COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 20961 RC1 00 .Sh8 An Index of prognosi )»ftH.ia»yii '"^C voo SWs (Enlumbta Mnturrsttg tn tt|f (Ettg of Nrm fork iAtUvtntt Stbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/indexofprognosisOOshor AN INDEX OF PROGNOSIS AND END-RESULTS OF TREATMENT AN INDEX OF PROGNOSIS AND END-RESULTS OF TREATMENT BY VARIOUS WRITERS A. RENDLE SHORT, M.D., B.S., B.Sc. (Lond.), F.R.C.S. (Eng. CAPTAIN R.A.M.C, Hunterian Professor, Royal College of Surgeons; Exaininer in Physiology for the F.R.C.S^ Hon. Assistant Surgeoti, Bristol Royal Infirmary ; Lecttirer on Physiology, University of Bristol. NEW YORK WILLIAM WOOD AND COMPANY MDCCCCXV PRINTED IK GREAT BRITAIN / KC\00 PREFACE This volume is issued as a companion to the Index of Treatment and Index of Differential Diagnosis brought out by the same pubHshers. Its principal aims are : (i) To set forth the results, and particularly the end-results, of various methods of treatment, in such a form as will enable the practitioner to obtain a fair, unbiassed, reasoned opinion as to the prospects of securing for his patient permanent relief, and the risks of such treatment. (2) To furnish data by means of which, apart from the question of treatment, one may seek to arrive at an accurate forecast of what will probably happen to the individual patient. Although the art of prognosis is vitally important — and nearly every intelhgent patient, or his friends, will ask for an opinion as to his prospects, and will judge of the capacity of the medical attendant by the accuracy of that opinion— it is extraordinary to find how little help is given by current text-books. Especially is it difficult to find rehable data as to the end-results of treatment, more particularly surgical treatment. Even large monographs on special diseases, though they usually advise certain measures, only express a pious opinion as to the probable results thereof, unsupported by any trustworthy figures. The compilation of the present Index has, therefore, been extremely laborious, because a painstaking search through the wilderness of modern medical literature in several languages has often yielded very small results. The editor has found it necessary to supplement the published records by investigating the end-results of treatment at the Bristol Royal Infirmary — upwards of a thousand patients having been communicated with for this purpose ; and other con- tributors have also taken great trouble to acquire, from their private or hospital practice, the necessary figures. The only way to express end-results in such a manner as to give authoritative guidance is by quoting statistics. Thus alone can the practitioner, unless his personal experience is far wider than ordinary, verify or quahfy the promises of an enthusiastic specialist. vi PREFACE Published end-results have been calculated on various systems, and may be hopelessly unreliable. Sometimes, for instance, the cases are too few to warrant generaUzation. Very many figures are vitiated by too early reporting ; patients with cancer, for example, having been followed up for a year or two only. There are three principal classes of statistics : (i) Reports culled from the literature ; (2) The records of individual surgeons ; and (3) Studies of hospital cases published by registrars or others. Pickings from the hterature are often absolutely misleading, because successes and curiosities have been selected for publication, while failures are unmentioned. The records of individual surgeons are sometimes touched with couleur de rose. Hospital figures are the most reUable, but are usually less favourable than the results obtained in private practice, where patients are naturally better able to look after them- selves. Throughout this book, therefore, careful note is taken of the source of the information, and its relative value is taken into account in the summing up. We believe, moreover, it will be found that the figures are so presented that they do not unduly obtrude themselves, or confuse the plain and simple conclusions of the text which accom- panies them. Lastly, this volume is unique ; nothing of similar character has appeared before or can compare with it. It, therefore, possesses a value entirely its own, and one which time will not diminish. Should it find sufficient favour with practitioners for further editions to be called for in the decades to come, the present compilation will yet maintain its position as a register of the progress of the heahng art up to the time of its appearance — a date memorable in the world's history as that of the Great War. It will be for the future to improve upon the end-results of treatment here recorded, which at the time of writing have attained " thus far, but no farther." A. RENDLE SHORT. {Editor.) June, 1915. LIST OF CONTRIBUTORS AND THEIR SUBJECTS W. Cecil Bosanquet, m.a., m.d., f.r.c.p. ; Physician to Consumption Hospital, Brompton, and Charing Cross Hospital. Diabetes. Francis D. Boyd, c.m.g., m.d., cm., f.r.c.p. ; Physician to Royal Infirmary, Edinburgh. Medical Diseases of Kidney. Dudley W. Buxton, m.d., b.s., m.r.c.p. ; Anaesthetist to University College Hospital and Royal Dental Hospital. AncBsthetics. J. Roger Charles, m.a., m.d., b.c, f.r.c.p. ; Physician to the Royal Infirmary, Bristol. Medical G astro-intestinal Diseases, Influenza, Acidosis, Gout, Drug Habits. Sir Thomas S. Clouston (the late), m.d., ll.d., f.r.c.p. ; Ex-President of Royal College of Physicians, Edinburgh ; Physician Superintendent, Royal Asylum, Edinburgh. Mental Diseases . Carey F. Coombs, m.d., b.s., m.r.c.p. ; Assistant Physician, Bristol General Hospital. Diseases of Heart and Arteries. C. W. Daniels, m.b., f.r.c.p. ; Physician to the Albert Dock Hospital, late Director of London School of Tropical Medicine. Tropical Diseases. Bryden Glendining, m.b., M.S., F.R.c.s. ; Obstetric and Gynaecological Tutor, Middlesex Hospital ; Gynaecologist to Hampstead and N.W. London Hospital. GyncBcology and Obstetrics. A. GooDALL, M.D., F.R.C.P. ; Assistant Physician to the Royal Infirmary, Edinburgh ; and G. L. GuLLAND, M.A., B.sc, M.D., F.R.C.P. ; Physician to the Royal Infirmary, Edinburgh. Diseases oj the Blood. E. W. GooDALL, M.D., B.S. ; Mcdical Superintendent, Eastern Hospital, Homerton. Infective Fevers. W. J. Greer, f.r.s.c.i. ; Surgeon to the Royal Gwent Hospital, Newport. Fractures. W. Sampson Handley, m.d., m.s., f.r.c.s. ; Surgeon to Out-patients, Middlesex Hospital ; late Surgeon to Bolingbroke Hospital. Cancer of Breast and Rectum, Melanotic Sarcoma. J. Ernest Lane, f.r.c.s. ; Senior Surgeon to St. Mary's Hospital and London Lock Hospital. Syphilis and Gonorrhaa. A. Latham, m.a., m.d., f.r.c.p. ; Physician to St. George's Hospital, Mount Vernon Hospital, and Senior Assistant Physician, Brompton Hospital. Pulmonary Tuberculosis, Diseases of Lungs and Pleura. COXTRIBUTORS Hugh Lett, m.b., ch.B., f.r.c.s. ; Surgeon to the London Hospital. Appendicitis. F. J. PoYNTON, M.D., F.R.c.p. ; Senior Phj-sician to Out-patients to University College Hospital and Great Ormond Street Hospital. Rheumatic Diseases. H. D. RoLLESTOX, M.A., M.D., B.C., F.R.C.P. ; Senior Physician to St. George's Hospital ; Physician to Victoria Hospital for Children. Diseases of Liver, Addison's Disease, Lymphadenotna. J. H. Seoueira, M.D., F.R.C.P., F.R.C.S. ; Physician to Skin Dept., London Hospital. Skin Diseases. James Sherrex, f.r.c.s. ; Surgeon to the London Hospital, and Senior Surgeon Poplar Hospital. Surgical Diseases of Stomach, Nerve Injuries. A. Eendle Short, m.d., b.s., b.sc, f.r.c.s. ; Assistant Surgeon, Bristol Royal Infirmary. General Surgery. PuRVES Stewart, m.a., m.d., cm., f.r.c.p. ; Physician to the Westminster Hospital and to West End Hospital for Xervous_Diseases. Nervous Diseases. J. W. Thomson Walker, m.b., cm., f.r.c.s. ; Surgeon to the X.W. London and Hampstead Hospital, and Assistant Surgeon to St. Peter's Hospital for Stone. Surgical Diseases of Bladder and Kidney. A. J. M. Wright, m.b., b.s., f.r.c.s. ; Surgeon to the Nose and Throat Dept., Bristol General Hospital. Diseases of Nose and Throat. AN INDEX OF PROGNOSIS And End- Results of Treatment ABDOMINAL INJURIES. — We have to consider the consequence of (i) Blows on the abdomen ; (2) Punctured wounds ; and (3) Gunshot wounds. It will be necessary to set these forth according to the viscera which may be injured. I. Contusions. — After a severe blow on the abdomen, the patient is usually seen within a few hours by a medical man, and the diagnosis and prognosis at first are often very difficult. Such injuries as a kick by a horse, buffer acci- dents, and cases where a vehicle has run over the abdomen, are always to be regarded as entailing very serious possibilities, because great force may have been localized upon a small area. It is extremely important to realize that the degree of shock when the patient is first seen is most misleading as a guide to diagnosis or prognosis. Thus, on the one hand, to take an extreme case, a powerful athlete may die outright as a result of a blow over the solar plexus, without any laceration of abdominal viscera whatever. An area the size of a half crown is well known to pugilists as the ' mark,' where a hard punch will induce instantaneous shock. If the injured person does not die at once, however, he will almost certainly recover completely, provided that the contusion of the abdomen has not ruptured any important viscera or vessels. On the other hand, the prevalent impression that after rupture of one of the important organs the patient's pulse will necessarily be quick and feeble, is misleading to the last degree, and many reputations have suffered because the doctor has seen a patient soon after the injury, and, trusting to the normal pulse and absence of shock, has sent him home with a good prognosis, whereas six hours later he was dying of internal haemorrhage. Most hospitals have tragic stories to tell of this calamity. Ruptured spleen is particularly apt to lie hidden in this way. In a series of 13 cases of rupture of various abdominal viscera .studied by the writer, in only 3 was the pulse over 100 when first seen, and these three all died within twenty-four hours. It ought to be well recognized that prognosis is absolutely impossible within a few hours of a severe injury of the abdomen, unless, of course, the patient is already obviously dying. Even if there are no symptoms whatever, he ought to be put to bed and carefully watched, the pulse being counted every fifteen minutes for several hours. It is usually possible to recognize, when he is warm in bed, and given hot applications for the abdomen, that the condition remains or becomes favourable if no viscera are torn. Morphia ought not to be given until the diagnosis is certain, as it masks symptoms. On the other hand, if important organs are torn, the condition will get worse, or at any rate there will be no improvement. The pulse-rate often rises and its volume diminishes, the face becomes an.-cious, the patient, as we say, ' looks bad,' and there is often rigidity of the abdominal wall. The temperature mav be subnormal. Vomiting is fairly common, but not necessarily important ; even slight haematemesis may be of no serious import. In a case under the writer's care, in spite of twice vomiting blood, a boy recovered without further trouble. I INDEX OF PROGNOSIS Evidence of free fluid in the abdomen, or the pallor and air hunger of great haemorrhage, are, of course, very grave signs. In ruptured spleen there may be fixed dullness in the left flank and shifting dullness in the right. Loss of liver dullness is of no importance. Such signs as the above are usually to be detected after watching the patient for four or five hours, and may, of course, be evident much sooner. They urgently demand laparotomy. In our experience at the Bristol Royal Infirmary, mistakes in diagnosis in cases thus watched are very uncommon, though it is often impos- sible to tell what organ is damaged. One possible result of a blow on the abdomen well deserves notice. The writer has seen two cases illustrating it. After a contusion of the right iliac fossa, acute appendicitis may come on rapidly. In the first case, following a blow by a foot- ball, there was pain, tenderness, and rigidity, but the patient looked well, the pulse was normal, and he walked up to the hospital. The local signs were attributed to the blow the day before, and the lad was told to rest at home. Two days later he was admitted with appendicitis and general peritonitis, and died. In the second case, the condition when first seen was exactly similar, but the temperature was taken, and found to be raised. This boy was operated on, and recovered well. The temperature is the clue to these very deceiving cases. Ruptured Intestine. — We are greatly indebted to the careful study of Berry and Giuseppe on 132 cases, being the total number treated in ten London hospi- tals from 1893 to 1907. The writer has been able to trace 6 more treated at the Bristol Royal Infirmary (1900-1912). Traumatic Rupture of Intestines. Without Operation With Operation Cases Died Eecovered Cases Died Ilecovered < London Hospitals Bristol Royal Infirmary 48 1 44 1 4 = 8% 84 5 67 1 17 = 20% 4 Many of the patients, of course, were admitted moribund, or had fractured pelvis or spine. Apart from operation, death usually ensued within twenty-four hours ; one patient lived ten days. The best results were obtained by early operation, which means within twelve hours. All the Bristol successes were treated from four to six hours after injury ; of the London cases, 13 out of 33 operated on within twelve hours recovered, but only I after the lapse of twenty-four hours. As regards site of the injury, duodenal tears were almost invariably fatal. It will be observed that, even apart from operation, 4 cases recovered in which abscesses or obstruction, developing subsequently, showed that rupture had occurred. One patient got well without operation who was thought too ill to have anything done ! After successful suture, the great majority of the cases seem to remain quite well. Of the Bristol cases, 3 were examined long afterwards, and had no trouble except a slight incisional hernia in i case ; 2 of these were seen by the writer six and eight years after the operation. A few of the London cases returned for obstruction or abscesses. Ruptured Liver. — Recent data concerning this injury are not easy to obtain. The writer has abstracted the records of 10 cases treated at the Bristol Royal Infirmary, of whom 6 were operated on and 2 recovered. One of the latter had ABDOMINAL INJURIES a small tear, and was not diagnosed for two days. The other recovery was operated on after five hours. Adding together the statistics during ten years in the Bristol series, and five years at St. Thomas's and the Middlesex Hospitals, one obtains a record of i8 cases operated on, of which 12 died and 6 recovered. Tilton reports the figures from ten New York hospitals during 1895 to 1905, whereof 7 out of 12 died and 5 recovered. Ruptured Spleen. — This injury is less common than the above. The dangerous tendency to produce no alarming symptoms for several hours has already been mentioned. Laspeyres has found in the literature 58 cases of splenectomy for rupture, of which 39, or 67-2 per cent, recovered ; but such records are likely to be far too favourable, as deaths are less written up than successes. Putting together the figures for the Bristol Royal Infirmary, St. Thomas', and the Middlesex hospitals, one finds 13 cases with 8 deaths and 5 recoveries. Ruptured Pancreas. — This appears to be a rare injury ; two large London hospitals had no case in five years. At the Bristol Royal Infirmary there have been 2 recent cases ; i died, the other recovered, and was well four years later. The fatal case furnishes an instance of a common sequel, namely, severe self- digestion of the tissues leading to subphrenic abscess. Mikulicz in 1903 col- lected from the literature 24 cases, of which 13 died without operation, and of the II operated on 7 were cured. Pancreatic cyst has followed injury of this gland. Ruptured Kidney. — Beall has given to us several tables of statistics collected from the literature and from hospital reports jointl}'', and therefore probably rather too favourable. Probably the same cases are included in several of the lists. The most useful figures are those of Delbet and Watson, which are as follows. It will be observed that of cases not operated on about two-thirds recover, of those submitted to nephrectomy about three-quarters, and all but about 5 per cent of those explored but found not to need removal of the kidney. No OPEKATION Nephrotomy NEPHRECToanr Cases Died Per cent Cases Died Per cent Cases Died Per cent Delbet Watson 225 273 103 81 45 30 50 99 2 4 7 7 44 115 11 25 25 22 When the only evidence is a transient haematuria, the patients make a perfect and complete recovery. When there is in addition a sv/elling in the loin, but no tear of the ureter and no early shock or haemorrhage, the outlook is good. Three cases, seen by the writer many years afterwards, had continued quite well. Marked signs of shock make a bad prognosis, whether the effusion of blood is into the loin or into the peritoneum. Two such cases at the Bristol Royal Infirmary treated by nephrectomy both died. Laceration of the renal pelvis or ureter leads to leakage of urine or hydronephrosis, which may suppurate, when the outlook becomes very grave. The outlook in children is very grave, accord- ing to Maas, 85 per cent die. Rupture of Bladder. — This is not very common. Two large London hospitals had no cases in five years. Of 6 cases at the Bristol Royal Infirmary, only i recovered, but usually the operation was undertaken too late to give the patient a chance. There can be no doubt that if there are not severe injuries besides. INDEX OF PROGNOSIS and no cystitis is present, earty diagnosis would save a larger proportion. One man fell into a ditch whilst intoxicated, and ruptured his bladder into the peritoneum. He was treated by a doctor in the country for a week ; sometimes he passed water himself, and sometimes a catheter was used. He was up and about most of the time. On admission, the abdomen was greatly distended ; at the operation, 13 pints of urinous fluid were evacuated, and twelve sutures were necessarj' to sew up the rent in the bladder. He died, but could no doubt have been saved by earlier operation. Collections of isolated cases from the literature, such as Quick's and Ashhurst's, are quite unreliable in estimating the true mortality, because fatal cases so often fail to get into print. The latter reports 22 cures out of 29 cases operated on bv various writers since 1893. 2. Perforating Wounds. — It is not possible to say much about the prognosis of stab wounds of abdominal viscera, because so much depends upon the circum- stances and upon early operation. Given prompt diagnosis and treatment, the majority of the cases ought to recover, just as a perforated gastric ulcer usually does ; but a few hours' delay, at any rate beyond twelve hours, will seriously jeopardize the patient's chances. When the signs of widespread peritonitis are present, the outlook is very grave, but by no means hopeless. Statistics are not easy to obtain. Tilton reports that of 13 cases of stab or shot wound of the liver from ten New York hospitals, 4 died and 9 recovered. The prognosis is, of course, much better than that of contusion. 3. Gunshot Wounds of the Abdomen. — The surgery of the South African and other recent wars has greatly modified our conception of this condition. Everjr- one went to South Africa expecting that there would be a great deal of abdominal surgery, but in practice the patients who were shot through the abdomen did far better without operation than with. No doubt this was partly due to the unfavourable conditions under which operations and after-treatment had to be conducted. The narrow-bore high-velocity modern bullet makes only a small hole in the intestines, and peristalsis is checked until the track is sealed, so that blameless recovery was the rule rather than the exception. Of 207 cases of gunshot wound of the abdomen, 143 recovered, and in 40 per cent of the patients no symptoms of visceral injury ever developed. The principal factor in the prognosis was transport. A long, rough journey to a base hospital made the outlook grave. If the patient was going to die, he usually showed urgent sym- ptoms of haemorrhage or peritonitis within forty-eight hours. Those who were shot through a diameter of the abdomen usually died. Some of the recovering cases developed a localized abscess. In the days when old-fashioned bullets and firearms were used, the prognosis of abdominal injuries was very grave. In the American Civil War, 90 per cent of the cases died, and the mortality was high in South Africa after Martini-Henry wounds. In civil practice, patients shot through the abdomen with revolver bullets or small shot will probably die apart from operation, and even after an early laparotomy there is grave danger. With regard to wounds of particular viscera, the conclusions reached by Makins, based on experience in the Boer War, were as follows : — Wounds of small intestine, unless a diameter of the abdomen was perforated, usually got well. Wounds of colon were more dangerous, and a localized abscess often formed. The prognosis after injury of the transverse colon was worse than that of the ascending colon or rectum. Wounds of the stomach usually recovered. In Avounds of the liver and spleen, unless they died outright of haemor- rhage, the patients nearly all got well. ACIDOSIS If the kidney was traversed, the patient usually recovered after slight haema- turia, but in a few cases hydronephrosis followed. Intraperitoneal injuries of the bladder usually did well, but nearly all the cases diagnosed as extraperitoneal perforation died. References. — Rendle Short, Lancet, 191 1, ii, 818 ; Berry and Giuseppe, Proc. Roy. Soc. Med. (Surg. Sect.), 1909, iii, i ; Tilton, " Ruptured Liver," Ann. Surg. 1905, 20 ; Laspeyres, Centr. Grenzg. 1904, vii, 152 ; Quick. " Ruptured Bladder," Ann. Surg, igoy, xlv. 94 ; Makins, Surgery of the South African War ; Beall, Med. /?ec. 1913, Ixxxiii, 64. A. Rendle Short. ABSCESS, SUBPHRENIC. — (See Subphrenic Abscess.) ACCESSORY SINUSITIS OF THE NOSE {See Nasal Accessory Sinusitis.) ACIDOSIS. — The prognosis of acidosis depends more on its cause than on its intensity, though, ccBteris paribus, the degree of the latter is a most important item. The most common conditions in which it occurs are diabetes mellitus, starvation, sudden withdrawal of carbohydrate food, after some anaesthetics, during febrile diseases, in the toxsemic vomiting of pregnancy, the cyclic vomiting of children, and in phosphorus poisoning. Although many factors, including the administration of mineral acids, may lead to diminished alkalinity of the juices of the body, and so produce a state of acidosis, here we are not referring to such conditions, but to an acid intoxication set up by the presence of oxybutyric acid, diacetic acid and acetone. To this form of poisoning children are more susceptible than women, and the prognosis is worse in children than in women. Similarly the outlook is worse in women than in men. These bodies not only exert a direct toxic effect on the tissues of the body, but also act detrimentally on account of their acid properties. In severe cases they are excreted in very large quantities, and this represents a large quantity of unused fuel, entailing a considerable loss of energy to the body. For purposes of prognosis it is necessary not only to determine the presence of acidosis, but also, so far as is possible, the degree of acid intoxication. By the usual tests the presence of these substances will be proved in the urine. Probably also the odour of acetone in the breath will be obvious. T. Stuart Hart, in the Quarterly Journal of Medicine, gives the following- method for estimating the acidosis index. He first demonstrates the presence of acetone by the usual test (Lange's). Secondly, he uses the ferric chloride method (Gerhardt's test) to show the presence of diacetic acid. He uses the following solutions for the determination of the acidosis index : — {a). The ' standard solution,' consisting of ethyl aceto-acetate i c.c, alcohol 25 c.c, and distilled water to 1000 c.c. {b). Ferric chloride solution, consisting of 100 grams of ferric chloride dissolved in 100 c.c. of distilled water. An equal quantity (10 c.c.) of (a) and of the urine to be tested is put into two test-tubes separately. To each of these i c.c. of (6) is added. After waiting a few minutes the intensity of the colour of the two is compared. If the solution in the {a) test-tube is lighter than the urinary solution, add known quantities of distilled water to the latter till the shade oi the two is the same. From the figures so obtained the ' acidosis index per litre ' is arrived at. Thus : ■ Acidosis Inde.\ per litre. Lange's test positive and Gerhardt's test negative = Oj Lange's test positive and Gerhardt's test positive Volume of urine solution 10 c.c = i 20 ,, =^2 ,, ,, ,, 100 ,, = 10 and so on in proportion. INDEX OF PROGNOSIS To obtain the 'acidosis index,' the 'acidosis index per Hfcre ' is multipUed by the amount of urine in litres passed in twenty-four hours. This method gives an ' acidosis index ' which can be translated in terms of /3 oxybutj^ric acid. Thus an acidosis index of ten is equivalent to the daily excretion of lo grams of i3 oxybutyric acid. Another helpful test is the reaction of the patient's urine to alkali given by the mouth, e.g., a patient who requires more than i oz. a day of sodium Ijicarbonate to make his urine alkaline, is suffering from acidosis of very con- siderable severity. In a healthy individual, 2 dr. of sodium bicarbonate will keep the urine alkaline for twenty-four hours. If, however, an excess of acid is being formed in the body, the soda will unite with the acid radicles and be excreted in the form of neutral salts, and thus fail to make the urine alkaline. The amount of sodium bicarbonate required to be given to induce alkalinity helps materially therefore in forming a prognosis. The reduction in the alkalinity of the blood will also give valuable indications, for if this is reduced it is almost certain that the rest of the tissues have suffered to a greater degree. The method more frequently used at the bedside is the determination of the percentage of nitrogen excreted in the form of ammonia, and the comparison of this percentage with the percentage of nitrogen excreted in the form of urea. The ammonia nitrogen in health is at most about 5 per cent of the urinary nitrogen, but in conditions of acidosis it not infrequently rises to 18 to 20 per cent, and readings as high as 40, 50, or even 60 per cent have been recorded. The nitrogen is apparently excreted in the form of ammonium salts, instead of being built up in the body into urea, in order to neutralize the condition of acidosis in the tissues and to save the mineral bases of the body. It must not, however, be assumed that acid intoxication exists because the percentage of ammonia nitrogen excreted in the urine is very greatly increased, for this proportion may be increased, not because there is any absolute increase in its amoiint, but because there is an absolute decrease in the amount of urea excreted. This not infrequently happens in conditions of protein or total starvation. It has been found that when the urea excretion faUs below 7 to 8 grams in the twenty-four hours, the relative percentage of ammonia nitrogen increases, and that this may occur apart from the presence of organic acids. An absolute as well as a relative increase in the output of ammonia nitrogen must be looked for, if this is to be used as a basis of prognosis. As much as 12 grams of ammonia nitrogen have been observed to have been excreted in twenty-four hours, being 40 per cent of the total nitrogen excreted. The total quantity of ammonia excreted forms an indication of the degree of acid intoxication, but not of necessity the amount of organic acid being simultaneously excreted. For the estimation of this, the test of Hart, mentione d above, forms a very useful guide. It is of the greatest value to make constant observations on the percentage of the ammonia nitrogen excretion in any given case to ascertain if it is running into greater danger; but the figures so obtained are of little value in comparing one patient with another, for a man may be in fairly good health who is excreting a much greater amount of ammonia nitrogen than one who is in diabetic coma. There appears to be little doubt that acid intoxication is responsible for the coma and other toxic syrriptoms in diabetes, and kills the patient; but the excretion of acetone bodies may go on for many months without acid intoxica- tion supervening. In starvation the condition is different, because, in spite of the fact that the ACROMEGALY patient suffers from acidosis, he can still assimilate and use carbohydrates if he can get them, and as he still possesses the power of utilizing cleavage carbohydrate derived from his own tissues, he probably dies rather from actual deprivation of food than from acid intoxication, a point which makes the outlook, as far as treatment is concerned, much more hopeful than in the corresponding state of diabetes. In post-aneesthetic poisoning it must be remembered that the patients have generally been starved, and that in starvation the total excretion of ammonia is to be estimated, not merely the percentage of the ammonia nitrogen, as this may appear unduly high, owing to the small amount of urea excreted. The prognosis is much improved if treatment with sodium bicarbonate and glucose is used before the administration of the anaesthetic. Glucose seems to be more effective than the alkali in preventing post-anaesthetic vomiting. When acidosis is present and diacetic acid excreted, it is said to be a favourable sign if the output of diacetic acid increases after the administration of sodium bicarbonate. This is explained on the assumption that the base unites with the acid and enables the acid to be excreted in larger amounts. /. R. Charles. ACROMEGALY. — -We now believe that this disease is due to an excess of secretion of the anterior lobe of the pituitary gland, and in many cases it is found that the sella turcica shows enlargement in the skiagram, and at the autopsy the gland is usuallj'- much increased in size. If the symptoms of hyperpituitarism come on before the epiphyses of the long bones have united, gigantism results. We have to consider, first, the natural prognosis, and then the effect of operation. In the great majority of cases there is no immediate danger to life, and the patient may not even be reduced to invalidism. The profession is much indebted to Dr. Mark for the graphic description he has given us of his own case. The principal troubles are likely to be neuralgic pains, protrusion of the lower jaw interfering with eating, and some limitation of the field of vision by pressure on the optic chiasma. In other cases, symptoms of hypopituitarism follow, possibly due to deficiency of the posterior lobe, leading to iinpotence in the male and amenorrhoea and sterility in the female. The subjects of gigantism are generally feeble, and seldom live to a great age. There are cases, however, in which the outlook becomes unfavourable owing to further increase in the size of the gland leading to intracranial pressure. This is much commoner in the converse condition of hypopituitarism (Frohlich's type) characterized by adiposity and atrophy of the genitals ; these patients are often suffering from a sarcomatous or cystic growth. When, therefore, in cases either of acromegaly, gigantism, or Frohlich's type, the patient complains of continuous severe headache, vomiting, and progressive blindness, which are found to be associated with slow pulse and optic neuritis or atrophy, it is probable that death is not far off. The cases of hypopituitarism are more ominous than those of acromegaly. Prognosis of Operation. — The operation mortality is not so high as one might suppose from the inaccessible situation of the gland. Von Eiselsberg reports 1 6 cases with 4 deaths (from acute meningitis). Gushing avoids opening the nasal sinuses so as to reduce the risk of sepsis, and has only lost 10 per cent out of 61 operations ; several of the patients were already desperately ill. The purpose of the operation was to relieve pressure by decompression, the base of the pituitary fossa being removed ; in other cases, part of the gland was excised, or a cyst evacuated. If the signs of intracranial pressure are marked and generalized, a subtemporal decompression gives more relief. With reference to the eventual results, von Eiselsberg claims that all his INDEX OF PROGNOSIS recovered cases were greatly relieved of their headache and amaurosis ; he followed some of them as long as four years afterwards. Gushing records improvement in half of his cases. Both observers remark that the bony enlargements of acromegaly may show reduction. Glandular feeding does no good in acromegaly and gigantism. In cases of the Frohlich type, feeding or injection is occasionally followed by remarkable benefit. References. — Gushing, PitiUiary Body and its Disorders ; Von Eiselsberg, Arch. f. klin. Chir. 1912, Dec. 8. ' ^. ^^^^/^ ^hort. ACTINOMYCOSIS.