffering from aphasia the disturbances in speech do not always affect to the same degree all the languages spoken by the patients. When recovery occurs, it does so usually systematically and progressively; the language that first returns is usually the one first learned. The patient begins by understanding before being able to speak. At times, however, there occurs an arrest in the process of recovery: the patient in such a case recovers only the ability to understand and then to speak the language usually spoken by him, or he may understand one or several lan- guages, but be unable to speak them. In such cases it is evident that there is no destruction of the cortical centres of speech, but only of shock to their elements. The varying intensity of such shock explains the gradation of the symptoms noted in the patients seen by the writer. Consequently it is rot, in general, necessary to claim the existence of multiple centres of speech, each one peculiar to one of the languages success- fully learned by patients speaking sev- 440 APHASIA. PATHOLOGY. eral languages. The paper is based on seven observations. A. Pitres (Rev. de M6d., Nov., '95; Revue des Sci. Med., '96). Case in which the patient, who had been under almost continuous observa- tion for eighteen years, was almost com- pletely aphasie. At the autopsy Broca's convolution was found to be intact. Bastian {Lancet, Dec. 19, '96). Case of motor aphasia at the begin- ning of scarlatina, in a girl aged 3 'A years. The aphasia appeared on the fourth or fifth day of the eruption; this differs from the usual time of appear- ance, which is late: i.e., about the time of appearance of renal symptoms, it be- ing a symptom of uraemia. The speech- disturbance disappeared after fifteen days. Brasch (Berliner klin. Woch., No. 2, S. 30, '97). Case in which the symptoms were word-deafness, verbal amnesia, jargon paraphasia, paralexia, loss of compre- hension of print, and agraphia, with retention of ability to copy Roman letters into script and with no visual defect whatever. The impairment of all ways of using language, so often ob- served as a result of auditory lesion, due to the fact that the auditory centre is normally active in spontaneous speech, reading, and writing, as well as in the comprehension of speech. H. T. Pershing (Boston Med. and Surg. Jour., Sept. 23, '97). Case of aphasia with frequent attacks of word-deafness and spasm of the right side of the tongue and face. At autopsy tumor was found in the lower part of the Rolandic fissure resting upon the first temporal convolution. Philip Zen- ner (N. Y. Med. Jour., Jan. 8, '98). Pathology. — Motor Aphasia. — Pure aphasia of articulation is due to a lesion of the foot of the third left frontal con- volution (Broca's convolution). If the lesion affects more than this region, other symptoms are present. If the lesion occupy but a portion of the region, the aphasia may be partial only: for in- stance, nouns only will be missing. In persons habitually left-handed a lesion of the third right frontal convolution may produce motor aphasia. In persons who are ambidextrous the aphasia is of slighter degree and is more transient. The lesion may be either cortical or sub- cortical. As a rule, in the subcortical cases the defect is rarely complete. Case in 4-year-old child. At the au- topsy several tubercular nodules were found in brain, one being at the base of the left third frontal gyrus. Mosny (Bull, de la Soc. Anat., Mar., '88). Case, lasting ten years, with distinctly causative subcortical lesion. Horizontal section through Broca's convolution showed at its base an old focus of soft- ening, 1 centimetre in diameter and 2 centimetres from the cortex; 1 centi- metre farther back was a second focus. A section 1 centimetre above the first showed an ancient, grayish focus in the white substance, on a level with the anterior half of the base of the third frontal, independent of the other two and on a plane anterior to them. Second case, with centre of softening in the white substance to the third fron- tal, prolonged, on a level with the in- ferior extremity of the Rolandic fissure, into the foot of the ascending frontal convolution. Dejerine (La Semaine Med., Mar. 4, '91). Case of complete motor aphasia conse- quent on fall. Ability to use right hand to write; left hemiplegia. At autopsy left hemisphere found normal; right hemisphere injured. The man had never been left-handed. Luys (La Semaine Med., Mar. 19, '91). Case of motor aphasia (partial) with agraphia (complete), alexia (partial), and occasionally auditory aphasia. Right hemiplegia. Vast focus of softening in the left hemisphere. Motor aphasia ex- plained by destruction of the third left frontal; motor agraphia by destruction of white matter connecting inferior pa- rietal with second left frontal; partial auditory aphasia by destructive lesion involving first temporal lobe. Incom- plete alexia due to destruction of inferior parietal lobe. Bernheim (Revue de M6d., May 10, '91). APHASIA. PATHOLOGY. 441 Case with right hemiplegia, with tem- porary conjugate deviation of the eyes, excited by attempts to converge the eyes strongly toward the middle line. The autopsy proved this to be due to irrita- tive implication, without destruction of the region shown experimentally by Fer- rier, Horsley, Beevor, Shafer, and Mott to be related as a centre to these move- ments. Delepine (Brit. Med. Jour., Sept. 10, '92). Case of pure motor aphasia, with ability to read and write down thought fluently with the left hand, due to ex- tensive softening, principally affecting the left frontal convolutions, extending deeply, even to the internal capsule in the white substance. Case in accord with the statement that ability to understand words might be retained, with complete involvement of the frontal convolutions, and that agra- phia does notj as claimed by some, belong to Broca's aphasia. Kostenitsch (Centralb. f. klin. Med., Mar. 31, '94). Motor speech-centre capable of further subdivision into subareas representing various perversions of functions which are in relation, through isolated lesions, to the subtypes of motor aphasia, includ- ing the ataxic and amnesic, the agraphie and others. Wylie (Archives Clin. de. Bordeaux, Oct., '93, to May, '94). Sole well-demonstrated anatomical lo- calization is that of the foot of the left frontal convolution. Bernheim (Le Bull. MSd., Oct., '94). Case of Jacksonian epilepsy accom- panied by motor aphasia without agraphia, conclusively proving that the former may exist without the latter. There is too great a tendency to regard language as a special and isolated phe- nomenon among manifestations of nerv- ous centres. Prevost (Revue Mgd. de la Suisse Rom., June, '95). Disturbances in fifteen cases of cortical motor aphasia due to destruction of Broca's convolution correspond exactly to the description given by Trousseau. Patients read as badly as they write. It is incorrect to maintain that they pre- serve ability to read mentally. Dgjerine (Le Bull. M6d., July 10, '95). Case of syphilitic apoplexy, right hemi- plegia, motor aphasia, and word-blindness without blindness for words or objects. Visual field showed no contraction or hemianopsia. Lannois (Le Bull. M6d., Sept., '95). Case of motor aphasia following in- fluenza which occurred in a previously healthy woman. There were likewise present paresis of the right arm, and paralysis of the left vocal cord. Sensa- tion was somewhat diminished on the right side of the face and in the right arm. The patient could neither speak, repeat, nor write a single word, but could understand everything and read both Written and printed words. The symp- toms were traced to two lesions: 1. To ulcerative laryngitis with peripheral paralysis of that branch of the inferior laryngeal nerve which supplies- the pos- terior cricoarytenoid muscle. 2. To cere- bral htemorrhage which caused the apha- sia and the paralysis of the face and arm. Kohan and Stembo (Schmidt's Jahrbucher, B. 250, H. 33, '96). Case showing that associated move- ments of the arm and hand, which are observed in certain people when speak- ing, may be unusually prominent m pathological conditions of the speech- centres. E. Eemak (Neurol. Centralb., Jan. 15, '97). Case of a man who, since his childhood, had practiced the deaf-and-dumb lan- guage, employing his right hand almost exclusively. After the occurrence of a cerebral thrombosis, he was entirely unable to communicate with this hand, although the paresis was not great. With the left hand he still expressed himself without difficulty. Grasset (Med. News, Jan. 16, '97). Case sustaining Pitres and Charcot's view that there must be a homologue of the motor speech-centres, viz.: a spe- cial graphic centre containing the mem- ories of the motions required for the execution of written characters. Destruc- tion of these memories causes inability to write in written characters, while writing with printed characters may be possible with the help of the visual let- ter- and word- memories. This centre of the graphic memories is, however, prob- 443 APHASIA. PATHOLOGY. ably situated in close proximity to the arm-centre; possibly both may be con- tained within the same cortical area. B. Onuf (Jour. Nerv. and Mental Dis., Feb., Mar., '97). There are four centres in the cerebral cortex which are concerned in the pro- duction of spoken and written language. Two of these, in the posterior parts of the cerebrum, correspond in position to the visual and (as far as is known) audi- tory centres, and are of the ordinary sen- sory type; the others, in the second and third frontal convolutions, respectively, are excitomotor centres for writing and speech. There is a system of commis- sures between the various centres, the value of which is exemplified by such actions as reading aloud and writing from dictation. When any particular Diagram showing the approximate sites of the four word-centres and their commissures. {Bastion.) channel is blocked, other commissures may take on the work. This is especially true of the eallosal fibres connecting the two hemispheres. Aphasia depends either upon damage to one or other of the four centres in the dominant hemi- sphere, or upon interruption of the com- missures connecting them. Attention called to the considerable power of re- ciprocal substitution possessed by the visual and auditory word-centres for the production of speech and writing, re- spectively, and to the fact that in all probability both auditory word-centres — and not, as formerly believed, the left alone — are accustomed to act on Broca's centre in the production of speech. H. C. Bastian (Lancet, April 3, May 1, '97). Case of complete word-blindness; right-sided homonymous lateral hemi- anopsia; no agraphia, but inability to read own writing; optical aphasia; temporary mind-blindness; the ability to spell correctly completely retained. Case of paralysis of the right hand and arm; aphasia; very marked word- blindness presenting the peculiarity that the patient could read many words (com- binations of letters) while he was abso- lutely unable to recognize the individual letters of which they were composed, with some impairment of the motor side of the speech-mechanism; partial right- sided homonymous hemianopsia, with some peripheral constriction of the sound half of each field. Case of word-blindness in a patient who had never learned to write; con- striction of the fields of vision chiefly toward the right; no obvious word- deafness; cardiac and renal disease; death; extensive old softening in the white matter of the left occipital lobe and of the left angular gyrus, and the back part of the first temporo-sphenoidal convolution. Case of word-blindness and agraphia; instead of reading individual letters as letters, the patient substituted a word commencing with the letter which he could not read — "George" for "G," "nearly" for "n," etc. Case of sudden cerebral attack after confinement; absolute deafness to all sound for sixteen days; temporary motor aphasia and word-blindness ; absolute word-deafness for four weeks; rapid recovery from the motor aphasia; partial recovery from the word-blind- ness; very slow and imperfect recovery from the word-deafness; slight para- phasia and slight paragraphia; echo speech; retention of the power of writ- ing from dictation and of reading aloud; no hemianopsia; redevelopment of acute cerebral symptoms (meningitis or cere- bri tis) six months after the original attack; hyperpyrexia; death. Sudden cerebral seizure due to embolic infarction in a man aged 25 years; temporary loss of power in the right side of face, right arm, and right leg; com- plete motor vocal aphasia; some — but, comparatively speaking, much less — agraphia; no word-deafness; no word- APHASIA. PATHOLOGY. 443 blindness; complete recovery of the power of writing; gradual, but slight, improvement as regards vocal speech; second embolic attack four months after- ward; increased paralysis of the right side of the face, of the right arm, and of the right leg; no increase of the motor vocal aphasia; marked increase in the agraphia; some word-blindness; no word-deafness; death four years after the original seizure. Seven out of twelve cases supporting the view that the right hemisphere must be regarded as forming an active part of the nervous speech-mechanism; in other words, that the so-called speech- centres and speech-faculties are bilat- erally represented. Byrom Bramwell (Lancet, Mar. 20, 27; April 10, 17; May 8, 22, '97). Advisability of enlarging the zone of language, as given by Dgjerine, so as to make it include a centre for concepts in the third temporal convolution, and pos- sibly extending over more of the mid- temporal region, and, in addition, a graphic motor centre in the caudal por- tion of the second frontal convolution. This zone of language unquestionably has its deepest organization and highest development in the region encircling the Sylvian fissure, for here is situated the auditory centre, out of which the others may be said to have been evolved, and the motor, articulatory, and visual cen- tres which are next in importance, as they have been next in development; but it must also include those portions of the brain in which concepts originate, and, if the views of those who believe in separate graphic motor centres are cor- rect, also those parts in which graphic motor images are represented. Charles K. Mills (Medical News, .June 5, '97). Agraphia. — True agraphia almost always occurs as a result of a lesion of the foot of the second left frontal convo- lution or of the subcortical fibres there- from. Agraphia is generally found, how- ever, associated with some form of motor aphasia, rarely existing alone. Case of a woman^ who, at 44, had an attack of right hemiplegia involving the tongue. She lost the abilitv to write Series of perimeter charts in a case of complete agraphia and almost complete word-blind- ness, with right-sided bilateral temporal hemianopsia. (The black area represents the blind parts of the fields.) Chart 1 represents the fields of vision on Nov. 17th. Chart 2 represents the fields of vision on Nov. 24th. Chart 3 represents the fields of vision on Dec. 1st. Chart 4 represents the fields of vision on Dec. 8th. Chart 5 rep- resents the fields of vision on Dec. 15th. (Byrom Bramxcell.) 444 APHASIA. PATHOLOGY. spontaneously and from dictation, but could copy. There was no word-deafness nor word-blindness. When 55, a second attack of hemiplegia occurred, this time of the left side, with complete loss of speech. A third and fourth attack oc- curred six years later, and death eight years afterward, at the age of 69. At the necropsy areas of softening were found in the left hemisphere (1) at the posterior extremity of the second frontal and (2) in the middle portion of the sec- ond frontal on the right side; (3) at the anterior extremity of the third frontal and posterior portion of the third fron- tal, extending into the ascending frontal (4) at the foot of the ascending fron- tal and parietal and (5) in the pos- terior portion of the ascending parietal. Two additional areas of softening were found at the base of the right hemi- sphere, but these, with No. 3, were sup- posed to have given rise to no symptoms. Nos. 2 and 4 caused symptoms of bulbar paralysis, No. 5 the left hemiparesis, while No. 1 — the lesion at the posterior portion of the second left frontal — was considered responsible for the peculiar form of agi'aphia. Charcot and Du- breuihl (Annual, '94). The above or similar eases reported do not prove that the centre for written language lies in the second left frontal. It is very difficult to isolate and localize a pure motor agraphia. Against the hypothetical existence of a centre for writing in the above case is the fact that no one could write with the feet as well as with the hands, although it can be conceived that a higher motor centre for writing may exist, connected with the lower centres for the hand and foot either of which may govern the periph- eral mechanism of writing. The same type of agraphia had accompanied motor aphasia in this case, in cases in which the lesion was of Broca's convolution. Dfejerine (Annual, '94). Case of a man of 26 who had been violently pushed, the head striking for- cibly against edge of a dresser. Injury was over right parietal eminence. For two or three days afterward showed the ordinary symptoms of concussion. Later he could not recognize letters or figures, nor name most things at sight, though he could point out anything named, and, a name being suggested, he repudiated the wrong one on every occasion. Spon- taneous writing was confined to his own name, which he wrote quickly. He could neither write from dictation nor read aloud. He could copy, but could not transfer printed into written, nor written into printed, characters. The field of vision was normal in both eyes. No hemianopsia was present. Gradually the patient improved. Not until the man Avas able to read aloud was there any sign of undeistanding any written question. He could read aloud a few combinations of figures, such as 100 and 1897, and write 1897 down in well-formed figures, but he could not recognize indi- vidual figures at sight, nor put them down from dictation. This suggests the possibility of there being a distinct group of cells the function of which is to store combinations of figures wliich might be called the visual figure-combination- centre as distinct from the visual figure- centre. Four divisions of the visual nerve-centre might be made: (a) one for letters; (6) one for numerals; (c) one for words; (d) one for combinations of figures. One would naturally expect only two subdivisions: (a) a centre for letters and numerals; (h) a centre for words and figure-combinations. But Hinshelwood has noted that there are cases in which the visual memory for letters is entirely lost, while that for figures is intact, or in which the visual word-memory only was affected. C. Mac- Vicar (Scottish Med. Jour., Nov., '98). Sensoey Aphasia. — Cortical word- deafness is usually caused by a lession of the middle or posterior portion of the first and second left temporal convolu- tion, chiefly the first. Auditory speech is not, however, so exclusively a left- brain function as is motor speech; hence the fact of incomplete and more tran- sient types of speech-defect from uni- lateral lesions of this region. Lesions affectins: the subcortical white fibres APHASIA. PATHOLOGY. 445 from this area give rise to the subcortical type of word-deafness, as it is termed. Case of lesion of the left temporal lobe in a left-handed man without word- deafness. Seppili (Alienist and Neurolo- gist, Apr., '93). Case of lesion cf the first, second, and third right temporal lobes, with word- deafness. Many similar cases are re- ported in literature; two cases of lesion of the left lobe in left-handed persons, without deafness, and thirty cases with Avord-deafness from lesions of the left temporal lobe in right-handed persons. Scavano (Revue Inter, de Bibliographie, June 10, '93J. Case of deaf-mutism, in an adult, due to symmetrical lesions in the two tem- poral lobes. The first and second tem- poral convolutions were replaced by cicatricial tissue; the third was atrophied and sclerosed. Seppili (Alienist and Neurologist, Apr., '95). Three autopsies in patients with sen- sory aphasia. There were softening and atrophy of the left first temporal con- volution. Case of subcortical aphasia noted. The patient could not speak and had no comprehension of spoken lan- guage. He had right hemiplegia. Soften- ing of the external capsule and lenticular muscles was found at autopsy. W. T. Worcester (N. Y. Med. Jour., Jan. 8, '98). Cortical word-blindness is caused by a lesion of the postero-inferior portion of the second left parietal convolution (angulo-occipital region). Lesions affecting the optic radiations of Gratiolet cause the subcortical variety of alexia. Interruptions of relations through commissural fibres with any of the associated speech-areas will, of course, result in one of the mixed forms of aphasia or in subcortical alexia. Fifty cases of sensory aphasia in which Broca's centre was not found diseased. In all some form of sensory aphasia was present, and in all the lesion lay in the lower posterior third of the brain. The convolutions were found affected in the following order: The first temporal in 38, the second temporal in 27, the in- ferior parietal in 21, the angular gyrus in 25, the supramarginal gyrus in 12, the occipital lobe in 12. Paraphasia may be caused by lesions in various locations. Word-deafness due to a lesion of the first and second temporal convolutions, and word-blindness may be produced by lesions lying in the region of the inferior parietal lobule, or extending over, an- teriorly from it, into the temporal region, or, posteriorly, into the angular gyrus and occipital lobe. Failure to recognize a word heard implies destruction of the temporal cortical area; failure to recall the name of an object seen implies the destruction of the temporo-oceipital asso- ciation tract in the subcortical white matter. If the lesion be extensive enough to involve the cuneus, or deep enough to reach the visual tract to the cuneus as it passes beneath the angular gyrus and convexity of the occipital lobe, it will produce hemianopsia; if not, actual blindness may not accompany psychical blindness. In either case it is found that when things are not recognized they can- not be named when seen. The visual memory-pictures lie in the angular gyrus and inferior parietal lobule. M. Allen Starr (Brain, July, '89). Case of word-blindness with agraphia, due to a spot of softening as large as a five-franc piece, occupying the whole of the inferior parietal lobe. Neither motor aphasia nor word-deafness was present. Serieux (Bull, de la Soe. de Med. Men- tale de Belgique, Mar., '92). Case of alexia, agraphia, amnesic aphasia, and word-deafness, due to tumor in the occipital lobe, having largely destroyed the subcortical commissural fibres in the angular gyrus. Weissen- burg (Archives de Neurol., July, '92). Case of pure word-blindness for letters, words, musical signs, Avith retained ability to read figures and calculate. No word-deafness nor difficulty in articula- tion nor any impairment of motor power or sensation. Four years later sudden seizure and death. For two days before death there were paraphasia and agra- phia resulting from the seizure, which was found at the autopsy to have in- 446 APHASIA. PROGNOSIS. volved the left inferior parietal convolu- tion and angular gyrus. Old yellowiah areas of softening with atrophy found in the lingual and fusiform lobules, the cuneus, and the apex of the occipital lobe; secondary degeneration in the splenium of the corpus callosum; and pronounced atrophy in the optic radia- tions. The right hemisphere was intact. Histologically, lesion least pronounced at level of lower lip of calcarine fissure and especially localized in the fusiform and lingual lobules, the tapitum, and the radiations of Gratiolet, and the inferior longitudinal fasciculus of Burdach were entirely destroyed. All of the structures in the descending branch of the calcarine fissures were involved in tlie softening. Conclusion that the lower portion of the inferior longitudinal fasciculus of Bur- dach contains fibres that connect the visual centre with the centre for lan- guage. Dejerine and Vialet (Comptes Rendus Heb. des Seances et Memoires de la Soc. de Biol., No. 28, p. 790, '93). Review of the literature of sensory aphasia, and several cases. Conclusion that the essential central lesion which produces word-blindness is the angular gyrus, there being but little evidence tending to show that the supramarginal gyrus has anything to do with this phe- nomenon. Shaw (Brain, Winter, '93). Hemianopsia and word-blindness are not necessarily associated. The frequent association of word-blindness with hemi- anopsia is explained by the intimate relations existing between the supra- marginal convolution and the bundle of optic radiations. In order to explain the absence of word-blindness in right lateral hemianopsia it is necessary to call at- tention to the intrahemispheric fibres of the corpus callosum; these latter are injured in subcortical alexia, or pure word-blindness. In order to obtain word- blindness without hemianopsia, there must be a lesion of the supramarginal convolution superficial enough to avoid injuring the underlying white fasciculi. Absence of hemianopsia in word-blind- ness or total aphasia affords a much more favorable prognosis. Joanny Roux (Revue des Sci. M6d. en Fi-ance et a I'Etranger, Apr. 15, '96). Prognosis. — Word-deafness may con- tinue permanently, but it frequently im- proves through the co-operation of other sensory centres, and especially the visual centre. The patient, noting the move- ments of the lips in those who are speak- ing to him, recalls motor images which articulation of the same words would require in him. Word-blindness does not improve in some cases; in others a painstaking and early re-education may be carried out by which new images may be created in the visual memory by the help of the motor and auditory memories. Aphasia proper, or aphemia, occasion- ally remains the same from the begin- ning to the end, no improvement being visible; usually, however, words return very gradually. Eecovery, in such cases, is never complete. Some cases recover almost immedi- ately. This almost always occurs in eases of complete aphasia, and would seem to be of dynamic origin, like the mutism of hysteria or of terrified persons. Case with agraphia, but without alexia, of eight years' standing. During an attack of anger a sudden pain was felt in the headj and this was followed by recovery of speech. Dobie (Lancet, Jan. 9, '92). In cortical motor aphasia the patient recovers the faculty of reading gradually in the following order: (1) appearance of the word; (2) association of syllables; (3) association of letters forming each syllable. Exact reverse of learning to read during childhood. Thomas and J. C. Roux (Le Bull. Med., July 10, '95). Systematic recovery occurs in cases in which the centres of speech are shocked, but not destroyed, by cerebral lesions which cause aphasia, and which grad- ually resume their functional activity. A. Pitres (Rev. de Med., Nov. 10, '95). If congenital aphasia is found in a child under three years, especially if it be rickety or hydrocephalic, the disorder APHASIA. TREATMENT. 447 may be due to a simple retardation of development; if the patient is more than three years old the prognosis must be very guarded. Herzen (Revue M6d. de la Suisse Rom., Nov. 20, '95). Agraphia is, in some cases, recovered from, in the sense that the patient learns to write with the left hand. The writing does not resemble that performed with the right hand, and in some cases it is written from right to left, as in mirror- writing. Three eases treated by practice in writing with the left hand; centromotor, marked improvement in a few months; centrosensory aphasia best treated by loud speech or singing. Gutzmann (Deutsche med.-Zeit., Feb. 8, '94). Supracortieal motor aphasia is less serious than cortical motor aphasia, be- cause the intelligence is less affected, the centre of language itself being intact and only the path of communication being interrupted. Recovery occurs more frequently than in cortical motor aphasia. The prognosis depends on the site and nature of the lesion. Incurable lesions may preclude improvement even in the slighter eases of aphasia. Extensive progressive lesions are, of course, worse than circumscribed ones. Haemorrhage, embolism, thrombosis, include the ma- jority of cases of aphasia. If death does not occur, even the worst disturbances of speech may be recovered from ; while, on the other hand, even slight afleotions of speech may persist throughout the remainder of life. Age is an important factor. Children may learn to speak again even after extensive damage to the speech-centres, whjreas small lesions in old people may produce a lasting aphasia. The individual power of learning un- doubtedly plays a part in the result. The longer the aphasia has lasted without any tendency to improvement, the worse the prognosis, and this is also the case where the intelligence steadily fails. Karl Bok (Festschr. des Stuttgart. Aerztl. Verein, '97). Treatment. — When there is no paral- ysis present mental overwork is a fre- quent cause of aphasia. Prolonged rest alone secures relief. Any disorder, con- comitant or causative, that may be pres- ent should receive careful attention. At the same time the patient should be taught to overcome the aphasic symp- tom; considerable patience is usually re- quired. When the aphasia is associated with right-sided paralysis or convulsions, the treatment of the latter condition by alteratives, potassium iodide or mercury if a syphilitic taint be present, some- times brings about rapid recovery. Case combined with amimla, the result of a kick of a horse on left parietal bone. Six weeks later, on examination, the patient was found without fever, pulse normal, appetite good, eyes and ears normal, and no paralysis, except of the fingers of the right hand. Over left parietal bone were three ulcers, the low- est of which was two centimetres over the left ear. It was about three centi- metres long, equally wide, bulged out, and showed distinct cerebral pulsation. The cranial vault was depressed about the ulcers. The depressed portions of bone were removed, the corresponding defect being covered «ith two flaps, after von Bergmann's plastic method. The paralysis of the hand disappeared rap- idly, followed by complete restoration of speech on the twenty-second day. Rosenberger (Centralb. f. Chir., No. 25, '90). Remarkably instructive ease of nine years' standing. By educating the right hemisphere, within six weeks acquire- ment of a vocabulary of over one hun- dred words and several invaluable short sentences. Kucliler (Priiger med. Woeh.,. Oct. 18, '93), Case cf ursemio aphasia. The patient, a man of 56, was suddenly seized with an apoplectic attack ; he regained conscious- ness, but presented aphasia, monoplegia of the right arm, and a systolic murmur at the base of the heart. Some days later the patient was seized with a sud- den attack of intense dyspncea, with Cheyne-Stokes respiration ; the urine 448 APHASIA. APIOL. was scant and very albuminous, and the blood contained seventy-five centi- grammes of urea to the litre. The pa- tient was bled immediately and recov- ered in two days, the monoplegia and the aphasia completely disappearing. Eendu (Gaz. Med. de Paris, Apr. 4, '96). Case of complete agraphia and almost complete word-blindness, with right-sided bilateral temporal hemianopsia, due to a lesion (gumma) in the region of the left angular gyrus, in which rapid and complete disappearance of all the symp- toms took place under the administra- tion of large doses of iodide of potassium. Byrom Bramwell (Lancet, Mar. 20, '97). The treatment of amnesic aphasia lies in efforts to stimulate the defective recol- lection of words. The words must be learned by heart, and then short reading exercises adopted. The exercises should be performed in front of a mirror, in order to restore the recollection of the necessary movements. In motor aphasia other parts of the brain may take on function. Single sounds, then syllables, and lastly words are taught. Writing exercises with the left hand should be performed along with the articulation exercises. The patient should be taught to form words from printed letters. The treatment of sensory aphasia is more diificult. The first attempts are made by means of written language. Lip-reading should be developed, and reading, writ- ing, and other exercises combined with it. The ease may be much complicated by a combination of different forms of aphasia. Much patience is required. Karl Bok (Festschr. des Stuttgart. Aerztl. Verein, '97). Injury to the skull, especially when there is depression of the inner plate, tumors, cerebral haemorrhage, and other conditions capable of inducing cerebral pressure require appropriate surgical procedures. Case combin-d with paraphasia greatly benefited by trephining. Fogliano (Gaz. deg. Osp., No. 4, '91). Cases illustrating the value of opera- tive measures: — Case of mind- and word- deafness after repressed fracture of the skull with sub- cortical haemorrhage; operation; com- plete recovery. Case of glioma of the left centrum ovale, monoplegia, word-blindness, alexia, agraphia, partial apraxia, and color- blindness; operation; improvement. Case of cyst of the brain in the foot of the left second frontal convolution; motor agi-aphia (?) from inability to spell; evacuation of the cyst; improve- ment; traumatic meningeal htemorrhage two months later; second operation; recovery. Case of oro-lingual paralysis and slight motor disturbance in writing of throm- botic origin; operation; recovery. Case of motor and sensory aphasia of seven years' duration, due to probable thrombosis followed by angioma; opera- tion; relief of pain; slight impi'ovement in speech. J. T., Eskridge, Clayton Park- hill, and E. J. A. Rogers (Med. News, June 20; July 11; Aug. 1, 15; Sept. 5, '96). Landon Caetee Gray, Wm. Beoaddus Pkitchaed, New York. APIOI. — Obtained from the volatile oil of parsley, and at low temperatures, is a stearopten or eamphoraceous solid made up of needle-like crystals; but at higher temperatures resolves itself into a yellow or straw-colored liquid. It has a slightly-acid reaction and is soluble in alcohol, ether, and chloroform. Most of the apiol of commerce is nothing but an oil of parsley, though the best has usu- ally a percentage of the latter added in order to insure fluidity at all temper- atures. It may be prepared in various ways, but the methods of manufacturers as published are usually obscure, and often open to severe criticism. So-called green apiol is the oil of parsley loaded with chlorophyl and vegetable fats. The red apiol that appears in the market, as well as the proprietary so-called "apio- line," is merely the yellow apiol oxidized by means of sulphuric acid. APOCYNUM CANNABIXUM. 449 Dose. — Owing to unpleasant odor and acrid taste, apiol is best administered in gelatin capsules or perles, each holding from 3 to 5 grains. Two to four capsules may be taken daily, preferably night and morning, beginning two or three days before the expected menstrual flow. Physiological Action. — Apiol is thought to mainly act upon the vascular system, causing congestion, and at the same time on the muscular tissue of the uterus. This view is based upon its action as an emmenagogue and by its effects upon the menstrual flow; yet it is also a regulator of uterine function. Therapeutics. — According to Griifith and Cerna, apiol (apioline) may be re- garded as the best emmenagogue at present known. It is indicated in amen- orrhoea due to ansemia from whatever cause. W. A. ISTewman Borland believes, however, that, in order to insure the best results, it should be combined with some preparation of iron; he also sug- gests that iron be given uninterruptedly until a few days before the expected ap- pearance of the menses. Then, continu- ing the iron, apiol may be prescribed in 5-minim doses, two or three times a day, until the appearance of the menstrual ■discharge. Apiol (apioline) strongly recommended for the relief of dysmenorrhcea and amen- orrhoea. Hill (Virginia Med. Monthl/, Apr., '91); Delmis (Le Prog. M6d., Apr. 25, '91). In the treatment of dysmenorrhoeal cases, where there is no tangible pelvic lesion demanding strictly local attention, or operative interference, I have of late come to rely on a single remedy: apiol, the active principle of Petroselinum sativum. Three illustrative cases of the neurotic variety of dysmenorrhcea, dem- onstrating the marked value of the drug as a therapeutic agent, D. S. Maddox (Med. and Surg. Reporter, .Tune 5, '97). 1- APOCODEINE. See Opiuji. APOCYNUM CANNABINTJM. — This is the root of the Apocynum Canna- linum, or Canadian hemp. The plant is gray or brownish gray in color, with rather thick bark and porous spongy wood. It contains, besides tannic acid, gallic acid, and gum resin, a bitter prin- ciple which is found in the market un- der the name of "apocynin." This is an amorphous resinous substance, not a glucoside, easily soluble in alcohol and ether, and almost insoluble in water. Apocynum itself is inodorous, and has a disagreeable, bitter taste. Dose. — The powdered root may be given in doses varying from 5 to 30 grains. In small doses it acts as a bitter tonic; in 10- to 15-grain doses it acts as a diaphoretic, diuretic, and laxative. In larger doses — 15 to 30 grains — it very considerably irritates the gastro-intes- tinal tract and gives rise to vomiting and diarrhoea. Dose of the decoction (1 drachm to 8 ounces), 1 y, to 2 ounces daily; of the tincture (1 part to 10), 5 to 10 minims. The U. S. P. fluid extract, in doses of from 10 to 30 minims, is a valuable preparation. Physiological Action. — Apocynum produces a very pronounced retardation of the pulse, with a very considerable enlargement of the pulse-wave and a marked rise of the blood-tension. The initial retardation of the heart is fol- lowed by an acceleration of the cardiac action, while the arterial pressure as- cends still farther. The cardiac retar- dation (first stage) is caused by an irri- tating action of the drug, both on the central and peripheral inhibitory appa- ratuses. The subsequent acceleration (second stage) is not dependent upon anything like paralysis of the inhibitory 450 APOCYNUM CANNABINUM. THERAPEUTICS. apparatus, since the injection of another dose of the infusion can again give rise to a retardation of the heart's work. On the injection of a very large dose the two stages are followed by a third one, which is characterized by cardiac arhythmia, the appearance of Traube's waves, and a gradual fall of the blood- pressure down to 0. The rise of the blood-tension during the first and second stages is dependent not only upon the stimixlation of the vasomotor centres in the medulla oblongata, but also (and that in a very considerable degree) upon the excitation of the spinal vasomotor centres. Moreover, the heart and blood- vessels themselves take a certain active part in the causation of the rise. Both the central and peripheral vasodilatory apparatuses remain wholly intact. (So- kalofE.) The physiological action of apocynum is clinically: To strengthen and tone up heart-action; to regulate markedly the irregular heart — not slowing the normal heart, nor increasing the blood-pressure, there being no contraction of the arteries. Its diuretic action is indirect and due to its "cardiokinetic" effect, and not through stimulation of the renal epi- thelium. Decoctions of the drug cause mainly catharsis and emesis. Dose of the tincture is 20 drops, increased to 30 drops thrice daily. T. S. Dabney (Ther. Gaz., vol. xxii, p. 730, '98). Therapeutics. — The action of the root of the Apocynum Cannabinum is similar to that of digitalis, without being cumu- lative. Cardiac Affections. — In cases of cardiac dilatation the fluid extract rap- idly diminishes the area of dullness. In cases of mitral and aortic insufficiency, with disturbed compensation, it is also valuable. The action of the root of Apocynum Camvabin'um is similar to that of digi- talis without being cumulative. In cases of dilatation the fluid extract rapidly diminishes the area of dullness. It in- creases the daily amount of urine, stops the palpitation, and promotes the ab- sorption of transudations. With the ex- ception of increased pulsation of the arteries of the head, it has no bad sec- ondary effects. A. G. Glinski (Wratsch, '95). Seven cases of mitral and aortic in- sufSciency with disturbed compensation in which the fluid extract of apocynum, 15 drops three times a day, was used. Great improvement noticed within three days. The cardiac impulse grew stronger, the pulse became more regular, fuller, and slower, its frequency in some in- stances decreasing from 130 or 120 to 56 or even 48 per minute, in 48 hours. The blood-pressure rose; cyanosis and pulsa- tion of the cervical vessels vanished; the area of cardiac dullness decreased; the daily quantity of urine increased (in one case it rose from 450 cubic centi- metres to 2800 cubic centimetres) ; the body-weight fell, the diminution varying from thirteen to twenty-one Russian pounds. No unpleasant accessory effects from the drug noticed. Grozdinsky (Wratsch, No. 19, '96). Dropsy. — The main usefulness of apocynum, especially when the fluid ex- tract is employed in doses of 7 to 8 drops, is in the treatment of dropsies. Such a dose, repeated at short intervals if nec- essary, causes copious watery discharges from the bowels, the flow of urine being increased. As tolerance is established by continued use, it is necessary to increase the dose when given for a long time. (Richmond.) It is also possessed of diaphoretic- powers, which exert an effect upon the dropsy. Apocynum properly administered is a. very remarkable diuretic. Doubtless it acts indirectly by increasing the arterial pressure, but it must also be a direct renal stimulant, and cause dilatation of the renal arterioles. So far as I know, this has not been demonstrated, but the effects point to such a mode of action. Its influence is best seen in those general APOCYXUM CANXABINUM. APOMORPHINE. 451. efl'usions that depend upon a want of vascular tone, and, whatever the reason, the empirical fact remains that most remarkable results have followed its use. A. A. Woodhull (Brit. Med. Jour., Dec. 11, '97). Violent catharsis and emesis follow its abuse and not its intelligent use, and it is a really trustworthy and singularly efficacious hydragogue, especially in ana- sarca. The true value of properly admin- istered apocynum is as a diuretic. It doubtless acts indirectly by increasing the arterial pressure, but it must also be a direct renal stimulant, and cause dilatation of the renal arterioles. A. A. Woodhull (Brit. Med. Jour., Dec. 11, '97). To assist in removing the solid oedema which often prevents the healing of vari- cose ulcers in the aged, apocynum has proved more useful than any other drug. F. E. Millard (Med. and Surg. Reporter, Apr. 16, '98). Apocynum is excellent in cardiac dropsy if a good preparation is employed. Large doses are apt to disagree, and small ones are preferable for diuretic ac- tion. One of its active principles — apo- cynin — appears to resemble digitalin in its effect upon the heart; so that the diuresis produced is evidently cardio- vascular in character, and it practically represents the diuretic principle of the drug. Apocynum causes no cumulative effects, and it will occasionally prove efficient in removing dropsical symptoms of cardiac insufficiency. T. B. McGee (Amer. Therapist, No. 10, 1900). APOMOEPHINE.— Apomorphine is a pseudo-alkaloid obtained by the action of HCl on morphine in sealed tubes at a high temperature. The base can be obtained from the resulting hydrochlo- rate of morphine by dissolving in water, adding excess of bicarbonate of soda, and extracting by means of ether or chloro- form. It is soluble in hot or cold water and in alcohol. In powder it is white; but a watery solution, though at first colorless, soon turns black. The salt generally employed, however,. is the hydrochloride: made by adding a small quantity of hydrochloric acid to a solution of apomorphine. It occurs in grayish-white crystals, which are odor- less and slightly bitter. It becomes green on exposure to light and air. Dose. — For adults Vis to Vo grain. Great care must be observed in using it in feeble persons. Death has been caused by ^/i5 grain under such circumstances. For a child of 18 months, ^/^^ grain; 2 years, Vm grain; 3 years, V35 grain; 5 years, V30 grain; 8 years, ^/jj grain. One-fifth of a grain should not be sur- passed in any case when given hypoder- micalljr, and ^/^ grain when administered by the mouth. The drug acts with more rigor in some individuals than in others. Its effects, therefore, should be watched. Case of a drunkard in whom ^/lo grain of apomorphine, hypodermically admin- istered, followed in five minutes by an- other ^Ao grain, caused collapse, uncon- sciousness, cold surface, and absence of pulse at the wrist. Westby (Brit. Med. Jour., Feb. 2, '89). When administered on an empty stomach, apomorphine produces vomit- ing much more readily than when ad- ministered after meals. The rate of absorption has much to do with the entire effect. When given hypodermic- ally, it is absorbed at once; when given on an empty stomach, it is absorbed more rapidly than when mixed with foods. Murrell (Brit. Med. Jour., Feb. 28, '91). A very important fact is the great tendency to decomposition shown by apomorphine hydrochloride on exposure to moisture or moist air. As it is also affected by light, it should always be kept in amber-colored bottles. Again, it should never be kept in solution, the latter being always made fresh when it is to be used. Serious symptoms have 452 APOMORPHINE. PHYSIOLOGICAL ACTION. POISONING. THEKAPEUTICS. followed neglect to heed this precau- tionary measure. Its purity may be tested by shaking up in a test-tube a 1-per-cent. solution. If the latter turns emerald-green, it should not be employed. (U. S. P.) Physiological Action. — The physio- logical action of apomorphine as an emetic may be gathered from its symp- tomatology, which is as follows: The administration of Vio grain hypoder- mically is followed in scarcely one-half minute by fullness of the head; the pulse is quickened and increased in vol- ume; the pupils slowly dilate; the face is flushed. Perspiration soon appears; the respiration become more frequent and the heart-beats more rapid; and before two minutes elapse emesis is pro- duced. Then comes the reaction, a gen- eral relaxation, lasting about an hour. The eyes are sunken, the pupils are widely dilated, and the face is pallid and drawn. Yawning inaugurates the period of recovery; sleep follows and upon awakening all effects have passed away. (W. D. Carter.) These effects indicate that the physio- logical action of apomorphine must be multiple. This has been found to be the case in experiments upon animals. The drug seems first to excite the cere- bral centres, then to depress them. The peripheral arteries become prominent and tense, indicating arterial tension, due to increased rapidity and force of cardiac action. It is primarily a stimulant and finally a paralyzant. In excessive doses it causes convulsions, but in a manner not yet fully understood. Therapeutic doses have no appreciable effect aside from acceleration of the pulse- rate, the maximum being reached about the time vomiting begins. This is due to stimulation of the accelerator mechan- ism. Following vomiting the pulse-rate decreases: the probable result of depres- sion of the heart-muscle, since it has been shown that apomorphine is a muscle- poison. The respirations are usually increased, though variably so, after decided doses. In case of lethal dose respirations cease as a result of paralysis of the controlling centres. Apomorphine has very slight, if any, influence upon temperature. Apomorphine Poisoning. — When poi- sonous doses are given to animals, the opposite of the above is the case; de- pression of cardiac action first occurs, followed by weakness and rapid pulse. The drug also acts as a eonvulsant through its influence upon the spinal cord, the convulsions being accompanied or followed by muscular paralysis. The respiratory centres are also deeply in- volved and death occiirs from respiratory paralysis. In the human being toxic doses of apomorphine produce collapse, uncon- sciousness, failing circulation and respi- ration, and all the symptoms of profound depression of the vital centres. Convul- sions usually precede the profound de- pression, and vomiting rarely occurs. ' Treatmmt of Poisoning. — The anti- dotes are strychnine, chloral, and chloro- form. These should be supplemented by the more diffusible stimulants, as ammonia, whiskj'', coffee, etc., together with external heat. Therapeutics. — Apomorphine is doubt- less the most reliable of our emetics and the one which acts most rapidly, but the effects obtained depend greatly upon the quality of the drug used. Untoward ef- fects of various kinds have been reported, including, besides those added to the normal action of apomorphine, marked depression. This latter has occasioned APOMORPHINE. THERAPEUTICS. 453 a certain amoimt of distrust on the part of the profession, which, however, has no reasonable basis, provided a pure drug can be obtained, and proper precautions are taken, the most important of which is to prepare the solution at the very moment it is to be administered. The value of apomorphine — according to Carmichel, who voices the experience of pediatricians who have used the rem- edy extensively — cannot be too highly esteemed as an emetic for children; the average time at which emesis occurs is much less than the period required by the yellow sulphate of mercury. It affords prompt relief in croup and capillary bron- chitis without being attended by nausea and violent retching, which makes it a great boon to children. Apomorphine used after antitoxin in- jections in laryngeal diphtheria wlien the swelling and softening of the false mem- brane cause signs of suffocation. A hypodermic dose of V12 grain induces vomiting and clears the larynx. Arn- stein (Med. News, Apr. 8, '99). It is an expectorant, in doses ranging from Vso to ^/so grain. As such it affords great relief in cases of bronchitis, tracheitis, and catarrhal pneumonia. A spray of apomorphine in weak solu- tion is sometimes recommended, but its use in this manner is hardly safe. It has been found valuable in whooping- cough to relax spasmodic attacks. (In- gram.) It has recently received much praise as a soporific — especially in acute alco- holism. Apomorphine, mixed with lanolin and applied to the skin, is a most valuable expectorant. For infants the strength of the ointment should be 1 grain to the ounce, the ointment being rubbed over the body three times a day, the skin being previously thoroughly cleansed. C. Smith (Texas Courier Record, Apr., '91). Case of a man suffering from paroxys- mal tonic convulsions with flushed face and bounding pulse. The condition was assumed to have been caused by excess- ive indulgence in alcohol. A hypodermic containing Vio grain of apomorphine hydrochlorate caused free emesis, and was followed by rapid improvement. J. Edward Tompkins (Med. Record, Jan. 14, '99). Apomorphine as an hypnotic found equally useful In all forms of insomnia regardless of the cause. It should be given in a single dose of about V30 grain, injected subcutaneously. The object is to give a dose that, on the one hand, is large enough to produce sleep, and, on the other, is so small that nausea and vomiting are avoided. Hence, individual susceptibility must be considered. It should be given when the patient is in bed, for its effect is very rapid and the patient will usually fall into a restful sleep Avithin five to twenty-five minutes. If no results are observed within one-half hour the dose is too small. The effect persists for from one to two hours, but in many eases of insomnia the patient will sleep all night. C. J. Douglas (N. Y. Med. Jour., Mar. 17, 1900) . Apomorphine acts as a prompt and well-nigh infallible hypnotic if injected subcutaneously in doses of about Vm grain. Although this is about the aver- age dose, yet for some patients this is too large, as it produces nausea, while in others a larger amount will cause no dis- agreeable symptoms. The dose should be so adjusted as to be large enough to produce sleep and small enough to avoid nausea. Douglas (Merck's Archives, June, 1900). Bronchitis. — Murrell recommends that apomorphine be given in large doses as an expectorant in this disease: V2 to 1 ^U grains. He also obtained excellent results from an ointment of: apomorphine, 1 grain; lard or lanolin, 1 ounce; the half of which is rubbed into the chest: a point of very great practical importance, especially in the treatment of children. Murrell also ob- 454 APOMORPHINE. THERAPEUTICS. served the expectorant effect in many by using the apomorphine as a spray. It was very marked when tlie drug was used in large doses, and a dose which would act as an emetic, if administered hypo- dermicallj', can be used as an inhalation without giving rise to this result. Ceoup. — In croup, where the case is urgent or where an expectorant effect is desired, ^/loo or ^/eo grain every fifteen min^^tes gives the happiest effect. As relief comes, the time of dosing is ex- tended to one or two hours, but the minimum dose is continued. When it is desirable to evacuate the stomach promptly, no remedy meets the case better than apomorphine. Cardiac de- pression following the use of the remedy should be promptly met by suitable stimulants and tonics. Gastealgia. — From the fact that it produces emesis by its action through the spinal nerve-centres, and not by irritation of the mucous membrane, it is a preferable remedy in inflammatory conditions of the stomach where emetics are indicated. Case of indigestion and violent gastral- gia in wliieli aponiorpliine was given hyp- odermically to produce emesis. Within two minutes the patient was entirelj' free from pain, fell asleep and slept for an hour, and was perfectly comfortable afterward. S. F. Morris (N. Y. Med. Jour., Nov. 10, '94). Poisoning. — The value of apomor- phine as an antispasmodic is attested by Edward Balm, of Hyderabad, who tried it in a distressing case of hiccough in a man, 50 years old, who had suffered from the affection for about six months. It is thus shown to be doubly valuable as an emetic in cases of poisoning from the ingestion of such drugs as strych- nine, that cause tetanic manifestations, although after poisonous doses of drugs such as chloral — in which the symptoms are quite the opposite — it is equally useful. Case in which recovery followed after a large dose of chloral. The patient, a young man, had taken suicidally 3 ounces of syrup of chloral (B. P.). He was found in the morning unconscious, Avith cold, clammy, and livid body; ster- torous respiration; small and quick pulse, and dilated pupils. The treat- ment consisted of an hypodermic injec- tion of Vio grain of apomorphine, which was followed immediately by profuse vomiting; the injection of a pint of hot, strong coffee; heaters, and flagella- tion. After two hours of treatment the patient could speak and swallow hot coffee. He continued to improve, and in twelve hours more, though somewhat dazed, had practically recovered. Hol- burton (Brit. Med. Jour., Nov. 12, '92). Case of attempted suicide by strych- nine in which the patient had swallowed a pill containing 1 % grains of the drug. Apomorphine, cutaneous frictions, cold douches, chloral-hydrate, and bromide of potassium brought about recovery. J. Augustin and P. Flor (Spitalul, Nos. 11, 12, '94). In very severe cases it may be neces- sary to administer Vio grain every ten minutes until some effect is obtained, or exhibit '/^ grain at a single injection. In feeble persons and in children great caution must be exercised. Case of strychnine poisoning in which apomorphine, in doses of Vis to Vio grain, subcutaneously injected, com- pletely subdued the convulsions, and, eventually, successfully antagonized the excitant alkaloid. Horsley (Canadian Practitioner, Dec. 6, '90). Case of a man who took a large dose of bromidia and became violently insane, requiring three men to control him. Soon after receiving ^/i, grain of apo- morphine he vomited, had a movement of the bowels, his mental condition was relieved, and he slept well the remainder of the night. Ingram (Southern Med. Record, Apr., '92). Hysteeigal Crises. — Apomorphine has been employed in a large number of APPENDICITIS. SYMPTOMS. 455 minor hysterical phenomena, in which the remedy gave prompt relief. The amounts used varied from ^/g to ^/ao grain, hypodermically administered, and were never followed by any alarming symptoms. (Horsley.) APOPLEXY. See Cerebral H^mor- EHAGE. APPENDICITIS (from Latin, appen- dere, to hang on; and itis, inflammation). Definition. — An inflammation of the vermiform appendix, frequently compli- cated with ulceration and perforation of its coats, caused by microbic infection, which may originate from irritation pro- duced by hardened fsecal masses, foreign bodies, or traumatism. Symptoms. • — Whether catarrhal or ulcerative, the attack presents itself usu- ally in a previously healthy person and begins with sudden intense pain in the right iliac fossa, frequently localized at a spot one and one-half to two inches from the anterior superior spine of the ileum toward the umbilicus (McBurney's point), and increased by pressure. This is the most important diagnostic sign ■ when associated with the other symp- toms. The pain may radiate from this point toward the umbilicus, the epigas- trium, the groin, and the testicles, and be attended by exacerbations. It may be felt in other parts, especially the epigastrium and the umbilicus, and may even be located in the left iliac fossa. One of the most significant symptoms of inflammation of the appendix, as distinguished from other pathological conditions that may develop in the right iliac fossa, is undoubtedly the tender- ness over McBurney's point. Too often it is assumed by the practitioner that there must be spontaneous pain in the right iliac fossa whenever acute ap- pendicitis develops. It is perfectly pos- sible, however, for an active inflamma- tion of the appendix to be dangerously progressive without the slightest pain in this region, or with only some pass- ing discomfort on movement. Yet a touch over the point midway between the anterior superior spine and the um- bilicus may reveal the existence of ex- quisite tenderness. This is the signifi- cant value of the diagnostic symptom discovered by the New York surgeon, and the real reason why McBurney's point has attracted the attention of the medical world. Editorial (Jour. Amer. Med. Assoc, Aug. 16, 1902). Nausea and vomiting are present in the majority of cases, but it does not furnish any information as to the seri- ousness of the ease. Vomiting present in 208 out of a series of 306 cases; it bodes neither good nor ill. Hood (Lancet, Sept. 18, '97). Fulminating appendicitis observed in three cases. In each case there was a premonitory stage lasting a few hours, during which the patient experienced abdominal malaise. The acute symp- toms which somewhat subsided after several hours, followed in twenty-four hours by violent and sudden increase of all symptoms. A few hours later pus, with a perforated and non-adherent appendix, was found. Gauze was used for drainage in preference to a tube. The three eases recovered. Richardson (Lancet, Mar. 23, 1901). The pulse is usually high, but the tem- perature-chart shows brit little, if any, rise. The most important point to bear in mind in the diagnosis of appendicitis is the fact that the temperature of the patient is a matter of no consequence as giving any clue to the condition of the appendix. R. T. Morris (Med. Rec- ord, Dec. 26, '96). Anorexia and digestive disorders are rarely absent. Diarrhoea and constipa- tion alternate, but either symptom may be a prominent one during the entire course of the attack. Eigidity of the right abdominal wall 456 APPENDICITIS. SYMPTOMS. is generally present, but circumscribed rigidity over the region of the appendix is present in about one-half of the cases. Circumscribed muscle-tension was ob- served one hundred and twenty times in three hundred cases. Shrady (N. Y. Med. Record, June 6, '94). If the case be one of simple catarrhal appendicitis, the above symptoms con- tinue two or three days and the patient gradually recovers. Leucocytosis has recently been sug- gested as an important sign. Method of differential diagnosis more accurate than the ordinary clinical meth- ods available, viz.: examination of the blood. In appendicitis with pus-forma- tion there exists a typical abscess, and in abscess-formation there is an increase in the number of leucocytes, the increase be- ing proportionate to the amount of pus- formation. If there is no leucocytosis, the case is either not one of appendicitis or one of the catarrhal form, and ex- tremely mild, or very severe and gan- grenous, the patient being in a moribund condition. This means of diagnosis and prognosis should be given a trial. H. Stuart MacLean (Virginia Med. Semi- monthly, Sept. 22, '99). The important feature is to differen- tiate between the catarrhal and non- penetrating forms, and the septic and gangrenous forms, of appendicitis. The following general rules suggested: A temperature in the beginning of 102°, or a temperature above 100° continuing until the second day, indicates operation. A rapid, feeble pulse, without rise of temperature, suggests a gangrenous or septic process. Leucocytosis of more than 20,000 indicates operation. A. L. Benedict (Med. News, Deo. 1, 1900). In the diagnosis of suppurative ap- pendicitis the white blood-count is of the greatest importance. A sudden hyperleucocytosis points to a complica- tion in an infectious fever, — typhoid, for instance, — and if sudden abdominal pain appear an exploratory incision is warranted, as is the practice in the Johns Hopkins Hospital. Hyperleuco- cytosis at once differentiates a sup- piirative appendicitis from simple co- litis, typhoid fever, ovarian neuralgia, impaction of fteces, and floating kidney. By a blood-count pus can be detected within twenty-four hours, and an un- favorable prognosis converted into a very favorable one. Robbin (Med. Record, Oct. 27, 1900). Variations from the above course are occasionally met with. The disease may come on insidiously and fever or pain be totally absent. Although such an onset is occasionally met with in adults, it is most likely to occur in children. Occa- sional colicky pains are sometimes the only early signs furnished, these being followed by the typical symptoms de- scribed above. Slight appendicular le- sions may be accompanied by alarming symptoms in hysterical patients, or in those mentally and physically below par. Spurious symptoms often cause hesi- tation. Case in which there were five attacks with symptoms of pericsecal ab- scess and intestinal adhesions. Soft and rather large appendix the only condi- tions present. In a second case, in which the only symptom was a painful spot, at least half a pint of pus found. Routier (Le Bull. Med., Jan. 30, '95). The symptoms in a case of mild catar- rhal appendicitis cannot at pi'esent, with certainty, be distinguished from those marking onset of case of the gravest type. J. W. White (Brit. Med. Jour., Feb. 9, '96). When examining a patient great at- tention should be paid to the unequal susceptibility shown by various indi- viduals; some react but little, while others, on the other hand, show reflex symptoms of great intensity. Two cases showing that very slight appendicular lesions in hysterical patients may be ac- companied by extremely alarming symp- toms. Rendu (La Med. Mod., Mar. 24, '97). The majority of errors in the diagno- sis of intra-abdominal inflammations consist in mistaking atypical forms for other morbid conditions. List of 11 cases in which the mistake of regarding APPENDICITIS. SYMPTOMS. 457 as appendicitis conditions which, upon operation or necropsy, proved to be other and unsuspected pathological processes. In 2 renal calculus, in 4 dis- eases of the uterine appendages, in 1 sarcoma of the ileum, in 1 cholecystitis, in 1 acute suppurative pancreatitis, and in 2 to general sepsis. Brewer (Annals of Surg., May, 1901). Progress toward simple perforation or perforation into a cavity bound by ad- hesions is probable, when on the third day after the onset of the symptoms there is localized superficial cedema, indicating deep suppuration, and when a doughy mass is felt at the seat of pain, which mass gradually assumes shape to the touch, unless distended intestinal coils, shown by local tympanites, or the ten- sion of the abdominal walls makes its detection impossible. In three hundred cases the tumor in the right iliac fossa rarely showed itself before the third day of pain and tender- ness. A tumor may, however, be due to accumulation of faeces in the caecum. Dullness on percussion is rarely recog- nized before the fourth daj'. G. F. Shrady (N. Y. Med. Record, Jan. 6, '94). Fluctuation does not generally occur until the second week. CEdema of the overlying integument does not occur until a paratyphlitic abscess has formed. G. F. Shrady (N. Y. Med. Eecord, Jan. 6, '94). Diagnosis is made almost certain by the presence of a bunch, usually situated in the right lo\ver quadrant of the ab- domen or near the liver or left side. It may be obscured by abdominal disten- sion or muscular rigidity. Gay (Boston Med. and Surg. Jour., Jan. 3, '95). The presence of slight oedema over the loin is an indication of the presence of deep-seated suppuration. Symonds (Brit. Med. Jour., .Jan. 26, '95). According to Lewin, the local applica- tion of heat will show whether an in- flammatory process has progressed to suppuration or not. In appendicitis, if pus has not formed, the application of heat will be a comfort to the patient. If pus is present, the pain will increase in severity. Eight of 10 cases in which heat was applied for two hours bj' hot compresses experienced marked relief, while in the other 2 there was increase of pain. These 2 died from extension of the suppuration. Spohr has had a similar experience in 15 cases. Editorial (Therap. Gaz., May 15, 1901). If suppuration is present and perfora- tion occurs on the fourth or fifth day, — i.e., after the adhesions have formed, — the symptoms do not, as a rule, vary from those enitmerated. When, how- ever, they do not assume a graver form during the first four days, the presence of protective adhesions is likely. Danger may exist without being shown by pulse or temperature. Pulse, tem- perature, and pain may decline, marking the occurrence of effusion: a deceptive calm. The sudden access of intense local- ized pain indicates a dangerous change in the local conditions. 6. F. Shrady (N. Y. Med. Record, Jan. 6, '94). A pulse-rate of 120 indicates a con- siderable infection, and, according to some, is an absolute indication for opera- tion. Richardson (Amer. Jour. Med. Sciences, Jan., '94). Too much stress must not be laid on the temperature, as recovery may follow a temperature of 105° F. and death may occur with one nearly normal. Richard- son (Amer. Jour. Med. Sciences, Jan., '94). When the symptoms are marked and a tumor cannot be felt, perforation has probably occurred before the adhesions were sufficiently perfect to protect the peritoneal cavity. If perforation has occurred early, — i.e., while the adhesions were still im- perfect, — there is usually a chill and vomiting; shock, more or less profound; diffuse, marked pain, instead of the lo- calized pain; acceleration of the pulse; an increase of temperature of 3° or 3° F.; scanty and dark itrine, showing high specific gravity. 458 APPENDICITIS. SYMPTOMS. The cause of diflfuse peritonitis com- plicating appendicitis, ascertained by personal clinical observations, is as fol- lows: 1. Peristaltic motion of the small intestines is the chief means of carrying the infection from the perforated or gangrenous appendix to the other por- tions of the peritoneum, changing a cir- cumscribed into a general peritonitis. 2. This can be prevented by prohibiting the use of every kind of food and cathartics by mouth, and by employing gastric lavage in every case in which there are remnants of food in the stom- ach or in the intestines above the ileo- csecal valve, as indicated by the pres- ence of nausea, vomiting, or meteorism. 