— It is probable that under this clinical term various forms of streptothricosis are also included, but it is not clear that there is an},- marked difference in behaviour. The prognosis depends principally upon two factors : the location of the disease, and the degree of septic infection which has supervened. To some extent also the nature of the treatment controls the end-result. Actinomycosis of the Appendix and Caecum. — This forms a fairly well-defined clinical group, of which the writer has seen 6 cases, and reported 2 more, in the wards of the Bristol Royal Infirmary. Up to 1907 there were about 150 cases in the literature, of which 27 were British, but it is certain that the real frequency is much greater. In about 60 per cent of cases of abdominal actinomycosis this region is affected. The outlook is very grave. Grill reported 77 cases, whereof 22 were said to be cured, 10 relieved, and 45 died ; but it is probable that this estimate is too favourable, in that the cases were not followed long enough. Patients of Gangolphe, Waring, and Blascko, and 2 seen by the writer, were apparently cured or relieved for months or years, but the disease returned, in one of the writer's cases after eight years, and death resulted. There are, however, a few authentic cures. The eight Bristol cases all died. The course of the illness is miserably chronic in the majority of cases, though some have died in a few weeks or months. Beginning like an ordinary appendi- citis, or occasionally with attacks of diarrhoea, a huge resistant mass gradualh- forms in the right iliac fossa, and abscesses open and burst through the skin. The pain is not great. By degrees the fungus spreads over the whole abdomen, metastases appear in or about the liver, and usually death from septic absorption follows in about nine to twelve months. By this time abscesses may have opened into the bowel, bladder, or other organs, producing faecal or urinar}' fistulse. Abdominal Actinomycosis in other Localities. — Next to the right iliac fossa, the ray-fungus most commonly affects the liver, and may come through the chest wall, as in a case seen by the writer. Almost any other organ in the abdomen may be affected, but rather uncommonly. The prognosis is unfavourable, but not hopeless. Jiron (quoted by Keen) gives the death-rate in abdominal actinomycosis as 71 per cent, which is prob- ably too flattering, as figures taken haphazard from the literature are apt to be. Actinomycosis of the Face, Jaw, and Tongue. — This is a common location, and a relatively favourable one if the diagnosis is made reasonably early. Huge swelling, with much induration but little pus, fixed to the jaw (usually the lower), but extending widely into the cheek or tongue, with a tendency to form sinuses, characterizes the disease. Given efficient treatment, however, it can usually be controlled, though it will be months before the patient is well again. Jiron quotes the mortality in this situation as 1 1 per cent ; here again the figure is probably too favourable. ADDISON'S DISEASE Pulmonary Actinomycosis. — The fungus may attack the lungs, or appear in the chest wall, forming a spongy abscess. In either case the outlook is very grave. Hodenpyl collected 34 cases, of which 32 died. The duration of life is about six to twelve months. Jiron reports that cases from the literature show a mortality of 83 per cent in thoracic cases. Actinomycosis of the Brain. — This is rare, and appears to be rapidly fatal. Actinomycosis of tlie Skin. — This is a favourable location, and though it may be very chronic, the considerable majority of the cases, if treated, are eventually cured. The Effect of Treatment. — The outlook is most favourable, of course, in situations where a radical removal can be undertaken, but actinomycosis of the appendix has several times recurred in the stump. Potassium iodide in large doses (240 gr. a day for months at a time) probably exerts a real curative effect, and the United States Commission reported that it cured 63 per cent cases in cattle. Copper salts, which are very poisonous to algae and moulds, are recommended both locally and by mouth, but statistics are not available. The best results are obtained by a combination of these methods with surgery. References. — Keen's Surgery, vol. i, article " Actinomycosis " ; Jiron (reference not found : incorrectly given by Keen) ; A. Rendle Short, Lancet, 1907, ii. p 760. A. Rendle Short. ACUTE YELLOW ATROPHY OF THE LIVER.— (5ee Liver.) ADDISON'S DISEASE.— In gauging the influence of treatment in Addison's disease, it must be borne in mind that periods of improvement occur spon- taneously, and may be erroneously explained as due to therapeutic measures. In this connection the generally admitted difficulty in foretelling a successful response to treatment in a given case is significant. Further, as in other grave organic diseases, the inauguration of treatment is often followed by transient improvement, due more to auto-suggestion than to any specific action of the drug. General Treatment. — The avoidance of fatigue and worry is always essential, and in advanced stages absolute rest in bed is most important, to prevent sudden fatal syncope. A patient whom I saw ten years ago with characteristic sym- ptoms is still alive, but has been in bed for eight years. Although open-air treatment has done good, and is reasonable on the ground that most of the cases show tuberculosis of the adrenals, protection from cold and exposure must be insured. Healthy and cheerful surroundings, with sun and warmth, by improving the general health and resistance, have an obvious bearing on the prognosis. In a few instances, of which Gaucher and Gougerot^ have collected six examples, syphilis appears to be the causal factor, and in these circumstances it is reasonable to hope that improvement will follow careful antisyphilitic medication ; but these patients bear mercury badly, and the administration of salvarsan would be a very risky proceeding. Organo-therapy in this disease is very disappointing as compared with the results in myxoedema. A small proportion of cases are permanently benefited or cured, marked improvement occurs in some instances, and that there is a real relation between the two is borne out by the onset of relapses when the treatment is stopped, and by improvement when it is resumed ; on the other hand, relapses and even death may occur during treatment. In nearly half the reported cases, treatment does not exert any influence, and in a few instances INDEX OF PROGNOSIS alarming symptoms appear to be due to the administration of suprarenal products. That arterial lesions comparable to those produced experimentally may be caused in Addison's disease by adrenal medication is unlikely, though Loeper and Crouzon^ report a case bearing this interpretaton. Adams'' critical analysis of 112 collected cases of Addison's disease treated by suprarenal medication shows that in 6, or 5-35 per cent, permanent benefit or cure resulted ; in 33, or 29-5 per cent, marked improvement followed ; in 49, or 43"75 per cent, no effect was noted ; and in 7, or 6-25 per cent, alarming symptoms were due to the treatnient. Tuberculin Treatment. — Although cases thus treated may undoubtedly improve or appear to be almost cured, as in Munro's* patient whom I saw, it must be remembered that even small doses of tuberculin may cause alarming symptoms, and probably for this reason the number of reported cases is very small. The prognosis in cases thus treated is complicated by the difficult}' of determining that a given case is due to adrenal tuberculosis. Cases of tuber- culous disease of the adrenals may fail to show any improvement after tuberculin. Operative Treatment would appear to be entirely contra-indicated by the liigh grade of asthenia characteristic of the fully-developed disease, and has onl}' been attempted in isolated cases. A tuberculous adrenal which formed a palpable tumour was renioved from a woman with the constitutional signs but without the pigmentation of the disease, and recovery followed (Oestreich)." Transplantation of an animal's adrenal into the testis of a patient with Addison's disease was carried out by Busch and Wright,^ who reported some improve- ment ; but death occurred two and a half weeks after the operation. Prognosis in Individual Cases. — Addison's disease, when so well established that it can be confidently diagnosed, appears to be almost always fatal sooner or later ; but it is well known that very considerable lesions of the suprarenals may be entirely latent, or may exist without any sj'mptoms, and that some degree of suprarenal inadequacy or ' Addisonism,' especially in chronic pulmonary tuberculosis, in which the symptoms suggest but fall short of those in Addison's disease, may be a temporary condition (Boinet).' The diagnosis in the early stages is difficult ; but while the possibility of error must be frankly admitted, cases diagnosed by thoroughly competent physicians may recover and remain perfectl}' well. Thus, I know a distinguished phj^sician who was diagnosed as a case of Addison's disease by Greenhow, a well-known authority on the disease, more than thirty years ago, and who has been a great athlete and is now in perfect health. Out of 293 cases collected by Lewin* in 1892, cure was stated to have occurred in ten. It is therefore probable that arrest may occur after initial sj^mptoms of slight intensity have been noticed. The average duration of symptoms in Wilks'^ cases was eighteen months, but some of these cases ran a very acute course. On the other hand, survival for ten or even more years after the onset of sj^mptoms has been recorded. The jnost acute cases are those in which the suprarenals are already damaged, usually by tuberculous infiltration, but in which symptoms are absent until, as the result of some acute infection or toxaemia, the available chromaffin substance is paralyzed, so that symptoms burst out in a fulminating manner, leading to death in a few days or weeks. Between the very chronic and the fulminating cases there are intermediate groups which contain most of the cases. Cases of simple atrophy of the adrenals appear to run a more rapid course than the more usual cases in which the glands are invaded by tuberculosis. Possibly this is because there is atrophy of the whole chromaffin system, which thus prevents any compensatory hypertrophy. ALBUMINURIA Pigmentation, which usually suggests the diagnosis, is much less important than asthenia as a guide to the course of the disease ; in fact, the most acute cases are commonly free from bronzing. In children, the disease is both rarer and runs a more rapid course than in adults ; it is said that two-thirds of the cases in children last less than a year (Castaigne and Simon^*'). The outlook is obviously worse in cases which steadily progress down-hill than in those which have periods of remission. Danger Signals. — Great asthenia and collapse, excessively subnormal tempera- ture, yawning, low arterial blood-pressure (e.g., a systolic blood-pressure of 65 mm. Hg), and disappearance of the radial pulse, point to imminent dissolution. I have twice found the radial pulse absent, and in both instances death followed within thirty-six hours. Severe vomiting and diarrhoea, and acute abdominal crises which may imitate appendicitis, are also grave signs. The onset of acute infections, such as influenza or pneumonia, makes the outlook almost hopeless. A high differential count of lymphocytes has been regarded as an unfavourable sign ; this is probably because it points to the co-existence of the status lymphaticus which favours sudden syncope or death. References. — ^Gaucher et Gougerot, Ann. des mal. ven., Paris, 1911, xvi, 321 ; ^Loeper et Crouzon, Bull. Soc. anat., Paris, 1903, s. 6, v, 918 ; ^Adams, Practitioner, 1903, Ixxi, 472 ; *Munro, Brit. Med. Jour., 1912, i, 665 ; ^Oestreich, Zeits. f. klin. Med., Berlin, 1897, xxxi, 123 ; *Busch and Wright, Arch. Int. Med., Chicago, 1910, v, 30 ; 'Boinet, Rev. de med., Paris, 1897, xvii, 136 ; ^Lewin, Chariie-Ann., Berlin, 1892, xvii, 536 : *Wilks, S., System of Medicine (Reynolds^, 1879, v, 359 ; ^"Castaigne et Simon, I.a pratique des maladies des enfants, 1910, iii, 307. ^_ £>_ Rolleston. ALBUMINURIA {see also Nephritis). — The question of prognosis when albuminuria is present must, in the first place, depend entirely on accurate diagnosis. Albuminuria may result from contamination of the urine by an albuminous liquid, such as blood, pus, or spermatic fluid. Such albuminuria is spoken of as spurious, false, or accidental albuminuria, and should be sharply differentiated from true albuminuria, where the albumin enters the urine from the glomeruli or uriniferous tubules. The differentiation between spurious and true albuminuria does not, as a rule, present any great difficulties, for a contaminating fluid usually contains a very large number of cell-elements, which form a sediment on standing, leaving a clear supernatant fluid which contains but a small proportion of albumin. Again, microscopic examination of the sediment will aid differentiation ; and tissue-elements may be present which do not belong to the urine. The occurrence of true pus-cells in large numbers points to an inflammatory affection of the urinary passages ; for though polymorphonuclear leucocytes are found in the sediment of a nephritic urine, they are never present in large numbers. When a diffused nephritis occurs in combination with an inflammatory affection of the urinary passages, the supernatant urine will contain a large proportion of albumin. When false albuminuria is present in association with a chronic interstitial nephritis, the proportion of albumin in the supernatant fluid may be small, and diagnosis may present difflculties : consideration of the total quantity of urine, and the condition of the cardio-vascular system, together with estimation of the blood- pressure, will always give valuable data for guidance in diagnosis. Physiological Albuminuria. — There can be no doubt that, if the tests used be sufficiently sensitive and delicate, albumin can be demonstrated in a large number of normal urines ; and it is now held that, though albumjn cannot be demonstrated in every healthy urine, yet, under physiological conditions — conditions quite within the limits of health — it may appear in such quantity as to be easily demonstrable by ordinary tests. This form of albuminuria occurs in INDEX OF PROGNOSIS healthy individuals before middle life, at intervals, and only in response to some definite stirmilus or strain, such as a heavy meal, unusual exertion, cold bathing, mental excitement, etc. If the urine be examined with the centrifuge, a few hyaline casts and cylindroids will be found, but no epithelial or granular casts. The albuminuria in such cases has no definite pathological significance, and the prognosis is good. Take, for instance, the athlete at the commencement of training : exertion may produce albuminuria, but as training proceeds, similar exertion may no longer produce it. Cyclical Albuminuria is distinguished from the physiological variety by the fact that no special exciting factor is required for its production, and the condition cannot truly be considered physiological. It occurs in young persons, who are frequently of poor nutrition and with a somewhat defective, atonic digestion. The urine shows a fairly high specific gravity, easily deposits urates, and contains albumin. The latter follows a recognized cycle : on rising, the urine is free from albumin ; but it appears during the morning hours ; it reaches a maximum in the early afternoon ; and it diminishes in the evening. The centrifuged deposit may show a few h^^aline, but never epithelial, casts. Cardio-vascular changes are entirely absent, and the blood-pressure is not above the normal. In these cases the prognosis is favourable. The patients are somewhat weakly individuals, whose digestion requires care and attention, but they do not ultimately develop nephritis. Under care they may, and do, enjoy good health ; though the albuminuria may persist for years, it ultimately disappears, and the expectation of life seems unaffected by the condition. Febrile Albuminuria. — During an acute infectious disease, it is common to get a small quantity of albumin in a urine which, otherwise, does not give the characters of a nephritic urine. It is possible that, in such cases, circulatory disturbances may come into play ; but the main causal factor is cloudy swelhng resulting from infection and intoxication. Strictly speaking, such an albumin- uria must be regarded as the first stage of an infectious nephritis, which may or may not develop into a definite nephritis. The presence of the albuminuria shows that the fever has had a marked effect on the organism. The general condition of the patient is often serious : the temperature is high, the pulse frequent, and dyspnoea and collapse may supervene. Most of these symptoms are, however, dependent upon the general disease, and not upon the renal disturbance. Prognosis will, therefore, be governed by the general condition. The albuminuria is merely an expression of the profound nature of the general disturbance, which has given rise to cloudy swelling of the tubular epithehum. In the large majority of cases, febrile albuminuria does not develop into definite nephritis, but disappears vnth improvement in the general condition. Albuminuria of non-febrile General Disease is found, especiallj-, in diseased conditions involving the blood, such as anaemia, leukaemia, scorbutus, and jaundice. The albuminuria, in such conditions, is largely to be accounted for by the blood-condition and the circulatory disturbances which so often accom- pany the primary disease. It is true that, in a certain number of cases, epithelial changes have been found in the kidneys ; but these are by no means constant. As a rule, prognosis will be guided by the general condition of the patient. The albuminuria is an expression of profound disturbance, and will, therefore, be a factor to be taken into consideration in guiding prognosis. Albuminuria occurring in the course of diabetes mellitus seems to stand in a different category. It has been ascribed to the excessive ingestion of eggs ; but, in the majority of cases, it is the expression of an insidious nephritis of the interstitial variety, and the patients, for the most part past middle life, show cardio-vascular changes. The question of prognosis is a mixed one ; for when ALBUMINURIA OF PREGNANCY interstitial nephritis develops in the course of diabetes, amelioration may take place in the diabetic symptoms and glycosuria may disappear. The prognosis then becomes that of chronic interstitial nephritis complicated wdth hyper- glycaemia ; that is to say, it is always grave. Albuminuria due to Circulatory Disturbances is common in cases of cardiac disease with loss of compensation and passive congestion of the kidneys. In these cases, imperfect circulation leads to deficient oxidation and secondary changes in the renal epithelium. An additional causal factor will be found in increased pressure in the renal veins. The quantity of albumin present is usually small, and examination of the centrifuged deposit will exclude nephritis. Prognosis will depend upon the influence of therapeutic measures in improv- ing the circulatory condition ; with improved general circulation, kidney function is re-established, and a diuresis follows, with disappearance of the albuminuria. Proteinuria. — Bence- Jones' proteinuria, in the majority of cases, occurs in instances of multiple myelomata ; though it has been found associated with other pathological conditions, such as leukaemia, chloroma, lymphosarcoma, myxoedema, and carcinomatous metastasis. The recognition of the protein depends upon its relatively easy precipitation below the boiling point, while, on boiling, the solution tends to clear. The prognosis depends, not on the protein- uria, but on the primarj^ disease. As a rule, it is utterly bad ; many sufferers only survive the recognition of their conaplaint a few" months. Cases are on record of a much longer duration, however ; one, indeed, where the condition persisted twelve years, and the patient appeared to enjoy fair health. Such cases are, however, exceptional ; as a general rule, the recognition of proteinuria justifies a very grave prognosis. Francis D. Boyd. ALBUMINURIA OF PREGNANCY (see also Eclampsia).— The frequency with which alouminuria occurs is variously given. The majority of reporters place the figure at lo per cent of all pregnancies, but Jaeger^ finds it present in 70 per cent of the women. This figure is certainly abnormally high, and the albumin is only to be detected by careful examination, and often only indicates a transient catarrh of the bladder. Albuminuria with casts was present in 7-3 per cent of women in the Johns Hopkins Hospital cases. Now, at the outset, one wants to know what proportion of the cases go on to eclampsia. There are, unfortunately, no recent figures obtainable, and earlier observers gave 70 per cent as developing such symptoms. The general view held at the present day is best expressed in the remarks of Tarnier, who said that he had never seen convulsions supervene in a case which had been on strict milk diet and rest for seven days. Unfortunately, the milk regime is not tolerated by pregnant women in some cases, and in others the patient cannot be induced to submit to it. Consequently it will be necessary to consider the prognosis from the point of view of (i) The clinical features ; (2) The examina- tion of the urine ; and (3) The duration of treatment. The prognosis in respect of (4) The fcetus must also be considered. I. The Clinical Features which should especially arouse anxiety are those commonly grouped under the heading of ' pre-eclamptic,' which include troubles of vision, amblyopia and transient blindness, severe persistent headache, haemor- rhages such as epistaxis, and finally epigastric pain. In addition, an oedema originally confined to the lower half of the body, but now extending to the upper limbs and to the face, is an indication of at any rate severe albuminuria. The development of such symptoms while under active treatment, should call for more energetic measures. Bailey- finds that the blood-pressure is raised in 14" INDEX OF PROGNOSIS the more marked cases of albuminuria, and a pressure exceeding 150 mm. Hg is to be taken as indicating an impending eclamptic seizure. 2. The Urine, beyond the daily reading of the quantity of albumin, will serve as a guide to the patient's condition by the total quantity of urine passed in the twenty-four hours, together with the amount of urea excreted. With a defective excretion of urea in a urine diminishing in quantity, the question of terminating labour should be considered. 3. The Treatment may be complicated by the fact that some people cannot take milk. In these cases good results are reported as following the administra- tion of a salt-free diet. If with rest, purgation, and careful dieting the condition becomes aggravated, then it becomes necessary to adopt measures for interrupting the pregnancy. Many cases miscarry' in spite of treatment. 4. Prognosis as regards the Foetus. — It is to be remembered that the fre- quency of prem„ature labour lowers the chance of survival, and further that the occurrence of placental hasmorrhages, which are often seen in albunainuria of pregnancy, are said to endanger the life of the fcetus, so that in many instances the child is still-born and even macerated. References. — ^Zeits. f. Geb. u. Gyn. Ixviii, Hft. 3 ; ^Surg. Gyn. and Obst. 191 1, Nov. Bryden Glendining. ALCOHOLISM. — {See Mental Diseases.) ANiEMIA, APLASTIC. — -This condition is apparently due to an exhaustion of the bone-marrow or to its inability to respond to calls upon it. It follows severe septic and toxic conditions ; in some of these the anaemia is aplastic from the beginning, so that regeneration never takes place ; in other cases, regeneration may first occur and then fail. Sometimes it has followed on pernicious anaemia. We have known cases occur after repeated or continued heemorrhage. In many instances no causal condition can be discovered, and in these we may suppose that an inherent vulnerability or weakness of the marrow renders it unable to respond to any extra demand on its functions. In most cases, however, aplastic anaemia is to be regarded as the terminal phase of a serious disease. The only possible chance of a favourable outcome would be the discovery of a removable cause. This, however, is a remote contingency. As a rule, a fatal termination may be expected in a few weeks or months ; in one of our cases there was a history of anaemia for only three weeks before admission to hospital; the red corpuscles numbered 1,300,000 per c.mm. Death took place ten days later ; the red cells had decreased to 800,000. Another case gave a history' of progressive anaemia for two years ; his red cell count was 625,000. Death occurred in seven weeks, the count having fallen to 340,000 per c.mm. Among the signs which indicate that a fatal outcome is imminent are a low red cell count and a low leucocyte count, especiall}^ a diminution of the granular cells. If nucleated red cells have been present, and either diminish or fail to increase in number as the red-cell count becomes progressively lower, we would suspect that the anaemia was aplastic. In both severe secondary and pernicious anaemia we usually expect to find that nucleated red cells become more numerous in the blood as the corpuscular count drops. The occurrence of haemorrhages is an unfavourable indication, and an attack of intercurrent disease renders a fatal issue doubly certain. G. L. Gulland. A. Goodall. ' ANAEMIA, PERNICIOUS.— (See Pernicious Anemia.) ANEMIA, SECONDARY 15 ANEMIA, SECONDARY. — Secondary ansemia may arise from a great variety of causes, and practically the only condition in which the prognosis is not more influenced by the causal factor than by the bloodlessness, is post-hajmorrhagic anaemia. Acute Post-hsemorrhagic Anaemia may be immediately fatal. No other condition causes so much anxiety to the patient. Pallor, giddiness, and faintness may be noticed before much blood has been lost. As soon as the blood-loss has become severe, the pulse becomes low in tension, small in volume, and irregular. All of these symptoms are readily recovered from. More serious are hiccough, nausea and vomiting. Persistent syncope is a very grave indication. Fibrillary tremors and delirium are of even more serious omen, and after convulsions have occurred recovery rarely follows. If the haemorrhage is checked before a fatal result takes place, the patient is not yet out of danger. The blood is diluted by fluid from the tissues and its res- piratory value is thereby diminished ; it is also possible that the resulting hydraemia leads to a destruction of some of the less resistant corpuscles. The maximum severity of the anaemia is therefore not reached till some days after the actual haemorrhage, but the danger to life is not so great as during the initial loss of fluid. A return of syncope and nervous symptoms at this stage would be a serious indication. It is hardly necessary to discuss immediate prognosis in the case of actual haemorrhage, since the matter is determined at once. When a serious haemorrhage has been arrested, it may be of vast import- ance to be able to estimate the subsequent course of events. The suddenness of the hemorrhage is a factor. If blood be lost slowly, or in two or three repeated haemorrhages, the patient has a better chance of life than if the same, or even a less, quantity of blood were lost rapidly ; as, in the former case, there is more time for the relationship between the body-fluids and blood- pressure to be re-adjusted. Infants and young children bear the eft'ects of haemorrhage badly, but in the cases which survive, regeneration is very rapid after two or three days. Elderly and weakly persons will obviously be worse subjects for a haemorrhage than the middle-aged and robust. In cases which do badly, the appetite almost entirely fails, there is nausea and sometimes sickness. The heart acts feebly and irregularly, fainting occurs, with or without change of posture, and fatal syncope ensues. Patients are querulous and irritable, and permanent damage may be done to the nervous system. Among the most distressing consequences is blindness, sometimes due to optic neuritis, sometimes to no discoverable lesion. Such results are fortunately very rare. It is sometimes asked how much blood can be lost without a fatal issue ensuing. This question can hardly be answered ; so much depends upon the suddenness of the haemorrhage and the age and strength of the patient. It may be said that if a robust adult is still alive by the time a haemorrhage is arrested, the chances are greatly in favour of his complete recovery. We can recall the case of a housemaid who was suddenly the subject of a large haematemesis. This was repeated the following day. A blood examination showed red corpuscles 400,000 per c.mm. ; hemoglobin something immeasurably low — less than 5 per cent. This case gave rise to great anxiety for several days, but the patient made an uneventful recovery. We hardly expect ever to see this case paralleled. The rate of blood-regeneration varies with the severity of the blood-loss and the condition of the patient. A robust patient will replace a blood-loss of 30 to 50 per cent in a month or six weeks. 1 6 INDEX OF PROGNOSIS Several months might elapse before such a haemorrhage was made good in an elderly or weakly person. It is often desirable to know the limits of anaemia which justify surgica intervention. Mikulicz long ago laid it down that operations should not be performed when the haemoglobin percentage was under 30. This appears to us to be as just and reasonable as any arbitrary rule in medicine can be. The cases where operation is demanded are chiefly those in which the operation is calculated to arrest haemorrhage. We can quote the following. In one instance hysterectomy was performed for bleeding fibroids after the haemoglobin percentage had fallen to 24. In another such case, the blood-examination before the operation revealed red corpuscles 2,000,000, haemoglobin 30 per cent, leucocytes 15,000. A fortnight later the corresponding figures were 2,900,000, 50 and 7500. It should be remembered that, in skilful hands, hysterectomy is practically a bloodless operation. The blood-examination may give some guidance to the eventual outcome of haemorrhage. A leucocytosis beginning from eight to twelve hours after the bleeding indicates two things : first, that the haemorrhage has been at least moderately severe ; and second, that the marrow is showing signs of reaction. The appearance of nucleated red cells about the second or third day is also an indication that the haemorrhage has been severe. Some guidance as to the progress of regeneration may be obtained by noting their relationship to thg degree of anaemia. A moderate number is to be expected in all severe anaemias. Their absence after repeated search, in a case of severe anaemia, would indicate a slowness or deficiency of regeneration on the part of the marrow. Chronic Secondary Anaemia. — The least complicated condition is that due to repeated hemorrhages. Among the common causal factors are bleeding piles, menorrhagia or metrorrhagia, gastric and duodenal ulcer, and worm infections. These are all curable conditions, and so far as the anaemia is concerned, it is imperative that treatment should be sufficiently early and energetic to forestall such a loss of blood as would leave the patient with a haemoglobin percentage of 40 or 30. As already seen, the latter is about the lowest limit at which surgical operations are practicable. If it is impossible to deal with recurrent bleeding, fatty degeneration of the organs will ensue. The heart becomes feeble and irregular, appetite and digestion fail, oedema becomes evident, there may be petechial haemorrhages and nervous symptoms. Death occurs from heart- failure or from failure of tissue-nutrition. A falling leucocyte count and a disappearance of nucleated red cells will indicate that the case is becoming one of aplastic anaemia (q.v.). Anaemia due to improper nourishment and unfavourable surroundings is not usually very severe, and is easily curable when the environment is improved. Chronic secondary anemia is also associated with a variety of toxic conditions- — sepsis, fevers, syphilis, malignant disease, and exhausting diseases such as nephritis, chronic catarrh of the alimentary system, and so forth. In many of these, the anaemia may become so pronounced as to be an element to be considered in estimating the outcome of the disease, but in all cases it would be taking an incorrect perspective to attempt to gauge the severity of the condition from the anemia, rather than from the broader point of view of the influence of the causal condition. G. L. Gulland. A. Goouall. ANiEMIA, SPLENIC. — In estimating the prognosis of a case of splenic anaemia, it is advisable to try to distinguish between true splenic anaemia or Banti's disease, due to an overgrowth of fibrous tissue in the spleen, and at a later stage in the liver, and primary splenomegaly or Gaucher's disease, where the essential anjEmia. splenic 17 lesion is a proliferation of endothelioid cells in the spleen. The latter condition is to be suspected, especially in young subjects, when other members of the family have been similarly affected, when there is a peculiar grey pigmentation of the skin, and when ansemia (in the initial stages) is slight. It may be noted, in the first place, that a very few cases diagnosed as true splenic anaemia by competent observers have apparently recovered without operative interference. Goetz^ records the case of a girl who had been deUcate from birth. At the age of five years an enormous enlargement of the spleen was discovered. The number of red and white corpuscles was normal. Haemoglobin was reduced to 70 per cent. There were repeated attacks of haematemesis, and ascites had to be relieved by tapping on several occasions. The child survived attacks of measles, bronchopneumonia and croupous pneumonia. At the age of fourteen an attack of haematemesis occurred, but the spleen had by this time diminished in size. No further symptoms occurred, and three years later the spleen could not be felt and the girl appeared to be in perfect health. Winter^ reports the case of a man, aged 35, whose spleen had been enlarged for at least four years. He had suffered from haematemesis and melaena, and the red-cell count fell to 1,800,000 per c.mm. Under treatment, the number of corpuscles rose to 4,800,000, and the patient returned to work, although the spleen remained large. Most of such cases have been treated with arsenic, or arsenic with iodides. Ten years ago, a youth of eighteen, suffering from splenic anaemia in an early stage, came under the care of one of us. Gastro-intestinal symptoms were very pronounced, and treatment directed towards the alimentary canal led to what has apparently been a complete recovery. Such favourable results as the foregoing are by no means common. Benefit sometimes follows the application of x rays to the spleen, but it must be admitted that in the majority of the recorded cases their use has not influenced the course of the disease. We can recall the case of a girl of seventeen who had a remission of symptoms for five years after a course of ;f-ray treatment. Symptoms then returned and ascites was found. The further application of the rays failed to do good. Another case is that of a lady, aged fifty, with an enlarged'spleen. She has had many exacerbations, but since the application of X rays she has had a remission of 18 months' duration. When a case is doing badly, or when the disease appears to condemn a patient to a life of more or less complete invalidism, the problem of prognosis resolves itself into the question whether removal of the spleen can be safely accomplished. The outstanding fact in this connection is that a large number of thoroughly successful cures have been effected. Immediate benefit has frequently followed in cases previously doing badly. A few unsuccessful cases have also been reported, and the presumption is that a good many more have been left un- recorded. Cases have died of haemorrhage or shock immediately after the operation ; others have been carried off by pneumonia ; and yet others have died of vague gastro-intestinal symptoms after a short interval. Armstrong^ collected 32 cases of splenectomy for splenic anaemia. Complete recovery followed in 22 instances ; a fatal result from haemorrhage or shock occurred in 9 cases ; i patient was unrelieved. At the discussion on the subject, reported in the Proceedings of the Royal Society of Medicine, June, 1913, 6 cases of splenectomy were reported ; in all six the patient recovered and the anaemia disappeared. The great majority of successful splenectomies have been in young subjects. In dealing with cases of splenic anaemia it should be remembered that its course is usually extremely chronic. Little change may be manifested for years. 2 1 8 INDEX OF PROGNOSIS Even a downward tendency is seldom progressive. Exacerbations may be followed by long remissions, and the patient may continue to show little change. The standard of health after an exacerbation is likely to be lower, but lost ground is sometimes recovered. The greatest danger lies in the possibihty of intercurrent disease, and this is the usual cause of death. The possibility of sudden haemorrhage, too, is always a source of danger. Hcematemesis, ascites, and exhaustion close the normal history of the disease. The risk of haemorrhage increases with increasing anasmia, and therefore, in cases where splenectomy is thought desirable, the operation should not be too long delayed. Another risk of delay is that the result of an intercurrent affection naay diminish or abolish the feasibihty of surgical aid. We have seen one such case, where fibrosis of the lung followed an attack of pneumonia and rendered the performance of splenectomy out of the question. Where operation is contemplated, and the presence of ascites might be recorded as a bar, the effect of a preliminary tapping might be tried. We have one case, a boy of sixteen, suffering from splenic anaemia of the Gaucher type, in whom a single tapping has kept the patient free from ascites for two years. There is now a slight return of fluid. Unfortunately the co-existence of mitral stenosis precludes operation in this instance. In the later stage of Banti's disease, splenectomy combined with a Talma or Drummond-Morison operation might offer the chance of amehoration. One success has been recorded by Tansini.* In primary splenomegaly (Gaucher), the course may be very prolonged. In Gau Cher's own case the spleen had been enlarged for twenty-five years. The condition is more common in young subjects, and most of them are carried off by intercurrent affections. The data regarding splenectomy are very scanty. A few successful cases have been recorded, and there appears to be no alternative which offers a reasonable hope of success. References. — ^Rev. Med. de la Suisse rom., 1910 ; -Dub. Jour, of Med. Sci., 1912 ; ^Brit. Med. Jour. 1906, ii_; *Riforma med., Rome, 1902. q, l. GuUand. A. Goodall. ANEMIA, SPLENIC, OF INFANCY.— This condition usually occurs in children between the age of ten months and two years, and these limits are very seldom overstepped. It is not yet settled whether the splenic ansemia of infants is a mere secondary or s^^mptomatic ansemia, or a special form occurring in infants. The latter is probably the correct view. Although the cause and concomitants may vary, the clinical picture and the blood-changes are constant and definite. It is associated with rickets in the great majority of cases. The estimation of prognosis is not easy. Recovery takes place in a large proportion, probably the majority, of cases. More cases die of a complication than of the anaemia itself. Pneumonia most frequently determines a fatal outcome. The severity of the rickets or other causal condition, and the general condition of the patient, are the chief guides to prognosis. Marked emaciation, severe gastro-mtestinal disturbance, or any complication, adds to the gravity of the outlook. Petechial haemorrhages or other manifesta- tions of purpura are particularly unfavourable. The size of the spleen gives no indication of the severity of the condition. The examination of the blood yields useful prognostic indications. The most serious is a very marked reduction in the number of the red corpuscles ; counts below 2,000,000 per c.mm. indicate dangerous possibilities, and this is especially the case if the colour index is low. The number of nucleated red cells in the circulating blood appears to have no ANESTHETICS 19 relationship to the severity of the anaemia or the gravity of the prognosis, nor is it a matter of practical significance whether the majority of the erythroblasts are normoblasts or megaloblasts. A high leucocyte count, e.g., over 60,000, is to be regarded as a serious indication. The presence of a few myelocytes has no special significance, but a large number, or an abnormally high percentage of lymphocytes, is of more serious import. Fowler lays stress on the grave significance of a high proportion of transitional forms. Other things being equal, the more nearly the leucocyte picture approaches that of a simple polymorph leucocytosis, the more favourable is the case. The best of all prognostic indications will be provided by the response to treatment. If a case begins to improve, a favourable outcome may reasonably be expected. Good hygienic surroundings, and treatment directed towards the amelioration of general health and removal of the causal condition, are more likely to be followed by good results than mpre specific measures. Arsenic and iron are not so clearly indicated as in most other ansemias. They may do good, but they should be employed with caution. The application of X rays, in our experience, does more harm than good. Splenectomy is not to be entertained. The enlargement of the spleen persists long after the anaemia has been cured. A greatly enlarged spleen may not become impalpable tiU after a year has elapsed. Cowan has reported two cases in which the condition appears to have passed into the adult form of splenic anaemia. G. L. Gulland. A. Goodall. ANESTHETICS. — The data required for arriving at an accura^te forecast as to risk to life under ansesthetics and analgesics are at once dif&cult to obtain and still more difficult to apply practically. If we employ the statistical method, an examination of the figures upon which conclusions are based as regards any given ancsstheiic reveals their fallacy. For example : although it is true that the death-rate under chloroform is put at about I in 3000 when statistics collected by various persons are added together, yet, if we accept this estimate as approximately true, we do not learn anything about the expectancy of life in any given case. If we analyze the figures which make up the total, and study the question of the person adininistering the anaesthetic, we find that the expert's return of deaths falls enormously below this figure. In different countries, again, we are given widely different figures. Those of Col. Lawrie in the case of a considerable number of operations upon natives in India, present a far lower death- and danger-rate than those of other men of experience in other countries. In the case of ether we find equally discordant results. One fact stands out prominently — that in countries or districts in which chloroform is mainly used while ether is the exception, the death-rate under the former is lower than in places in which ether is most employed and chloroform is seldom relied upon. In individual hospitals we find that the death-rates differ ; and when we investigate the possible reasons for this, we find that the death-rate varies directly as the type of the anaesthetist. When the last is a student who has a brief tenure of office, the results are unfavourable ; when special men undertake the duties of anaesthetist, and remain in office for a long time, or when special anaesthetists are employed, the death-rate is lowered. We may conclude, then, that one factor of importance is the anasslhetist. When he is well trained, and gives his undivided attention to his work, the safety of the patient is greater. Nor is this due merely to the hypothesis that such an individual adopts the best methods. These methods vary within the widest hmits ; and while some persons will extol one type of procedure, another will prefer one INDEX OF PROGNOSIS which differs from the other in toto ccbIo. If we compare the results obtained by the two men, they being expert in their pecuhar systems, we shall find their results practically identical. But if their methods are pursued by a large number of students, most of them lacking in experience and judgement, and liable to errors of technique, we shall discover that methods do really constitute an important factor making for danger or safety, for the incidence of death is favourable with some methods, unfavourable with others. Recurring to the administrator as a factor, we find, further, that few ■ experienced men at the present day adopt one anaesthetic or one method to the exclusion of all others, and so the important element of judgement, itself the result of wide experience alike of failure and success, comes to play an important part ; and the selection alike of anaesthetic and method intervenes and modifies the incidence of danger. This again introduces a third factor, the condition of the patient. Let us make this clear by an illustration. Nitrous oxide gas is regarded, and rightly so, as being the least dangerous of the general inhalational anaesthetics ; and yet, if it is employed for a patient suffering from some obstructive disease affecting his air-passages, e.g., angina Ludovici, the risk to the patient's life is infinitely greater than would be the case if chloroform, an anaesthetic at the opposite pole to nitrous oxide gas as regards safety, had been employed. The inexperi- enced man would probably select nitrous oxide gas for such a case, pursuing general principles, and kill the patient ; the experienced man would select the chloroform, and save the life. The statistical method fails us in this particular. It would record such a death as being due to nitrous oxide gas ; and although such was actually the fact, yet it does not in any way demonstrate that this anaesthetic, as such, is less safe than chloroform ; indeed, the opposite is certainly true. It further happens that in many cases the condition of the patient is so serious that it becomes absolutely necessary either to deny him the benefit of an anaesthetic, and often by so doing increase his risk through shock, or to select an anaesthetic or analgesic which is peculiarly free from risk to life. Under such conditions, many must die, and the statistical method would, by recording such deaths against the practically innocuous anaesthetic, create a spurious death-rate for it. In this last illustration it will be observed that a fourth factor has made itself evident — the nature and gravity of the operaiioyi for which the anaesthetic is being administered. Now, in all the statistics at present in our hands, the grand totals merely reveal the actual number of deaths occurring under any given agent ; no account is taken, either of the method adopted, itself often as important as the anaesthetic ; of the experience and ability of the adminis- trator ; of the nature of the operation — for example, whether it was upon the air-passages, and so likely to cause special dangers under an anaesthetic ; of the severity of the operation, its duration, and the degree of trauma it necessitated ; of the condition of the patient as regards resistive power ; or of the presence of intercurrent toxaemia, asphyxia, shock, and so on. The only exact method of arriving at the incidence of danger of anaesthetics is by experiment, but here again this plan supplies less information than we need in the present investigation. It tells us that any given anaesthetic, or succession or mixture of anaesthetics, acting under known conditions of time and circum- stance, upon normal individuals, will produce certain results. We can estimate the progressive effects of increased concentration, or of hmitation of oxygen or of carbon dioxide : but although we can crudely reproduce a few pathological conditions, we cannot with certainty learn by this means what are the effects of the interaction of either anaesthetics or analgesics upon diseased tissues. ANMSTHETICS 21 The perversion of the nerve-controls existent in cases of exophthalmic goitre ; the congeries of conditions grouped under the term lymphatism ; those conditions which underlie the state called delayed chloroform poisoning : these are incapable of experimental reproduction in a form which would enable us to estimate the incidence of danger when anaesthetics are in use in their presence. We must, however, consider as the first step in arriving at a prognosis in any type of patient under any anaesthetic, the accepted physiological behaviour of the anaesthetic towards normal individuals ; and next, since pathological states are but variants from the physiological, we can deduce the probable effect of any given anaesthetic when acting upon a patient with a known morbid lesion. For example : we know that nitrous oxide gas lowers the actual oxygen content of the blood, and hence of the tissues ; further, that at a point this declension will produce tissue-asphyxia. Now, if the patient's pathological lesion has, by its effects, already lowered the oxygen content of the tissues, the administration of nitrous oxide gas is probably contra-indicated ; or if this anaesthetic is employed, we should look for a much speedier superinduction of asphyxia than in the normal person. In this case the choice of the method would come to our aid ; for by employing an appropriate mixture of this anaesthetic with oxygen, the danger in certain cases would be obviated. Thus we see that we cannot separate the anaesthetic itself from the method of its employment, if we are to arrive at a precise prognosis or incidence of danger in any given type of cases. A further difficulty is encountered in our inquiry when we pass from the type of patients to any individual member of the group. Although he may conform to the peculiarities of the group, yet he will in very many cases reveal some departure from these which is apt to invalidate any general statement as to his immunity from danger. We have to deal with two entities, the conscious and the anaesthetized ; and since the bridging over the passage between perceptive senscience and anaesthesia — the period of induction — is the acme of the curve of danger in any form of anaesthesia, we are compelled to study the psychological reaction of the patient towards the anaesthetic, as well as the physiological reaction of the drug towards the patient. It is the danger of fear-shock, which in pre-anaesthetic days — as indeed at the present day — occasionally proved fatal, which becomes most formidable when we have to decide between the use of an anaesthetic which abolishes consciousness, and an analgesic, whether local or spinal, which prevents perception of pain, but fails to remove the fear lest pain will come. While some persons experience no such dread, others faint even though no actual pain from trauma has occurred. The problem before us has to be studied from yet a further aspect. The dangers connected with either anaesthesia or analgesia are not ended when the operation has been completed. The after-effects, mental and bodily, may either prejudice convalescence, or produce actual and grave pathological condi- tions such as mania, or pulmonary, renal, or hepatic lesions ; and these may ultimately prove fatal. Having considered these general aspects of the subject, it remains to discuss those factors which we have shown to make for the incidence of danger or its avoidance, to indicate how far these dangers can be foreseen, and bj' what means they can be best prevented or mitigated. The factors making for safety or danger during anaesthesia or analgesia are : 1. The (a) anesthetic or {b) analgesic itself. 2. The method of employment. 3. The experience and knowledge of the person giving the drug. 4. The condition of the patient. INDEX OF PROGNOSIS 5. The nature and duration of the operation, and the intercurrent conditions such as trauma, and the shock arising as a result thereof. 6. Post-operative effects. I. a. Ansesthetics. — The chemical and physical properties of the known anaesthetics determine the following law as regards their safety or the reverse : All drugs containing one of the haloid elements — chlorine, bromine, iodine — being protoplasm poisons are more dangerous than those in which the haloid is replaced by oxygen. The danger increases directly with the amount of the chlorine, etc., present. The lower the boihng-point and the greater the specific gravity of the hquid, the greater the danger. The gaseous anaes- thetic is safer than the liquid, and the liquid than the solid — a law which follows from the preceding one asserting the greater safety of the highly volatile over the less volatile drug. Hence we should expect that the order of safety of the commoner anassthetics would be as follows : nitrous oxide ; ether ; ethyl chloride ; chloroform ; ethyl bromide. CUnically, we find that for normal subjects this order is correct ; while, experimentally, we obtain practically identical results. Treated statisti- cally, the incidence of death is : chloroform, i in 3000 ; ethyl chloride, i in 13,000 ; ether, i in 23,000 ; nitrous oxide, i in 200,000 ; raixtures of nitrous oxide and oxygen, uncertain, but a very low rate prevails. These figures, however, cannot be accepted as being more than rough approximations. In the case of ethyl chloride the estimate given is probably much too favourable to that anaesthetic. Waller's experiments concerning the effect of chloroform and of ether upon nerve tissue led him to believe that the former was seven times more dangerous. This is important, as deaths due to ansesthetics, when they arise from overdosage — as opposed to what may be called mechanical conditions — are brought about mainly through the poisoning of the centres in the medulla oblongata. But, as has been pointed out above, the incidence of death is largely dependent upon the condition of the patient being such as to be adversely affected by particular anaesthetics ; and so it is necessary to consider briefly what are the distinguishing actions of the commoner ansesthetics, and their bearing upon pathological lesions of the systems concerned with the processes of life. Chloroform produces haemolysis— as does ethyl chloride in a less degree ; chloro- form also diminishes the activity of glandular epithelium, and ultimately acts as a protoplasm poison, destroying tissue Ufe. Its effects upon the tissues vary directly with the nature of the latter ; thus, nervous tissues suffer most, the heart muscle more than the voluntary, and the voluntary muscles more than the involuntary ; the hver is the most vulnerable of the viscera, then the kidneys. This is, perhaps, best understood by stating that if the various tissues are subjected to chloroform-containing fluids, the percentage strength required, firstly to inhibit function, and ultimately to destroy the tissues' power of functionating, is lowest in the case of the highly-organized tissues such as nerve cells and fibres, while in the case of other tissues, higher and higher strengths or percentage values have to be used to inhibit or destroy. The elimination of chloroform is comparatively slow, and any interference with the functional activity of the usual emunctaries, such as progressively occurs as chloroform inhibits their action more and more, tends to the accumulation of the anaesthetic, and its storing up in the tissues, with disastrous effects. When, however, care is taken to avoid such a strength of vapour as produces this inhibition of tissue function, this danger is avoided. Ethyl chloride and ethyl bromide, so far as we know, behave similarly ; but ANESTHETICS 23 as they are seldom employed for any but brief periods, little is definitely known of their prolonged effects. Ether causes haemolysis, but unless asphyxial complications are permitted, its effect is slight in this direction. It stimulates all the cells except those concerned in the urinary function. The secretions of the mouth and respiratory tract are markedly increased. In the amounts employed in anaesthesia, it produces at first excitation of function, and then inhibition, but not destruction, of the protoplasm. Hence, if the inhibition is permitted to extend to a dangerous degree, the tissues recover their power of function when favourable conditions are re-established. Ether acts powerfully upon bacteria. It possesses a great avidity for fatty material, and so it is believed, upon experimental evidence, tends to destroy phagocytes by damaging their essential fatty environment ; hence phagocytosis is lessened or destroyed until the ether is eliminated and the phagocytes are able to re-assert their function. Owing to its ready volatihzation, ether rapidly dissociates itself from the tissues ; its elimination requires con- siderable absorption of heat, and hence it occasions a fall of body temperature. It certainly causes some tissue irritation, revealing itself in catarrhal conditions ; especially is this so in the case of the lungs and kidneys. The extent of this action, so far as the renal structures are concerned, was investigated by me with the aid of Dr. Goodman Levy, and the conclusion at which we arrived was that, provided the amount of ether perfusing the renal vessels was not excessive, interference with function was slight. The comparison of chloroform and ether in this connection is valuable. The former anaesthetic is less prone to initiate albuminuria, although more apt to increase its amount if pre-existing. Ultimately, chloroform tends to cause necrobiosis of renal epithelium, while ether does not ; though it must be admitted that this deleterious result only follows excessive quantities of the former anaesthetic. Nitrous oxide resembles ether in its stimulating action upon cells. This is followed by inhibition of function. It unquestionably possesses a specific action, and does not superinduce unconsciousness either by depriving the tissues of oxygen, or by splitting up and causing superoxidation (apnoea). As to some extent it replaces oxygen in the haemoglobin of the erythrocytes, and probably in the fixed cells, its effect is commonly associated with a superadded asphyxial effect. This, however, is concomitant rather than essential, so that when it is obviated, the power of nitrous oxide to induce insenscience is in no way hindered. Mixtures of ancBsthetics, such as the A.C. (i volume of alcohol to 9 of chloro- form), the C.E. (2 of chloroform to 3 of ether*), and the A.C.E. (i of alcohol, 2 of chloroform, and 3 of ether), act variously and variedly according as they are administered by one method or another. In hot weather, chloroform and ether mixtures given by an open method produce mainly an ether effect at first, and later a chloroform effect. A closed or semi-closed method promotes a chloroform effect, modified by the dilution due to the other ingredients of the mixture. It is not safe to assume that true antagonism exists in such mixtures, since the component anaesthetics evaporate individually and at different temperatures. Further, they possess a various coefficient of ' spread ' when sprinkled upon an absorbent surface such as lint or gauze, and the rate of evapora- tion may be taken roughly as varying directly as the spread and inversely as the wetting ; while the heavier vapours sink towards the reclining patient, the lighter rise and escape into the atmosphere of the room. Schafer, * There are several varieties of this mixture in use besides that named. For example : I volume of chloroform to 2 of ether ; equal volumes of chlorcform and ether ; i volume of chloroform to 4 of ether. 24 INDEX OF PROGNOSIS however, has demonstrated that the alcohol-chloroform mixture is, in fact, more stable, so that a certain amount of antagonism is existent. This was assumed in the case of the A.C.E. mixture also, and is probably true, though to a less extent, although the ether component acts as a diluent, not as an antagonist, to the chloroform. It will be observed that when alcohol, ether, and chloroform are shaken together, heat is generated, a fact which appears to indicate a more intimate association than exists in simple solutions. The employment of mixtures of the vapours themselves, by some method such as that suggested by Gwathmey, removes many of these objections. Such elaborations as those of Schleich's or Wertheim's solutions are too infre- quently employed to need analysis. Gaseous mixtures, such as that of nitrous oxide and air or oxygen, fall into another category. Here the oxygen or air merely supplies the necessary aeration and so obviates tissue asphyxia, hence permitting of the extensive employment of nitrous oxide gas. The hyperpnoea commonly existent with the methods in use lessens the carbon dioxide content of the blood, leading to acapnic condi- tions ; so that the addition of carbon dioxide gas to the nitrous oxide-oxygen mixture finds favour with some persons, and is employed for prolonged opera- tions. The simplest method of supplying carbon dioxide is by allowing partial re-breathing, and this is provided for by Teter and others in their apparatus for prolonged administration of these gases for the purposes of major surgery. Such combinations as amyl nitrite and chloroform, somnoform (ethyl chloride, methyl chloride, and ethyl bromide), and ethyloform, a more dangerous variant of the last, need merely to be mentioned as extremely unsatisfactory agents. We now come to the employment of alkaloidal bodies in association with general anaesthetics. Those most commonly in use are atropine, morphine, scopolamine, omnopon, strychnine. We may add chlor-butyl, although it is not alkaloidal. Atropine. — The use of this drug, gr. j^. given hypodermically one hour before inhaling an anassthetic, has revolutionized the methods of etherization. Its action checks the excessive secretion of the buccal and respiratory areas, and so removes one of the great drawbacks of ether. The dose has to be varied according to circumstances. In some persons, persistent throat dryness follows its use. Children, as a rule, tolerate atropine well. A further advantage of atropine is that it lessens the irritabihty of the pneumogastric nerves, and so minimizes the danger of vagal inhibition of the heart under chloroform. Hoelscher's observations appear to prove that much of the post-anaesthetic chest trouble is due to the aspiration into the air-passages of sahva and mucus impregnated with the anaesthetic ; hence, lessening this secretion by atropine diminishes the risk ; further, since swallowing the mucus mixed with condensation of the vapour of the anaesthetic promotes a catarrhal condition of the stomach and causes vomiting, atropine lessens sickness. Although atropine materially lessens the nausea and vomiting due to the anaesthetic, it fails in a few cases, especially if sepsis is present. Morphine, scopolamine. — There is no question that although morphine and atropine are commonly employed together, these drugs act better and more safely when combined with scopolamine. The pharmacological law which recognizes that several drugs exert synergic action in some directions, while they antagonize in others, holds with regard to these alkaloids. Thus the respiratory centre which is depressed by morphine is stimulated by the atropine bodies ; while scopolamine acts concurrently with morphine in producing suspension of the consciousness. Scopolamine is a dangerous drug when used by itself ; its undesirable qualities are lessened or removed, however, when it is associated ANESTHETICS 25 with morphine and atropine. The outstanding advantages of these drugs are : that they soothe the mental fear of the patient, and they lessen the amount of the general anaesthetic required. The disadvantages are that they disguise, to some extent, the guides to anaesthesia by interfering with pupillary phenomena ; they prolong induction, as the breathing is more shallow, and the thoracic excursions are diminished ; they induce a prolonged and profound sleep consecutive to the operation which, although highly beneficial to the patient, requires special and heedful watching, lest malposition of the head, falling back of the tongue, trickling of blood into, or accumulation of mucus about, the glottis, lead to interference with respiration. Their use presupposes that the patient has been carefully examined to ascertain if there is any contra-indication to the use of morphine. In local or spinal analgesia, the use of these drugs is obviously beneficial ; but it needs caution in the case of thecal injection, lest the action of the stovaine or novocain, travelling somewhat high, should interfere with the medullary centres already drugged by the morphine which has been injected. Omnopon. — The difficulty of standardizing the preparations of morphine has led to the adoption of a mixture of opium alkaloids with a morphine action, under the name of omnopon (pantopon) . Dr. Sahli