3. The patient can be supported by the use of concentrated predigested food ad- ministered as enemata not oftener than once in four hours, and not in larger quantities than 4 ounces at a time. 4. This form of treatment, when instituted early, will change the most violent and dangerous form of acute perforative or gangrenous appendicitis into a compara- tively mild and harmless form. A. J. Ochsner ( Amer. Surg, and Gynaec, Jan., 1902). Perforation is also accompanied by distension of the abdomen, and symp- toms of grave diffuse peritonitis appear, followed by collapse. Dullness affords an early clue to the presence of pus. Distension of the abdomen depends, for its importance, upon its cause. Opium may cause it or gas may form. If peri- stalsis is not inhibited no alarm need be felt. Distension due to local infection is of the gravest import. Richardson (Amer. Jour. Med. Sciences, Jan., '94). Increase of both pulse and temperature from a condition showing a slightly ac- celerated pulse and a temperature of 100° to 101° F., combined with increase of the other symptoms, indicate a danger- ous condition. G. F. Shrady (N. Y. Med. Record, Jan. 6, '94). General abdominal distension is the most dangerous symptom. Gage (Boston Med. and Surg. Jour., May 24, '94). A point of marked dullness in cases without any pronounced inflammatory symptoms was always found when the appendix was indurated and adherent to the adjacent tissue. In all of 19 cases in which dullness was present pus was diagnosed. This was verified either by operation or by autopsy, except in 2 cases. H. T. Miller (Med. Record, Feb. 9, 1901). The actinomycotic form is character- ized by slower progress and less acute symptoms. In the rheumatic form there is miich tenderness over the appendix. No tumor or dullness can be detected. Arthritis, however, is present. Case of rheumatic perityphlitis show- ing much tenderness in the right iliac fossa, but no tumor or dullness; with arthritis. The diagnosis proved by the fact that the salicylates rapidly pro- duced a beneficial eflfeot. I. Burney Yeo (Brit. Med. Jour., June 10, '94). The infectious form is distinguished by a rapid course. The disorder called by Poncet "acute infectious appendicitis" is distinguished by its rapid involvement of the perito- neum, without ulceration, perforation, or gangrene. It results from occlusion of the orifice of the appendix by inflam- mation, and absorption of its contents; the presence of the bacillus coli com- munis is thought also to have an im- portant influence. Clinically, it does not difi^er from other forms of the disease except in its rapid course. Margery (Jour, de Med. et de Chir. Pratique, Feb. 25, '93). When appendicitis occurs during preg- nancy, the attack is usually sudden and begins with abdominal pain which grad- ually becomes localized; this is followed by the typical symptoms. This condition must be carefully differentiated from tubal pregnancy. The prognosis is grave. Appendicitis complicating pregnancy is difficult of recognition and the cause of great mortality. Hrawacek cites 13 cases of catarrhal appendicitis with preg- nancy, 5 cured without operation, 11 operations, and 7 deaths. Case in which APPENDICITIS. DIAGNOSIS, GENERAL. 459 abscess associated with a necrosed ap- pendix was removed without disturbing the pregnancy; three months afterward the patient gave birth to a healthy child, having a normal delivery and puerpe- rium. Appendicitis sometimes appears as a complication of diseases of ovaries and appendages. Martin in 171 oper- ations for right-sided salpingitis and 276 double-sided found appendicitis 6 times in connection therewith; Dilhrssen in one and one-half years, out of 322 lapa- rotomies, had 10 eases of diseased ap- pendix; Ochsner, of Chicago, in 51 oper- ations for primary appendix found 15 times secondary disease of the append- ages. Otto Falk (Centralb. f. Gynilk., Feb. 17, 1900). Diagnosis, General. — During exami- nation gentle manipulation is necessary, lest an abscess be present and the adhe- ■sions he delicate and unable to stand the traction or pressure. (McBurney.) The amount of manipulation necessary to make a complete diagnosis should be of the very lightest possible kind. Any- thing more than very light manipulation in one of these cases must be accom- panied by a certain amount of danger, because we do not know the thickness of the barrier between abscess-cavity and the peritoneum. McBurney (Buffalo Med. Jour., June, '96). The location, direction, and extent of the appendix have an important bearing on the clinical history of appendicitis, considering the variations of the appen- dix in length, direction, and location, and the varying site of the cscum. It is quite possible to feel the normal appendix in most cases. If one palpates gently with two or three fingers on the opposite side one can readily get the landmarks. The ascending colon is the first landmark. Three fingers are placed upon the rectus muscle, then brought down over the edge of the muscle, three fingers of the right hand being used to feel with and the three fingers of the left hand to press with. The examining fingers are pressed by means of the three others down under the border of the right rectus abdominis muscle at the level of the navel, and slowly drawn to the examiner. The landmark, the as- cending colon, is then felt to slip out from under the fingers, and, by repeating the process toward the csecum, one soon comes to the end of the latter, and there begins to hunt for the appendi.x by roll- ing the CEecum to one side or the other of the finger-tips. The proximal end of the appendi.x is found near the distal end of the caecum; the remainder of the appendix is followed in any direction. The proportion of appendices that cannot be palpated will become smaller as the finger-tips become educated. The very delicate sense of touch is preserved if the left hand is used for pushing upon the examining hand. Robert T. Morris (In- ternational Jour, of Surg., Aug., '98). Auscultation of the lungs and heart sometimes affords information. Examination through the rectum is of value in determining the presence of pus in advanced cases. In the earlier stages this procedure is of no value. Examination of the urine may assist in the location of the inflammatory proc- ess and in determining the activity of metabolic processes. Glycosuria was also found present in three cases examined by Leidy. In 228 consecutive cases of appendicitis in which there was an operation there were 7 errors in diagnosis; these include 1 each of old typhoid-fever complications, peritoneal tuberculosis, cancer of appen- dix, congestion of appendix, hysteria, pneumonia, and sequelae of measles. As the number of errors is small compared with the total number of cases, it is con- cluded that appendicitis is one of the most readily diagnosed of all diseases. In 4 of the eases in which an incorrect diagnosis was made the operation was of benefit to the patient. Robert T. Morris (N. Y. Med. Jour., Apr. 8, '99). The youngest patient on record oper- ated on was sixty-one days old. Chil- dren seem to bear general septic infec- tion better than adults. The two con- 460 APPENDICITIS. DIAGNOSIS, DIFFERENTIAL. ditions from which infantile appendi- citis must be differentiated are intus- susception and tuberculous peritonitis. The most reliable source of information lies in the careful examination of the abdominal wall, which, in a child, is very easily accomplished. Abdominal disten- sion, frequent and shallow respiration are common. T. H. Manley (Jour. Amer. Med. Assoc, June 1, 1901). Every death from appendicitis, in an individual otherwise well, excepting those of the fulminating type, could have been prevented by the use of the knife at the proper time. If one is to operate early, an early diagnosis is necessary. If the three cardinal symp- toms of appendicitis are kept in mind, the early diagnosis is, in nine eases out of ten, very simple. The three cardinal symptoms are pain, tenderness, and rigidity. J. B. Deaver (New York Med. Jour., Dee. 7, 1901). We can best diagnose the locality of the disease by the following method: Ask the patient to point the finger quickly to the spot where there is the most pain without looking at the abdo- men. Eepeat this proceeding a number of times until you are certain that the right point has been obtained. Then the course of the appendix will lie be- tween the base of the organ and this point. Where no mass can be felt in the region it is impossible correctly to diagnose a perforation or gangrene. Where the mass can be felt and persists longer than two or three days without diminishing in size or indeed even in- creasing, it always has pus for a nu- cleus. C. A. Elsberg (Med. Record, April 5, 1902). There are a certain number of cases in which the diagnosis of appendicitis is so evident that no one questions the propriety of operation. There are other cases in which the symptoms remain permanently, subjecting the patient to frequent exacerbations. There is a third class in which the symptoms abate never to return, on the one hand, or to return at intervals, on the other hand, until relieved or until death oc- curs. In any case of appendicitis in which the diagnosis is undoubted and the services of a competent surgeon can be secured, operation should be done. James Tyson (Proceedings Amer. Med. Assoc; Phila. Med. Jour., June 21, 1902). Diagnosis, Differential. Intestinal Obstruction. — In this disorder the rise of temperature occurs late. Stercoraceous vomiting is observed in serious eases. Volvulus generally pre- sents itself in children. Typhlitis. — This disease is charac- terized by a gradual onset, a typhoid course, and a prolonged convalescence. The pain on pressure in typhlitis is dull, while in appendicitis it is sharp. Typhlitis is more a disease of corpulent aged individuals leading a sedentary life; appendicitis is an affection of young adult males. Benoit (L'Union Med. du Canada, Mar., '94). Esecal distension of the caecum some- times causes irritation of the mucous membrane, and presents symptoms sim- ilar to those of appendicitis. This con-, dition may be excluded by the fact that the tumor preceded the pain, by the ab- sence of vomiting and rigidity of the abdominal wall, and by the small amount of pain and tenderness. Typhoid fever is to be excluded by gradual rise and higher temperature range, by the absence of tumor and rigidity of the muscles in the right iliac region, and by the nervous phenomena and spots. In typhoid fever the characteristic stools will probably be found, and in appendicitis constipation, or, if diarrhoea, it is not characteristic. Intestinal obstruction presents the symp- toms of shock from the first, if it is acute, and there is no elevation of tem- perature. The constipation is more marked than in inflammation of the ap- pendix, save in those cases where paresis of the intestine is present. Vomiting is a characteristic symptom of intestinal obstruction. In renal calculus the pain radiates from the right lumbar region to the hypogastrium and is very severe, but disappears after the lapse of some hours as quickly as it came. The testicle is retracted and the patient is without APPENDICITIS. DIAGNOSIS, DIFFERENTIAL. 461 fever. The absence of fever by no means excludes appendicitis, however. Gall- stones may be simulated by an abnor- mally located appendix which is in- flamed. In the female inflammation of the Fallopian tube and extra-uterine pregnancy can usually be excluded by a bimanual examination in connection with the clinical history of these conditions. J. Garland Sherrill (Louisville Jour, of Surg, and Med., Apr., '99). A number of cases of chronic colitis seen in which the question was raised as to wnether the condition was not really a chronic appendicitis, but no case of acute appendicitis of so grave a nature had been seen as to mal^e it unsafe to give a laxative or injection for fear of producing perforation where the question was raised as to whether the condition was really an acute ap- pendicitis or acute colitis. When per- foration is threatened in acute ap- pendicitis, the diagnosis is usually not difBcnlt to make. One or two cases of unmistakable chronic colitis personally . seen which were entirely cured by re- moval of a diseased appendix. This would seem to indicate that the inflam- mation in these eases had begun in the appendix and extended to the colon, the primary and chief lesion, however, being in the appendix. McBurney (Med. Rec- ord, April 19, 1902). • TuBEECULAK TYPHLITIS. — Slow as- thenic course, diarrhoea, and a higher temperature usually distinguish this dis- ease. The diagnosis between appendicitis and tuberculous typhlitis is often ob- scure. The latter may be localized at one point of the csecum, causing a small, hard tumor without viscous surround- ings. Rlehelot (L'Union Med., Nos. 39, 40, '92). Case in which symptoms of appendi- citis were such as to leave little room for doubt. Nevertheless, the appendix was free from disease, and tuberculous ulceration and narrowing of the caecum were alone found after death to account for the symptoms. H. W. Page (Lancet, .July 3, '97). TuMOES. — In cancer— the neoplasm which occurs most frequently in the intestines — the subject is usually beyond his fortieth year. Slow progress and the cachectic face are important differenti- ating signs. Judgment should not be passed too hastily on tumors in the caecal region; eight cases in which tumors of that re- gion were connected with the csecum. Richelot (L'Union Mfidicale, Apr. 2, '92). Case of epithelioma of the caecum and appendix simulating recurrent appendi- citis. Sourdille (Bull, de la Soc. Anat., Dec, '94). Myxoma of vermiform appendix simu- lating recurrent appendicitis, in a girl, aged 23, admitted with a history of two attacks of (supposed) appendicitis. The appendix was thickened at the end, and upon being opened showed a pellucid shining tumor the size of a small bean. No record of a similar specimen found. Churton (Brit. Med. Jour., May 15, '97). In the case of a boy with symptoms of chronic appendicitis there was found by operation a round-celled sarcoma of the appendix with involvement of the mesen- teric glands; patient recovered after re- moval of the csecum, a portion of the ileum, and a V-shaped piece of mesentery. J. C. Warren (Boston Med. and Surg. Jour., Feb. 24, '98). Anomalous cases of appendicitis which may be mistaken for neoplasms in the iliac fossa. A hard tumor develops slowly, with progressive emaciation and cachexia. After a long period the mass becomes softer, evidences of suppuration appear, and on making an incision pus is evacuated, the tumor then disappear- ing. Legueu and Beaussenat (Revue de Gynec. et de Chir. Abdora., No. 2, '98). Typhoid Fevee. — Perforation occurs late in this disease, while the tempera- ture, the petechia, and other character- istics readily serve to distinguish it. When there is doubt as to whether a case is typhoid or appendicitis, the operation should be postponed if con- stitutional signs are severe and local ones hard of detection. When the ab- dominal symptoms — pain, tenderness. 462 APPENDICITIS. DIAGNOSIS, DIFFERENTIAL. rigidity, with or -without distension — call loudly for operation, the abdomen must be opened, in spite of the possi- bilities of typhoid; but cases suggesting typhoid as strongly as appendicitis should, until the diagnosis is perfectly clear, be carefully observed. One should proceed in doubtful eases with extreme caution; every means of investigation should be exhausted before subjecting the patient to an operation. In those cases in particular in which the sus- picion of typhoid fever is present, the abdomen should not be opened unless the indications are strong. When, in spite of repeated examinations and the greatest care, the surgeon is convinced that tj'phoid fever is not present, ex- ploration, even if it proves him wrong and shows that typhoid does really ex- ist, loses the sting of carelessness and haste. The blunders that mortify are those which would be unnecessary were the examination painstaking. M. H. Kichardson (Boston Med. and Surg. Jour., Jan. 9, 1902). DisoRDEES OF THE UTERUS, adnexa, and pelvic cellular tissue, especially sal- pingitis, are conditions which may cause confusion, especially the latter. Exam- ination of the genito-urinary organs sometimes establishes the differential diagnosis. By placing the patient on her left side with the shoulders low and the legs drawn up, it is much more easy to de- tect the position and condition of the appendix and also to differentiate it from the uterine adnexa than by palpa- tion of the patient lying on her back. Even when no great intestinal distension is present, the depth at which the appen- dix might lie is greater, and the tension of the abdominal walls is likely to be more marked in the dorsal position than when this lateral method is employed, if no intestinal adhesions are present. (J. C. Simpson.) In appendicitis the pains are more violent, but more strictly localized, and radiating pains are absent. In catarrhal salpingitis, especially if the ovaries share in the inflammation of the tubes, the pains radiate toward the thigh; the alarming symptoms also show a notice- able remission toward the third or fourth day. (Vineberg.) In an acute progressive case the ab- domen is so rigid that deep palpation is difiicult and dangerous. A rigid abdo- men is the principal differential sign between acute appendicitis and salpin- gitis. (E. T. Morris.) Simple appendicular colic or parietal inflammation of the appendix may be accompanied, in hysterical persons, espe- cially women, by nervous symptoms, simulating severe diffuse peritonitis. Talamon (Med. Mod., No. 24, '97). Three eases of tubo-ovarian congestion diagnosed as appendicitis. Colicky pains in the right iliac region five days after the end of the menstrual period; simi- lar attack a year previously. A rectal and vaginal examination revealed a re- troflexed uterus, with enlarged tender ovary and tube on the right side. J. C. MacEvitt (Brooklyn Med. Jour., Apr., '97). Six cases of appendicitis in the female in which it Avas impossible to positively establish the diagnosis before opening the abdomen. If the pain and the tumor are high up in the region of the right tube and ovary, appendicitis probably present. If the hymen is intact an in- flammatory enlargement on the right side is probably due to appendicitis. Eichelot (Le Gyngc, June, '97). Acute puerperal parametritis may be- gin in the same manner as perforation of the appendix, but the symptoms are less severe, those of diffuse peritonitis being absent. It is more difficult to distinguish be- tween perforation of the appendix and the rupture of a pus-tube or ovary. If recovery takes place, the parametritis and paratyphlitis exudates can usually be diagnosticated by their characteristic shape and position. Kriiger (Deut. Zeit. f. Chir., B. 45, H. 3 and 4). APPENDICITIS. DIAGNOSIS, DIFFERENTIAL. 463 Diagnosis is not easy when inflamma- tion of tlie right tube and ovary and of the appendix occur at the same time. We have in both rapid pulse, rise of temperature, pain, vomiting, and tym- panites. However, appendicitis begins more acutely. If a chronic case, there is a history of one or more former sharp and sudden attacks. Lesions of tubes and ovaries are of older date and have a history of menstrual disorder. Pain of appendicitis is acute, frequently violent, beginning over the solar plexus, radi- ating over the whole belly, and finally settling in the right iliac region. In ad- nexal disease the pain is dull and heavy, and never sharp and lancinating until the peritoneum is involved. Patient is more alarmed in appendicitis than in dis- ease of the adnexa. Location of tender- ness is different: in appendicitis it is on a level with the anterior spine; in ad- nexa, trouble is in the pelvis. In the latter, vaginal examination reveals the site of tenderness; in the former, one can touch and move the organs in the pelvis without producing pain. Vomit- ing is more common in appendicitis. Rigidity of the muscles of the abdomi- nal wall over the right iliac region is almost always present in appendicitis, and generally absent in inflammation of the tubes and ovaries. In case of doubt chloroform should be given, and by its aid the enlarged and tortuous appendix can be felt or by a bimanual examination disease of the adnexa may be discovered. Hunter McGuire (Southern Med. Record; Canada Lancet, May, '98). Neuralgia in the region of the appen- dix, renal colic, particularly when pro- tracted and febrile, cholecystitis, per- foration of duodenal or other ulcers along the gastro-intestinal tract and diseases of the internal genitalia may simulate this affection. E. G. Janeway (Med. Record, May 26, 1900). Appendicitis is much more common in women than is supposed, because of the frequency with which it is mistaken for ovaritis of the right side. Several per- sonal patients had been treated for a prolonged period. The pain of appendi- citis is more sudden in its onset, and much more acute and is often accom- panied with nausea. Muscular spasm is usually marked; the general dis- turbance is greater, and the progress more rapid. An intact hymen points to appendicitis. F. W. McRae (N. Y. Med. Jour., Feb. 2, 1901). Miscellaneous Disohdees. — Accord- ing to Deaver, movable kidney is to be differentiated as follows: In appendicitis there is more apt to be fever and in- creased pulse-rate, the rigidity of the abdominal wall does not involve such a large area, there is a circumscribed and acutely-tender point, the tenderness is more superficial, and there is an absence of a movable tumor which readily slips from between the examiner's fingers. Chronic appendicitis is present in from 80 to 90 per cent, of women with symp- tom-producing movable right kidney. This frequency constitutes chronic ap- pendicitis one of the chief, if not the chief, symptoms of movable kidney. Twenty per cent, of all women have movable kidney or kidneys; 4 per cent, of all women have symptom-producing movable kidney or kidneys; 4 per cent, of all women have appendicitis, while 3 Vs per cent, of all women have both symptom-producing movable kidney and appendicitis; only 'Z™ per cent, of all women have appendicitis and well- anchored kidneys. A movable left kid- ney never produces appendicitis. Mov- able right kidney probably produces chronic appendicitis by indirect pressure upon the mesenteric vein, the return- circulation of the appendix being ham- pered by compression of the vein between the head of the pancreas and the spinal column. George M. Edebohls (Post- graduate, Feb., '99). Infectious catarrhal inflammation of the iile-duds and ulceration of these ducts may occasionally simulate appen- dicitis. Biliary colic is to be differen- tiated by jaundice, absence of fever, peculiar color of the stools, finding of gall-stones in the passage, and by the more severe and continuous pain, radiat- 464 APPENDICITIS. ETIOLOGY. ing usually from the chest-margin to the umbilicus. Simple empyema of the gall-lladder is diagnosed by the onset, the location and character of the pain and tenderness, and by the area and degree of rigidity. Acute phlegmonous cholecystitis and gangrene of the gall-bladder may usually be diagnosed by the existence of more acute symptoms, more general perito- nitis, by the rapid and shallow respira- tion, location of the pain and tenderness, and by the greater tendency to a rapidly fatal issue. Perforated gastro-intestinal ulcers are diagnosed by predisposing age, history of previous gastric or intestinal disturb- ances, sudden acute pain in the epigas- trium, followed by collapse, and last by the presence of bloody vomiting, or, in the case of intestinal ulcers, by the haemorrhage from the bowel. Perfora- tion occurring in typhoid may be very difficult to tell from a concurrent ap- pendicitis. Extra-uterine pregnancy is to be rec- ognized by the existence of the usual subjective signs of pregnancy, by vaginal examination, and by the absence of in- flammatory symptoms prior to the rupt- ure. (Annals of Surg., Mar., '98.) Etiology and General Characteristics. — Young adults, especially males, consti- tute the majority of cases. Appendicitis occurs at all ages, however, though very rarely during infancy. Among 489 cases found in literature 392 were males and 97 females. Pravaz (These de Lyon, '88). Of 90 cases, 73 per cent, were under thirty years of age; 76 per cent, were males, 24 per cent, females. Bigelow (Vis Medicatrix, Oct., '91). Report of 517 eases seen in the leading Montreal hospitals showing the condi- tion to be most common between the ages of twenty and thirty, and to occur twice as often in males as in females. G. A. Armstrong (Lancet, Sept. 18, '97). Study of 80 cases treated by Broca; 70 not previously published. Propor- tion of boys to girls, 58 to 21; 5 were aged between 2 and 5, 25 between 5 and 10, and 41 between 10 and 15 years. :Mlle. Gordon (These de Paris, No. 101, Heredity seems to act as a predispos- ing factor in connection with an arthritic diathesis. Three cases in which appendicitis seemed to follow family lines. The first patient had lost a daughter one year before from peritonitis, resulting from appendicitis. She had had three pre- vious attacks. The second, a child, 11 years of age, had a first cousin, 12 years of age, operated on for appendicitis. The third, a boy aged 13 years, had lost an elder brother, who had died of general peritonitis. A gangrenous appendix also found in this case. W. T. Smith (Med. Record, Sept. 12, '96). Heredity as a predisposing cause. The author refers to the fact that for- eign writers have reported a number of families in which this disease was fre- quent. Talamon says that the reason this subject has been overlooked in medicine is due to the fact that the clinical forms and methods of treatment of appendicitis have been discussed, to the neglect of the etiologj'. The author reports three family histories in which appendicitis and bowel disturbance were very common. In the first family there was a train of symptoms going through all the members of the second genera- tion. These refer to gastro-intestinal disorders associated with nervous symp- toms and circulatory disturbance. In the third generation there was appen- dicitis. In the second family the father probably had appendicitis, and he as well as the mother had constipation. All the members of the second genera- tion had some gastro-intestinal disturb- ance. Three of the members of this family had appendicitis. In the third generation of the same family constipa- tion was the rule, and in the fourth APPENDICITIS. ETIOLOGY. 465 generation there were two cases of gas- trectasis. F. Forschheimer (Amer. Med., Oct. 5, 1901). " he local inflammation may be caused y^ the intrusion of: — 1. Micro-organisms, specific, and non- specific, of which constipation, dietetic indiscretions; neighboring catarrhal, ty- phoid, and tubercular processes; constric- tion, torsion, or strain are the primary etiological factors. Cases due to actino^ mycosis are occasionally observed. Trau- matism, blows upon the abdomen, etc., sometimes produce inflammation of the appendix. The great frequency of this aflfeotion is due to the fact that the appendi.x is a funetionless structure of low vitality, removed from direct faecal current; bacterium coli commune is always present and is capable of great virulence when constriction of the appendix or lesions of its mucous membrane or other coats are present. J. William White (Therapeutic Gazette, p. 385, '94; Brit. Med. Jour., Feb. 9, '95). Case of appendicitis due to trauma- tism, the patient, a boy of 16 years, hav- ing been struck in the right iliac region by the handle of a push-cart. Distinct tumor in the right iliac region, marked tenderness moat acute over McBurney's point, and some pyrexia. The tip of the appendix found gangrenous. W. S. Coley {Med. Record, Feb. 15, '96). A strain may apparently originate an attack: a point of medico-legal impor- tance. An already damaged appendix is especially susceptible to such injury. Many acute attacks of appendicitis com- mence during sleep. Rutherford Mor- ison (Edinburgh Med. Jour., Mar., Apr., May, '97). The disease is of growing medico-legal importance, as many cases are of trau- matic origin, and may therefore give rise to proper suits for damage or valid claims against accident-insurance companies. W. B. Small (Med. Record, Sept. 10, '98). In three hundred male and one hun- dred and eighteen female adult autop- 1- sies the appendix was found so fre- quently adherent to the psoas muscle while free from adhesions when situated elsewhere tliat the conclusion that trauma of the psoas muscle is most pro- ductive of appendicitis is inevitable. Byron Robinson (Annals of Surg., Apr., 1901). Three cases showing that a slight in- jury may give rise to a fatal attack of appendicitis, A small deposit of hard fffical matter in the appendi.x may, after prolonged retention, set up localized necrosis, which is not likely to cause mischief so long as it involves only the inner layers of the appendical wall. Any injury inflicted on the abdomen may rupture the intact external coat, and cause the infected contents of the appendix to penetrate the abdominal cavity. Direct or indirect traumatism may produce an attack of appendicitis in a healthy subject, but in most trau- matic cases a laceration caused by a confined enterolith is the starting-point of the inflammation. Schottmuller (Mitt, aus der Gren. der Med. und Chir., B. vi, H. 1 and 2, 1901); Neumann (Arehiv f. klin. Chir., B. Ixxii, H. 2). 2. Irritating fsecal matter, which fre- quently forms hard egg-shaped fsecal con- cretions of various sizes; foreign bodies, — cherry-stones, orange-seeds, buttons, spicules of bone, etc., — which penetrate into the interior of the appendix through deficient action of a valve which usually closes its opening, or on account of ex- cessive patency of the latter. Grape- seeds were at one time thought to play an important role as etiological factors, but a painstaking investigation by Ed- mund Andrews showed that this was not based on facts. Indeed, it is quite prob- able that foreign bodies play a very small part in the production of attacks of appendicitis, hardened faecal masses be- ing excluded. Study of four hundred specimens of the vermiform appendix. Fsecal stones found thirty-eight times; equally fre- 466 APPENDICITIS. ETIOLOGY. quent in both «exes. The appendix un- dergoes a process of retrogression, in length, in its histological structure, and spontaneous obliteration of the lumen. The average length is eight and one- fourth centimetres; greatest length at- tained between the ages of 10 and 30; the shorter the appendix, the more fre- quent the obliteration. Ribbert (Vir- chow's Archiv, B. 132, H. 1, '93). Of one hundred and forty-six adult eases recorded by Matterstock sixty- three had faecal concretions and but nine had foreign bodies. J. 0. Affleck (Int. Med. Mag., Oct., '93). Two hundred cases of appendicitis ex- amined for seeds. In one case a few strawberry-seeds found, while none of the others contained more than a fsecal concretion in the form of a foreign body. Gallant (Med. Record, Feb. 15, '96). Investigation as to the question of the part played by grape-seeds in the eti- ology of appendicitis, based upon all cases found in the Chicago hospitals dur- ing a period of fourteen years: 3709 in number. Instead of finding that a large number of eases had occurred during August, September, October, and No- vember, — the grape-eating months, — it was actually found that a smaller num- ber of cases had been observed during these months each year. Edmund An- drews (Jour. Amer. Med. Assoc, vol. xxvii, p. 1193, '96). Appendicitis caused by a full-sized Asoaris lumbricoides in the appendix. J. Price (Va. Med. Semimonthly, Jan. 29, '98). The vermiform appendix is a common habitat of thread-worms; very probably they breed there. In 200 autopsies on children under twelve years of age thread-worms were present in the intes- tines in 38, or 19 per cent., and in those children over twelve years of age the percentage was much higher, viz.: 32 per cent. In no less than 25 out of the 38 cases the worms were found in the appendix, and in 6 the appendix was the only part of the alimentary canal where the worms were found. In 1 case where pain had been complained of in the right iliac fossa the appendix contained HI worms, and was in a catarrhal condition. In several other cases the appendix was in a similar condition. The idea that thread-worms are chiefly found in the lower part of the colon is therefore erro- neous, and injections, in order to be effective, must be sufficiently bulky to reach the caecum, as much as 16 to 20 ounces being often tolerated by children of from six to twelve years of age. Still (Brit. Med. Jour., vol. i, p. 898, '99). One thousand four hundred cases col- lected from various sources in the last ten years, and only about 7 per cent, found of true foreign bodies. In 700 of these cases in which definite statement was made as to the nature of the for- eign bodies, 45 per cent, were fsecal con- cretions. The only foreign body observed in 250 cases of appendicitis at the Johns Hopkins Hospital was a segment of a tape- worm. J. F. Mitchell (Johns Hop- kins Hosp. Bull., Jan., Feb., Mar., '99). As previously shown, appendicitis may be caused by ova of the ascaris. lumbricoides and trichocephalus dispar. This view sustained by five other eases. Hence, in all cases of appendicitis the- stools should be examined for worms or their ova. When possible, santonin and thymol should be given. Raw veg- etables, salads, strawberries, etc., and unboiled or unfiltered water should b& prohibited those with appendicitis, or subject to it, and their stools examined from time to time. Metehnikoff (Jour, des Prat., Mar. 23, 1901). Notwithstanding the frequency of worms (ascarides and triehocephali) among the Chinese and Europeans liv- ing in China, not a single case of ap- pendicitis met with in the European population, some 120 persons, under per- sonal care. Yet in a young Russian woman and in two missionaries abdom- inal pains suggesting appendicular colic seemed to depend on the presence of a taenia; they ceased on the expulsion of the parasite. The rarity of appendi- citis in the Chinese appears to confirm the opinion of Keen and Lucas-Cham- pionni&re as to the predisposing influ- ence of meat diet, meat in China being a luxury within the reach of few. Matignon (Bull, de I'Acad. de MSd.^ Mar. 26, 1901). APPENDICITIS. GENERAL PATHOGENESIS. 467 General Pathogenesis. — The vermi- form appendix is a glandular organ pre- senting a certain analogy to the tonsils and liable, as well, to follicular, mucous, submucous, infectious, exudative, and ulcerative disorders. The appendix is rather a glandular organ than an organ of absorption; its mucous glands and lymphoid tissue are greatly developed. In the angle formed by the appendix, the cfecuni, and the small intestine there is a lymphatic gan- glion not before described. Clado (Bull, de la Soc. de Biol, Jan. 30, '92). Like the tonsil, the appendix abounds in closed adenoid follicles, and, like ton- sillitis, appendicitis recurs in patients who are predisposed to it. Since ton- sillitis is one of the most frequent mani- festations of influenza due to a change in the seasons, it is not to be wondered at that appendicitis should occur under the same conditions. Three illustrative cases. P. Merklen (Univ. Med. Jour., Apr., '97). An absolutely healthy appendix is never attacked by appendicitis, but may become involved by continuity from catarrhal inflammation of the cteoum. Appendicitis has always a gi-adual begin- ning without symptoms, followed by signs of sudden acute inflammation. A pointed foreign body in the appendix may give similar symptoms rapidly fol- lowed by perforation. The appendix is predisposed to attacks by chronic ill- ness. While ftecal concretions are usually found in a healthy appendix, they may occur in granular or tuber- cular appendicitis. Stricture or stenosis of the appendix may occur. Non-puru- lent appendicitis rarely contains a fsecal concretion. Gangrene occurs earlier in purulent than non-purulent appendi- citis; gangrene is more rare with strict- ure or stenosis of the appendix than with granular appendicitis. Minute haemorrhages occur and the infection reaches the lymph-channels. Periap- pendicular abscess may develop without perforation, rarely even at some dis- tance from the appendix, and may be wholly absorbed, with recovery. Ste- nosis of the appendix rarely heals spon- taneously, and the presence of a con- cretion usually causes suppuration, though it may reach the ca>cum. Only about one-third of all cases run a mild course. Of 282 patients with appendi- citis, but 84 were non-purulent. Riedel (Archiv f. klin. Chir., vol. Ixvi, Nos. 3 and 2, 1902). An appendicular inflammatory proc- ess is almost invariably started by the bacillus coli communis. In a certain proportion of cases other micro-organ- isms, especially the staphylococcus py- ogenes and streptococcus, are also found. Experiments in rabbits showing that. any obstruction of the mouth of the ap- pendix is sufficient to cause appendicitis. The bacillus coli found in pure culture remain inoffensive until obstruction of the opening causes their multiplication. Roger and Josu6 (Jour, des Practiciens^ Feb. 8, '96). The coli bacillus, undoubtedly, may alone exist in the exudate. In 20 cases examined, all purulent, 10 were asso- ciated Avith other bacteria, the most im- portant of which in 6 cases was the streptococcus. It is probable that ia appendicitis the coli bacillus is aided by other bacteria, which it soon out- numbers and destroys. Achard and Broca (Gaz. Heb. de M6d. et de Chir., Apr. 1, '97). New method of studying the removed appendix. Within a few hours after re- moval the appendix should be distended with 95-per-eent. alcohol, through a con- ical nozzle of a small syringe tied tightly into its cut end by a ligature, which is tightened as the syringe is withdrawn. The distended organ is then immersed twenty-four hours or more in alcohol of the same strength. It is then ready for section. If it is sliced centrally from end to end, its interior will be a revela- tion to the surgeon. Whereas the out- side may preserve the cylindrical form of a normal appendix, and may give little or no evidence of inflammation, the interior (if the patient has had one 468 APPENDICITIS. GENERAL PATHOGENESIS. or more attacks) will show one or sev- eral of the conditions illustrated by the annexed cuts. Robert Abbe (Med. Rec- ord, July 10, '97). Histological study of the various forms of follicular appendicitis: I. Recurrent formed from the faeces and contain no food-remnants, they are derived from the mucous secretion of Lieberkiihn's glands; the latter are hypertrophied from their activity. 3. The obliteration of the vermiform process is a pathological proe- 7 " " 10 Figs. 1, 2, and 3. — A fsecal concretion blocking the canal. Figs. 4, 5, and 6. — Interior ulcerations. Figs. 7, 8, and 9. — Cicatricial strictures, often of pin-hole aperture only. Fig. 10. — Multiple strictures with intermediate pockets, containing suppurating and catarrhal products and confined by greatly hypertrophied muscular and mucous coats. Fig. 11. — Partial obliterating appendicitis. These five varieties are subject to minute variations. {Robert Abbe.) appendicitis has its principal location in the follicles. 2. Fseeal concretions, which are frequently found in appendicitis, are a result of the appendicitis ; they are not ess Avhieh follows follicular appendicitis. 4. Gangrenous appendicitis in which all the coats of the organ are destroyed simultaneously is fortunately of rare oc- APPENDICITIS. GENERAL PATHOGENESIS. 469 currence. Pilliet (Le Prog. Med., Jan. 29, '98). There are at least four distinct vari- eties of appendicitis obliterans: an exu- dative variety; a variety characterized by mucosal hyperplasia, and sclerosis; a variety characterized by submucous hy- pertrophy; a reparative variety. In all U-shaped appendix with central constriction. Lower segment found empty. (Brun.) (I.a Pr9bScMc applications of unguentum hydrargyri. BLEPHARITIS. TREATMENT. 579 Case of vaccination ulcer on the upper lid of a female adult, probably inoculated while washing a child, which had re- cently been vaccinated. Hirschberg (Centralb. f. prak. Augen., Jan., '92). Case of vaccine blepharitis. Lower lid showed two ulcerating patches at the ciliary margin, close to the external canthus. Infection probably occurred from contact with a vaccine pustule on the arm of a sister. C. Zimmennan (Archives of Ophthal., Apr., '92). Case of accidental vaccinia of the eye- lids; latter oedematous and painful, their edges at both outer canthi exhibiting a purulent ulcer with indurated margins. Thompson (London Lancet, July 23, '92). Blepharitis ciliaris (funinculous) is a ■variety peculiar to no local or reflex con- dition, btit is caused, as a rule, by an infection. Such inflammations follow the usual course of furuncular inflam- mations and abscesses, and the secretion from the localized slough furnishes the typical "furuncle bacillus." For this reason alone the boils, or furuncles, not necessarily "styes," recur, and acute autoinfeetion through the. mouths of the Meibomian follicles occur and recur, unless severe antiseptic precautions are rigidly enforced. Hot fomentations with boiled water, followed by drenchings with borated or weak sublimate solutions (1 to 3000) are best. When furunculous abscesses are evacuated spontaneously or by the knife, a focus of infection is established, and we must use dilute listerin, Dobell's solution. Seller's solu- tion (tablets), electrozone, or dioxide of hydrogen, until complete healing has taken place. Fomentations are best made while the patient reclines. Squares of "spongiopilin" or pledgets of absorb- ent cotton covered with "oil-silk" are most convenient. Following hot fomen- tations, the eye should be lightly covered and protected from draughts. Half-grain doses of sulphide of calcium in nill form two or three times a dav after meals are recommended as a pre- ventive for styes. Sympson (Brit. Med. Jour., Nov. 24, '88). Hydrogen dioxide of special value in the treatment of blepharitis marginalis. After the eye has been cocainized the drug is applied to the lid upon a cotton tampon. Daily sitting. Ayres (Amer. Jour, of Oph., Feb., '94). Successfully employed the above treat- ment for the past two years. Essad (Eecueil d'Ophtal., Apr., '94). Loss of cilia caused by destruction of glands is seldom seen, but such loss of cilia robs the eye of its protection against light. Cilia generally grow again unless the edges of the lids are sclerosed and deformed with cicatrices from neglected ulcerations about the mouths of the hair- follicles. Closure of the puncta laerymalia is a most serious complication. All careful operators take great pains to cleanse the cilia, especially the superior ones in any case. It is unsafe to operate with bleph- aritis present, as the secretion would in- fect the wound. In phlegmonous, or erysipelatous, blepharitis ciliaris with abscess of the upper lids, and in cases of ecchymosis or other swellings, these should be evacu- ated, the eyeball being cut into. A fact worth noting is that blepharitis ciliaris is seldom found accompanying myopia. If blepharitis ciliaris is a symptom of functional strain of reflex eye origin, headaches are seldom present. If, on the contrary, headaches are the one symp- tom, blepharitis, or blepharadenitis, is generally conspicuous by its absence. If one eye be used more than the other, or if one eye be not used at all, more or less blepharitis ciliaris will likely indicate the amount of strain. Blepharadenitis is only an aggravated subacute or chronic form of blepharitis ciliaris, in which the mouths of the 580 BLEPHAKITIS. BORACIC ACID. Meibomian follicles have become closed and the lining membrane of the glands has become subacutely or chronically inflamed. Eetention-cysts and abscesses with pyogenic membranes secrete pus from granulating sacs and deform the lid. Unless every particle of diseased gland with its pyogenic membrane be carefully removed, recurrence will take place, and injury to the tarsal cartilage will cause deformit3^ Epiphora, entropium, and ectropium will ensue, and with them what is best described as "wrinkled lid" will remain as a permanent source of trouble, and rub its irregular siirfaces over a cornea doomed to destruction from irritation and ulceration. We can recall the time spent years ago in fighting blepharitis and blepha- radenitis until its true ease was recog- nized and understood. At present, and in the light of modern ophthalmic surgery, we recognize in blepharitis, or blepharadenitis, only a symptom which in a general way promptly yields to treatment when we remove the cause. The elimination of the latter as promptly brings relief in other directions: not only by improving the vision, but also by curing life-long headaches and other neuroses. Charles S. Tuenbull, Philadelphia. BORACIC ACID. — Boracic, or boric, acid appears in the form of white, trans- lucent or lustrous scales or needles, and is usually prepared by adding hydro- chloric acid to a hot solution of borax (sodium borate); when comparatively fresh it exhales a faint odor of benzoin. It has a warm, acrid taste; acid reac- tion; and is freely soluble in alkaline media, in oils, and in chloroform; 1 to 3 in alcohol; 1 to 15 in boiling and about 1 to 25-50 in cold water. The solubility in cold water varies so greatly with different specimens as to seem un- accountable, but doubtless depends upon the source of the acid, the mode of its manufacture, and the resultant purity or impurity. In 1889 Catanis proposed to render the acid more soluble by mix- ing 120 parts with 10 of calcined mag- nesia and 750 of water, whereby a con- siderable proportion of the former is in solution in excess. From the fact that boracic acid forms borates with most of the alkaloids, it has been advised that they be employed when the acidity of the drug is to be feared. Preparations and Dose. — Boracic acid, 5 to 15 or 30 grains. Borate of ammonium, 10 to 20 grains. Borate of sodium (borax), 15 to 30 grains. Borate of zinc, for external use only. Physiological Action, — Boracic acid and all its salts are deemed more or less antiseptic, and the former has attained special repute because of its inexpensive- ness, general harmlessness, and unirri- tating character. But purity is always a matter to be carefully considered, both as regards external and internal use. It is not so commonly employed as an internal medicament, perhaps, as the sodium salt, becaiTse of its somewhat pimgent and acid taste, and partly be- cause it is deemed less convenient to prescribe in aqueous mixtures. In ex- cessively large doses, however, both it and the salts depress the spinal centres, and may prodiice progressive loss of voluntary and reflex activity without affecting nerve or muscle. Schiff is re- sponsible for the statement that boracic acid, when locally applied to nerves, causes the part to lose the power of oris'inatins;, but not of transmitting, im- BORACIC ACID. PHYSIOLOGICAL ACTIOX. 581 pulses; so that, if the galvanic current be applied to the part of the nerve which has been exposed to the drug, no mus- cular contractions result; but, if the poles be placed above this part, the distal muscles respond at once (Wood). Some persons, however, appear to be able to bear with impunity almost fabulous doses of the drug, which evidences that its exact phj'siological status is undeter- mined and chiefly a matter of specirla- tion. In doses of 30 to 60 grains often re- peated, boracic acid is likely to induce nausea and vomiting, and, if persisted in (or even in large, single doses), to give rise to concatenation of s3"mptoms in- dicating gastro-enteritis. Bruswanger (von Eenterghem and Laura) remarked diuresis with increased desire to urinate to follow doses of from 30 to 120 grains; he believes that the acid is eliminated through the kidneys as an alkaline borate, in which conclu- sion Eabuteau concurs. Polli, however, does not believe that the acid undergoes any alteration, but that it is passed un- changed. H. C. Wood states that it is rapidly eliminated with the urine, and also escapes with the perspiration, saliva, and fasces. It increases elimination of urea, as well as the flow of urine. Untoward Effects. — Though Gau- cher insists that it would require 2 ^/^ ounces, per daj', administered for several days in succession, to produce dangerous symptoms, his confidence is not sup- ported by general evidence, for it has been known, in considerably smaller doses, to induce parenchymatous ne- phritis. This is especially true of its sodium salt, which is a dangerous rem- edy as regards most renal maladies, and seems to possess the power of provoking malignant degeneration where a morbid process has already been set up in the kidne3's. George T. Welch reports two eases in which the application of tam- pons of powdered boracic acid produced general toxic symptoms: in one case the skin had a dried, "charred" appearance, and in the other there was collapse; in both there was verj' marked coolness of the vagina. Mododewkow chronicles a death from washing the stomach with a 2 Va-per-eent. solution; but there are no valid grounds for believing the me- dicament had anything to do with the fatality. Lemoine observed a bluish-gray line on the gums, as if from lead poison- ing, in a case of epilepsy to which so- dium borate had been given. Bran- thomme also reports two cases suffering with carbuncle who were poisoned through the daily application of 30 grains of the acid. The symptoms had no relation to the malady, for in the one case was restlessness and a feeling of burning under the whole skin, in- tense thirst, a temperature of 38.8° C, and the body covered with red patches; in the second case an eczematous erup- tion, anorexia, and insomnia appeared. In both cases the untoward symptoms subsided immediately on withdrawal of the acid applications. Wbat is said of the acid will, in a general way, apply to its salts. Two eases of profuse dermatitis fol- lowed the administration of boracic acid. In the first case the condition developed on three separate occasions following the administration of the drug. The patient finally died some time after the last attack in uraemia following an alcoholic debauch. The manifestations in the sec- ond case were similar to those in the first in that they followed prolonged ad- ministration of boracic acid. Two forms of borax poisoning must be distin- guished: one in which a large quantity of the drug is rapidly absorbed from the alimentary canal, from some serous or other cavity, or from an extensive raw 582 BOKACIC ACID. THERAPEUTICS. surface, causing vomiting and diarrhoea, general depression, skin-rashes, and par- tial paralysis of the nervous and mus- cular systems; occasionally death. The other class results from the administra- tion of boracic acid or borax in compara- tively small doses for long periods. In some of these cases the kidneys are dis- eased, in others albumin appears in the urine, and in several fatal cases uremic symptoms were described. E. B. Wild (Lancet, Jan. 1 , '99). Therapeutics. — The scope of boracic acid as an antiseptic is very wide, for it has been employed in almost every conceivable surgical process: as a de- tergent for painful and suppurating wounds and ulcers; as a basis for in- jections and ointments of all kinds; in collyria; as an insufflation powder for the ear; to wash out irritable bladders and dilated stomachs; as an application to skin maladies. In suppuration of the middle ear packing of the meatus Avith pure, im- palpably-powdered boracic acid is to be preferred to insufflation; this method is safe if the ears be inflated daily. Seely (Weekly Med. Review, Mar. 10, '89). Otorrhea is one of the most difficult to cure of all conditions affecting the ear. Boracic acid perfectly meets the indication of a non-iiTitant antiseptic. Bacon (Amer. Ther., June, '95) . The use of borax or boric acid as a preservative in butter and cream in the quantities specified in the recommenda- tions of the English Commission is justi- fied both b}' practical results and by scientific experimentation. The dusting of the surfaces of hams and bacon which are to be transported long distances with borax or boric acid, not exceed- ing 1.5 per cent, of the weight of the meat, is effective, and not objectionable from a sanitar}' standpoint. Meat thus dusted with borax or boric acid does not become slimy, because the preserva- tive thus used prevents the growth of aerobic, peptonizing micro-organisms. V. C. Vaughan and W. H. Veenboer (Amer. Medicine, March 15, 1902). Boracic acid has been very extensively employed in the treatment of eye mala- dies. Bourgeois, of Eheims, recommends it for phlyctenular and granular con- junctivitis; Smith, of Chattanooga, as a wash for ophthalmia neonatorum; Dimissas introduces, every night, an ointment of boracic acid between the ej^elids after operating for cataract; but iSToyes declares the drug should be used with caution, and of a strength of not more than 1 per cent., since he has seen a diffuse keratitis develop from a 4-per- cent, solution. It is probable, however, that, when untoward results accrite to the use of a 4-per-cent. solution in the eye, even after cataract extraction, such is due to the quality of the acid employed. In measles, too, frequent bathing of the eyes, nose, and ears with warm boracic-acid solution is to be recom- mended as beneficial and comforting to the patient. This drug has, also, been employed in the treatment of chancroid as a dust- ing-powder; as an injection, and also internally administered, in cystitis; in naso-pharyngeal catarrh, especially the troitblesome form seldom seen except in children; in chronic constipation, by applying the dry powder direct to the rectal mucosa; in watery solution and in ointment form to the urethra for gonorrhoea; in the form of ointment to the pustules of variola to prevent pit- ting, etc. In spite of the reputation accruing at one time, it is doubtful if any material benefit is ever derived from the use of this acid in any but the milder and less stubborn varieties of skin disease. It may, however, prove a valuable adjunct to other treatment. AVlien there is a profuse discharge from an eczematous patch, I direct the BORACIC ACID. AMMONIUM BORATE. 583 latter to be washed with a weak solu- tion of boraeic acid, then dried with muslin bags containing the dry acid duly incorporated with finely-powdered starch. Malcolm Morris (Practitioner). Similar procedures have been recom- mended by many authors. Gaucher, ■corroborated by Sevestre, Compy, and Cadet de Gassicourt, however, goes fur- ther, and declares that he has secured rapid recovery in eczema, and also in contagious impetigo, by employing it in glycerole of starch, 1 to 30; he insists that this combination offers all the good to be obtained from oil of cade without any of the disadvantages of the latter. In the erysipelas of the newborn Lemaine lauds this drug above all others. He holds that the malady is derived from an attenuated puerperal septicemia in the mother, and so directs the application of hot solutions of the acid, and subcutaneous injections of the same, cooled, twice daily. Matigon, of Bordeaux; Mackenzie and Abbott, of London, as well as many others, express a decided preference for boraeic acid, or for the tetraborate of sodium (this latter being merely a com- bination of boraeic acid and borax), above all other medicaments for the pur- pose of preparing solutions intended to be used in the pleural cavity, especially after pnetimotomy or aspiration. In 1890 Edmund Andrews, of Chicago, published the results accruing to a series of experiments undertaken to determine the value of the acid as an antiseptic. He placed 2 drachms of fresh pork mus- cle in each of a series of bottles, and added different percentages up to com- plete saturation of acid solution. The result seemed to prove that even the strongest solution cannot inhibit the growth of mycelia, and further that no species of germs can thereby be entirely prevented from growing; that boraeic acid only covers a raw surface with a moisture that is not distinctly antiseptic, but is nevertheless rather unfavorable to the growth of bacilli. Unfortunately for Dr. Andrews's conclusions, however, they are based upon incomplete experi- ments, and consequently imperfect data. As has before been remarked, the acids of commerce vary greatly according to source and mode of manufacture; con- sequently a series of experiments should have been made with different products. Moreover, the evidence is now over- whelmingly positive that a moderately pure boraeic acid is antiseptic, though only in slight degree; but it commends itself to the medical man especially be- cause it is practically odorless and in- nocuous. Internally the acid appears to have been successfully employed in a variety of maladies. Gaucher administered from 7 to 20 grains daily to a number of patients suffering with pulmonary tuber- culosis, and claims that both the local and general symptoms were improved, while the sputiim lost its foetid charac- ter; it had, however, no action upon the bacilli. Tertschinsky gave boraeic acid in 240 cases of enteric fever in doses of from 13 to 15 grains three or four times daily, with only 9 resulting fatalities. Kee- gan also successfully employed it in a considerable number of cases. Ammonium Borate. This may be prepared by dissolving 1 part of boraeic acid in 3 parts of hot liquor ammonia of a specific gravity of 0.960, and cooling to crystallization. It appears as white or transparent eight- sided crystals, with strong ammoniaeal odor; soluble in the ratio of 1 to 12 in cold water. It is employed both topically and internally in cystitis, and internally in renal diseases, where, in either case, 584 BORACIC ACID. BORAX. THERAPEUTICS. there is an excess of acid or earthy phos- phates. The value of the remedy, how- ever, is doubtful, though in some few instances it appears to afEord slight re- lief. It has been tried in epilepsy also, but with negative results. Sodium Biborate; Sodium Borate; Borax. This, the best known and most gen- erally employed internally of all the borate salts, has for many centuries been alternately lauded and condemned by the medical profession, though it has always retained a status in domestic pharmacy and therapeutics. As found in the shops, it appears in colorless transparent monoclinic prisms, shining, odorless, and effervescent in dry air. It is soluble in half its weight of boiling water, 1 to 16 in cold water; insoluble in alcohol, but very soluble in glycerin and fats. The addition of a small amount of sugar greatly increases the solubility of borax; it will also rapidly liquefy a solution of gum arable which has be- come gelatinous from the presence of borax. Editorial (Amer. Medico-Surgical Bulletin, Oct. 25, '97). It also has a faint, sweetish taste and alkaline reaction; in solution it absorbs carbonic acid and dissolves fibrin, albu- min, casein, and uric acid. As a general rule, sodium borate be- liaves like the alkalies, and, therefore, it should not be associated with the salts of the alkaloids. In mixtures of this kind the patient is likely to take most of the alkaloid in the last dose, with harmful effect. A. Dujardin (Union Med. du Nord-est, Nov., '91). Therapeutics. — As an application to mucous membranes, because of its mildly antiseptic and soothing effects, borax in solution is almost without a peer; many maladies make most happy recoveries under its use that with other remedies of more pronounced astringent or irri- tant character prove most vexatious. Especially is this true of some of the lesser diseases of the eye and naso- pharynx, the milder forms of conjunc- tivitis, certain forms of rhinitis, ulcer- ative stomatitis, etc. Sodium borate in camphor-water secures a pleasant, harm- less, and grateful collyrium that may advantageously be employed, either alone or in connection with other remedies, in most inflammatory conditions of the eyes. In ulcerative stomatitis, swab with water acidulated with a few drops of acetic acid and follow by painting with borax (1 part) dissolved in glycerin (8 parts). Garrigues (Med. News, Oct. 1, '92). In atrophic rhinitis solution of so- dium borate in glycerin, sufficiently diluted with water, may be sprayed into cavities; glycerin prevents fonnation of crusts; sodium borate prevents decom- position of exudation. Musehold (Revue Inter, de Med. et de Chir., Apr. 25, '95). There can be no doubt of the value of boracic acid and borax as local applica- tions in aphthous ulcerations, diphtheria, and other inflammations of the mouth, in which the crystals of the sodium salt may be permitted to slowly dissolve on the tongue. H. 0. Wood ("Therapeutics: its Principles and Practice," ninth ed.). Sodium borate is frequently employed against stomatitis and against aphthous ulcerations of the mouth, as in ptyalism, glossitis, anginas, etc. It is evident that the antizymotic property of sodium borate is the deterring influence. Von Renterghem and Laura (Dosimetric Med. Review, Dec, '97) . The last authors quoted very justly believe that this medicament offers cer- tain advantages in the treatment of some skin diseases, since it may be employed topically to dissolve the pellicles of the epidermis joined together by sebaceous matter, thereby acting as a detergent; in pruriginous or eczematous eruptions due to the accumulation of products of the sudoriparous glands the salt is often most effective. BORACIC ACID. BORAX. THERAPEUTICS. 585 Congenital ichthyosis in a child treated by washes of sodium borate. Shenvell (Jour. Cut. and Genito-Urin. Dis., Sept., '94). In erysipelas Sevestre employs baths at 93.2° P. containing 16 ounces of so- dinm borate, which, he claims, lowers the temperature and tends to heal the eruption. In 1894 Ciaglinski and Hewelki de- scribed a case of black tongue present- ing a patch of mold extending as far back as the ciicumvallate papillte that contained black pigment and closely resembled the fungus known as Mucor rhizopodiformis. By means of borax washes the tongue became clean in a couple of days. Both borax and boraeic acid have been recommended as injections for an in- flamed bowel, but their utility cannot be very pronounced. In severe cases of infantile diarrhoea daily irrigation of the larger bowel is most beneficial during the height of the disorder. I employ borax: 1 drachm to a pint of warm water. Carter (Pro- vincial Med. Jour., May 1, '94). That sodiiim borate has some action upon the central nervous system is ap- parent, but this is so ill understood that it is impossible to formulate any definite physiological basis for its internal ad- ministration. It has been empirically recommended for a multitude of dis- eases, including locomotor ataxia, paral- ysis agitans, cholera, etc. Have used sodium borate with excel- lent results in paralysis agitans. Sacaze (Bull, de la Soc. de Med. Mentale de Belgique, Mar., '94). Borax in doses of 80 to 90 grains daily is to be highly recommended as a proph- ylactic against cholera. During the epidemic in Italy during 1864-65 none of the villagers employed in the borax works were affected, while in a village in close proximity one-third of the in- habitants died. I opine that the drug kills the germs in the alimentary canal. Cyon (Compt.-Rend. Acad. Sci., xcix, 149). Looking at the drug from the stand- point of the author last quoted, and admitting its mildly antiseptic property, — which are undoubted, — it is easy to discover the reasoning that has led to its use in septic diseases. So, too, the solvent action of the borates as regards uric acid, and their tendency to elimi- nate urea, explain why borax often yields gratifying results when employed in uric-acid lithiasis; but it should always be most freely diluted with water. Another peculiarity of borax, also un- defined, is its affinity for the genito- urinary organs. In some cases it relieves uterine haemorrhage with surprising promptness: an action that can only be explained by reflex through the nervous system. But it is in epilepsy that borax has been most exploited in recent years though its use in this direction is by no means new; and for a brief period it was thought an absolute panacea had been discovered. But H. C. Wood, who tried it in a number of cases, succeeded only in inducing marked gastro-intesti- nal irritation in every patient. In order to avoid gastric and skin troubles by reason of large doses, I would suggest the borax be given with consid- erable doses of naphthol or bismuth salic- ylate. Fere (La Semaine Med., Feb. 4, '92). Of twenty-five cases one was cured and all relieved but six. Treatment was con- tinued from one to seven months. Dijoud (Lancet, July 18, '92). Borate of soda is superior to potassium bromide in symptomatic epilepsy, but of less value in nervous epilepsy. Mariet (Le Prog. M6d., Oct. 10, '92). The prolonged exhibition of the salt may induce cutaneous troubles, consist- ing principally of seborrhoeic eczema of the scalp. The hair is shed, but grows again when the administration of the 586 BORACIC ACID. BRIGHT'S DISEASE. borax is stopped. Fere (Lancet, Dee. 23, '92). Borax as a means of relief seems to have established for itself a fixed and permanent position. Gray, Pritehard, and Shultz (Annual of the Univ. Med. Sci., vol. ii, '94). Borax is a useful remedy against con- vulsive attacks of an epileptic character. Angelucci and Pieraccini (Lo Sperimen- tale. No. I, '94). Borax given alone is disappointing in some respects, but given with the bro- mides its action is much better and the combination superior to either drug alone. Alexander (Liverpool Medico- Chir. Jour., July, '94) . On the whole, borax is of no value in epilepsy. Lui and Guicciardi (Revista Speri. di Fren. e di Med. Legale, etc., Sept., '95). It may be imagined that iinder certain circumstances borism may give rise to accidents every whit as grave as those of bromism, with the difference that those arising in the kidneys are more insidious and more difficult to remove. This fact, more than all else, perhaps, has led to a very general abandonment of the drug, though a few still persist in its iTse, with more or less varying results that apparently depend upon the toler- ance exhibited by the individual patient. Teteaboeate of Sodium. — Boymond, in 1893, called the attention of the Societe de Therapeutique to a new product which he termed "boro-borax," and for which was likewise claimed anti- septic properties superior to those of corrosive sublimate. This is simply the tetraborate of sodium in solution, and appears to be a trifle more powerful than a corresponding solution of boracic acid. A solution may be extemporaneously made by adding 26 drachms of boracic acid to a quart of distilled water and then neutralizing by sodium borate. Zinc Borate, or Tetraborate. This is an amorphous, white powder obtained by the interaction of zinc sul- phate and sodium borate in hot water. Like all new agents of its class, when first introduced wonderful antiseptic power was claimed for it, but this ap- pears to have not been sustained. It is freely soluble in acid media only; has been employed as a dusting-powder for raw surfaces; but it does not appear to offer any advantages over boracic acid, while its almost insoluble character in- hibits its use in conditions where the latter is always available. BRAIN. See Ceeebeal Abscess, Ceeebeal H^moeehage, Encephali- tis; Head, Injueies of, etc. BREAST. See Mammaet Gland. BRIGHT'S DISEASE. Acute Uephritis. Definition. — An acute inflammation of the kidnej's, and either of a mild, severe, or grave character. It may be more or less diffuse in nature. Three varieties of acute renal disease are de- scribed by Delafield under the term acute Bright's disease: (1) acute degen- eration of the kidneys, (2) acute exuda- tive nephritis, and (3) acute productive nephritis. Symptoms. — The onset is sudden, as a rule, but varies with the exciting cause of the nephritis. Chilliness, nausea and vomiting, pain in the back, and, within twenty-four hours, dropsy are seen in some cases. Children are subject to con- vulsions (urssmic), and in severe cases adults are no less liable. Fever may be present, but it is neither constant nor high. The early appearance of cedem- atous puffiness of the eyelids and face, and of pallor of the skin, is character- istic. Soon, and sometimes at first, a swelling occurs about the ankles and BRIGHT'S DISEASE. ACUTE NEPHRITIS. SYMPTOMS. 