has shown that the chlorides of these alkaloids are capable of being standardized, and so a definite dose with a known morphine effect can, it is asserted, be obtained. This substance is employed, in a similar way to morphine, in association with other alkaloids. The dangers of ether in the direction of pulmonary and renal sequelae, and those of chloroform in that of cardiac enfeeblement, are diminished by using these alkaloids adjuvantly; and this is markedly so in the case of irritable heart conditions, such as different forms of tachycardia. The use of these alkaloids would increase the danger in all states in which the respiratory system is hampered, either through cerebral or circulatory causes. Hence, in operations upon the brain or spinal cord if chloroform is to be used, also in cases in which cyanosis or breathlessness is present — unless when the latter is due to cardiac instability — their use is detrimental. Strychnine is given hypodermically just before an anaesthetic, with the view of antidoting chloroform, but it does not accomplish this object ; indeed it is probably detrimental, and when associated with morphine produces little if any beneficial effect, although it prolongs induction, and causes the muscular rigidity of the patient to be emphasized. If strychnine is of any value in the small doses usually adopted, it is only in the direction of stimulating the respiration. Chlor-butyl. — Chlor-butyl (gr. xv.), given ninety minutes before the anaes- thetic, determines drowsiness, and certainly diminishes the risk of after- sickness. b. Analgesics. — The dangers of cocaine, both in endermic injection, intra- thecal injection, and when introduced into the urethra, are so well known that most persons have relinquished its use. Novocain is probably the safest drug for local and regional analgesia, if properly sterilized and employed with the addition of adrenine. Stovaine seems less employed in local analgesia, owing to its damaging effect on the tissues ; but it is certainly one of the safest of the drugs used in intra- thecal injection. It produces some haemolysis, and its use is not free from the liabihty of being followed by oculomotor paralysis. Tropacocaine and alypin have their advocates, but probably neither is as safe as stovaine for spinal analgesia. The question of combining these drugs with adrenine is discussed under another caption (see Methods of Employment). The prognosis as to danger in the use of local and spinal analgesia is extremely 26 INDEX OF PROGNOSIS difficult to estimate, as so much depends upon the method employed and the condition of the patient, and these are variants in all cases. This fact renders generalization of no practical value. We know, however, that these methods, especially the intrathecal injection of drugs, have inherent sources of danger, since when the analgesic has once entered the tissues it is impossible to abrogate its action. Slight errors in technique also matter more in such procedures than in inhalational methods. Assumiing experience, absolute asepsis, and careful regulation of the dose, the danger to life is probably slight in the hands of experts, and the sequelae are not necessarily serious. It is, however, impos- sible, in the present state of our knowledge, to promise total immunity from them, or to forecast the degree of their severity. Statistically, the death-rate under spinal analgesia is given by various authorities as follows : — Mortality of Spinal Analgesia. Reporter Cases Deaths Hahn - - - - Patterson Reclus - Zahradnickj^ Wainwright Strauss - 708 7807 2000 4679 16300 22717 8 20 6 12 14 46 Total 54211 106 This gives, roughly, a mortality of i in 500. Too much importance must not be attached to such figures, as many of the continental surgeons state that they have used the method in thousands of cases without a death. The same caution applies to statistics of deaths under general anaesthetics. If we accept a recent estimate from the United States, we have — chloroform, i death in 2,500 cases ; ether, i in 16,000 ; nitrous oxide, i in 200,000. But many specialists have employed these anaesthetics without a single death. A study of the elaborate tables and precis of fatalities issued by the British Medical Association in 1900* shows that comparatively few of the deaths, recorded with sufficient precision to admit of exact classification, are due wholly and solely to the anaesthetic. The factors adopted by the workers on this committee were — the anaesthetic, the operation, and the state of the patient at the time of the operation. Although the number of cases examined was com- paratively small, 25,920, yet it is sufficiently large to form, a fair basis for comparison. However, the last two factors, the operation and the state of the patient, which may at first sight appear to be constants, are in fact not so. This is shown by the consideration that, for patients whose bodily state is extremely unfavourable, the ' safest ' anaesthetics are relied upon ; so that these agents are employed under desperate circumstances, with results which give for such anaesthetics a less favourable incidence of fatality. A further point which has to be taken into consideration, when comparing the results of general anaesthesia with spinal and local analgesia, is that whereas the statistics of the first comprise every type of administrator, including many who are quite inexperienced and Report of the Anaesthetics Committee appointed 1S91. ANESTHETICS 27 even devoid of medical knowledge, the second gives the work of keen experts whose care and acumen are unquestionable and whose technique is as good as our present knowledge of analgesia permits ; nor is this knowledge slight, since the stage of experimental groping has passed, and methods and technique are practically settled. Opinions, again, are in absolute conflict about what pathological conditions contra-indicate the spinal method. It may be useful to indicate briefly the consensus of views. The method is recommended in acute abdominal con- ditions, for operations below the umbilicus, especially in ' acute appendix ' cases ; also when acute or serious bronchial or pulmonary disease exists and the lungs are waterlogged ; and in severe glycosuria, and gangrene of the extremities. Whether patients with serious cardiac lesions, with excessive blood-pressure, or with pronounced albuminuria, should have the spinal method is very doubtful. The decision could only be made by scrutiny of each case. Whereas, formerly, the old and feeble, suffering from serious abdominal trouble, were regarded as good subjects for spinal methods, this view is not at present universally held. In cases of intestinal obstruction complicated with stercoraceous vomiting, the spinal method was looked to as a way out of a dangerous impasse. Un- happily, several deaths have occurred through faecal drowning when spinal analgesia was obtained, the features of which were identical with those occasion- ally met with when general anaesthesia was adopted. When feasible, local analgesia is undoubtedly safer than is the spinal method for such patients, but it fails to remove the distress arising from handling the viscera. If the dangers of sepsis are omitted, local analgesia offers few disqualifica- tions, except that it is only applicable in comparatively few cases, unless we are willing to inflict a certain amount of pain, pain which is sometimes severe. Its best use is undoubtedly when combined with light narcosis, whether by alkaloids or inhalation. It must be remembered that persons who were subjects of the status lymphaticus have died under the method, even though no overdose had been given. Another danger which is not always recognized is that nervous persons, and those whose mentality is unstable, are liable not only to serious neurasthenia, but even to delusional mania, as sequelae of a trivial operation performed under local analgesia. Also after-pain is stated to be more severe when local analgesia has been employed. To sum up : in serious conditions it is best to restrict spinal analgesia to patients who are not good subjects for the methods of general anaesthesia, unless the greater facility of obtaining muscular relaxation by the former method gives the surgeon a better chance of performing an operation in the success of which the patient's life is involved. Local analgesia, unless by regional methods, is dangerous in septic cases ; it is valuable for small and superficial operations ; its success in exophthalmic goitre is at least doubtful, unless associated with a general anaesthetic. 2. Methods of Employment. — Since the dangers arise from overdosage, or from using an anaesthetic by some method which embarrasses the circulation, respiration, nerve controls, or metabolism of a patient already suffering from disease of one or other of these systems, the method selected makes for safety if it gives the administrator absolute control of the dosage of the anscsthetic, or for danger if it fails in this regard and further imposes upon the patient an increased disability. Hence, dosimetric methods of giving chloroform, always desirable, are essential in operations upon persons with feeble circulation (cardiac disability), in cases of goitre or lymphatism, and in operations upon the cen- tral nervous system. 28 INDEX OF PROGNOSIS SufEocative conditions contra-indicate the employment of ether or nitrous oxide, since these anaesthetics provoke venous engorgement of the air-passages, as well as the adoption of closed methods. Posture becomes an integral part of the method in operations upon the thorax when an abscess cavity opens into a bronchus, since turning a patient upon his sound side may lead to filling his unaffected lung with fluid. Open ether methods are at the present time regarded as peculiarly safe ; but if used without atropine, they promote excessive secretion, and are apt to bring about excessive stimulation, which in its turn leads to exhaustion of the nerve centres and finally to collapse. Infusion methods (ether), while of great value in prolonged exhausting opera- tions and in cases of profound blood-loss, are liable to cause cedema if excessive quantities of saline are allowed to enter the circulation. Hedonal, when infused, unless in cranial surgery, is dangerous, sincfe the effect persists for hours, and patients may die before the drug is eliminated ; they incur special risks from malposition in bed, and from even slight haemorrhage, since the blood may pass into the air-passages. Such dangers are peculiarly apt to arise in all operations upon the mouth, nose, and upper air-passages. In these cases, whether chloroform, infusion of ether or hedonal, or colonic etheriza- tion is adopted, the method used must enable the patient to retain his larj^ngeal reflex, otherwise foreign material will invade the lungs. It is urged in favour of the insufflation and pharyngeal methods, that such an accident is impossible ; and were the technique of these plans less difficult, there is no doubt that one or the other would give the patient the best chance of avoiding these accidents. Although maintaining a high level of safety, the method of prolonged nitrous oxide administration, with or writhout oxygen, whether by the nasal route or by the apparatus of Teter or Boothby, is less safe than when employed for one brief inhalation. A severe strain is imposed upon the respiration ; and the heart and blood-vessels, unless healthy, are overtaxed as the blood-pressure becomes raised. Intratracheal insufflation, so far as we know at present, presents great possi- bilities of good ; but even sUght errors of technique may cause serious inter- ference with the pulmonary circulation through prolonged plus pressure being maintained in the lungs, although obviously this is not a necessity of the method. The methods of colonic etherization are valuable, both for operations on the air-passages and on the thorax, lungs, and pleura. They prove most dangerous unless the air-ways are kept patent, and also when the colon has been weakened by disease, and especially if ulceration has existed. If liquid ether enters the bowel, serious proctitis will ensue; and excessive injection of the vapour has caused meteorism, and even rupture of the bowel. The ether (75 per cent) in oil method of Gwathmey is yet on its trial ; it has been recently shown to be less free from danger than was originally supposed. Patients at times remain unconscious for many hours, nor has it been free from fatalities. The danger of intermittent a-dosimetric methods in the use of chloroform has long been recognized, but recent work has shown that unless complete anaesthesia is induced, cardiac fibrillation is produced. Yandell Henderson believes the condition is really due to acapnia ; but whatever theory we adopt to explain the phenomena, there is no doubt that methods which bring about this condition are fraught with grave danger to the patient. However, chloroform given by a dosimetric system is certainly safer than when an open method is employed. The depth of narcosis can be controlled by dosimetrj^ since it is as easy to employ a high as a low percentage value of vapour. If experts restrict the strength to values of 2 per cent or less, it is because evidence exists which proves these values are the safest. ANESTHETICS 29 With regard to the methods of giving ethyl chloride, it may be said that the open plan much used by Hornibrook in Melbourne is reputed safer than closed methods. Prolonged use of this anaesthetic presents much the same dangers as does chloroform, unless careful dosage is adopted. Spinal and Local Analgesia. — Broadly speaking, injection above the lumbar region is far more dangerous than at the place of election between the spines of the second and third, or third and fourth, lumbar vertebrae. Experience points to the danger of the method being increased if adrenine is combined with the analgesic, and to the absence of any commensurate benefit from prolongation of the period of insensibility to pain. In local or regional analgesia, on the other hand, adrenine together with novo- cain lessens the dangers, provided the quantity of adrenine is strictly limited. That adrenine is a dangerous drug has been shown by Goodman Levy and others, especially when used in conjunction with cocaine in nasal surgery. This is peculiarly the case when chloroform is also used and light narcosis is main- tained ; cardiac fibrillation appears to occur, with a fatal result. 3. The Administrator. — This factor has been already dealt with in the first part of the article. 4. The Physical and Mental State of the Patient. — Extremes of Life. — The rule of giving chloroform to persons up to six years of age and to those over sixty is a survival of the myth that children and women in labour enjoy immunity from danger from that anaesthetic. As a matter of fact, children are peculiarly liable to danger, owing to their proneness to lymphatism and to post-operative toxaemia (delayed chloroform poisoning, or acidosis). As regards old age, two points have to be carefully weighed. A person advanced in years must have considerable stamina to attain his age, and so is usually a good subject. Indeed, age — and this is the second and more important point — must be reckoned less by years than by the healthiness of the tissues, especially of the lungs and blood-vessels. To return to the question of children, it is beyond the scope of our present purpose to discuss whether lymphatism — status lymphaticus — exists as a pathological entity ; it is proposed to discuss the symptoms and pathological conditions grouped under these headings, and to indicate their bearing upon the question of the safety or danger of anaesthesia. Status lymphaticus — Lymphatism. — This condition is commonly overlooked in life, but of late years post-mortem examinations have shown certain lesions, not only in infants and children, but in older persons. The lymphatic follicles and glands throughout the body are enlarged, the heart is commonly small, and the aorta is sometimes markedly diminished in size. The chronic enlargement of the tonsils and the presence of post-nasal adenoid growths produce imperfect pulmonary ventilation, so that the child suffers from lack of complete aeration of its blood and tissues. There is frequently a persistent thymus, but it is very doubtful whether this, save in most exceptional cases, can produce mechanical interference with breathing. Its presence may be seen sometimes as a shadow in a skiagram, although the absence of the shadow does not disprove its presence. Some enlargement of the thyroid gland is present in about 50 per cent of the cases examined. It is believed by some authorities that the condition is associated with a toxaemia, due to internal secretion of the ductless glands, which renders the heart peculiarly liable to failure. The fat of the body is increased, the skin is said to be harsh and liable to pigmentation, and the mental outlook is perverse ; thus, although the child is often mentally bright, he is irritable, easily annoyed, and incapable of much self-control or prolonged 30 INDEX OF PROGNOSIS exertion ; hebetude and introspection focus his mental attitude. Clinically, the dominating symptom is the appalling liability to sudden death from heart- failure without adequate cause. The prick of a hypodermic needle, the entry into a bath, sudden cold, may claim him as a victim. Into this group come infantilism, cretinism, and cognate conditions. There seems little doubt that although the incidence of deaths associated with this condition is small when compared with the incidence from other states, yet given a pronounced case of lymphatism, the danger incidence is great, the catastrophe ensuing upon mental shock, fear, pain, or overdosage. The chief danger appears to arise in the large number of cases which show no marked symptoms in life ; nor can one say definitely that every case of a child with enlarged hypertrophied tonsils and glands may not belong to the type, even though his symptoms are ill-defined. That thousands of such children pass through the ordeal of anaesthesia without scathe goes without saying, while we know that the use of a local analgesic (tropacocaine) in a safe dose has been associated with the death of a lymphatic patient. It must be borne in mind that one type of lymphatic patient is marked by respiratory danger, the other by circulatory catastrophe. The ' sudden death ' of the German writers is designated white death, while the less sudden fatality of primary respiratory origin is known as blue death. It is probable that in estimating the share of danger from the anaesthetic, we have to consider not only whether one or another drug is more dangerous, but whether, owing to the dyscrasia, all drugs are dangerous unless we are keenly alive to the fact that such delicate persons cannot withstand the same doses and concentrations of anaesthetics as are well within the zone of safety for the ordinary individual. It is less that the anesthetic is dangerous, than that it is the way the anaesthetic is presented to the lymphatic patient which courts disaster. Although chloroform is associated with a majority of these deaths, it is not proved that it is, indeed, the most perilous. It must be remembered that chloroform is the anaesthetic of choice and the one most usually employed for young persons and for operations upon the upper respiratory tract, and that it is such persons who suffer from lymphatism and usually require this type of operation. It is, however, probable that chloroform is dangerous in status lymphaticus owing to the fall of blood-pressure it entails, since it is this decline in blood-pressure which is peculiarly prone to cause death in such cases. When an inexperienced anaesthetist is administering the anaesthetic, ether or an ether mixture is safer, and offers the best chance of success, but it should be given after a hypodermic injection of atropine. Death associated with lymphatism has occurred during the use of most of the general anaesthetics, and even when local analgesia has been adopted. Acidosis — Post-operative Toxcemia — Delayed Chloroform Poisoning. — Deaths following what appeared a normal anaesthesia, obtained by chloroform, by ether, by ethyl chloride, or by a mixture of these, have been imputed to the prolonged efiect of the anaesthetic upon the glandular structure of the liver and the kidneys, as well as upon the muscular structure of the heart. The onset of events is marked by uncontrollable vomiting between the twelfth and forty-second hours after the inhalation ; the vomit is foul and watery, greenish in colour at first, but brown later. There is marked restlessness or delirium, with intervals in which the patient is apathetic, and this apathy may end in fatal coma. The urine is scanty, and commonly contains albumin and diacetic or /3-oxybutyric acid. The breath has the apple-hke smell of acetone. The patients are usually young, commonly poorly-nourished infants or children ; neither the gravity of the operation nor the duration of the anaesthesia appears to count. ANESTHETICS 31 In a large number of patients whose urine was examined before the anaesthesia and subsequently to the operation, diacetic acid was found to be present before operation, and few of these developed severe symptoms. Indeed, it has been demonstrated that mere change of dietary, restriction (starvation) or improved feeding, is associated with diacetonuria. The pathology of the condition is certainly obscure, and not a few instances of septic changes in the organs have been advanced as cases of ' delayed chloroform poisoning.' Opie, indeed, has produced fatty changes similar to what is described as ' delayed chloroform poisoning,' by means of bacteria {B. coli and Streptococcus pyogenes). On the other hand, Leonard Guthrie and others have certainly demonstrated that the lesions — destruction of the glycogenic function of the liver, degeneration of the paren- chymatous tissues of many organs, and marked fatty degeneration in the organs of the alimentary tract — occur without the incidence of sepsis, syphilis, or other distinctive disease. Association with cyclic vomiting has been suggested, but although probable, it cannot be considered proved. Most authorities agree that the perversion of the hepatic function leads to failure of metabolism of carbo- hydrate foods, consequent upon which is destruction of glycogen and some damage to the tissues, with liberation of fatty acids. The condition is, however, uncommon, and even those who have had wide hospital experience have seen few cases, unless we group all patients who incur prolonged post- operation vomiting as suffering from this appalling perversion of metaboUsm. That the anaesthetic is but one factor in producing this toxaemia is obvious, but that it may act in this way is equally certain. Experiments on animals have demonstrated that repeated inhalation of anaesthetics, and excessive strength of vapours, as well as accumulation of the anaesthetic in the tissues, produce destructive tissue effects quite similar to those described above. The association of this toxaemia with diabetes and glycosuria is more than probable. Prognosis is difficult, since we cannot be sure if children with normal urine may not develop acidosis subsequently ; but when they are weakly, have suffered from cyclic vomiting, are febrile, and presumably suffer from sepsis, it is certainly grave unless the anaesthetic can be postponed for a few days and the carbo- hydrate deficiency counteracted by rectal injections of dextrose or glucose. Such rectal feeding (glucose §j in saline gvj), given every three or four hours, is excellent both before the anaesthesia and as soon as the vomiting appears. It has been suggested that the intravenous infusion of saline containing 6 per cent of dextrose offers even a better means of supplying the requirements of the organism. Whether the commonly adopted method of introducing large quantities of alkalies is of much value is open to question ; it does no harm, but at best it is only treating a symptom, and not removing the cause of the pathological perversion of metabolism. As has been stated above, diacetic acid is too commonly present in the urine of all patients for its discovery before operation to veto the employment of an anaesthetic, although it would indicate the selection of ether, if that agent is otherwise appropriate, and enforce the necessity for careful limitation of the quantity of the anaesthetic given. Beesly has pointed out that acetonuria is virtually always present in the cases which are septic, but that chloroform increases the danger of fatality. In 19 appendix abscess cases when chloroform was given, 14 died ; in 24 when ether was administered, 2 died. It must be borne in mind that acidosis is the result of many conditions, and so these have to be differentiated. Thus, it may be {a) symptomatic ; {b) due to the use of various drugs ; (c) associated with diabetes ; {d) associated with cyclic vomiting ; (e) associated with inhalation of chloroform, and to a less degree with that of other anaesthetics, e.g., anaesthol (Torek) ; (/) associated, as it commonly is, with infancy. 32 INDEX OF PROGNOSIS Anezmia, whether it be accepted as merely symptomatic of physical depressioa or not, is a very important factor in estimating the dangers of general anaesthetics. It is stated that when the haemoglobin falls below 50 per cent of its normal, chloroform, and even ether, become dangerous ; Mickulicz accepts 30 per cent below normal as dangerous. Yet the danger of operating when the haemoglobin content is unduly low does not impress those who see such perils lurking in haemolysis produced by anaesthetics — for haemolysis certainly occurs as a result of trauma per se. It is probable that Snow's dictum is correct, and that when a patient is judged to be fit to undergo an operation, he is also fit to be subjected to anaesthesia. The main points which need attention are — the limitation of the amount of the anaesthetic which is given, and the careful selection of the method. Haemolysis is less, of course, when analgesia is employed ; and if the condition of the poorly-nourished nervous system is deemed to be satisfactory, the spinal method or local analgesia should replace inhalation. There is, however, a risk in these cases, too often ignored, of the supervention of psychic shock and consequent circulatory catastrophe. The danger of chronic, as opposed to acute, anaemia is greater ; especially is this so if the blood drain in the latter case is due to repeated and severe haemor- rhages, such as occur in metrorrhagia. In the first case, behind the condition is some serious dyscrasia, probably a perversion of the blood itself ; in the latter, it is a mere temporary numerical loss of erythrocytes. When the surgical aspect of the case permits of delay, pre-operation treatment is advisable, and especially is this the case with young persons. An infusion method offers us the obvious advantage in these cases of combining anaesthesia with a supply of a physiological fluid which is competent to counteract the deleterious depletion of the circulating fluid. Exophthalmic Goitre-^Th-e. incidence of danger in these cases is so great, that many continental authorities who enjoy an experience of somewhat crude methods of anaesthetizing, discountenance the use of general anaesthesia, substi- tuting a local analgesia. But the danger is not obviated by this procedure, since the psychic shock is not removed, and it is this condition which makes for a fatal result. Unless the elaborate method of Crile, ' stealing the thyroid,' is adopted, and local analgesia is combined with the employment of both hypnotics (scopola- mine, morphine, and atropine) and the oxygen-nitrous oxide mixture, we have to decide whether chloroform or ether should be employed. Crile's method, unless carried out in its entirety and to the last detail, is not satisfactory ; and in this country it is difficult to isolate a patient from her friends, to maintain the mystery as to the date of operation, and ultimately to perform it without a formal consent. A fatal result, which is always possible, would give rise to grave questions of responsibility which needs must be carefully faced beforehand. The choice of the anaesthetic resolves itself into that of the method. Un- doubtedly a preliminary drowsing with suitable hypnotics is advisable, whether local or general methods are pursued. Local systems are admitted to fail when the thyroid is being dislocated, and this increases the danger. Chloroform with oxygen is only safe when a dosimetric method is employed, as a serious fall of blood-pressure spells disaster. Ether, even if guarded by atropine and given by an open method, often causes dyspnoea in goitre cases, owing to the large excess of bronchial secretion it excites. It has a further disadvantage in that its stimulating effect cloaks the signs of shock, and often leads to the performance of a more extensive operation than the patient can bear. As soon as the ether effect has passed, profound collapse sets in, and death is Uable to occur. This calamity is especially likely to ensue when ether has been given in unstinted quantity. ANESTHETICS 33 Serious Lesions of the Nervous, Pulmonary, Circulatory, Renal, or Metabolic Systems. — In estimating the incidence of fatality among patients suffering from the above, we have to consider, less the actual disease, than the effects which it has brought about in the physical well-being of the patient. If, in the case of disease of the nervous system, we recognize that there is, or may be, pressure about the pons Varolii or the medullary centres, we know that any profound narcotization of the respiratory centre will make for extreme danger. Again,, when well-marked arteriosclerosis exists, there can be no doubt of the danger of using a general ansesthetic given by any method which involves rise of blood- pressure, since it promotes a grave risk of a cerebral haemorrhage. Equally perilous in cases of advanced pulmonary, bronchial, or pleuritic disease would it be to employ an anaesthetic which would increase respiratory difficulty, and so throw back a strain upon a heart probably taxed already to its utmost capacity, A mere cardiac valvular lesion, when compensation is complete, or even renal disease confined to one kidney, need not, with care, involve the patient in greatly enhanced risk under anaesthesia. Septic Conditions. — It has been said that the pathological lesions seen after septic fever and after chloroform toxaemia are closely akin. This fact induces the anaesthetist to employ ether in acute septic cases, either by inhalation, insufflation, intravenous infusion, or colonic absorption methods. Probably septic states of the thoracic walls and contained viscera alone furnish exceptions to this contention. However, as Graham has shown that phagocytosis is delayed by ether, even that anaesthetic is not without its risk, while spinal analgesia may prove dangerous in marked septicaemia, although safe in localized disease such as. acute appendicitis.' If ether is employed, the injection of 5 oz. of pure olive oil per rectum, as soon as the patient is carried back to bed, has been shown to> assist the rapid return of the power of phagocytosis. 5. The Nature and Duration of the Operation and Intercurrent Conditions associated therewith. Shock — Blood-pressure — Body Temperature.