587 legs, and in severe cases dropsy involves the whole body. The scrotum, penis, or labia may, in such cases, become enor- mously distended, the skin presenting an almost translucent appearance. Often local symptoms are absent, as pain and tenderness in the lumbar re- gion; they are never marked. Micturi- tion may be frequent and accompanied by a slight burning and vesical tenesmus, ■due to the concentrated urine. In very severe dropsy the tense, dry skin may become sensitive or even painful on pressure. Bodily movements are often painful and difficult in cases of marked anasarca. Urgemia may be heralded by intense headache and backache. A urinary examination is always nec- essary, as in mild cases the renal con- dition may be overlooked. There may be no further symptoms than a general malaise. The urine in acute nephritis furnishes ■distinctive characteristics. The total quantity passed in twenty-four hours is diminished, and may even be very ■scanty, varying from 5 to 25 ounces (150 to 740 cubic centimetres). There may be suppression in cases of toxic ■origin, when an acute degeneration or necrosis of the renal epithelium occurs, ■and in the very severe exudative inflam- mations. The specific gravity is early increased to 1025 or more, though later it may fall to 1015 or 1010. The color is darker than normally and is usually smoky red, or reddish brown, according to the amount of blood contained. A more or less abundant flocculent sediment ap- pears on standing, if the normal mor- phological constituents are present in great quantity. Some red blood-corpuscles and renal •epithelium are found microscopically, together with the characteristic hyaline. blood, and epithelial tube-casts. The urine is acid in reaction, and on boiling throws down a thick, curdy precipitate of albumin, which varies in weight from V4 to 1 per cent. The urea is dimin- ished. There may also be other symptoms during the course of acute Bright's dis- ease, as those of hydrothorax, ascites, and hydropericardium, in cases in which great general oedema is present. The first-named condition is bilateral and gives rise to dyspnoea; the second in- creases the dyspnoea by pressing the diaphragm upward; and the last im- pedes the heart's action. Striimpell describes a form of pneumonia that sometimes develops in severe cases of acute nephritis, — a "stiff inflammatory oedema," — midway between lobar and broncho- pneumonia. There may also be oedema of the conjunctiva, soft pal- ate, and larynx. The pulse is often hard and tense, and, though slow at first, it may become accelerated later. Cardiac hypertrophy may be present in a slight degree. The aortic second sound is accentuated. Epistaxis appears occasionally, and sub- conjunctival hsemorrhages sometimes follow unwitnessed uremic convulsions. Dryness and uremia of the skin form a constant condition. Urfemic manifesta- tions may supervene at any period in the disease, appearing early in the most severe cases, with intense headache and backache, vomiting, and convulsions. The above may be considered a de- scription of the common form of acute nephritis resulting from exposure; the clinical course differs somewhat in other cases. Occurring as a complication of the infectious fevers, except scarlatina, acute nephritis may be characterized by the very slight degree, or even by the absence, of dropsy. Albuminuria, ham- 588 BRIGHT'S DISEASE. ACUTE NEPHRITIS. ETIOLOGY. aturia, anemia, and urfemia mark the graver affections. In scarlatinal nephri- tis, however, anasarca is common, and a slight oedema, at least, is quite con- stant. Mild affections show simply a slight quantity of albumin and a few hyaline casts, indicative of the paren- chymatous degeneration. The typhoid state may follow the subsidence of the acute toxic symptoms in cases of degen- erative nephritis due to mineral poison- ing; this is marked by prostration, mus- cular twitchings, stupor, coma, and death. Hasmaturia may be pronounced in the so-called nephro-typhoid condi- tion, in which typhoid fever begins with marked symptoms of acute nephritis. The nephritis of pregnancy, as a rule, is gradual in its onset. The albumin increases in quantity from month to month, reaching a high percentage dur- ing the eighth and ninth. Some hyaline casts are found; but otherwise there are few morphological elements. Red blood- corpuscles rarely may be seen in the urine. Up to the time of delivery the danger of eclampsia is constant, but re- covery is rapid in uncomplicated cases after the birth of the child. In acute (productive) nephritis, where there is a tendency to the formation of patches or wedges of fibrous tissue, there is a higher fever, there are cerebral and circulatory disturbances of a typhoid nature, as well as ansemia, dropsy, and a highly albuminous urine, even though there be no blood-corpuscles and few casts. Dropsy is most marked in the legs. There are a progressive and rapid loss of flesh and strength, dyspnoea, vomiting, diarrhoea, and convulsions or coma and end in death. Milder cases last from two to four weeks, and appar- ently recover; albumin and casts per- sist, however, until another and a simi- lar attack occurs after an interval of weeks or months. Thus, the first acute attack is subject to chronic recurrence, until a fatal seizure takes place. Etiology. — Acvite nephritis more often appears before than after the middle time of life, though it may occur at any time. Males are more often attacked than females. Analysis of 270 cases of Bright's dis- ease. Nephritis occurred more frequently in males than in females (3.309 to 2.74) j most common during the period of great- est activity of the body. Of the 270 eases, 140 were acute, 85 being htemor- rhagic. Of these 140 cases of acute Bright's disease, 70 per cent, could be traced to acute infectious diseases, only 2.85 per cent, being directly traceable to cold. Agnes Bluhm (Deutsches Archiv f. klin. Med., B. 17, H. 3, 4) . Of 251 cases of chronic nephritis ob- served by Heubner in Leipzig, 214 occurred in adults and 37 in children. He subsequently saw 28 cases in children in Berlin, mostly after scarlet fever. Of these 65 cases, there were 3 of paren- chymatous nephritis, 4 of contracted kidney, and 5 of chronic hsemorrhagie nephritis. Brill and Libman (Jour, of Exper. Med., Sept. and Nov., '99). Occupations necessitating exposure to cold and wet offer special predisposing conditions. The long-continued use of alcohol will also, as a rule, prove a pre- disposing cause of acute Bright's disease. Among the exciting causes of acute diffuse nephritis are: — ■ 1. Those acting on the skin, as cold, dampness, extensive burns, and chronic skin diseases. It is often difficult to determine the relative influence of alco- holic excesses and the exposure incident thereto. Acute intoxication from beer- drinking may result in an acute nephri- tis, but it is yet likely that in most cases the exciting cause is the cold acting upon the individual in his exposed and maudlin condition. Acute nephritis may also be caused, at times, by exposure HEIGHT'S DISEASE. ACUTE NEPHRITIS. ETIOLOGY. 589 to cold and wet apart from and in the absence of alcoholic indulgence; in such cases it is to be presumed that there is an inherent weakness of the kidneys, or a susceptibility rendering these organs the vulnerable point in the system. The physiological toxic agents embrace the poisons of the acute infections; in a majority of cases, however, scarlet fever is the primary affection. Usually the nephritis appears during the second or third week of convalescence, though it may supervene at the height of the dis- ease. Among 97 cases of scarlet fever, but 4 exhibited the symptoms of Bright's dis- ease. Of 45 cases of measles but 1 evinced renal involvement. In 162 cases of erysipelas, Bright's disease occurred 7 times and simple albuminuria 17 times. Among 481 cases of variola it appeared but once: in a child 12 months old. In 93 cases of diphtheria it occurred but 4 times and simple albuminuria but 6 times. Of 74 cases of tonsillar angina, 4 eases presented evidence of nephritis and 20 were albuminuric. Among 10 cases of ulcerative endocarditis it oc- curred once. Out of 360 cases of acute rheumatism, but 4 were affected second- arily by acute Bright's disease. Acute nephritis is not rare in acute pneumonia, occurring in 26 out of 140 cases. Agnes Bluhm (Deutsche Archiv f. klin. Med., B. 17, H. 3, 4). Very grave nephritis supervening in the first seven days of scarlet fever, thus differing from the late nephritis; to it must be ascribed the fatal termination sometimes noticed in the early stage of scarlet fever. Inflammation extending to the papilla constitutes the most essen- tial characteristic; leads to retention of urine and dilatation of the eanaliculi. Aufrecht (Rev. des Sci. Med. en France et a I'Etranger, July 15, '94) . Renal disease is associated with in- sanity in two ways: (1) acute transient delirious mania, an acute toxsemia, or ursemic insanity, and (2) a progi'essive cerebral degeneration, with chronic renal disea.^e as the primary cause. In this type the mental symptoms during the earlier stages vary from a mild dementia to mania or delirium. In due course, however, complete dementia re- sults not unlike paralysis of the pro- gressive type known as general paralysis of the insane. In some cases the spinal symptoms become marked, and changes in the spinal cord are found after death. The dyspnoeic and gastrointestinal forms of uraemia are sometimes seen in the insane, but it is with the comatose and convulsive types that asylum phy- sicians have chiefly to do. Out of 3000 cases admitted to Beth- lem since the year 1SS8, 172 had albumi- nuria on admission (or 5.7 per cent.) ; of these 172, as many as 40 (or 23 per cent.) recovered from the mental at- tack; of the remaining 132, 37 died of general paralysis and 20 of senile de- mentia, and the remaining 75 became incurables. On careful analysis of the details of these 172 cases is to be noted the comparative frequency of such symptoms as inequalities of the pupils, tongue tremors, alterations and defects of speech, sluggishness or exaggeration of the knee-jerks, and not infrequently hemiplegias, or other symptoms of ar- terial and cerebral degeneration. The cases diagnosed as general paralysis ap- peared to have been of three types: (1) parasyphilitic types, which correspond most closely to the classical descriptions of general paralysis; (2) types of cere- bral degeneration due mainly to vas- cular changes consequent upon kidney disease; and (3) types of associated mental and motor defects in which the kidney disease is merely coincidental, the mental and motor symptoms being due to other factors, such as sunstroke, malaria, post-febrile and toxic states. T. B. Hyslop (Practitioner, Nov., 1901). 2. Acute nephritis may also be the result of other of the infectious fevers (small-pox, typhus, typhoid, relapsing fever, cholera, diphtheria, yellow fever, measles, chicken-pox, erysipelas, septico- pyemia, acute lobar pneumonia, cerebro- spinal meningitis, dysentery, acute ar- 590 BRIGHT'S DISEASE. ACUTE NEPHRITIS. ETIOLOGY. ticular rheumatism, and tuberculosis; syphilis is rarely a cause). Interesting case of haemorrhagic ne- phritis consecutive to grippe, in a woman 32 years of age, the haematuria lasting three weeks. Bock (Deutsche med.-Zeit., Apr. 2, '94). Case in which mortal nephritis fol- lowed mumps. Le Boy (La France Med. et Paris Med., Nov. 23, '94). Occurrence of nephritis in secondary syphilis in a case investigated in Birch- Hirsehfeld's laboratory. The patient died in coma. At autopsy the lungs, spleen, liver, lymphatic glands, and kid- neys were all found to be the seat of more or less interstitial inflammation. The kidneys were large, and on section showed signs of subacute interstitial nephritis; the epithelium of the tubules, which were much compressed, was only slightly affected. These changes believed to have been due to syphilis. The ne- phritis could not have been of mercurial origin, for it would have been parenchy- matous, and not interstitial. Doederlein (Miinchener med. Woeh., Oct. 13, '96). Acute interstitial nephritis found in 42 cases of infectious diseases, most fre- quently in diphtheria and scarlet fever. The interstitial tissue in these cases is infiltrated diffusely and in feci by cells resembling the plasma-cells of Unna. No satisfactory explanation can be given for the almost constant tendency of the infiltrating cells to collect, especially in the boundary zone of the pyramids, the subcapsular region of the cortex, and around the glomeruli. W. T. Council- man (Jour, of Exper. Med., July and Sept., '98). It may also supervene as a primary condition, and the brunt of the attack may be sustained either by the kidney, rather than by any other part, or by the organism as a whole, as in the fevers. Mannaberg has described such cases, and has demonstrated the presence of strep- tococci in the urine. Relation of acute nephritis and the streptococci found in endocarditis, espe- cially those of experimentally induced bacterial endocarditis. In eleven cases of acute Bright's disease the urine found to invariably contain streptococci, which disappeared from the excretion with the disappearance of the symptoms of dis- ease. In patients affected by other maladies, and in healthy individuals, this micro-organism was not found, al- though searched for in a long series of samples of urine. Mannaberg (Zeit. f. klin. Med., B. 18, H. 3, 4). A number of cases of renal inflamma- tion due to a characteristic bacillus, from cultures of which he has been able to reproduce the nephritis in rabbits. The symptoms are in general similar to those in other cases of nephritis, but usu- ally are of a mild fonn, and are apt to show a predominance of the gastric phenomena. Letxerich (Zeit. f. klin. Med., B. 18, H. 5, 6). Renal inflammation characterized by the presence of micro-organisms, which present themselves as rods and spores (cocci), the former three micromilli- metres in length, sometimes bearing a sporangium. Hopkins (Pacific Med. Jour., Apr., '90). The tendency even now is to attribute too large a share to cold in the causa- tion of nephritis. Taking the infective diseases alone, the alterations brought about by the micro-organisms in the renal tissue may pass without leaving any trace, but they may also become chronic, causing changes in the epithe- lial elements and interstitial prolifera- tion. M. Vignerot (Arch. Gen. de Med., Oct., '91). Bright's disease, an infectious disorder in which the micro-organisms act upon the kidneys. (1) Hyperacute infectious Bright's disease; (2) acute infectious Bright's disease; and (3) attenuated in- fectious Bright's disease. Fiessinger (La Sem. Med., May 12, '94). Case of primary acute hsemorrhagic nephritis, in a man 42 years of age, co- existent with the presence in the urine of large quantities of the staphylococcus pyogenes albus. Baduel (Riforma Med., Aug. 7, '94). Seventy eases showing causal relation- ship between ulceration of the duodenum and interstitial or tubal nephritis, or BRIGHT'S DISEASE. ACUTE NEPHRITIS. PATHOLOGY. 591 both combined. Perry and Shaw (Prac- titioner, Dec, '94). Case in which nephritis was due to infection through skin wound. Sacaze (Eevue'de M6d., Feb., '95). Case in which ulcer appeared as first symptom in case following a rapid course, showing at autopsy degeneration of convoluted tubules with slight ar- teritis. Etienne (Le Bull. Med., July 14, '95). When toxic substance reaches kidney through nutritive artery it exerts an elective action upon the epithelial cells of convoluted tubules, with lesions of protoplasm, steatosis, and coagulation necrosis. Vandervelde (Jour, de M6d., de Chir., et de Pharm., vol. iv. No. 2, '95). Case showing that absorption of ali- mentary ptomaines which kidneys can- not eliminate may give rise to lethal poisoning. Dieulafoy (Annual, '96). Three cases of hemorrhagic nephritis caused by infection of the blood with bacteria which otherwise did not pro- duce evident symptoms. In the first case a general infection of the blood, the liver, the kidneys, and the spleen with streptococci was found at the autopsy; the disease had continued for eight months and presented, as its only symp- tom, hsemorrhagic nephritis; there was no fever except during the last two weeks of life. In the second ease symp- toms of endocarditis and of haemorrhagic nephritis were combined; the blood con- tained intra vitam staphylococcus albus, and the same bacterium was found on the growths on the mitral valve. In the third case the examination of the urine revealed the presence of staphylococcus albus in great quantity. The author in- sists on the fact that a general infection of the organism with bacteria of differ- ent species may reveal itself only by the presence of hsemorrhagic nephritis, and he believes that the haemorrhages which occasionally occur during the course of an ordinary nephritis may be caused by a temporary invasion of bacteria in the blood. Hoist (Norsk Mag. f. Laege- vidensk., p. 825, '99). Report of Corr. Ed. F. Levtson. 3. Chemical toxic agents include tur- pentine, cantharides, carbolic and sali- cylic acids, potassium chlorate, iodoform, the mineral acids, and inorganic poisons, such as phosphorus, arsenic, mercury, and lead. Acute renal inflammation may be caused by the excessive ingestion of highly-acid, spiced, or adulterated foods (as from salicylic acid and lead chromate). Large number of substances — canthar- ides, styrax, balsam of Peru, cubeb, tui- pentine, mustard- and crotou- oils, naph- thol, carbolic and oxalic acids, phos- phorus, etc. — which act upon the kidney as poisons by causing acute diffuse nephritis. Lenzmann (Deutsche med.- Zeit., Aug. 6, '94) . Two cases of acute nephritis, in chil- dren 8 and 6 years of age, after the use of betanaphthol ointment for the pur- pose of curing the itch. The youngest, child died. Baatz (Centralb. f. klin. Med., Sept. 15, '94). Experiments with various toxics, and clinical facts show that the pathological process is a uniform one, the epithelium of the convoluted tubules, the epithelial cells of the straight tubules, the glome- ruli, the interstitial tissue, and vascular walls being, in turn, involved. Bur- meister (Virehow's Archiv, B. 137, H. 3). 4. Pregnancy may act as a cause of acute nephritis (gravidarum). In such cases it usually appears in primipars, in the last months of gestation, and is prob- ably the result of renal engorgement due both to mechanical pressure and to nutritive disturbances in the kidney, owing to the altered blood-condition. 5. Latent chronic nephritis may form the cause of a manifest acute nephritis. Pathology. — There is a considerable variation in the anatomical changes in and the appearance of the kidneys, ac- cording to the degree of involvement. Between the very mild and grave cases there is an intermediate series of con- tinuously more marked pathological 592 BRIGHT'S DISEASE. ACUTE NEPHRITIS. PATHOLOGY. changes dependent upon the amount of poisonous material circulating in and eliminated by the kidneys, as well as upon the intensity and duration of its toxic action. There may be no microscopical change in the mildest cases. As a rule, how- ever, the kidneys are slightly enlarged, swelled, and somewhat softened, though these conditions are more evident when the interstitial exudation is abundant and inflammatory oedema is evident. On section the organs may appear red and congested or they may be pale and mottled. In the former case hffimor- rhages may appear beneath the capsule (acute hsemorrhagic nephritis); it is more usual, however, to see red, hyper- semic patches alternating with opaque and whitish portions, both on the outer and the cut siirfaces. Especially is the cortex swelled, turbid, and pale, or slightly congested in the mildest cases; in severe attacks it is deeply mottled (red and pale glomeruli) or hypersemie. The surfaces are smooth and the capsule non-adherent. The pyramids usually show an intense-red color. In the very mild cases, already referred to, changes may be noted microscopic- ally that are not visible to the naked eye, there being simply a cloudy swelling or a granular (parenchymatous) degen- eration of the epithelium of the Mal- pighian tufts. Bowman's capsule, and of the uriniferous tubules of the cortex. In the absence of exudative changes in the interstitial tissue, however, this can- not be called true acute nephritis. The acute parenchymatous degeneration may be limited almost exclusively to the glomeruli, as in some cases of scarlatina, and from this fact has arisen the term "glomerulonephritis." The muscles are either swollen or absent; the cells are swollen, opaque, and irregular in shape; and the cell-contents are granular (albu- minoid or fatty). The death of the cells — owing to coagulation necrosis or disintegration, desquamation", and hya- line degeneration of masses of the cells in the tubules — marks a further stage in the process. Acute degenerative changes are frequently found in the acute infec- tious diseases, or when inorganic poisons have been introduced into the body. In phosphoric poisoning there may be an actual fatty degeneration of the epithe- lium, either proceeding from the cloudy swelling or occurring as an independent development. In severe cases a rapid necrosis of the cells is also met with. True acute nephritis exhibits not only changes in the parenchyma (epithelium), but also an inflammatory exudate be- tween the tubules, consisting of serum, leucocytes, and red blood-corpuscles. In some places the kidneys show only a slight cellular infiltration of the inter- tubular tissues. In others the intersti- tial tissue is swelled by the coagulated serofibrinous exudate, many leucocytes, and some erythrocytes, besides the des- quamation of necrotic epithelial cells and the presence of hyaline casts in the tubules. The inflammatory exudate col- lects, also, in the Malpighian bodies and tubules. The tubules may be dilated and choked with degenerated cells, or more frequently the straight tubules are clogged with hyaline easts. The lining epithelium, especially in the convoluted portion of the tiibules, is often flattened. The white blood-corpuscles infiltrating the stroma 'of the kidneys are collected in foci in the cortex, and not, as a rule, equally diffiTsed. The outlines of the individual capil- laries are lost, and the glomerular epi- thelium of the capsule — especially that covering the inside of the capillaries of the tufts — is swelled and opaque. New BRIGHT'S DISEASE. ACUTE NEPHRITIS. DIAGNOSIS. 593 epithelium appears in most instances of diffuse exudative nephritis, and a res- toration of the glomerular function oc- curs. According to Delafield, in the productive variety of acute diffuse ne- phritis, however, certain lesions are more permanent in character from the outset in the glomeruli and stroma, and hence the increased gravity of the disease. Superadded to the usual exudative con- dition are the following changes: (a) a growth of the cells lining the capsules, such as to form a mass that compresses the tuft, "and leading, finally, to obliter- ation of the vessels and fibroid glome- ruli"; (&) a growth of the connective tissue parallel to, and surrounding, one or more arteries having thickened walls, and forming more or less numerous and regular strips or wedges in the cortex. The new tissue between the tubules is, in the more intensely acute cases, largely cellular; in those of a subacute type it is relatively dense and fibrous. Pleural, pericardial, and peritoneal dropsy, as well as anasarca, are also found in those dying of acute Bright's disease. Meningitis, cerebral oedema, and lobar pneumonia are also sometimes seen post-mortem. Diagnosis. — Acute Bright's disease can hardly be overlooked when the urine is carefully examined chemically and microscopically. The eclampsia of pregnancy can, however, be recognized only by repeated examination of the urine, especially during the last months of pregnancy. Case of subacute nephritis subsequent to an attack of simple herpetic tonsillitis. On the fifteenth day an eclamptic crisis suddenly set in, accompanied with anuria. Urine contained 1 '/, drachms of albumin per quart. The crisis became more frequent, coma set in, and the patient died with broncho-pneumonia. Histological examination of the kidneys 1- showed, on the tubular epithelia, an im- mediate lesion with cloudy tumefaction and coagulation necrosis. Siraud (Revue Inter, de Bibliographic, Apr. 25, '94). Three cases of acute interstitial ne- phritis. The first was a case of general streptococcic infection after abortion; the second also followed abortion, but the kidneys were sterile; the third was due to streptococcic infection and oc- curred with broncho-pneumonia second- ary to otitis media. Councilman in 1898 reported 42 cases, in which he found Unna's plasma-cells to be the most numerous cells of the renal exudate, lymphocytes and polynuclear leucocytes being also present in variable numbers. In the three cases plasma-cells and lymphocytes were present, but in each case there was, in addition, the eosino- philic leucocyte, a cell not hitherto de- scribed in nephritic exudations. W. T. Howard, Jr. (Amer. Jour. Med. Sci., Feb., 1901). Acute Bright's disease should be sus- pected, and the urine examined, in every case showing pallor of the skin and puffy eyelids, whether general prostration of the health is apparent or not. The char- acteristic symptoms of acute exudative nephritis, as commonly seen when the condition is due to cold or occurs in scarlet fever, are the following: Head- ache, restlessness, muscular twitching, nausea and vomiting, a tense pulse, moderate fever, dropsy, and anaemia. Tube-casts and albuminuria are constant. It should be borne in mind that slight albuminuria occurring in the course of pregnancy or during any of the fevers, without casts, is not a true nephritis, although the latter may be a more or less remote consequence of the glandular de- generation of the renal epithelium asso- ciated with the febrile albuminuria. In addition to the presence of albumin and hyaline and cell- casts, however, a di- minished quantity of sooty-looking urine and the discovery of red and white 38 594 BRIGHT'S DISEASE. ACUTE NEPHRITIS. PROGNOSIS. TREATMENT. blood-corpuscles will render the diagno- sis positive. The history of the case and the causal factors are also to be taken into consideration. Prognosis. — A case of ordinary exu- dative nephritis following exposure to cold and wet runs a course varying from a few days to three or more weeks. There is a steady diminution of the albuminuria, which finally disappears together with the casts, while the daily quantity of lighter urine and the daily excretion of urea increase. The char- acter and intensity of the renal inflam- mation, and the primary disease or caus- ative conditions largely determine the prognosis. Scarlatinal nephritis gives much less hope of recovery than does nephritis due to exposure to cold after alcoholic excesses. Recovery usually takes place easily after the acute paren- chymatous degeneration that accom- panies diphtheria, typhoid, and other infectious fevers, as well as pregnancy. In acute yellow atrophy, however, and in yellow fever, cholera, severe phos- phoric or mercurial poisoning, death may occur from the intense and wide- spread necrosis of renal epithelium. The dropsy and albuminuria gradually dimin- ish in favorable cases of ordinary exu- dative nephritis, while the color of the skin and the quantity of urine and urea increase; so that recovery is established in from three to six weeks. The albu- min may persist for some time after the disappearance of the dropsy, and then gradually disappear; rarely, however, in unfavorable eases, albuminuria may con- tinue and the affection become chronic parenchymatous nephritis, even after the dropsy has disappeared. Acute nephritis presents a number of serious and often dangerous symptoms. Among these are severe general oedema, dropsical effusions into the serous sacs (as hydrothorax), ursemia (especially when beginning with cerebral manifes- tations, as convulsions or coma), and, finally, inflammation of the internal organs, as pneumonitis, pleuritis, peri- carditis, peritonitis, and meningitis. Eecovery is quite common in cases of marked general dropsy in the absence of ureemia. Suppression of the urine, however, if it last more than twenty-four or forty-eight hours, is usually a fatal symptom. In those cases, also, in which the nephritis has a productive character, the prognosis is unfavorable, though life may, in some cases, be prolonged for several years. Case of acute Bright's disease ending fatally in seventeen days in a child, 3 months old, and not consequent upon a skin affection or scarlatina. T. B. Green- ley (Amer. Pract. and News, June 15, '98). Treatment. — The first object in the treatment is to relieve the congestion and inflammation, since the renal func- tion is diminished by these conditions; by these means we restore the excretory function. It is, therefore, in order ta restore the functional equilibrium by their antiphlogistic influence, that the single or combined use of diaphoretics and cathartics is employed, and not that the skin and bowels shotild be made to perform the work normally done by the kidneys. Absolute rest in a warm bed and in a warm room is of primary importance, and, in order to promote a constant and free action of the sweat-glands, woolen underwear and blankets should be used. These measures are of importance both in mild and severe cases. The diet should consist of bland liquid foods only, and the patient should be urged to drink freely of water (plain, distilled, or carbonated), lemonade,. BRIGHT'S DISEASE. ACUTE XEPHRITIS. TREATSIEXT. 595 skimmed milk, or buttermilk, all of which are of especial value when hot. Thin meat-broths may be allowed later in the course of the disease, although a strict milk diet is preferable. In rare eases in which there is severe pain, local blood-letting, by means of leeches or cupping over the loins, may be useful; these measures are seldom needed, however, and a more salutary effect may often be gained by hot fomen- tations. Diminution of the oedema and the elimination of urea and other uri- nary constituents retained in acute ne- phritis are best attained by exciting a profuse perspiration. The congestion of the kidneys is also relieved by this vicarious action of the skin. The same results may also be accomplished by means of the hot-air or hot-water bath and the hot wet pack; in most cases the last method proves effective. It is easily applied by wringing a blanket out of hot water, wrapping the patient in it, and surrounding him, first with a dry blanket and, finally, with a rubber cloth. According to the condition, the patient may remain in this improvised steam bath until free sweating has continued for an hotir or more. Children suffering from scarlatinal nephritis may either be treated thus, or by immersion in hot water for twenty, thirty, or more min- utes; the child is then wrapped in warm sheets or blankets, after lightly drying the skin, and warmly covered in bed. Hot air or vapor may also be generated beside the bed and introduced beneath the cradled bed-clothing by means of a tin funnel and pipe. The drinking of hot lemonade or soda-water, or of water containing spirit of Mindererus, will stimulate the sweating. Should these measures fail, as in ursemia, perspiration may be started by an hypodermic injec- tion of pilocarpine, Vs to ^/o grain; it will then continue to pour out upon the application of heat. Serious conse- quences sometimes attend the use of pilocarpine, and the heart and pulse must always be carefully watched. The sweating should be repeated as often as the patient's strength will permit, until the dropsy disappears. The depression of the heart's action produced by pilocarpine is very similar to that caused by nicotine. The toxic effects of the drug are best overcome by atropine. 'SMiere toxic effects result from the administration of pilocarpine, the ordinai-y circulatory stimulants should also be resorted to. Probably the only cases in which pilocarpine could be used with safety are those in which there is simple hypertrophy of the heart, with a strong action. The contractive power of the heart is what should be depended upon as a guide. Its employment is cer- tainly contra-indicated if there is any dullness over the lungs, or pneumonia, emphysema, pleurisy, coma, fatty de- generation of the heart, or cardiac in- sufficiency. To ascertain the condition of the cardiac muscle, auscultation with the binaural stethoscope is called for, and any impairment of the first soxmd of the heart should make one hesitate to use pilocarpine. C. J. Proben (Med. Xews, Aug. 1, '96). Pilocarpine liable to produce a kind of broncliorrhoea which is almost always fatal. Case seen in consultation of a child, 2 years of age, who had recently had scarlet fever. The attack was not a severe one, but it was followed by kidney disease, which resulted in general ana- sarca. A single dose of pilocarpine was administered, and as a result of this bronchon-hoea was rapidly produced, ac- companied by the most intense dyspnoea, so that the patient soon succumbed. Other cases seen, however, in which the remedy acted with the most happy effect. J. Lewis Smith (Med. Xews, Aug. 1, '96). While pilocarpine is a dangerous remedy, which should always be used with great discrimination, bad effects never personally observed from its use; only from '/,; to '/,. grain administered. 596 BRIGHT'S DISEASE. ACUTE NEPHRITIS. TREATMENT. however, usually combined with some cardiac stimulant, such as strychnine or digitalis. J. Blake White (Med. News, Aug. 1, '96). External application of pilocarpine in the dorso-lumbar region, employing an ointment of 3 ounces of vaselin and from % grain to 1 V2 grains of pilocarpine nitrate. Surface frequently covered with a layer of cotton, which is allowed to remain on during the day. Out of eighty cases, the acute were rapidly restored to health and chronic cases were improved. There was marked diaphoresis and diu- resis and albumin often disappeared from the urine. Julia (Lyon Med., Dec. 6, '96). Hydragogues, as elaterium, the saline cathartics, and compound jalap powder, are useful as adjuvant measures. The extract of elaterium (^/e to ^/4 grain) is prompt in action, and magnesium or sodium sulphate (1 drachm) given in hot concentrated solution every hour, or a calomel purge, may also be recommended. In extreme cases of dropsy it may be necessary to relieve the tension and dis- tress by the use of a small trocar and cannula, with a drainage-tube (Southey) attached to the latter after the trocar is withdrawn, or by multiple punctures. If either hydrothorax, hydropericardium, or ascites assumes serious features, as- pirations will become necessary. To the diaphoretic treatment may be added V2" ounce doses of the spirit of Mindererus in water. This, combined with aconite, aids in controlling the fever that may be present and in preventing the vasocon- striction that is often premonitory of nrsemic symptoms. If the urajmic convulsions do not promptly yield to diaphoresis and cathar- sis, venesection must be resorted to, the withdrawal of as much as a pint or two of blood often saving life. Occasionally inhalations of chloroform are needed to subdue the violent convulsive seizures, as in eclampsia. Their recurrence may be prevented by the use of rectal injec- tions of potassium bromide (1 drachm) and chloral (V2 drachm). Contraction of the arteries with in- creased tension and beginning muscular twitchings require the use of chloral- hydrate, nitroglycerin, and, possibly, morphine. Nausea and vomiting may be held in control by minute doses of cocaine, cracked ice, dilute hydrocyanic or hydro- chloric acid, bismuth, or by the addition of soda- or lime- water to the milk. There is little advantage in diuretics other than the simple diluent drinks already mentioned, at least early in the course of the disease. Later, potassium bitartrate or acetate, sodium benzoate, as adjuvants to the water, and stimulants to relieve cardiac depression, or caffeine citrate and the infusion of digitalis, may be given, well diluted. In infectious nephritis of young sub- jects, with or without anasarca, tinct- ure of cantharides in doses of 10 to 12 drops is very beneficial. It is contra- indicated in the interstitial nephritis of arteriosclerosis and in lead poisoning. Mile. A. Myszynska (These de Paris, No. 24, '96). Care must be taken during convales- cence that the patient be not exposed to cold. The diet must not be changed to solids either too suddenly or too rapidly, and particularly does this rule hold in the matter of meats. Milk should form the mainstay of the dietary, and light watery vegetables, fruits, and cereals may be gradually added. The ansemia will indicate the ferruginous tonics. The fatal result is reached in many cases only because the rigid course of management necessary to stem the prog- ress of the disease is not enforced until irreparable mischief is done to the kid- neys. The patient should avoid fatigue, mental wear, errors in diet, exposure to cold or damp, and keep the skin thor- BRIGHT'S DISEASE. ACUTE NEPHRITIS. TREATMENT. 597 oughly protected. The urine should be examined at stated periods (monthly) to ascertain whether any trouble is still lurking or has been redeveloped. Jacob Price (Med. and Surg. Reporter, Apr. 24, '97). Not a single e.xact clinically expei'i- mental basis found in all the literature for the exclusion of dark meats in chronic nephritis, but only hypothetical affirma- tions over the greater content of irri- tating products (especially nitrogenous extractives) for the kidneys in brown meat. In a personal case a patient with chronic parenchymatous nephritis who took V2 pound of poultry daily for five days excreted the same amount of ni- trogen and a trifle more albumin than he did in the next five days, in which, in- stead of the poultry, he took an equiva- lent amount of nitrogen in beef. In many cases also a restriction of the amount of fluids to 42 or 50 ounces can be of great advantage. This treatment is peculiarly applicable to those cases with cardiac asthma and dilation of the heart. Patients with interstitial ne- phritis suffer no diminution in the elimi- nation of the important metabolic prod- ucts by the restriction of liquids to 1 'A litres. Von Noorden (Verhandl. d. Cong, f. innere M6d., p. 386, '99). Indication for milk diet. The prevail- ing custom to put the patient on a strict or partial milk diet has been strongly condemned by von Noorden, Lancereaux, and others, the second named holding that it is oulj' advisable in desquamative nephritis, and not in the interstitial variety. Great care should be taken to deter- mine whether the albuminuria is func- tional or due to a kidney lesion, which can only be ascertained by a prolonged and careful investigation of the patient's antecedents and habits. If it be con- cluded that there is a chronic nephritis, the medication must assume a depurative character, as no medicines are capable of curing the disease. Milk is very valu- able in such cases. In functional cases, however, the cause may be nervous, gastro-hepatic, gouty, or due to gravel, rapid growth, or menstrual disorder, and here treatment should be directed to the cause. As a result of neglect, such transient albuminuria may become per- manent, owing to chronic injury of the renal epithelium. In these cases milk may be largely used or not, as may seem best in regard to the general health and nutrition, and its digestibility in indi- vidual instances. Marboux (Lyon Mfid., Feb. 11, 1900). Indications for milk diet. In cases of functional albuminuria, as in the early stage of gout or in lithiasis, at the time of puberty, menstrual or digestive albu- minuria, an exclusive milk diet evokes no other result than great weakness and sometimes an intense degree of anaemia, without causing a disappearance of the albumin. The same cases improved under a mixed diet in combination with some Avater cure. It is necessary to de- termine the source of the albuminuria. If a chronic nephritis of whatever origin is present, the nutrition of the patient must be the first consideration. Here milk is at once a medicine and a food. If simple albuminuria with no renal ele- ments in the sediment is noted, if it is dependent upon some nervous, gastro- hepatic, or gouty factor, or if a calculus is the cause, the cause must be treated, since the albumin may eventually have a deleterious effect upon the epithelium of the kidney. In such cases a mixed diet containing milk is to be advised. Victor Scheiber (Wiener med. Blatter, Mar. 8 and 15, 1900). Patients with chronic nephritis seem to thrive best on a mixed meat diet, neither the white nor the dark meat of fowls appearing to be injurious. A. Pabst (Berliner klin. Woeh., June 18, 1900). Carefully regulated habits in regard to dress, exercise, and diet, and a change to a warmer, drier, and more equable climate, are necessary in cases that are convalescent from the very serious forms of nephritis, in which the renal paren- chyma, by the persistence, at intervals, of a slight albuminuria, is shown to have been somewhat damaged. In acute nephritis in children, rest in bed and strict milk diet; from one to 598 BRIGHT'S DISEASE. ACUTE NEPHRITIS. TREATMENT. two scarified cuppings on each side of the spine, with mustard plasters; every two hours 2 Vi drachms of benzonaph- thol and 2 ^/„ drachms of milk-sugar in an effusion of cherry-stalk; morning and evening cold boiled-water enema; once or twice a week julep and scammony; dry friction of the body, and asepsis of the mouth. Perier (Jour, de Med., Apr. 29, '94). When acute or subacute attack ap- pears, more or less long sojourn in bed, patient lying between blankets. Warm climate, but not on or near the sea. Brushing of skin, but no baths, lest patient take cold. Moderate exercise or massage. Pregnancy contra-indicated; sexual sobriety important. Milk the food and medicine par excellence; 2 quarts daily need not be exceeded. When marked improvement, vegetarian diet. Purgatives and diuretics only remedies needed, and caffeine subcutane- ously if heart show sign of failure. Sapelier (Bull. Gen. de Ther., Nov. 30, '94). Hot baths and milk diet best meas- ures. Diuretics useless. Though calo- mel acts as such, stomatitis is difficult to avoid. Eepenak (St. Petersburger med. Woch., Apr., '95). Examination of six thousand speci- mens at Denver, a mile above sea-level. Influence of high altitude: Acute ne- phritis, though uncommon, is exception- ally severe. Amyloid disease is less fre- quent than text-books infer. Chronic parenchymatous nephritis is not influ- enced. The chronic interstitial type of this disease is influenced favorably by the tonic, invigorating climate. Slight, transient albuminuria, due to high blood-pressure, is frequent. E. 0. Hill (Jour. Amer. Med. Assoc, May 12, 1900). Puncture of the kidney has recently been recommended. Puncture of the kidney to relieve ten- sion and cause cessation of albuminuria. Exploration of the kidney had been undertaken to discover if there were a co-existing morbid condition present. Good results followed and appeared in- explicable. They were thought to be due to such factors as the division of a nerve, the moral effects of the operation, etc. After several cases showed the same re- sults, a different explanation became necessary. In three subsequent cases, one of scarlatinal nephritis, one of nephritis from exposure to damp and cold, and one of nephritis following influ- enza, the albumin disappeared from the urine directly after surgical treatment; it was, therefore, believed that the albuminuria was due to a state of ten- sion in the kidney, which was relieved by the operation. In a proportion of cases of nephritis albuminuria disap- pears; in others it is very persistent. It is in these that surgical exploration of the kidney is indicated. This is particu- larly the case when the kidney compli- cation is grave from the outset and there is more or less suppression of the urine, and when, after a limited time, the renal symptoms do not tend to disappear. The operation of exploration is so safe that it is justified in all severe renal disorders. "The kidney should be ex- posed by a moderate incision from the loin, so as to enable the operator to feel the organ distinctly both in front and behind, aided, of course, by pressure exercised on the kidney by the hand of an assistant from the front of the ab- domen. If, in conjunction with the pres- ence of albumin in the urine, the kidney is found in a state of tension, such as I have illustrated, three or four punctures may be made through the capsule in various directions; or, should the organ be found in a state of higher tension, then a limited incision into the cortex may be practiced. After one or other of these measures has been executed, the wound should be lightly packed with gauze or a drainage-tube substi- tuted. In either case the incision should be dressed in such a manner as to pro- vide for the free escape of either blood or urine or whatever products may be exuded." Reginald Harrison (Med. Weekl}', Oct., '96; Med. Record, Nov. 7, '96). Case of a woman suffering from a nephritis with profuse haematuria and alarming symptoms of ursemia in which the disease was checked by a nephrot- omy. Results given in 24 instances of intervention in nephritis, complicated by BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. 599 grave symptoms. In 9 cases of nephritis with hsematuria there were 7 nephrec- tomies with 2 deaths and 5 recoveries, 1 nephrectomy witli recovery, I simple exploration with recovery. In 4 eases with subacute infectious nephritis these were submitted to nephrectomy and all recovered. In 8 cases of acute infectious nephritis there were 3 nephrectomies with recovery, and 5 nephrotomies with 2 deaths and 3 recoveries. As to the therapeutic results, in the first set the hsematuria disappeared at the same time the urinary secretion and elimination of urea were re-established. The pain abated in the nephralgias. The albumin disappeared in the cases of subacute ne- phritis, and the fever and other symp- toms in the severe infectious cases also disappeared. Pousson (Jour. Cut. and Genito.-Urin. Dis.; Ther. Gaz., Apr. 15, 1900). Exudative Chronic Nephritis. Definition. — A chronic diffuse inflam- mation of the kidneys, attended with epithelial degeneration, exudation from the blood-vessels, and permanent con- nective-tissue changes in the renal stroma. This is one of two varieties of chronic Bright's disease, and is identical with Delafield's chronic productive (or diffuse) nephritis with exudation. Symptoms. — The symptoms of an acute parenchymatous nephritis may persist in a lesser degree until the con- dition becomes a chronic one; particu- larly is this true of the albuminuria, the ansemia, and the dropsy. As a rule, however, the disease develops slowly and gradually, and in a subacute manner, although there is seldom an early indi- cation of renal derangement. There may be merely a loss of appetite, attacks of indigestion, nausea, headache, dull- ness, perhaps some pallor, and a general impairment of health and strength. The complexion then takes on a blanched appearance and there is soon puffiness of the eyelids or swelling of the feet or ankles, or both. There is a gradual ex- tension of the oedema up the legs, and as the day grows it becomes worse; on rising in the morning it may have en- tirely disappeared. In the majority of cases the quantity of urine is diminished. In the later stages of the disease, how- ever, it may be nearly or quite normal, and in protracted cases of pale contracted Iddney, or when absorption of the drop- sical effusion is in progress, it may even be slightly increased. An acute nephritis supervening upon the chronic condition may now cause a very scanty or suppressed secretion of urine. In cases of scanty urine the spe- cific gravity is, of course, increased, and vice versa. Albuminuria is often present to a decided degree. The albumin may constitute from one-fourth to three- fourths of the urine in volume, or from 1 to 3 per cent, by weight; thus the daily loss of albumin may be consider- able. The albuminuria of Bright's disease is always characterized by great oscilla- tions in the quantity of albumin ex- creted at different hours of the day, be- cause either of the richness of alimen- tation in nitrogenous substances or of causes that escape us and should be classed among hsematogenous albumi- nurias. Semmola (Inter, klin. Rund., Jan. 17, '89). In many instances where those au- thorities claim to obtain an albuminous reaction in normal urine they are really dealing with mucin. Plosz (Orvosi Hetilap, Nos. 42 and 43, '90). The clinical significance of albuminuria as a symptom has undoubtedly dimin- ished during the last twenty years. Cases of "functional" albuminuria con- stitute from one-half to one-third of all the cases of albuminuria that come under notice. Ralfe (Brit. Med. Jour., Feb. 20, '93). Six cases in which autopsy showed the presence of Bright's disease, and in which the urine, carefully examined dur- 600 BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. ing life, showed, at certain times, no albumin, although symptoms of ursemia were present. These observations, to- gether with similar ones of Lepine, Lan- cereaux, and others, tend to show that albuminuria is not always a faithful symptom in nephritis. Dieulafoy (Bull, de I'Aead. de Med. de Paris, June 6, '93). Certain cases of Bright's disease may exceptionally, and sometimes for a rather long period, show no albumin in the urine; but there may sometimes be renal insufficiency without serious renal lesions. Too often a case is diagnosed as a contracted or enlarged waxy kidney, when the autopsy shows but slight le- sions; diagnosis should only have been renal insufficiency. Lgpine (Lyon Med., July 9, '93). Casts are invariably present when a true organic lesion exists. Cardiovas- cular tension is another symptom almost invariably present in the early stages of renal cirrhosis. Occipital headache, with momentary attacks of vertigo, is rarely absent. In addition, there is usually a somewhat ill-defined appearance of want of perfect health, restless movements, coated tongue, foul breath, pale lips, and lifeless or waxy appearance of the skin. Danforth (N. Y. Med. Exam., Aug., '93). Albuminuria is absent in the inter- stitial forms, while the skin is frequently dark in color in the parenchymatous forms. Dabney (Inter. Med. Jour., Nov., '93). There is a non-albuminuric nephritis exclusive of the cases of typical fibroid kidney. In this form of nephritis albu- minuria may be completely absent, while signs of renal insufficiency, and even ursemia, may appear. The urine is di- minished and sometimes highly colored, but there is no cardiac weakness. Stew- art (Med. News, Apr. 14, '94). No albumin is to be found in the urine in some cases of nephritis. Such a ne- phritis may be due to the introduction of a specific virus from the external geni- tals. Fienga (N. Y. Med. Record, Apr. 21, '94). Rapid elimination of such substances as iodide of potassium, quinine, turpen- tine, and the bromides shows that the kidney is healthy, while delayed or diminished elimination gives sufficiently precise information as to the degree to which the organ is affected. Bassett (N. Y. Med. Record, Apr. 21, '94). Presence or absence of albumin in the urine is not nearly of as much diagnostic and prognostic importance as the mor- phological evidence of kidney disease afforded by the presence or absence of casts. Ludwig Bremer (Med. Review, June 29, '95). The quantity of urea is much dimin- ished. The urine contains an abundant sediment, consisting of urates, casts, red and white blood-corpuscles, epithelial cells, granular debris, and fatty granular cells, and is in color turbid and some- times smoky-yellow. There are tube- casts of different varieties, the narrow or broad hyaline, fatty granular, and epithelial casts being most commonly noted. The oedema is prominent and persist- ent, gradually extending all over the body; thus pitting may be obtained on pressure on the limbs, chest, abdomen, and back. The loose subcutaneous tissues, as of the penis, scrotum, and eyelids, are es- pecially distended. Only in chronic hsemorrhagic nephritis may the oedema be absent or very slight. Chronic exu- dative nephritis, especially with large white kidney, shows a pasty, pallid skin and anasarca as its most distinguishing characteristics. For several months the dropsy may be of moderate degree and almost stationary; it then grows worse insidiously, in spite of all efforts at treat- ment, and death ensues in a month or two. Case in a man, 50 years of age, in whom cedema had occurred in various positions: face, hands, feet, and scro- tum. At one time he was rather sud- denly seized with severe attack of dyspnoea, due to an oedema of the pharyngeal walls and those of the upper part of the larynx. In the course of sev- BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. 601 eral days, under the use of a spray of carbolic acid and an absolute milk diet, the oedema disappeared. Mendel (Ann. des Mai. de I'Oreille, etc., May, '91). Form of oedema which is to be ex- cluded in the consideration of the symp- toms of Bright's disease. It is super- ficial in persons free from any traces of albuminuria and unaffected by any alterations of heart or lungs. In none of the cases met has the author been able to establish any relation ■^^■ith the htemic condition, as in chlorosis. The administration of iodide of potassium having led to rapid disappearance of the oedema from four cases, the phenomenon ascribed to some syphilitic affection of the vasomotor system. Tschirkow (Meditzinskoje Obozrenije, No. 2, '91). A large number of cases in which (Edema of the glottis was the only symp- tom of Bright's disease localized in the larynx. Occurs as an incident in the course of the disease or as the initial symptom of latent Bright's disease. Twelve such cases recorded. It may lead to death in several hours. Maire-Amero (Ann. des Mai. de I'Oreille, etc.. Mar., •94). Three cases of swelling of the eyelids associated with occasional albuminuria, two cases of occasional swelling of the eyelids but without albuminuria, and one case of occasional swelling of the eyelids in which albumin was always present in the urine, all in children. In none was there a history of scarlet fever. These may indicate the early stages of insidious nephritis with small white kid- ney, but more likely only of vasomotor instability or defective metabolism. T. Fisher (Brit. Med. Jour., Apr. 14, 1900). There may be present in serious cases dropsy of the serous sacs, with its accom- panying distressing symptoms; oedema of the larynx and lungs may then super- vene, causing sudden death. Dyspncea may occur, both toxic and nervous, as well as mechanical or cardiac, in origin. On lying down, cardiac dyspnoea, due to failure of the heart's action and seen in many instances, is aggravated, as a rule. Dyspnoea of uraemia is divided into three forms: simple, characterized by acceleration of respiration and diminu- tion of the fullness of respiration; par- oxysmal, or Cheyne-Stokes, in which a period of apnoea alternates with one of dyspnoea of regularly varying fullness and the spasmodic, which closely simu- lates spasmodic asthma. Lancereaux (Jour, of Nerv. and Mental Dis., May, '91). In many instances there is too great a tendency to regard as cardiac a toxaemio dyspnoea. In such cases of dyspnoea, where no auscultatory symptoms are present, even if the urinary phenomena are not calculated to impress very strongly the fact of a decided renal alter- ation, the possibility of uraemie origin should be gravely considered. Several instances where the withdrawal of car- diac stimulants and morphia, given with a view of correcting a cardiac error, and the substitution of remedies and meas- ures for the correction of a toxaemia, were followed by a successful result. Landouzy (Jour, de Med. et de Chir. Pratiques, Aug. 10, '91). [It has long been believed that the dyspnosa of advanced Bright's disease is of toxfemic origin, and so it probably is in a number of instances; at least, in a certain degree. But, aside from the direct action of the toxic retention substances upon the respiratoiy centres or upon the respiratory tissues, there must be remembered the circulatory ele- ment. Allen J. Smith, Assoc. Ed., Annual, '92.] Attention called to the many similar features between the dyspnosa of Bright's disease and that from accepted cardiac origin, — the breathlessness on even slight exertion, the distressing paroxysms at night, the influence of the horizontal position in increasing the severity, and the fact that Cheyne- Stokes respiration is not infrequent in either. Steell (Med. Chron., Oct., '91). Particular attention to the high arte- rial tension in cases of chronic Bright's disease, and to the renal inadequacy and retained substances as an important factor in the etiology of the symptom. Musser (Times and Register, Oct. 17, '91). 602 BEIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. It may be provoked by vasoconstric- tion, and is, in such cases, a signal of uraemia. Form of uraemia which manifests itself in the mouth and pharynx: bucco- pharyngeal uraemia. Marked by the presence in the mouth and pharynx of a thick, gummy mucus, covering the Malls of these cavities. When it is de- tached the membrane beneath is red and dry, but not ulcerated, although the similarity to a pseudomembranous for- mation is close enough to mislead the incautious. It is not infrequently ac- companied with hiccough, bulbar dysp- noea, and other cerebro-spinal phenomena, and presents a number of analogies to vomiting known to be of central origin. Lancereaux (Sem. Med. and Gaillard's Med. Jour., Mar., '91). With these conditions may be asso- ciated catarrhal bronchitis, with cough and expectoration. There is frequently a moderate degree of cardiac hypertrophy of the left ven- tricle; later there are dilatation and weakness of both ventricles. There is an accentuation of the aortic second sound and an increase of the pulse- tension. Origin of the cardiovascular changes in Bright's disease; the hypertrophy of the heart is a true hypertrophy with, in some cases, a mild interstitial myocar- ditis, the left ventricle alone being en- larged in a little over half of the cases, the remainder showing enlargement of both ventricles, the right never being en- larged alone; the changes in the blood- vessels are first an inflammation affect- ing the intima^ and then a secondary degeneration both of the intlma and of the muscularis^ which is not hy- pertrophied, even when thickened. Two divisions may be made to include the cases of associated cardiovascular and renal disease, the first being arterio- sclerotic in which some irritative sub- stance in the blood, such as lead or the poison of gout, excites a primary endarteritis in the whole arterial sys- tem including the kidnev; the second division includes those cases in which the renal disease is primary, and, as the damaged kidneys are unable with the ordinary rate of the circulation to elimi- nate all of the products of metabolism brought to them, those which remain be- hind influence the heart through the nervous system to propel the blood faster, and hypertrophy results; when this hypertrophy affects the right ven- tricle it is the result of the increased blood-supply to it; the blood-vessels be- come affected later, both by the original cause of the renal disease and also by the toxic state of the blood due to de- fective renal function. Tyson (.Jacobi Festschrift; Phila. Med. Jour., May 26, 1900). Headache, vertigo, sleeplessness, nau- sea and vomiting, diarrhoea, and stupor, coma, or delirium may all develop and form the symptoms of a ursemic condi- tion. These S3'mptoms, as a rule, precede a fatal termination. The convulsions that are common to chronic nephritis without exudation do not appear, however. In quite a large number of cases albumi- nuric neuroretinitis occurs, and is evi- denced by dimness of vision and field- defects. In certain eases of marked oedematous distension the skin of the legs becomes subject to a red eezematous eruption. The temperature is practically normal in the absence of such complicat- ing inflammations as pericarditis, endo- carditis; pneumonitis, and ulcerative colitis, all of which are rare conditions. Chronic exudative nephritis may either continue from bad to worse, and death may end all in a year or two, or anaemia, albuminuria, and dropsy may appear in a person that has, for years previously, enjoyed apparently good health. After a first attack a second proves fatal within a few months. On the other hand, certain cases may show a slight pallor, a slightly diminished quantity of urine of high specific gravity. BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. ETIOLOGY. 603 and containing albumin, and yet may complain of no inconvenience for years. Decided attacks may then occur at in- tervals, during which the dropsy, dysp- noea, etc., may be absent, although a certain amount of albuminuria persists; these attacks last for several months. The average duration of the disease varies from one and one-half to three years. Etiology. — Chronic nephritis with exudation may either follow acute diffuse nephritis (as of scarlet fever or preg- nancy), or simple chronic congestion and chronic degeneration of the kidneys. It arises insidiously more frequently, however, and without any previous acute manifestation. Males are more subject to this form of chronic Bright's disease than females. Cases occurring in chil- dren are usually preceded more or less recently by scarlatinal nephritis. Heredity in chronic nephritis. Family histoiy whicli showed in tliree genera- tions in one family eighteen cases of chronic nephritis. Almost all the mem- bers of the family in these three genera- tions were subjects of nephritis. They had the disease for years, but reached an advanced age, and, almost without exception, became ursemic and died in coma. The sex was equally divided. This series indicates a hereditary disposi- tion of the kidneys to become diseased. Pel (Zeit. f. klin. Med., B. 38, B. 1, 2, and 3, 1900). Young adults are more commonly af- fected with the usual form, developing subacutely. Beer-drinkers, and those who are accustomed to using malt and alcoholic intoxicants, seem especially liable to the disease. Even in cases where other manifestations are absent, it is not improbable that, in the in- sidious cases, some toxic or infectious agency may act slowly and persistently, and be the cause of the nephritis. The disease has been observed in cer- tain individuals living in malarial re- gions, and persons working under an exposure to cold and wet, or living in humid, marshy districts, seem more liable to the renal malady than those who are more carefully shielded from such influences. A form of chronic albuminuria of less prognostic importance is that associated with chronic malaria. This is probably due to venous congestion during the at- tacks of ague. Lauder Brunton (Brit. Med. Jour., Feb. 20, '93). Three cases of nephritis following malarial fever, in \Yhich the symptoms, including albuminuria, disappeared on the administration of quinine. Stephan- owicz (Wiener klin. Woch., No. 20, '93). Cases of parenchymatous degeneration of kidney, proved by autopsy, in which the causative element was chronic ma- larial infection. A. Gray (Jour. Ark. Med. Soc, Dec, '94). Case of nephritis in which ordinary treatment gave no result. A character- istic access of ague pointing to etiology, large doses of quinine caused rapid im- provement. Bermann (N. Y. Med. Eec, Dee. 23, '94). Acute form less frequent among sol- diers in Algeria and Tunis than in France, showing the influence of tem- perature as cause; while the reverse is the case as regards the chronic form, pointing to effect of malaria in the eti- ology of Bright's disease. Famechon (Archives de Med. et de Pharm. Mili- taires, Jan., '95). Conclusions to be drawn from a study of the relation of chronic nephritis to malarial disease: In some localities malarial fever should be given a promi- nent position in the etiology of chronic as well as of acute nephritis. In all cases of malarial fever the urine should be closely watched. A blood-examina- tion should be made in all cases of ne- phritis occurring in those who have visited or lived in a malarial district, as it often happens that the severe grade of nephritis resulting may mask entirely the clinical picture of malarial fever. C. 604 BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. PATHOLOGY. W. Larned (Johns Hopkins Hosp. Bull., July, '99). This so-called "parenchymatous" form of chronic Bright's disease may find its cause in tuberculosis, syphilis, or chronic suppuration, and in such cases it is usu- ally combined with amyloid disease (waxy degeneration). Epithelial nephritis may follow in the course of syphilis, tuberculosis, and lep- rosy, and which are quite distinct. It begins suddenly, as does subacute nephri- tis, but its progress is slow. The urine is not abundant, is strongly albuminous, and the prognosis always gi-ave on ac- count of the danger of uraemia. Lan- cereaux (Le Bull. Med., Jan. 11, '93). Syphilis may lead to a nephritis re- bellious to treatment. Dieulafoy (Bull, de I'Acad. de Med. de Paris, June 20, '93). Case developed suddenly without usual causes, during seeondaiy period of syph- ilitic infection. Thiroloix (Concours M6d., July 13, '95). The nature of chronic nephritis: 1. The different forms of Bright's disease are to be regarded as various stages in the same general process, there being a unity pervading the whole pathological picture. 2. All forms of nephritis are due, in the immense majority of oases, to infective agents; the acute, to the usual specific germs of the primary dis- ease, and the chronic, as a general rule, to the bacillus coli, though other germs may sometimes be concerned. 3. Acute Interstitial inflammation and subsequent connective-tissue hyperplasia are the key- note of the process; this is, however, preceded by parenchymatous degenera- tion. 4. The point of invasion by the bacillus coli is the gastrointestinal tract; those of other germs may be various. 5. The liver and mesenteric glands are the first barriers of defense; and the endothelial cells of the capillaries and the secreting tubules of the kidney have the power of ingesting bacteria, this being an attempt at inhibition and elimi- nation. A. G. Nieholls (Montreal Med. Jour., Mar., '99). Pathology. — There are several types of kidney included in this disease, yet in all the changes of structure are essen- tially identical, and the variations, when they occur, depend upon the cause and duration of the nephritis. The large white kidney (without waxy degeneration) may be either normal in size or enlarged, and is pale or yellow- ish in color. The surface is smooth and the capsule is easily stripped off. On section the cortex appears broader than normally, and is either yellowish white throughout or may present opaque yel- lowish or whitish areas with mattings of red. In some cases the pyramids are congested. The following changes may commonly be observed microscopically: The renal epithelium is swelled, hyaline, granular, or fatty, and is more or less disintegrated or flattened; there is an enlargement of the glomeruli, awing to the growth of the capsule-cells and of the cells covering the capillaries; and, in certain cases, as a result of the con- nective-tissue thickening of the capsule, the tuft of capillaries is atrophied. There is some thickening of the arterial walls, and a moderate growth of connective- tissue may be noted in patches around the glomeruli and tubules. The latter contain hyaline and granular casts. The small white kidney (secondary contracted kidney) is, in most instances, probably a later stage of the preceding condition, in which the epithelial degen- eration becomes more pronounced, and the connective-tissue growth and the resultant cicatricial contraction become prominent features. The kidneys are about normal in size; owing to a shrink- age in the large white kidney, the sur- face is slightly granular and the capsule proportionately adherent. In color they are usually grayish or yellowish (pale granular), and there may be a certain amount of red mottling. The consist- BRIGHT'S DISEASE. EXUDATIVE CHRONIC NEPHRITIS. TREATilENT. 605 ency is firmer than that of the large white kidney, and the surface, on sec- tion, shows, in the somewhat narrowed cortex, yellowish-white foci of fatty- degenerated epithelium; hence the term "small, granular, fatty kidney." Micro- scopically we find extensive degeneration and disintegration of the epithelium of the glomeruli and convoluted tubules, atrophy of the parenchyma, and a cor- responding increase in the interstitial connective tissue. There may be an as- sociated waxy degeneration. The large red or variegated kidney of chronic hemorrhagic nephritis forms a third variety. The kidneys are found, as a rule, enlarged, red, swelled, and con- gested-looking or mottled; frequently they are "bumpy," or slightly bosselated. The capsule is slightly adherent to the depressions between the bosses. The sec- tion shows congested portions and gray or yellow spots corresponding to the ansemic and fatty-degenerated portions. Eed spots, due to small hsemorrhage, may also be noticed on both the outer and cut surfaces of the kidney, and small cortical hemorrhagic areas or striations, brownish-red in color, are distinctive. Microscopically the appearances are those of acute nephritis superadded to those of the large white kidney, and consist of fatty granular degeneration, epithelial proliferation, atrophied capillary tufts, thickened glomeruli capsules, and, in some places, a growth of interstitial fibrous tissue. In either place inflam- matory cedema and celhilar infiltration of the intertubular tissue may be noted, as well as the dilated tufts of capillaries with surrounding cellular hyperplasia. This variety of chronic nephritis is fre- quently seen in inebriates. Prognosis. — The prognosis is invari- ably bad, though life may, in certain eases, be prolonged. Death may occur in severe cases in from three months to a year, from urjemia, dropsy, dilatation of the heart, or from other complica- tions. Cases of a year's duration seldom recover, and those in which advanced secondary contraction of the kidney may be assumed may be considered hopeless; they often terminate suddenly. Earely there may be a complete recovery; this occurs particularly in children following an attack of scarlet fever. According to the quantity of urine passed in the twenty-four hours, and the amount and persistence of the albumin, is the prog- nosis made, as well as upon the degree of cardiovascular and retinal changes. Eelapses may occur in apparently favor- able cases, and acute attacks may super- vene. Study of several hundred of cases of nephritis has shown that chronic ne- phritis is not an incurable disease; re- covery occurs in rare cases. It may exist for years without causing ap- parent constitutional disturbance. The average duration in three hundred and thirty-two cases of chronic nephritis was nineteen months. Acute nephritis is less common than has been sup- posed; many cases that were formerly so classified are found to represent exacerbations of chronic nephritis. R. C. Cabot and F. W. White (Boston Med. and Surg. Jour., Aug. 10, '99). Treatment. — This is conducted much as in acute nephritis. The uremia and dropsy are treated symptomatically. The diet is of great moment, skimmed milk and buttermilk being depended on as much as possible when the dropsy is marked. When the dropsy is slight, more solid food, white meats, vegetables, and fruits, and an out-door life should be recommended. Prolonged, sudden exercise and severe exercise should be prohibited. Importance of combating the tendency to anaemia, the prognosis remaining good 606 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. as long as this condition is averted. Stephen Mackenzie (Brit. Med. Jour., Feb. 20, '93). Woolens should be worn next to the skin, and residence in a warm, dry cli- mate may aid in extending life. Nitroglycerin may be needed in cases with contracted and tense arteries, with a tendency to ursemic twitehings, and digitalis may be useful in cardiac weak- ness. Basham's mixture for the ansemia and unirritating diuretics will prove of value, and strontium lactate, in doses of from 15 to 20 grains, three or four times daily, may be tried in some cases. Three cases of nephritis treated by lactate of strontium; an excellent diu- retic in the acute forms and in acute attacks occurring in the course of the chronic form. Da Costa (Med. News, Apr. 21, '94). Child, 5 years of age, who suffered from chronic Bright's disease and whose urine contained large quantities of serum-albumin and globulin. Lactate of strontium increased the quantity of urine and solids excreted and the pa- tient rapidly recovered. Gillespie (Med. Chronicle, Sept., '94). Lactate of strontium is beneficial, in a large number of cases, when sclerosis has not begun. It produces nausea in powder, but not when dissolved in water, 1 to 6 parts, three or four tablespoonfuls being given daily. Ried (Med. and Surg. Reporter, Jan. 26, '95). Lactate of strontium tried in 10 cases of Bright's disease : 3 of acute parenchy- matous, 6 mixed, and 1 interstitial. The favorable action of salts of strontium on the kidneys is not due to their dimin- ishing putrefaction in the intestines. Direct experiments with bacteria show- ing that the antiseptic properties of lac- tate of strontium are insignificant, and that the presence of ethero-sulphurie acids in the urine is not influenced by the use of the drug. Bronowski (Medy- cyna. No. 1, '96). There is a great deal of mischief done by iron in Bright's disease. It may be laid down as a rule to ■which there is almost no exception that tlie iron is not indicated, and should not be prescribed, in cases of acute Bright's disease. On the other hand, after the acute symptoms have passed away and convalescence sets in, iron is very useful. A second class of cases in which iron is contra-indicated is chronic interstitial nephritis, in which it is more promptly and dangerously harm- ful than in any other form of Bright's disease. The form of Bright's disease in which iron is best borne is chronic paren- chymatous nephritis. The proper dose should be determined by an examination of the stools, and, if these are decidedly blackened, too much is being given. Basham's mixture is no more diuretic than the bulk of water which constitutes its menstruum. James Tyson (Journal Amer. Med. Assoc, July 23, '98). Methylene has also given satisfaction in some cases. Methylene-blue is recommended in chronic nephritis. Dose, from 3 to 5 grains a day. Man of 58 years, suffering from' chronic Bright's disease with renal congestion and albuminuria, was ad- mitted to the hospital. On the 25th of February he was passing six grammes of albumin a day. He was given a modified milk diet and treatment with alkalies and tannin. Shortly afterward he was placed upon methylene-blue in dose of 4 grains a day. On the 3d of March he was passing four grammes of albumin; four days later he was passing two grammes; and on March 10th he was passing 20 grains. Lemoine (Jour, des Praticiens, May 22, '97). Non-exudative Chronic Nephritis. Definition. — A chronic diffuse inflam- mation of the kidneys, indicated by a growth of connective tissue in the stroma, degeneration and atrophy of the renal parenchyma, and by marked changes in the cardiovascular system. Symptoms. — The symptoms may re- main latent for a considerable time, even for years, while the morbid productive changes are gradually effected in the kidneys. They may not become evident until late in life, even though the kid- BRIGHT'S DISEASE. NON-EXUDATIVE CHKONIC NEPHRITIS. SYMPTOMS. 607 neys may be in an advanced state of degeneration. Some complicating condi- tion may also supervene, as pericarditis or pneumonia, causing the development of grave renal symptoms. As a rule, however, ursmia makes its appearance with headache, stupor, or convulsions, dyspnoea, nausea and vomiting, and a tense pulse. This seizure may be re- covered from. There is now an interim, of variable duration, in which there are drowsiness, lassitude, a disordered diges- tion, headache, failing vision, dyspnosa, and frequent micturition, with a more or less impaired general health. Then fol- lows another uraemic seizure, still more severe, if not fatal. If not fatal, the general health is still more reduced, and confinement to the house or bed is nec- essary; at last the vital forces can no longer compensate for the destruction of the renal parenchyma. Contracted kid- ney may sometimes first be manifested by spasmodic dyspnoea (urEemic-cardiac). There is a marked gradual onset of periods of drowsiness during the day that are uncontrollable; an attack of hemiplegia may be the first sign of the disease. In other cases a progressive loss of flesh and strength, with a dry, harsh, wrinkled skin, may be, from the begin- ning, the only clinical features, until death results from sheer feebleness and emaciation. The variability and involve- ment of the symptoms render it advis- able to describe them under the various systemic divisions. There is an increase in the daily quan- tity of urine excreted so great that it causes a frequent desire to micturate, not only during the day-time, but two or three times through the night. This may be aggravated by the hyperacidity of the urine and by the irritability of the prostate gland (especially in advanced years) that are so often associated with renal cirrhosis. The total quantity of urine for the twenty-four hours may measure several quarts in marked cases of the disease. It may be slightly de- creased early in the attack, when the degeneration and destruction of the par- enchyma are in their incipiency; but, as the "blood-flow to the parts that remain must, cceteris paribus, be as great as it would have been to the whole of the organs if they had been intact," excess- ive pressure is brought to bear within the capillaries, owing to the compensat- ing cardiac hypertrophy, and the secre- tion of the urine, especially of the watery elements, becomes more active. Diabetes may be suggested by the polyiiria, but the urine is clear and pale-yellow in color, the specific gravity being seldom above 1010 or 1012, and it may be as low as 1002 or 1005. Albumin occurs in traces only, or may even be absent altogether (glomerular atrophy); this is noted especially in the urine voided in the early morning. The urea is dimin- ished, and there is little or no sediment. On careful examination, microscopically, there may be found a few casts (usually narrow hyaline), perhaps some leuco- cytes, and, rarely, a few red blood-cells. Late in the disease or in the presence of a uraemic exacerbation or a complicating inflammation, the urine may be dimin- ished in quantity, the albumin increased, and numerous casts be found in the more apparent sediment. Hematuria is a rare condition. Epistaxis may form a serious symptom. Case of cerebral hsemorrhages in ad- vanced Bright's disease. Symptoms of the chronic interstitial form with marks of a slight, old, retinal haemorrhage. One night the patient became quickly sleep- less and delirious, and was found, the following morning, in a comatose condi- tion. His temperature was slightly sub- normal; there were no convulsions; the 608 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. bladder was not distended; pulse, 80, small, compressible; pupils equal, a little dilated, reacting to light ; no strabismus ; no paralysis. Croton-oil was given, and hypodermics of pilocarpine; but the coma deepened, the breathing becoming stertorous, the chest filling with rales, and pulse and respirations failed almost synchronously. At post-mortem, to the left of the aqueduct of Sylvius, there was a small hcemorrhage, of the size of a pea, flattened from above downward in its site in the pontine part of the floor of the fourth ventricle. Walsh (Med. Press and Cir., Nov. 26, '90). Epistaxis in Bright's disease due to a sanguine dyscrasia, to alterations of the vessels supplying the nasal mucous mem- brane, to cardiac hypertrophy, and to increased arterial tension. Occurs most frequently in the interstitial form of Bright's disease, and is apt to appear principally at the beginning and at the end of the malady. Sometimes it is the first sign which excites a suspicion of the affection. Savemy (These de Paris, '91). Conditions in which hfemorrhage may occur in Bright's disease: high tension, modifications in the structure of the arteries, and hypertrophy of the heart. Potain (Jour, de M6d. et de Chir. Pra- tiques, Aug. 10, '94). Importance of haemorrhage from the nose and into the ear as early manifes- tations of Bright's disease. Illustrative case. The so-called cases of spontaneous or idiopathic hsemorrhages into the ear ought all to be carefully investigated as to the possibility of an underlying ne- phritic cause. He would speak of a tym- panitis or myringitis albuminurica, just as we speak of rhinitis albuminurica. Haug (Deutsche med. Woch., Nov. 5, '96). Sudden oedema of the larynx may also supervene, and is always a grave condi- tion. Transudations into the pleural sac (hydrothorax) and the lungs may pre- cede the fatal termination. Dyspnoea is either ursemic or cardiac and is usually worse at night; a true orthopnoea, with Cheyne-Stokes breathing, may be ob- served in association with uremic stupor and coma, and near the end of the pa- tient's life. The signs of hypertrophy of the heart (particularly of the left ventricle) may be elicited, though symptoms referable to the heart itself are absent, unless dila- tation and feebleness, sudden arterial contraction, or endocarditis occur. In- spection and palpation show the apex- beat to be displaced downward and to the left, and the impulse to be increased, heaving, and rather circumscribed. In cases of co-existing emphysema, and later, when dilatation may eclipse the hypertrophy, these signs may become less evident. The left border of deep cardiac dullness extends outside the nipple-line in the fifth or sixth inter- space. The first sound of the heart is loud and may be reduplicated. Accent- uation of the aortic second sound is a distinctive sign, and indicates increased vascular tension; it may have a metallic quality in some cases. There may also develop a mitral systolic murmur as the result of relative insufficiency. There is increased tension of the pulse, the latter being hard, persistent, and incompress- ible; the pulse-wave is also increased in duration (pulsus tardus). Most of the palpable arteries are hard, thickened, and tortuous, owing to the arterioscle- rosis. As soon as compensation fails, symptoms of breathlessness on exertion, palpitation, and the like, appear; often these occur in paroxysms and constitute "cardiac asthma." The resulting stasis causes a transudation into the lungs (bronchorrhcea, pulmonary oedema) and later to osdema of the extremities. Of 106 fatal cases of chronic (intersti- tial) nephritis, 20 died from cerebral hsemorrhage; in all of these cases both kidneys were diseased, cedema of the extremities not being recorded in a single BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. 609 instance and oedema of the lungs in only 2, thus showing that all was going on well until the fatal rupture. The re- maining cases died from oadema, princi- pally involving the lungs and pleurjE. OSdema is, therefore, the most common cause of death; this occurs in conse- quence of the stretching of the auriculo- venbricular orifice, allowing of regurgi- tation. A mitral murmur is by no means always present. Arterial sclerosis is marked in the cases dying from cere- bral haemorrhage, and this might ac- count for the non-dilatation of the au- riculo-ventricular orifices. The heart- sounds assumed a clanging tone in sev- eral instances preceding the fatal result observed. Hawkins and Russell Dodd (Clinical Soc. of London; Annual, '94). Since they are indicative, as a rule, of grave urjemia, the symptoms referable to the nervous system are of great im- portance. There may be neuralgic pains throughout the body, and insomnia, and cephalalgia is frequent. Later great drowsiness is often a premonition of ursemic coma. Muscular twitchings may precede convulsions, and should attract attention to the imminent danger. Cere- bral apoplexy with hemiplegia may form the first symptom of contracted -kidney, and is apt to occur in cases of marked hardening and weakening of the arteries. Hemorrhagic pachymeningitis and hsem- orrhage into the brain-substance may also occur. The hemiplegia may last until the end, or it may disappear soon and be followed by subsequent attacks at intervals. Dieulafoy believes numb- ness, formication, and pallor of the fin- gers ("dead finger") to be sometimes the earliest symptoms of chronic Bright's disease. The dead finger is a vascular trouble in cardiac disease, or an hysterical phe- nomenon, and has nothing to do with Bright's disease. The principal sign of renal insufficiency is the toxicity of the urine. The excretion of nitrogen in con- siderable quantity by the faeces is also 1- a good sign. G. See (Bull, de I'Aead. de Med. de Paris, June 27, '93). Of the symptoms referable to the special senses nephritic retinitis often forms the earliest evidence of chronic Bright's disease. There may or may not have been present a slight dimness of vision prior to the ophthalmoscopical examination. There is a partial loss of vision in both eyes (amblyopia), and in grave cases sudden and complete blind- ness may come on (ursmic amaurosis; as the result of a neuroretinitis. The optic papilla is swelled, and surrounded by retinal haemorrhages or by white dots and streaks ("feather-splashes"). The varieties of albuminuric retinitis are (1) neuritis (optic papillitis, or in- terstitial neuritis with swelling and round-cell infiltration of the connective tissue of the nerve, leading, in some cases, to atrophy of the nerve-fibres). (2) Neuroretinitis, in which the retinal expansions of the optic nerve become swelled and ultimately granular and fatty. With these changes are associated A\hite patches, of which there are tW'O kinds: («) rounded, soft-edged areas of lymph-exudation and (6) smaller, bright, radiated streaks or specks. The latter are mostly seen radiating from the yel- low spot. Their glistening appearance is due to the refractive power of the minute oil-globules of Avhich they consist. (3) Periarteritis; chiefly affecting the outer coats of the arteries, and causing them to become thickened, and to en- croach on the lumen so as to obliterate the smaller ones. This condition is asso- ciated with haemorrhages and capillary dilatations. (4) Diffused opacity of the retina from oedema. Diagnosis: None of the ophthalmic ap- pearances described are pathognomonic of Bright's disease. Similar forms of neuritis and neuroretinitis are met with in cases of cerebral tumor, while haemor- rhages may occur in cases of leucoeythas- mia, chlorotie and pernicious anaemia, and purpura. Multiple retinal periar- teritis, though generally associated with 39 610 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. nephritis, is met with apart from this condition. The ophthalmoscopical ap- pearance must always be confirmed by some of the more obvious signs of Bright's disease. Causation: Four causes: (1) dys- crasia, or altered condition of the blood; (2) secondary degenerative changes in the small blood-vessels; (3) excessive pressure of blood within the vessels; (4) an inflammatory process of the affection of both vessels and nerves. Many re- gard the changes as purely degenerative. Prognosis: The gi'ave class of cases includes diffuse neuroretinitis, radiating patches around the yellow spot, and mul- tiple periarteritis. These are most com- mon in contracting granular kidney. When the changes are marked he would place the extreme duration of life at two years, whatever the state of the general health might be. An exception to this rule is in the case of puerperal nephritis. Here the condi- tion mainly depends on pre-existing dys- crasia of the blood, of which the retinal changes are only another local expres- sion. Recovery is general, if pregnancy does not recur. The dyserasia is not de- pendent solely upon renal disease. The benign class of cases includes simple oedema, hsemorrhages, and soft- edged patches. All these conditions may subside, and their presence does not make the prognosis of the case better or worse. One may conclude, therefore, that the prognosis is based upon the nature of the ophthalmoscopical changes discov- ered, and upon the nature of the ne- phritis which caused them. In interstitial nephritis, retinitis is a measure of the general amount of vas- cular degeneration present. Advanced retinitis characteristic of interstitial nephritis, together with other signs of that disease, mean a speedy death. On the other hand, signs of retinitis equally characteristic of other forms of nephritis are due to toxfemia rather than to vascular degeneration, and as such may be cured. Saundby ("Lectures on Renal and Urinaiy Diseases," '90; from review in Treatment, June 24, '97). Tinnitus aurium, deafness, and vertigo are not uncommonly present. Nausea, anorexia, and dyspepsia are frequent conditions. Severe vomiting may precede an attack of uraemia. Ursemic diarrhoea may occur, and there may also exist a catarrhal gastritis for some time, the tongue being thickly coated and the breath heavy and urin- ous. Case in which the existence of a typh- litis was, for a time, suspected; true nature of the case declared by a ursemic headache accompanied by blindness. Second case in which the cephalalgia was the most marked feature. These intes- tinal derangements characterize so large a class of urtemics, the disturbance being generally of the nature of diarrhoea, that practitioners should constantly suspect those seeking treatment for persistent alimentary troubles of being affected with an underlying nephritis. Taylor (Cincinnati Lancet-Clinic, Nov. 15, '90). Examination of the conditions of the stomach in twenty-six cases of chronic parenchymatous and interstitial nephri- tis, mostly in middle-aged patients, show- ing that renal disease has a marked in- fluence upon the chemistry of gastric digestion. Kravkoff (London Med. Recorder, Jan. 20, '91). Action of various constituents of the urine upon intestinal peristalsis. It is probable that, among the substances re- tained, there is some substance directly paralyzant to intestinal movement. It is not a very uncommon occurrence to have the ursemio diarrhoea followed by a condition of intestinal paralysis, and cases of uraemia have unwittingly been operated upon for the relief of a sup- posed intestinal obstruction. Hirschler (Wiener med. Woch., Mar. 21, '91). Warning against the administration of an opiate in any diarrhoeal patient above 50 years of age, owing to the untoward effect of opium in cases of renal insuffi- ciency. Musser (Times and Register, Oct. 17, '91). Digestive troubles associated with dis- eases of the urinary apparatus often BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. SYMPTOMS. 611 disguise the latter. Alapy (Revue de Th6r. M6dico-Chir., Oct. 15, '93). Twenty-two cases of ulceration of the intestine coincident with renal affec- tions, and eight cases of hiemorrhagio extravasation without ulceration. Situ- ated at all points of the intestine, but especially about the ileum, principal characteristic being that they were ac- companied by haemorrhage. Dickinson (Brit. Med. Jour., Jan. 13, '94). Complications in the digestive tract. E.xamination of 17 cases, — 3 of large waxy kidneys and 10 of secondary and 4 of primary contracted kidney, — intes- tinal lesions in most of them, from simple catarrh to diphtheritic exudation. Fischer (Deutsche med.-Zeit., Aug. 9, '94). There is, as a rule, no oedema in renal sclerosis, and when it does occur (as in the ankles and limbs) it is due to car- diac dilatation and failure. The skin is dry, and the jDores sometimes appear lustrous with minute scales of urea. The skin has often, also, a cj'anotic tinge, with a certain degree of pallor. Trouble- some eczema and pruritus are often pres- ent, and muscular cramps may make the patient still more uncomfortable; the latter occur at night and especially in the calves of the legs. Other cutaneous disorders may also occur. 1. There is a bright-red diffused rash which appears chiefly on the trunk, less extensive on the neck, arms, and thighs, and very seldom on the face, hands, or feet. It is distinguished from the some- what similar rash produced by natural or artificial diaphoresis by its locality, by the absence of sudamina, and by its appearing when no hot-air baths or other means have been used to produce sweat- ing and when the skin is harsh and dry. As it does not, as a rule, either itch or smart, and only remains a few days. Most often seen in eases of chronic tubal nephritis. 2. There is a papular eruption with large, discrete, rather dark-red pimples seated on a dry, rough, and sometimes scaly surface. This more often seen on the outer side of the thighs and legs, the shoulders, and e,\tensor surface of the forearms, but it also may affect the loins and the abdomen. Personally never seen on the face or on the hands and feet. 3. Apart from the mere coincidence of eczema with Bright's disease, there may be observed in some cases a moist der- matitis resembling eczema in its aspect, but accompanying the arms or the legs, without affecting the flexures of the joints, the face or the ears, without the irritation commonly present, and with- out having previously appeared. 4. On two occasions a very extensive and profuse dei-matitis seen, closely re- sembling the universal exfoliative derma- titis of Wilson, very red, very scaly, occupying the scalp, palms, soles, and genitals, as well as the trunk, face, and limbs. It has come on after the symp- toms of Bright's disease have appeared, in cases of chronic interstitial nephritis, with little dropsy, and cardiovascular changes already apparent. P. H. Pye- Smith (Brit. Med. Jour., Nov. 30, '95). Debility and emaciation become ex- treme, with the gradual faiure of the general niitrition. UiEemia may supervene at any time, and may even form the first symptom; it may also be sudden and severe in its attack (acute uraemia), or gradual, mild, and insidious (chronic). These ursemic attacks may be accompanied by either a normal temperature, or by moderate fever; the temperature may even be sub- normal, in chronic ursemia with prostra- tion, coma, a feeble pulse, and delirium. Among the complications that Eiay occur in the red, granular, and con- tracted kidney are the following: Pleu- ritis, endocarditis, pericarditis; pneu- monia, either lobar or lobular; laryngitis, bronchitis, hepatic cirrhosis, gastritis, enteritis, peritonitis, meningitis, emphy- sema, phthisis, and mental disorders. Early in the establishment of chronic Bright's disease, especially the intersti- tial variety, the mind seems somewh&t 612 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. ETIOLOGY. fogged or "muddy," the soundness of business judgment is apt to be impaired; there are irritability, petulance, and de- pression often noted; the patient may become a little self-distrustful, suspi- cious, or somewhat secretive about his affairs or intentions; he is easily an- noyed by loud noises, is disinclined to exercise his intellect, apt to doze in the day and be wakeful at night, and in many ways indicates the approach to the borders of insanity. Andrew Clark (Brit. Med. Jour., Feb. 4, '83). Case of a patient who suffered from insanity and chronic nephritis. When- ever the renal disease was exacerbated, the patient's mental condition also be- came worse. Case of a lady, in whom the autopsy showed interstitial nephritis, who passed the last weeks of her life in a state of acute delusional insanity. Raymond (Gaz. Med. de Paris, Nos. 25 and 26, '90). Similar case, except that the patient became cataleptic and manifested bulbar phenomena a short while before death. Brissaud and Lorring (Gaz. des Hop., Nos. 31 and 32, '90). Important to distinguish those cases where the insanity exists along with, but independently of, the renal condi- tion, not being influenced either in its inception or in its manifestations by the nephritis, and those cases which are •called into being by the toxication from the renal inadequacy, or those which, •existing perhaps latently as an heredi- itary predisposition, are intensified by the influence of the disease of the kidneys so as to become manifest. The latter classes of cases may be examined as to their mental condition, with a view of estimating as well the degree of failure of the renal function; while they are more yielding, the treatment of the un- derlying nephritis modifies the sympto- matic mental condition. Joffroy (Le Bull. M6d., Feb. 4, '91). Case in which alternation of coma with maniacal outbursts and with occa- sional delirium marked clearly the re- lationship between the ordinary manifes- tations of uraemia and conditions of alienism. The patient eventually recov- ered from all active symptoms. Remon- dino (Jour, of Nerv. and Mental Dis., Oct., '91). Number of cases and statistics show- ing the frequency of nephritis in in- sanity. Bondurant (Jour, of Nerv. and Mental Dis., Nov., '92). Affections of the kidneys are very common among the insane. Uraemic poisoning is one of the most frequent causes of insanity. Alice Bennett (Alienist and Neurol., Oct., '94). [We doubt very much whether Dr. Bennett finds many followers in her con- fession of faith. We venture the pre- diction that, of 1000 cases in ordinary life, as many cases of kidney disease will be found as in the same number of the insane, if general paretics are excluded. We have made it a subject of careful observation for some years, and have not found the proportion of kidney lesions which Dr. Bennett appears to have observed. In the few cases of "grave delirium" which have come under our care this point has been especially examined with negative results, and the same may be said in the majority of in- stances of mental depression and anxiety. Bkush, Assoc. Ed., Dept. of Mental Dis., Annual, '91.] Mental aberration — illusions, halluci- nations, general confusion, impairment of memory, aphasia, neuralgia, paral- ysis, etc. — connected with renal lesions. Bremer (Med. News, Oct. 20, '94). A large majority of patients present- ing retinal lesions die mthin a year after they are first discovered. Out of 419 of Bell's cases he found that 72 per cent, were fatal at the end of the first year and 90 per cent, within two years. Possauer reports that all men applicants at his clinics were dead within two years. Of the women 32 per cent, survived that period. It seems that among private patients only 59 per cent, of the men died within two years and 53 per cent, of the women. Edward Jackson (Medical News, Feb. 15, 1902). Etiology. — Sometimes the cause of the slow, primary, diffuse degeneration, atrophy, and fibroid contraction of the kidneys is quite obscure, and in certain BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. ETIOLOGY. 613 cases it would seem to be "only an an- ticipation of the gradual changes which take place in the organ in extreme old age" (Osier), — the "senile kidney." Heredity undoubtedly plays a part in the causation of certain cases, and its iniiuenee has extended down through the third and fourth generations. Age and sex also exert an influence, the disease being more common in males than in females, and usually beginning near middle life. It is rarely manifested symptomatically until the fiftieth or six- tieth year. A special tendency to scle- rotic degeneration of the arteries, from whatever injurious influence, whether chemicotoxic or parasitic, renders the patient more prone to interstitial ne- phritis, though prolonged irritation by such agents may also cause the disease in persons whose cellular nutrition is usually not defective. Alcoholism, uric acid, and lead, giving rise to chronic poisoning, have all been assigned as causes of the disease. Chronic malaria and syphilis also probably exert a causative influence. Habitual overeating and overdrinking no doubt frequently cause granular atro- phy and sclerosis of the organ, owing to the imperfect assimilation of the sub- stances ingested and the constant excre- tion of irritating products by the kidney caused thereby. A wide-spread cause of the disease is the continuous and even moderate use of alcohol for many years; especially is this true in the case of spirituous liquors. It is just as probable that the excessive use of red meats in the diet leads to the production of the iiric acid that induces the renal condi- tion (uricffimia-lithsemia) by deranging the hepatic function (Murchison). Gout may also cause chronic Bright's disease, and is allied to the above; this occurs perhaps more frequently in Eng- land than in this country, where liths- mia and nervous dyspepsia are more often seen. Striimpell states that severe articular rheumatism is sometimes followed by contracted kidney. Chronic nephritis when met with in ehloroties depends upon an arterial lesion; patients affected with the two diseases are clearly descendants of gouty arteriosclerotic ancestors. Lancereaux (Bull, de I'Acad. de Med. de Paris, p. 727, '93). Appearance of gi-eat quantities of urie acid in the blood of nephritis not as constant as observations of Jacobi might lead one to think. Fodor (Centralb. fiir klin. Med., Sept. 7, '95). The absorption of toxic substances from the intestinal iract plays the most important role in the etiology of chronic nephritis. The importance of this is very practically acknowledged by the range of dietetic treatment for the affec- tion. The morning purge, colonic irriga- tion, and excitation of the intestinal functions generally, lead to prompt amelioration of the nephritic symptoms. On the otlier hand, serious nephritic con- ditions are ushered in by intestinal acci- dents. The first symptoms of uraemia or of kidney insufficiency are usually noted in the gastro-intestinal tract. The coated tongue, the nausea, the pain in the back, the oxaluria, etc., are all common symp- toms of nephritis and intestinal dis- turbance. After the kidney function is- lowered the liver-cells degenerate be- cause of the presence of toxic sub- stance; the liver then fails to metab- olize substances that come to it, and' adds its own quota of toxic material to the blood, which still further irri- tates the kidney. The vicious circle of influence thus formed continually de- teriorates the general condition. The inactive life of many city people is undoubtedly a cause for the develop- ment of toxic systemic products that irritate the kidneys. Almost invariably such people overeat, and this adds to the manufacture of toxins. In these patients the urine is often quite toxio when injected into animals. The basis 614 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. PATHOLOGY. of these metabolic disturbances is often an atonic intestinal catarrh. This con- dition, however, is perhaps itself a manifestation of uraemie conditions. Constipation is a very uncertain effect. Though long continued in some people, it fails to produce any serious systemic effect, while in others its existence for a comparatively short time produces many and even serious symptoms. Coprostasis provides in the material de- tained in the intestinal tract a very favorable cultvire-mediuni for micro oes. These not only produce poisons them- selves, which are absorbed with serious effects, but they also consume normal food-material in the intestines and leave only degradation products to be taken up for the body-nutrition. These factors are especially active in the production of chronic nephritis, and the realization of this furnishes the best indications for treatment. A. R. Elliott (Proceedings Amer. Med. Assoc; Medical News, June 21, 1902). Anxieties, worries, and the liigh nerv- ous tension required by modern business activity and by social life (the latter, particularly, in elderly ladies) favor the development of chronic Bright's disease. Associated with these causes are usually to be found an overindulgence in rich foods and sedentary habits. The cold, moist climate of ISTew Eng- land and the Middle States seems, to Purdy, to predispose to contracted kid- ney. Hydronephrosis, chronic pyelitis, and chronic congestion of the kidney (of cardiac origin, etc.) may cause a chronic productive nephritis without exudation, though never the true "con- tracted and red-granular" kidney. Bright's disease is not primarily a kidney disease, but is really a circula- tory distvu'bance. The brain and kid- neys, the end-organs of the circulation, suffer most. It may well happen that death comes on from brain-lesion at a time when the kidneys are yet in rea- sonablv good condition. Details of a case in which, by careful dieting and avoidance of extremes of temperature or other hurtful factors, the kidneys were spared, yet the fatal issiie came through the brain. The brain is a very sensitive organ, and may show signs early in the case. The kidneys are in- sensitive, and may not react until late in the progress of the arterial changes. The first sj'mptoms of Bright's disease may be those of increased arterial ten- sion. There may be, because of this, increased frequency of urination or oc- casional nose-bleed or persistent head- ache. A very early symptom may be functional gastric disturbance from in- creased blood-pressure. These gastric symptoms must not be confounded with the nausea and vomiting of later stages of nephritis. The prenephritic condition of Bright's disease may be detected in the irregularities of the circulation. These may give rise to clumsiness m the use of limbs or to actual paresis of one or moi'e members. There may be tem- porary aphasia, and this symptom may recur several times, passing off com- pletely in the interval. The earliest symptoms of Bright's disease if carefully looked for will nearly always be found in the brain. L. Faugeres Bishop (Pro- ceedings Amer. Med. Assoc; Medical News, June 21, 1902). Pathology. — The reduction in size and weight is about equal in both organs in genuine primary contraction of the kidneys. The two kidneys may together weigh not over two ounces, and they may be only one-half or one-third the normal size. They are frequently imbedded in thick, adipose tisstie, and the capsule is thick, opaque, and very adherent; so that, on stripping it off, portions of the renal cortex come away at the same time. The outer surface of the organ is red, irregularly granular, or finely nodular, and occasionally small cysts are present. The tissue is firm, dense, and resistant to the knife. The cut surface shows a thin, atrophied cortex, with dark-reddish streaks alternating with pale portions. BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. PATHOLOGY. 615 The pyramids are darker than the cortex, and are also diminished. In the gouty contracted kidney they show fine stria- tions of sodium urate or of uric acid, or crystals representing uric-acid infarc- tions. The principal changes are seen microscopically to be an increased pro- duction of connective tissue, especially in the cortical substance, and a more or less proportionate degeneration and atrophy of the renal parenchyma. The destruction of the latter is due to the circulation of noxious agents, but it is replaced by cicatricial fibrous tissue (Weigert). This new tissue is not uni- formly distributed in the cortex, but appears in irregular masses around the shrunken glomeruli or between the tubules. In the pyramids the distri- bution is more general. The glomeruli are, in many instances, very small and fibrous in advanced cases; in the earlier cases the cells of the tufts and capsules are swelled and multiplied and a small- celled infiltration may be seen around the glomeruli and tubules. This cellular infiltration later becomes fibrillated and ends in thickening. The changes in and the growth of the capillary and intra- capillary cells and of those around the tufts are partly responsible for the glomerular atrophy, as are also the cap- sular thickening and hyaline or waxy degeneration and the thickening and occlusion of arterioles. The tubules show decided changes, some being in- cluded in masses of connective tissue, with resiilting compression-atrophy and even obliteration of the lumen. Others show constriction by the intertubular connective tissue, the lumen ekswhere thus being increased; this is especially prominent in the granules on the outer surface of the kidney, and little cysts may be seen here and there by the naked eye, as the result of damming back the urine in the tubules thus afl:ected. The epithelium lining these tubules shows granular, fatty, or waxy degeneration, and may be either flattened, cuboid, or swollen in variety. The tubes may con- tain fatty or granular debris and tube- casts. In a former paper it was concluded that an actual physical alteration of the tissues is brought about by the toxic substances retained in the blood owing to the insuificient action of the kidneys. This alteration leads to oedema, on the one hand, and to a rise of arterial press- ure, on the other, due to increased periph- eral resistance. From this follows the hypertrophy of the heart. This theoretical view now confirmed by actual experiment. Physiological so- dium-chloride solution was injected hypo- dermieally in cases of nephritis without oedema, and it was found that the arti- ficial oedema thus produced was not ab- sorbed for from five to ten days, while if the same were done in non-nephritic cases, even when heart disease was pres- ent, it disappeared in a few hours, or in three days at the latest. This proves that the absorptive power of the sub- cutaneous tissue is much restricted in Bright's disease. Eeichel (Centralb. f. inn. Med., Oct. 15, '98). The growth of fibrous tissue in the walls of the arteries, causing sclerosis, forms an important change in most instances. The intima (endarteritis), media, and adventitia are all thickened by the hyperplasia of connective-tissue elements, and the arteries and capillaries are, in this way, mostly occluded by the obliterating endarteritis or by their conversion into connective tissue. "VVaxy or hyaline degeneration is also seen. These changes may sometimes form the primary condition that leads to granular and contracted kidneys, and may repre- sent the renal effects of a general arterio- sclerosis. In a case of interstitial nephritis ter- minating in cerebral atrophy, aneurismal 616 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. dilatations of the cerebral arteries ob- served, besides an hsemorrhagie area filled with fluid blood, which might have been taken for an aneurism, which was in reality due to rupture of the artery and successive hsemorrhages into the cerebral substances. Israel (Berliner klin. Woch., Jan. 29, '94). The urea introduced into the circula- tion leads to a constriction of the vessels of the periphery. Retention of urea causes elevation of vascular pressure and is the cause of cardiac hypertrophy in patients with Bright's disease. Chia- ruttini (Inter, klin. Eund., Feb. 18, '94). Cardiac hypertrophy is an almost con- stant attendant upon chronic, non-exu- dative, productive nephritis, and its de- gree depends upon the extent of the renal, and also of the general arterial, degeneration and sclerosis. Cor iovinum has been applied to the organ, on ac- count of its extreme size in this affection. The left ventricle only is hypertrophied in moderate enlargements. Among the many complications of chronic Bright's disease may be men- tioned cirrhosis of the liver, pulmo- nary emphysema, cerebral hemorrhage, chronic endocarditis, endarteritis, peri- carditis, and bronchitis. Prognosis. — Chronic interstitial ne- phritis varies in duration, and in uncom- plicated cases it may last for five, ten, twentj^, or possibly thirty years. The duration may, however, be very much shortened by complications or intercur- rent affections, or the condition may not be appreciated, as often occurs, when the post-mortem examination discovers the characteristic kidneys in one who had no symptoms of renal disease dur- ing life and whose death was directly due to some intercurrent affection. Life is destroyed sooner or later by this dis- ease, unless the patient first dies from some intercurrent malady. Irreparable damage to the orafans results from the gradual destruction of the renal paren- chyma and its replacement by scar-tissue. The fact, however, that the process is slow and its duration, therefore, long allows a preservation of life for many years, and often with comparative com- fort. The prognosis depends much upon the general condition of the patient, the cardiovascular system, and upon the presence of uraemia and inflammatory complications. A not far distant end is indicated by cardiac dilatation and in- sufficiency. Haemorrhages, diarrhoea, persistent vomiting, nephritic retinitis, coma, and delirium render the prognosis exceedingly grave. Convulsive and apo- plectic seizures are often fatal. Haematuria, a frequent accompaniment of nephritis, is of grave import. Case of Bright's disease kept in comparatively good health by strict attention to diet and climate several years. As soon as haematuria appeared, however, he rapidly lost ground and died. Any appeai-ance of blood, hoAvever slight, in chronic nephritis denotes an early demise. Dieu- lafoy (Jour, de Mgd., May 10, '97). Treatment. — A strict hygienic regime following an early appreciation" of the disease will, to a considerable degree, prevent the advance of the cirrhotic process. ISToxious substances that have an etiological influence must be removed as thoroughly as possible and avoided. Uric-acid formation must be reduced by dietetic supervision, alcohol must be in- terdicted, and lead — when the causative factor — must be prevented from further poisoning the system by a change of occupation. The heart and blood-vessels are also preserved by the diminution of these irritants. The hygienic treatment embraces a regulation of all the habits of the body and the mode of living. The malady is incurable; therefore the pa- tient himself must be treated, and not the malady. A suitable dietary must BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. 617 be formulated for each individual, and Saundby's rule furnishes a good work- ing principle: "Eat very sparingly of butchers' meat; avoid malt liquors, spirits, and strong wines." An absolute milk diet may be necessary for short periods in the presence of gastric irri- tability, but undue weakness will be the result of a continued restriction to milk alone. Authors are by no means unanimous as to the best diet for patients with chronic Bright's disease. All the a priori reasons urged in favor of milk or any other particular diet were fallacious. The only way to attack the problem is carefully to observe the condition of the urine and the condition of the patient upon different diets. 1. Quantity of urine. Usually more urine was secreted upon farinaceous or milk diets than upon full diet. 2. Specific gravity. The diet had no certain influence on this, but, on the whole, it was lower on milk and fari- naceous diets than on full diet. 3. The quantity of albumin passed. The figures showed that nearly always the albumin passed was more upon milk diet than upon farinaceous, and less upon full diet than upon either milk or farinaceous. Patients always best avoided loss of albumin by a full diet. 4. The quantity of urea passed. The influence of diet upon this was most un- certain; often less urea was passed upon full diet than upon farinaceous, and less upon farinaceous than upon milk. Some times the reverse was true. 5. General condition of the patient. The cases distinctly showed that a full diet was not more liable to lead to uraemia than any other; in fact, in one patient full diet appeared to ^Ya^d oflF ursemia, and the patient ultimately re- covered. The patients always felt and seemed much better and stronger on full diet, or on farinaceous diet with meat or eggs added, than on milk or farina- ceous only. Hale White (Brit. Med. Jour., Apr. 29, '93). Loss of albumin main point to be coun- teracted. Loss not made up by increase of proteid food. Rich proteid diet may lead to retention of nitrogenous e.xtract- ives. Hence, 6 ounces of meat, 13 ounces of bread, liberal allowance of vegetables and fruit, 1 Vs ounces sugar, 5 ounces fat a typical diet in chronic albuminuria. Milk mainly useful in acute cases when loss of appetite, or in addition to above mixed diet. Hirschfeld (Zeit. fiir Krank- enpflege, May, '95). A light, nourishing diet is, therefore, advisable. Lean meat may be allowed once daily in favorable cases, and vege- tables, greens, fruits, and light, well- cooked, farinaceous articles may also be partaken of. Tea, coffee, and cocoa may be drunk. The use of the natural min- eral waters aids in the renal circulation and keeps the kidneys flushed. As a rule, a mixed diet will be advantageous. The carbohydrate and nitrogenous ele- ments (sugars and starches) should be used in moderate amounts, but fruits and pure fats are to be strongly recom- mended. Von Noorden announces that in cases of contracted kidney and the early stage of heart-weakness the elimination of the products of metabolism is not in- fluenced to any extent by a reduction of the amount of fluid taken daily. Albumin does not seem to be materially changed either by an increase or de- crease in the amount of liquid ingested. Moreover, in Bright's disease, when the heart is failing, a diminution of the quantity of water proves beneflcial. The reduction of the quantity of liquid is advised in the early stages. He has also noticed that after the ingestion of a large quantity of water in contracted kidney there is enlargement and weaken- ing of the heart. In the advanced stages, with a corresponding degree of arteriosclerosis with hypertrophy of the heart, restriction of liquid is impera- tive. The average quantity of liquor advised is 2 pints. Professor Ewald confirms von Noorden. The bath treatment was based on the assumption that the action of the skin had a certain connection with functions 618 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. of the kidneys, and that by stimulating the former a disorder of the kidneys might be benefited. J. M. Groedel (Practitioner, Dec., 1901) has never seen any curative re- sults from the drinking of waters. His experience is that the bath treatment in eases of parenchymatous nephritis is contra-indicated. He divides cases of contracted kidneys into two groups. In the first group are those in whom the circulatory system is not greatly dis- turbed. The second group consists of those who show an advanced degree of insuflRcieney of the heart, which is more or less distinctly dilated. In the first group of cases the Nauheim baths are suitable, but in the second group baths are contra-indicated. It has been said that carbonic-acid saline baths always increase the blood-pressure, but this is not the fact, and it has been proved that in cases of arteriosclerosis we are able to regulate the baths in such a way as not to increase the blood-pressure, but rather to reduce it. If this is the case, these baths should also be beneficial in contracted kidney. The baths of Nauheim have the effect of reducing the blood-pressure for a longer period than the artificial baths. The more carbonic acid the bath contains, the more the temperature may be lowered, but not below 90° F. The baths seem to dilate the peripheral vessels, a con- dition brought about by the irritation of the gas and . the reduction of the blood-pressure; they lighten the work of the heart and lead to a saving of that organ, which gives it a chance of recovering strength, and this is still further promoted by the direct stimu- lating and tonic effect of these baths. The increase in the diuresis is ascribed to the strengthening of the heart. Editorial (Phila. Med. Jour., Aug. 23, 1902). Persons that take considerable exer- cise may have considerably more food than those who are stout or who lead sedentary lives. Gastric disorders re- quire a liquid diet until the digestion is restored, or the elimination of all but the soft and bland foods. All extremes of activity (bodily, mental, and emo- tional) are to be avoided. After violent muscular effort, there is an increase in the quantity of leucocytes and epithelial cells normally found in urinary sediment, and likewise the apparition of cylinder-casts. Penzolt (Munchener med. Woch., Oct. 17, '93). Physical exercise should be moderate and regular, and, if the climate be warm and dry, it should be taken in the open air. The patient should never be sub- jected to the vicissitudes of worry, anx- iety, or to the tension of competition. Indulgences of whatever nature, if they tend to unbalance self-control or disturb the equanimity of the patient, must be strictly prohibited. Often life may be prolonged by a change of residence to a warm, dry, and mild climate, since the variability and humidity of temperate climates, particu- larly during the winter season, tend to aggravate the disease. A sea-voyage or a sojourn at some southern European re- sort may be very beneficial. Medicinal treatment is employed for the following indications: The bowels should be kept free by the assistance of laxatives or by laxative alkaline mineral waters. Papoid, peptenzyme, and other digestants, with bitter tonics, are useful in cases of furred tongue and indigestion. Acids or alkalies, according to their spe- cial indications, may also be used simul- taneously. High vascular tension is to be met by the cautious use of nitroglycerin in grad- ually increasing doses, beginning with 1 minim three or four times daily, until all danger of rapture of the vessels is over. Nitroglycerin for a considerable length of time, so proportioning the dose that the intervals shall be comparatively short, — never less than four times daily. BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. G19 — and the amount never more than that just necessary to cause the slightest feel- ing of fullness in the head or to slightly quicken the pulse. In this way a re- markable tolerance of the drug is ob- tained. Stewart (Ther. Gaz., Sept. 15, '93). Among the first indications which sug- gest themselves considering the cardio- vascular conditions resulting from renal disease is immediate and free venesection on the occurrence of ursemic convulsions. Sixteen or twenty ounces of blood should be taken at once, followed by a calomel purge. If a single withdrawal of blood does not stop the convulsions it may be repeated, and recurrent ursemic con- vulsions may be met bj^ further vene- section. In acute tubular nephritis bleeding on account of convulsions may be followed by immediate and remark- able improvement. A further indication for treatment may be deduced from the fact that the damage to the vessels and heart through which much of the suffering attending renal disease is brought about, and by which life is shortened, is due to high arterial tension. The reduction of the intravascular pressure ought to be an object continually held in view. For this purpose the vascular relaxants have been tried: nitroglycerin, the nitrites, and the tetranitrate of erythrol. Un- fortunately the effect of these sub- stances is very fugitive ; but the last named, which is slower and more per- sistent in its action, may sometimes be given with advantage. The best means personally known of exercising a definite influence on unduly high intra-arterial pressure is through mercurial aperients. A dose of calomel, 3 to 5 grains, will often avert impending convulsions or prevent their recurrence: will relieve the headache, stupor, and twitchings : and may prevent uraemic paroxysmal dyspnoea in advanced kidney disease. So also a single grain of pilula hy- drargyri or hydrargyri cum creta, with rhubarb or colocynth and hyoscyamus, once, twice, or three times a week, ac- cording to the degree of tension in the pulse, exercises a favorable influence in the earlv stages of chronic Bright's disease, both on the sjTnptoms and on the course of the disease. W. H. Broad- bent (Practitioner, Nov., 1901). The other extreme, of a very low ten- sion that induces dropsy, and compli- cations, usually ursemic (convulsions, dyspnoea, and headache) also call for therapeutic assistance. Headache, ver- tigo, and the so-called renal asthma (dyspncea) are also often relieved by nitroglycerin. Morphine hypodermically employed is of conspicuous benefit in the shortness of breath of uraemia. Ursemic asthma yields promptly to hypodermic injections of morphine. On the other hand, persistent distress of breathing may be due to dropsy, and such a condition is not im- proved by the use of morphine. The headache and sleeplessness occurring in ursemic patients can generally be re- moved by the hypodermic injection of morphine. Sydney Ringer (Jour, of Amer. Med. Assoc, Oct. 8, '98). Low tension, with scanty albuminous urine, oedema, and signs of dilatation, requires heart-tonics and stimulants, in conjunction with purgatives. Digitalis is effective, and especially in infusion, combined with strychnine nitrate or with caffeine citrate. The dropsy calls for calomel and the salines. Uremic symptoms are to be managed, as in acute Bright's disease, by means of free catharsis and profuse sweating, and occasionally by phlebotomy. In convul- sions, severe headache, or dyspnoea, in- halations of amyl-nitrite or chloroform, or the h3'podermic injection of morphine, Ve grain, may be tried. When there is a probable malarial or syphilitic origin, contracted kidney may be benefited by the use of arsenic and the iodides, re- spectively. No medicaments, however, can ever transform the connective-tissue cells into secreting kidney-cells or re- store the destroyed renal parenchyma. 630 BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. To analyze thoroughly the results of treatment in Bright's disease one must have a clear conception of the histology and physiological functions of the kid- ney. Its complex pathology must be clearly understood. All the etiological factors must he given full consideration. The etiological factors are numerous and very complicating in their action. Only one, it any, of these can be reached by surgical intervention. Most of the etiological factors can be modified or removed by well-directed dietetics and therapeutics. Histologically speaking, Bright's disease can be cured. Phys- iologically speaking, the etiological fac- tors can be modified, and often removed, the symptoms held in abeyance, while the renal glands perform their functions normally. Bright's disease is by nature an oscillatory malady, accompanied with frequent remissions and exacerba- tions. Remissions must not be mistaken for cures. Rational dietetics and thera- peutics offer the largest possibility for a complete physiological cure. A well- regulated mixed diet, especially if com- posed largely of the animal class, when it can be tolerated, yields the best re- sults. All therapeutics to be rational must be directed, not at the pathological lesion per se, but toward establishing a more perfect digestion and metabolism and a decrease in the work imposed upon the renal glands. W. H. Porter (Medical Record, Sept. 27, 1902). The surgical treatment of Bright's dis- ease seems to afford considerable hope as a source of relief and, in some cases, of cure. "During the past year," says an editorial writer in the Journal of the American Medical Association, ISTov. 15, 1902, "there has been a great deal of in- terest in this subject, particularly since the appearance of Edebohls's paper (Med. Eecord, Dec. 21, 1901), in which he claimed eight complete recoveries from various forms of chronic Bright's disease at least one year after decortica- tion of the kidney. After report of such brilliant results several operators under- took the procedure, but with less satis- factory results than Edebohls reported.' It seems certain, however, that operative measures relieve or cure certain cases of nephritis, and it is a highly-important question to determine just what classes of cases are suited for intervention. "From a careful study of a series of 17 cases which he has operated on for vari- ous forms of chronic nephritis, Kovsing, Professor of Surgery in the University of Copenhagen, attempts to formulate some rules as to the proper treatment in such cases. He divides the cases into aseptic and infectious nephritis. In tlie aseptic cases he found that diffuse parenchy- matous nephritis was not influenced by operation. A case which he classed as chronic glomerulonephritis recovered af- ter operation, he believes, more from rest in bed than from any favorable re- sttlt from the operation. In diffuse hsem- orrhagic nephritis tliere is much danger in operating and the results are not sat- isfactory. In four cases of interstitial nephritis and perinephritis fibrosa oc- curring with uric-acid and oxalic-acid diatheses his results were satisfactory. Operation is frequently undertaken with a diagnosis of stone in the kidney in such cases and gives relief without any stone being found. The severe pains which are present in these conditions he be- lieves indicate operation. Pain always indicates tension within the kidney cap- sule, it does not matter what form of nephritis exists. But the most impor- tant group of cases is that caused by some form of infection. Eight of his cases were of this character and the con- dition was only discovered after most painstaking examination. Urine ob- tained under aseptic precautions should be accurately examined chemically, mi- croscopically, and bacteriologically, in every case, whether we suspect that we have to deal with an infection or not. BRIGHT'S DISEASE. NON-EXUDATIVE CHRONIC NEPHRITIS. TREATMENT. G21 In case pathological constituents are I'onnd, cystoscopy and catheterization of the ureters should be employed. In his cases KoTsing found infections of the urine from the staphylococcus aureus, staphylococcus albus, streptococcus py- ogenes, and bacterium coli. Tlie entire clinical picture did not differ in these cases from that in the aseptic forms of nephritis. Neither was there any differ- ence in the chemical constituents of the urine or of the appearance of the kidney when it was exposed. The results of op- eration in these cases were very much more satisfactory, however, than in asep- tic cases, and Eovsing believes that his cases show definitely that unilateral chronic nephritis may be of infectious origin; that it may affect a greater or smaller part of the kidney, or that we may have a double partial infectious nephritis. Stripping off the kidney cap- sule, which gives such favorable results in eases of aseptic interstitial nephritis with perinephritis and severe pain, also has a favorable influence on inflamma- tory processes. In hfemorrhagic cases he believes that splitting the kidney will, give favorable results in the milder in- fections, such as by the bacterium coli, but it is dangerous in the more virulent infections. Eesection of the diseased part in case of local infectious nephritis which entirely resembled chronic aseptic nephritis led to cure in two of his cases. "Further investigation is needed to prove the value of Eovsing's suggestions. Up to this time infection with ordinary pyogenic bacteria has not been consid- ered such an important etiological factor in cases of chronic nephritis, though it might have been suspected that the cases following scarlet fever, erysipelas, and other forms of infectious disease were of this character. The careful study of this class of cases which Eovsing suggests, if carried out by competent observer.?, could not fail to give important results. If further study of such cases proves that we can find such definite indications for operation as are above suggested a great advance has been made and un- doubtedly many lives will be saved. The skepticism of many surgeons as to the advisability of operating in every case of this kind seems warranted from our present knowledge, and, until definite grounds have been shown from more careful study of large series of cases by competent men, routine operation for chronic nephritis in any case cannot be considered an established surgical pro- cedure." By persevering effort the author has been enabled to see or get word from all tlie patients operated on by him. so that he could present the status up to date. The first renal decapsulation ever performed for the relief of chronic Bright's disease was done by him on June 10, 1892, and the patient was permanently cured. This case, together with reports of the five preliminary operations which led up to this pro- cedure, was published in the Medical News of April 2, 1898. Subsequent papers giving reports of other cases of his ovra and a resume of the work of other surgeons in this field were pub- lished in the Medical Record of May 4 and December 21, 1901, and of April 26, 1902. From 1892 to 1901, inclusive, the writer personally operated on 19 cases, and during the year 1902 on 32 eases. Of this total of 51 cases, 29 were in males and 22 in females, and the average age was 34 years. In 32 eases the Bright's disease was far ad- vanced. In 41 of the oases the period which had elapsed between the first recognition of the disease and the opera- tion varied from 1 month to 19 years. The general average of this period was 3 '/s years, and in 32 cases it was fully 4 years. Nearly all the oases were at- tended by cardiac or other complica- tions. Of the 51 cases, 29 were of G22 BEIGHT'S DISEASE. BROillDE OF ETHYL. chronic interstitial nephritis, and in all but 9 only one kidney was operated on; 14 were of diffuse nephritis and 8 of parenchymatous nephritis. If only one kidney was affected by Bright's disease, he said, the patient suffered very little, and the condition might be discovered only accidentally. The chances of success for the opera- tion are enhanced by the patient's re- maining in bed for a week previous to it. This gives the heart a rest, if car- diac complications are present, and affords the best facilities for any pre- liminary treatment that may be re- quired, as well as for systematic in- vestigation 01 the quantity and condi- tion of the urine. There are three con- ditions the presence or absence of which affect the facility with which the opera- tion may be performed: 1. Great length and obliquity of the twelfth rib. This difficulty must be overcome by posture and a modification of the incision. 2. Obliquity or firm appearance of the kid- ney. When there is firm fixation it is generally necessary to incise the capsule at any point that can be reached. For separating the capsule the rubber-cov- ered index finger is the best instrument. 3. The firm or more or less weak at- tachment of the capsule. Great caution and gentleness should characterize all attempts at decapsulation. In this operation there is often considerable danger of destroying some of the al- ready diminished working tissue of the kidnej', and it should never be per- formed except by surgeons who are alreadj' more or less familiar with renal surgerj' in general. The danger is greater from the condition present than from the operation itself. The pro- cedure, however, should not be too pro- longed; so that one hour should be the limit for the decapsulation of two kid- neys. The writer has often found half an hour sufficient for operating on both organs. A "team operation" has been proposed, with two surgeons each work- ing on a kidney, but this would hardly be feasible, as two operators, each with his necessary assistants, would inevi- tably interfere with the prompt accom- plishment of each other's work. An- other expedient suggested is that only one kidney should be decapsulated at a time ; but this too, is to be deprecated, as the time that the patient would be rmder an antesthetic for two separate operations would necessarily be longer than for operating upon both kidneys during one period of ansesthesia. George H. Edebohls (Medical News, March 7, 1903). James M. Anders, Philadelphia. BROMIDE OF ETHYL.— Bromide of ethyl, or hydrobromic ether, is an anses- thetic prepared by combining bromine with alcohol in the presence of phos- phorus. It was discovered by Serullas, a French chemist, early in this century. It is an extremely volatile and colorless liquid, sweetish to the taste, and pos- sessing an alliaceous odor. It presents the advantage over ether in not being inflammable. It is quickly eliminated from the system, and its after-effects are slight. Another preparation — bromide of ethylene — is frequently dispensed in- stead of the bromide of ethyl; it causes nausea when inhaled, and in no way pos- sesses the qualities of the latter. Bro- mide of ethyl is, however, frequently found impure in the shops, and to this cause are due many of the untoward re- sults met with. Dose. — Bromide of ethyl cannot be used for prolonged operations, owing to its high volatility. The dose, which varies with the age of the patient, should not exceed 6 drachms. The administra- tion of bromide of ethyl should not be prolonged beyond two minutes. The operation may usually be begun twenty seconds after the first inhalation. Physiological Action and Untoward Eifects. — Bromide of ethyl causes death by arresting the heart's action, and the cases should be watched as if chloroform were being administered, — respiration and pulse simultaneously. The prelimi- BROMINE AND ITS DERIVATIVES. 623 nary preparations for its administration are tlie same, and the recumbent posi- tion obligatory under all circumstances. Arrest of the heart may be caused, how- ever, through vasomotor influence origi- nating in an intoxication by compounds formed in the system. Therapeutics. — Bromide of ethyl — as it causes muscular rigidity — should not be used in operations in which relaxa- tion of the muscles would be of assist- ance. It also increases the chances of haemorrhage. BEOMINE AND ITS DERIVATIVES (BEOMIDES, BROMATES, ETC.) . — Bromine is a dark-reddish-brown, vola- tile fluid, emitting pungent and acrid fumes, caustic in action and taste. It is sparingly soluble in water (1 to 33), very soluble in chloroform, and likewise in ether and alcohol, both of which, however, it gradually decomposes. It combines freely with bases to form salts. As regards the bromates, the small proportion of bromine contained entitles them to consideration only in connection with their respective bases. The list of bromides is somewhat extended, there being no less than seventeen salts, and these, with half a dozen bromates and a number of other compounds, bring the total of bromine derivatives up to thirty- one. Some, however, are to be regarded as chemicals purely, or chemical curiosi- ties, rather than medicaments, and a few are so rare or expensive as to inhibit gen- eral employment. Bromide of ammonium is a white, granular salt that may, however, with exposure to light and air take on a more or less yellowish hue. Its action is prac- tically the same as that of the potassium, sodium, calcium, lithium, and strontium salts, at least as regards the nervous sys- tem. It also, in small doses, is, to some extent, an alterative and hepatic stimu- lant; but in this particular is no better than, and perhaps not so active as, potas- sium bromide. It is the least palatable of the bromine salts, has a pungent, saline flavor (bromine taste), and is odorless. Calcium bromide is capable of evolv- ing 80 per cent, of bromine: a propor- tion greater than obtains to any other bromide; hence it has been lauded as a succedaneum for all the salts of alkaline base. It is had as a white, deliquescent salt, possessed of the usual pungent saline taste. Lithium bromide presents much the same physical properties as the fore- going; is sharp and bitter to the taste, white, granular, odorless, and the most difficult of all the salts to keep, owing to its deliquescent character. Potassium bromide appears as color- less, odorless, cubical, translucent, non- hygroscopic crystals of bitter, pungent, saline taste, and contains an average of 67 per cent, of bromine. Sodium bromide exhibits a consider- ably larger percentage (77.5) of bromine than its potassic congener, and, though it has characteristic bromine taste, it is most palatable of all the salts, and the best borne by the stomach, though this latter claim has been disputed in favor of strontium bromide. It is a white, odorless salt, fairly permanent under all ordinary conditions of the atmosphere, and is found in the shops in two forms: as a granular powder and as small, mono- clinic crystals. Strontium bromide is a comparatively recent addition to the materia medica, and occurs in colorless, odorless crystals, only less deliquescent than lithium bro- mide, and possessed of the usual bitter, saline flavor; it contains 65 per cent, of bromine. Bromal, tribromaldehyde, or tribro- 634 BROMINE. PREPARATIONS. maeetyl-oxide, is a limpid, colorless, oily liquid possessed of a peculiar, sharp odor and irritating taste, obtained through the decomposition of alcohol by bro- mine; it is soluble in water, alcohol, and ether, but is not employed medic- inally. Its derivative, bromalhydrate, however, was introduced with a view of affording an analogue of, and substitute for, chloral-hydrate, but has failed to secure the favor of medical men so con- fidently expected. It is a crystalline solid with the taste of bromal. Bromalin, or bromethylformamide, contains only about half as much bro- mine as potassium bromide, — i.e., about 34 or 35 per cent., — and offers no ad- vantages over the common bromide salts; hence requires little attention. It must not be confounded with hromelin: a preparation representing the digestive principle embodied in the pine-apple. Bromamide is a synthetic body ob- tained by the union of bromine and formamide, and occurs in colorless, odor- less, needle-shaped crystals insoluble in hot, but slightly soluble in cold, water, freely so in hot alcohol, and also in ether. Bromol, or tribromphenol, like the preceding, is a synthetic product, had by the action of bromine on an aqueous solution of carbolic (phenic) acid; it is precipitated as silky crystals that are in- soluble in water, but readily soluble in alcohol, chloroform, ether, glycerin, and fats. The bromates can hardly properly be considered in connection with bromine and the bromides, since their therapeu- tic relations are markedly those that ob- tain to their base, hydrobromic acid excepted. The proportions of bromine are comparatively small as compared with bromides, though it must be ad- mitted that their action as salts is, in considerable measure, different from that of their alkaloidal derivatives. Preparations and Doses. — Bromine, external use only. Bromide of ammonium, 10 to 60 grains. Bromide of arsenic (Clemens's solu- tion), 1 to 5 minims. Bromide of barium, ^/k, to 1 grain. Bromide of cadmium, ^/g to V4 grain. Bromide of calcium, 30 to 90 grains. Bromide of camphor (monobromated camphor; camphor monobromide), 3 to 10 grains. See Camphor. Bromide of ethyl (inhalation only). See Bromide of Ethyl. Bromide of gold, Vs to V2 grain. See Gold. Bromide of iron, 3 to 10 grains. See Iron. Bromide of lithium, 20 to 150 grains. Bromide of mercury, Vj to 1 grain. See Mercury. Bromide of nickel, 2 to 10 grains. See Nickel. Bromide of potassium, 10 to 120 grains. Bromide of silver, V4 to 1 grain. See Silver. Bromide of sodium, 20 to 150 grains. Bromide of strontium, 30 to 150 grains. Bromide of zinc, 1 to 3 grains. See Zinc. Bromal, 1 to 3 grains. Bromalhydrate, ^/j to 5 grains. Bromalin, 10 to 130 grains. Bromamide, 10 to 15 grains. Bromoform, anaesthetic and antispas- modic, 1 to 7 drops according to age. Bromol, ^/jg to ^/g grain. Bromohydric acid, dilute, 2 to 120 minims. See Hydrobromic Acid. Bromohydrate of caffeine, 1 to 6 grains. See Coffee. BROMIDES. UNTOWARD EFFECTS. 