— It is impossible in this place to go into any lengthy discussion of surgical shock. From whatever cause it arises, we know that trauma in certain regions, and involving certain structures, appears to bring about conditions which are commonly grouped under the term ' shock,' often associated with surgical procedures which in themselves do not seem serious and do not involve any great ' insult to tissue.' Such operations are those which involve the opening of the large somatic or cranial cavities — laparo- tomies, coeliotomies, opening of the thorax, exploratory operations on the brain and spinal cord. Further, when viscera, and especially certain serous membranes, are dragged upon and dislocated, such shock eventuates. In the case of serous- membranes. Professor Yandell Henderson contends that the loss of carbon dioxide produces acapnia, a determining cause of heart failure. Undoubtedly the opening of such cavities leads to changes in the haemodynamics of the body which may gravely prejudice the carrying on of the normal circulation. This is indicated, for example, by the rapid recovery of the patient when the abdo- minal walls are closed. We know that shock may be regarded as loss of body heat and fall of blood-pressure, and hence it becomes necessary that the anaesthetic, and method of using it, should be so safeguarded as to prevent an additional declension of either blood-pressure or body temperature. Since elimination of the anaesthetic, if from the lungs and kidneys, predicates abstraction of heat, it follows that the less anaesthetic there is employed the less will be the drain on the body heat. A fall of blood-pressure is usually dangerous, but if the initial blood-pressure is high, or if it is desired to prevent any engorgement of the vessels, as in cranial 3 34 INDEX OF PROGNOSIS and spinal surgery, chloroform is adopted to facilitate the surgeon's work by- lowering the blood-pressure. The addition of oxygen removes the danger of the lessened activity of the respiratory centre. Haemorrhage antecedent to, or involved in, an operation is best met by introducing saline pari passu with the anassthetic ; hence we adopt ether infusion, colonic etherization with tissue infusion, or some kindred method. Prolonged operations are often necessary, and may prevent the use of spinal methods ; and their dangers as regards anaesthetics are — either excessive faU of blood-pressure leading to profound collapse, or undue stimulation followed by even greater collapse after the anaesthetic has ceased to be used ; while an after- danger exists owing to the cooling and shock engendered by the eUmination of the large amount of the anaesthetic which has entered and become segregated in the tissues. The first danger is that of chloroform, the second is that of ether. The two conditions being compared, we find that the chloroform collapse is more rapidly and more readily surmounted than is its counterpart due to ether. In prolonged anaesthesia, such dangers can be avoided by careful moderation of the dosage. As time goes on, especially if traumatic shock and haemorrhage occur, extraordinarily little anaesthetic is needed, and this minimum should never be exceeded. The ' mixed method ' of using scopolamine-morphine and atropine before the general anassthetic, is most valuable in such cases, as it allows the anaesthetist not only to lessen the dose required for induction, but practically to maintain anaesthesia without inhalation. If this is overlooked, and the anaesthetist employs a large quantity of the anaesthetic, the patient is subject to grave risks. Overdosage causes extreme shock at the time of the operation, and collapse after its completion. Severe or Persistent Vomiting. — It is often necessary to subject a patient to an operation to relieve a condition which itself causes or has caused severe and persistent vomiting. Further, it is often necessary to perform an operation upon viscera interference with which commonly brings about serious after-sickness. Vomiting, at all times troublesome, may actually determine death through exhaustion, since sleep and immobiUzation are necessary in order that traumatized tissues may heal. Therefore, in selecting the anaesthetic and method, we should take into consideration the likehhood of after-vomiting, and adopt measures to minimize the dangers arising from it. Patients vary within wide limit in their hability to vomiting. The types of vomiting may be roughly grouped as follows : — a. Catarrhal. This arises from irritation of the gastric mucous membrane. It is commonly due to swallowing mucus and saliva saturated with an inhaled anaesthetic. Children, dehcate women, ' bad sailors,' the obese, and dj^speptics are most prone to this trouble. Unless the patient is unduly feeble the prognosis is favourable, as the condition soon passes off. b. Head vomiting. This arises from circulatory^ conditions, when not due to operative procedure on the brain, and can be obviated by avoidance of the lowered head position. Unless there is obvious necessitj'' for adopting the dorsal decubitus, a half-sitting posture lessens after-sickness. c. Visceral reflex vomiting. Operations, with or without general anaesthesia, upon the appendix, the kidneys, or the uterus, are pecuharly hable to produce serious vomiting ; especially is this so in regard to the kidneys. Probably both [h) and (c) fall into the category of toxaemia in many cases and are closely aUied to the so-called delayed chloroform poisoning. As with all patients who are the subject of toxaemia, the prognosis is favourable or the converse according as two factors are recognized and dealt with : traumatism ANESTHETICS 35 by handling and dragging upon viscera, and excess in the quantity of the anaesthetic given. A careful study of the conditions influencing sickness and general ' upset ' after anaesthetics, made by the present writer, brought out very clearly the following fact. Whenever undue venosity of the blood was present, vomiting and severe after-collapse were developed. This condition may exist ab initio, as in the case of chronic bronchitics, when bronchitis, emphysema, and a dilated feeble heart are dominating the organism ; in toxaemias, such as cholsemia, uraemia, septicaemia ; or it may arise through exhaustion of the central nerve-controls through collapse following excessive stimulation, or through the employment of unnecessarily large quantities of the anaesthetic or too concentrated a vapour. The prognosis is worse in the case of ether than in that of chloroform, since very large quantities of the former are given during the operation, and it is only after its completion that the collapse is observed. Speaking generally, the prognosis as regards vomiting after general anaes- thesia is favourable. Avoidance of ' insult to tissue,' maintenance of body temperature, minimizing the amount of the anaesthetic, and avoiding the swallowing of mucus by giving atropine or chlorbutyl before the inhalation, with a correct placing of the head — lateral posture during operation, half -sitting posture later — will prevent serious sickness. The dangers in severe cases arise from the stomach rejecting all nourishment, and from absence of sleep. Here rectal or intramuscular injections of saline and dextrose, and the use of morphine in suitable cases, will be efficacious. Morphine, however, when given after chloroform will sometimes cause sickness, and in a curious way. The patient recovers from the anaesthetic, without nausea or sickness, and seems extremely well for twelve or twenty-four hours, when severe vomiting comes on and is at times very troublesome. Vomiting after spinal analgesia is not infrequently severe and prolonged, especially if much encephalalgia exists. Although extremely severe in a few cases, the condition is transitory and amenable to treatment. Stercoraceous Vomiting. — A much more dangerous condition may arise in cases of intestinal obstruction. The contents of the stomach and intestines are regurgitated, rather than vomited by muscular effort, and usually the flow commences as soon as the muscular tonus of the cardiac and pyloric orifices becomes lessened by the anesthetic. It occurs both when general anaesthesia and spinal analgesia are employed. Unless it is possible to prevent aspiration of the material into the air-passages, the prognosis is most unfavourable. Even initial lavage is not a complete safeguard, although it should be used when practicable. As the back pressure is constant, when the stomach is emptied the intestinal contents stiU flow into it, so that the best method is to maintain a constant irrigation of the stomach, and have the shoulders and head of the patient kept high during the operation. Laryngeal reflex should be kept active. In very serious cases, intubation of the larynx with forced respiration, as obtains in intratracheal insufflation, or the method of a preliminary tracheo- tomy suggested by the present writer^, may be employed. 6. Post-operative Effects. — It is unnecessary to dwell upon the immediate, and usually slight, after-effects of anaesthesia or analgesia. The more serious ones, i.e., those threatening life, which occur within forty-eight hours or so after the operation, are respiratory, circulatory, nervous, metabolic, and renal. These have all been dealt with in the preceding sections, but may be summarized in this place. In persons previously affected by bronchitis, inhalation of unwarmed vapour of ether or chloroform may determine a recrudescence of the disease. It is most common with the former, partly because the vapour is more irritating, and partly 36 INDEX OF PROGNOSIS because it lowers the body temperature from o"5° to 3° F. during a prolonged inhalation. Bronchitis following chloroform is, as a rule, more severe, and associated with greater tissue destruction. Prolonged administration of nitrous oxide and oxygen in major surgery, unless the gases are warmed, may cause bronchial trouble, but it is an infrequent complication. It has been shown that when much bronchorrhoea is caused, the buccal, mucous, and bronchial secretions are aspirated and enter the smaller bronchi, setting up irritation. Tight band- aging, by impeding basal raovements, prevents these fluids being expelled, and a pneumonic inflammation is initiated, since pneumococci are usually present in the mouth. As Dr. William Pasteur has shown, many cases of so-called ' ether pneumonia ' are really instances of massive pulmonary collapse, due to trauma affecting the diaphragm. Pneumonia of a septic type is liable to follow profound narcosis when operations upon the tongue, jaws, or upper air-passages have been performed, and is due to aspiration of blood, particles of growth, pus, or con- taminated saliva and mucus. Such complications will usually reveal themselves within a week of inhalation. Prophylaxis. — -Before the operation, the teeth, mouth, and nasal passages should be assiduously cleansed, and unhealthy gums painted with an iodine preparation. If the breath is foul and the stomach unhealthy, lavage and careful asepticizing of the alimentary tract with salol or other means may be pursued. Atropine, given hypodermically, will lessen or prevent bronchorrhoea and salivation. The anaesthetic vapour should be warmed and moistened, and given so that the laryngeal reflex is active subsequently to full anaesthesia (third degree of narcosis) having been obtained by the induction. After the operation, the patient's body temperature must be maintained, and he must be protected from draughts as he is conveyed back to bed. Hydrothorax and oedema affecting the bases may follow the exhibition of ether by inhalation if the kidneys are diseased and albuminuria exists. It may be associated with acute oedema of the tongue and larynx, and is usually fatal. If an undue quantity of saline is introduced by the method of ether infusion, pulmonary oedema is a serious danger ; and hence strict limitation of the amount must be practised, especially if renal inadequacy exists. Persons suffering from angioneurotic cedema are in serious danger lest the air-passages should suddenly become involved. I have met with one such case, and gave chloroform while tracheotomy was performed. Both local analgesia and ether are contra-indicated for these cases. All anaesthetics, when inhaled in great quantity, especially if the oxygen content of the blood is not kept at about its normal during the administration, may cause tissue cooling, catarrh, irritation, and necrobiosis after the operation. The law is certainly true that the after-effects of an anaesthetic are, in severity and frequency, a function of the amount taken. If the vapour as it enters is warmed, some of its deleterious effects are removed. Post-operative headache, back-ache, vomiting, oculomotor paralysis, and paralysis of the bladder and rectum, may follow spinal analgesia. We do not know for certain whether these arise through irritation of the analgesic or through alteration in the amount of the cerebrospinal fluid. Their occurrence is rare, but at tiraes these sequelas are alarming. Some surgeons regard them as evidence of errors of technique ; but even so it is not possible to avoid them entirely, nor should we minimize their gravity when they arise. The possibility of acute mania or delusional mania consecutive to operations undertaken under local analgesia must be remembered Such cases are rare and the ultimate prognosis is favourable, though the condition causes great distress to the patient's friends. Reference. — ^Buxton, " Fscal Vomiting during Anaesthesia, a Suggested Method of Obviating its Danger," Brit. Med. Jour., 1910, Apr. 23. Dudley W. Buxton. ANEURYSM. ABDOMINAL 37 ANEURYSM, ABDOMINAL. — It is needful to remember that aneurysm of the abdominal aorta and its branches is an obscure disease, hard to detect in early stages ; so that when the physician meets with a case in which there is no doubt as to the presence of an abdominal aneurysm, the sac is already large. Unhappily, the newer method of diagnosis by skiagraphy does not give as much help in the discovery of aneurysms below the diaphragm as it does in those situated within the chest. The stealthiness of the early stages of the disease is prejudicial to the patient's chance of recovery ; a sac that can be felt is not likely to be ' cured.' General Outlook. — I do not know of any proved example of complete and final cure of an abdominal aneurysm large enough to be diagnosed as such. Of course there are examples of what appeared to be a pulsatile swelling connected with the abdominal aorta failing to kill the patient ; but these are usually cases of atheroma, and not of real aneurysm. Again, it is not an unusual experience to encounter healed abdominal aneurysms in the course of a post- mortem examination ; but these are small, as a rule, falling far short of the size which must be attained if the sac is to be detected clinically. Moreover, abdominal aneurysms are not seldom multiple ; in the patient who dies from rupture of one sac, another may be found completely obliterated by lamellae of clot. True ' cure ' of abdominal aneurysm diagnosed during life is therefore almost, if not quite, unknown. In spite of this, patients may live for a considerable time after the onset of symptoms ; in one of Nunneley's series, collected from the St. George's Hospital records, the duration of the case extended over nine years ; while one of the Guy's Hospital patients, whose cases were tabulated by J. H. Bryant, lasted twelve years. These are, however, exceptions to the general rule ; and the average expectation of life from the onset of symptoms, judging from the 86 cases included in these two series, is not more than fifteen months. The short- ness of this period, as compared with that of thoracic aneurysm, is no doubt largely due to the greater difficulty of diagnosis ; it cannot be ascribed to any added element of danger in the abdominal variety, for there is not the same risk of injury to vital structures that there is in aneurysm within the chest. Aneurysm of the abdominal aorta is usually limited to the retroperitoneal tissues, and it is into these tissues, in the great majority of instances, that the fatal rupture which terminates most cases occurs. The course of abdominal aneurysm is short because its earlier stages are not productive of symptoms. Sudden Death.— In almost two-thirds of Nunneley's cases, in all of which the diagnosis was verified by post-mortem examination, the end came suddenly. In nearly all of these it was due to rupture, usually into the retroperitoneal tissues, rarely into the peritoneal cavity. It is this predisposition to rupture that makes an abrupt termination rather more frequent here than in aneurysm of the thoracic aorta ; for, curious as it may seem when we reflect upon the varied opportunities presented to the thoracic aneurysm of rupture into neighbouring hollow viscera, it is the abdominal aneurysm, limited as it is by the parietal peritoneum lying in front of it, that bursts the most readily. In many instances the end is dramatically sudden, no warning of its approach being given until the patient drops dead. In others, a period of collapse sets in abruptly, with or without pain, a few hours before death. It is therefore essential to remember that when a patient with abdominal aneurysm faints away, it is likely that his hours will be few, particularly if severe pain accompany the onset of the faint. It is the more necessary to bear in mind this liability to concealed haemorrhage, because it is so rare to find bleeding from an abdominal aneurysm declaring itself in the form of haematemesis, or melaena, or other external haemorrhage. 38 INDEX OF PROGNOSIS Features of Prognostic Significance. — Everything that predisposes to activity on the part of the patient is prejudicial to recovery or prolongation of life. This factor counts for less, however, than in thoracic aneurysm, probably because the pain of abdominal aneurysm is so crippling as to reduce nearly every one of its victims to a state of complete invaUdism. For this reason, neither the age nor the occupation of the patient seems to have rauch bearing on his expecta- tion of life, if we may judge from the records of cases. Sex, again, is of little importance, or at least it is difficult to assess sxiy importance which may attach to it, for abdominal aneurj^sm is a rare disease in women. Apart from such evidences of rupture as have already been mentioned, there is no help to be gained from the nature of the symptoms and physical signs in arriving at an accurate prognosis. It is true that, in a very few cases, surgical treatment has achieved satisfactory results ; but the number of these is so small that it is impossible to generalize as to the features which promise success along these lines further than to say that extirpation is only possible when it is a branch of the aorta, and not the aorta itself, that is implicated. Such aneurj^sms, e.g., of the renal or hepatic arteries, are diagnosed with the greatest dif&cultj^ and are oftenest found by accident or through exploratory laparotomy, so that there are no indications to enable the clinician to forecast a successful result. Influence of Treatment on Prognosis.^ — The question that we should hke to be able to answer is : Does any more radical method of treatment yield better results than the usual plan of rest in bed, with, restricted diet, and drugs ? Proximal ligature of the abdominal aorta has been practised, both for aneurysm of the aorta and of its branches, in each case with immediately fatal results. The hepatic artery has once been successfully tied on the proximal side of an aneurysmal sac ; but this aneurysm is extremely rare and seldom diagnosed. Moreover, in 3 other cases, this operation was fatal. Aneurysm of the iliac artery within the abdomen and pelvis has been attacked by proximal ligature in 33 instances where the results have been recorded ; recovery ensued in 9, the operation killing the remainder. Extirpation is clearly impossible in nearly every kind of intra-abdominal aneurysm. It has, however, been successfully carried out in the treatment of aneurysm of the renal arter^', the kidney being excised together with the sac. Acupuncture, the method introduced by MacEwen, cannot, as a rule, be safely undertaken except after incision of the belly wall. It is true that in MacEwen's case this precaution was not taken, and the result was nevertheless satisfactory, the patient being ahve and at work tvvo and a half years later ; in other cases, however, death has followed immediately after needhng. Introduction of wire into the sac, Moore's method, has been practised 10 times for abdominal aneurj'sm, death following more or less immediatelj' in all but 2 instances. Corriadi's modification consists in the passage of a galvanic current through the wire introduced into the sac. This procedure has been put to the test in 13 instances of abdominal aneurysm. The best result was in one of Finney's cases, the patient dying, three and a half years after operation, from rupture of the sac. In one other case the patient did well, djdng eight months later of dysenter3\ The fate of a third patient is unknown, but cure was improbable. In the other cases, death followed within a few days. It appears, therefore, that all surgical methods hitherto devised introduce an unjustifiable risk without offering any certain advantages to counterbalance it. One or two other plans of a somewhat less dangerous nature have to be considered. Prolonged proximal compression through the abdominal wall, the method introduced by Murray, of Newcastle, and successfully applied by him to one ANEURYSM, INTRATHORACIC 39 patient who was alive six years later, has its limitations, and also involves certain risks. In the first place, there are but few cases of abdominal aneurysm in which the aorta can be compressed on the proximal side of the sac, which generally lies too near to the costal border to leave room for compression. In the second place, the pressure which is necessary, if it is to be effective, is such that it introduces a risk of injury to the bowel and other abdominal viscera, and fatal results have already been produced in this way. A preliminary laparotomy might remove this risk, but it introduces fresh disadvantages, so that this method cannot be said to promise better results for most patients with abdominal aneurysm. Gelatin injection : there is, lastly, this method of Lancereaux. Though good results have followed in a few instances, no improvement has been recorded in the majority of published cases. There is some risk of tetanus following the injection, though this has been circumvented by more careful sterilization of the gelatin. It is to be feared that this method does not improve the patient's prospect of cure. It seems, therefore, that we must be content, for the present at any rate, with the ordinary medical treatment, along the lines introduced by TufneU — absolute rest, reduction of diet and particularly of fluids, and administration of potassium iodide in full doses. This does not promise any great likelihood of cure, but it is at least free from risk ; and since the patient is already invalided by pain, it does not impose any great restriction upon the activities which he would otherwise be free to pursue. Carey F. Coombs. ANEURYSM, INTRATHORACIC. — Aneurysm, and fusiform, diffuse dilata- tion of the aorta, must be considered apart, since the factors influencing prognosis are totally different in the two affections. This article, therefore, is devoted to a summary of the prognostic factors of sacculated aneurysm within the thorax. The outlook in a patient afflicted with this disease depends on the balancing of two factors : the rate of growth of the aneurj^sm, and the rate of coagulation within the sac. Increase in the size of any aneury^sm threatens to end the patient's life by haemorrhage ; to this, in the case of aneurysm within the chest, are added the various disabilities and dangers involved in pressure on vital or sensitive organs and tissues. General Outlook. — Does complete recovery ever occur? In quite a number of autopsies, ' healed ' aneurysms of the thoracic aorta and its branches have been found, but these were not detected during Ufe. A few cases have been recorded in which an aneurysm, unmistakably present and even projecting through the thoracic wall, has become sohd and remained so for periods of over ten years. The longest duration of which I can find any record was in a case quoted by Osier, in which the patient lived over twenty years after the condition was first diagnosed. So favourable a result as this is, however, highly improbable, even in these days of early diagnosis by radiography. As to the average duration of life from the onset of symptoms, de Havilland Hall's recently published figures are of value, since they relate to patients whose position in life enabled them to take all possible precautions. In 27 cases carefully followed up, the average duration of hfe amounted to about three years. It is more than probable that this period, brief as it is, is too long, if patients be included who are obliged to work. In estim.ating the expectation of life that can be held out to any given patient, therefore, it is fair to take this as a basis : that though he may live for ten or fifteen years from the moment of discovery, it is not hkely that he will last for more than three years. 40 INDEX OF PROGNOSIS Sudden Death. — ^Thoracic aneurysm is one of the notorious causes of sudden death. To the dangers never absent from a heart whose coronary arteries are diseased — as they are in a majority of cases of aneurysm, — are added those of rupture, with rapidly fatal haemorrhage ; and, in a few instances, those of aortic insufficiency. In de Havilland Hall's experience in private practice, about one-third of his patients died suddenly. This sudden termination may be due to cardiac failure or to rupture. The omens pointing to the former possibility are not different from those of chronic cardiac disease generally ; paroxysmal cardiac pain, dyspnoea on exertion, the alternating pulse, and physical signs of aortic regurgitation, all enhance the risk of an abrupt failure of the contractile power of the heart. In de Havilland Hall's Westminster Hospital statistics, over 40 per cent of the deaths were due to cardiac failure. Aneurysms pointing externally rarely burst suddenly ; indeed, leakage of blood into the subcutaneous tissues may continue for quite a long while in such cases without foreshadowing rupture, and the patient may die eventually of exhaustion or some such cause. Aneurysms of the intra- pericardial aorta are particularly liable to burst into the pericardial sac ; this is immediately fatal, but in most cases the diagnosis has not been made. Fatal haemorrhage occurs more frequently in patients who present evidences of pressure on the trachea, bronchi, or oesophagus, than in those who do not show these signs. The rupture may also pour its blood into the mediastinal tissues ; this also is more likely to happen if the sac arise from the transverse or descending part of the arch. Curiously enough, patients in whom the aneurysm bursts into a great vessel — superior vena cava or pulmonary artery — often survive the immediate shock of the catastrophe and Kve for weeks or months. A common direction of rupture is into the left pleural sac ; this is particularly apt to occur in aneurysm of the descending aorta, and kills quickly. Features of Prognostic Significance. — The age of the patient has a little bearing on the outlook ; the older the patient the better the prognosis. " Healed aneurysm is rarely seen in a man under forty " (Osier). This is partly due to the quieter life of elderly men. The sex is of some importance ; women carry aneurysms without final mis- adventure longer than men, presumably because they are subjected to less physical strain. The occupation and social position of the patient is a consideration which influences the prognosis along the same lines ; the man who can take things quietly, and rest as much and as long as he needs, stands a far better chance than the man who must work or starve. Of course, there are extraordinary exceptions ; men with large aneurysms have been known to work at laborious occupations for years, but the great majority are not so fortunate. Most thoracic aneurysms are syphihtic in origin, and result directly from spirochaetal infection of the aortic wall. Unhappily, it is not always possible to detect this morbid process in the pre-aneurysmal stage, and once the aneurysmal sac has reached such dimensions that it produces s3^mptoms, the aortic wall is injured beyond repair ; yet early diagnosis, such as is now possible by means of radiography, does undoubtedly improve the patient's chance. "This comes about in two ways : vigorous mercurial treatment, if instituted as soon as the diagnosis is made, prevents extension of the aortic disease ; and the patient also comes under restraining influences in time to obviate, or at any rate to postpone, disaster. The site of the aneurysm has a most important bearing on the patient's hope of survival. Something has already been said about this in considering the ANEURYSM. INTRATHORACIC 41 risks of sudden death. Broadly speaking, it is the aneurysm that springs from the ascending extrapericardial portion of the aorta that lasts longest ; its tendency is to extend to the right into the lung, or forward by erosion of the chest wall, and in spreading in either of these directions it encounters structures of relatively little importance : the pain that is caused by injury of intercostal nerves wears the patient's strength down ; but when the aneurysm bulges forward as a definite tumour consisting mainly of solidly packed clot, it is astonishing how long life may last. Even when the swelling has attained a very large size, the patient may carry it for months, or even years. The writer recollects one such case, in which the aneurysmal sac presented over the greater part of the right front, below the right costal border, and also below the inferior angle of the right scapula ; and yet the patient survived in hospital for several months, and died eventually of exhaustion, though the sac had leaked through the front of the chest wall for weeks. One of the worst things that can happen to an aneurysm arising from this part of the arch is rupture into the superior vena cava ; this often leads to death in a few days, though, in one case seen by the writer, the patient survived for several months after the rupture occurred. Rupture into the pulmonary artery is less immediately fatal, especially when the communication is established gradually, as it is in some cases. The most quickly fatal form of aortic aneurysm is that which arises from the intraperitoneal portion ; this type shares with coronary aneurysm a peculiar predilection for rupture into the pericardial sac, a calamity which is fatal at once, or in a very short time. Possibly earlier diagnosis might help to avert this ; but even with the x rays it is not easy to be sure of the presence of this type of aneurysm, and while it is still comparatively small, the fatal rupture is apt to occur. Aneurysms springing from the transverse aorta are especially dangerous on account of their proximity to vital organs, and to hollow viscera into which rupture may occur. Approximately one-third burst, especially into the trachea, left bronchus, or oesophagus, or into the left pleural sac. The danger of rupture may be apprehended, therefore, when the physical signs point to the existence of pressure in these directions ; and particularly if the sac appears to be dribbling into one or other of the hollow tubes. Apart from the danger of rupture, there is that of interference with important functions ; asphyxia from pressure on the trachea may end the patient's life ; the oesophagus may be compressed and swallowing hindered ; or — more probable still — pressure on the left bronchus may lead to retention of secretions, with bronchopneumonia or some other form of pulmonary infection. Any evidence pointing to such occurrences is of the gravest import, for pulmonary infections of this type do not take long to kill. Aneurysms of the descending portion of the arch and of the descending intra- thoracic aorta are very apt to rupture, especially into the left pleural cavity ; in Dr. Oswald Browne's statistics, collected from St. Bartholomew's Hospital, this was the end of more than one-third of the cases of descending thoracic aneurysm. Next after this comes rupture into the oesophagus or left bronchus. The sac that bursts in these directions is often quite small ; the writer recollects making an autopsy in a case of fatal haemorrhage into the oesophagus from an aneurysm no larger than a walnut. When the difficulties of diagnosis, and therefore the improbability of early treatment, are taken into account, it is easy to see why the prognosis is so gloomy in cases of descending thoracic aneurysm. Dissecting thoracic aneurysm, curiously enough, often spares its victim for 42 INDEX OF PROGNOSIS years after the etiological rupture has taken place. A case of survival for thirty years is on record, and there are others nearly as long. Aneurysms arising from the great vessels, in the intrathoracic portion of their course, have yet to be considered. It might appear that the prognosis would be more favourable in such cases, since they seem to offer a possibility of surgical attack. As a matter of experience, however, the outlook is no better than in the case of aortic aneurysm. The sac so often arises close to, if not actually at, the point where the vessel leaves the aorta, and the aorta itself is so frequently the seat of advanced syphilitic disease, and even of a second aneurysm, that little more chance of successful treatment is offered than in the case of aortic aneurysm. Lastly, there are one or two general considerations. Multiplicity of Aneurysms. — The possibihty of these must never be forgotten. Occasionally, the sac which is obvious may be undergoing solidification, while another undetected aneurysm, or a new pouch of the primary sac, may be spreading in a different direction. Before a favourable prognosis can be given, therefore, every effort must be made to exclude the presence of a second sac. Situation of Hcsmorrhage. — Speaking broadly, haemorrhage to the surface, whether direct or through a hollow viscus, is less deadly than internal bleeding : it may stop itself by the fall in blood-pressure which it induces ; whereas, in haemorrhage into a closed space, there is not only loss of blood, but also disturb- ance of internal pressure, to be considered. Rupture into the pericardial sac, for example, is fatal, not because it deprives the patient of blood, but because it embarrasses the heart. Evidence of Solidification. — The most favourable omens in any case of thoracic aneurysm are those which point to solidification by deposition of fibrin ; they are limitation of pulsation, hardening and shrinkage of the sac, and increase in the density of the A^-ray shadow. Unhappily, it is not possible to study these processes satisfactorily in many cases ; only those which are pointing through the thoracic wall can be palpated ; but when, in such cases, the tumour is becoming harder and throbs less, the outlook is relatively favourable. Even so, the possibility of spread in another direction must be kept in mind. Influence of Treatment on Prognosis. — Is it possible to say that the outlook is improved by the adoption of any particular line of treatment ? The results achieved by the various plans of treatment in use must be compared in order to answer this question. First, there is what may be called the ambulatory plan. The patient is restrained from severe exertion, but he is allowed to walk about and do his business, provided it does not entail heavy labour ; drugs, usually potassium iodide in full doses, being given meanwhile. Remarkably good results are achieved in some cases, particularly when the patient is a reasonable being, and able to regulate his life wisely ; but over against these successes must be set a large number of failures, including a considerable percentage of sudden deaths from rupture. It is impossible to form a definitely calculated estimate of the expectation of life to be offered to the patient who chooses this plan, or is obliged to be content with it; but the writer, judging, from out- patient experience, would, on an average, place it at something within two years. Second, the Tufnell plan must be considered. This term includes absolute and prolonged rest, with restriction of diet, especially in the matter of fluids ; convalescence is jealously guarded, and there is no eventual return to heavy bodily work. Here again it is very difficult to supply figures, for a large number ANEURYSM OF PERIPHERAL ARTERIES 43 of patients undergo treatment which is a compromise between, or combination of, this plan and the preceding one. De Havilland Hall's figures, relating to 27 cases, show that the average expectation of life in patients who have followed the Tufnell plan for as long as they could endure it, and have subsequently ordered their lives as peaceably as they might, is about three years from the onset of symptoms. Remarkable successes are sometimes achieved by this plan, provided the period of absolute rest be repeated from time to time as symptoms dictate ; and from a survey of the available facts, the writer is inclined to claim that a higher percentage of survivals over five years is to be found among patients undergoing this than among those following any other method. Third, the gelatin treatment, introduced by Lancereaux, was rather discounted at first by the fact that it was followed by tetanus in a few cases. This, however, can be avoided ; and the method has been fairly tried. Kingston Fowler's results, in 12 cases treated along these lines at the Middlesex Hospital, did not, in his opinion, show any superiority over those attained by other methods. Lastly, surgical methods remain to be considered. Attempts at extirpation of an intrathoracic sac arising from the aorta have, without exception, been immediately fatal. According to Monod and Vanverts, who examined records of 77 recent cases of innominate aneurysm treated by distal ligature of the common carotid with the subclavian or axillary artery, temporary improvement followed in 57 per cent, immediate death in 14 per cent, and the remainder were classed as failures. Of late years American clinicians have given a thorough trial to wiring methods, i.e., treatment by the introduction of wire into the sac of the intra- thoracic aneurysm, with or without the passage of a galvanic current through the wire. Even when due allowance is made for the desperate nature of the cases to which such a plan is likely to be restricted, the results cannot be regarded as encouraging. In Eshner's table of 38 cases, death followed in exactly half, within a month of the operation ; but i patient survived for twelve years. Of Hall's 22 cases, i lived for five years ; and of Finney's 23 cases, I lived for three years. Regarded from the prognostic view, there- fore, it does not seem that longer life can be promised to the patient who submits to this operation. To sum up, the truth is that the outlook in any case of thoracic aneurysm is bad ; the average expectation of life is not more than three years, and even this brief period is not likely to be attained if the sac be projecting backwards from the transverse or descending aorta. Life is more likely to be prolonged if the patient is able to submit himself to the ordeal of complete rest with restriction of diet, and if the diagnosis be made early. Carey F. Coombs. ANEURYSM OF PERIPHERAL ARTERIES.— Although spontaneous cure of a peripheral aneurysm has been known to occur, it must be very rare. In these days of surgery it is almost invariably the practice to operate instead of waiting to see what nature might do ; but in the pre-antiseptic era various methods of natural cure, by extension of clot from the sac, ' plastic arteritis,' pressure of the sac on the artery, etc., were described, and in a few cases an aneurysm has been known to slough away en masse. Further, aneurysms are not always progressive, but may last for years without appearing to do any harm. In the end, however, the recorded cases all required treatment for severe symptoms. The writer has seen a carotid aneurysm in a woman who had had it for many years and suffered little or no inconvenience, and was therefore unwilling to have it operated on. They are more rapidly 44 INDEX OF PROGNOSIS progressive in the young and vigorous than in feeble old persons with a reduced circulation. The life of a patient wdth an aneurysm is, however, always in jeopardy. Sooner or later it is liable to rupture into the subcutaneous tissues or externally, causing rapid death from loss of blood, or such grave disiategration of the cellular planes as may lead to the necessity for amputation. Occasionally suppuration may take place. The deadly nature of the disease is emphasized by the fact that even in the infancy of the surgical art, before anaesthetics or antiseptics had robbed it of its terrors, when nothing but the direst necessity led the surgeon to abandon the expectant method and perform a major opera- tion, there were a number of well-estabhshed methods for the operative treat- ment of aneurysm. Apparently the condition used to be commoner than it is now. We must allow due weight to the experience of these early surgeons, that the poUcy of letting an aneurysm alone usually led to disaster ; but the exact frequency of such disaster we have no figures to show, nor are we Ukely to have in the future. Treatment by Compression has almost been given up, except where operation is quite impossible. It is painful and tedious (the average time in 26 cases was nineteen days). It only cures a minority of the cases ; thus Barwell found that of 148 instances of popliteal aneurysm treated by compression between 1870 and 1880, 68 succeeded and 80 failed. It may reduce the prospects of success of the subsequent ligature by dilating up the collateral circulation. Treatment by Operation. — We are greatly indebted to the excellent studies of the literature by Monod and Vanwerts for our knowledge of the end-results of the various methods of treatment of aneurj'sm. They have done their best to eliminate the usual fallacies of statistics collected from recorded cases instead of consecutive hospital series, but it is probable that successes and new methods figure a little too prominently even in their carefuUy-compiled tables. In a study of 410 recorded cases, they found that after proximal hgature about three-quarters were cured, 12 per cent failed, and 6-5 per cent suffered from gangrene. There was often persistent pain from adhesions of nerves to the sac. Of cases treated by extirpation, 90 per cent were cured, and 4 per cent developed gangrene. Of 105 cases treated by Matas' method of aneurysmorrhaphy, conserving the artery if possible, 85 were cured and 12 died. Their results may be set out in tabular form thus : — Aneurysms or Old Arterial H.ematomata. Method Cases Cured Died Gangrene Failure per cent per cent per cent per cent Ligature 138 74 rr I 6-5 12 Extirpation . . . - 205 90 3 4 1-5 Antvllus . - - - - 41 80 17 25 Aneurysm, oblit.* 62 88 8 7 '5 Op. conservativ. j 46 73 20 22 * Slatas* obliterative aneurysmorrhaphy. t llatas' reconstructive methods. (The percentages do not always total exactly 100, because they are expressed in round figures, and soma ol the gangrenous cases also died.) ANEURYSM OF PERIPHERAL ARTERIES 45 The following tables are quoted by Tscherniachowski from various sources to illustrate the frequency of occurrence of gangrene after various older methods of operation : — Arm Leg Total Cases Ganfirene Cases Gangrene Cases Gangrene Monod r Ligature and '. Antyllus Vanwerts t Extirpation 10 5 32 per cent c 68 19 145 per cent 11-7 5-2 6-2 78 24 177 per cent 10-2 4-1 5 f Ligature Wolff -^Antyllus - (.Extirpation 12 2 11 16-6 71 5 44 19-7 20 18-1 83 7 55 19-3 14-2 14-5 After aneurysmorrhaphy, gangrene occurred in 3-3 per cent, and recurrence in 2-7 per cent, of 149 cases extracted from the literature by Gardner (1910). We shall now take up the principal arteries in turn. Popliteal Aneurysm. — Of 20 cases treated by the older methods in the London Hospital, ligature in Scarpa's triangle gave the best results, but the literature quoted above shows that extirpation is better on the whole. Monod and Vanwerts compare the older methods with the conservative operation of Matas thus (in some cases the result is not known, hence the tables appear not to balance) :— Method Cases Cures Deatlis Gangrene Failure Conservative operation Non-conservative operation - 38 206 32=88-8% 180=87-3% 5=2-4% 14=6-8% 4=11-1% 6=3% Gangrene has, however, been known to follow aneurysmorrhaphy. It will be seen that the proportion of cures is about the same ; the ligature and extir- pation methods run more risk of gangrene, whereas the Matas operation is more likely to be followed by recurrence. Femoral Aneurysm. — Here again the cures are about the same with the older and the newer methods, and one has to balance risks of recurrence against risk of gangrene. Monod and Vanwerts have obtained the following statistics from the litera- ture : — Method Cases Cures Deaths UanSrene Failure Conservative operation- Non-conservative operation - 34 166 31=91% 149=90% 2=5-8% 11=7-2% 7=4-3% 1=3% The authorities differ as to whether, if ligature is adopted, it is wiser to tie the common femoral or the external iliac, the former being more likely to cure 46 INDEX OF PROGNOSIS the aneurysm, and the latter more Ukely to avoid gangrene. No doubt, when feasible, the best of the non-conservative operations would be the Antyllian or extirpation. External Iliac Aneurysm. — This rare disease may be treated by ligature of the common iliac artery by the intraperitoneal route, by extirpation, or by aneurysmorrhaphy. Matas gives the results as follows, using only post- 1880 evidence, but the data are not very clearly set forth : — Method Cases Cured Deaths Gangrene Failure Ligature . . . - Extirpation . - - - Aneurysmorrhaphy 21 5 7 9 4 4 10 3 7 1 1 9 6 1 Of the 7 patients treated by Matas' method, one became gangrenous and died, another relapsed and ruptured, and a third died of pulmonary embolism. The others appear to have been cured. Monod and Vanwerts report 9 cures and 10 deaths after various operations. Gluteal Aneurysm. — There appear to be no reliable figures relating to the treatment of this condition which do not go far back into pre-antiseptic times, and are therefore valueless. Delbet reports 12 out of 14 cases cured by the operation of Antyllus. Bergmann teaches that cure can often be obtained by the injection of ferric chloride, and Vanwerts declares that ligature of the internal iliac gives excellent results. Subclavian Aneurysm.— Monod and Vanwerts report : — Method Cases Cured Failure Died Proximal Ligature - - - - Extirpation . - . . - 63 11 44 10 9 10 1 For many years a curious fatality hung over the operation of tying the first part of the subclavian, and the first 19 cases all died, but the last 10 French cases have all recovered (up to 191 1). Axillary Aneurysm. — Using once more the statistics of Monod and Vanwerts : Method Cases Cures Deaths Gangrene Failure ■Conservative operation - Non-conservative operation - 6 63 4=66-6% 51=81% 1=16% 3=4-7% 1=16% 2=3% 1=16% 5=8% The non-conservative operations include ligature of the subclavian, extirpation, and the method of Antyllus, whereof extirpation, when possible, is the best. Innominate Aneurysm. — It is very seldom possible to apply a proximal ligature, but a considerable number of cases have been treated by tying the carotid and subclavian arteries. In the older literature there was a heavy mortality from sepsis and haemorrhage, and out of 120 cases only 7 cures resulted (Jacobsthal) ; but Vanwerts is able to quote 77 recent operations, whereof 14 per cent died, 57 per cent improved, and 19 per cent failed. ANGINA PECTORIS 47 Carotid Aneurysm. — Monod and Vanwerts could only find one case of aneurysmorrhaphy, which was fatal. The results of the older methods may be set out thus : — Method Cases Cures Deaths Failure Ligature ------ Extirpation - - - - - Incision ------ Aneurysmorrhaphy . - - - 16 17 3 1 13 14 2 3 1 1 3 Arteriovenous Aneurysm. — This is usually the result of a stab or bullet wound, and, as Makins has pointed out, it is wise to wait some months after the latter injury before operating. Mere proximal ligature may reduce it to an aneurysmal varix, but will not be curative ; the essential point is to separate the artery and the vein. Vanwerts has collected 15 cases of quadruple ligature of the artery and vein each, above and below; 3 became gangrenous, and 9 were cured. Extirpation, practised in 117 cases, gave 95 per cent of cures, and 1-7 per cent gangrene. Nowadays arteriorrhaphy might well be tried. Gangrene is of course more likely to follow operation on the common femoral or popliteal than on the vessels of the arm or the superficial iemoral. Aneurysmal Varix. — In the great majority of cases this does no harm, and a bandage is sufficient treatment. If it is necessary to do anything, the best results have followed ligature of the artery above and below ; simple proximal ligature is futile. Arteriorrhaphy would be worth a trial. References. — Keen's Surgery, 1909, vol. v, article "Aneurysm"; Tscherniachowski, Deut. Zeit. f. Chirurg. 1913, June, i ; Monod and Vanwerts, Rev. de Chirurg. 191 1, 663. A. Rendle Short. ANGINA PECTORIS.— When we say of a patient that he is suffering from angina pectoris, we mean that he is troubled by bad attacks of cardiac pain, which constitute a prominent feature of his case. An account of the prog- nosis in angina becomes, therefore, an account of the prognostic significance of a symptom, and not a summary of the menaces contained in a definite disease. Angina pectoris will here be spoken of as a symptom of organic disease of the heart ; imitative attacks will be alluded to at the end. True angina is always evidence of one thing — impaired contractility in the wall of the left ventricle. This is often (but not always) associated with inter- ferences in the supply of blood to the myocardium, through the coronary arteries. Now inadequacy of contractile power in the ventricular myocardium is a serious matter, and any lesion that can produce it is a veritable shell in the engine-room . The first statement to be made, therefore, is that angina is always a grave symptom in any case of cardiac disease. Its appearance in a patient who has never shown any previous evidence of a lesion of the heart must always call for a minute investigation of the case from every point of view, to ascertain the precise nature of the injury that is causing it. On the other hand, when a patient who is known to carry a damaged heart has his first paroxysm of angina, the prognosis is made graver than before, simply because it shows that the vital part of his heart, the muscle of his left ventricle, is becoming unequal to the demands which are made on it. It must be added that the very occurrence of angina introduces into the case a risk of sudden death ; this point will be examined in detail later. The average period elapsing between a first attack and the patient's death is not easy to ascertain. INDEX OF PROGNOSIS General Outlook. — In order to determine the outlook in any given case of angina, four points must be examined : (i) The nature of the cardiac lesion ; (2) The circumstances provoking the attacks ; (3) The nature of the attack itself ; and (4) The condition of the heart after the attack is over. I. The Cardiac Lesion. — Angina pectoris occurs in connection with acute as well as with chronic disease of the heart, but far more frequently with the latter ; probably because any acute disease which injures the myocardium severely enough to cause angina will quickly go on to a fatal issue. From the prognostic point of view, a classification which divides the myocardial states responsible for the occurrence of angina into those which are primary and those which are secondary, is of more value than a division into acute and chronic lesions. The primary conditions are those in which the myocardium itself is diseased ; the chief examples of these are cardiosclerosis, cardiac syphilis, alcoholic degeneration of the myocardium, and acute infection of the myocardium in such diseases as rheumatism and typhoid fever. The secondary causes of angina are those in which the myocardium is relatively free from disease, yet unequal to some abnormal circulatory strain thrown upon it, the chief examples of which are disease of the aortic valves and high arterial tension. Even this classification has only a limited value, for the two classes overlap at certain important points : for instance, cardiac syphilis and disease of the aortic valves frequently coincide ; so also do cardiosclerosis and high blood-pressure. Nevertheless, the classification is of some service in the present connection if it emphasizes the fact that the outlook is graver in those cases where angina is directly connected with disease of the myocardial tissues than in those where a fairly healthy myocardium is confronted with a task too heavy for it. In determining the nature and seriousness of the cardiac lesion responsible for anginal attacks, therefore, it is necessary to give an idea of the state of the myocardium, the arteries, the arterial tension, and the valves of the heart. All signs pointing to gross disease of the myocardium make the prognosis graver ; such signs are feebleness of the pulse and heart-sounds, embryocardia and gallop- rhythm, the alternating pulse, dyspnoeic attacks too readily provoked, oedema of the ankles. On the other hand, if the impulses be powerful and thrusting, and indicative of hypertrophy of the left ventricle, and signs of some extraneous cause such as aortic incompetence or high arterial tension be present, the prognosis is better, and particularly where the extraneous cause is one that can be modified and reduced by treatment (high arterial tension), or is, at least, not progressive (post-rheumatic incompetence of the aortic valves in an adult). Of course, very high tension that does not yield in the least to treatment is a grave cause of angina, for it is likely to be progressive. Again, angina as a symptom of aortic insufficiency is of far more sinister import when associated with syphilitic disease of the aortic valves than in cases of post-rheumatic valvular disease ; for in the former case there is sure to be progressive myocardial disease associated with the valvular lesion ; whereas, in the latter (provided the patient be over twenty), the risk of direct myocardial injury is remote, and such myocarditis as may occur tends towards recovery and is not progressive. The aortic incompetence of general atheroma hes midway between the two ; the myocardium is directly attacked through disease of its nutrient arteries, and it will become worse, but not rapidly so, as in the case of syphihs. Sometimes, of course, the prognostic import of the angina is overshadowed by that of other findings, as when signs of aortic aneurysm are discoverable. A general rule applicable to all cases of angina, however, is : the worse the myocardium, the worse the prognosis. The marks of a bad myocardium are to be found partly in the patient's own statement, partly by physical examination, and partly by inference. ANGINA PECTORIS 49 2. The Circumstances Provoking Anginal Attacks. — These circumstances are of various kinds ; the chief are exertion, emotion, meals, and external cold. In a number of cases no provocation is discoverable, the attack coming on while the patient is at rest in bed. Two obvious generahzations spring into the mind at once, or rather, two aspects of the same generahzation. The first is that the more readily the attacks are provoked, the worse the prognosis. There is much less menace in angina which comes on in the middle of a sprint to the station than in that which brings to an abrupt termination an attempt to walk up a barely perceptible incline, even though the former be the severer attack. The second is that if the provocative cause be a controllable one, the outlook is by so much the better. Obviously the man who only gets angina after overloading the stomach is in a better case than the one whose attacks are provoked by all sorts of causes, and by no apparent cause at all. In this sense, it is better to have one cause for the attacks than many ; for example, the man who only gets attacks when he stoops to do his boots up can foresee his danger and circumvent it by taking care, while he who never kiiows what petty excitement or effort may throw him into peril cannot be so precisely forewarned, and thereby forearmed. In this connection, the patient's temperament is important ; the headstrong man, who will not be advised, must expect evil consequences if he will ndt curtail his activities and hve within the limitations of his myocardium. If he can and will avoid such circumstances as have been found to provoke attacks, the prognosis is better. 3. The Nature of the Attack itself. — Here it must be acknowledged that a priori reasoning is singularly apt to mislead. The severe attack is not necessarily more dangerous than the sUght one. Patients have been known to live for years after a tremendous bout of prolonged agony of mind and body, while others sink rapidly after an attack which was so slight as to be misinterpreted at the time. The one Hne of inquiry into the nature of the attack which goes to the root of the matter is that which seeks to discover whether or no there are evidences of grave myocardial embarrassment during the paroxysm. Thus, the prognosis is worse if the attack be accompanied by respiratory changes (grouped breathing or ' cardiac asthma ') ; so, also, if the pulse become slow and there are evidences of heart-block, or if the patient faint during the paroxysm. Such data are of much more importance than the severity and distribution of the pain. One point that gives some help is the effect of vasodilators ; attacks that are readily relieved by the exhibition of nitrites are less portentous of evil than those that are refractory to treatment, presumably because the angiospastic factor, the one which is neutralized by nitrites, is less threatening than the myocardial, which is influenced only indirectly by this form of treatment. 4. The State of the Heart after the Attack. — This is of the greatest significance. Here, again, it is the condition of the myocardium that matters ; has it been definitely and perceptibly worsened by the attack, or by the changes which provoke it ? Two or three examples will serve to illustrate this point. A strong man of over seventy had for some time been getting shorter of breath, but there had been no pain till one day after walking up a very gentle incline ; even then it was not very severe, and soon passed off under treatment. However, the heart-sounds were feebler after it than before, the patient was bluer and more breathless, and the feet began to swell ; in a few days he died rather suddenly in his armchair. In another case, a patient with aortic regurgitation of the atheromatous type, who had survived years of anginal attacks, one, at least, 30 severe and obstinate as to necessitate the use of chloroform, died within a few days of a comparatively slight seizure of pain, which was followed by the develop- ment of a pericardial rub with quickening of the pulse. A third patient, who 4 50 INDEX OF PROGNOSIS had been troubled with severe angina for over a year, had a sudden attack in bed one day ; on the following day his cardiac dullness had perceptibly increased, and a pericardial rub was heard ; a day later he died suddenly in bed. In this last case the right ventricle was found ruptured at the autopsy. Anything which points to the myocardium having taken a downward step during the attack points also to an active degeneration in progress, and therefore to an early termination. Signs of pericarditis are particularly ominous, for they are manifestations of some gross change in the cardiac muscle, such as infarction or rupture. So much, then, for the general outlook in any patient with anginal attacks ; it all turns on the state of the myocardium before, during, and after the attack, and the degree of overstrain needed to bring out that inadequacy of which angina is a symptom. There are, however, two other questions which we must be ready to answer : the likehhood of sudden death, and the probability of recurrences of the attack. Sudden Death. — Patients who have had sharp bouts of angina do not ask about the risk of sudden death ; they have tasted its bitterness already, and know so much of the danger that they do not care to know more. The relatives, however, not seldom want to know " whether he is likely to go off in an attack " ; and this is not unreasonable, for the patient looks more than half dead if the paroxysm be at all severe. Further, writers of fiction and of medical text-books have insisted so much on the association between angina and sudden death that the two ideas have become inseparably linked in the pubhc mind. Now, while it is perfectly true that in a few dramatic instances the heart stops during the paroxysm, it is equally noteworthy that a considerable majority of those who are subject to angina do not die during the attack. Having explained this to the friends, it is advisable to give a rather fuller explanation of the risks of sudden death implied in anginal attacks : that although the onset of cardiac pain must not be regarded as necessarily threatening imminent death, yet the very occurrence of such attacks is a warning that the muscle of the heart is barely equal to its work ; that it may fail abruptly or acutely with or without forewarnings of pain ; and that death is apt to follow attacks of pain after an interval of days or hours. The actual imminence of sudden death, in any given case, depends entirely on the conditions found to underhe the patient's hability to angina ; those points to which attention has been directed as giving a key to the general prognosis in any given case wiU also assist in an estimation of the risk of sudden death. Recurrence. — Another question that the patient may dare to ask for himself after the first attack bears on his liabihty to a return of the experience. Now he may be quite truly assured that it is possible that he may never have it again, particularly if that which provoked the first attack be some avoidable circum- stance, such as going out insufficiently clad on a frosty day, over-eating, and the like. A surprisingly large number of persons have only one attack, or else a few attacks at long intervals ; while some go through a series, and come out into smooth water again. Such good fortune falls especially to those whose heart is in fair condition, but overtaxed by a high arterial tension, or by leaking aortic valves and a laborious occupation ; and only to such of these as are willing to go softly. Indeed, it is here that the whole philosophy of angina comes in. Pain is a warning, a protective phenomenon, which says to its victim, " Don't do that again " ; if the anginal patient will listen to this advice, he will escape further punishment. Where, however, the heart is the seat of syphihs, or the arteries are profoundly degenerated, the friends must be warned of the likelihood of recurrences, and of all that we have seen impUed in them. Moreover, it is well ANTHRAX 51 to bear in mind the fact emphasized by Mackenzie, that cessation of pain is not always a good prognostic sign ; if accompanied, as it sometimes is, by the onset of mitral insufficiency, with anasarca and increasing dyspnoea, the patient may be regarded as having entered on the last stage of his journey, even though he may never again have any suspicion of angina. Pseudo-angina. — A final word remains to be said about the shadowy group of cases designated 'pseudo-angina,' 'toxic angina,' and so on. Climacteric women are liable to attacks of pain which is more or less obviously cardiac ; and over-smoking may bring on the same kind of trouble. Obviously, such attacks, which do not depend for their origin on organic disease of the heart, do not carry with them any menace to the patient's life ; moreover, they will cease to occur when the cause has ceased to operate. The whole difficulty of prognosticating truthfully in such cases, then, lies in diagnosis of the cause or causes of the attacks. The task is to find out whether or no we are dealing with a sound myocardium ; if the physical signs and other circumstances (the patient's age and his position, consumption of tobacco, nature of attacks, and so forth) point away from serious disease of the myocardium, then the prognosis is good. Indeed, this is the whole secret of successful prognosis in cases manifesting angina pectoris. It is a symptom of myocardial inadequacy, and the prognosis varies directly with the state of the myocardium : good heart muscle, good prognosis ; bad heart muscle, bad prognosis. Carey F. Coombs. ANTHRAX. — The outlook in cases of malignant pustule is much better now than in days gone by, and has been still further improved by the introduc- tion of antitoxic sera such as Sclavo's and Mendez's. In the years 1 850-1886, Koch reported a mortality of 39 per cent, and in 1905 Legge estimated the English mortality as 26-5 per cent (261 cases), and the German as 13 per cent (446 cases). Since that time Heinemann has collected statistics which show a marked improvement, and give us some guide as to the relative value of different methods of treatment. He collects from the literature : — 268 cases treated by various ointments and lotions - 9 '3 per cent died 814 ,, ,, excision, cautery, caustics - - 7 1073 ,, (Buenos Aires) treated by Mendez's serum - 4"2 ,, 80 ,, treated by Sclavo's serum .... 3-7 ,, The mode of obtaining these figures probably makes them too favourable, as literature reports are notoriously apt to publish the successes and let the failures drop into oblivion ; but many years ago Lengyel and Koranyi, in a consecutive series of 146 cases treated surgically, were able to report a death-rate as low as 9" per cent, so probably it is fair to take the mortality in the serum cases as 5 per cent, and in those treated by excision as 8 to 10 per cent. Much depends, of course, on the time at which the patient is first treated, these good results being only obtained in early cases. Death usually follows in five to eight days, and spontaneous cure is said to be quite uncommon. It would be difficult to verify this statement nowadays, because every case seen would be treated. When oedema is very great, the prognosis is unfavourable, and wounds of the head and neck are more than twice as dangerous as those of the limbs. When the temperature is high and the patient shows marked signs of systemic infection, recovery is unlikely. Woolsorters' disease, that is, a general infection either of the lungs or intes- tine without a skin pustule, is happily rare, but is extremely fatal. Reference. — Heinemann, Deut. Zeit. /. Chirurg. 1912, 309. A. Rendle Short. 52 INDEX OF PROGNOSIS ANTRAL EMPYEMA. — [See Nasal Accessory Sinusitis.) ANTRUM, GROWTHS OF.