635 Bromohydrate of conine, V30 to Vi„ grain. See CoNiuii. Bromohydrate of quinine, 1 to 20 grains. See Quinine. Bromohydrate of scopolamine, Vjeo to Vioo grain. See Scopolamine. Bromoliydrate of strychnine, ^/^o to V20 grain. See Strychnine. Untoward Effects and Physiological Action. — Bromine, per se, cannot be ad- ministered internally because of its poi- sonous and powerfully corrosive prop- erties. When brought in contact with organic matters it rapidly oxidizes and destroys them; hence its chief use is as a disinfectant (1 to 500); it also, some- times, for like reason, finds employment as a topical application in hospital gangrene, phagedenic ulcers, sloughing chancroids, and like morbidities. The common bromine salts are in a general way identical in action, the chief difference being intensity and palata- bility, which, of course, are determined by the amount of bromine each contains, and the character of its base. Potassium bromide is, perhaps, the salt best known and most generally employed, and a general description of its physiological properties may be considered as typical of the ammonium, calcium, lithium, sodium, and strontium salts. Originally potassium bromide was in- troduced as an alterative and resolvent, and substitute for the iodide salt, and in small doses it often answers these purposes. But no sooner was its seda- tive action on the nervous system made apparent than its earlier uses were lost sight of, and to a degree that has prac- tically buried all other properties in oblivion. It depresses the brain and spinal cord in medium doses, rendering the same markedly anaemic if pushed or exhibited in larger doses. If the doses are still further increased and continued. anaesthesia of mucous membranes of eye, throat, and nose is observed, which, doubtless, extends to the entire digestive and intestinal tract, though the evi- dences thereof are not markedly ap- parent in the rectum. Bromides di- minish sexual desire, and, when pushed to the extreme of bromism, may destroy the same, or at least place in abeyance for a considerable period; at the same time the contractility of muscular fibre is diminished, and capillary circulation retarded. First of all the sensory col- umns of the spinal cord are depressed by bromides, next the sensory nerves; next the brain and motor columns of the cord; finally the motor nerves. While small doses do not seem to appreciably disturb the heart's action, larger ones depress, and, pushed to ultimate toxicity, death occurs with arrest in diastole. Brominism is the first definite meas- ure of toxicity, and, unfortunately, bromide of potassium and most of its congeners are eliminated very slowly; hence cumulative action. The cerebral symptoms are: a sense of mental weak- ness, heaviness of the intellect, and fail- ure of memory; partial aphasia; great somnolence and depression of spirits (H. C. Wood). With these there may be decided impairment of sensibility of the skin, to a degree that considerable heat applied elicits no complaint (Peeche). There is usually violent frontal head- ache; but this often occurs ere the stage of brominism is reached; and bronchial catarrh and cough sometimes supervene. Where brominism assumes a chronic character, there is a nauseous, foetid breath, congestion and oedema of uvula and fauces, disturbances of sensa- tion as regards vision and audition, loss of appetite, and hallucinations either with or without mania. Routine prac- 626 BROMIDES. UNTOWARD EFFECTS. tice in prescribing bromides may lead to mania. The pernicious system of prescribing bromides recklessly for epilepsy and other nervons disorders may lead to scTere mental diseases. On taking bromides a considerable amount of bromine is retained in the body, and the output of it only comes to equal the intake when the organism has, as it were, become saturated with the element. If no more bromide be then taken, bromine excretion goes on very slowly, and its presence can be recognized in the urine for several weeks. Excre- tion takes place chiefly through the kid- neys, but it is also present in all the fluid secretions. While bromides are be- ing taken, the amount of chlorides in the urine is greatly augmented, and from this the conclusion is drawn that bro- mine ousts chlorine to a certain extent from its combinations in the body- tis- sues and fluids. During the administra- tion of bromides small quantities of iodine are found in the urine in some eases, and disappear when the bromides are stopped. The iodine seems to be de- rived from that present in the thyroid gland, but this is not quite certain until further observations can be made. F. Fessel (Mfinchener med. Woch., Sept. 26, '99). A condition of the brain may be pro- duced similar to that occasioned by ex- cessive haemorrhage; i.e., an increased tendency to convulsive action (Clark, Gowers, Eosenbach). The action is not only on the cerebral circulation, but also in the cells of the gray matter of the cord. Paresis is often induced, with in- ability to walk, sometimes more marked on one side of the body than on the other and simulating hemiplegia; there may be failure of memory, going on to partial paresis, with involuntary move- ments of bowels and bladder. In a case of Jacksonian epilepsy, in a child, a drachm of potassium bromide was given daily. The father, a druggist, reasoned that, if this amount kept the disease in check, 2 or 3 drachms during the same period ought to work a cure. But the child speedily sank after the larger doses were instilled and became an imbecile. Also two children were taking bromide; one lost all memory of words and the other all idea of time. Voisin, Stark, Kiernan, Moyer, Eock- well, Seguin, Spitzka, Alexander, and others have reported cases of convulsions arising from traumatic epilepsy that, under the influence of bromides, were replaced by furor. Cases of grand mal and petit mal have been reported in which their use rendered the patients unmanageable, violent, homicidal, queru- lous, irritable, and suspicious. The last author quoted cites several more cases, eight in all. L. W. Baker, of Baldwinsville, three more. Laborde also observed priapism and sexual ex- citement sometimes amounting to saty- riasis follow the use of bromides. Win- ters, of JSTew York, has recorded many instances of visual hallucinations. Kier- nan, of Chicago, and Numro, of Edin- burgh, also observed marked aphrodisia. "That these untoward effects closely simulate the effect produced in epilepsy there can be no doubt, yet the weight of authority, and indeed the weight of evidence, is in favor of the opinion that these phenomena result most often from the suppression of epileptic explosions" (Bannister and Alexander). "To give the bromides alone is to postpone the explosions and generally intensify them. The very fact that a sudden suppression of bromide admin- istration is followed by a severe ex- plosion is clear evidence that the drug acts rather like a load keeping down a safety valve." (Spitzka.) Not the least unpleasant sequelae — Bromide of Potassium Eruption. ATLAS OE L' HOPlTAL ST.LOUIS, BKOMIDES. UNTOWAKD EFFECTS. 627 both as regards patients and medical attendants — that supervene as the result of continuous bromide administration, even in what are often considered very moderate doses, are the manifestations of brominism seen upon the skin. These may range all the way from a simple erythema to a rubeoliform or scarlatini- form rash, up to acne, pemphigus, fu- runeular swellings, and most foul and stubborn ulcerations that, too often, per- haps, are deemed evidences of a syph- ilitic diathesis. These are, for the most part, distinctly traceable to morbid changes in the sebaceous glands, in turn induced by impeded capillary circula- tion and obtunded nerve-fibrillEe. Such eruptions, if not recognized, are very annoying to treat, and are practically impossible to relieve until the bromide is suspended and in great measure elim- inated from the system. It is claimed that the simultaneous administration of arsenic tends to inhibit such sequelae; but this is not, by any means, univer- sally true. The late Brown-Sequard was accustomed to combine belladonna with bromides, which frequently proves a most effective measure. Case of a robust, well-developed child, 3 years of age, suffering from an ulcer on calf of leg, resembang a boil, covered at the apex with raspberry granulations bathed in adhesive, sanious pus. In a few days the ulcer was surrounded with acne pustules, which coalesced with the original lesion until the latter covered a large part of the gastrocnemius mus- cle; skin tawny or bronze; breath very offensive. The pustules were im- mense, and resembled varicella more than acne. Finally the sores threatened the whole leg below the knee. It was found the child occasionally suffered at- tacks of vertigo, for which a neighboring physician with a repiitatioi^ for "curing fits" had prescribed large doses of am- monium bromide, under the supposition that he was treating a case of epilepsy. Fullerton (Memphis Med. Monthly, Oct., '97). {See colored plate.) The evidence is overwhelming that the bromides are not the harmless medic- aments that they are generally assumed to be; also that their present universal and routine employment should be abandoned for more rational and physio- logical methods of procedure. When a patient who has been taking bromides for some time complains of a salty or bitter taste soon after the drug has been ingested, especially if there is increased secretion of saliva, suggestions of foetid breath, or a burning sensation in the mouth, whether accompanied by nausea and eructations or not, such should be regarded as evidence of impending bro- mism, and measures taken accordingly. It must be remembered, moreover, that these evidences may result from the administration of ordinary medicinal doses — 10 to 20 grains in the adult — ■ when frequently repeated, since the emunctories are not able to excrete this amount. Interstitial nephritis is a com- mon sequel to brominism. Of all the bromine salts, that of am- monium is the most apt to induce tox- icity, since the effects upon the sensory portion of the spinal cord are most marked. Bromides of lithium, potas- sium, and calcium rank, respectively, second, third, and fourth as regards poisonous qualities. Collapse under either the ammonium or potassium salt may arise either through the base or the bromine constituent; but the potassium bromide is more apt to be at fault in this respect. It is sometimes a difficult matter to determine where the blame should rest; but withdrawal of the potassium bromide, substituting there- for another salt, — that of sodium, for in- stance, — may lead to definite decision. But the most innocuous (apparently) of 638 BROMIDES. UNTOWARD EFFECTS. bromine salts, when long-continued or pushed to extremes, are apt to induce collapse; and fatal pathological changes in both kidney and liver have been ascribed to their use, with considerable reason and probability. Calcium bro- mide is claimed to be the least depress- ing, but this is not altogether borne out by long experience in its use. Case of infantj subject of a bromide eruption. Child when brought for treat- ment was 7 months old, irritable, and dentition was in progress. It was very feverish and would not sleep; stools were offensive. A simple carminative mixture was given, 2 grains of bromide of ammonium being added. Two days after commencing this, the rash ap- peared, and was well marked on the forehead, and there was an extension to the scalp and to some extent to other parts of the body. The child had been very greatly relieved by the treatment, although the rash was still well marked on the tenth day of treatment. Seymour Taylor (Brit. Jour, of Derm., May, '98). Lithium bromide requires to be ad- ministered in larger doses than its con- geners, and often proves the most irri- tating of any to the digestive system. The strontium salt is least disturbing to the stomach when continuously admin- istered for considerable periods, and by many held the least likely to induce bromism; indeed, H. C. Wood believes it stimulates appetite and increases the activity of the digestive organs, which, however true of small and medium doses, at moderate intervals, is not a fact regarding medium doses with brief in- tervals long continued or larger doses. The chief advantage of the salt is that its base is practically non-toxic. Barium bromide may be dismissed with the state- ment that it offers no advantages over the other bromide salts, and it has the marked disadvantage of possessing a very poisonous base. It is also claimed for this salt that it stimulates mucous membrane, improves appetite and diges- tion, etc., and though this is, in a meas- ure, true, such are referable to the metallic base rather than the acid source. Sodium bromide is undoubtedly the most convenient, and to considerable degree the most safe of the bromide salts. Suitably diluted, it is no more disagreeable to the palate than the bulk of mineral waters, and it is, moreover, when accompanied by abundance of fliiid, almost as readily eliminated. It must be remembered, in employing this drug, that it is not only essential, but of paramount importance, that the system be continually saturated, and flushed, so to speak, with water in abundance. Though some doubt its efficacy as compared with the ammo- nium, calcium, and potassium salts, it certainly is least depressing to both cir- culation and nervous system, and less irritating to the emunctories. In epi- lepsy it is questionable if the results desired are not those that accrue to toxicity rather than those of purely remedial character, for here free stimu- lation appears to inhibit prevention of paroxysms. But as a nerve-sedative purely, continued experience with so- dium bromide invariably leads to in- creasing favor on the part of both pre- scriber and patient, until the verdict ulti- mately becomes overwhelmingly positive. Bromalhydrate in large doses is a poison of great intensity, death rapidly resulting from paralysis of heart and sometimes of respiration also, preceded by minutely-contracted pupils, marked dyspnoea, and general convulsions. It lowers blood-pressure by powerfully de- pressing the circulation and vasomotor centres; it is equally depressant to the cord, especially the motor columns thereof. When employed in hypnotic doses, sleep is induced by direct action BROMIDES. UNTOWARD EFFECTS. 629 on the cerebrum, causing brain-anemia. Larger, but non-toxic, doses induce distinct lowering of body-temperature. Like chloral, to which it was expected it would prove an analogue, it is antisep- tic; and it is likewise markedly and painfully irritant to mucous membranes and raw surface. It is eliminated by the kidneys but slowly, and in the form of urobromic acid. Bromalin, inasmuch as it contains only about half as much bromine as potassium bromide, requires to be given in large doses, but its effects are sup- posed to be identical with the latter. It is claimed, moreover, that it is less prone to provoke unpleasant sequels; but clinical experience is not yet suffi- ciently ample to permit of drawing definite deductions. Bromalin used in two cases of well- pronounced bromine exanthema. Al- though complete disappearance of the ex- anthema was not brought about by the remedy, yet a favorable effect was exer- cised by the bromalin, which exhibited a more powerful sedative action than the potassium bromide previously used. Bromalin is the only remedy that per- fectly replaces the bromides of the al- kalies and that is almost entirely free from the by-effects of the latter. Bijhme (E. Merck's 1898 Bericht). Bromamide evinces its chief activity upon the cerebrum, which it materially depresses; hence its reputation as an hypnotic; nevertheless, it is inferior to many other drugs in this respect. In larger doses it is more markedly de- pressant, exerting its action upon the spinal cord, whereby it becomes an anal- gesic. In medium doses it stimulates the respiratory centres; but here, again, when pushed to the verge of toxicity, an opposite result accrues that may re- sult in total paralysis. In small doses it influences the circulation but little; but in larger depresses the heart, and, if increased, the action of the organ is entirely suspended. Thus it is a remedy far more powerful for evil than good, and furthermore there is little confidence to be placed therein, since, once exposed to air and light, chemical changes take place whereby \t develops greater tox- icity. A dose taken from one container to-day that appears harmless, if repeated a week later may prove dangerous. Until more is known of the product, and until its manufacture and preservation can be encompassed by greater safeguards, in- suring stability and uniformity, the drug is best relegated to the list of curious chemicals. Bromoform is best known for its anaes- thetic properties, but is sometimes ap- plied to relieve the pain accruing to cer- tain morbid ulcers, and here appears to be both an antiseptic and a local anjcs- thetic. After inhalation it may be de- tected in the form of hydrobromic acid in the urine. It is highly toxic, more- over, and induces symptoms of collapse, accompanied by great weakness, cya- nosis, dilated and fixed pupils, and cold- ness of extremities, but seems to be easily eliminated from the system under the use of stimulants and tepid baths. Case of a child, 10 months old, that took by inadvertence about a drachm of bromoform. In a short time slight cya- nosis had developed, the pupils were pro- foundly contracted and phenomena of respiratory and cardiac paralysis had made their appearance. The tongue pre- sented a brownish discoloration, and the breath the characteristic odor. Artificial respiration was at once instituted, and the cutaneous surface was stimulated through hot bathing and cold douches to the head, the tongue meanwhile be- ing pulled forward rhythmically. These measures were maintained for two hours, when an injection of ether was made. This was followed by trismus and spasms of the extremities. The injection was, however, repeated twice at intervals of 630 BROMIDES. POISOXING BY BROMIDES. half an hour, and gradually improvement began to set in. Van Bommell (Deut. med. Woch., No. 3, '96). It is probable that in the system bromoform gives origin to chloroform. Rembe (Der Kinderarzt, viii, 49, '97). Bromoform poisoning in a case of per- tussis in an infant. The bromoform was given in a prescription with sj'rup of orange-peel, alcohol, and water. As the specific gravity of bromoform was greater than that of the other ingredients in the mixture, it naturally sank to the bottom of the bottle, and the mixture, in order that it be properly given, should have been thoroughly shaken before adminis- tering it. This not having been done, the bromoform precipitated, and must have been given in one dose in the last tea- spoonful contained in the bottle. This showed the importance of prescribing this drug in its pure form, without the addition of any diluent. Louis Fischer (Annals of Gynec. and Fed., June, '97). Simple formula for bromoforra-and- chloroform mixture: — IJ Bromoform, 18 grains. Chloroform, 8 minims. Rum, 4 fluidounces. Whereas alcoholic solutions of bromo- form precipitate in excess of water, this mixture with chloroform does not pre- cipitate, no matter what are the propor- tions of water present. Gay (Jour, of Med. of Bordeaux; La Sem. Mi5d., No. II, 1900). Two cases of bromoform poisoning; the children found lying side by side, with breath smelling strongly of bromo- form, with faces pale, eyes closed, pupils contracted, and limbs flaccid. Artificial respiration, brandy and strychnine hypo- dermically administered, and lavage with hot water and hot coffee brought con- sciousness in about one and one-half hours. Stokes (Brit. Med. Jour., May 26, 1900). Case of bromoform poisoning in a girl, aged 6 years, who took I */; drachms of pure bromoform. Patient became un- conscious. There was no pulse at the wrist, the heart was beating very irregu- larly about 120 per minute, the respira- tions were verv shallow and about S per minute, the face and lips were livid, and pupils were pin-point and did not react to light. Lavage with sodium- bicarbonate solution, then Condy's fluid, followed by strong eoflfee and sal vola- tile both by tube and per rectum were efficient means of treatment. T. Brown Darling (Brit. Med. Jour., June 2, 1900). Bromol has a peculiarly disagreeable, pungent odor, and a sweetish, astringent, but not unpleasant taste, and, as may be imagined from its derivation, is power- fully antiseptic. It is unfortunate it should have secured a designation that is likely to cause it to be confounded with bromal. It has been employed both externally and internally, but definite data are lacking regarding physiological properties when introduced into the liv- ing economy. Bearing in mind its source, it should, for the present at least, be regarded as a drug demanding great caution in its employment. It is said to be excreted by tlie kidneys as tribromphenolsulphuric acid. Poisoning by Bromides. — It has re- peatedly been denied that bromides per se ever induce fatalities, but the evidence already deduced is proof sufficient of their dangerous character. Careful ex- amination of literature also reveals the fact that fatalities are, by no means, of infrequent occurrence, and the sus- picion is forced that many deaths that should have been ascribed to the toxic action of bromides have been ignored or mistakenly ascribed to the malady for which the drugs were prescribed. Hameau reports case of a young woman who took four and one-half pounds of bromide during ten months, and while in a condition of cachexia with yellowish skin, copper-colored eruption on forehead, colic, gastralgia, etc., suddenly became greatly pros- trated; had delirium with profuse sweats, followed by death in four days. H. C. Wood ("Principles and Practice of Ther.," '94). BROMIDES. POISONING. TREATMENT. THERAPEUTICS. 631 Case of a woman who took five pounds of potassium bromide in less than a year, and, while having very pronounced sj^mptoms of brominism, was seized with delirium and suffered from hallucina- tions of sight and hearing; declared she was being poisoned. Death followed. Eigner (Wiener med. Presse, Nos. 25-34, '96). A number of deaths can only be ex- plained by the inordinate use of bro- mides. The patients sink into a condi- tion of apathy from which they cannot be roused. Have seen three autopsies and have knowledge of five more wherein the excessive use of bromide salts gave rise to fatality. Janeway ( Amer. Medico-Surg. Bull., May 16, '96) . Bromof orm, owing to its kinship with, chloroform, is an active toxic and its ad- ministration should be carefully watched. In bromoform poisoning attention must chiefly be given to the heart and lungs. The heart is stimulated by in- jections of ether and camphor. As re- gards the respiration, the head should overhang, the mouth be kept open, the tongue drawn forward, and the mucus cleared out of the larynx. Artificial respiration and faradization of the phrenic nerves should be adopted. There is no specific antidote. Bijrger (Munch, med. Woch., May 19, '96). Case of bromoform poisoning success- fully treated by giving the child an emetic and an hypodermic injection of '/i2o grain of strj'china. The bromoform precipitated in the mixture and the greater part of it was consequently given in the last dose. W. E. Cheyney (Archives of Pediatrics, Feb., '97). Treatment of Bromism. — This con- sists, first of all, in suspending the drug; next in promoting excretion by the emunctories, the kidneys and skin espe- cially, coupled, if need be, with support- ing treatment to heart and general cir- culation, and endeavors to restore to normal the status of the nervous sys- tem. The mercurial salts are often of marked value, especially the iodide as found in combination with arsenic in Donovan's solution. Occasional purges by large doses of calomel are also very efEective, and, when given to the amount of 30 to 50 grains at bed-time, this drug is not only without depressing after- effects, but tends to stimulate the kid- neys and emunctories to renewed ac- tivity. Theoretically, pilocarpine, or jabo- randi, would be considered of use; but to an economy already generally de- pressed, with circulation and nervous system suffering from the poison, these might prove boomerangs; atropine and belladonna are much more preferable and reliable. Therapeutics. — The chief use to which the bromides, especially bromide of po- tassium, have been devoted is the treat- ment of epilepsj^ but the weight of evi- dence tends to show that while they may decrease the number of paroxysms, they positively never afford other relief, and many times the condition resultant upon their use is worse than before treatment began. Again, at least 5 per cent, of epi- ■ leptics cannot bear any bromide, even in small doses. Use the three salts in epilepsy — am- monium, potassium, and sodium — in combination in doses of from 40 to 80 grains morning and evening. In strictly nocturnal seizures one dose at night only. Treatment should be persisted in for at least three years. Arsenic is a valuable adjunct to the bromides. Eulenberg (Ther. Monats., Nov., Dec, '92). When a bromide is given in conjunc- tion with borax the action is better than with either salt alone. Alexander (Liverpool Medico-Chir. Jour., July, '93) . Twelve eases of epilepsy: 8 male and 4 females, of ages ranging from 10 to 50 years; no predisposition, no syphilis. In 4 the fits occurred at least once a week, in the other 8 at intervals varying from 1 to 8 weeks. Bromide of stron- tium, 20 grains, with 5 to 10 grains of bromide of ammonium or sodium, were 633 BROMIDES. THERAPEUTICS. given night and morning, largely diluted with water. Strontium increased rap- idly to 60 grains twice daily when the smaller doses failed to control the at- tacks. The majority took the latter drug without any depression, but gen- erally -with the production of acneic rash on face. Fowler's solution of ar- senic added to the mixture controlled the rash and increased appetite. The number of attacks in all cases was materially decreased, and in 8 there was no return after intervals of from 4 to 16 months. Roche (Med. Press i.nd Circ, Aug. 12, '92). It has been recommended to combine adonis vernalis and codeine with bro- mides in the treatment of epilepsy, but careful investigations on the part of many observers are not at all assuring in this direction. The cures do not appear to be in any way effected save by the bromides alone, and the combination does not, in any way, prevent the complications and dis- agreeable symptoms which arise from the use of bromide salts. Taty (Lyon MSd., Dec. 29, '95; ibid., Jan. 5, 12, '96). Chorea. Convulsive and Paroxys- mal Maladies. — The bromides have also been extensively employed in chorea, but without any great measure of success. They are, however, often most effective in hysterical seizures, asthma, the milder forms of whooping- cough and puerperal eclampsia and in- fantile convulsions; also have been lauded in tetanus, laryngismus stridu- lus, and seizure that sometimes follow thyroidectomy. Stridulous laryngitis in children is, doubtless, due to inflammation of the larynx, the spasms being the sole danger. Here 60 to 70 grains of bromide of potas- sium should be administsred daily, even to a child so young as four and one-half years; intubation or tracheotomy may be added in menacing cases. Huchard (Revue G6n. de Clin, et de Ther., No. 38, '94). The excitability of the nervous sys- tem and convulsive symptoms that fol- low thyroidotomy may be diminished and suppressed by the use of potassium bromide. Gley (La Sem. MSd., Apr. 13, '92). The symptoms of tetanus in dogs caused by total thyroidectomy can be overcome by large doses of potassium bromide; fifty animals operated upon were thus kept for two years, and two more for six years. Canizzaro (Deut. med. Woch., No. 184, May '92). Bromoform has steadily been gaining favor as a remedy for pertussis. Bromoform employed in 40 cases of pertussis with good results. For chil- dren, under 6 months, the daily dose is from 2 to 3 drops, for children of from 6 months to a year, from 3 to 4 drops. The daily dose should be administered in three portions. It is prescribed in an emulsion made of almond-oil, gum arabic, gum tragacanth, cherry-laurel water, and water. For the first two or three days the paroxysms of coughing may appear to be aggravated, but after the third or fourth a marked improvement is noticed. The remedy, however, is not uniformly successful. Marfan (Revue Internat. de Med. et de Chir., Apr. 25, '96) . Results of treatment in 874 cases of whooping-cough, 832 cases being out-door patients, the remainder being seen in private practice. The drugs used inter- nally were potassium bromide, tincture of belladonna, codeine, quinine, anti- pyrine, phenacetin, antifebrin, and bro- moform. Bromoform acted better than any of the drugs, vomiting and other com- plications being almost unknown and the beneficial results being observed in from forty-eight to seventy-two hours. Eross (Jahrb. f. Kinderh., B. 42, H. 3 and 4). About a thousand cases of convulsive cough at the polyclinic of Monaco treated with bromoform, all with most favorable results. In order to avoid all danger of poisoning, the adoption of a mixture with alcohol and glycerin is recommended. Mueller (Miinch. med. Woch., No. 38, '98). Heart Disorders. — In cardiac neu- ritis and in angina pectoris the bromides have been recommended, though it is admitted, as regards the latter malady, BROI\nDES. BRONCHIECTASIS. 633 that only excessive closes can be of bene- fit; in the former the most that can be expected is to obtund the reflexes, and this is equally true of their use in Meniere's disease and attacks of nervous vomiting. In acute attack of M6ni6re's disease efforts should be made to subdue the excitability of the nerve-centres. Bro- mide of potassium, 10 to 20 grains three times daily, and rest in the recumbent position usually suffice to relieve. Mae- Kenzie (Brit. Med. Jour., May 5, '94). A girl, 8 years of age, of neurotic parentage, had curious attack of vomit- ing at intervals of about six weeks each; the vomited matter was highly acid, and there was a burning sensation in the stomach. Potassium bromide, and also chloral, per rectum, proved useful. Snow (N. Y. Med. Jour., July 1, '93). Dtsmenoeehcea. — Sir James Y. Simpson was wont to rely upon potas- sium bromide in connection with guaiac and magnesia for the treatment of func- tional dysmenorrhoea, and the sodium salt in conjunction with gelsemium has proved most beneficial in the hands of many. Bromides, too, are often of value in the casual forms of mental alienation that appear in very nervous females and are ascribed to the menstrual function. There is an intimate relation between menstruation and insanity. The prog- nosis in menstrual insanity is favorable, and the treatment resolves itself into the use of general and ovarian sedatives, specially the bromides. Ball (Journal de Med., Mar. 20, '92; Annales d'Hypnol. et de Psych., Feb., '92). In four cases the administration of bromide of sodium induced erection and seminal emissions. The same drug pro- duced orgasm in a girl; and in a boy suffering from seminal emissions as the result of masturbation the trouble was increased. Monroe (Med. Stand., May, '91). Infectious Diseases. — Especially in the exanthemata and infectious diseases the bromides often prove of the utmost value if given in small and often-re- peated doses, in allaying nervous excite- ment and combating insomnia. Bromal has given good results in diph- theria when dissolved in glycerin (1 to 25) and applied topically to throat. Also internally in cholera infantum, in doses of from Vu to V» grain. Rademaker (Lancet, London, Oct. 10, '91). Reflex hemicrania from carious tooth relieved in three hours by a 15-grain dose of bromamide; premenstrual headache in like manner relieved in two hours. Relieves rheumatic pains. Best given in capsules, suspended in fluid, or dry on the tongue. Caill6 (N. Y. Med. Jour., Feb. 20, '92). Gout. — In some gouty people Brun- ton has found 20 grains of potassium bicarbonate with 10 to 20 grains of potassium bromide useful, taken when the feeling of irritability comes on. It frequently soothes, and, furthermore, has the effect of lessening worry even in those who are not irritable. Brunton also finds potassium or so- dium bromide and sodium salicylate of value in the irritability of temper that is sometimes a precursor of headache, and likewise in heart disease. But bro- mides are contra-indicated in the car- diac depression that accrues to an alco- holic or opium debauch, and moreover are most dangerous. Such are cases re- quiring bread and are offered stone; the already-depressed heart and nervous sys- tem demand toning up and stimulation, whereas the bromine preparations make the patient worse. G. Archie Stockwell, New York. BRONCHIAI TUBES, FOREIGN BODIES IN. See Eespibatort Pas- sages, Foreign Bodies in. BRONCHIECTASIS. Definition. — A more or less uniform dilatation of the bronchial tubes, of one 634 BRONCHIECTASIS. VARIETIES. SYJtPTOMS. or both lungs, which may be localized or extend to the finer ramifications. Varieties. — The dilatation may be cylindrical, involving the medium-sized tubes and, less frequently, the smaller bronchi and bronchioles, or saccular, the caliber of limited portions of the bronchi being enlarged, and forming bag-like cavities of various dimensions. "Bron- chiolectasis" is a term proposed by Kan- thack for those cases in which only the bronchioles are involved. Symptoms. - — In practically all the eases of bronchiectasis there is a his- tory of prolonged bronchitis, of pleu- risy, catarrhal pneumonia, broncho- pneumonia, or some other acute pulmo- nary disorder. A few follow the inhala- tion of some foreign body of sufficient size to occlude a bronchus. When bron- chiectasis follows bronchitis, the symp- toms of this disease assume a modified character: the cough becomes more severe and paroxysmal and the amount of expectorated material is greatly in- creased. This copious expectoration — which may reach over a pint a day • — especially occurs early in the morn- ing or after a sudden change of post- ure, even when the patient is in bed. At first giving off a sour odor, it gradu- ally becomes foetid, and this foetor be- comes so marked that the atmosphere around the patient is almost unbearable. In cases of long duration the expectora- tion is brownish and, when examined microscopically, is found to contain Charcot-Leyden crystals and masses or bundles of fatty-acid crystals. Various kinds of bacteria, leptothrices, etc., are also found, some of which are of external origin. The tubercle bacillus is seldom detected unless the patient be concomi- tantly suffering from tuberculosis of the lungs. The temperature, which during the presence of bronchitis alone may have been normal or slightly above the normal level, now shows a tendency to rise near evening. The curve is irregular and may reach 105°. When the disease fol- lows pulmonary disorders, attended with pyrexia, this is increased with the ac- cession of fcetor. As a result of septic absorption, manifestations simulating those of hectic, as observed in consump- tion, usually occur, and the patient may succumb. Pulmonary gangrene is not an infrequent complication and promptly leads to a fatal ending in the vast ma- jority of cases. Intense pain in the head in these cases indicates involvement of the meninges, while the cerebral press- ure induced may give rise to hemiplegia, athetoid movements, and finally stupor. This complication occurs in about one- half of the cases. In children the disease is frequently the result of whooping-cough or of bron- cho-pneumonia, the mechanical origin of the dilatation of the bronchi being mainly due to repeated and forcible coughing, the weakened resistance of the bronchi through infiammatory softening causing them to yield to the undue air- pressure. This is especially the case when inflammatory disorders involving the bronchi have repeatedly occurred in the patient. Cases of broncho-pneu- monia or chronic bronchitis in which recurrences have repeatedly shown them- selves are therefore the most prone to bronchiectasis. When the cylindrical dilatation is not great, the physical signs do not differ markedly from those observed in the causative disorder. But a comparative point of value is that furnished by ex- amination during a fit of coughing, when marked gurgling may usually be noticed, which gurgling varies according to the amount of accumulated secretion. Dur- BRONCHIECTASIS. DIAGNOSIS. ETIOLOGY. 635 ing normal and even deep respiration increased roughness as compared to the ordinary signs of the primary disorder may be present; but the information thus obtained is not sufficiently dis- tinctive to warrant for this symptom more than a confirmatory position among the signs present. Loud gurgling dur- ing coughing and foetor of the sputum are conjointly, however, strong evidences that bronchiectasis is present. When distinct saccular bronchiectasis is present, the characteristic signs of pul- monary cavities are pre-eminent, but most marked in the majority of cases at the base instead of the apex of the lung involved. Cavernous and amphoric signs are usually marked. The disease being unilateral in a larger proportion of the cases, confusion with tuberculosis is pos- sible when the left side is involved, and when the bronchial dilatation is not con- fined to the base. In many cases in whicli the diagnosis is doubtful, or the auscultatory signs do not give reliable results and fail to lo- calize with precision the bronchieetasie cavities, the Roentgen rays will reveal them on the fluorescent screen. A radiographic examination will, in most instances of multiple cavities, reveal the presence of all. Radioscopy, however, is not an absolutely infallible means of diagnosis. Tuffier (Bull, et Mem. de la Soc. de Chir., Mar. 6, 1900). When bronchiectasis is due to the presence of a foreign body, it is caused by the violent cough induced, which gives rise to undue pressure within the tubes. The excessive coughing may also cause free portions of the lung to be- come dilated. The same condition may be brought about by stricture or com- pression occurring in the course of mor- bid processes which mechanically inter- fere with the free passage of air through the tubes. It may, in this manner, com- plicate phthisis and aneurism. Diagnosis.- — The conditions for which bronchiectasis is apt to be taken are pul- monary tuberculosis and circumscribed empyema. PULMONAET TUBEECULOSIS. In this disease tubercle bacilli are usually found in the sputum. The lesions are located at the apex of either lung, generally the left; while in bronchiectasis they are more disseminated and involve the base. In tuberculosis there is a history of hasmoptysis, gradual loss of flesh and strength, and the cough is not inclined tc be paroxysmal. This disease occasion- ally acts as the exciting cause of bron- chiectasis, however, and the apex may be the seat of bronchial dilatation. ClECUMSCEIBED EMPYEMA. In this disease there is a clear history of acute onset, with pleuritic symptoms, and a sudden evacuation of large quantities of pus. The dyspnoea is not usually of long standing and generally comes on with comparative suddenness. Distinct dull- ness over the purulent area serves to in- dicate the true condition present. The data for forming a correct diag- nosis are: The sputum, especially as re- gards (a) foetor, (1)) daily amount, (c) physical characters, and (d) method of expectoration. Fcetor of breath on coughing. Physical signs of chest, in- cluding the signs of cavities, especially in relation to (a) their size, distribu- tion, occurrence, and symmetry; (b) their generally non-progressive char- acter and daily variations. The tem- perature-range in bronchiectasis varies within very wide limits. It may remain normal for many weeks at a time, even when the sputum is offensive. On the other hand, it may conform to one of the remittent or intermittent types, with a range of as much as four or five degrees. T. D. Acland (Practitioner, April, 1902). Etiology. — When chronic bronchitis is the primary cause of bronchiectasis the patients are usually past middle life. 036 BEONCHIECTASIS. PROGNOSIS. PATH0L0C4Y. with the exception of the form due to foreign bodies, wlrich may invade the respiratory tract at any age. Dilatation of tire bronchi is more liliely to present itself during early middle life. As stated, it usually follows primary disor- ders of the lung, but it is most prone to do so in persons weakened by diathetic conditions or untoward habits. Under the former may be classed alcoholism, syphilis, gout, and rheumatism. Under- the latter alcoholic conditions tending to mechanically induce an increase of the bronchial air-pressure by interfering with the free egress of the atmospheric current; laryngeal paralyses; laryngeal, infralaryngeal, and tracheal hypertro- phic processes; neoplasms or aneurisms compressing the trachea or the larger bronchi; foreign bodies in any part of the inferior respiratory tract, etc., are as many possible causative factors. Ex- posure to cold and wet, dust, irritating gases, etc., tend to increase the local dis- order by promoting the tendency to local congestion. Adenoid vegetations tend to predispose a child to the affec- tion. Prog^nosis. — Bronchiectasis being, as a rule, a secondary disorder, its prog- nosis depends, to a great measure, upon that of the disease acting as cause. Again, the degree of dilatation induced — whether it be cylindrical, circum- scribed, localized, or diffused — bears an important influence upon the course of the disease. A slight modification of the bronchial lumen does not necessarily preclude the enjoyment of practically good health; when, however, the lumen of the tubes is markedly increased or studded with saccular dilatations, the infectious processes already described are apt to present themselves at any time and greatly aggravate the danger. Pro- gressive emphysema and gangrene are among the complications to be expected. Dilatation and hypertrophy of the right ventricle is frequently observed in cases showing a history of pertussis. On the whole, well-marked bronchiectasis does not tend toward recovery. A successful result is to be hoped for when appropriate measures are instituted at an early date — measures calculated to aid Nature's curative processes. This, of course, emphasizes the need of an early diagnosis, for, when fibrous replace- ment of the pulmonary parenchyma has occurred to any marked extent, a cure is seldom obtained. The expectoration then persists and foetor recurs. Pathology. — The bronchial tube in some cases is only temporarily dilated; this occurs in children after whooping- cough or acute pneumonic disease. It is far more common, however, when there has once been dilatation, to have re- peated attacks of inflammatory trouble, and the dilatation continually increasing year by year. The effect on the bron- chial tubes themselves is probably first of all swelling, sometimes observed in the mucous membrane, which becomes velvety in appearance; the muscular coat of the smaller bronchi then becomes tumefied and its resistance is weakened. Owing to the frequent attacks there is a considerable fibrosis or peribronchial thickening around these dilated bronchi. In some cases, however, instead of hyper- trophy of the small tubes there is thin- ning and dilatation. When the bronchi are large this dilatation is very striking. On post-mortem are found large cavities with many valvular reflections of the mucous membrane, — an exaggeration of the normal condition of the bronchial tube; so that a large cavity seems to be partitioned off by these valvular septa, especially in the sacculated form of bron- chiectasis; there is a small opening. BRONCHIECTASIS. TREATMENT. 637 which is the bronchial tube leading to it. Not only are the bronchial tubes afEected, but the surrounding area of lung is also involved. It is afEected iu two ways: First an extensive inflamma- tion spreads from the peribronchial con- nective tissue, which is continuous with the whole frame-work of the lung. This tissue sends out delicate filaments be- tween th€ alveoli of the lung, and this net-work is again continuous with the pleura and with the septa passing in from the pulmonary pleura. This frame- work becomes indurated, the chronic in- fliammation round the tubes continues until there is an interstitial fibrosis, — an interstitial thickening of the pulmo- nary substance round the dilated bron- chial tubes. But such a lung with dilated tubes is especially liable to re- peated attacks of catarrh or catarrhal pneumonia; therefore specimens some- times show evidences of acute catarrhal pneumonia, but more often those of a chronic indurative pneumonia. The consolidation due to chronic pneumonia is distinct from the first, and is char- act-erized by a reticular thickening, or fibrosis, of the connective-tissue elements forming the frame-work of the lung. The contents of the alveoli are in many cases consolidated, and the appearance is not of recent, but of organized, ex- udation. When stained with eosin and hfematoxylin, the eosin picks out the blood-vessels. The centre of the alveoli may thus be shown to be filled with small cellular elements and small blood- vessels, indicating that it is becoming fibroid and organized. As the disease proceeds there occur further complications, which end some- times in death. In many eases ulcera- tion of the bronchial tubes supervenes. In the bronchial tubes the retained secretions become putrid, full of micro- organisms, forming the foul sputum characteristic of such cases. Very often this goes on till ulceration takes place, and when once ulceration occurs any form of septic disease as a final cause of death may appear. Very common causes are found to be septic pneumonia and septic abscess in other parts of the body. Above all, abscess in the brain seems to be one of the commonest causes of death occurring in such cases. Besides septic pneumonia, death may take place from acute catarrhal pneumonia, especially where the patient has been subject to chronic bronchitis associated with rather frequent attacks of acute broncho-pneu- monia. (Habershon.) Autopsy in a case of fibroid-lung bronchiectasis. Lung: Showing fibriod induration. The upper lobe is uniformly solid, gray, and very firm. The middle lobe is not so firm. The lower lobe is congested and shows an area of fibrous induration in the lower part. Extending through these solidified portions are tubular bronchiectasio cavities with blood- stained walls. Brain: Section through the right hem- isphere of the brain about the paracen- tral convolution, in the upper part of which is an abscess-cavity the walls of which are Irregular. The association of brain-abscess with bronchiectasie cavities has frequently been noted. Williamson has recently reported that out of 39 cases of brain- abscess, 17 were associated with putrid bronchiectasis. Livingood (Johns Hop- kins Hosp. Bull., Dec, '97). Treatment. — A very important point in the treatment of bronchiectasis is to see that the cavity or cavities are fre- quently emptied. This can generally be effectively done by partially inverting the patient, at first two or three times a day, and later once a day. The simplest plan to adopt is for the patient to hang himself over the edge of the bed or couch so that his legs rest on it and his 638 BRONCHIECTASIS. TREATiSIENT. body is supported by his hands on the floor. This partial inversion is followed by cough and the evacuation of a consid- erable amount of offensive sputum. (Hector Mackenzie.) Quincke's suggestion of treating bron- chitis and bronchiectatie processes by posture favored. In acute processes the measure is useless. In cases of foetid bronchitis the relief obtained is marked. The posture is the dorsal one with the foot of the bed gradually raised by means of bricks. It is practiced morning and evening for an hour each. In fifteen minutes some result should be achieved; if no sputum is obtained by this time, the procedure is usually useless. In ordinary cases the entire day's secretion may thus be evacuated. O. Jacobsohn (Berliner klin. Woch., Oct. 8, 1900). The above suiBciently illustrates the inadvisability of giving remedies such as narcotics to arrest the spasmodic cough- ing: a mechanical device employed by nature to rid the dilated areas of ac- cumulated purulent liquids. The so- called ezpectorants are useless, and the disinfectant aromatics but serve to mo- mentarily check the foetor of the breath, whether applied by means of respirators or atomizers. The vapor or spray so produced hardly penetrates beyond the trachea. The medicaments employed must reach the diseased areas either directly or through the blood-current. The intralaryngeal injection of anti- septic liquids recommended by Grainger Stewart accomplishes to a degree the de- sired result in the small proportion of cases in which the dilatation only in- volves the larger bronchi. A drawback connected with methods in which professional dexterity has to play a role is that the patient does not always receive as many applications as his condition would require in order to obtain the best results. Measures which the patient can carry out himself are therefore always to be preferred. A method at once beneficial and easily carried out is to resort to the prone posi- tion, as described above, and to admin- ister drugs which are eliminated by the lungs. The allyl compounds are very effect- ive, and Vivian Poore has recommended garlic as especially valuable. A "clove" of garlic is to be chopped up and boiled in beef-tea and given three or four times a day. Hector Mackenzie found garlic most useful for diminishing the foetor of the breath, and recommends in the case of children the syrup of garlic of the United States Pharmacopoeia. A drachm of this may be given to a child three times a day with an equal amount of syrup of Tolu. For an adult 2 or 3 grains of powdered garlic may be given in a cachet, or 2 to 4 drachms of the syrup. The balsams also possess curative properties, but do not reach the diseased areas when applied by means of the atomizer. Molle has observed rapid improve- ment, amounting practically to cure, in children by the use of the following mixture : — I^ Eucalyptol, 10 parts. Creasote, 25 parts. Tincture of benzoin, 50 parts. Copaiba, 80 parts. Oil of sweet almonds, enough to make 200 parts. Thirty drops of this mixture are in- jected into the rectum, in a little milk, and the amoimt is gradually increased to one or two teaspoonfuls. One injection daily is suiScient. The child experiences a temporary burning sensation to which it rapidly grows accustomed. If this treatment is persisted in for months, all the symptoms are said to diminish, and the general condition is correspondingly improved, even proceeding to a cure. BRONCHIECTASIS. TREATMKNT. 639 The ordinary commercial coal-tar creasote is highly recommended by Arnold Chaplin, the aim being to empty the dilated tubes of the foetid material and to prevent their becoming filled again. According to this author, and the argument is sustained by the excel- lent results obtained, in order to fulfill the qualifications given above, a drug is needed which, while it is strongly anti- septic, must at the same time be pungent and acrid enough to induce violent ex- pulsive efforts. These conditions are, according to Chaplin, fulfilled by the common commercial coal-tar creasote. The mode of application is as follows: A room about seven feet square by seven feet high must be obtained, and this must be rendered tolerably air-tight. It is well to have the room on the top of the house, or away from it, as there will be less chance of the vapors generated from the creasote causing annoyance to those living in the house. In the centre of this room a small stand about 1 ^/j feet high is placed, and on this an ordi- nary spirit-lamp which admits of being raised or lowered. Over the spirit-lamp, on a tripod, an enameled-tin dish is placed, and into this is poured about half a pint of the coal-tar creasote. The creasote is heated until the dense pun- gent fumes are given off. The patient, clothed in an old dressing-gown, is placed in the room as soon as the lamp is lighted. As soon as the fumes begin to come off, an urgent desire to cough comes on, and soon the cough becomes more or less incessant, and attended with the expulsion of large quantities of phlegm. After the sitting has lasted from a half to one hour the patient may leave the room, and wait until the next day before taking another sitting. This should go on steadily from day to day for two months. For the first day or two not much benefit will be noticed, but very soon the expectoration becomes reduced and the odor less disgusting, and before very long the patient, who before was unbearable, is able to mix with his friends, and, unless he has a fit of coughing, his breath is quite free from smell. After two months the pa- tient seems practically cured, but he must take a sitting at least three times a week if he will keep his expectoration free from odor. With the cessation of the foetor comes increased appetite and strength. Children do not bear the treatment well, and the benefit to them is not nearly so marked. The method is an unpleasant one, however, and it requires all the persuasive powers of the physician to keep the patient up to the necessity of going on with the application of the drug; but after a few sittings patients generally become used to it. Secondly, the fumes of the creasote produce run- ning and smarting of the eyes and nose; but this can be prevented by introducing two plugs of cotton-wool into the nos- trils and covering the eyes with a pair of glasses rimmed round with India rub- ber. Beyond these there are no draw- backs to the treatment, and it can con- fidently be recommended as likely to improve the condition of the patient if persevered in for sufficient length of time. Creasote found of mucli value, admin- istered in the form of carbonate of crea- sote, ^/j drachm three times a day. Price Brown (Canadian Practitioner, Feb., '96). Surgical measures have been resorted to with the view of reaching, by ex- ternal incision and draining, the cavi- ties containing foetid accumulations. But the fact that the latter are very rarely localized within a restricted area 640 BRONCHIECTASIS. BRONCHITIS. at once condemns so severe a remedy, that involves complications, especially pneumonia, which may soon cause the patient's death. The only kind of case in which it might in the least be war- rantable is where the presence of but a single bronchiectasic cavity can abso- lutely be established by physical exami- nation, and even then only when it is near the surface. Two cases of bronchiectasis in which great relief was given during the par- oxysms, and some more permanent bene- fit afforded, by placing the patient lying down on the bed the foot of which was raised twelve or fourteen inches. The immediate result in both cases was a great sense of relief, a diminution in the frequency and severity of the cough, a lessening of the sputum, a complete cessation of the gush of expectoration, and presumably the liberation of the affected pulmonary areas from entan- gling slime and from any further plug- ging with muco-pus. The postural method is also useful in contributing to the comfort and relief of patients suffer- ing from general catarrhal affections with tenacious mucus, as well as in the later stages of pulmonary excavation in phthisis. William Ewart (Lancet, July 13, 1901). In treating bronchiectasis the meth- ods placed in the order of their effi- ciency may be classified, as follows: — 1. Inhalations of volatilized antisep- tics: (a) creasote vapor-baths ; (bj in- halations of creasote, oil of peppermint, eucalytus, etc. 2. Subcutaneous and intravenous in- jections of antiseptic fluids. 3. Internal medication. 4. Surgical treatment (incision and drainage). The most successful means of reliev- ing the foetor, and occasionally, but by no means always, of lessening the amount of the expectoration, is the in- halation under certain conditions of crude creasote-vapor, as originally sug- gested by Dr. Arnold Chaplin. It is necessary to carry out this treatment systematically and thorovighly. The details are as follows: A small room, free of any furniture except that of the simplest kind, and without hang- ings, is selected. It should have good ventilation provided mainly by means of a small fireplace, or in summer by means of Tobin's tubes. The patient should be provided ^vith a comfortable wooden chair. On a small table is ar- ranged an evaporating dish of the capacity of about half a pint, heated over a spirit-lamp. It is advisable not to consent to the use of a Bunsen gas- burner. Into the evaporating basin is put commercial creasote. The creasote is slowly vaporized, and as the dense fumes begin to rise the patient commences to cough, and not only are the tubes cleared of the offen- sive secretions, but the deep inspirations which follow serve to draw the crea- sote-vapor into the smaller bronchioles, bringing it into immediate contact with the decomposing pus in the dilated tubes. A twofold object is thus effected: the cleansing of the tubes and the evacuation of their contents. It is in this combination that the creasote vapor-bath is more effectual than any other form of treatment. Until the patient becomes more or less accus- tomed to them, the fimies, which are very penetrating, cause a considerable amount of distress, and it is mainly the great benefit which is derived from the treatment which encourages pa- tients to continue it. The volatilization of a large amount of crude creasote makes everything in a mess, and the patient's clothes must be protected, and no ornaments or pictures must be left upon the walls. T. D. Acland (Practitioner, April, 1902). Chahles E. de M. Sajous, Philadelphia. BKONCHITIS. Definition. — An inflammation of the mucous membrane of the bronchi, usu- ally including the trachea. It occurs as a primary affection or as a feature of many general diseases, especially the exanthemata. BRONCHITIS. ACUTE. SYMPTOMS. 641 Varieties. — Bronchitis may be sub- divided into four distinct forms: the acute, in which the inflammatory process is more or less severe, but of limited duration; the chronic, in which organic changes in the mucous membrane main- tain the activity of the final stage of the previous form; the foetid, which differs from the two previous forms by the foetid odor of the sputa; the fibrinous, or plastic, which is characterized by the presence of pseudomembranous easts formed in the bronchi. Capillary bronchitis, so-called, being in reality a form of catarrhal pneumonia, will be treated under Pneumonia. Acute Bronchitis. Symptoms. — The course of acute pri- mary bronchitis is fairly uniform. After exposure to cold, wet, or, oftentimes, to a close atmosphere, there is a feeling of malaise accompanied by chilly sensa- tions or, more rarely, a pronounced chill. Within a short time slight fever devel- ops, and coincidentally with this or shortly afterward a feeling of constric- tion or oppression beneath the sternum, which is intensified by deep inspiration. Cough soon appears, but is at first dry, harassing, and not productive of relief. The temperature is usually elevated by a few degrees, but in children may rap- idly rise to 102° or 103° F. In the course of twenty-four hours the cough increases in severity, and by the end of that time is accompanied by the expec- toration of a small quantity of glairy mu- cus produced only by inordinate effort. Gradually the cough becomes softer, the expectoration increases in amount and becomes opaque and finally yellowish. As expectoration increases the substernal discomfort lessens, the general feeling of illness diminishes, and the tempera- ture falls to almost, if not quite, the normal point. After three or four days 1- (sometimes sooner) the only symptoms remaining are frequent cough and a rather copious expectoration of yellow- ish-white muco-purulent material occa- sionally appearing as distinct clumps. The cough gradually lessens, the expec- toration becomes less profuse, until finally the patient recovers completely after the course of a week or ten days. In cases running a short course the mucous membrane probably becomes at once normal, although one attack of bronchitis frequently leaves behind it a certain susceptibility. In children the initial general symp- toms are more severe, the temperature elevation is greater, there is no visible expectoration until the fourth or fifth year, and vomiting is more frequent. Catarrhal pneumonia and atelectasis are frequent complications which may cause a fatal termination. In the aged there is but little general disturbance at the outset, but the disease is apt to assume a subacute or chronic course, or the disease may end fatally in those enfeebled by advanced years or structural disease in other parts. Physical examination in the early stages may show nothing or merely a few scattered sibilant rales. The respirations are slightly increased in frequency and a little more shallow than in health, ex- cept in infants, where the respiratory rate may be greatly increased. In the course of the first twenty-four hours there develop sibilant rales over areas on both sides of the chest, but especially in the spinal gutter. These rales rapidly shift their position and may be either produced or dissipated by the act of coughing. As the swelling of the mu- cous membrane increases or mucus is secreted in sufficient amount to mate- rially alter the calibre of the larger tubes, sonorous rales appear. The out-pouring 642 BRONCHITIS. ACUTE. DIAGNOSIS. ETIOLOGY. PATHOLOGY. of mucus in larger amounts causes the appearance of moist, mucous rales in ad- dition. In the absence of involvement of the pulmonary parenchyma percussion gives negative results. Palpation fre- quently, especially in children, reveals a coarse fremitiis, which may be found to disappear after free expectoration or vomiting. The occurrence of complicat- ing pneiimonia or atelectasis produces the signs peculiar to those conditions. Diagnosis. — The diagnosis presents no difficulty except in the determination of the primary or secondary origin of the trouble. The chief difficulty occurs ip children, where time alone may be able to decide the question as to whether the bronchitis is "simple" or is the premoni- tory stage of pertussis or measles. Etiology. — The causes may be classi- fied as mechanical, chemical, infectious, and toxic. Of mechanical causes are the inhalation of dust, particles of food, etc.; of the chemical as the inhalation of irri- tating gases (such as chlorine); of in- fective, that occurring in the course of measles is the most marked. Among the toxic causes the poison of ursemia and possibly that of some of the infections must be included, the latter upon the theory that the inflammation is produced by the excretion of toxins by the respira- tory tract. Exposure to cold and damp is an etio- logical factor probably acting by lower- ing bodily resistance and allowing the invasion of the mucous membrane by micro-organisms constantly present, but under ordinary circumstances impotent. The possibility of bronchitis being produced by the elimination through the respiratory passages of materials or- dinarily passed out through the other emunctories cannot be certainly cast aside. Bronchitis has also been ascribed to the effects of ether, employed as an ansesthetic. The infective nature of acute bron- chitis has not hitherto been generally accepted. In health the great majority of observers find the lower air-passages sterile, the bacteria being withdrawn into the upper air-passages, chiefly by the nasal mucous membrane and the adenoid tissue of the pharynx. Jundell, for ex- ample, examining the tracheas by means of a special instrument, in forty-three people found it either quite sterile or else containing only scanty transitory bacteria. Personal cases grouped in two sec- tions: — Cases of bronchitis without pneumonia 27 Cases of bronchitis with pneu- monia 22 In all but 6 pathogenetic bacteria were found in great numbers. Of these, those most frequently pres- ent were streptococcus pyogenes — found in 2 cases in pure culture, in 19 in association with other pathogenetic bac- teria; diplococcus pneumoniae — found in 15 eases of pure bronchitis and in 8 of bronchitis with pneumonia, and in these 23 cases in large numbers in all but 2, never in healthy bronchi; in- fluenza bacillus — found in 17 out of 49, never alone. Acute bronchitis is an infective dis- ease, not due, however, to any specific organism; it is usually a mixed infec- tion, the most important agents being the streptococcus pyogenes and the diplococcus pneumoniae. The infiuenza bacillus not infrequently produces bron- chitis apart from influenza. Eitchie (Jour, of Path, and Bact. ; Practitioner, May, 1901). Bronchitis is frequently caused by the extension of diphtheria and erysipelas from the upper tract, but in that case cannot be considered as simple bron- chitis. Pathology. — The mucous membrane is injected, of a bright-red color, is thick- ened, and thrown into longitudinal folds. The surface is usually covered with more BRONCHITIS. ACUTE. PKOGXOSiy. TKEATMENT. 643 or less mucus or muco-pus. On section there is found leucocytic infiltration of the deeper layers. The epithelial layer shows active proliferation of the cells; goblet-cells are numerous and greatly distended; the cells of the mucous glands are swelled and granular; and the cili- ated epithelial cells are seen to be shed in large numbers. The streptococcus bacillus predomi- nated in all eases of bronchitis in influ- enza. In quite a number, and some of the worst, it was the only bacterium found in the expectoration. In 23 cases the streptococcus was associated with staphylococci alone; in 3 cases strepto- cocci, staphylococci, and the influenza bacillus were associated; in 27 cases the streptococcus alone was found. The in- fluenza bacillus disappeared after a short time, and was replaced by the streptococcus. F. Forchheimer (Med. News, June 1, 1901). Many instances observed of localized bronchitis in which the sputum is crowded with diplocoeeus pneumoniae. This suggests that these micro-organ- isms are the essential causal factor in a large proportion of such eases. This germ tends to affect localized areas in one or more pulmonary lobes and usually runs a benign course. There is also a tendency of recurrent attacks to implicate the same area again and again. P. W. Williams {Bristol Med.- Chir. Jour., June, 1902). Prognosis. — In patients beyond the age of infancy and in those not debilitated by senility or serious organic disease re- covery invariably occurs. In young chil- dren recovery is the rule; but the dis- ease is of more gravity than in older children and adults, this gravity increas- ing inversely as the strength and age of the child. The chief danger in older children and in adults lies in the tend- ency to recurrence and consequent per- manent change in the mucous mem- brane. Treatment. — Treatment varies some- what with the age of the patient. A few general directions apply to all ages. Equalization of the circulation and stim- ulation of all lagging emunctories are important early measures. In all cases purity of air, equable room-temperature (69° to 70° F.), and a slight excess of moisture in the air are essential. In young infants the child should be clad rather more warmly than ordinarily, a cotton or woolen jacket should be ap- plied, and the chest should be rubbed twice daily with camphorated oil or a mixture of equal parts of olive-oil and amber-oil or turpentine. A croup-ket- tle, to the water in which has been added compound tincture of benzoin (1 fluidrachm to 1 pint) should be em- ployed for ten or fifteen minutes every hour or two, and in winter a broad, shallow pan of water should be kept in front of the source of heat in order, by its evaporation, to moisten the air of the room. Morrell has observed great bene- fit from inhalations of warm vapor of wine of ipecacuanha, ten minutes at a time, three or four times a day. The hot, dry chamber of the Turkish bath has been the means of aborting attacks of bronchitis, and deserves a trial ; the patient to be driven in a closed vehicle to and from the bath, and with moiith and nose protected with woolen comforter. I am fully persuaded that the indiscriminate recommendation of the bronchitis-kettle is a great error; it has contributed to the deaths of not a few to my own kno^Yledge. Alexander Duke (Med. Press and Circular, Feb. 3, '97). Ordinarily in the early stage a simple fever-mixture with the addition of a small quantity of ipecac will be all that is required. Of the febrifuges the citrate of potash with or without the addition of small doses of tincture of aconite in accordance with the fever and cardiac excitement will be found useful and sim- 644 BKONCHITIS. ACUTE. TREATMENT. pie. After the formation of mucus has started and the fever has subsided the chloride of ammonium, in doses of ^/^ to 1 grain, should replace the fever-mixt- ure. Ordinarily no further medication is required except for the use of mild laxa- tives to keep the bowels thoroughly opened. In removing the extra covering on the chest care is to be taken that the change be not made too rapidly, but that small portions should be taken away at a time. If at any time marked oppres- sion of breathing occurs from accumula- tion of mucus, the production of vomit- ing by a full dose of ipecac will cause prompt clearing of the tubes. In feeble children stimulants may be required, and where the heart's action is weak the car- bonate or aromatic spirit of ammonium may, with advantage, be used instead of the chloride. Apomorphine, freshly compounded in acidulated mixture, is the best of all relaxing expectorants. In ^Ao-grain doses, at two or three hours' inteiwals, rarely fails to cause a free sero-mucous flow in twelve to thirty-six hours. Rest is an essential adjuvant. Codeine sul- phate in Vo-grain doses, given independ- ently, is the best sedative. Thomas Hubbard (N. Y. Med. Jour., July 18, '96). In acute bronchitis of adults a com- bination of acetate of ammonium, spirit of nitrous ether, and ipecacuanha or antimony is commonly used, and no bet- ter combination can be employed. But an error is often made with regard to the dose of two of these substances. One should begin with doses of 3 drachms of the acetate of ammonium, and increase the amount to 6 drachms if the skin does not act freely. Spirit of nitrous ether may possibly act in Vrdrachm doses, but in doses of 1 to 2 drachms, especially when repeated at short intervals, it has commonly a very distinct effect as a di- aphoretic. D. J. Leech (Practitioner, May, '98). In older children and in adults a pre- liminary hot foot-bath, to equalize the circulation and start the emunctories, is of value. The application of mustard poultices or turpentine stupes to the chest certainly gives relief and probably hastens cure. The use of a cotton or woolen jacket is not so important as in infants, but is of value. In those beyond the age of infancy ammonia salts can be used earlier in the disease, the chloride acting especially well in combination with compound licorice mixture. Usu- ally no other medicine, save possibly laxatives, is required unless the latter part of the attack is prolonged, in which case small and frequently repeated doses of the oil of eucalyptus, gaultheria, or copaiba may be given in capsule. In the aged it is important to sustain the general strength and especially to watch the condition of the right heart. Stimulants are usually necessary; and it is important to change the patient's position at short intervals in order to facilitate expectoration and to avoid the effects of gravity in causing congestion or atelectasis of dependent parts of the lung. Many expectorant drugs other than those mentioned above are em- ployed, but it is a question whether their action upon digestion does not offset any possible good effect upon the bronchitis. The use of oxygen in inhalation is sometimes objected to on the ground that it is not a really curative agent. This is true, but the inference that it is not worth giving is believed fallacious. It does often remove cyanosis, and a con- tinuous condition of cyanosis must be an evil. It is probable that the inhala- tion of oxygen is generally commenced too late. Belief that its early use pre- vents the advent of that pronounced cyanosis so often seen, and which, when it is once established, may be only slightly benefited by oxygen. It thus gives patients an additional BRONCHITIS. CHRONIC. SYMPTOMS. 645 chance of life, and, furthemiore, in most cases it gives marked relief. If we ob- jected to give drugs in ailments unless they had a direct curative influence, our use of the pharmacopoeial remedies would be vei-j' limited. D. J. Leech (Praeti tioner, May, '98). Verba santa is extremely efficacious in the treatment of the second stage of bronchitis; it seems to diminish the watei'y and mucous constituents of the phlegm proportionately, so that this does not become more difficult of expectora- tion. The dose is 15 to 45 minims of the liquid extract. It forms a somewhat muddy mixture with water, but the addition of ammonium carbonate or bicarbonate of soda makes it clearer. Bronchial spasm in the course of the second stage of bronchitis is best treated with caflfeine or iodide of potassium. F. H. Edgeworth (Bristol j\Ied.-Chir. Jour., Sept., '99). In children true asthma is very rare, and chronic bronchitis does not occur. Bronchitis often recurs, or may be pro- longed, but it never becomes chronic. Emphysematous bronchitis is the most common form in children. There is al- ways some dj'spnoea, yet never marked asthmatic paroxysms. AVhen a child has many attacks, his bronchi become distended from loss of elasticity. This bronchitis is commonly observed with the infectious diseases, and in rachitic, lithEemic, or tubercular children. From 5 to 15 drops of I-per-cent. solution of iodide of arsenic thrice daily, with meals, has proved valuable in this con- dition. R. Saint-Philippe (Jour, de Med. de Bordeaux, May 5, 1901). Arsenic iodide is the best remedy in that form of infectious bronchitis which occurs in scrofulous children after grippe, measles, or whooping-cough. ■\Vhen taken with food it is said to be practically tasteless, easily digested, and well borne. The following formula is used: — B Arsenic iodide, 0.3 gramme (o grains). Distilled water, .30.0 grammes (1 fluidounce). Dissolve without the aid of heat. Five drops of this solution are given in a glassful of milk with each meal, the dose being increased by 1 drop morning and evening imtil 15 or even iiO drops are being taken as a dose. Ihe maximum dose is given for about a month, then gradually reduced to 5 drops, and this quantity is continued for a week, and then again increased as before. Saint-Philippe (.Jour, des Praticiens, xvi. No. 16, 1902). The following combination is useful: — Syr. scillee, I ounce. Ext. lobelife fld., I drachm. linct. opii, 2 y. drachms. ijxt. ipecac fld., 15 drops. Syr. pruni Virg., 1 V, ounces. Syr. picis liq., q. s. ad 4 ounces. M. Sig. : One teaspoonful in water four times a day. (Jour. Amer. Med. Assoc, .Jan. 31, 1903.) Chronic Bronchitis. Symptoms. — The onset of chronic bronchitis is usually insidious. It may follow immediately upon an acute at- tack which fails to subside or it may be gradual in its beginning, as in cases re- sulting from the long-continued inhala- tion of irritating material, such as me- tallic or crystalline dust or chemical vapors. Cough is the most prominent symptom. It is usually worse in the morning and after meals, but may give most trouble at night. It is usually ac- companied by free expectoration of thick muco-purulent material of white, yel- lowish-white, or green color, at times twanged or streaked with blood. In a small proportion of cases there is no ex- pectoration (dry bronchitis). Cough and expectoration are for a long time the only symptoms, but in ad- vanced cases (especially in elderly peo- ple) the right heart feels the strain of overcoming the increased tension in the pulmonary circuit, becoming dilated and causing circulatory embarrassment in the other organs (stomach, liver, and kid- neys). Pulmonary emphysema, bron- chiectasis, and asthma are the other 646 BRONCHITIS. CHRONIC. ETIOLOGY. PATHOLOGY. sequelas encountered. Exacerbations are readily excited, obstinate, and prone to leave increased organic change. Bronchorrhoea, so-called, designates but an exaggerated flow of the bron- chial secretions. These may be more or less watery, mucoid, or muco-purulent. As much as six pints have been expec- torated in one day by a single patient. On physical examination but little may be found in the "dry" form. Other- wise the findings will depend upon the extent and duration of the disease and the presence or absence of its consequences upon the remainder of the respiratory apparatus. In uncomplicated cases in- spection gives no result. On palpation a strong fremitus may be felt from the vibration of mucus within the air-tubes. The bubbling and rattling of this mate- rial may be audible at a distance. On percussion there is no change unless the pulmonary structure is already involved or bronchiectases have formed. On aus- cultation loud bubbling and mucous or sibilant and sonorous rales are heard, which shift their position or may be en- tirely dissipated by cough. Sometimes the breath-sounds over one portion of the lung may be feeble for a time from partial obstruction by mucus to the en- trance of air. The diagnosis presents no difficulties if careful examination of the chest and of the sputum be made. Etiology. — The chronic form is pro- duced by the same causes as those men- tioned under acute bronchitis acting for a longer time or frequently repeated. Insanitary surroundings, debility, and possibly inherited vulnerability are strong predisposing factors. Gout would seem also to be to some extent a pre- disposing cause. Mitral disease and enlargement of the tracheo-bronchial glands are contributing conditions be- cause of their causing interference with the return-flow of blood and lymph from the bronchial tree. Chronic bronchitis is very apt to be found in the two extremes of age. In children it may be associated with ad- enoid vegetations and enlarged lymphat-, ics and hypertrophied tonsils. Among older persons the more common causes of chronic bronchitis, aside from lym- phatic and scrofulous tendencies, are the gouty diathesis, insuilicient action of the heart, emphysema, and asthma. Six cases of bronchitis and bronclio- pneumonia caused, respectively, by chlorine-gas, sulphurous-acid gas, for- maldehyde, kerosene-smoke, and smoke containing some unknown acid fumes. In the first three cases the irritants had only caused bronchitis, while in the last three broncho-pneumonia developed. The writer concludes that the above forms of bronchitis are much more painful in the beginning than the or- dinary kind. They are likely to have loud, rough, wheezing rales, and, in the case of certain chemicals, fine, moist ones as well. This form of -bronchitis may easily go on to a broncho-pneu- monia. Hall (Phila. Med. Jour., Dec. 20, 1902). Pathology. — The appearance of the bronchi difl:ers much in accordance with the duration and severity of the disease. In the mildest forms the mucous mem- brane is of a dull-red or slate color, thickened, and corrugated longitudi- nally. In more severe or long-standing cases atrophy of the mucous membrane is present in places; and this atrophy may extend to the deeper layers of the tubes. Consequent upon this atrophy there is dilatation of varying degrees (see Bronchiectasis). When all of the coats are involved, infiltration and fibrosis of the surrounding connective tissue takes place, giving rise to one variety of fibroid disease of the lung. In elderly people the cartilaginous rings BRONCHITIS. CHRONIC. PROGNOSIS. TREATMENT. 647 frequently undergo calcification, render- ing the tubes rigid. Ulceration may oc- cur, but is rare unless bronchiectasis has occurred or there is tuberculous or syph- ilitic infection. Other organs are in- volved secondarily, such as the right side of the heart (hypertrophy or dilata- tion) or the pulmonary structure (em- physema, fibroid disease). Histologically sections of the bron- chi show marked proliferation of the epithelial layer, or, in long-standing cases, great denudation thereof. New formation of connective tissue within the tissue proper of the bronchi and in the peribronchial connective tissue is seen to an extent corresponding to the duration of the disease. Commensurate with the fibroid change in the walls there is atrophy of the proper cellular ele- ments. Prognosis. — The prognosis depends greatly upon the surroundings and so- cial condition of the patient. If re- moval from the chief causative factors (injurious occupations, unfavorable cli- matic conditions, etc.) is possible, the condition is curable except for possibly some permanent structural changes in the bronchial walls. Even with these the patient may be, to all intents and purposes, well. In the aged, in those already sufl'ering from cardiac degenera- tion, or in cases with serious structural changes (bronchiectasis, emphysema) the outlook as to cure is unfavorable, and as to amelioration is doubtful. Treatment. — The prime factor in treatment is the removal of the cause (insanitary surroundings, inhalation of dust, etc.). When the patient lives in a changeable or vigorous climate trans- plantation to an equable and mild re- gion is of itself often sufficient to pro- duce cure. Prophylactic measures to decrease the liability to exacerbations are important. The wearing of woolen underclothing, in order to prevent chilling of the surface; the practice of cool bathing on rising, in order to pro- mote vascular tonus of the skin; the correction of nasal and pharyngeal anomalies in order to do away with any "weak spots" favoring the "catching of fresh colds" — these are important ele- ments in treatment. At times treatment of the bronchial condition is best carried out by treat- ment of systemic faults or of an existing cardiac lesion in combination with more direct treatment of the bronchial ca- tarrh. In many cases an important element is the "building-up" of the pa- tient. One of the most valuable drugs is strychnine, which acts as a general tonic and is particularly valuable in stimulating the respiratory centre and toning-up the muscles, thus enabling the cough to be more efEectual. Its value in the aged is very great. Expectorant remedies are certainly of value, yet it must be borne in mind that they are very apt to upset digestion. Among them the ammonium compounds occupy a leading place. Where the ex- pectoration is scanty and the sputum viscid, the chloride is to be used; where the right heart is laboring, the carbon- ate acts best; when there is indigestion and especially flatulent distension the aromatic spirit is preferable. Iodide of potassium is of great value in liquefying the sputum, while its ab- sorbefacient properties may possibly di- minish the hyperplasia in the bronchial walls. In gouty cases it is of particular benefit. Cases of bronchitis of many years' standing cured with ichthyol given inter- nally in daily amounts of not less than V= drachm. It should be administered in gluten capsules in order not to be freed 648 BKONCPIITIS. CHRONIC. TREATMENT. in the stomacli. L<; Tanneur (Bull. Med., Jan. 24, '99). Encouraged by the favorable reports on the use of ichthyol in tuberculosis, grippe, etc., W. B. Jennings (St. Louis Med. and Surg. Jour.) began to use the drug in the common form of bronchitis in children which so often follows measles, whooping-cough, and acute, in- fectious diseases in general. He gives the histories of eight cases demonstrat- ing the good effects of ichthyol in the above-named conditions. It was admin- istered in the following combinations:— Ichthyol, gr. xxxii. Glycerini, Spt. aurantii, of each, 3ss. Aquse, ad gij. The author gives the following con- clusions: 1. The first dose often causes nausea and vomiting, but later the child grows inured to the taste of ichthyol. 2. Children under one year of age do not take ichthyol well. 3. To avoid the unpleasant effects of ichthyol it should be given after meals. 4. Increasing doses are not necessary for good results in childi-en. (Merck's Archives, July, 1902.) Case in a girl of 13, witn bronchitis, of six years' duration, following pertus- sis, accompanied with dyspncea, bloody expectoration, and spasmodic, violent coughing, which failed to improve on any treatment, including morphine, po- tassium iodide, creasote, belladonna, ipecac, sodium benzoate, bromoform, etc. She grew worse and had an attack of htemoptysis. Then powdered ichthyol was given, 15 grains a day. The effect was marvelous. Cough and expectora- tion both disappeared rapidly and she quickly recovered. H. de Brun (Jour, des Praticiens, Nov. 29, 1902). The balsams and various expectorant oils are of much value used by inhala- tion and internally. By inhalation they act directly upon the mucous membrane, while when given internally they exert their influence locally upon their excre- tion through the respiratory organs. The most useful are the compound tinct- ure of benzoin and the oils of eucalyptus, gaultheria, sandal-wood, cubebs, and copaiba. For inhalation these drugs may be used on the Yeo respirator, in a croup-kettle, or in a nebulizer. Crea- sote is of value where the stomach will tolerate it. Menthol, used by inhalation, is an excellent expectorant, allaying the violent attacks of cough. Topical treatment by direct inhala- tions from No. 65 Davidson atomizer, connected with an air-tank of about thirty pounds' pressure. The tip intro- duced into the mouth and the patient is instructed to make as prolonged an aspiration as possible, to inhale gently and repeatedly, drawing it into his lungs. Formulae found most useful: menthol, 1 to 2 per cent.; creasote, 1 per cent. ; camphor, '/j to 1 per cent. ; eucalyptus, 2 per cent.; pine-needles, 2 per cent.; in albolene or benzoinal. Average quantity to be inhaled is 2 drachms, after which the patients begin to gag. Kuh (Chicago Med. Recorder, Mar., '93). The treatment of bronchitis divides itself into modification of the function of the bronchial mucous membrane so as to alter the secretion, and also with the object of combating congestion to facilitate expectoration, to calm the cough, and to improve the general health. The chief agents which, after absorption, are eliminated by the re- spiratory passages, consist in greater part of balsams, of plants containing essential oils, sulphur and its com- pounds, and the iodides. Of the first class in particular are tar, balsam of Tolu, benzoin, turpentine and terpine, eucalyptol, and creasote. The incon- venience attending all is that they ex- ercise an irritant influence upon the stomach. Copaiba, though rarely em- ployed, nevertheless is found to be very efificaeioxis. Turpentine is usually employed in capsules holding 3 or 4 minims, but ter- pine has qiiite largely taken its place. Creasote aids in getting rid of the secre- tion, and acts deleteriously upon tu- bercle bacilli. The balsams are usually employed by inhalation. BRONCPIITIS. FCETID. SYMPTOMS. 649 Eucalyptol may be prescribed in cap- sules containing 1 grain and given three or four times a day; it is preferable to turpentine as it is not so apt to produce disturbance of stomach and kidneys. Lyon (Revtie de Th6r. Medico-Chir. ; Ther. Gaz., May 15, '97). In the treatment of senile bronchitis strychnine and ammonium carbonate are in the first rank. In acute exacerbations of chronic bronchitis ammonium carbon- ate, in 5- or 10-grain doses, given in 2 or 3 ounces of milk, is of great service. For chronic bronchitis and convales- cence from the acute form, strychnine sulphate, in from Vio to V20 grain, every three to six hours, not only does quite as much as the ammonium salt, but, in, addition, is a more powerful stimulant to the right heart. To disinfect the ex- pectoration, creasote carbonate, in 20- drop doses, given in 2 ounces of sherry, repeated every four hours until puru- leney disappears, is effective. Ordinary creasote should never be given to the aged. AVith copious secretion and diffi- cult expectoration this is the drug of choice. The use of opium or any of its alkaloids is most strongly condemned. Wilcox (Amer. Jour, of Med. Sciences, May, 1900) . Eespiratory g3'mnastics, by increasing pulmonary capacity and accelerating the pulmonary blood- and lymph- circula- tion, are efBcient. External applications to the chest-wall are of doubtful value in the absence of acute exacerbations and of pulmonary or pleural involvement. Systematic daily practice of full, deep inhalations of pure atmospheric air, and the judicious exercise of the deep mus- cles of the chest, are of great advantage. (Cassell.) In bronchitis, as in the case of collec- tions of pus, the object of treatment is to facilitate the draining away of the exudation. Often in the early morning the bronchitic brings up a large quantity of sputum by the help of more or less persistent coughing. At this time the patient should lie as flat as possible for a couple of hours, so as to assist the draining of the secretion into the large bronchi, and hence its expectoration. The patient can expectorate by turning the head to one side. After a few days the foot of the bed may be raised 8 or 12 inches. In suitable cases in two to four A\eeks there is a considerable dimi- nution in the sputum. This mode of treatment is adapted to cases of chronic bronchitis which have led to a cylindrical or sacculated bronchiectasis in the lower lobes of the lung. It is of no avail in cases of diffuse, and especially recent, bronchitis, with general secretion, or in cases of abscess-cavities communicating laterally or incompletely with the bron- chi, or of cavities with irritating eon- tents. Quincke (Berl. klin. Woch., June 13, '98). The diet should be nourishing and should be strictly regulated to the condi- tion of the digestive organs. Excess of starches is to be avoided because of their tendency to cause flatulence and con- sequent mechanical interference with respiration. In cases associated with gout the question of diet is one of ex- treme importance. Foetid Bronchitis. This form is only difEerentiated from others by the odor of the sputum. In many cases this is due to retention of the secretion in bronchieetatic cavities. (See Beonchiectasis.) Symptoms. — Fretid bronchitis begins as an ordinary bronchitis, which later as- sumes the purulent form; or it may be ingrafted upon a chronic pneumonia, a bronchiectasis, or even a suppurative pleuritis that has perforated into the lung. The early symptoms are those of simple bronchitis. The pulse is rapid and there is continuous fever, but the temperature-record is usually irregular. The change to purulent inflammation may be marked by a chill or a succession of chills. Eespiration is accelerated, and the severe cough causes the abundant 650 BRONCHITIS. FCETID. ETIOLOGY AND PATHOLOGY. TREATMENT. expectoration of an alkaline, semi- liquid, putrid sputum, which sometimes amounts to seven or eight hundred cubic centimetres per day. This sputum pos- sesses an odor said to be quite charac- teristic of the disease, and resembling somewhat that of acacia-blossoms. The disease may terminate favorably, or it may cause death by the development of pneumonia, bronchiectasis, abscess, or gangrene. There seems to be no specific sign or symptom of the affection, unless it be the peculiar odor of the sputum, which Lumniczer claims is developed by the growth of the bacilli that cause the disease. (Whittaker.) Death is generally due to exhaustion or through some intercurrent disorder kindred to the major affection. Ulceration, ampullar dilatation of the bronchi, pneumonia, pleurisy, gangrene, and metastatic purulent deposits in other regions are the main complications of this stage of bronchitis. Abscess of the brain may thus become the cause of death. Etiology and Pathology. — It is prob- able that in all cases retention of the secretion, with bacterial activity, is the cause of the foetor. Leyden and Jaffe found small rod forms, to which they gave the name "leptothris pulmonalis." They also noticed in the putrid sputum numbers of spirilla and infusoria. Lum- niczer describes a short, somewhat curved bacillus, which he found in great numbers in the plugs of pus and detritus expectorated, which give the sputum its characteristic foul odor. More recently Hitzig isolated two species of bacillus, the one presenting the characteristics of the coli bacillus — short, thick rods — did not liquefy in gelatin; was found pathogenic for guinea-pigs and rabbits. The second did not liquefy in gelatin and was pathogenic for mice and guinea- pigs. This question may still be said to be sub judice. Besides the causative factors acting in the case of chronic bronchitis, re- peated exposure to dust, especially that originating from dyed woolens or cotton fabrics, is prone to lead to the foetid form: a mere complication of those already described. Treatment. — The agents recommended in chronic bronchitis are also valuable here, especially the balsams, terpine, tur- pentine, or terebene. Five to 10 min- ims of the latter in capsules, taken after meals, are very effective in most cases. The preparations of tar, already mentioned, are also valuable. In cases in which the foetid expectoration only occurs at intervals, sandal yields gratify- ing results. Narcotics should be avoided. Hyposulphite of soda has been highly extolled; it promptly changes the char- acter of the expectorated material and thus eliminates the fcetor. Naphthalin is an excellent remedy in foetid bronchitis. Following mixture may be given: — • IJ Naphthalin, 1 drachm. Absolute alcohol, Syr. of wild cherry, of each, 1 Vz fluidounces. Fl. ext. of squill, 4 fluidrachms. Tinct. of aconite, 8 drops. Teaspoonful every three hours. The following capsules may be also taken with the above: — R Iodoform, Calcium phosphate, of each, 24 grains. Powd. ipecac, Ext. of hyoscyamus, of each, 6 grains. Powd. opium, 4 grains. Oil of anise, 10 drops. Divide into twenty-four capsules. One every three hours. Pirnot (St. Louis Med. Era, Sept., 1900). Intratracheal injections have been rec- BRONCHITIS. FIBRINOUS. SYMPTOilS. ETIOLOGY. 651 ommended, the agents used — menthol, camphor, etc. — being dissolved in oil or albolene. A Pravaz syringe with a long curved tip, which may readily be in- troduced into the larynx, is used. Fif- teen to 30 minims are well borne, and if properly applied excite comparatively no cough. Nitrate-of-silver solutions of varying strengths have also been em- ployed, but one exceeding 10 grains to the ounce is apt to excite laryngeal spasm. Still, much stronger solutions have been employed with impunity. Fibrinous, or Plastic, Bronchitis. In this variety the secretion from the mucous membrane tends to form co- herent easts of the bronchial tree. Symptoms. — Fibrinous, or plastic, bronchitis is characterized by the occur- rence of paroxysms of cough and dysp- noea, which immediately cease on the expectoration of the casts. The par- oxysms are usually preceded and fol- lowed by a sort of catarrh. Hasmop- tysis may be absent or it may be very 'serious. It usually ceases at once with the ejection of the casts. As a general thing, but little pain is present, except that caused by coughing. In acute cases the temperature may rise to 104° F.; in chronic cases it is seldom above nor- mal. Sometimes the onset of an attack is marked by one or more rigors: sug- gestive of pneumonia. As a rule, each attack consists of a number of short par- oxysms. It may subside after a few days never to recur again, or may last continuously for ten, fifteen, or twenty years. (West.) Auscultation and percussion reveal signs similar to those witnessed in chronic catarrhal bronchitis, but they occupy a limited area like those of ob- structed bronchioles; from time to time, intense paroxysmal cough occurs, accom- panied with dyspnoea and cyanosis, end- ing in the expectoration of the pathog- nomonic sputa. Etiology. — Although syphilis and tuberculosis have been considered as etiological factors, it is probable that these diathetic afEections were probably, in the cases reported, but concomitant disorders — manifestations originating in local and general depravity. Indeed, in many cases no diathesis, inherited or acquired, could be discerned. There seems, however, to be a familial tend- ency to the affection, several members of individual family having sufEered from it as a result of bronchial catarrh. This sufficiently indicates how obscure is our knowledge of the causes of this affection. Plastic bronchitis occurs fre- quently after pneumonia. In some cases it is associated with grave skin affections. There seemed in one case, also, to be a relation between the formation-casts and the catamenia. (West.) Analysis of all the cases recorded in the literature show that they can he grouped in nine classes as follows: I. Chronic bronchitis with expectoration of branching easts of the bronchial tree. 2. Acute bronchitis with expectoration of branching casts of the bronchial tree. 3. Cases in which branching casts were not expectorated, but were found in the bronchi at autopsy. 4. Casts ex- pectorated, but not showing branching. 5. Branching easts expectorated asso- ciated with organic heart disease. 6. Branching casts expectorated in pul- monary tuberculosis. 7. Small casts, often non-branching, associated with asthma. 8. Casts m the bronchi asso- ciated with pulmonary cederaa following thoracentesis. Cases incompletely re- ported. The most important form is the first, and the results show that it occurs in either sex, increases to middle age, and then declines, and in several cases the patients were exposed to dusty atmos- pheres. Occasionally some infectious disease precedes the attack, or there 652 BRONCHITIS. FIBRINOUS. PATHOLOGY. may be some chemical irritant, or a family history of tuberculosis. Nearly all the patients had suffered from chronic bronchitis for some time. The symptoms consist of an exacerbation of chronic catarrh. The disease is par- oxysmal and may last for many years. The symptoms are dyspnoea, cough, oc- casionally slight fever, and very occa- sionally haemoptysis. The physical signs are not characteristic, there may be all types of rales, and the patient may emaciate considerably. The subjective symptoms are usually oppression and tightness until the cast is expectorated. A curious feature is that in many eases there has been an associated affection of the skin. Of those casts examined the majority were composed of mucin. The bronchial mucous membrane usually does not show any characteristic change. In the acute form the symptoms are somewhat similar, but there is usually a history of an acute infectious disease. Bettman (Amer. Jour. Med. Sciences, Feb., 1902). Pathology. — The casts may be found rolled up in the form of balls in the sputum. On mixing the sputum with water the casts are unrolled and may be spread out with needles. In some cases they are associated with Cursch- mann's spirals and Charcot-Leyden crystals. Bronchial casts are occasion- ally seen in croupous pneumonia, in diphtheria, and in htemoptysis, but these casts are to be explained other- wise than as examples of fibrinous bron- chitis. Eppinger has observed that in croupous exudation there seems to be a central condensed mass of exudate, which serves as a nucleus upon which are deposited successive layers of trans- lucent fibrin. The mucous membrane is not infiltrated, as it is in a croupous exudation. Eppinger advanced the idea that on account of a chronic congestive catarrh of the bronchi the permeability of the walls of the vessels of the sub- mucous connective tissue is increased and allows the fibrinogenous substance of the blood to escape. This transuda- tion, moreover, is favored by the attenu- ated epithelial covering of the tubes: a condition that is the direct result of the catarrhal inflammation present in nearly all these cases. The exact cause of this cast-formation has not been definitely determined. That the casts are com- posed of mucus, and not of fibrin, has been definitely proved by Graudy. In a case in which the casts were expelled in great numbers Stirling foitnd that the majority measured from 3 to 4 inches, some as much as 6 inches. They had evidently been deposited in sitccessive layers and in concentric laminse, which could be separated when dry. They consisted of coagulated albumin soluble in alkalies. They showed fibrillary mate- rial, in the meshes of which were numer- ous leucocytes and fat-globules, some haemocj'tes, and epithelial cells. Octa- hedral crystals, said to be similar to those found in bronehitic asthma, have been observed by others, but the spirals seen by Curschmann were not found by Stir- ling. Case in which the autopsy showed that the pseudomembranes extended from the posterior nasal outlets clear down to the third divisions of the bronchi. The only bacteriological ele- ment found was the staphylococcus. 3. Glover (Anna, des Mai. de I'Oreille, du Larynx, etc.. No. 5, '96). Case in which the patient had suffered from the disease for some years, and was constantly expectorating bronchial casts. All the cover-slips from the casts showed streptococci; the inner surface showed micro-organisms of varying kinds, probably coming from the saliva. The disease due to the streptococcus; ^larmorek's antistreptococcic serum used. After two months' treatment the patient was discharged much improved. The reaction to the antistreptococcic serum a further proof of the nature of BRONCHITIS. FIBRINOUS. TREATMENT. 653 the disease. Claisse (Comptes-Rendus de la Soc. de Biol., Apr. 3, '96). Histological appearances in the bron- chi of a patient snflfering from this dis- ease who died of cardiac failure. Neel- sen had found them to consist of mucus: a view which had hitherto met with no support. In this case the easts were found to consist apparently of fibres inclosing masses of leucocytes and large, swelled, round epithelial cells. Weigert's fibrin stain gave no colora- tion, thionin a faint pink; Curschmann's spirals were absent, this being the sole point of difference from Neelsen's re- sults. The casts were thus composed of mucus, and not of fibrin. With re- gard to the bronchi, the epithelium was intact except in a few spots; Weigert pointed out many years ago that fibri- nous exudates only arose where the epithelium had been shed over large areas. In the case under notice the goblet-ceUs were unusually numerous, and the glands had undergone mucoid degeneration, their ducts being filled with mucus. The origin of the casts was thus obvious. Graudy (Centralb. f. allgem. Path., vol. viii, No. 13, '97). Examination of two cases secondary to valvular disease. Stained by Wei- gert's method, they showed very fine fibrin-fibres, most of the casts not tak- ing any stain (lithium carmine.) Chem- ical examination also showed the ab- sence of fibrin, but proved that the easts were made up chiefly of mucin. The casts were of acid reaction, and the writer thinks this is the cause of the coagulation. According to his view something, probably the action of bac- teria, causes the bronchial secretions to become acid. The mucus then coag- ulates. The same explanation appeared to the casts sometimes expectorated in croupous pneumonia, and was able to confirm his view in a case of the latter disease. A. Habel (Centralb. f. inn. Med., No. 1, '98). Case in which microscopical examina- tion of the lungs showed a rather exten- sive tuberculosis of the pulmonary tissue, but no tuberculosis of the bronchi. In fact, the mucous membrane of the bron- chial tubes was practically normal. In the pulmonary tissue a considerable quantity of fibrin was also present. Bac- teriologieally, only streptococci were found. Apparently there is desquama- tion from the alveoli of the lung, and masses of fat and epithelial cells are sometimes found in the easts. These con- ditions occur acutely and by a process analogous to that in eases of asthma: that is to say, as a result of desquama- tion itself, an exudation due to nervous influence, and a subsequent coagulation. The nature of the irritation is very various. Schittenhelm (Deut. Archiv f. klin. Med., B. 67, H. 3 and 4, 1900). Treatment. — The treatment does not differ from that of other forms of bron- chitis except the fact that alkalies (po- tassium iodide and carbonate) and alka- line steam-sprays are of more decided value. The iodide of potassium acts by stimulating secretion and thus assisting in the elimination of the pseudomem- brane. It must, however, be given in large doses. Inhalations of alkalies recommended. Especially valuable are aqua calcis, alone or with equal parts of water, or with 2 to 5 per cent, of carbonate or bicarbonate of sodium, in which the casts are soluble. Stirling (London Pract., June, '89). Case in which 45 grains in divided dose was administered daily to induce mucoid exudation in the bronchi and facilitate the ejection of the casts, which, in the present case, were found to consist mainly of mucin containing staphylococci and a special bacillus. The patient was permanently cured. Huchard (Semaine Med., July 28, '95). Potassium iodide is probably the most useful remedy in all forms of the dis- ease, as it increases the bronchial secre- tion when given during the acute parox- ysm, and thus aids in expelling the casts. It also seems to lessen the tendency to recurrence of attacks if given in full doses and for a long period 654 BUCKTHORN. BURNS. of time. J. W. Brannan (Med. News, Aug. 15, '96). Feedeeick a. Packaed, Philadelphia. BRONCHOCELE. See Goitee. BEONCHO-PNEUMONIA. See Pneu- monia. BRONCHORRHCEA. See Beonchitis. BUBO. See Syphilis and Ueinaey System. BUBONIC PLAGUE. See Plague. BUCKTHORN (CASCARA).— The bark of the European buckthorn (Eliam- nus frangula) and that of the Californian variety {R. pu'rshiana), in spite of the interested claims of manufacturers, are practically identical in medicinal effect; if there is any superiority, it lies with R. frangula. Both require that the bark should be carefully gathered, dried, and allowed to lie for at least two years in order to get rid of a principle therein that is likely to induce griping. The active (neutral) principle — "cas- cara sagrada," the source of the Cali- fornian bark — is supposed to be a gluco- side, termed "cascarin," but this bap- tism is entirely superfluous, since it is identical with the principle found in the European bark, known as frangulin and xanthin. Physiological Action. — -Buckthorn and cascara are laxative, slightly tonic, and stomachic. If both are prepared and administered in the same way, the results will be found to be identical. Preparations and Doses. — Abstract buckthorn (or cascara), 3 to 15 grains. Extract buckthorn (or cascara), 1 to 8 grains. Extract buckthorn (or cascara), taste- less, 1 to 8 grains. Fluid extract buckthorn (or cascara), 3 to 45 minims. Fluid extract buckthorn (or cascara), aromatic, 3 to 45 minims. Cascara cordial, 1 to 4 drachms. Elixir buckthorn, ^/^ to 2 drachms. Cascarin (or frangulin), concentration, 1 to 8 grains. Therapeutics. — These preparations, to secure their best laxative effects, should be given half an hour after meals, and increased or diminished in dose, or re- peated at lesser intervals, according to the action desired. In habitual consti- pation the best results are obtained by giving small doses at frequent intervals, thereby securing a continuous impres- sion on the digestive tract. BUNION. See Tendons, Buesitis. BURNS. Definition.- — A burn is a high grade of acute inflammation, following the direct or indirect application of dry or moist heat to a portion of the cutaneous or mucous surfaces. Varieties. — For ease of comprehen- sion burns have been separated into grades according to their severity. The character of inflammation observed in these grades is governed by the exciting agent, its capacity for the absorption of heat, the duration of its contact, and the susceptibility of the part acted upon. Solid substances (copper and iron) and the fixed oils (olive and linseed) cause a greater impression than volatile (alco- hol, ether, and chloroform) or aqueous (water and vapors) materials. Certain articles, owing to their tenacity (copper), although absorbing the same amount of heat as others (iron), cause more decided destruction. The length of contact, giving in the shorter periods a superficial incineration BURNS. SYMPTOMS. 655 and in the longer a deeper destruction, is of importance in determining the grade of inflammation. The more dense and thick portions of the skin (buttocks, palms, and soles) offer greater resist- ance than those of thinner (face, neck, and abdomen) texture. The effect upon the system will de- pend upon the character of person at- tacked, those of stronger constitutions being the more able to controvert shock than those of weaker frame. A temperature, slightly increased above the normal (as, for instance, 100° F.), produces only a slight hypersemia (first degree: dermatitis ambustionis erythematosa), which may disappear shortly after breaking the contact, while a rise to 150° F. will cause some appear- ance of vesicles and bulla (second de- gree: dermatitis ambustionis vesiculosa et bullosa) and destruction of the epi- dermis, the efEect of which is not re- lieved for days after the removal of the burning substance, and yet, on the other hand, heat at the boiling-point of water (313° F.) may cause a complete carbon- ization of the part, resulting in the formation of eschars varying in color from a yellow up to a dark brown or black or, in other words, the production of gangrene (third degree: dermatitis ambustionis escharotica sen gangrenosa). Symptoms. — The effects of a burn upon the body-structure are both local and constitutional. The former often results in great disfiguration or destruc- tion of tissue, while the latter depresses the vital forces or terminates in death. Local Effects. — In burns of the ■first degree the appearances produced are superficial. There will be observed a dis- tinct hyperaemia with redness of varying intensity from the slightest blush up to a pinkish red or brownish red. This may or may not be entirely effaced by pressure. Persons of fair complexion or thin, delicate skin are affected more greatly by the same amount of heat than will be those of darker hue or more dense integument. Swelling is present to a slight degree and does not extend far beyond the limits actually exposed to the burning substance. This type of bum is produced by indirect contact with the flame of a lighted match, prox- imity to a heated metal, escaping steam, and the actinic rays of the sun. With or without treatment the effect of burning to this extent may disappear shortly after removing the exciting cause. Eesolution takes place in this variety by the disappearance of the swelling, the serous infiltration being absorbed, the color diminishing to the normal except in those cases in which a slight degree of pigmentation is left in the form of ordinary increase, which usually disappears as time progresses or where the sun's raj^s cause perhaps a per- manent stain such as lentiginous patches. The linear fissures of the skin appear prominent because of the semidetach- ment of the membrane between them, which, as time passes, the new skin form- ing beneath compels their complete de- tachment in the form of minute flakes of deadened epithelium. In burns of the second degree the in- flammation, while yet superficial, may still occupy the entire epidermis. In some cases the upper layers alone of the cuticle may be destroyed, while vesicles or bulla may be observed over the af- fected surface. In still other cases the corium is stripped entirely of its epi- dermal covering or particles of the mem- brane may be rolled into whitish masses over its exposed surface. These vesicles or bulla may be produced directly by the contact of the heated article or indirectly by the consequent inflammation. They 656 BURNS. SYMPTOMS. may retain their contents or, owing to the increased flow of serum, their walls, becoming thin and losing their elasticity, rupture, thus allowing the escape of a continual discharge over the denuded surface. The true skin, which is ex- posed either entirely or at points, shows a highly-reddened surface, over which this continual exudation may be ob- served. The papillary vessels are seen to be deeply congested, or, if ruptured, their flow of blood intermingles with the discharge of serum and gives it a tint of red. Swelling is present in both of these conditions, but is governed by the extent of surface and the density of the part involved. In this type of condition actual contact with the heated substance takes place either in shorter or longer durations. Such articles as heated iron, transient or lengthened action of flames, and boiling liquids may be the exciting agent. The effects of this form of burn do not always shew to what extent they have progressed immediately upon the removal of the cause, because of the sys- temic conditions which may be induced. Pain is always present to a minor or ma- jor degree. Eesolution takes place through co- agulation of the serous discharge, which occupies the involved area as a fibro- albuminous covering, beneath which the new skin is allowed to form. After the new integument has progressed almost to its normal aspect this covering, which by this time has become a darkish crust, becomes loosened and falls off, exposing a thin, delicate skin, through which the more vascular structures immediately beneath are observed. It is not for weeks, months, or even years that the normal pinkish-red tint of the skin is restored. Burns of this character usu- ally leave a fairly-normal aspect to the surface and rarelv cause the formation of cicatrices. If a cicatrix is formed, it is generally superficial and flattened, resembling, to a marked degree, the flat, sebaceous warts observed in the aged. In the burns of the third degree the inflammation or destruction may be su- perficial, extending over considerable area, or deep, affecting the subcutaneous tissues, muscles, and even bones. In those of the superficial variety the ex- tent of surface-involvement may be vari- able, in one instance occupying a por- tion comparing with the size of the hand, and in others being observed upon por- tions ranging from six or seven inches to areas as large as one limb or even one-third or one-half of the surface of the body. In this variety the epidermis alone may be destroyed and expose the corium to view, covered with particles of charred cuticle, or the corium itself may share in the destruction, being deposited over the affected areas in strips of dried eschars. The parts uncovered by these destructive influences present, either the corium or subcutaneous tissue, a highly- vascular aspect, from which there is a continuous exudation of serum inter- mingled with the escaping blood. The dead tissues vary in proportion according to extent of heat, its length of contact, the thinness or density of the part in- volved, and the amount of surface en- compassed. They may be thin or thick, large or small, and retain their hold for longer or shorter periods. Eesolution takes place in the uncov- ered variety in the same manner as de- scribed under the foregoing degree, while in the covered variety granula- tions spring up beneath the charred re- mains which, after a time, desiccate and fall off, exposing a similar surface to that of the second degree. In the deeper form of burn the extent of surface involved may be small or BURNS. SYMPTOMS. 657 large, but may dip down to varying depths. It may be limited to the de- struction of the skin (epidermis and corium) and the subcutaneous tissues, or it may expose the muscles, attack the nerves and blood-vessels (allowing hem- orrhage), and even the' bone. The amount of charring will usually be very great and will lay about in masses over the burned surface, thus preventing a view of the destruction beneath. In some cases the degree of loss will be so enormous that the bone will be entirely stripped of all covering. Hemorrhages will often be encountered and may re- sult fatally. Fractures of bone will oc- casionally complicate matters. This variety will show both the first and sec- ond degrees at areas remote from the greatest destruction. Resolution even in the milder cases is slow, and before such happens surgical interference may be demanded. The same appearances may be noted throughout its process as found in the superficial variety, but to a different degree. The causes which bring about this form of burning are usually dry heat (flames or contact with electric wires), and it generally causes much greater destruction than will moist heat. The effect upon the system is generally of an alarming character, and shock may carry off the person before relief can even be attempted. Electric and X-ray Burns. — Burns from electricity may be observed in all the varieties mentioned above. They may follow direct or indirect contact. Examples of direct contact are observed after handling live (charged) wires, and may be found to destroy all parts with which it comes into touch, or life even may be the forfeit. Case of severe electrical bum in an electrician employed in the electric plant used to furnish power to the city street- 1- car line and to the arc and incandescent lights of the city. The patient had acci- dentally brought his back in contact with the positive and negative keys of the switchboard of arc-line furnishing 96 street-lamps and carrying 4000 volts of electricity. He was released by the tissues' being burned away in two pits about three inches in diameter and down to the bony structures. The intervening space between these pits, which were ten inches apart, was roasted, and after the lapse of a few weeks was lifted out. It weighed two pounds and a half. The sloughing was such that the cotton, bandages, clothing, and bed were sat- urated with pus. Recovery. J. F. Weathers (N. Y. Med. Jour., Apr. 2, '98). The following peculiarities attributed to electrical burns: At first they look dry, crisp, and bloodless, and are exca- vated. But serious oozing and hyper- Eemia occur within thirty-six hours, pain is moderate, and the systemic shock con- siderable. N. W. Sharp (Phila. Med. Jour., Jan. 29, '98). A most recent form of burning of the skin from the indirect contact of elec- tricity is by the x-ray apparatus. Close proximity to the ray by either covered or uncovered parts result either in a super- ficial or deep inflammation of the skin. It may be observed a few hoitrs after ex- posure to the rays or may be delayed for several weeks. Gilchrist, of Baltimore, in a case did not see any eiSect for sev- eral (three) weeks after exposure, while Crocker, of London, observed a case in which the effects were produced in one day thereafter. This form of burning attacks the skin alone in some instances, while in others the deeper structures, as the muscles, tendons, nerves, and bones (periostitis and ostitis resulting) are in- volved. The effects may remain for days, weeks, or even months after the application. X-ray burns are supposed by some to be produced by the action of the ray or by particles of aluminium or 658 BURNS. COMPLICATIONS. platinum reaching and being deposited in the tissues by others. The x-ray per se is incapable of injur- ing tlie tissues of the patient, and the dermatitis, which has been called an x- ray "burn," is the result of an interfer- ence with the nutrition of the part by the induced static charges. The patient may be absolutely pro- tected from the harmful effects of tliis static charge by the interposition between the tube and the patient of a grounded sheet of conducting material that is readily penetrable by the x-ray, a thin sheet of aluminium or gold-leaf spread upon card-board making an effectual shield. C. L. Leonard (N. Y. Med. Jour., July 2, '98). Burns of Mucous Surfaces. — The mu- cous surfaces may be affected by the in- halation of flames, vapors (volatile or boiling acids), boiling liquids (water, slacked lime), and by certain substances acting directly, such as ammonia and sulphuric and hydrochloric acids. The mouth, pharynx, larynx, bronchi, and the oesophagus, as well as the stomach, share in the attack. The eye often, from its exposed position, is the seat of burn. Conjunctivitis often results from irritants coming into direct contact with the eye, and if the exciting agent is not soon removed great destruction of sub- stance or sight may be the result. Constitutional Effects. — The ef- fects of burns of the first degree upon the system are generally slight and are limited to pain, which disappears shortly after the removal of the exciting agent, but often may last for several hours. In burns of the second degree the pain accompanies the phenomena not alone for hours and days, but often for weeks and even months. The shock may be of a transient character or of an alarming intensity. It may be encountered at the time of accident or be delayed for peri- ods varying from hours to days there- after. When small areas are involved, the depression may soon be relieved, but when one-fourth or one-third of the body is attacked death may intervene. Burns of the third degree may be so severe that death intervenes before pain has time to appear. Shock at this stage is therefore observed early and of the worst character. Early mortality is gen- erally due to the shock, while late mor- tality usually occurs during the stage of suppuration. Vomiting is often ob- served in both the second and third de- grees. Children suffer more from burns than do adults, and women more severely than men. The temperature is not af- fected by burns of the first degree, but is a marked symptom in those of the second and third. At the time of acci- dent it may decrease from one to three degrees below the normal (to 97° or even 95°) and remain at that point until reaction begins, which is in about 36 or 48 hours, when it rises during the nest 12 to 18 hours to 104° or 106° or more, at which point it remains for a period of 8 to 10 daj's (possibly rising and low- ering at irregular intervals), when gran- ulations, now in a fair formation, act as a retarding agent. Complications. — The after-effects of burns may be concentrated upon the vis- cera (neural, thoracic, and ventral cavi- ties) or directly upon the part affected (cicatrices, contractions, and fractures of bone). Burns of the first degree remain uncomplicated, while those of the second and third present many variations. The meninges (arachnitis following burns of the head), as well as the brain proper, may become congested or even highly inflamed, the sufferer presenting all the symptoms of restlessness and delirium, ending either in convulsions or coma. Tetanus is an early complication ob- BURNS. COMPLICATIONS. 659 served. Bronchitis and pneumonia often resiilt either from inhalations or indi- rectly from surface burns. Congestion in the kidney has been noted, with re- sulting albuminuria or hsemoglobinuria, while in many cases the urine becomes exceedingly scanty. Autopsies have shown rupture of the diaphragm and stomachy accompanied by contraction of the bladder. Amyloid degeneration in the viscera has been noted after pro- longed siippuration. Inflammation of the gastro-intestinal tract with the for- mation of an ulcer (usually one, but more rarely several) of the duodenum (at its pyloric end) frequently occurs. This ulceration may begin early (four or five days) or it may be delayed for weeks, although, without the appearance of rec- tal hEemorrhage or perforation, with con- sequent peritonitis, we have no means of determining its presence. At times this inflammation extends to the colon and causes diarrhoea. Burns affecting either the chest or abdomen are the inducing cause, although severe burns at other points may produce them. Septicaemia, pyeemia, or erysipelas (the streptococci being found after death in the blood) may be the fatal ending. Autopsies on the bodies of five small children who had died of severe burns: The most noticeable gross lesions were cloudy swelling of the liver and kidney, acute swelling of the spleen, and swell- ing and congestion of the lymphatic glands and other lymphatic tissue. Mi- croscopically the most interesting lesions noted were parenchymatous degeneration of the kidneys and liver, focal areas of necrosis in the liver, and pronounced focal necrosis in the lymphatic tissue. The lymphatic tissue was affected throughout the body. The Malpighian corpuscles of the spleen, the tonsils, the gastric lymphatic follicles, the enteric, solitary, and agminated follicles, and the lymphatic glands, all showed essentially the same changes. The lymphatic glands were much swelled and at times con- gested. The earliest changes were in the follicles, and consisted of an oedematous swelling. This was more marked toward the centre of the follicle. In areas of less advanced alteration the lymphocytes «ere merely less closely packed together than is usual, but in the areas of more marked change the lymphocytes were swelled and their nuclei fragmented. The focal degeneration in the lymphatic follicles of the tonsil and of the stomach and in the Malpighian bodies of the spleen is essentially similar to that of tlie follicles of the lymphatic glands. In these areas of degeneration in the lym- phatic tissue we find appearances essen- tially similar to those seen after the in- jection into the body of various bacterial and other toxalbuminous substances. Tlie lymphatic glands from the cases cf skin-burn might readily be mistaken for the lymphatic glands of children dead of diphtheria. The lesions in the other organs are also essentially similar to those found in the bodies of persons dead from acute infectious diseases. One of the main causes of death after burns, therefore, is in a to.Ksemia caused by alterations in the blood and tissues, the direct effect of the elevations of tempera- ture. Bardeen (Johns Hopkins Hosp. Bull., Apr., '97) . The theories of the causes of death from bums may be divided into four classes: (I) death from shock or extreme pain; (2) embolism, thrombosis, and destruction of the blood-elements; (3) pya^mic infection through the burned surface; (4) poisons formed by the ac- tion of heat on the tissues, or autoin- toxication from deficient excretion by the skin. By experimenting upon dogs and rabbits it is personally claimed that the intoxication theory is the correct one. Injection of large quantities of artificial blood-serum subcutaneously appeared to save life in several cases. Azzarello (Giorn. Ital. delle Mai. Ven. e delle Pelle, fase. 11, '99). Two sets of experiments conducted to determine the influence of the skin in producing the poisons which lead to a fatal issue in burns, from which it is con- cluded that the blood itself, rather than 660 BURNS. DIAGNOSIS. tlie tissues, is the seat of the chemical change. E. Scholz (Miincheiier med. Woch., Jan. 30, 1900). 1. The entire pathological picture presents great similarity to the condi- tions found in the diseases characterized by the presence of toxins of bacterial origin in the blood. 2. Damage to the lymphatic tissue is a constant feature, but is not neces- sarily focal, some cases presenting only diffuse degeneration. The cases which live but a few hours after infliction seem more likely to present a focal con- dition than those which live a longer time, as the condition which the writer interprets as proliferation and phagocy- tosis is one which may very rapidly dis- appear. 3. The focal lesions are not a true necrosis, but rather a proliferation of the endothelial cells of the reticulum and the capillaries, and a phagocytosis by the leucocytes and endothelial cells, to which latter is due the fragmented, disintegrated appearance which suggests a true necrosis. John McCrae (Amer. Medicine, Nov. 9, 1901). The attempt of nature to restore a covering for these denuded tissues often results unwisely. Vicious scars, ad- hesions of contiguous parts (causing webbed fingers, the arm being attached to the side by granulations), and deform- ities may be encountered. Cicatrices ■may be small and flat or large and rugous. The skin may be as soft and ipliable as in the normal state, or tightly stretched and drawing the parts from their anatomical position. Calcareous degeneration or even epithelioma may attack the scars. Pressure upon the terminals of the nerves may either cause neuralgia or spasm of the glottis, which may demand surgical interference for its removal. Finally, keloidal tumors may be observed as a consequence of vicious scarring. They will not differ from those produced by other abnormalities and will accept all the gyrations en- countered in other conditions. All of the scar may not be affected with keloid, as, for instance, one end may show the prolongations, while the other resembles ordinary cicatrices. The contractions of the skin after scarring may produce great deformity and the hand may be drawn backward upon the arm or talipes cal- caneous may result or other disfigura- tions too numerous to mention may be shown. Exposure of joints has taken place followed by ankylosis. Bones have been fractured from loss of substance (cooking of the muscles). Siag^nosis. — Ordinarily the recognition of burns is not a difficult task, although the differentiation of the varieties, espe- cially of the second and third degrees, may demand careful examination. Burn- ing flesh with destruction of its particles, exposure of the underlying tissues (mus- cles, bones, etc.), will be a train of symp- toms not to be controverted. The dif- ference between burns and scalds often may occasion difficulty, but the fact of the greater and deeper destruction of the former with the more superficial char- acter of the latter will generally be suf- ficient. The loss of hair follows the former because of this deep destruction of the hair-follicle and papilla. Legal aspects of burns. In cases where the persons have been alive when they were exposed to the fire, soot is found in the ramifications of the trachea and bronchi. If the red blood-corpuscles are found disintegrated and disfigured throughout, then this is a further sign of a person having been burnt while alive; the blood of animals which have been burnt or scalded after death shows only occasionally a few broken-up, cre- nated, or polymorphous red corpuscles; as a rule, the red blood-corpuscles retain their shape and integrity, and appear only swelled and paler. Robert Neupert (Friedreich's Bl. f. ger. med. u. Sani- tsetspol, vol. xlviii, pt. 3, '97). BURNS. PATHOLOGY. 661 The diagnosis of death from burns cannot be made solely from the e.xtemal appearances. Blisters which are not filled with serum arise during life. Bright-red blood of charred corpses arises from the direct physical action of the heat and from the production of car- bonic-oxide hsemoglobin. The presence of carbon monoxide in the blood is an almost positive proof that the person during life was not exposed to the influ- ence of fire. The finding of soot or charred material in the respiratory pas- sages is certain evidence that the indi- vidual was living and breathing during and in the presence of a fire. Lipkau (Deutsche med.-Zeit., Aug. 13, 1900). Pathology. — The condition immedi- ately following a burn is that of dimin- ished blood-supply to the part attacked. This seems in part to be due to the de- creased size of the vessels, probably fol- lowing a spasm of the vasomotor system. As the blood is prevented entrance into the smaller blood-vessels there is a con- sequent engorgement of the viscera, with actual congestion or even inflammation of their mucous linings. The process does not end here, but we note a change in the corpuscular elements of the blood itself; the lumina of the blood-vessels are decreased, which allows the for- mation of thrombi with more or less complete general stasis and possibly re- sulting in a cardiac paralysis. This over- stimulation of the mucosae may account for the degenerate changes which have been observed in the abdominal viscera, ending, as stated, in the formation of ulcerations of the duodenum or which have caused the extension of the inflam- mation to the colon and terminate in the production of diarrhoea and hfemor- rhage. Thus the mode of death is ap- parently due in some cases to the forma- tion of pulmonary thrombi which oc- casion this paralysis of the heart. Other cases probably end in narcotic poisoning from absorption of the dead epithelium or from the burned clotliing or other adhered materials. The gases of the blood diminish markedly. The organism of burned per- sons manufactures toxins in large quan- tity and of characteristically noxious quality. E.oger and Guinard (La Se- maine Med., Nov. 3, '94). The cause of death from severe burns is intoxication by pathological cleavage- products of the body-proteids, which are caused to break up into abnormal and poisonous compotmds. Their presence in the urine is of grave prognostic import, for one of the cases did not appear at first to be of great severity, although it terminated in death. Sigmund Fraenkel and Spiegler (Wiener med. Blatter, No. 5, '97). Of the theories that have been held as to the cause of death in eases of burns, Sonnenburg's is the most probable: that of a. reflex lowering of the vascular tone, with consequent cardiac paralysis; but parenchymatous changes and degenera- tions in the kidneys, Kings, brain, etc., are to be taken into account. Case in which numerous streptococci were found in the blood after death, this showing- that burns should be treated with strict regard for antisepsis. Tsehmarke (Cent, f. Chir., July 10, '97).. After examining the blood in ten cases the writer records the following points; The blood flows sluggishly, and is of a peculiar dark, purple appearance. An immediate increase in the number ot erythrocytes, in severe, but not fatal, cases, of from 1,000,000 to 2,000,000 per cubic millimetre, takes place within a few hours; in fatal cases, of from 2,000,000 to 4,000,000 per cubic milli- metre. A rapidly increasing leucoeytosis constantly occurs, — in cases ending in recovery often of 30,000 or 40,000 per cubic millimetre ; in fatal cases usually above 50,000 per cubic millimetre. Morphological changes in the erythro- cytes are slight. The percentage of neutrophiles is somewhat above the normal, but not so much as in the ordinary inflammatory leucoeytosis. A considerable destruction of the leuco- cytes takes place, especially in very severe burns. Myelocytes may be pres- 662 BURNS. PROGNOSIS. TREATMENT. ent in small numbers in severe cases. There is, as a rule, marked increase in the nimiber of blood-plates. E. A. Locke (Boston Med. and Surg. Jour., Oct. 30, 1902). Prognosis. — The termination of tliis class of injuries is often of serious import especially when medico-legal questions arise. This should be determined by the several factors which arise in each case. Consideration must be given to indi- viduality of the sufferer, both his age and constitutional acquirements; the ex- tent of the burn, both as to surface and depth involved; the location of the in- jury, and the nature of the exciting medium. The effects upon strong, ro- bust subjects are not so marked as upon those of weaker constitutions, and, while the same degree or extent of burn will soon be recovered from by the former, the most dire results may follow in the latter persons. Thus it may be noticed that burns among machinists, glass- blowers, plumbers, and foundrymen will not be so serious as would the same de- gree or extent among clerks or those engaged in gentlemanly pursuits. Col- ored persons suffer less severely than do the white. Females, on account of more delicate systems, are less able to resist shock than are the males. Middle life is not so severely affected as are children or aged people. Some persons may be able to resist the shock only to be car- ried off by the complications that arise. Surface involvement seems to exert a greater depression or fatality than does depth of tissue. A burn, even of the first degree, which occupies an extended area and those of the second may terminate fatally if one-fourth or one-third of the superficial parts are involved; a fatal issue may also occur in burns occupying one-half of the body-surface. A burn of the second degree which occupies only a limited extent of surface, but which de- stroys the epidermis entire, may end in recovery, while those of the third may, through their deep involvement, produce complications with which we are unable to combat. Burns occupying the abdo- men give the highest mortality, while those of the thorax are only second to a slightly minor extent; but those of the head, neck, and limbs prove fatal in many instances. [Of 26 cases seen by Sajous after a boiler explosion, on the Lake of Geneva, in 1892, 22 died within a few hours after the accident, although, with few excep- tions, the scalds, though involving the greater part of the body, did not reach beyond the epidermic layer, excepting over the face and hands. Ed.] Of the 298 men killed or injured on the Japanese side of the Battle of the Yalu, a large number had received burns cover- ing an area of more than one-third of the body. Only 2 out of the 57 cases of this class recovered. Susuki (Boston Med. and Surg. Jour., Dec. 9, '97). The nature of the exciting medium often governs the termination of burns, and those produced by cohesive bodies cause the greater destruction of part or life. The length of time required for the partial or complete reparation of the sur- face may be an important question in medico-legal cases. This can only be governed by the type of injury, the length of contact of the exciting agent, the nature of the affected person, and the general aspects of the case in ques- tion. Treatment. — Constitutional. — The constitutional treatment is to be directed toward the relief of pain, the restoration of the depressed vitality at the time of accident, — i.e., sustaining the system throughout the entire restorative proc- ess. Pain is best relieved by opium, or its alkaloid, morphine (preferably by hypodermic injection), because these agents have little, if any, depressing ac- BURNS. TREATMENT. 