— {See Jaws, Tumours of.) ANUS, IMPERFORATE. — Many years ago, Harrison Cripps made a study of the operation mortality in this condition under various circumstances. He pointed out that although the prognosis apart from operation is, of course, hopeless, except in cases where the rectum opens into the vagina, yet occasion- ally the children may survive for a surprisingly long time ; one infant at St. Bartholomew's Hospital, whose parents refused operation, was still alive a month later, vomiting faeces three times a day ! Mortality in Ninety-eight Cases treated by Different Operations. Operation Cases Deaths Dissection from the perineum Puncture from the perineum Coccyx resected . . . . Opening into vagina Iliac colostomy Lumbar colostomy Miscellaneous . . 37 17 8 14 16 3 3 14 14 5 1 11 I A study of 37 cases of this condition, treated at St. Thomas's Hospital, shows how few of the infants grow up to adult age in reasonable comfort. An exception must be made in favour of little girls with imperforate anus and recto-vaginal fistula. These survive, and at some later period a plastic operation can be performed. It will be very dif&cult to get control without stricturing, however. The writer has seen one such patient treated with fair success. Of the 37 cases referred to, 20 died in hospital : 2 of peritonitis, 5 of shock, and 13 after laparotomy or colostomy. Of the 17 who left hospital alive, 10 have been lost sight of. Of the other 7, 2 died, aged nine and twelve months respectively, of deaths probably unconnected with the anal condition ; i died, aged two months, of ' wasting ' ; i died, aged four months, of intestinal obstruc- tion ; I died, aged three years, after operation to close a colostomy ; 2, aged nine and seven years respectively, are still living, one quite well, the other with a recto-urethral fistula. Cripps gives case-histories of a number of successful recoveries. It is probably fair to conclude that about half the patients operated on die almost at once, and that about half of the survivors die in early infancy. A quarter of the total might survive, as far as the anal trouble is concerned, but some of these are in permanent discomfort. The most favourable cases are those with only a mere septum separating the bowel and the anus, but it will be seen that one child Uved to the age of three years, even with a left iliac colostomy. References. — Cripps, "Diseases of the Rectum and Anus," 3rd ed. ;. St. Thomas's Hosp. Rep., 1911, 156. A. Eendle Short. AORTA, DILATATION OF. — Either in relation to thoracic symptoms, or in the cause of routine examination, it is no uncommon experience to find evidences of diffuse dilatation of the aorta. The introduction of skiagraphy has done much to enlighten us as to the frequency with which the thoracic aorta is dilated. APHASIA 53 While it would be out of place to enter fully into the pathogenesis of this condition, it is essential to have some understanding of the factors which enter into its production. These are two, the dynaiinc and the degenerative. Dynamic Origin. — The simplest example of this kind is to be found in post- rheumatic insufficiency of the aortic valves ; here there is little question of any degeneration of the aortic wall ; for though the rheumatic process is liable to injure this structure, it seldom does so to any intense or abiding extent. Yet in many cases of long-standing aortic regurgitation, there are the clearest evidences of a diffuse enlargement of the arch of the aorta ; so much so, indeed, that many writers have recorded such cases as examples of ' rheumatic aneurysms.' The explanation is not hard to find : each ventricular systole throws an excess of blood into the aorta and overdistends it. Clearly, there is no question of prognosis here apart from that of the disease itself. Degenerative Origin. — This type of dilatation, on the other hand, is perfectly exemplified in syphilis of the aorta. Here we have to deal with an actual and progressive disease of the aortic wall. Mixed Origin. — A combination of the two factors is encountered in cases of aortic dilatation combined with high arterial tension ; in such cases, the aorta stretches, partly because it is subjected to an abnormal tension from within, partly because it is — in most cases, at any rate — the seat of a dystrophic process. Even here, however, the latter factor is of minor importance ; the fact that the aorta is dilated, is of far less weight in regard to prognosis than the fact that the arterial pressure is raised. It is clear, from this brief account of the etiology of aortic dilatation, that its bearing on the outlook of any given case is that of its cause, and it will be more profitable to refer the reader to the articles dealing with cardiac syphilis, arterio- sclerosis, high arterial tension, and aortic regurgitation, than to encourage any attempt to forecast the future of a case without reference to the origin of the dilatation. Carey F. Coombs. AORTIC DISEASE. — [See Heart, Valvular Disease of.) APHASIA. — The prognosis depends upon the underlying cause. Most cases of aphasia are the result of organic lesions of the cerebral cortex. Some of them are due to embolism from cardiac lesions ; others, the majority, are due to arterial thrombosis ; whereas cerebral haemorrhage is relatively uncommon as a cause. In embolic cases, the arterial obstruction usually reaches its maximum at once, and does not tend to extend. In thrombosis, on the other hand, there is a tendency for the lesion to spread and become more extensive, corresponding to the amount of disease in the cerebral arteries. Cerebral thrombosis occurring in the early half of adult life is most likely to be syphilitic in origin ; whereas, after middle life, arteriosclerosis may occur, not only from syphilitic disease, but also from senile arteriosclerotic changes. Syphilis should always be looked for by the various tests at our command, since syphilitic cases have a better prog- nosis, if promptly treated, than non-syphiUtic ones. Cerebral abscesses (most commonly in the left temporal lobe) and meningitis are among the less common organic causes of aphasia ; whilst cerebral tumours are still more infrequent, producing aphasic symptoms either by direct infiltration of the speech-centres or, more usually, by conipression. In many cases of aphasia from organic disease, there is a co-existent right-sided hemiplegia, more or less profound according to the situation and extent of the brain lesion. It is important, however, to remember that it is the cortical part of a brain lesion which is mainly responsible for the aphasic symptoms, and that 54 INDEX OF PROGNOSIS deeper-seated lesions of the white matter may produce the most profound hemi- plegia without any evidence of aphasia. In organic lesions which are still advancing — e.g., in spreading vascular lesions of any sort, in cerebral abscesses, meningitis or tumours, — aphasia is not likely to improve ; on the contrary, it tends to get worse. But in cases where the organic lesion has come to a standstill — e.g., after an attack of cerebral embolism or thrombosis, after successful evacuation of a cerebral abscess, or after relief of pressure by removal of a cerebral tumour (provided that the tumour has not infiltrated the speech-centres, but has only compressed them), — ^the speech-centres, or so much of them as remains undamaged, may gradually resume their function ; whilst the subsidiary speech-centres in the opposite side of the brain may, by education, undergo development. The degree which such compensatory activity of the speech-centres may attain is very variable. The prognosis is best in children ; under the age of five or six years, provided no profound dementia be present, compensation practically always occurs, and the aphasia usually clears up completely. In old age, on the other hand, the probabilities of re-education of subsidiary speech-centres are very remote, and little or no improvement is to be looked for. In early adult life, or middle age, individual variations are so great that an accurate prognosis in any particular case is well-nigh impossible. Patients with word-deafness are more difficult to re-educate than those with word-blindness. The co-existence of word-deafness and word-blindness in severe degree renders re-education impossible, while the absence of both word-deafness and word-blindness, as in simple motor aphasia, renders the prospects relatively much more favourable. Temporary Aphasia.— A transient aphasia, usually slight in degree and evidenced mainly by a difficulty in naming objects, may arise from mere debility or ex- haustion in an otherwise healthy person. In other cases, the condition is due to temporary slowing or stasis of blood in diseased cortical arteries ; such attacks are to be regarded as warnings of threatened thrombosis, and call for energetic treatment of the arterial disease, especially if it be syphilitic in origin. Temporary aphasia also occurs from localized arterial spasm, the patient recovering suddenly and completely within a few hours. We also meet with it in general paralysis of the insane as part of a ' congestive attack.' Certain cases of migraine are preceded by an aura of temporary aphasia, usually accompanied by a subjective sensation of tingling in the right arm, face and tongue, and followed by left-sided headache. Aphasia may also be present, for a short time, after the occurrence of an epileptic fit, doubtless owing to temporary cortical exhaustion. Lastly, we may have temporary aphasia in urajmia, from toxic affection of the speech- centres. Purves Stewart. APLASTIC ANEMIA.— (See Anemia, Aplastic.) APOPLEXY.— (See Strokes.) APPENDICITIS : Acute and Chrome. ACUTE APPENDICITIS. Results of Operation. — In the year 1912, 936 cases of appendicitis were admitted to the London Hospital. Among them were 38 cases which for one reason or another were not operated upon ; 2 of these were moribund when they were admitted and died shortly aferwards. I have excluded these 38 patients and completed a series of looo cases by adding 102 others, 70 men and 32 women, who were admitted to the hospital at the beginning of 191 3. APPENDICITIS 55 Of the looo cases, 698 were operated upon during the attack, 302 during the quiescent stage. Of the patients who were operated upon, 32 died, which gives a mortaUty in all cases of 3'2 per cent. Among the 302 operations performed between the attacks there were 2 deaths, a mortality of 0-7 per cent. These patients were suffering from actino- mycosis of the appendix ; death was due in both cases to extension of the disease, and did not follow immediately upon the operation. I have divided up the 698 patients who were operated upon during the acute stage into four groups, according to the condition found. In the first group are placed those patients who had general peritonitis ; there were 80 of these, 16 of whom died, giving a mortality of 20 per cent. In the second group are 211 patients who had an abscess ; 204 recovered and 7 died, giving a mortality of 3-3 per cent. In the third group are those who had local peritonitis only, including those cases in which the peritonitis was diffuse but did not involve the whole of the peritoneal cavity ; these numbered 123 with 6 deaths, a mortality of 4"8 per cent. Finally, in the last group are placed those patients in whom the inflammation was limited to the appendix and there was little or no evidence of local peritonitis ; in this group are 284 patients, i died, a mor- tality of 03 per cent. Table A. — Present Mortality in Operations for Appendicitis. Total Recovered Died Mortality During quiescent stage 302 300 2 per cent 07 During acute stage : General peritonitis - Abscess . - . . Local peritonitis Inflammation localized to appendix 80 211 12:5 284 64 204 117 283 16 7 6 1 20 3"3 4-8 0-3 Total 698 G68 30 4-3 Grand Total (all cases) 1000 968 32 3-2 From these statistics we can form some idea as to the prognosis in the different forms of acute appendicitis if the patient is submitted to surgical treatment ; and for easy reference I have collected them together in Table A . It is, however. far more important to draw attention to the way in which the prognosis varies according to the time at which operation is undertaken. I found on examining the statistics of the London Hospital, that out of 162 patients who were operated upon during the first twenty-four hours of an attack, only 2 died, giving a mortality of 1-2 per cent; of cases operated upon during the second twenty- four hours of an attack, 152 in all, 6 died, a percentage of 3-9 per cent; whereas of those in whom operation was postponed until the third day of the attack, 115 in all, 10 died, or 8-7 per cent. I do not think that any deductions can be drawn from the death-rate of the cases operated upon from the fourth to tjie ninth days, as the numbers are so small. But attention may be drawn to the fact that of the 58 patients operated upon on the tenth day or later, only I died. If Table B is examined for details of these cases, it will be seen that 40 were cases of abscess and in 14 the inflammation was limited to the 56 INDEX OF PROGNOSIS appendix; in other words, that in 54 cases the condition was well localized, consequently there was much less danger in operating upon them than in cases which were not so locahzed. Table B. — Mortality of Operation on the Different Days OF THE Attack, Day Infleimed Local Peritonitis Abscess General Peritonitis Total R. D. R. D. R. D. R. D. 1 R. D. per cent I St dav 1)9 1 35 13 13 160 2 1-2 2nd day 62 39 1 2D 1 20 4 146 6 3' 3rd day 40 10 3 43 2 12 105 10 8-7 4th day 22 10 1 10 6 1 48 2 4 5th day 12 3 17 3 1 35 1 2-8 6 th dav 5 4 11 1 21 7th dav 9 . 3 23 1 fi 2 41 3 6-8 8th day 4 1 5 10 qth day 2 1 5 2 1 9 4 30 loth dav 1 or later/ 14 3 1 40 57 1 1-7 Day not | stated / 14 8 12 1 36 1 2-7 Total 283 1 117 6 204 7 64 16 668 30 4-3 R — Recovered. These statistics illustrate the value of early operation, during the first twenty- four hours of the attack if possible, and the cases are sufficiently numerous to justify the statement that operation during the first twenty-four hours is attended with extremely little risk ; operation during the second day with considerably more risk, though it is still small ; but if operation is postponed until the third day, the prognosis is much more serious. Some may argue that the results obtained in the operations on the tenth day or later are strongly in favour of postponing operation. The reply of course is that it is generally impossible to tell in which cases the inflammxatory process will become localized and operation may be deferred with safety. I would once more point to the total mortality of 3-2 per cent in this series, compared with the total mortality of 17-2 per cent in another series of 1000 cases which I collected in 1905 ; at that time operation was very rarely performed in the first stages of the attack, but was postponed as long as possible in order to allow the attack to subside, or failing this, to allow the inflammation to become locahzed. The earlier statistics illustrate the results of postponing operation, the present ones the result of operating early. If all cases could be left with safety until the tenth day, the general mortality would be still lower than it is ; but unfortunately they cannot, and it is therefore our duty to remove the appendix at a time when the risk is reduced to a minimum, that is, during the first twenty-four hours, a procedure which offers the prospect of a mortality of only 1-2 per cent. Complications of Acute Appendicitis. — Unfortunately it is by no means rare for the patient's convalescence to be delayed by certain complications which may arise during the attack. Thus we find that out of 698 patients operated upon during the acute stage, in 85, that is I2'2 per cent, various complications arose. Among them were 25 cases of faecal fistula, 22 cases of secondary APPENDICITIS 57 abscess, 17 pulmonary complications, and 12 cases of intestinal obstruction; 3 patients had more than one complication ; for example, of two of the cases of pleural effusion, one was associated with a subdiaphragmatic abscess and the other with bronchopneumonia — and the patient with empyema also had a subdiaphragmatic abscess. That 12-2 per cent of all patients operated upon during an attack of appen- dicitis, or one in eight, should suffer from complications is very unsatisfactory, but even so it is a great improvement on former results. The explanation of this improvement is easy ; there can be no doubt that it is due to operating early instead of postponing it until the patient has developed an abscess or general peritonitis. For on investigating the 85 cases in which complications arose, we find that in all but six there was an abscess or peritonitis, general or local ; in the great majority an abscess or general peritonitis. Of the 6 cases in which the inflammation remained localized to the appendix, i was a case of intestinal obstruction in which the appendix itself formed the obstructing band, and probably became gangrenous in consequence of the cutting off of its blood supply by the stretching of the appendix and its mesentery. Table C. — Complications which Occurred Amongst 6g8 Cases Operated upon During THE Attack. Complications No. of Cases Secondary abscess - Subdiaphragmatic abscess Faecal fistula . . - - - Thrombosis - - - - - Pulmonary complications : (i) Empyema - - - - (2) Pleural effusion (3) Bronchopneumonia (4) Lobar pneumonia (5) Bronchitis . - - - Intestinal obstruction . . . - Pylephlebitis . . - . - Cystitis - - . . . Haematemesis, ha;maturia, purpura 22 4 2:") 4 1 4 7 2 3-17 12 2 1 1 Total number of complications Total number of patients affected 88 *85 'One of the patients with pleural effusion also had a subdiaphragmatic abscess, and another had bronchopneumonia. The patient with empyema had a subdiaphraj^matic abscess. Secondary Abscess. — Secondary abscesses form a large proportion of the complications, for as will be seen on reference to Table C, a secondary abscess developed in no less than 22 of the 85 patients, apart from the four patients who had a subdiaphragmatic abscess. The majority occurred in the pelvis, in the rectovesical pouch, as a natural consequence of the routine adoption of the valuable Fowler's position, which causes all free fluid in the peritoneal cavity to gravitate to the pelvis. But the number of these cases of secondary abscess is unnecessarily large, for it is due, I think, to inadequate drainage. A few years ago there was a tendency to leave drainage tubes in too long ; more recently the pendulum has swung to the opposite extreme, and drainage is not continued long enough, and indeed 58 INDEX OF PROGNOSIS in some cases not employed where it is necessary. I well remember my disgust on visiting my wards one afternoon, to iind that three cases of acute appendicitis, which I had operated on a few days previously, had each developed a pelvic abscess, thanks to a misguided enthusiasm which led a new house surgeon to remove prematurely the drainage tubes which had been placed in the recto- vesical pouch. Fortunately the prognosis is good— none of the cases of secondary abscess proved fatal. Subdiaphragmatic Abscess. — A subdiaphragmatic abscess occurred 4 times. In I case it was associated with clear fluid in the right pleura, and in the other cases with a right empyema. All four occurred in old-standing cases ; in 2 there was general peritonitis, and operation was not performed until the fifth and sixth days of the attack ; in 2 there was an abscess. All 4 cases recovered. These results are unusually good. Hoffmann quotes Korte, who collected 60 cases, with a mortality of 33-3 per cent. Barnard collected 76 cases : 40 lived and 36 died, a mortality of 47-4 per cent. Of these, 12 were not operated on, and they all died. Of the 64 who underwent operation, 24 died, a mortality of 37'5 per cent. But of the 21 consecutive cases operated upon by Barnard himself, only 17-7 per cent died, a proportion which is a truer representation of the mortality of subdiaphragmatic abscess at the present day. This is largely due to the pioneer work done by Barnard in this direction, and also to further advances in our methods of diagnosis and treatment. We must regard a subdiaphragmatic abscess as a serious complication. For although the four cases mentioned above all recovered, the number is too small to justify any deductions as to the mortality of this condition ; nevertheless the fact that they all did recover is encouraging. [See also Subphrenic Abscess.) Fescal Fistula. — A faecal fistula is far more likely to occur in a patient who is operated upon late in an attack than in one who has been operated upon within the first forty-eight hours. It may result from any of the following causes : 1. Direct extension of the gangrenous process from the appendix to the caecum or ileum. 2. Imperfect occlusion of the appendix stump. This may occur in cases in which only part of the appendix has been removed, as the proximal part could not be discovered, or it may occur in those cases in which an invaginating purse- string suture, placed in the wall of the caecum round the insertion of the appendix, has either cut through the inflamed and oedematous tissue or given way. 3. Actual tearing of the intestine at the time of operation. 4. Patches already ulcerated and eroded, which, when freed from the adhesions which support them, perforate. 5. The pressure of a drainage tube on the intestine. In cases of prolonged suppuration, this pressure, combined with sepsis, may give rise to ulceration of the intestine, with subsequent formation of a faecal fistula. Most of these fistulae can be avoided by early operation ; the following case may be given as an example. About two years ago I operated upon a boy of 18, thirty-six hours after the onset of the attack. The appendix was gangrenous, and continuous with it was a gangrenous patch on the caecum the size of a five-shilling piece. The appendix was removed, the gangrenous part of the caecum invaginated, and the patient made a rapid and uninterrupted recovery. If an early operation had not been undertaken, a faecal fistula would have been inevitable. Of the 25 cases of faecal fistula, there were only 4 in which the operation was performed within the first forty-eight hours. In the great majority of cases the faecal fistula followed an old-standing abscess. In the present series, faecal fistula occurred 25 times in 698 acute cases, or 3-6 per cent. APPENDICITIS 59 As regards prognosis, it appears, therefore, that in acute cases 3-6 per cent of patients will develop a faecal fistula. If,- however, the operation is undertaken within the first twenty-four hours, or even the first forty-eight hours the chances of a fistula forming are so slight as to be negligible. Of the 25 patients with faecal fistula, 3 died. With regard to the fistula itself, as a rule it closes spontaneously, in the majority of cases within fourteen days. It is rarely necessary to operate, but if the fistula persists, the question of operation must be considered. Thrombosis. — This is another complication which is met with less frequently than formerly. Thrombosis of the femoral veins occurred 4 times, twice on the right side and twice on the left. The symptoms usually occur from two to three weeks after the beginning of the illness. There is first a slight rise of temperature, the following day a little pain in the affected limb along the course of the vein, with probably slight cedema of the foot, and the next day the oedema becomes more marked. The first case was that of a boy with a retrocaecal abscess, who had been ill for five days before his admission to the hospital ; the second case, a man of 45, had an abscess and had been ill for ten days ; in the third case, a man of 53, there was no abscess, but the operation was a difficult one and there were many adhesions. The fourth case was a man of 65, who had general peritonitis with a gangrenous appendix, and who had only been ill for a day and a half. In the latter case there is little doubt that the age of the patient and his feeble circu- lation predisposed to thrombosis. All four patients recovered. In considering the prospect of a case of femoral thrombosis, one must remember the danger of its giving rise to pulmonary embolism, and bear in mind Hoffmann's statement that out of 39 patients who had femoral thrombosis, pulmonary embolism occurred in 22. The ultimate prognosis of thrombosis of the femoral veins is good in young subjects, although the leg will probably remain cedematous for many months. Wearing an elastic bandage, and massage after a due interval, cause great improvement. Pulmonary Embolism. — In connection with thrombosis we must consider the extremely important condition of pulmonary embolism. In 4000 cases of appendicitis, Hoffmann reported 39 cases of thrombosis of the femoral veins, and no less than 22 of these gave rise to pulmonary embolism, 18 of the 22 cases proving fatal. McWilliam, in 685 acute cases, found 4 cases of pulmonary embolism, of whom 3 died on the third, ninth, and tenth days. If we take these two reports together, we see that out of 26 cases, 21 died, a mortality of 8o-8 per cent. Garre and Quincke allude to the varying mortality of pulmonary embolism in the statistics of different authors. They quote the following : — Lotheissen found 52 deaths out of 61 cases = 83-3 per cent. Albanus .. 10 ,, ,, 23,, =: 43"5 Gebele . . 11 ,, ,, 14 ,, -- 79 ,, Wyder .. S ,, ,, 12 ,, =-66 The difference is probably due to the inclusion of slight cases by some authors, while others only included cases in which the symptoms were pronounced and severe. Pulmonary embolism is, perhaps, the greatest tragedy of surgery, and any treatment which is likely to prevent this calamity should receive most careful attention. Hoffmann has obtained remarkable results by making the patient stand up out of bed, even if only for a minute, the day after operation, and this 6o INDEX OF PROGNOSIS is repeated on subsequent days. If it is quite impossible for the patient to stand, passive and active movements of the lower extremities are instituted and, later, massage. His statistics embrace all cases up to the 3'ear 1912, and this treatment was begun in the year 1908. After the introduction of this treatment there were only 3 cases of thrombosis and emboli, compared with 36 in the previous years, and none of these three had been made to get out of bed the day after operation. This is most suggestive, and the treatment is worthy of very careful consideration. The mortality of severe cases of pulmonary embolism appears to be about 75 per cent, but as was pointed out by Sir Douglas Powell, in all probability many of the cases of bronchopneumonia, empyema, and pleurisy, which arise as complications of appendicitis, are really embolic in origin. Fortunately, we can say that at the present time, with modern methods of treatment, fatal pulmonary embolism is an extremely rare complication of appendicitis. In 4 cases the pulmonary artery has been opened and the clot removed by Trendelenburg's operation. The most successful case was a woman operated upon by Kriiger ; she lived for five days and a quarter after the operation, and died from purulent pleurisy. Other Pulmonary Complications. — Pulmonary affections form a large propor- tion of the total number of the complications, viz., 17 out of a total of 88. Reference to Table C will show the relative frequency of the different conditions, bronchopneumonia heading the list, and pleural effusion coming second. Empyema only occurred once, and then was in association with a sub- diaphragmatic abscess. Pleural effusion occurred in 4 cases. In one, the patient had been lH three weeks and had a subdiaphragmatic abscess. The second patient was operated upon for general peritonitis on the third day of the attack, and developed double pleurisj' and bronchopneumonia. Both of the other two patients had local peritonitis, and the fluid was on the right side of the chest. In the 8 other cases of bronchopneumonia and lobar pneumonia there was an abscess or peritonitis in 6. Bronchopneumonia developed in one case of acute appendicitis in which the inflammation was limited to the appendix ; and in another similar case, in which there were adhesions and free fluid in the peritoneal cavity, the patient had right lobar pneumonia. A patient of 64, who had a perforated appendix and was operated upon four days after the beginning of the attack, died from bronchitis and heart failure. These results are striking evidence of the relation between late operation and pulmonary complications, and indicate the prophj-lactic value of operation during the first twenty-four hours of the attack. Intestinal Obstruction. — Intestinal obstruction is a grave and not uncommon complication of appendicitis. I find that it occurred 12 times, that is, in 1-2 per cent of all cases, or in 1-7 per cent of the acute cases. The obstruction may be either paralytic or mechanical. In the paralytic variety or ileus, there is paralysis of the intestine with resulting symptoms of intestinal obstruction. In my present series there were 5 exam.ples of this condition, and 4 of them died. In its milder forms it is commonly met with, and therefore it is possible to assume that there were other cases in which ileus was present to a slight degree but no mention has been made of it. WTien ileus occurs in an attack of appendicitis it is alwaj^s of grave prognosis, but less so when it occurs early in an attack than later. In the former condition, particu- larly when it is present before operation, it is often possible to overcome it by appropriate treatment ; but when it occurs in the later stages, the prognosis is APPENDICITIS 6i very grave. Much can be done to relieve the patient by turpentine enemata and the hypodermic administration of eserine in yj-^ gr. doses every six hours, which may be combined with hypodermic injections, of strychnine. Mechanical obstruction occurred in 7 cases, of which 5 recovered and 2 died. It may be due to the presence of adhesions, producing a kink in a piece of intestine, or adhesions may take the form of a band, which may form a loop round a piece of intestine and so ensnare it ; or a loop of intestine may pass underneath the band and become strangulated in that way. Lastly, the appendix itself is not very uncommonly the immediate cause of intestinal obstruction. I recently operated upon a patient in whom the tip of the appendix was adherent to the root of the mesentery ; it had formed a loop, and through this loop a piece of intestine had passed and was tightly gripped. Not only was the intestine gangrenous, but also the appendix itself. When the appendix forms the constricting band, the prognosis becomes rather n\ore serious, as not infrequently the stretching of the appendix has cut off its blood-supply, and gangrene has followed, with resulting general peritonitis. In these cases the primary condition appears to be that of intestinal obstruction, with secondary gangrene of the appendix. Ruge found 44 cases of intestinal obstruction in 2,385 cases of appendicitis, a proportion of i-8 per cent, which is not very far from the proportion of 1-2 per cent in my cases. Among these 44, there were 14 cases of ileus, 7 of which recovered and 7 died. In the other cases, the appendix itself formed the constric- ting band in no less than 6 ; of these only 2 recovered, and 4 died. The frequency with which intestinal obstruction occurs depends largely on the time at which the primary operation is performed, as is the case with nearly all the other complications of appendicitis. It is interesting to note that in all of my 12 cases either an abscess or general peritonitis existed. None of these cases had been submitted to what is known as early operation, that is, within the first twenty-four hours, or even the first forty-eight hours. The real secret of successful treatment of intestinal obstruction in appendicitis is to prevent its occurrence. The prognosis is grave. Out of the 12 cases in the present series, 6 recovered and 6 died, while out of Ruge's cases 23 recovered and 21 died — a total of 29 recoveries and 27 deaths, giving the high mortality of 48-2 per cent. In discussing intestinal obstruction due to appendicitis, one must bear in mind the possibility of an attack of appendicitis leaving behind it bands and adhesions, which may cause intestinal obstruction at a later date. Jaundice. — Speaking generally, whan jaundice complicates an attack of appendicitis, the prognosis is grave. Hoffmann has recorded 11 cases ; in nearly all of them there was acute perforative appendicitis ; in several, diffuse peritonitis or extensive abscesses. He regards jaundice as a sign of very severe illness, especially if it appears early in the attack. Reichel thinks that jaundice may arise from the spreading of infectious material, and therefore advises that in the case of an abscess, one should be content with opening it and nothing more, when the disease has existed forty-eight hours. Eight of his 18 patients who had jaundice recovered — a mortality of 55-55 per cent ; but of Aldehoff's 14 cases, 11 recovered and only 3 died. Jaundice may be due to various causes and may appear at various stages of the illness. The following are the principal causes : — (i) Simple catarrhal jaundice ; (2) Toxaemia ; (3) Direct extension of the inflammation from the appendix to the gall-bladder and biliary ducts ; (4) Pylephlebitis ; (5) The so-called delayed chloroform poisoning. 