663 tion upon the cardiac functions. The dose required will be much greater than ordinarily used, because of the sudden character and great amount of depres- sion in these injuries. Vitality must be restored as quickly as possible, and the use of ammonia (preferably carbonate), strychnine, and caffeine (because of their stimulating effect upon the cardiac muscle); hot drinks, such as milk and tea; alcoholic drugs in the form of whisky or brandy, and the production of local or gener- alized sweating. A most desirable plan of restoring heat is by using hot-water bottles placed at regular points so as to diffuse its effects. Other means, as, for instance, covering the body with a sheet and conveying heat through a pipe or by placing heated bricks beneath this covering. To keep the sufferer fairly comfortable during the local treatment stimulation must be kept up, care being taken not to produce overactivity and thus allow reaction to prove as deleteri- ous as the effect of the burn. The functions of the body must be regulated, the bowels being kept free or confined, according to the conditions present; the action of the kidneys should be watched. In some cases it may be wise to anaesthetize the patient during the first few hours immediately follow- ing the burn, and especially during the first dressings of aggravated cases. Local. — The local treatment is to be directed toward the limitation of the re- sulting inflammation, the prevention of septic infection, assisting the normal elimination of the eschar, the develo]i- ment of granulations, and limitation of the deformity. In burns of the first degree little or no treatment may be demanded. In the more aggravated cases of this type the application of home measures, such as bicarbonate of sodium, the white of egg and sweet oil (equal parts), lead- water and laudanum, and the various hot or cold means generally at the dis- posal of housewives. Burns of the second and third degrees must be more strenuously treated. It is often a difficult problem to know which is the more soothing application to be advised and from which we may get the better result. In one case hot applications, in another cold; in some wet, and in others dry, measures are to be given. The vesicles, if numerous, should be untouched; but if only a few, they are best evacuated. Prof. S. D. Gross was wont, in many mild and severe cases, to use ordinary white-lead paint; the results achieved were often marvelous. [This is a remarkably efficacious meas- ure. Mere paintiug of the burn, as if it were an article of furniture, etc., causes immediate cessation of the pain. Ed.] The use of carbolized vaselin (15 to 30 grains to the ounce), watery solutions of carbolic acid (about 20 grains to the ounce), subnitrate of bismuth (V2 to 1 drachm to ounce of ointment of zinc oxide or petrolatum), boric acid (either in watery saturated solutions or oint- ments of either zinc oxide or petrolatum in strengths varying from ^/, to 2 drachms to the ounce), bicarbonate of soda in almost full strength (in ointment or watery solutions), and starch in vary- ing proportions will usually be found very efficacious. Turpentine, where granulations are sluggish, will give excellent results used either in full or diluted strengths, giv- ing care not to produce too much stimu- lation. H. L. Mclnnis states that spirit of turpentine applied to a burn of either the first, second, or third degree almost at once relieves the pain, while the burn 664 BURNS. TREATMENT. heals. After wrapping a thin layer of absorbent cotton over the burn, the cot- ton is saturated with common turpen- tine and covered with bandages. Being volatile, the turpentine evaporates, and it is therefore necessary to keep the cot- ton moistened with it. When there are large vesicles, these are opened on the second or third day. It is best to keep the spirit off the healthy skin if possible to avoid the local irritation. Turpentine applied to a burn of either the first, second, or third degree will al- most at once relieve the pain. The burn heals very rapidly. It is applied as fol- lows: After wrapping a thin layer of absorbent cotton over the burn it is saturated with the turpentine and band- aged. The common eonmiereial article found in every house is sufficient. H. L. Mclnnes (Brit. Med. Jour., Sept., '96). Surgery of this day has placed many excellent antiseptics at our disposal, and there is no better application than bi- chloride of mercury in the proportion of 1 or more grains, preferably the former, to 1000 parts of water and kept in con- stant contact, the dressings being made without removing the former cloths. Ichthyol in watery solutions (1 or more drachms to the ounce), or in glyc- erin similar strength), or even in oint- ment form (with zinc oxide or petrola- tum, about 1 to 3 drachms to the ounce) and the iodine derivatives, such as iodol, aristol, europhen (given preferably in ointment, 15 to 30 grains to the ounce of petrolatum or lard) are reliable meas- ures. Ichthyol is efficacious in treatment of burns of the first and second degrees. It allays the pain at once and slight superficial burns heal rapidly. In burns of the second degree with the formation of bulla, even when extensive areas are involved, the remedy also acts favor- ably. It is used dry, diluted with zinc oxide or bismuth, the powder being spread evenly over the surface; in oint- ment (10 to 30 per cent.) ; or as a com- bination of these two methods. The powder is the most satisfactory form in extensive burns of the first degree, and should be plentifully applied. In extensive burns of the second degree the soft paste is preferable. The zinc-oxide powder may be com- bined as follows: — 1} Zinc oxide, 20 parts. Carb. magnes., 10 parts. Ichthyol, 1 to 2 parts. While the paste is mixed as follows : — IJ Carbonate of lime, 10 parts. Zinc oxide, 5 parts. Oil, 10 parts. Lime-water, 10 parts. Ichthyol, 1 to 3 parts. Leistikow (Monat. f. prak. Derm., Nov. 1, '95). Ichthyol used in eases of severe burns with remarkable success. It is applied pure and in a rather thick layer, talcum powder being then liberally sprinkled on it, and plenty of cotton batting applied, the whole being fixed in place by means of a strip of soft material. The bandage should not be renewed. After three or. five days it is removed. If the contents of large vesicles are gelatinous, or if the vesicles are already cracked, it is neces- sary to remove the detritus before ap- plying the ichthyol. Disinfection is entirely unnecessary. Should the bandage have become wet through from excessive secretion on the second day, it should be removed, and a new application of ichthyol with fresh cotton be made. Fr. E. Mueller (Aerztl. Rundseh., No. 21, '99). Thiol has been found useful for all degrees of burn. According to Bidder, it allays pain very rapidly and arrests cutaneous hyperemia. In this manner it tends to prevent ulceration and scar- ring. Thiol especially valuable in burns of the second degree. Suppuration and cicatrices are avoided even after burns of the third and fom-th degrees. The BURNS. TREATMENT. 665 parts are first washed with a weak anti- septic solution, and the cuticle that may be hanging loose from ruptured blisters is removed, taking care to leave intact those that have not opened. After dusting the burn with boric acid the entire surface of the burned region and the skin around it are painted with a solution of equal parts of thiol and pure water. A layer of greased cotton is then laid on the burn, and kept in place with a loose bandage. Giraudon (These de Paris, '95). Aristol — which occurs in crystals of a light-reddish-brown color, soluble in water, slightly soluble in alcohol, and freely soluble in ether and fats — is another valuable agent in burns of the second and third degrees, and has been found strikingly effective where other remedies have failed. Pain is almost instantly relieved and healing is rapid. Haas (Deutsche med. Woch., p. 783, '94). It may be used in the form of powder or mixed with oil or vaselin. The sur- face should be disinfected with a boric- acid lotion, and after opening the vesi- cles aristol is applied and the whole is covered with sterilized cotton-wool, gutta-percha paper, and a bandage. The application of aristol powder directly to the wound at the beginning hinders the dressing from soaking up the secretion; when the latter has diminished, how- ever, aristol may be applied either alone or in a 10-per-cent. ointment with olive- oil, vaselin, and lanolin. Aristol is of great service in the treat- ment of scalds and burns. After a thorough disinfection and cleansing of the burned area, and the opening of the vesicles, a dressing is . applied of aristol salve, smeared upon sterilized gauze in a layer of about the thickness of a knife- blade, and this dressing is changed daily. The dressing is covered with cotton, and held in place with gauze bandages. In personal cases, at first an aristol salve, consisting of 5 grammes; ol. olivse, 10 grammes; lanolin, 40 grammes, was ap- plied, and, when the wound surface had become smaller and granulations had formed, aristol powder was dusted on, and covered with gauze and cotton. Edward Roelig (Deutsche med.-Zeit., No. 56, '99). Of late the French surgeons have lauded picric acid used in saturated solu- tions with water (increasing the solubil- ity by means of the addition of 1 ounce of alcohol, as the acid is soluble to the extent of only 2 drachms to the quart of water). They claim that it is par- ticularly useful for the relief of pain and that it greatly assists the formation of granulations. I can subscribe to both of these statements, as many excellent results have followed its use in my hands. A remedy for burns must be analgesic, antiseptic, and also keratogenous : three qualities possessed by picric acid in so- lution of 1 to 200. Its use is also free from accidents sometimes caused by antiseptics. Filleul (L'Union Pharm., Deo., '95). Picric acid employed extensively, using a solution made by dissolving 1 Vj drachms of picric acid in 3 ounces of alcohol, which is then diluted with 2 pints of distilled water, a saturated solu- tion being thus procured. The clothing over the injured part should be gently removed, and the burnt or scalded portion should be cleaned as thoroughly as possible with a piece of absorbent cotton-wool soaked in the lotion. Blisters should be pricked, and the serum should be allowed to escape, care being taken not to destroy the epi- thelial surfaces. Strips of sterilized gauze are then soaked in the solution of picric acid, and are so applied as to cover the whole of the injured surface. A thin layer of absorbent cotton-wool is put over the gauze, and the dressing is kept in place by a light linen bandage. The moist dressing soon dries, and it may be left in place for three or four days. It must then be changed, the gauze being thoroughly moistened with the picric- 666 BURNS. TREATMENT. acid solution, for it adheres very closely to the skin. The second dressing is ap- plied in exactly the same manner as the first, and it may be left on for a week. The great advantages of this method of treatment are: First, that the picric acid seems to deaden the sense of pain; and, secondly, that it limits the tendency to suppuration, for it coagulates the albuminous exudations, and healing takes place under a scab consisting of epithelial cells hardened by picric acid. A smooth and supple cicatrix remains, which is as much superior to the ordi- nary scar from a burn as our present surgical sear is superior to that obtained by our predecessors, who allowed their wounds to granulate. D'Arey Power (Medico-Surg. Bull., Feb. 10, '97). Personal experience in fifty cases has shown that it is advisable to let the shreds of clothing which have been burned into the skin remain until the second dressing; the cloth having been asepticized by burning, it will do no harm by remaining, while removal can only be accomplished by stripping away the flesh. The cloth will act as a capil- lary drain into the skin and it will pro- mote a permeation of the acid solution into the injured tissue. At a second dressing the thoroughly-soaked fibres can be more easily removed. Dressings soaked in picric-acid solution do not ad- here as much as other applications. Thompson (St. Louis Med. Review, Feb. 20, '97). Picric acid is only useful in burns of first and second degrees, its particular action being to stimulate the growth of epidermis. It allays pain. In burns of tlie third degree it checks suppuration, but does not hasten granulation. C. Willems (Ann. de la Soc. Beige de Chir., May 15, '98). The best topical application to hasten cicatrization in burns is picric acid. Its application is recommended from super- ficial burns to those of the third de- gree. It is contra-indicated in deep, old, or suppurating burns, and in very young children. Technique consists of antiseptic cleansing of the burn in a picric-acid bath of 1 per cent., with a careful preservation of the epidermis. This washing is to be repeated, taking all possible care to prevent raising the epidermis. When bums are very super- ficial, remarkable cures have been ef- fected by painting with ether or alcohol saturated with picric acid. Dakhyle (Le ProgrSs M6d., Jan. 7, '99). The combination of picric and citric acids, which Esbach devised for the de- tection of albumin, is more effective than the picric acid alone, in burns of the second degree. Esbach's solution consists of 10 parts of picric acid, 20 of citric acid, and 1000 of water. Without any elaborate at- tempts at antisepsis the bullae and vesi- cles should be opened with a clean blade and the fluid applied freely, care being taken that the solution reaches the in- terior of each one. The combination after the first smart has passed removes the pain very quickly. After the excess of fluid has drained oflf the part may be covered with tissue or soft gauze and left undisturbed for several days. After two or three days the fluid should be reapplied to such areas as are moist and the part carefully recovered. E. M. Alger (Ther. Gaz., June 15, '99). For burns in infancy and children the best application is a 1-per-cent. aqueous solution of picric acid. This gives al- most immediate relief from pain, and healing takes place rapidlj'. After the burned area has been coated once or twice with the solution a thin laj'er of absorbent cotton may be applied dry, and over this a layer of impervious tis- sue, and, finally, as much cotton as may be required for warmth, protection, ex- clusion of air and germs, and over this a loose bandage. Charles Warren Allen (Pediatrics, Mar. 15, 1901). Some French observers also claim that it is not poisonous, and that, excepting its effect upon the urine, which it turns very yellow, it has no other bad effects; but negative evidence has been adduced, however, and several cases of poisoninfj (smarting at the part of application, with the production of vomiting in tlie course of twenty-four hours) have been BURNS. TREATMENT. G67 recorded by Walther, Berger, Labouche, Tuffier, and others. Colic, diarrhoea, yellowish discoloration of the skin, sleep- iness, and scanty, dark-colored urine were the main symptoms. Calcined magnesia is a valuable agent for the treatment of burns of the first and second degrees. The affected parts are covered with a thick layer of a paste, which is prepaicd by mi.xing the calcined magnesia with a certain quantity of water. This paste is allowed to dry on the akin, and when it becomes detached and falls off it is re- placed by a fresh application. Very soon after the paste is applied the pain ceases, and under the protective covering formed by the magnesia the wounds recover without leaving the cutaneous pigmenta- tion which is so often observed to fol- low burns that have been allowed to remain exposed to the air. Vergely (Revue M6d., Feb. 10, '96). Iodoform is anaesthetic and antiseptic. It may be left in situ for a considerable period — a week — without necessitating a change of dressing. It should not be strewn upon the raw coriiim nor upon granulating tissues. After accidents by burning, and par- ticularly where the surface of the skin destroyed has been very extensive, atrophy of the optic nerves has resulted. It is also known that iodoform is capa- ble of giving rise to a form of toxic amblyopia, resembling somewhat closely that produced by alcohol or tobacco. Whether these eye-symptoms are due to the burn in all cases, or to absorption of iodoform (and similar substances) ap- plied to the wound, the possibility of the occurrence of a condition so very serious ought to be borne in mind. Terson .(Arch. d'Opht., Oct., '97). Nitrate of potassium, or nitre, has been found to be useful in all kinds of burns, and may be employed to great advantage when the other agents described cannot be had. It acts mainly as a refrigerant by causing notable lowering of the tem- perature of the liquid used as solvent. If a burned hand or foot is plunged into a basin of water to which a few spoonfuls of the nitrate have been added, the pain ceases rapidly; if the water be- comes slightly heated, the pain retui-ns, but it is allayed as soon as a fresh quan- tity of the salt is added. This bath, which is prolonged fi'om two to three hours, may bring about the definitive disappearance of the pain and even prs- vent the production of blisters. The ap- plication of the compresses also exercises the same influence. By this means tlie pain is allayed and cicatrization takes place without delay. Poggi (Revue M6d., Feb. 16, '96). Any complication, such as bleeding, of small or large vessels, must be checked by appropriate surgical measures. Sep- sis must be prevented by the early re- moval of any obnoxious material. Parti- cles of dead skin laying over the surface are to be removed, clothing if present, if that can be accomplished without any further destruction of the tissues, thereby exposing the healthy parts, or producing pain to the sufferer. Emphasis upon the great importance of keeping the injured part aseptic; the patient may recover from the shock only to die of blood-poisoning. This is espe- cially to be feared where the side of the face and the chest are extensively burnt. The wound should be at once thoroughly disinfected. It is then covered with sub- nitrate of bismuth, and then with iodo- form gauze, kept in place by light band- ages. Tschmarke (Deutsche Zeit. f. Chir., vol. xliv, pp. 346-392, '97). The fatal result in severe burns is due to the absorption of a toxic substance derived from chemical changes in the burnt tissues. The lethal tendency is best met by removing the necrosed tis- sues and infusing saline solution. Three cases of very severe burns in which the patients were in a most critical condi- tion, with stupor, suppression of urine, etc., in which recovery followed as a re- sult of this method. The infusion was repeated daily for several days. Para- scandolo (Centralb. f. Chir., Apr. 27, 1901). 668 BURNS. TREATMENT. Calcium liypochloride an excellent antiseptic. It is not largely used for burns, and therefore attention is called to the good results which have been obtained by the author. Having been dissatisfied with the usual methods of treating burns, putting up one foot of a smith, who had been burned on both feet, with calcium hypochloride, and the * other one with oil was tried; the foot treated with the calcium healed in a fortnight, while the other took four weeks. A cool bandage with oil is now applied on the first day, which causes the vesicles to form quickly, and after twenty-four hours these are opened, under antiseptic precautions. Com- presses steeped in the solution are then applied, and this is renewed after twenty-four hours, but they are kept moist by pouring on fresh solution dur- ing that time. It is of importance to leave the compresses on as long as pos- sible, and to keep them constantly damp. Great care must be exercised in removing the old compresses not to disturb the scabs under which the wound is to heal. The solution which the author uses is: — B Calc. hypochlor., 2.4 to 5 grammes (37 grains) (circa). Aquae destil., 9.900 grammes (35 ounces) . Solve, filtra, et adde: — Spt. camphor., 5 grammes (85 minims). E. Tichy (Deutsche med. Woeh., July 17, 1902). Granulations may often be assisted by powders of acetanilid in full strength, dusted over the surface, or by the use of some of the iodine derivatives, such as iodol, europhen, or aristol (15 to 60 grains to the ounce of powdered starch or ointment), applied to the exposed sur- face. Limitation of deformity is a very seri- ous problem. Splints are to be placed so as to prevent the parts from losing their anatomical relation and should be kept applied for some time after the parts have healed because of the in- herent tendency of the contraction for long periods, even years, after the ap- parent cure. Bandages are to be kept continuously applied to prevent con- tiguous surfaces from becoming agglu- tinated. Massage must be advised at the very earliest moment so as to restore the pliability of the part and prevent anky- losis, when a joint is involved. Even with all the measures that we can adopt the loss of skin-tissue may be so extensive that skin-grafting will be the only means with which we can hope to restore the integrity of the part. The relief of cica- trices or contractions, ankylosis, or press- ure upon the nerve-filaments sometimes requires the most energetic siirgical in- terference. Electrical Burns. — Electrical burns, according to Elder (Montreal Med. Jour., Jan., 1900), from contact with a "live wire" differ greatly in their behavior from ordinary burns. At first the clin- ical picture is very much that of moist gangrene or that of severe frost-bites. The pain is often very severe. The shock present is due both to the electrical con- tact and tO' the burn per se. They re- quire one and a half to three times as long for recovery as ordinary burns. The sloughing affects principally the muscles and blood-vessels, and the blood does not appear to show anj' tendency to clot in these burns. Case of severe burns caused by an electric current of 2000 volts. The pa- tient, an electrician, 23 years old, came in contact with a live wire and received severe burns of the head, chin, right shoulder, and wrists. The burn on the head was followed by necrosis of the bone and suppuration of some of the gray matter, for which the patient was trephined. After a protracted illness the man made a good recovery. Lapsa- koff (Bolnitchnaja Gazeta Botkina, Oct. 16, 1902). Treating Electrical Burns. — The treat- CAJUPUT-OIL. 669 ment found most ef&cacious by Elder (Montreal Med. Jour., Jan., 1900) is to keep the limb in a warm carbolic-lotion bath of 1 in 100 strength, taking pre- cautions against the possibility of the occurrence of secondary hemorrhage. If secondary hemorrhage occur, or when a definite line of demarkation has formed, the necrosed tissue must be removed. In many cases amputation is necessary, but the skin-flaps should not be closed, be- cause large masses of muscles are sure to slough away subsequently. The wound should be allowed to granulate, and sub- sequently be skin-grafted. Immediately after the burn hypodermic injections of morphine (Vg grain) and strychnine (V30 grain) may be given alternately. To lessen the offensive odor the 1 in 100 carbolic lotion may be replaced by a bath of 1 in 10,000 perchloride of mercury. In addition, morphine, phenaeetin, caf- feine, chloral-hydrate, and potassium bromide may be administered together. Treatment of electrical burns consists in immobilization of the part and pro- tection with sterile gauze, and, if the burn is extensive, skin-grafting. Mally (Eevue de Chir., Mar. 10, 1900). J. Abbott Cantkell, Philadelphia. BTJTYL-CHLORAL. See Chloral. CADE. See Junipee. CAFFEINE. See Coffee. CAJUPUT-OIL. — This is a bright- green, mobile, volatile oil had by dis- tillation from the leaves of the Melaleuca leucadendron {M. cajuputi): a tree in- digenous to the Orient. It has a strong camphoraceous odor and aromatic, bitter taste. A rectified oil is also obtainable, which may be colorless or of light-bluish- green hue, but with age is apt to turn yellow. With an equal volume of alcohol cajuput-oil affords a clear solution which either has a slightly-acid reaction or is neutral. The chief constituent is held to be cajuputol, which is claimed to be identical with eucalyptol, though this requires verification, therapeutically at least. Preparations and Doses. — Cajuput-oil, 1 to 10 minims. Essence of cajuput (oil of cajuput, 1; rectified spirit, 9), 10 to 60 minims. Cajuput mixture (Hunn's life-drops: oils of cajuput, anise, cloves, and pepper- mint, of each, 1 part; rectified spirit, 4 parts), 30 to 60 minims. Physiological Action. — Taken inter- nally, oil of cajuput causes a sensation of warmth in the stomach, excites the action of the heart and arterial system, and subsequently induces copious dia- phoresis. Externally, either alone or combined with equal parts of soap-lini- ment or olive-oil, it is rubefacient. Therapeutics. — This is a remedy of much power and value, one too much neglected in general practice. Unfort- unately its therapeutic value is not un- derstood, and its chemical relation, real or supposed, has done the drug great injustice. It is powerfully stimulant, carminative, stomachic, antispasmodic, anthelmintic, and antiparasitic; also has a slight narcotic and anodyne action. Gout and Rheumatism. — When ap- plied topically, and also given internally, in these affections, this remedy is often of the greatest service; it should be given by the mouth in 4- to 6-drop doses, as often as every second hour, and some- 670 CALCIUM. PREPARATIONS. PHYSIOLOGICAL ACTION. times every hour in retrocedent gout, in which it is especially serviceable. Intestinal Fluxes. — In cholera in- fantum, cholera nostras, Asiatic cholera, and the lesser intestinal fluxes, it has been greatly lauded, and, while it often appears of incalculable value, it is known to be a somewhat uncertain remedy. Nervous Diseases. — In hysteria it is sometimes beneficial, particularly hys- terical dysmenorrhoea; also in those neuralgias that are of purely nervous type, — i.e., not dependent upon a local- ized inflammation. Febrile Maladies. — In low fevers it is, perhaps, the best diffusible stimulant known, and it deserves far greater at- tention as regards this class of maladies than has been hitherto accorded to it. External Use. — Externally applied, cajuput-oil is of value in the treatment of a number of skin maladies. It is also useful, oftentimes, in sprains and con- tusions, etc. CALABAR-BEAN. See Phtsostigma. CALCIUM.— This metal is not found in nature in its pure state, but appears in the mineral kingdom as marble, lime- stone, calcspar, gypsum, selenite, alabas- ter, fluorspar, apatite, phosphorite, etc.; in the animal kingdom as a phosphate and carbonate. It is present in all vegetables. Calcium is a light, yellow, very hard, malleable, and ductile sub- stance that melts at red heat, tarnishes in air, and decomposes water. It is rapidly acted on by dilute acids, and when heated burns with a brilliant, white light. In medicine it appears only in the form of salts, and the physio- logical action is modified by the indi- vidual acid constituent. Preparations and Doses. — Calcium bromide, 10 to 60 grains. See Bromine. Calcium benzoate, 5 to 10 grains. See Benzoic Acid. Calcium carbonate (precipitated), 5 to 40 grains. Calcium chloride, 5 to 15 grains. Calcium hippurate, 1 to 5 grains. Calcium hypophosphite, 3 to 6 grains. Calcium iodide, 1 to -1 grains. See Iodine. Calcium lactate, 1 to 5 grains. Calcium phosphate (precipitated), 10 to 30 grains. See Phosphorus. Calcium sulphate (gypsum). Used in the preparation of plaster of Paris. Calcium sulphide, ^/n, to 3 grains. Calcium sulphocarbolate, 2 to 5 grains. Calcium salicylate, 2 to 8 grains. See Salicylic Acid. Calcium hypophosphite, syrup, 1 to 4 drachms. Calcium iodide, syrup, 15 to 30 minims. Calcium lactophosphate, syrup, 2 to 4 drachms. Lime-water, 1 to 4 ounces. Lime-water, chlorinated, 30 to 60 minims. Physiological Action. — Lime neutral- izes any excess of acid in the stomach and intestines. It is but slowly absorbed and passes into the blood only in small quantities, although sufficient is taken up to promote nutritional changes. It also exerts a digitalic action on the heart : when the proportion of lime present is deficient, the contractions are weak; but when the quantity is increased they be- come powerful. It is eliminated by the intestines, and to some extent by the kidneys, inasmuch as the urine becomes alkaline under its administration. Pure precipitated carbonate of cal- cium appears to be medicinally of less value than the impure form, which ob- tains the names of "precipitated" and "prepared chalk"; both are neutral CALCIUM. THERAPEUTICS. 671 salts and antacids, but the latter is more astringent. Calcium chloride is stimulant, astrin- gent, alterative, resolvent, and antisep- tic. Calcium sulphide acts very much like the chloride, but is more powerful. The effects of both depend upon their power to readily and quickly part with their gaseous constituents, viz.: chlorine and sulphuretted hydrogen, respectively. The former is more powerfully irritant and cathartic. Lime-water is chiefly antacid, but at times appears to act as a sedative to the gastric viscus. It, as well as certain of the lime salts, not infrequently gives rise to disturbance of digestion and loss of appetite; vomiting has been observed to follow its employment. There may be an increase in the amount of urinary secretion, but the stools are usually re- tarded, though sometimes diarrhosa is a result. Calcium peroxide forms a yellow alka- line powder slightly soluble in water. It possesses a decidedly good action in acid dyspepsia and summer diarrhoea occurring in children. It acts as a powerful antiseptic because of the nas- cent oxygen liberated in the intestines. Daily dose ranges from 3 to 10 grains, according to the age of the child; best given in milk. It is advisable to dis- pense the preparation in parchment papers preserved in well-closed glass- stoppered bottles, to prevent decomposi- tion. I. Eeszkowski (Merck's Bericht, 1900). Therapeutics. — Diarrhceas. — - Pre- cipitated chalk is chiefly employed for its neutralizing effect upon the acid secretions of the prima vice; hence finds place among the remedies recom- mended for the diarrhoeas of infancy and childhood; it is also astringent, and usually prescribed in conjunction with opium. It is not, however, the valuable remedy claimed by earlier writers, and its place, to considerable degree, has been most advantageously usurped by bismuth subcarbonate and cerium oxa- late; further, the more modern treat- ment of intestinal fluxes is directed toward removal of the cause, rather than, as formerly, combating a mere symptom. Calcium chloride — not calx chlorata — has on several occasions been relegated to the list of obsolete remedies, but as often has been again brought forward. There is very little difference in ther- apeutic applicability from that of calcic sulphide, except in degree of activity and size of dose; therefore the remarks re- garding one may be safely considered as equally true of the other. As Alteratives and Eesolvents. — - Both are applicable to a number of mala- dies, chiefly those of a strumous, septic, or pseudoseptic character; they have likewise been employed to some extent in the different forms of tuberculosis. It is freely soluble in water. Skin Disorders. — Chloride of cal- cium will often abort furuncles and pro- duce a salutary influence upon all stru- mous cutaneous affections: acne, lupus, etc. It has recently been recommended as a depilatory. In many instances it will abort fu- runcles, but the most marked effect of calcium chloride is in acne. All stru- mous cutaneous affections, especially lupus, are often benefited by it. The caries and necrosis of the same diathesis, rickets, indurated glands, and tabes mesenterica are also conditions in which it may be employed with some expecta- tion of benefit. Ovarian and uterine tumors are reported to have decreased in size under long-continued use of the drug. It is also a powerful irritant and cathartic. In all itching skin diseases calcium chloride may be given after meals. There are no absolute failures, but it remains to be determined in what class 672 CALCIUM. CAMPHOR. of cases it is most useful. Saville (Brit. Med. Jour., vol. i, '97). Calcivun sulphide recommended as a depilatory. It is perfectly harmless to the skin and does not irritate abraded surfaces. It can be made by heating a granulated mixture of plaster of Paris (calcium sulphate) with granulated wood-charcoal (to take otf the oxygen). A high temperature is necessary, and it is best obtained by means of gas. A muffler is used — i.e., set in cinders or bone-ash — and the mixture is heated to redness. The dry, rose-colored or whit- ish product is applied to the skin in a wet condition, or it may be put on dry ana then wetted. A. W. Brayton (Jour. Amer. Med. Assoc, Apr. 16, '98). Pneumonia. — In the past the remedy has been much lauded in pneumonia, and lately it has again been recom- mended in this malady. In lobar pneumonia calcium chloride reduces temperature and keeps it within safe or normal limits in spite of the con- tinuance of physical signs. Moreover, there is a tendency for the morbid proc- ess to be arrested at whatever stage the drug is given in efficient doses, whereby the course of the disease is shortened or rendered milder. Also there is singular freedom from all anxiety, distress, and danger: a freedom not usually asso- ciated with continuous high tempera- ture. Crombie (Practitioner, London, '96; Med. Age, Mar. 10, '96). HEMORRHAGE. — On the plea that chloride of calcium was capable of in- creasing the coagulability of the blood Wright, Freudenthal, Perry, and others have tried this preparation in the bleed- ing of haemophilia. It is to be given in 2-grain doses every four hours. Acting on Fi-eund's theory that co- agulation of the blood is directly pro- portionate to the excess of calcium phosphates, these salts were employed in serious heemorrhages ; 15 Vs grains were given every 2 hoiu^s in water until 2 or 2V2 drachms of the hypophosphite of calcium was administered. Metror- rhagias, intestinal hsemorrhages (ty- phoid), gastrorrhagia, and epistaxis were very rapidly checked. For check- ing most haemorrhages this may be re- lied upon. M. Silvestri (Bull. MSd., Feb. 6, '98). Influenza. — In doses of 1 grain daily calcium sulphide has, on various occasions, shown a very favorable action over influenza, and not infrequently the attack is aborted. Calcium eosolate is valuable in the treatment of diabetes insipidus, diabetes mellitus, and chronic ulcerative phthisis. Dose is from 4 to 10 grains three or four times a day. It is soluble in from 8 to 10 parts of cold and in 7 parts of hot water. H. Stern (Jour. Amer. Med. Assoc, xxxiv, p. 467, 1900). CALCULI, BILIARY. See Chole- lithiasis. CALCULI, SALIVARY. See Sali- vary Glands. CALCULI, VESICAL. See Urinary System, Surgical Diseases of. CALOMEL. See Mercury. CAMP FEVER. See Typhus Fever. CAMPHOR. — This is a peculiar, con- crete, volatile substance obtained by sublimation from the Cinnamomum cam- plwra : a native of China, Japan, and some of the isles of the East Indian Archipelago. Camphor is also found in white crystals in the fragments in the wood of Drrjopalanops campJiora. It appears in small quantities in various other plants, and Tenasserim camphor, which is of fair quality, is a yield of the leaves and stalks of Blumea grandis (or campher). It is sparingly soluble in water, but freely so in alcohol, ether, chloroform, and fluid and volatile oils; vrith chloral or carbolic acid it forms a clear liquid. As found in the shops, it is a white, translucent gum of tough. CAMPHOR. PREPARATIONS. PHYSIOLOGICAL ACTION. 673 almost crystalline structure, possessed of a pungent, bitter taste that leaves in the mouth a feeling of coolness. Camphor is incompatible with acids, iodine, etc. Camphoric acid is formed by oxidation of camphor with nitric acid, and appears as a white, microcrystalline powder, very slightly soluble in water, with a faint aromatic odor and slight, saline, cam- phor taste. - Camphor-chloral is merely a mixture of equal parts of gum-camphor and chloral-hydrate whereby is produced a colorless, syrupy liquid, which is soluble in alcohol, ether, chloroform, benzin, glycerin, fixed oils, and aqueous solutions of chloral; but when added to water it is decomposed, the chloral passing into solution, while the camphor is precipi- tated. Camphor-menthol is made by rubbing together equal parts of menthol and camphor whereby a clear liquid is formed. Camphor-thymol is made in the same way, precisely, as camphor- menthol. Other compounds are formed in like manner of the two foregoing by combining camphor and salol and cam- phor and resorcin. Camphor-oil is a crude residual product resulting from the distillation of camphor-gum. Camphor-monobromate, or monobro- mated camphor, is had by heating cam- phor-gum and bromine, previously dis- solved together in benzin, and then crys- tallizing from hot alcohol; it is almost insoluble in water, but readily dissolves in alcohol, chloroform, ether, and fixed oils. Camphor-salic3date may be prepared by heating together carefully 84 parts of camphor and 6.5 parts of salicylic acid, until a liquid, homogeneous solution is formed, which becomes a crystalline mass on cooling; this again becomes unctuous when compressed, and liquefies when rubbed on the skin. It may be obtained in definite crystals from a benzin solution. It is slightly soluble in water and glycerin, about 1 to 20 in fats or oils, and is decomposed by hot alka- line solutions. By boiling with water it hydrates into an oily liquid. Carbolized camphor, or phenol-cam- phor, is had by adding 2 parts of cam- phor-gum to 1 part of carbolic acid, and is a colorless, oily liquid, soluble in fixed oils, alcohol, and ether, but nearly in- soluble in water and glycerin. Preparations and Doses. — ■ Camphor- chloral, 2 to 20 minims. Camphor, carbolized, external use only. See Phenic Acid. Camphor-gum, 2 to 20 grains. Camphor-liniment (camphor, 1; olive-, peanut-, or cotton-seed oil, 4). Camphor liniment, compound (cam- phor, 20 drachms; lavender-oil, 1 drachm; strong ammonia-water, 5 ounces; rectified spirit, 15 ounces). Camphor-menthol, 1 to 5 grains. Camphor, monobromated (bromide of camphor), 1 to 12 grains. Camphor-oil (crude), external use only. Camphor, salicylated (salicylate of camphor), 1 to 5 grains. Camphor spirit (tincture of camphor), 5 to 30 minims. Camphor-thymol, 1 to 5 grains. Camphorated oil (camphor, 1; sweet almond oil, 9), 5 to 60 minims. Camphorated tincture of opium (pare- goric), 30 minims to 4 drachms. See Opium. Camphoric acid, 5 to 30 grains. Physiological Action. — Externally camphor is somewhat rubefacient, readily irritating the skin. Given in- ternally, it acts chiefly upon the brain, cord, and circulatory apparatus. In small doses it increases the action of the 674 CAMPHOR. THERAPEUTICS. heart and arteries: the pulse is rendered softer and fuller. It exhilarates the spirits, and excites warmth of body, pro- moting diaphoresis; but these effects are transitory and fleeting and apt to be fol- lowed by depression. In larger doses it is sedative, antispasmodic, somewhat hypnotic and analgesic, and sometimes markedly anaphrodisiac. In poisonous doses it irritates the gastro-intestinal mucous membrane; induces nausea, vomiting, vertigo, delirium, maniacal ex- citement, and convulsions of an epilepti- form character; cardiac prostration and muscular weakness are often very pro- nounced. It is antidoted by emetics, rapid-acting cathartics, and stimulants. Case of a lady, 78 years of age, who took an unknown quantity of spirit of camphor. About an hour after taking it she became comatose, and finally ap- peared to be dead. Consciousness re- turned after a considerable interval, and it was found on examination that her right hand and right side of her face were paralyzed. In four weeks she was able to walk about the room with assist- ance. Some five months later she could pick up a pin from the floor with the af- fiioted hand, and there was no perceptible trace of the facial paralysis. Treatment consisted of tonic doses of nux vomica and gentle massage to the affected parts. T. B. Greenley (Amer. Pract. and News, July 15, 1900). Camphor-chloral combines the virtues of the two drugs from which it is de- rived; it is sedative, hypnotic, and nar- cotic. Monobromated camphor is moderately stimulating and diaphoretic, but is scarcely a succedaneum for other bro- mides; it decidedly lowers temperature; is anodyne, antispasmodic, and narcotic; in large doses, sedative. In very large doses it depresses and weakens the heart's action. Salieylated camphor acts very much like monobromated camphor; it is less antiseptic, however, and more analgesic. Very large doses of either this or the monobromated form induce muscular trembling and clonic convulsions. Camphoric acid is antiseptic, some- what diuretic and astringent, and anti- sudorific. It is eliminated chiefly by the urine, which it renders clear and acid. The physiological action of the other preparations is not sufficiently differ- ential to require mention. Therapeutics. — As an Antigalacta- GOGUE. — The external uses of camphor are many and varied, and exemplified in almost every household. The tincture applied to the breasts of the nursing woman proves markedly antigalacta- gogic: an effect which is heightened and materially aided if the same is also ad- ministered at the time by the mouth. The most desirable method is to di- minish the patient's drink, administer purgatives, and place over the breasts an ointment or liniment of camphor; to also give camphor internally in doses of 1 or 2 grains, once, twice, or thrice daily. When both tlie external and internal treatment bj' camphor are resorted to, the decrease in the secretion of milk is quite remarkable. Herrgott (Indfip. Med.; Med. Age, '97). Febeile and Infectious Diseases. • — In low forms of pyrexia camphor is often a remedy of great value. A solu- tion in acetic acid was at one time held to be an almost specific in common con- tinued, pestilential, exanthematic, and puerperal fevers; and even yet it is ad- mitted to be of great value, but difficult to administer. It is, however, contra- indicated where there is either a flesh- red tongue or tenderness of the abdomen with diarrhoea. Latterly, more espe- cially in Europe, the hypodermic admin- istration of camphor dissolved in sweet almond oil is lauded in these maladies; CAMPHOR. THERAPEUTICS. 675 also in asthenic and advanced stages of acute inflammations when the vital povcers are greatly exhausted, and in delirium accompanied by depressed nerve-energy; but it sometimes requires to be reinforced, so to speak, by other stimulants and sedatives. In the main, however, the administration hypodermic- ally has little to commend it over in- gestion by the stomach. In infectious diseases, the exanthe- mata, pleuro-pneumonia with meningeal symptoms, in infectious endocarditis, etc., more especially if the patient is in a condition of collapse, 15 to 45 minims of a 10-per-cent. solution of camphor- ated oil afford prompt relief, employed subcutaneously. Even so much as 15 grains of camphor daily, far from ag- gravating, ameliorated cerebral symp- toms. From 7 to 15 grains produce remarkable restorative effects. Schill- ing (La Med. Moderne, Nov. 30, '95). In influenza, pneumonia, typhoid, broncho-pneumonia, etc., camphorated oil yields good results, but should be administered before the patient is too weak; it produces an increase of ar- terial pressure, free expectoration, and a feeling of physical well-being. If given by the mouth its taste may be disguised by essence of pepermint. It appears to be contra-indicated where there is great cerebral excitement. Tuassia (Gaz. deg. Ospitali, Mar. 8, '92; Brit. Med. Jour., Mar. 26, '92). Camphoric acid in ^/^-drachm doses one hour before bed-time, with a glass of milk or water, is of value for night- sweats. The medicine is best given dry on the tongue, and then washed down with water or milk. Coston (Ther. Gaz., Mar. 15, '99). In small-pox and other exanthemata, when the eruption has receded, camphor in small and oft-repeated doses fre- quently causes restoration; but if there is inflammation of important viscera the drug is contra-indicated. Mental and Nervous Diseases.- — In the past, camphor obtained a fore- most place in the treatment of insanity, and there is every reason to believe it is now too much neglected. When the patient is of nervous temperament, or there is deficient nerve or vital power; when the head is cool and the mental affection independent of vascular full- ness or action; when there is much rest- lessness, low, weak pulse, or cold, clammy skin; or when exhaustion follows the foregoing or is superimposed on pre- vious excitement, the drug may usually be given to marked advantage; but it is not to be advised when there is cerebral excitement with a hot skin, full pulse, and wild countenance. In puerperal in- sanity, especially, it is frequently of the most service; but here, as in all other conditions of mental alienation, it re- quires to be employed with discrimina- tion. Diseases of the Heart. — In heart- maladies camphor is occasionally very beneficial; it will frequently quiet tumultuous palpitations and remove the dyspnoea which often attends hyper- trophy with dilatation. Camphor is to be recommended hypo- dermically in heart-failure, preferably employing camphorated oil. In a case in which the patient had a number of times been absolutely pulseless and ap- parently lifeless its use was followed by the most gratifying results. West (Phila. Polyclinic, Oct. 16, '97). Intestinal Fluxes. — Camphor, either in powder or tincture, is an excellent and popular remedy for the diarrhoeas of summer and autumn, which so often assume a choleraic form. When the body is cold as ice, there is great prostration, the voice squeaky and husky, and the upper lip retruded, the effect of the remedy is said to be often marvelous. It is essential to use the strong solu- tion or essence (spirit) of camphor, of 676 CAMPHOR. THERAPEUTICS. which 3 minims should be given on a cube of sugar or on a crumb of bread every five minutes. After one or two doses the diarrhoea ceases, the pulse be- comes stronger, color returns to the face, and the patient is on the high road to recovery. The tincture is almost equally useful in the initial rigor of acute spe- cific diseases and in severe chill. Mur- rell ("Manual of Mat. Med. and Ther.," '96). Few, if any, remedies are comparable to camphor in summer diarrhoea and cholera. Its benign influence in the latter disease is most conspicuous, for it generally checks the vomiting and diar- rhoea immediately, prevents cramp, and restores warmth to the extremities. It must be given at the very commence- ment, and repeated frequently, other- wise it is useless. Four to 6 drops of the strongest tincture should be given every ten minutes until the symptoms abate, and then hourly. Ringer and Sainsbury ("Hand-book of Ther.," '97). Therapeutics of Various Preparations of Camplior. — Monobromated and salic- ylated camphor have been employed in diarrhosaj dysentery, epilepsy, chorea, hysteria, asthma, neuralgia, etc. Not one is as marked in stimulant action as the camphor-gum or tincture, but the mono- bromate is an hypnotic of considerable power and an invaluable antispasmodic. There is no better remedy than the monobromate in the treatment of in- fantile diarrhoea and the convulsions of dentition. Curryer (Chicago Med. Times, July, '91). Marked success is had in relieving chordee by using suppositories of cam- phor-monobromate. Vanderbeck (Pacific Med. Jour., June, '91). Salicylated camphor is said to be of marked utility when applied in the form of ointment to lupus and rodent ulcer. It is also employed in diarrhea, but is in no way superior to the monobromate. Camphor-chloral has found its chief employment in mania, delirium tremens, etc. It is said that the sedative effect is far in excess of that of either of its constituents. Prolonged narcotism, last- ing several days, had followed excessive use of the drug. Applied topically it is often efEective in relieving neuralgic pains. Phenicated camphor was originally introduced as an ansesthetic and as an antiseptic dressing, but seems to have found favor with some in the manage- ment of skin maladies. It is a useful application in toothache due to an exposed and inflamed pulp. A valuable deodorant to correct the foetor arising from syphilitic ulcerations, malignant growths, gangrene of the lungs, bronchorrhoea, and pneumothorax. It reduces the discharge and relieves the pain in acute otitis media; a 10- per- cent, solution in glycerin should be used. Also available in otorrhoea and in acute perforation of the tj'mpanic membrane in 1- or 2-per-cent. solution. Is an efficient antiseptic in foul and in- dolent ulcers, and may be used in the form of a lotion: 8 to 15 grains to the ounce. Butler ("Text-book of Mat. Med., Ther., and Phar.," '96). Thymol-camphor has been suggested as a preparation that would be valuable in dermatological practice, but has re- ceived, apparently, but little attention. Used in pruritus of scrotum and in pediculosis pubis with apparently good results. Applied to the normal healthy skin, it does not cause any irritation or redness. Schaefer (Boston Med. and Surg. Jour., '90). Menthol-camphor is very like the fore- going. It has been exploited for the treatment of catarrhal maladies, includ- ing "hay" asthma or fever, acute laryn- gitis, etc. In hypertrophic nasal catarrh, with excessive and disordered secretion, a 2.5- per-eent. solution of the drug has given excellent results. It was equally eflfect- ive in chronic hypertrophic rhinitis, as well as in eczematoug and herpetic erup- tions. Bishop (Kansas City Med. Index, Mar., '92). CANNABIS INDICA. 677 Camphoric acid is one of many reme- dies introduced with a view to treating tuberculosis by destroying bacilli, but it has failed to fulfill the role laid down for it. Latterly it has been employed in a host of nervous diseases, and as a remedy against night-sweats, cystitis, etc., and it has appeared to be of some value in the management of epilepsy. Ordinary angina and catarrhal pharyn- gitis were much improved by gargles of 14- to 1-per-cent. solution; applied by brush or as a spray, in fourteen eases of laryngitis it gave excellent results. Proved gratifying in cystitis, but its inhalation in lung diseases was without noticeable effect. Hurtleib (Wiener med. Presse, Feb. 23, '90). It is a powerful innocuous antiseptic, especially in gonorrhoea, cystitis, and diphtheria. A dose of 1/2 drachm in one case induced gastric irritation and vomit- ing. Warman (Gaz. lekar.. No. 36, '89; Prov. Med. Jour., Jan., '90). Camphor-oil has never found a definite place in medicine except domestically, and then for external use only. Latterly, however, a few spasmodic attempts have been made to give it place, and sug- gestions have been thrown out regarding its internal adminstration. It is a crude product of uncertain strength, and it can serve no purpose that cannot be better filled by a solution of camphor- gum in oil of sweet almonds. Oxycamphor is a colorless, crystalline powder, soluble up to 2 per cent, in cold water. It may be administered in gela- tin capsules. The daily amount may be as much as 30 grains. It is of value for the relief of dyspnoea due to pulmonary, cardiac, or renal disorders. Alfred Ehrlich (Centralb. f. d. gesammte Ther., H. 1, S. 1, '99). CANCER. See Tumors. CANCRUM ORIS. See Mottth, Gak- GREXous Stomatitis. CANNABIS INDICA SEU SATIVA.— Indian, European, and American hemp are one and the same, except as modified by locality, climate, soil, and culture. The plant attains its highest medicinal virtues when grown in the tropics or subtropics, inasmuch as here it develops a larger amount of resin (churrus). The dried flowering tops of the female plant are the parts employed medicinally, and it is essential to medicinal virtue that the resin be not removed; these tops in their crude condition are known as gunjah. The Arabian hasheesh, Hindoo bhang, and Mohammedan majoon are practically identical, being aromatic con- fections into which not only cannabis Indica, but the powdered seeds of stra- monium, enter. Hasheesh is not, as has been stated, "the broken stalks of the hemp made up into fruits." The chemistry of hemp is not well un- derstood. The resin, or churrus, accord- ing to Egasse, is the active principle, and has received the name of "canna- bin"; but Helbing gives this title to a supposed alkaloid of syrup-like con- sistency and brownish- or greenish- black hue, scarcely at all soluble in water, but freely so in ether and alcohol. Jahns insists that the only alkaloid is choline, and all other supposed principles are impure choline. Inasmuch as this same name obtains to a base found in plants and animals, formerly known as "sinha- line" and "titineurine," and described chemically as oxy-ethyl-trimethyl-am- monium, its applicability is questionable. Cannabindon is another derivative of hemp, and appears in the form of a dark, cherry-red syrup. The eannabine alkaloid of Merck is had in fine needles, but its relations to the entire drug are not yet fully deter- mined; it is not even known that it is a true alkaloid. So, too, there is found in market another "alkaloid" bearing the same title, and which is a translu- 678 CANNABIS INDICA. PREPARATIONS. PHYSIOLOGICAL ACTION. cent, brown, syrupy liquid, with the hemp odor. Cannabine tannate is a yellowish- brown powder with a tannin-like taste, not unpleasant smell, insoluble in pure water and ether, soluble in alcohol, and freely so in water made alkaline; it is said to be free from the two acrid and volatile oils peculiar to hemp and which are generally held to be rapidly-acting irritant poisons. Cannabinine is a yel- lowish-brown, syrupy liquid with an odor very similar to that of nicotine. Cannabindon is a purified churrus of dark-brown color, the consistency of treacle, and a most disagreeable taste; it is insoluble in water. In the Orient churrus is smoked, and also manufactured into an intoxicating drink. A butter is also employed in the Hindoostani peninsula. Preparations and Doses. — As a whole, cannabis is one of the most valuable of drugs, but is sadly handicapped by the uncertainty that attends all pharma- copoeial preparations. Attempts to pre- pare by methods of assay have not been attended with any marked degree of suc- cess, owing to the fact that such have necessarily been based on the amount of the extractive. Too little is known re- garding the so-called active principles to place any reliance on them as guide^s; consequently the sole dependence of the prescriber is the character of the manu- facturer, and the ability of the latter to iudge of the crude drug employed. For such reasons cannabis requires to be employed with judgment and caution. It has been noted, too, that larger doses are required in temperate climes than in the tropics and subtropics to produce a definite effect; but the real truth, doubt- less, lies in the fact that the drug de- teriorates with age and by transporta- tion; perhaps loses some undetermined volatile constituent. The same precise preparation may prove active to-day; but, given to the same patient under equally favorable conditions a few weeks later, may prove practically inert. Honi- berger observed that a resinous extract prepared for him in Calcutta was very much less energetic when he reached London. Cannabis Indica abstract, y, to 4 grains. Cannabis extract (solid), V* fo ^ grains. Cannabis extract (fl.uid), V2 to 6 minims. Cannabin (resin), 1 to 5 grains. Cannabindon, '^/„ to 1 minim. Cannabine (alkaloid), ^/j to 4 grains. Cannabin tannate, 2 to 15 grains. Cannabine (liquid), 1 to 3 minims. Cannabinine, V^ to 1 grain. Cannabis tinctiire, 5 to 30 minims. Cannabis-butter, 3 to 8 grains. Liquor cannabis (Lees's), 15 to 60 minims. Physiological Action. — The alkaloids appear to be purely hypnotic in action; but all other preparations exhibit, in a general way, the action of the crude drug. Minute doses are sedative to the spinal centres, and even when frequently repeated exhibit little to be remarked, except, perhaps, there may be slight con- traction of the pupils; but there is, nevertheless, inculcated a feeling of comfort and well-being, and not infre- quently the drug appears to steady the action of the heart. Larger doses are stimulant; they first induce increased arterial action, followed by exhilaration, and, as the latter passes off, drowsiness or stupor succeeds, that may be almost cataleptic; but the awakening is free from malaise, nausea, headache, or other untoward symptoms; the pupil of the eye is expanded. The preliminary effect CANNABIS INDICA. POISONING. TREATMENT. THERAPEUTICS. 679 is more powerful and lasting than that of opium, and the slumber it induces is commonly disturbed by dreams and spectral illusions. Also the sensory nerves are affected, as is evidenced by marked numbness and tingling, ushering in cutaneous ansesthesia and diminution of the muscular sense. Appetite is gen- erally stimulated, and marked aphrodisia is not uncommon. Withal it is a valu- able anodyne and antispasmodic, its in- fluence being manifested through the brain and cord. Cannabis Indica likewise exhibits a marked predilection for the genito- urinary apparatus, being strongly stimu- lant or sedative to the mucous tissue thereof in accordance with the mode of exhibition and size of dose; it is some- times markedly diuretic, and appears to be excreted in part by the kidneys; but beyond this the eliminative process is unknown. Further, in atonic conditions or inertia during labor, it stimulates uterine activity and induces physio- logical contractions, and at a time when ergot and kindred remedies prove use- less. The effects of cannabis Indica vary ac- cording to the manner in which it is talcen into the system. When smoked, exhilaration is most manifest, while when talcen by the mouth in small quan- tities this is generally not observed. Where an immedate effect is desired the drug should be smoked, the fumes being drawn through water. By the mouth, one hour to two hours are necessary be- fore absorption occurs, but the effects are more lasting than when it is inhaled. The hemp when taken as an inhalation may be placed in the same category as coffee, tea, and kola. Used by the mouth it should be classified with the narcotics. No danger is to be apprehended while the heart remains strong and regular. Dixon (Brit. lied. .Jour., Nov. 11. '09). Poisoning by Cannabis Indica. — In large doses the drug appears toxic, and yet, strange to say, in spite of the enor- mous quantities (relatively) that have been ingested on certain occasions, either accidentally or purposely, a case of death directly referable to this drug has yet to be recorded. In a case after cannabis Indica in large dose the existence of muscular contrac- tions was noted, followed later by con- vulsive movements, evidently due to ac- tion of the drug on the spinal cord. Aside from acceleration of the pulse-rate and feeling of fullness in the artery at the wrist, there was, just previous to the occurrence of unconsciousness, a sense of extreme tension in the abdominal blood- vessels: they felt distended almost to bursting. After some hours the urine was markedly increased in quantity. No constipation resulted. There was no fore- boding nor fear of impending death. Robert C. Bieknell (Thera. Gazette, No. 1, p. 13, '98). Treatment of Poisoning. — Cannabis is antagonized by caustic alkalies, vinegar and other acids, strychnine, electricity, antimonials, and blisters to the nape of the neck. Therapeutics. — Hemp is soporific or hypnotic, anodyne, antispasmodic, nerv- ine stimulant, and, as already remarked, in some measure diuretic, aphrodisiac, and oxytocic; consequently its scope of usefulness is a most extended one, par- ticularly in nerve-maladies. Its most important effects are to be found in the mental sphere, as, for in- stance, in senile insomnia with wander- ing. An elderly person (perhaps with brain-softening) is iidgety at night, goes to bed, gets up, thinks he has some appointment to keep, that he must dress and go out; daylight finds him quite rational again. Here nothing can com- pare in utility to a moderate dose of cannabis. In alcoholic subjects, how- ever, it is uncertain and rarely useful. In melancholia it is sometimes service- able in converting depression into ex- altation. In the occasional night-rest- 680 CANNABIS INDICA. THERAPEUTICS. lessness of paretics, and the "temper dis- ease" of Marshall Hall, it has proved eminently useful. In neuralgia, neuritis, and migraine it is, by far, the most useful of drugs, even when the disease has persisted for years; many victims of diabolical "sick headache" have for years kept their sufferings in abeyance by taking hemp at the threatened onset of the attack. It relieves the lightning pain of ataxia, and also the multiform miseries of the gouty. Again, in chronic spasm, whether epileptic or choreic, it is of great service; also in the eclampsia of both children and adults. In brain- tumors or other maladies in the course of which epileptic seizures occur followed by coma, the coma being followed by delirium, — first quiet, then violent, the delirium then passing into convulsions, and the whole gamut being repeated, — Indian hemp will at once cut short such abnormal activities, even when all other treatment has failed; but in genuine epilepsy it is of little avail. J. Russell Reynolds (Lancet, London, Mar. 2, '90; N. Y. Med. Jour., June 7, '90). Cannabis Indica employed with good effect as a local ansesthetie to relieve dental pain. The tincture is diluted three to five parts with alcohol, and is introduced into the cavity of the tooth by means of a tampon of cotton. These tampons are also placed about the gum below the tooth. If the alcohol is too strong the tincture may be diluted by means of hot water. Aarousin (Jour, de M6d. de Paris, Oct. 30, '98). Cannabis Indica may be employed in the solid extract, from 8 to 20 grains being given. With a few exceptions, its efficacy is limited to those diseases directly traceable to nervous derange- ment. Pain not due to distinct patho- logical lesions forms the chief indication for its administration, and relief is usu- ally obtained promptly. H. E. Lewis (Merck's Archives, July, 1900). In tetanus cannabis Indica Las been found very efficacious at times, and in those cases wherein it is not curative it seldom fails to afford some measure of relief. Hat Fever. — The usefulness of hemp in allaying morbid irritability of the nervous system is such that it has been suggested for employment in the form of vasomotor coryza popularly denominated "hay fever" or "hay asthma"; but there seems to have been no critical trial thereof. The idea, however, is both commendable and rational, and worthy of experiment. Cannabis is often efficacious in other asthmas, either given by the mouth or burned and its fumes inhaled. Delirium Tremens. — In delirium tremens the drug is often most satisfac- tory; here its action resembles opium and wine, but is much more certain. It produces a great change of mind in the patients, readily dissipates the horrors, quiets nerve-hyperffisthesia, and con- duces to cheerfulness; but great dis- crimination is necessary in application. Uterine Hemorrhage. — In menor- rhagia and other uterine fluxes hemp is often invaluable if judiciously employed; and so, too, it may prove valuable in impending abortion. Mention has al- ready been made of its power upon the gravid womb inactive through inertia, and it is equally efficacious as a prevent- ive of post-partuni haemorrhage or as a remedy after "flowing" has begun, but requires to be given in full dose and sometimes in conjunction with ergot. Here half-drachm or even drachm doses of the fluid extract may be exhibited, since — strange to say — in such cases it never exhibits the ordinary physiological effects; there is no excitement, no in- toxication, and no tendency to somno- lence; only a feeling of quiet well-being, and that the condition is one of perfect safety. Effect upon Reproductive Organs. — Cannabis, too, is especially available for sensitive ovaries. Indeed, it seems sedative to all the pelvic contents; and CANNABIS INDICA. THERAPEUTICS. 681 it is thus that it acts as an aphrodisiac by allaying functional nerve irritation, not, as has been supposed, by stimulating erethism; and yet the latter effect may be had from large doses, but is apt to be most fleeting or else assume the form of a priapism in man and nymphomania in woman that is not gratified, much less satisfied, by sexual indulgence. It exerts a very marked effect upon the reproductive apparatus. In the early stages of gonorrhoea small doses combined with gelsemium will subdue the disease much sooner and more safely than the old method of ruining the digestive powers with large doses of copaiba and turpentine. Combined with gelsemium it subdues inflammation of mucous tissue. In spermatorrhoea in highly nervous subjects it is especially valuable. It will do good service com- bined with pareira brava in cases of irritable bladder. Goss ("Text-book of Mat. Med., Phar., and Special Ther.," '89). Choleea. — In the Orient it is a favorite remedy for epidemic cholera; patients in actual collapse have revived after taking a full dose. It seems to stimulate the nervous centres at a period when their influence is all but suspended. It is by no means a universal panacea as regards this malady, and seems to little afl:ect the dark races, probably because they are generally more or less habitu- ated to its use. Cardiac Diseases. — In violent palpi- tations of the heart the drug is often markedly remedial, especially when the non-utility of all other agents has been proved. The late Dr. Christison, of London, especially extolled it; he em- ployed it in a large number of instances with unequivocal effect, and by its aid succeeded in relieving a case of twenty- one years' standing. Skin Diseases. — In eczema and other cutaneous disorders accompanied with intolerable itching, cannabis gives relief when local treatment does not, but it must be employed in a way to secure its full and prompt effect. In skin diseases associated with intense itching, particularly senile pruritus, where local applications fail to relieve, cannabis Indica is often used with great benefit; and, though there are rarely any untoward manifestations, it is best, perhaps, to give at first in small doses and then gradually increase. Mackenzie (La Sem. M6d., No. 14, '94; Univ. Med. Mag., Dec, '94). Digestive Disorders. — In certain diseases of the stomach and digestive apparatus the drug is often available, and preferable to opium, in that it does not inhibit (but, instead, increases) ap- petite; does not interfere with the secre- tions of either pancreas or liver, and does not constipate or .check renal secretion. Cannabis Indica is very valuable in the treatment of gastric neurosis and gastric dyspepsia. It allays painful sen- sation and improves appetite. It has no action on atony or dilatation of the stomach, but is of great service in pro- moting stomach digestion in cases of hyperchlorhydria ; in anachlorhydria it acts feebly. Intestinal digestion is also improved by its use. On the whole, it may be considered as a true sedative of the stomach, and it lacks the disad- vantages that accrue to opium, bismuth, potassium bromide, antipyrine, etc. Germain See (Bull. G6n. de Th6r., July 29, '90). In anorexia following exhaustive dis- eases — where there is repugnance and intolerance of food in almost every form that is not relieved by acids, nux vomica, and bitters — from 5 to 10 minims of tincture of cannabis, or 14 to V2 grain of the solid extract, given thrice daily before meals, often brings back the appetite in two or three days. In dyspeptic diarrhoea also, and the first months of true tropical diarrhoeas, it is often of great service. Tropical diarrhoea is primarily and essentially a disease of the liver, and mercury should 682 CANNABIS INDICA. CANTHARIDES. be administered to medicate that organ, while the cannabis acts by diminishing the irritability and excessive peristalsis of the intestines. McConnell (Prac, London, Feb., '88). Cephalalgia. — Many have praised the drug in the treatment of headache, even the severe forms attending cere- bral growths, or where the cephalalgia is dependent on urasmie poisoning. It is almost a specific for that con- tinuous form of headache which begins in the morning and lasts all day, the pain being generally dull and diffuse, but marked by occasional exacerbations. Mackenzie (La Sem. Med., No. 14, '94). Cannabis Indica is an excellent remedy for megrim, or sick headache, and it is somewhat surprising that it is not more frequently employed ; the ex- tract may be given in doses of from Vj to Va grain in the form of a pill. When the patient suffers constantly from headache, or is liable to an attack on the slightest provocation, a pill may be taken three times a day for many weeks at a time without the slightest fear of the production of any untoward effect. Should the patient not speedily obtain relief, care must be taken to ascertain that the extract employed is physio- logically active. Excellent results are often obtained by administration of pills containing 4 grains of cannabin tannate, one being given three times a day after meals. Murrell ("Manual of Phar. and Ther.," '96). Cannabis Indica is an invaluable rem- edy in the treatment of disturbances of the sensory centres. It is one of the best remedies in headaches of many kinds, and is especially useful in cephalic sensations so common in individuals of neurotic habit. Tincture or fluid extract preferred. Five to 10 drops of fluid ex- tract may be taken on moist sugar, swal- lowed with a draught of water. Angel Money (Australasian Med. Gaz., Feb., 1900). EHEUjrATiSM. — Here cannabis has been lauded for both its analgesic and curative effects, yet it is questionable if it deserves the encomiums bestowed; but it may tend to alleviate pain, and it also increases appetite and mental cheer- fulness. Respieatoet Diseases. — It is also a capital sedative to the upper respiratory tract, and is a favorite factor in many cough-mixtures; Fothergill long ago commended its use in phthisis pulmo- nalis. It most perceptibly relieves the cough ; it aids by its stimulating and ex- hilarating qualities, and supplies a place that cannot be filled by any other drug. Lees (Med. Rec, vol. xlix, '95). Renal and Ueinaey Maladies. — It is also frequently recommended in Bright's disease where the urine is tinged with blood, and upheld as an almost specific for urethral spasm, for chordee, and the acute stage of gonor- rhoea; also in gonorrhoea and vesical irritation, and in spermatorrhoea. CANTHARIDES.— The blister-beetle, or "Spanish fly," a coleopterous insect, also called lytta, is collected in Russia, Sicily, and Hungary, but is also found in Spain, France, Germany, and other parts of Europe. Representatives are found in various parts of the world, notably in the Levant and eastward, in Senegal, South- ern and Central America, and in Chile. The insect is about an inch long, per- haps one-fourth inch broad, flatfish, cylindrical, with filiform antennae; it is black in upper part, with long wing-cases, and has large membranous, transparent, brownish wings; elsewhere of a shining, coppery-green hue. The powder is grayish- or blackish- brown, containing green, shining particles, with strong, dis- agreeable odor and acrid taste; is soluble in alcohol. Cantharides is often adulter- ated, especially when powdered with other beetles, exhausted flies, and ground gum-resin euphorbium; but these can be detected, or at least surmised, by testing CANTHAlilDES. PKEPAHATIONS AND DOSES. G83 for the yield of cantharidiue, which should not be less than 4 per cent.; it rarely exceeds 5.5 per cent. Preparations and Doses. — Cantharides, powdered, V^ to V2 grain — not tit to be employed in crude form. Cantharides cerate, for blisters only. Cantharides cerate (made with alco- holic extract), external only. Cantharides tincture (5 per cent.), 1 to 30 minims. Cantharides vinegar, external only. Cantharidine, not employed. Cantharidate of cocaine, Vjo,, to Vioo grain. Cantharidate of potassium, Vioo to V200 grain; hypodermically only. Cantharidal collodion. Cantharidal liniment. Cantharidal oil, external only. Cantharidal ointment. Cantharidal paper (blister-paper). Cantharidal plaster with pitch. Cantharidal warming plaster. The powder of cantharides is too acrid and irritating to be employed except in very minute doses or well covered by other substance, and, even then, pref- erably in capsules. Its chief employ- ment is as the component part of cerates, liniments, ointments, and other epi- spastic galenicals. Cantharides cerate, "blister-plas- ter," or "flying blister," is made by mix- ing 96 grains of finely-powdered "flies," 60 grains of yellow wax, 68 grains of prepared suet, 24 grains of resin, and 48 grains of lard, the whole, when thor- oiTghly incorporated, being spread on a suitable piece of sheep-skin or adhesive plaster. The "warming" plasters are of two kinds. One is obtained by adding, to a strong infusion of 4 ounces of canthar- ides, 4 ounces each of oil of nutmeg, yellow wax, and pure resin; and then incorporating with 3 '/^ pounds of resin- plaster and 2 pounds of soap-plaster, the last two being previously heated; it should have a decidedly-yellow hue. The other, also termed cantharidal pitch-plaster, is composed of Barbadoes pitch, to which ordinary cantharidal cerate is added to the amount of 8 per cent. Cantharidal, or "blistering," col- lodion is a thick liquid formed by add- ing 1 ounce of pyroxylin (gun-cotton) to 20 ounces of the blistering liquid known as cantharidal liniment; this latter is obtained by macerating for twenty-four hours 8 ounces of canthar- ides in 4 ounces of acetic acid, then percolating the mixture with a pint of ether until 20 ounces are obtained. Another liniment is composed of 15 parts of cantharides in sufficient turpen- tine to make 100 parts. Cantharidal, blistering-, or epi- spastic paper is merely a good wax- or paraffin- paper coated on one side with a mixture of 4 ounces of white wax, 1 ^/j ounces of spermaceti, 2 ounces of olive- oil, 6 drachms of resin, 8 drachms of cantharides, and 6 ounces of water, — the whole heated together, — then adding 2 drachms of Canada balsam after reject- ing the watery liquid. By digesting 3 parts of cantharides in 10 parts of olive-oil for ten hours over a water-bath, cantharidal oil is ob- tained. Cantharides ointment is a mixture of 1 ounce of the flies with an equal amount of yellow wax and 6 ounces of olive-, cotton-seed, or peanut- oil. The "vinegar" may be prepared by digesting, at 200° F., and subsequent percolation, 2 ounces of cantharides, 18 ounces of acetic acid, and 2 ounces of glacial acetic acid. Cantharidine, or cantharidal cam- CANTHARIDES. PHYSIOLOGICAL ACTION. POISONING. phor, is found in glistening rectangular prisms, which melt at 318°; heated higher it gives off a heavy, white, very irritating vapor, condensing unaltered to crystals. It is easily soluble in acetone, sulphuric acid, and glacial acetic acid, less so in chloroform (1 to 80), very little in 90-per-cent. alcohol, 1 to 500 in pe- troleum ether, and 1 to 5000 in water; the aqueous solution, though practically tasteless, is by no means devoid of vesica- tory power even in the minutest quanti- ties. Cantharidine is also soluble in fatty oils and gives an acid reaction to very sensitive litmus-paper; it volatilizes at 100°. It likewise combines readily with alkalies to form soluble salts. If nitric acid is added to eantharidinate of sodium, crystals of cantharidine are at once precipitated. The foregoing paragraph sufficiently explains the formation of cantharidate of potassium, which, however, seems only to have had an ephemeral existence. Cantharidate of cocaine is a mixture of cantharidate of sodium and cocaine muriate, and occurs as a white, inodor- ous, amorphous powder with a sharp taste, readily soluble in alcohol, ether, petroleum spirit, and hot water. Its uses are the same as those of the potas- sium salt. Physiological Action. — All species of cantharides are powerfully irritant when applied to the skin, and likewise vesi- cant, these two properties depending upon the cantharidine. Internally the drug, can be given properly only in the form of tincture, for obvious reasons (see Poisoning), though the powder is sometimes, though rarely, mistakenly employed; and even the tincture should be employed only in connection with copious diluents and demulcents. Suit- ably administered, the tincture is a stim- ulant diuretic, and it appears also to ex- ert a specific influence upon the mucous membrane of the genito-urinary sys- tem, particularly the neck of the bladder. In larger doses it is highly irritant, and it is not an uncommon accident for suf- ficient of the drug to be absorbed during applications to the skin to cause great irritation of the kidneys, as evidenced by painful micturition and bloody urine. The inflammation produced by can- tharides begins in the gloraeruli and not in the straight tubes. The first condi- tion of the kidneys noticed after the administration of the drug is extravasa- tion of leucocytes into the glomeruli and an exudation of a fibrous matrix. This is followed by filling of the glom- eruli and the proximate tubules with a granular fluid, after which comes swell- ing of the cells of the capsule. Next in order swelling of the cells of the collecting tubes and of the whole uri- nary tubule is observed.; and in the last stage multiplication of the cells of the straight collecting tubes which are thrown off so that their lumen becomes filled with exuded cells. Murrell, Lond. ("Manual of Mat. Med. and Therap.," '96). Lahousse finds that cantharides afi:eets simultaneously the Malpighian bodies, the renal tubules, and the matrix of the kidney. The Malpighian vessels are greatly congested; albumin, leucocytes, and a few red corpuscles escape; the epithelium covering the vessels lining the capsule swell and desquamate; the endothelium of the vessels swells and may choke their lumen, the tubule-cells swell, become granular, and die. The tubules contain hsemoglobin in the form of brilliant-red homogeneous cylinders. Leucocytes escape into the matrix. Other observers hold that the Mal- pighian bodies are alone, or chiefly, aflfected. Ringer and Sainsbury ("Hand- book of Therap.," '97). Cantharidal Poisoning. — The drug in non-medicinal doses is an acrid, corrod- ing poison, the chief symptoms being a burning sensation in the throat, violent pains in stomach and bowels, nausea. CANTHARIDES. POISONING. TREATMENT. THERAPEUTICS. 685 vomiting, and purging, — the dejections being frequently bloody and purulent, — great heat and irritation of the urinary organs, sometimes accompanied by pain- ful erethism, and in the male painful priapism, quick and hard pulse, labo- rious breathing, convulsions, tetanus, delirium, and syncope. The morbid ap- pearances are principally inflammation and erosion of the stomach. If the flies or powder have been ingested, character- istic debris will be found adhering to the mucous coat of the stomach and in- testines, and, if recent, mixed with the contents of the prima vice generally; powder of cantharides has been identi- fied in the stomach nine months after death; there are also discoverable the marks of violent inflammation through- out the urinary organs; but such are usually most prominent when the poi- soning is not fatal. The kidnej's are frequently gorged with blood, as is the brain. Treatment of Cantharidal Poisoning. — There is no known antidote for this drug, and all toxic cases require to be treated in consonance with the indica- tions afforded by each individual case; it frequently can be little beside pallia- tive. The promotion of free vomiting is generally imperative, further fostering by means of warm demulcents and dilu- ents; diluents are in order even after emesis has accomplished all possible. Bland oils have been suggested, but these are dangerous, since they are apt to sep- arate the cantharidine, which is very soluble therein, and thereby enhance and hasten toxicity. Opium, even chloro- form by inhalation, is sometimes de- manded to allay the excruciating suf- fering or to control convulsions. Opium enemas and frictions also will find place. Camphor often alleviates the most dis- tressing symptoms, and bromides may be required. The smallest amount of tincture known to have induced fatality is 1 ounce; of the powder, 48 grains. Case of cystitis caused by the u.se of cantharides as a blister. The symptoms were of considerable severity. Mono- bromated camphor was given both by tlie mouth and by enema; but no relief was obtained. The condition, however, yielded promptly to the influence of cocaine. Albarran (Lancet, Lond., Dec. 12, '92). Therapeutics. — The internal admin- istration of cantharides finds less favor than it did half a century back, doubt- less because of the many accidents that have followed its employment. Some years ago the tincture was lauded as a powerful depressant, contrastimulant, and antiphlogistic, and advised to be used in acute inflammation, but even the Italian physicians, who were the strong- est supporters of the drug in this con- nection, soon abandoned it for other and more safe medicaments. At present it finds its chief employment in the man- agement of genito-urinary disorders, and, among French physicians, in diseases of the skin and scalp. The late Dewees considered the tincture in doses of 10 minims, gradually increased to twice or thrice this amount, to be an absolute specific in amenorrhcea; but how he avoided symptoms of strangury, when administering the larger doses, consid- ering the potent nature of the remedy, is something of a mystery. Incon-tinence of Urine. — ■ Where this depends upon an atonic state of the bladder, the tincture may often be given with excellent effect; it appears to act locally, stimulating the parts and restor- ing a healthy tone to the bladder. Small doses of cantharides may be relied upon to cure the slight inconti- nence of urine which, with women, is frequently associated with paroxysmal cough. Half a drachm is prescribed 686 CANTHARIDES. THERAPEUTICS. with 4 ounces of water, and of this a teaspoonful is talcen hourly. It rarely fails to effect a cure in twenty-four hours. Murrell, Lond. ("Manual of Mat. Med. and Therap.," '96). Women, especially middle-aged women, often suffer from a frequent desire to pass water, or an inability to hold it long; sometimes this occurs only in the day on moving about. In these cases micturition may cause no pain, neither is there likely to be any straining, sneezing, or coughing. Sometimes both sets of symptoms are present, due ap- parently to weakness of the sphincter of the bladder. One or two drops of tincture of cantharides, three or four times a day, will, in many cases, afford great relief to these troubles, and some- times cure them with astonishing rapidity, even when the symptoms have lasted for months or years. Ringer and Sainsbury ("Handbook of Therap.," '97). Ueinaht Suppression. — The drug has also been recommended as a remedy for suppression of urine, but on what physiological grounds it is difficult to imagine; the evidence afforded is too flimsy to be worthy of consideration from even an empirical stand-point. • As AN Aphrodisiac. — In the treat- ment of impotence the drug has, espe- cially of late years, received its greatest employment, and the affirmative evi- dence is not without weight, though many have experienced nothing but fail- ure from its use. Sloughing of the penis may occur from the employment of can- tharides, even in what are deemed safe medicinal doses. Internally employed, rarely, in doses of 4 to 10 drops three times a day in a mucilaginous mixture for impotence; but must be used carefully because of the danger of causing albuminuria. Roth ("Mod. Mat. Med.," '95). Bmmenagogue and Abortifacient. — Both these properties are claimed for cantharides, and it is generally admitted that the claims possess a measiire of truth, but also that its employment for either purpose is little, if any, less than criminal. Sloughing of the labia is a frequent result from this use of the drug. Urethral, Prostatic, and Cystic Maladies. — The drug has been em- ployed in all these conditions with, at times, very apparent benefit; but that its application is by no means universal is evidenced by the fact that it frequently fails. The conditions when it is likely to prove of value, therefore, require to be carefully considered and studied out. It certainly is of no value, of itself, in syphilis, but given in conjunction with mercury salts it materially enhances their activity. After its separation by the kidneys cantharides acts as an irritant to the urinary tact, and it may be employed for this action in cystitis, in gonorrhoea, and in gleet. One drop of the tincture, though 5 are sometimes required, should be given three or four times a day ; this treatment is particularly useful in cases where there is a frequent desire to make water, accompanied by great pain in the prostate gland and along the urethra, while at other times severe twinges of pain are felt in the same parts. The urine, under these circum- stances, may be healthy, or it may con- tain an excess of mucus or even a small amount of pus. A drop of the tincture, three times daily, will, in the majority of instances, abate or remove chordee. Ringer and Sainsbury ("Hand-book of Therap.," '97). Diseases of Kidney. — As a Diuretic. — A half-century ago, on the Continent of Europe, tincture of cantharides was largely employed in albuminuria, begin- ning with small doses and gradually in- creasing to 60 minims, and it is authori- tatively declared that this procedure was often attended with decided benefit; the caution is given, however, that it is not always sitccessful, and that, moreover, it is a dangerous remedy in the hands of the inexperienced. In granular disease CANTHARIDES. THERAPEUTICS. 687 of the kidney, too, the drug has been most favorably mentioned, particularly by Copland, the author of a famous "Dictionary of Practical Medicine." The drug is powerfully diuretic under certain conditions, but is not a desirable remedy to exhibit by itself; it is a most valuable adjunct to digitalis, however, when this latter remedy is employed for the express purpose of promoting diu- resis. ScuBvx; Cheoijic "Whooping-cough. — These are two more maladies for which the drug has been employed, but with no apparent success; and in whooping- cough it has never appeared to be of benefit except when combined with cin- chona and opium. Skin and Scalp Diseases. — In lepra, eczema, and psoriasis cantharides still is in considerable repute, but does not secure the same degree of form that ac- crued to it in the latter part of the last, and early part of the present, century. It is advised that the tincture be given in 3- to 5-drop doses, three times daily, the amount to be increased by 5 drops every six or eight days, until the limit of tolerance has been reached. Ear Diseases. — In deafness depend- ing upon a thickened state of the drum- membrane, and where there is much ir- ritation of the external meatus, many practitioners in the past believed they had secured great benefit by applying a strong cantharidal ointment — 1 to 2 — below and behind the ear thrice daily. Nervous and Spinal Disorders. — • In epilepsy cantharides has been favor- ably mentioned, and was at one time held in considerable esteem by the older practitioners, but it does not appear to possess any special virtues in this direc- tion. It has, however, sometimes seemed to be of marked benefit in paraplegia, but only when it exercised a diuretic effect. Also it is often available when there is serous effusion into the vertebral canal, as in spinal dropsy, and both its internal administration and application externally in the form of blistering cerate tends to promote absorption of the effused fluid. Eespiratory, Cardiac, and Drop- sical Maladies. — Cantharides is occa- sionally administered internally with benefit in passive dropsies with a view of stimulating the action of the kidneys, but it is inadmissible in sthenic or acute cases; it should be administered in con- junction with some other diuretic, how- ever, such as a decoction of broom, in- fusion of digitalis, or sweet spirit of nitre. In the form of blister the cerate is also xiseful in these maladies, as well as in pericarditis, pleuritis, pneumonia, and more rarely phthisis. Within a few years the cantharidate of potassium has been employed as a remedy for pulmonary and laryngeal tuberculosis, on the strength of some experiments undertaken by Liebreich; also the cantharidate of cocaine. Lie- breich's theory is that the inflammatory processes set up by the cantharidin pro- duce a transudation of sanguineous mi- crobicidal serum. The chief points to be decided are whether cantharidinates have any ac- tion on diseased, particularly tubercu- lous, tissues, and, if so, whether this, effect is obtained before any disturbance is produced in other organs, such as the kidneys. The eantharidinate gives rise to an increased exudation from the capillaries; hence its beneficial action; but there is no hypersemia. Advanced tuberculosis, however, should be treated with extreme caution, for the kidneys are often fattily degenerated. Improve- ment has been recorded in other than tubercular processes, — e.g., in chronic laryngitis. Any local application of a eantharidinate is not rational, as it only produces irritation. In hundreds of in- CANTHARIDES. CATALEPSY. jeetions made, there has been no more danger to the patient than from the use of mercury or arsenic. Liebreich (Therap. Monat., June, '92). Eecently, Liebreich and others have recommended the subcutaneous use of eantharidin in combination with alka- lies in the treatment of tuberculosis. While the value of this method is still undetermined, the accumulated testi- mony gives little encouragement for its employment in this affection. In pneu- monia, pericarditis, etc., cantharides is a most useful vesicant. Blisters.- — These are applied to es- tablish a degree of inflammation or irri- tation on the surface of the body, and thus to substitute a mild and easily man- aged disease for an internal and intract- able one, on the principle that two sets of inflammation cannot be carried on at the same time: a theory that admits of some question; to stimulate the absorb- ents and thus cause the removal of effused fluids; to act as derivatives; to stimulate the whole system, and raise the vigor of the circulation. A few rules flnd universal application as re- gards the use of these agents, viz.: Never apply a blister at the beginning of in- flammation, — never until the acute stage has been subdued by other means. Never apply where the skin is thin or tender nor over a bony prominence, as great irritation will result, and the heal- ing will be slow and difilcult. In many instances, as in acute laryngitis, it is not advisable to apply a blister directly over the seat of the disease, as it sometimes aggravates the symptoms; indeed, a blister is often more efficacious if applied at a remote point, as to the heel in sci- atica or lumbago. As a rule, it is not advisable to allow a blister to remain on the part to which it is applied more than two or three hours,- — only until it has produced considerable redness, when the process may be completed by soft, warm poultices. A blister has been known to produce abortion when applied to the neck or chest of a pregnant woman. Blisters applied to a scorbutic person are apt to induce ulceration and gangrene; and the same is, in a measure, true as regards this application to children, who, as a rule, bear vesicants badly. Finally, the danger of absorption of cantharides from cantliaridal vesicants, sufficient to induce untoward phenomena, and even toxicity, should always be considered. Violent strangury has resulted in some instances from the application of a blis- ter to the penis with a view of prevent- ing masturbation. CAPILLARY BRONCHITIS. See Pneitmonia, Cataeehal. CARBOLIC ACID. See Phenic Acid. CARBUNCLE. See Suegical Dis- eases OF Skin. CARCINOMA. See TmiOES. CARDIAC ANEURISM. See Aneu- rism. CARTILAGINOUS TUMORS. See TuiiOES, Enchondeoma. CATALEPSY. — From Gr., zaTd?.>7- -^(g, seizure. Definition. — Catalepsy is not a dis- tinct disease, but a symptom of a disor- dered condition of the highest nerve- centres: the cerebral cortex. During the attacks, which are intermittent, the nervous system, especially the lower, is CATALEPSY. VAPJETIES. 689 in an excitable state; the higher centres have lost control over the lower; the face at times is as passive and expression- less as that of a marble statue, while in some cases the face seems to indicate mental agitation; there is impairment, or apparent loss, of consciousness, vo- lition, and sensation; the patient lies, sits, or stands with muscles in a state of tonic or rigid immobility, and if the head or limbs are placed by an attendant in awkward, or what are usually uncomfort- able, positions, they may remain so for an indefinite period, minutes or hours, without any apparent voluntary effort or evidence of fatigue on the part of the patient. All these manifestations represent but a series of nervous phenomena in- dicating a deranged condition of the nor- mal functioning power of the general nervous system; we are therefore pre- pared to learn that in a few cases it may be the only obtrusive evidence of disease; that it may occur associated with hys- teria, or that it probably may be one of the manifestations of this affection; that it may be an epiphenomenon of certain organic diseases of the brain, such as abscess, tumor, softening, meningitis, haemorrhage, etc.; that it may be found in epilepsy, insanity, chorea, or, in fact, in almost any condition of the nervous system in which the inhibitory or con- trolling power of the higher nerve-cen- tres over the lower is greatly impaired or lost during the attacks. Varieties. — As to the varying condi- tions under which the phenomena may be manifested, with modifications of the symptoms in different cases, those who have regarded catalepsy as a distinct dis- ease, sui generis, have spoken of "true" and "false" catalepsy: catalepsia vera and catalepsia spuria. With most of these writers there is but one form of 1- catalepsy: that in which the limbs or any fl.exible portions of the body present a condition likened to a figure of soft or easily-molded was (so-called flexibilitas cerea), in which the parts, without any apparent voluntary effort on the part of the patient, remain for an indefinite time in the positions in which they may be placed. My individual impression is that cata- lepsy, unassociated with organic disease, denotes an hysterical condition, and is then one of the numerous manifestations of hysteria or an affection closely allied to it. In some cases the cataleptic phe- nomena may be the only evidence of dis- ease, but this is so rare that some observ- ers have never met with an example. It may probably be placed between epilepsy and hysteria in the scale of maladies, but nearer the latter than the former, and, as regards the nature of its chief feature, it may be regarded as essentially one of the motor. But there is also distinct interference with the in- tellectual processes, and interruption of the connection between the will and the motor centres. W. K. Gowers ("Quain's Die. of Med.," vol. i, p. 285). [It is no more surprising that catalepsy should occur from organic disease of the brain than that hysteria should manifest itself under similar circumstances, and, in some instances, become so prominent as to lead the unwary observer to mis- take a tumor or some other lesion for the functional disturbance. Indeed, it seems to me that this is another reason for regarding catalepsy as one of the manifestations of hysteria or its twin- sister. In Colorado hysteria in its ex- aggerated forms is almost unknown. During a residence of fourteen years in this State I have not met with a single case of catalepsy in which the cataleptic phenomena were prominent or consti- tuted the sole evidence of the nervous disturbance. During my residence here my practice has been almost entirely limited to the diseases of the nervous system (mental and physical), and I 690 CATALEPSY. SYMPTOMS. have seen eases from nearly every por- tion of the State, and many from the adjoining States and territories. If ctlier observers shall find that so-called true catalepsy is only found in places favorable for the development of hys- teria in its most pronounced type, it will show, at least, that the phenomena of the former are closely associated with those of the latter, if, indeed, they are not a part of them. Further, the course, duration, prognosis, and treatment of catalepsy are almost identical with those of hysteria. J. T. Eskkidge.] I shall first endeavor to give a descrip- tion of the cataleptic phenomena in cases in which they occur as the principal or only symptoms of the nervous disorder, then as they are found associated with other, and often graver, nervous de- rangements. Symptoms. — The symptoms of cata- lepsy are not easily described, as the phenomena observed are seen under so many different conditions. In a very few cases the cataleptic phenomena are the only obtrusive evidences at the time of the attack of a disordered state of the nervous system; in a second class the symptoms of hysteria are so pronoiinced that it is difficult to determine which is the real affection; in a third the cata- leptic phenomena form a part of a graver disease, such as insanity, epilepsy, or organic trouble of the brain; in a fourth the nervous symptoms are the results of certain poisons or toxsemic states; and finally in a fifth the peculiar nervous disturbances are a part of the phenomena witnessed in a state of hypnosis which has been introduced by a method that greatly agitates and excites the higher nerve-centres. I shall first try to give a description of catalepsy as free from complications as possible, then will fol- low references to cataleptic phenomena as met with in association with other nervous disorders. Catalepsy is essentially a paroxysmal or intermittent affection. For its devel- opment in its typical form it probably always requires on the part of the sub- ject a certain predisposition, an unstable and excitable nervous condition, a tend- ency to hysterical manifestations, most prominent among which is hypersensi- tiveness of some of the special senses. The paroxysms vary greatly in their severity and duration. The pronounced symptoms usually come on suddenly, but these are often preceded by headache, slight hysterical manifestations, giddi- ness, gastric symptoms, or hiccough. The special symptoms are ushered in by all or part of the voluntary muscles sud- denly becoming rigid, the limbs remain- ing in the positions in which they were arrested by the onset of the attack. In some cases the arm stops in the act of carrying a cup to the mouth; the latter remains open and the whole body assumes a fixed position, as if petrified. At first the muscles are quite rigid and resist strong passive motion; but soon the rigidity is followed by a soft, wax- like state of the muscles. The limbs may then be placed in various positions by moderate passive motion, and in these they will remain for several minutes, or even for hours in some cases. If an arm or a leg is placed at a right angle with the body, with no support except that given by the muscles in a state of in- creased tension, it woidd be main- tained in this uncomfortable position for a considerable length of time; but after awhile the limb from force of gravity begins gradually to descend. Two important observations may be made at this stage of the attack that have considerable diagnostic value. One is that the patient's features and respira- tion show no evidence of fatigue or vol- untary effort, and the other is that if a CATALEPSY. SYMPTOMS. 691 weight of a few pounds is suspended to the limb, or passive motion is exerted to overcome the tension of the muscles that hold the limb in its position, the mem- ber gradually descends, without any ex- tra effort being exerted to keep it from falling. Consciousness is always im- paired, and sometimes apparently com- pletely lost, from the first. The degree of disturbed consciousness varies in dif- ferent cases. In some cases it seems to be completely abolished. [I think Dr. C. K. Mills is right in cautioning against haste in believing that unconsciousness is complete in a given case. J. T. Eskkidqe.] In a few cases in which the cataleptic condition of the muscles is well marked the patient makes no attempt to answer questions or to move when the skin is irritated, because volition is in abeyance; but the patient may know everything that goes on around her. The pulse, temperature and respiration are slightly changed. The pulse is slow or normal; the temperature is usually a little sub- normal; sometimes it is one or several degrees below the normal; respiration is quiet, shallow, and sometimes almost im- perceptible. The face is pale, the eyes wide open and looking horizontally for- ward. Sometimes the lids are partially or gently closed. The pupils are dilated, often react to light slowly, but in some cases they show no response. The fundi and optic nerves have been found anas- mic, according to ^. A. Hammond. The features frequently present a blank or placid appearance, but in some cases they show evidences of mental agitation. The skin is often very cool and pale, especially if the paroxysm is prolonged; this with the almost imperceptible res- piration and expressionless features, open eyes, and dilated pupils — give the patient the appearance of death, for which catalepsy is said to have been mis- taken. Cutaneous sensibility is often abol- ished; in some cases it is only impaired; rarely a condition of hypersesthesia has been observed. The cornea, conjunctiva, and pharynx may present no evidence of sensation, or they may retain partial sen- sibility; so that the eyelids will close when the eyeball is touched, and the re- flex of the pharynx may be obtained. In some cases the power of deglutition is said to have been lost, but, more com- monly, when the food is placed on the posterior portion of the tongue it will be swallowed. The deep reflexes are usually lessened; they are rarely increased, and in some cases absent. They may be present on one side and absent on the other, although the wax-like condition, of the muscles is bilateral. The func- tions of the special senses seem to be im- paired or abolished, although in some eases it is possible to elicit a response from the patient by stimulating the or- gan of hearing, and occasionally that of sight. The electrical reactions of the muscles and nerves have been found normal, lessened, and in exceptional cases increased. The paroxysms, even if prolonged, do not remain at their height for a great length of time. They may last only a few minutes, hours, or in rare cases days. In the prolonged attacks there are usually intermissions or remissions, during which the patient completely or partially arouses for a few minutes and then relapses. Hammond says the par- oxysm generally disappears as abruptly as it began. "A few deep inspirations are taken, the eyes are opened, or lose their fixedness, the muscles relax, and consciousness is restored, but no knowl- edge of what has occurred is retained." It is probable that in the majority of 692 CATALEPSY. COMPLICATIONS. cases there is gradual restoration to con- sciousness, the patient remaining be- wildered and stupid and the muscles more or less rigid during the emergence from the cataleptic state. Eulenburg states that in some cases the attacks may disappear quite suddenly. "The pa- tients recover at once full consciousness and the normal use of their muscles, take up their employment which had been interrupted, continue the sentence previously commenced, and conduct themselves as if not the slightest thing had intervened." [I have seen a few svieh cases, but I have looked upon them as epileptic in character, and of the variety known as petit mal. The subsequent course of two of these has shown that my appre- hensions had been well founded. -J. T. EsiiEIDGE.] Continuing, Eulenburg says: "Much more frequently the patient's recovery is only slow and gradual; they are at first somewhat stupid, as if awakening from an unusually sound sleep. Sensi- bility is still diminished, the power of the will weakened; a certain amount of the stiffness of the muscles still remains for some time, which renders motion dif- ficult and slow." The frequency of paroxysms varies greatly in different cases. One or more attacks may occur in the twenty-four hours; they may be repeated every few days, weeks, or months. Just as we find in epilepsy, so we not infrequently ob- serve in catalepsy, that if the paroxysms return every few weeks or months several attacks may occur at these times within a period of a few days. In rare instances only a few paroxysms are observed dur- ing life-time, separated from each other by a period of years, as we find in some cases of epilepsy. In still more excep- tional cases only one attack occurs. During the interval of the attacks little or nothing may be observed to dis- tinguish the subject from a normal per- son. More commonly, especially when the paroxysms occur frequently and with any regularity, the patient is irritable, nervous, hysterical, and complains of lassitude, and sometimes of dizziness and headache, during the interval of the attacks. Complications and Concomitant Dis- orders. — The complications, or, better, the disordered conditions of the nervous system which the phenomena of cata- lepsy may complicate, are numerous. Hysteria and catalepsy are so nearly alike in many of their phases that it is not always possible to draw any distinct line between the two affections. The cases complicated by hysteria may pre- sent one of the following conditions: All the phenomena of catalepsy may be present, but in addition thereto therj may be numerous and pronounced symp- toms of hysteria, both during the attacks and in the intervals; or the seizures may be so typically hysterical that were it not for the symptoms of catalepsy at the time of the paroxysms the case would be termed one of pure hysteria. In fact it is such, with the phenomena of cata- lepsy added. Such cases are usually chronic, little influenced by treatment, and the patient during the intervals be- tween the paroxysms may present all kinds of hysterical symptoms, even con- vulsions. What has been said in regard to cata- lepsy complicated by hysteria applies in no small degree when this affection is associated with trance, ecstacy, somnam- bulism, and certain forms of somnolency. These are all nearly allied to hysteria when they are due to a functional dis- turbance of the nervous system. Catalepsy often occurs in association with epilepsy, chorea, insanity, or or- CATALEPSY. COMPLICATIONS. 693 ganic diseases of the brain. In chorea cataleptic phenomena have been met with, and in some instances these have been quite pronounced with states of automatic action resembling certain phases met with in hypnotism especially in children. Epilepsy may be associated with cataleptic symptoms, but we should be careful in the study of these cases to determine whether the latter are not evi- dence of true epilepsy. In those cases of supposed catalepsy in which conscious- ness is suddenly recovered and the pa- tient immediately returns to the nor- mal condition, finishes the employment which had been begun before the attack, or continues a sentence that had been interrupted, and acts as though nothing had happened, it is quite probable that the symptoms are epileptic in character. [Dr. Thomas King Chambers says: "Catalepsy is sometimes very brief and sudden. I have a young lady now under my care, for non-assimilative indigestion, of whom I received the following ac- counts from a mother of more than ordi- nary intelligence and power of observa- tion. She said that her daughter was fond of reading aloud, and that some- times in the middle of a sentence the voice was suddenlj' stopped, and a pecul- iar stiffness of the whole body would come on and fi.x the limbs immovably for several minutes. Then it would re- lax, and the reading would be continued at the very word it stopped at, the pa- tient being quite unconscious that a parenthesis had been snipped out of her sentence, or that anything strange had happened. She grew much better under tonic and restorative treatment, and gradually ceased to have these singular attacks; but after about a month's interval, as she was one evening engaged in playing a round game of cards, she suddenly went off into a regular epi- leptic fit, which was followed by sleep, and she did not recover consciousness till the next morning. This fit could be accounted for by certain errors in diges- tion, and she has had no recurrence of it, or of the catalepsy, though four months have passed over. So I hope it was epilepsy of an intercurrent or curable sort." One feels that this must have been a vain hope, and, had the history been subsequently continued for a period of a year or more, it would probably have shown that the case was one of epilepsy, and not of the "curable sort." The next case that he reports is more serious. "But sometimes the epi- lepsy preceded by catalepsy is of a more serious sort. I remember a much-re- spected lecturer in this metropolis in whom the petit mal of epilepsy assumed this form. He used to be attacked some- times in the middle of a sentence, with his hand wielded in demonstration be- fore his class. He would remain per- fectlj- stiff for a minute or so, with mouth open and arm extended, and then resume his sentence just where he had dropped it quite unconscious that any- thing had happened. After a time the seizures assumed the more usual and, more fatal form." (Reynolds's "Systerat of Med." [Hartshome], vol. i, pp. 654- 55). I have seen several cases of epi- lepsy, especially in children, the first symptoms of which simulated those of catalepsy. J. T. Eskbidge.] Cataleptic symptoms in eight rachitics" aged from eighteen months to three and one-half years. The phenomena were manifested by the persistence of the posi- tion given to a limb. When the leg was raised, for instance, it was maintained in this position for a long time, often as long as fifteen to twenty minutes, in one case even as long as forty minutes and then falling very slowly. If the position of the limb or parts of it was changed, even to a very uncomfortable attitude, the immobility would be maintained for an equal period of time. This phenom- enon was more constant and distinct in the leg than in the arm. There was no tremor in the limb; during this cata- leptic state the reflex e.xcitability seemed diminished. Epstein (Revue Men. des Mal. de I'Enfance, Jan., '97). Insanity, especially stuporous insanity, the graver forms of melancholia, cata- tonia (of Kahlbaum), and paretic de- 694 CATALEPSY. DIAGNOSIS. nientia may be associated with cataleptic conditions. These are most typically seen and most frequently met with in catatonia, in which increased motor ten- sion is one of the diagnostic symptoms of the disease. In the other forms of in- sanity the cataleptic phenomena seem to be accidental. Their presence in any form of insanity indicates profound nu- tritional changes, and therefore adds gravity to the prognosis. Cases of or- ganic disease of the hrain only infre- quently present symptoms somewhat similar to catalepsy. Cases of tumor, abscess, haemorrhage, softening, trau- matic injuries of the brain, and of men- ingitis, especially of the tubercular vari- ety, have presented temporary symptoms of catalepsy. It is important to bear in mind that organic disease of the brain may be the cause of cataleptic phenomena, lest an organic lesion should be mistaken for an affection that is functional in its nature. Chloroform or ether narcosis; opium poisoning in extremely rare instances; and certain toxsemic states, probably from autoinfection, may cause conditions simulating catalepsy. It is so rarely that ■one meets with a case of opium poison- ing in which convulsions or cataleptic phenomena are present that were the physician not on his guard there would be great danger of mistaking the case for a lesion of the pons, or some condition other than that caused by a lethal dose of opium. Hypnosis and catalepsy need no dis- cussion here, further than the statement that many of the cases of catalepsy re- ported as occurring in very young chil- dren of two or three years of age present symptoms somewhat similar to those seen in hypnotized subjects, especially in those in which the hypnosis has been induced by the Charcot method, such as having the subject stare at a bright ob- ject, held in such a position as to cause the eyes to converge and look upward. Unilateral cataleptic phenomena are often seen in hypnotic subjects. It may often be developed at the will of the hypnotist. Diagnosis. — "The peculiar rigidity of catalepsy is characteristic, invariable, and renders the diagnosis a simple mat- ter," says Gowers. In the last edition of his great work on "Diseases of the Nerv- ous System" the writer states that "the diagnosis of catalepsy presents no dif- ficulty." That the peculiar rigidity and wax-like flexibility must be present be- fore we are justified in making a diag- nosis of true catalepsy, I think, will be accepted by almost every clinician, but that these conditions may be present as prominent symptoms in certain grave diseases of the central nervous system, and possibly mislead the physician in mistaking the cataleptic phenomena for the real disease, must also be borne in mind. In the face of the possibility of the occurrence of such an error, it seems to me that it is the first duty of the phy- sician in the diagnosis of catalepsy, as it is in hysteria, to determine whether the cataleptic phenomena are caused by some organic lesion. The same principle holds good here as applied to hysteria. The presence of numerous symptoms point- ing to a functional affection of the nerv- ous system is of less importance in the diagnosis than the detection of one posi- tive symptom of an organic lesion. All cases of catalepsy should be carefully studied and the patient systematically examined lest organic disease escape de- tection. Trance, somnambulism, ecstasy, or hysteria in its ordinary form is readily distinguished from catalepsy on account of the wax-like flexibility in the latter. CATALEPSY. DIAGNOSIS. 695 Should cataleptic subjects go into a trance, or an hypnotic state, or become ecstatic, or hysterical, the presence of the characteristic symptoms of catalepsy would probably determine the diagnosis in favor of the latter affection. There might be danger of mistaking a case of catatonia for catalepsy were one not on his guard. Of the former, Spitzka says: "The most striking phenomena of the disorder are its cataleptic periods. The catalepsy is typical and extreme. For days, weeks, nay months, the patients are immobile, resembling sitting corpses, requiring to be fed by the stomach- pump, to be carried to and from their beds, and betraying neither by look nor word that they have any mental activity left." Case of a patient who was, on one oc- casion, placed witli one foot on tlie ground and the other on the bench be- hind him, head flexed extremely, one arm raised to the horizontal position before him and the other in the same position behind him. The patient re- mained in this awkward, and what would be for a normal person impossible, position for an hour or more before hia arms began gradually to descend. In another case the patient retained any possible position in which he was placed for a day at a time. The history of the ease, which would show a pathetical emotional state, with a tendency to repetition of certain words and phrases, together with the prolonged cataleptic periods serve to determine the nature of the case. Spitzka ("Insanity"). There is little danger of mistaking catalepsy for the other forms of insanity with which it may be associated. In hysteria uncomplicated with the cata- leptic phenomena, the local position of the spasm and the absence of the wax- like condition of the limbs would dis- tinguish it from catalepsy. In hysteria when the limbs are rigid they cannot be flexed without using considerable force. The peculiar position of the hands in tetany and the resistance of- fered by the muscles to putting the limbs in different positions would pre- vent mistaking this affection for cata- lepsy. There is probably no danger of confounding catalepsy for epilepsy if the paroxysms are observed by a person of intelligence, except in those cases of the latter disorder in which the initial symp- toms closely resemble catalepsy. A sud- den return to consciousness after the exhibition of cataleptic symptoms, the patient resuming his work at the point at which it had been left off or con- tinuing a sentence from the word at which the interruption had occurred, just as if nothing had happened, is strongly suggestive of epilepsy. Catalepsy may be feigned. Of course, it is an easy matter for a person to breathe quietly, and allow his limbs to be placed in different positions, as if they were made of soft wax, but it is not possible for one to maintain awk- ward and uncomfortable positions for a considerable length of time without the breathing, the appearance of the face, and the jerky tremor of the muscles showing evidence of fatigue. In cata- lepsy if a weight of several pounds be attached to the outstretched arm or slight force is employed to depress it, the limb will gradually descend to the side of the body without the person showing any evidence of effort to keep it from falling. Simulators, on the other hand, invariably endeavor to prevent the limb from being carried down by force. Finally, catalepsy is said to have been mistaken for death. The waxy flexibility of the limb is never found after death. Anyone who has employed the ophthal- moscope to examine the optic nerves after death can never mistake the ap- 696 CATALEPSY. PROGNOSIS. ETIOLOGY. pearance of these and the whole fundi. Everything is blanched and bloodless. In the absence of the ophthalmoscope the stethoscope may be employed to de- tect the heart's action; a glass mirror may be held before the mouth and nos- trils to determine whether the patient is breathing; the temperature of the body may be taken, but this, like the use of electricity, is not of much value to as- certain whether the patient is dead or alive, unless some hours have elapsed to allow the temperature of the body to fall and electrical changes to take place. Of tests for death, immediately after its oc- currence, there is none, in my experi- ence, equal to the use of the ophthal- moscope. Prognosis. — Hammond thinks the dis- ease does not, in the vast majority of cases, tend to become worse either in regard to severity or frequency of the paroxysms, especially in those cases in which the exciting causes are removed. Catalepsy due to malaria is curable. When the affection is the direct result of temporary emotional disturbance and the neurotic element of the subject is not too profoimd, a cure may take place. It is in this class that we sometimes meet with only one, or a few, attacks during a life-time. Traumatism to the head or spine may give rise to catalepsy that may be only temporary in character. In the majority of cases catalepsy, like hys- teria, is a chronic affection and may last months, years, or even a life-time, with few or many paroxysms, depending upon modifying circumstances, especially edu- cation, the morale of the patient, the fre- quency, intensity, and character of the exciting causes. Catalepsy is probably never the direct cause of death. Etiology. — The causes of catalepsy are predisposing and exciting. The consti- tutional neuropathic condition of Grie- singer is the favorable soil for the devel- opment of numerous neuroses, such as hysteria, insanity, epilepsy, chorea, and the phenomena of catalepsy. The hys- terical neurosis is the one best suited for the manifestation of the cataleptic phe- nomena. Congenital preformations, as Eulenburg terms them, of certain por- tions of the central nervous system pre- dispose to catalepsy. In families in which in one or more members hysteria or catalepsy has developed, other nervous disorders — such as insanity, epilepsy, chorea, or alcoholism — are often found. In some cases epilepsy precedes the man- ifestation of cataleptic phenomena; in others epilepsy begins with symptoms of a cataleptoid nature. The inheritance of degenerative tendencies favor develop- ment of most neuroses. Description of a ease studied by Dr. George E. de Schweinltz in a child, fe- male, 2 '/. years old, in which cataleptic phenomena, with a condition of automa- tism very similar to the manifestations exhibited by some hypnotized subjects, were witnessed for a period of several weeks. C. K. Mills ("System of Med.," edited by Pepper, vol. v, p. 316). Case of catalepsy alternating with violent mental excitement in a married woman. The attacks appeared at or about the menstrual period. During one of the menstrual periods she passed a membranous cyst of the uterine cavity and complained of dysmenorrhoea and menorrhagia. Recovery followed treat- ment of uterine disorder. Stone (Lan- cet, Apr. 20, 1901). This nervous disorder is most fre- quent at puberty and from that period to the thirtieth year. A number of cases have been observed in children. Moti, referred to by Mills, records eleven cases met with in children from the fifth to the fifteenth year, the average being nine years. Quite well marked catalepsy is some- times observed in voung children of one CATALEPSY. ETIOLOGY. 697 or two years ^¥hen they are ill. Prob- ably they fall into a sort of stupor; or often it seems that they are rendered hypnotic, as it were, by the presence of strangers. Strumpel ("Text-book on the Practice of Med.," p. 754, Eng. trans.). Women are more likely to suffer from catalepsy than men, but tlie difference is not great. Of 148 cases collected by Fuel, 80 occurred in females and 68 in males. Malnutrition, caused by insuf- ficient or improper food, or conditions that interfere with digestion and assimi- lation, favor the development of cata- lepsy. Prostration following the acute fevers or profound mental or physical exhaustion would probably not give rise to the disease in a person who formerly had a healthy and normal nervous sys- tem; but in a neurotic subject such a cause might greatly enhance the predis- position, and with the addition of any emotional disturbance it would probably be sufficient to cause the development of the phenomena. Strong and suddenly-induced emotion may be classed among the first of the ex- citing causes. It may be in the form of moral shock, fright, anger, profound sorrow, great apprehension of evil, in- tense mortification, or religious excite- ment. The emotion is in the form of de- pressing moral affections, as chagrin, hatred, jealousy, and terror at bad treatment. Puel (Mills: Pepper's "Sys- tem of Med.," vol. V, p. 318). It is evident that any emotional in- fluence that is great enough to disar- range suddenly the workings of the higher nerve-centres in a neurotic sub- ject may be sufficient to produce various emotional manifestations, among which we may class catalepsy. It is undoubtedly true that prolonged, depressing meditation and apprehension may give rise to the disease. The appre- hension and uncertainty antedating and attendant upon childbirth may favor the development of the nervous state or even give rise to it if the labor is fol- lowed by complications or depressing conditions. Case following the second confinement. Before the labor the woman had been very nervous, following it were a chill and rather high fever for a short time, and forty-eight hours later catalepsy with distinct hysterical symptoms de- veloped. S. S. Cornell ("Psychological Med.," Mann, p. 470). Painful menstruation, pregnancy, the parturient state, sudden suppression of menstruation, dysmenorrhoea, and mas- turbation are supposed to be causes of the disorder. Mills refers to reflex irri- tation as an exciting cause, and instances a case of preputial irritation, relieved by circiimcision, occurring in the practice of Dr. James Hendrie Lloyd. Case recorded by Austin, in his work on "General Paralysis," in which the cataleptic seizure was apparently due to ffecal accumulations. The attack dis- appeared promptly after the bowel had been emptied by means of an enema. Mills (Pepper's "System of Med.," vol. V, p. 318). Traumatism, such as blows to the head or spine, may give rise to catalepsy. Eu- lenburg cites a case seen by Jamieson in which a blow on the right side of the back was followed by an attack. Peri- odic attacks of catalepsy have resulted from malaria, and yielded promptly to antimalarial treatment. Hammond men- tions one case in which worms in the intestinal canal were the apparent cause. Gastro-intestinal irritation in general is a frequent cause of catalepsy as well as of hysteria. Mills mentions the fact that catalepsy may occur as an imitation of epidemic nervous disturbance. Epidemic of icterus in children associ- ated with catalepsy; the children al- lowed their limbs to remain motionless in whatever position the examiner 698 CATALEPSY. ETIOLOGY. placed them. This condition persisted for about nine days, when it was fol- lowed by slow improvement. The liver was enlarged in all cases, but were not tender. Cases all recovered. O. Damsch and A. Kramer (Berliner klin. Woch., Mar. 21, '98). Opium and ansesthetics have given rise to nervous conditions in which cataleptic phenomena have been prominent. Eu- lenburg, in discussing theory of the mus- cular condition in catalepsy, says: "The observation often made, that narcotics and antesthetics, at a certain stage of their action, before the production of narcotism, may give rise to slight epi- leptic phenomena"; then adds in a foot- note: "I have myself seen an exquisite case of flexiiilitas cerea, alternating with trismus, opisthotonos, and general con- vulsions, in a patient poisoned by mor- phia (by 0.09 gramme — 1 V3 grains — of the hydrochlorate)" ("Cyclopsedia of the Pract. of Med.," Ziemssen, vol. xiv, p. 379). Eosenthal refers to somewhat similar results following the adminstra- tion of anassthetics and poisonous doses of morphine. In a somewhat ancient American med- ical periodical (No. Amer. Med. and Surg. Jour., vol. i, p. 74, '26) Charles D. Meigs, of Philadelphia, gives an inter- esting accoi-mt of a case of catalepsy produced by opium in a man 27 years of age. The man had taken laudanum. His arms, when in a stuporous condi- tion, remained in any posture in which they happened to be left; his head was lifted off the pillow and so remained. "If he were made of wax," says Meigs, "he could not more steadily preserve any given attitude." The patient re- covered under purging, emetics, and bleeding. C. K. Mills (Pepper's "Sys- tem of Med.," vol. V, p. 319). Darwin, quoted by Meigs, mentions a case of catalepsy which occurred after the patient had taken mercury. He re- covered in a few weeks. [I have often observed a rigid condi- tion of the limbs in patients while tak- ing an anesthetic. It is a frequent occurrence under such circumstances, and is seen just before the stage of narcosis is reached. J. T. Eskridge.] It is important to bear in mind that a condition simulating catalepsy, tris- mus, and general convulsions may occur from lethal doses of morphine. Such phenomena from the poisonous effects of opium must be exceedingly rare, and are probably indirectly due to the pecul- iar nervous organization of the patient. Hypnosis, induced by the Charcot method, such as having the subject stare for eight or ten minutes at a bright ob- ject held so as to cause the eyes to look upward in convergence is often attended by cataleptic phenomena: the so-called first stage of hypnosis of Charcot. I have never seen this condition in hyp- nosis induced by the Nancy, or suggest- ive, method, provided no suggestions were made to develop muscular rigidity. Catalepsy occasionally occurs in asso- ciation with insanity. It has been met with in connection with mania, melan- cholia, and paralysis of the insane. When it is observed among the insane it is most commonly found in the graver forms of melancholia, and in profound conditions of stupor. The mental con- dition under such circumstances is the cause of the cataleptic phenomena. One form of insanity, catatonia, first de- scribed by Kahlbaum, of Gorlitz, about twenty-three years ago, is always in its typical form attended by motor tension sufficiently marked to maintain the limbs in whatever position they may be placed for hours, or even a day or more, if we may accept the statements of Kahl- baum and Spitzka. Finally, numerous organic diseases of the brain are sufficiently often attended with cataleptic phenomena to demon- CATALEPSY. PATHOLOGY. 699 strate a causative relationship between the organic cerebral lesion and the mani- festation of the motor tension. These phenomena have been seen more com- monly as transient symptoms in tumor, abscess, hagmorrhage, and softening of the brain, and in meningitis. It is a common experience to find a cataleptoid condition suddenly develop in cases of organic disease of the brain. It is prob- able that partial cataleptic states of the muscles would be detected more fre- quently than they are were physicians to examine for them in every case of brain disease coming under their obser- vation. Conclusions after a study of fifteen cases: Cataleptic states which develop in the course of psychoses are often slight, brief, and partial. With increase of muscle-tension and enfeeblement of voluntary psychomotor activity they are often due to enfeeblement of perception of fatigue and to the persistence of com- municated motor images; they may de- velop in a number of mental maladies, especially in alcoholic delirium, melan- choly, mental confusion, manias, peri- odic insanity, the delirium of degen- erates, and in congenital or acquired mental feebleness; they may precede or follow an epileptic crisis; hysteria is rarely connected with them; there is no catatonia of Kahlbaum; and these states are easily simulated. Paul le Maitre ("Contributions a I'Etude des Etats Cataleptiques dans les Maladies Mentales," p. 96, '95). Pathology. — The examinations of the bodies of some cataleptic subjects, who during life presented undoubted evi- dences of organic disease of the brain, have revealed certain gross lesions of the central nervous system, especially of the brain. These findings prove nothing in regard to the pathological anatomy of catalepsy, because the autopsies, held on the bodies of persons who during life presented distinct symptoms of cata- lepsy without evidence of organic brain disease, have been attended with abso- lutely negative results. We are, indeed, in absolute ignorance of the pathogene- sis of catalepsy. In regard to the theory of muscular rigidity and the wax-like flexibility of the limbs, observed as the most signifi- cant symptom of the phenomena of cata- lepsy, speculation has been rife. In the present state of our ignorance concern- ing the intimate nature of the subject, the most elaborate theories are only speculations. In the normal condition the constant muscular tonus seems to be sufficient to adapt the muscles for lengthening and shortening without any disturbance of the harmony of action between the synergic and antergic groups of muscles concerned in extending and flexing the limbs. The nervous reflex concerned in maintaining the nicely-adaptable mus- cular tonus is composed of the muscle- nerves and the motor cells of the spinal cord. We have every reason for believ- ing that the higher nerve-centres con- trol, probably by inhibition, the lower ones; and that in case the inhibitory power of the higher centres over the lower is impaired or lost, the latter cen- tres may run riot and cause exagger- ated muscular tonus. In catalepsy the highest nerve-centres seem to lose their inhibitory power over the lower; and hence we find an increase of the mus- cular tonus. Did we not have to go further and explain certain other phe- nomena observed in catalepsy we should have little difficulty in accepting the theory that impairment or loss of the inhibitory power of the higher nerve- centres is the direct mechanism by which this afliection is produced. In other and widely different conditions from the one under consideration, in which we know 700 CATALEPSY. TREATMENT. that the communication between the higher and lower nerve-centres is made ditiicult or entirely impossible, as wit- nessed in lesions in the upper portion of the cord and in the motor regions of the brain, the muscular tonus is not only increased, but the deep reflexes are also increased and the typical wax-like condi- tion of the muscles, as observed in cata- lepsy, is rarely seen. In catalepsy, on the other hand, while the muscular tonus is increased, the deep reflexes are dimin- ished. It is a curious fact that compara- tively mild passive motion will cause the limbs to mold themselves in various positions in catalepsy; yet a far greater stimulant to muscles, muscle-nerves, and cutaneous nerves — the strongest faradic or galvanic current — fails to accomplish the same result. [This does not seem to me so difHcult of explanation as Eulenburg seems to infer. By passive motion the limbs are not made, even in catalepsy, to assume different positions on account of any stimulation, either direct or indirect, communicated to any reflex nervous ap- paratus, but the change in position of the limb is the result of mechanical force, applied usuallj' to the best ad- vantage to accomplish the desired re- sult. On the other hand, when elec- tricity is applied to a group of muscles to cause flexion or extension of a limb, the power does not act to the same ad- vantage to cause the limb to assume different positions as is the case when passive motion is employed; besides in the use of strong currents of electricity diffusion of the currents to a greater or less extent takes place, and in eon- sequence, indirect stimulation of the an- tagonistic group of muscles results. J. T. ESKEIDGE.] Eosenthal thinks the waxy mobility is due to reflex contraction. Eulenburg, in commenting on this conclusion, states: "To the latter view we are at all events driven; but just the 'how?' and the 'wherefore?' of the form or reflex action is, alas! still unknown to us." At the present day it is impossible to account for all the phenomena that oc- cur in catalepsy. That it is a symptom of a disordered condition of the highest nerve-centres, the cerebral cortex, seems to be a fact. That during the attacks, the nervous system, especially the spinal representatives of it, is in an excitable state, with a disarrangement of the nor- mally-adj listed influence of the higher nerve-centres over the lower appears to be equally true. When the pathology of hysteria is thoroughly understood then we shall be able to explain many, if not all, of the manifestations observed in catalepsy. Until then we may observe and gather facts to be utilized. [No one in discussing the theory of the mechanism of the phenomena that occur in catalepsy has apparently taken into account the possible influence of suggestion. ' J. T. Eskridge.] Treatment. — This should consist of measures for the relief of the paroxysm, and the employment between the attacks of those agents most likely to aid in toning up the nervous system, together with such changes in the daily life and surroimdings of the patient as are best adapted to improve the mental state. Two cases showing the beneficial effects of thyroid medication after the complete failure of other methods of treatment. Conclusions: 1. That in conditions marked by inhibition of sensory, motor, and mental activity, without gross or- ganic lesion, such as are met with in catatonia and in certain types of stu- porous insanity and melancholia, we may expect benefit from thyroid medi- cation, judiciously used. 2. That the effects of thyroids in full dose bear a striking resemblance to many of the symptoms of Graves's dis- ease, namely: orbicular weakness, con- secutively conjunctivitis, skin eruptions, and temporary bronzing, without icterus CATALEPSY. TREATMENT. 701 of the eyes, profuse local foetid sweats, subjective sense of heat and thirst, ex- cessive metabolism, decided tachycardia, and the absence of any fixed relation between pulse-rate, respiration and tem- perature. Joseph G. Rogers (Amer. Jour, of Insanity, July, '97). During the paroxysm it is always well to unload the bowel with a high enema, consisting of about 3 pints to 2 quarts of warm water to which 1 or 2 ounces of the tincture of asafoetida have been added. After the bowels have been thor- oughly opened in the manner indicated, Vz ounce of the tincture of asafoetida in about 4 ounces of water may be thrown into the bowel high up and allowed to remain. If the attack is severe 15 or 20 grains of chloral-hydrate may be added to the tincture of asafoetida for the small enema, in which case milk should be used instead of water. If the stomach contains any undigested food Vie grain of apomorphine may be given hypodermically. A free emesis even when there is no undigested food in the stomach may aid in aborting the par- oxysm. To shorten the attack inhalations of amyl-nitrite or an hypodermic of ^/i„o grain of nitroglycerin may be employed with advantage. Cool applications to the head and passing a piece of ice up and down the spine several times and following this by briskly rubbing the spine with a coarse towel greatly aid in establishing reaction. A mustard plaster to the nape of the neck and one over the stomach have the same effect. DiflFusible stimulants, especially ammonia, may be used with advantage. During the intervals the treatment and general management are of consid- erable importance, and should receive as much attention as in a case of hysteria. In the first place careful attention should be paid to the food and organs of diges- tion. The diet should be nutritious, easily digested, and abundant. If neces- sary, digestion may be aided by the ordi- nary means. A free action of the bowels should be obtained each day. Iron, arsenic, quinine, and strychnine should be employed in the building-up process. Systematic, but not violent or over- fatiguing, exercise should be insisted upon for all those who are not too weak. A little gymnasium can be arranged in most bed-rooms, and the beneficial re- sults to be derived from regular exercise for a few minutes night and morning can scarcely be estimated until after one has tried it. A cool or cold sponge- or plunge- bath should be indulged in night and morning, following the exercise. At the same time the patient should be kept in the open air as much possible. If the patient is a child or young adult the education should be judiciously su- pervised, and all oversentimental and emotional books excluded. Companion- ship for such patients, be they children or adults, is of great importance. In short, everything in reason that tends to develop muscle and improve the men- tal and physical condition of the patient should be encouraged, while exhaustion, depressing agents, poor nutrition, and emotional excitement should be avoided if possible. J. T. ESKRIDGE, Denver. 4i>'\j:.,