62 INDEX OF PROGNOSIS 1. Simple Catarrhal Jaundice. — I recently saw a case of this sort in Avhich the patient's illness began with vomiting ; catarrhal jaundice shortly followed, and next day pain began in the right iliac fossa. Operation was performed within thirty-six hours and an acutely inflamed appendix removed. The jaundice followed the usual course of catarrhal jaundice and subsided in the usual way, after a brief period in which the stools were clay-coloured, the urine contained large quantities of bile pigment, and the skin and sclerotics were deeply tinged with yellow. This is the least serious form, and may be met with in varying degrees ; in some cases there is merely a slight and evanescent tingeing of the sclerotics, but in others, as in the case just described, the patient may pass through a typical attack of catarrhal jaundice. 2. Toxcsniia. — -The second class consists of cases in which the jaundice appears to be the result of toxaemia. A good example of this kind has been described by Hollander. The patient had well-marked jaundice with an appendix abscess. The abscess was opened and drained, and a gangrenous appendix removed. The jaundice disappeared within two or three days. In consequence of his experience in this case, Hollander suggests that when jaundice^ is present in cases of acute appendicitis, it indicates that the appendix is gangrenous. There are also mild cases in which the jaundice appears in the early stages of the attack and passes off shortly after operation ; they probably belong to this class also. 3. In the third class are placed cases in which there is a direct extension of inflammation of the appendix to the gall-bladder, and numerous adhesions are found about the gall-bladder. 4. Pylephlebitis.- — -The fourth class is composed of cases which are still more serious. I refer to those in which the jaundice is due to portal pyaemia or acute pylephlebitis. These cases are fortunately rare. In the 1000 cases which I collected in 1905, there were 4 of pylephlebitis, all of which died. In the present series there were 2 cases, one of which was due to actinomycosis. It is, however, important to remember that jaundice is not alwa^'s present in these cases. In neither of the 2 reported by Bidwell, one of which recovered, was there jaundice. The diagnosis of the condition is generally easy. The usual history is that of an attack of acute appendicitis, the formation of an abscess, and after a varying interval, the onset of rigors, and a few days later, the appearance of jaundice. A little later still, the Hver maj'- enlarge and become tender. It is interesting to note, however, that this is by no means invariably the sequence of events. I remember a patient who was, some years ago, in the London Hospital under my care with jaundice, enlargement of the liver, and tenderness in the region of the gall-bladder. There was a history of an acute attack of pain on the right side of the abdomen three weeks previously ; the temperature was raised. A diagnosis was made of acute cholangitis secondary to gall-stones ; but operation proved that the patient had pylephlebitis with a small retrocaecal abscess and a perforated appendix. I have been rather struck, in the few cases which I have met with, by the comparatively mild local signs of appendicitis ; but this cannot be taken as the rule, for in 7 cases reported by Hoffmann, 2 followed acute appendicitis, 3 after incising an abscess, and 2 after operation for diffuse peritonitis. Sasse, however, reports 2 cases in which the appendicitis was of such a mild t^'pe that the patients were not confined to bed ; but about ten days after the beginning of the attack they developed symptoms of pylephlebitis, and died a few days later. The gravity of the condition Ues in the fact that, as a rule, the liver is riddled with smaU abscesses, and so is beyond surgical treatment. Of Hoffmann's 7 cases, in only 2 was there an abscess sufiQciently large to be incised ; one APPENDICITIS 63 of these recovered, but the other patient died. In my own experience I have had 2 cases which recovered, one of them a patient with a large abscess, which was drained, and the other a case of considerable interest, in which, on exposing the liver, I found numerous small abscesses the size of a pea or less ; the Staphylo- coccus pyogenes aureus was found in pure culture, a vaccine was prepared, and the patient made a good recovery. While the prognosis in cases of pylephlebitis is necessarily grave, it is not hopeless ; an exploratory operation should be performed, and the condition found dealt with by drainage where possible, otherwise by vaccines. It goes without saying that in these cases the primary focus of the disease, namely, the appendix, should always be removed. With regard to prophylactic treatment, Wilms has published a very remark- able case in which he ligatured the efferent veins leading from the appendix. This patient had had five rigors ; but after the veins were ligatured the rigors ceased and the patient made a good recovery, without gangrene of the intestine or any interference with peristalsis. Sprengel attempted to carry out a similar operation in a patient upon whom he had operated and from whom he had removed a gangrenous appendix thirty-six hours after the beginning of the attack. Nine days after removal of the appendix the patient had a rigor and, subsequently, two or three every day. Sprengel's attempts at ligature were unsuccessful, and a faecal fistula developed at the lower end of the small intestine, probably due to gangrene through interference with the circulation. As he points out, the operation is likely to be difficult enough in a normal subject in the absence of inflammation, if there is no mesentery to the colon, and where there is a large amount of subserous fat ; but if, in addition, the structures round the appendix are acutely inflamed, it becomes almost impossible to isolate the veins ; and even if the veins are secured, the danger of ligaturing the arteries as well, and so giving rise to gangrene, is very great. 5. Delayed Chloroform Poisoning. — In the last class I would place cases of so-called delayed chloroform poisoning. This most distressing condition I have met with in varying degrees on several occasions, but fortunately have only lost one patient through it. This was a considerable number of years ago, shortly after attention had first been drawn to the disease. The patient was a little girl of eleven, upon whom I operated and removed an inflamed appendix within thirty-six hours of the onset of the attack. Chloro- form was given and the operation was straightforward, but twenty-four hours afterwards she began to vomit. The vomit at first consisted of ordinary gastric contents, but later it contained altered blood and became cofiee-ground in character. With the onset of vomiting her mental condition became a httle clouded ; later she became delirious and, finally, comatose. Jaundice set in thirty- six hours after the operation, and at the end of forty-eight hours was well marked ; it was not limited merely to the sclerotics, but extended over the whole body. The breath smelt strongly of acetone, the temperature was slightly raised, the pulse-rate steadily increased in rapidity and became proportionately weaker ; the respirations towards the end were irregular and approximated to the Cheyne- Stokes rhythm. The abdominal condition appeared to be entirely satisfactory ; the abdomen moved well on respiration, was soft, and there was no distention. She died sixty-four hours after the operation. This was a typical case of so-called delayed chloroform poisoning. The first symptom is usually vomiting, which comes on for no obvious reason about thirty-six hours after the operation, and the case is frequently fatal within forty- eight hours from the onset of the vomiting. I must, however, point out that jaundice is not present in all these cases. 64 INDEX OF PROGNOSIS It is not necessary to enter here into the various theories. Guthrie, however, says that children who suffer from cychcal vomiting are particularly liable to be victims of post-anaesthetic poisoning, and that the administration of an anaesthetic on the eve, or during an attack, of cyclical vomiting is attended by grave risk, and should be avoided if possible. With regard to prophylaxis, it is particularly important in the case of children not to starve them, and not to purge them too violently before the operation. Dextrose and soda bicarbonate should be given before and after the operation. With regard to the prognosis in these cases, many of them recover after prompt treatment by the administration of large quantities of dextrose and soda bicarbonate, and the mortality is far less now than it was before attention had been drawn to the condition and the proper treatment realized. Pylephlehitis . — This has been discussed at sufficient length in class 4, above. Apart from a case of actinomycosis, there was only one case in the present series, and this fortunately recovered. Jaundice, although present in a certain number of cases, is not necessarily a feature of pylephlebitis. Gastro-intestinal Hcemorrhage. — Melaena or haematemesis occurring in a patient suffering from acute appendicitis is a matter of grave importance, all the more so as in the majority of cases it is impossible to relieve the condition by surgical methods. In some cases the haemorrhage comes from a duodenal ulcer, in others from the stomach, either from a gastric ulcer or from numerous small erosions ; in other cases, again, it may be impossible to say where it comes from, even on post-mortem examination. About twelve months ago I operated on a patient who was suffering from an attack of appendicitis with a large pelvic abscess. He had been ill for two weeks. At the operation I removed the appendix and drained the abscess. All went well until five days after the operation, when he suddenly collapsed ; his face became blanched and his pulse almost imperceptible. He improved under appropriate treatment, and shortly afterwards passed an offensive motion containing a very large quantity of altered blood ; during the subsequent week he had several similar attacks, though less severe. All this time he had melaena, ■ frequently three or four motions in the twenty-four hours. The question of operation was raised, but negatived, as his condition was such that any operative interference would almost certainly have proved fatal, apart from the fact that it was impossible to decide the source of the haemorrhage. Fortunately it gradually ceased, and he ultimately made an excellent recovery. Hoffmann reported 7 cases of severe gastro-intestinal haemorrhage. In 3 patients there was general peritonitis at the time of operation, in i there was an abscess, and the other 3 were operated upon at an earlier stage. Only one patient recovered ; of the other 6 cases, in 2 the haemorrhage came from a recent gastric ulcer ; in another there was serious erosion of the gastric mucosa ; in a third the post-mortem showed no cause for the severe haemorrhage ; one patient died from haemorrhage in a few hours, seven days after a smooth appendicectomy in the acute stage — there was no post-mortem examination ; the seventh case was a boy who was making a straightforward recovery from general peritonitis, and died suddenly from severe haemorrhage — the post- mortem examination revealed a duodenal ulcer, with erosion of the splenic artery. In 1908 Schwalbach collected 28 cases of gastro-intestinal haemorrhage after operations for appendicitis, and added 2 of his own ; 17 patients died and 13 recovered. The mortality in his series was directly proportionate to the severity of the appendicitis : 9 patients had diffuse peritonitis — they all died ; 8 patients had an abscess with localized peritonitis — 5 died and 3 recovered ; 6 patients had acute appendicitis with only slight peritonitis — 3 died and APPENDICITIS ■ 65 3 recovered ; 7 patients were operated upon during the quiescent period — these all recovered. One-third of the cases occurred in children. Schwalbach thinks that the haemorrhage is the result of thrombosis in the venous and arterial circulation in the omentum and mesentery. Fortunately this is a rare complication ; it only occurred once in my present series of cases, and the patient recovered. If, however, a patient who has been operated upon for acute appendicitis has an attack of gastro-intestinal hsemor- rhage, the prognosis becomes grave in direct proportion to the severity of the appendicitis. In most cases, surgical intervention is contra-indicated ; treatment should be carried out on medical lines. Hcematuria. — Haematuria is a rare but interesting complication of appendicitis, and its pathology is still somewhat obscure. Slight haematuria may be caused by the rupture of an appendix abscess into the bladder, but the amount of blood is, as a rule, very slight, and there is but little difficulty in making the diagnosis. On the other hand, a number of cases have been reported in which haematuria occurred on several occasions after an attack of pain in the right side of the abdomen, and the condition was supposed to be one of renal colic. It was only later, when symptoms of appendicitis definitely declared themselves, that the true diagnosis was made, and the patient was cured by removal of the appendix. Cases of haematuria in appendicitis may be roughly divided up into two main groups. In the first may be placed those cases in which the appendix does not lie in contact with any part of the genito-urinary tract, and in the second, those in which the diseased appendix is actually in contact with the kidney, ureter or bladder. In 6 out of 15 cases discussed by von Frisch, the appendix was adherent to the lower part of the ureter. As a general rule, the haematuria follows an attack of pain in the right side of the abdomen, and in a few cases the colic and haematuria are brought on by violent exercise. Occasionally the haematuria is preceded by little or no pain. The following case described by Hammersley is fairly typical. A lady had attacks of vomiting with shivering and colic, every three months. Two days after the beginning of each attack, blood appeared in the urine, and on one occasion the urine appeared to be almost pure blood. The attacks were brought on by unusual bodily exertion. On examination, nothing abnormal could be detected, apart from a movable right kidney ; the kidney was not painful or enlarged. There was no tenderness in the appendix region. Ultimately an attack occurred which was associated with a rise of temperature, and tenderness in the right iliac fossa was present for the first time. The appendix was removed, and was found to be lying behind the caecum, adherent to the right kidney and ascending colon. The patient had no further attacks of colic or haematuria. A somewhat similar case in which the colic and haematuria followed exertion has been described by von Frisch. Another remarkable case has been reported by Carless. A woman had typical attacks of renal colic, with a history of previous, severe pain in the right side. She was relieved after the passage of blood in the urine and a little gravel. The kidney and ureter were explored with a negative result. A week later the patient died from a perityphlitic abscess. The post-mortem examination showed that the appendix was lying on the back of the abdomen and hanging down over the pelvic brim in the region of the ureter. In other cases, as in a boy under my care some years ago, haematuria may supervene without any severe attack of pain. I saw my patient, a boy of twelve, during his second attack of haematuria. No tenderness was to be made out on abdominal examination ; the kidney was not enlarged ; there was no rise of 5 66 INDEX OF PROGNOSIS temperature. On examination with the cystoscope, blood was seen coming from the orifice of the right ureter. On examination of the urine, the Bacillus coli communis was found in pure culture. The hsematuria rapidly subsided. Two months later I operated upon him for what was supposed to be his first attack of appendicitis ; but on removing the appendix I found it to be the seat of old-standing disease. In this case the appendix was not in contact with the kidney, ureter, or bladder. The patient remained well and had no further haematuria. It is interesting to note that in the majority of cases nothing abnormal is to be found in the urine apart from the blood. This is found in varying quantities, and it is not uncommon to find blood-casts in addition to altered blood corpuscles. The most striking feature of the condition, however, is the way in which the hsematuria clears up after removal of the appendix, and does not recur. As for the explanation of the haematuria, in some cases there can be no doubt that there is a direct spread of the infection to the kidney, as in a case reported by Seelig, in which a perityphlitic abscess and a gangrenous appendix lay on the kidney. In cases in which the appendix is adherent to the ureter, it may cause venous congestion and consequent bleeding from the mucous membrane of the ureter, or inflammation and swelling of the mucous membrane, which may give rise to obstruction of the ureter and so predispose to acute pyehtis and haema- turia, as in the cases recorded by Hunner. These two theories will not, however, account for cases in which the appendix is not in contact with any part of the urinary tract. They must probably be explained either on the ground that there is a toxic nephritis, or that the kidney is the site of emboli or thrombosis. Von Frisch thinks that the haematuria is probably due to embolism or thrombosis, the presence of blood-casts supporting this theory ; he suggests that a retrograde thrombosis may take place, owing to the free communication between the veins of the capsule of the kidney, the veins of the peritoneum, the lumbar, and the retroperitoneal veins. Although the theory of toxic nephritis will not hold good in the majority of cases, owing to the rapid recovery of the patient from the attacks, and the way in which no trace of albumin, no casts, nor renal epithelium are to be found in the urine subsequently, still it may occur occasionally. The prognosis in the haematuria which is usually associated with appendicitis is excellent, as these cases clear up as soon as the appendix has been removed, leaving no trace, so far as we know, of any after-effects. On the other hand, if the haematuria supervenes whilst the patient is gravely ill from an acute attack of appendicitis, particularly if it is comphcated by an abscess or general peri- tonitis, the prognosis is more serious. Bacteriology. — There is no doubt that the great majority of cases of appendi- citis are due to the Bacillus coli communis and Streptococcus pyogenes, either separately or together. In most cases the former is to be found alone, in others the Bacillus coli and Streptococcus in pure culture. Other organisms, both aerobic and anaerobic, are sometimes found, but they usually play a sub- sidiary part and only represent a secondary infection. The prognosis in the case of a streptococcal infection is, as a rule, more serious than in the case of infection by the Bacillus coli. Kelly states that the Streptococcus pyogenes is especially associated with cases of very severe infection, and is the usual cause of extensive and rapidly fatal peritonitis. This fully bears out my own experience, and I have frequently found it present in cases of severe infection, with gangrene of the appendix and possibly extension to the caecum. Those cases in which the temperature remains raised for a week or ten days after APPENDICITIS 67 removal of the appendix, in spite of apparently satisfactory drainage, are not uncommonly due to streptococcal septicaemia. If the abdomen is explored, but little pus will be found, and what there is is present in small loculi. If the adhesions are broken down to let out these smaU collections of pus, there is a great danger of faecal fistula. Pregnancy. — -There has been a good deal of discussion on the relation between pregnancy and appendicitis, and the influence of the one upon the other ; but the number of cases that have been reported is comparatively small, and it is there- fore difficult to draw any satisfactory conclusions. In the present series there were only 2 patients who were pregnant, one three months and the other six months ; in one the appendix was inflamed, without the formation of pus or peritonitis. The wound healed by first intention, and the patient made an excellent recovery. In the other case the illness was of longer duration, and there was local peritonitis at the time of operation ; but the patient recovered, pregnancy being undisturbed. If a patient, who has recently recovered from an attack of appendicitis, becomes pregnant, is she likely to have a recurrence of the appendicitis during her pregnancy ? Apart from the ordinary probabilities of a recurrence of an attack of appendicitis independently of pregnancy, we have to take into consideration the altered intra-abdominal conditions. These have given rise to a good deal of speculation on the part of various authors, with the result that exactly opposite opinions have been held. On the one hand, we can say that the constipation which is so frequently present in pregnancy is a predisposing factor, and would favour an attack of appendicitis. On the other hand, the connective tissue in the lower abdomen becomes looser and all the parts more vascular, which would not favour such an attack. But when we take into consideration the actual facts, we see that the number of women who suffer from appendicitis during pregnancy is extremely small. For example, among the 1000 cases of appendicitis which I collected in 1905, there were 309 females, and 6 of them were pregnant, a proportion of, roughly, 2 per cent. In the present series there were 394 females, 2 being pregnant, a percentage of about 0-5 per cent. This proportion is somewhat larger than that which obtains in the statistics of Sonnenburg and Krogius, quoted by Renvall. Sonnenburg, among 2000 cases of operation for appendicitis on both sexes, had 4 cases of pregnancy, and Krogius, in 900 cases, had i of pregnancy. Renvall also quotes Fraenkel, who, out of 40,000 gynaecological and obstetric cases, had only 4 cases of appendicitis associated with pregnancy, and Schauta, who had 4 cases out of 30,000. Now although it is obvious that when the total period of the pregnancies of any one woman is taken, it forms only a very small part of her life, the number of pregnant patients in the above statistics is so exceedingly small that it suggests that pregnancy does not have any particular influence in predisposing to an attack of appendicitis. Further, Renvall found that attacks of appendicitis, whether primary or secondary, depend but little, or not at all, on the month of pregnancy, because the number of cases which occurred in the second and third months, when the uterus can exert no pressure and no traction on the appendix , was proportionately equal to those which occurred in the later months of pregnancy. We may therefore consider that the influence of pregnancy on the incidence of appendicitis is not proved. We next pass on to consider the probable course of events in a patient who has an attack of appendicitis during her pregnancy. First of all, one can say without hesitation that if operation is performed in the early stage, that is, within the first twenty-four hours, the prognosis difiers very little from that in 68 INDEX OF PROGNOSIS a patient who is not pregnant, and the same holds good for a certain number of cases of abscess, namely those which do not come into contact with the uterus. If, however, the uterus forms part of the wall of an appendix abscess, the prog- nosis becomes more serious. The great danger, of course, is the possibility of miscarriage or labour ; for the rapid diminution in the size of the uterus will break down the adhesions and flood the peritoneal cavity with the pus which escapes from the abscess. Several cases have been reported in which the patient died from general peritonitis, the result of a ruptured appendix abscess, two or three days after labour. With regard to the effect on the pregnancy, a simple appendicitis does not necessarily predispose to abortion or labour. On the other hand, if an abscess has formed, the prospects are not so good, for if it lies in contact with the uterus there is a considerable probability that it will bring about miscarriage or labour, a probability which becomes a certainty if there is general peritonitis. At the same time it must be remembered that abscesses have been evacuated without disturbing the pregnancy. Lastly, with regard to the child ; in nearly all cases in which appendicitis puts an end to the pregnancy, the child is born dead, or dies within a few hours of its birth. An interesting case has been reported by Pinar, in which the B. coli communis was found in pure culture in the vessels of the umbilical cord. Kronig also reported a case in which the B. coli communis was found in pure culture in the organs of the foetus, in the placenta, and in the large uterine veins. What then is the best line of treatment to adopt in a patient who becomes pregnant shortly after an attack of appendicitis ? If the attack was a severe one, I think that she should be advised to have the appendix removed as soon as possible, for appendicectomy in the quiescent stage is attended with very little risk to the patient and is not likely to disturb the pregnancy. In this way, the danger of a recurrent attack during her pregnancy will be avoided, an attack which might be accompanied by abscess or general peritonitis, and which would possibly prove fatal to both mother and child. If, however, the attack was a very mild one, and therefore a recurrence less likely, and if the patient would be within reach of surgical aid during the whole of her pregnancy, then one might wait for a further attack to develop, on condition that operation should be performed as soon as the diagnosis has been made. When to Operate. — ^We now have sufficient data to discuss the vexed question, when to operate in appendicitis. There is a steadily growing consensus of opinion that operation should be performed in all cases of appendicitis as soon as the condition is diagnosed. For at the beginning of an attack it is frequently extremely difficult, and generally impossible, to give a prognosis and to say whether the patient will get well without operation or not. From time to time various methods and tests have been announced which it was hoped would indicate the necessity for operation or not ; but none of them have been found to be absolutely reliable. First there was the qiiestion of leucocytosis. Then there was the test administration of castor oil; if the patient was not worse after the castor oil, operation was not performed ; if he was, operation was considered to be indicated— a very dangerous method, one which should never be used in private practice, and extremely rarely in hospital. Oehlecker drew attention to the fact that the viscosity of the blood increases in proportion to the severity of the attack, and shows in an especial degree how widely the peritoneal cavity is involved. The more extended the peritonitis, the higher the viscosity ; but it does not tell how far the appendix itself is diseased ; for example, an appendix may be gangrenous, but if it lies on the outer side of the APPENDICITIS 69 caecum and there is little or no peritonitis, the blood may only show a very slightly increased viscosity. Then again, at one time it was said, " If the patient is not improving at the end of forty-eight hours, operate." My reply to this is, of course, that one should not wait until the end of the first forty-eight hours ; but if the diagnosis has been made, operation should be performed at once. To emphasize this, we need only point to the figures given above, which show that the mortality in patients operated upon during the first twenty -four hours is 1-2 per cent, during the second twenty-four hours 3-9 per cent, and during the third twenty-four hours 8-7 per cent. It may be objected that it is not necessary to operate upon all cases of appendicitis, and that many of them will subside without any operative inter- ference whatever. This is perfectly true. The crucial point, however, is that, in most cases, we cannot tell at the beginning of an attack whether it is going to be a catarrhal one, or whether gangrene will set in. Any surgeon who has a fairly wide experience of operating on these cases can readily call to mind patients who presented symptoms and signs of a comparatively mild attack of appendicitis, but in whom a gangrenous appendix was found at operation. Kiimmell, in discussing the importance of early operation, mentions that out of 237 cases upon which he operated during the first forty-eight hours of the attack, 115, nearly 50 per cent, showed a gangrenous or perforated appendix. Then again, apart from the very small mortality of operations performed during the first twenty-four hours, a point of great importance is this, that by operating early and removing the diseased focus, the chances of complications supervening are greatly diminished. This is particularly the case with such complications as ileus and the other forms of intestinal obstruction, thrombosis of the femoral veins, pylephlebitis, and so on. For example, if we compare my T905 series of cases with the present series, we find that the number of cases of faecal fistula has been reduced from 49 to 25, and of thrombosis of the femoral vein from 12 to 4. There were only 17 cases of pulmonary complications as opposed to 45 in 1905, and 2 cases of pylephlebitis as opposed to 4. Further, with very few exceptions, all the complications in the present series occurred in patients who, at the time of operation, were suffering from either abscess or general peritonitis. Another point in favour of early operation, apart from the prevention of such grave conditions as the formation of an abscess or general peritonitis, is the fact that, in the great majority of cases, it is possible to close the wound and obtain union by first intention. Where an abscess or general peritonitis is already present, this is not possible, and we have to face the possible development of a. ventral hernia, apart from the prolonged stay in bed which ^ is necessitated by these conditions. Lastly, another point of considerable importance in the prognosis is the fact that appendicitis is essentially a disease where relapse is the rule, and freedom from recurrence is the exception. The only cure is operation : medical treat- ment may be successful in tiding the patient over an attack, but the probability that further attacks will supervene is very great. Of 233 cases collected b}' Karrenstein, 50-2 per cent had further attacks, 60 per cent in the first year, 20 per cent in the second, and 20 per cent subsequently. Of 1933 cases, Kiimmell found that 989, or 51-1 per cent, had had previous attacks. When operation is performed in the early stages, the appendix can always be removed, and thus the possibility of further attacks be obviated. Recurrence. — The question of recurrence must be considered from three stand- points : First, the probabiUty of recurrence in a patient who has an attack of 70 INDEX OF PROGNOSIS appendicitis, mild or acute, without abscess formation ; second, the recurrence of symptoms after appendicectomy ; and third, recurrence after an abscess when the appendix has not been removed. Statistics which are compiled at the present day have not the same value as those of five or six years ago, owing to the greater frequency of operative interference. For nowadays, not only is it the rule for a patient who has an attack of appendicitis to be operated upon, either immediately or at the conclusion of the attack ; but also many- cases of chronic appendicitis, where there has never been an acute attack, are recognized and treated by operation. The great tendency to recurrence is pointed out by Hoffmann, who found that of 2331 cases operated upon for appendicitis, no less than 1202, that is 51-1 per cent, had had previous attacks, and this, he says, was the minimum, for in a large number of cases there was no mention as to whether the patient had had a previous attack or not. I have already referred to Karrenstein's conclusions : we there see, that of patients who are going to have recurrent attacks of appendicitis, 80 per cent will have them within two years. But at the same time it must be borne in mind that attacks maj^ recur after as many as eighteen, twenty, or even twent}-- two years have elapsed. It seems possible that as the attacks are repeated they become less severe. In 1905 I found that of 299 patients who had an appendix abscess, 1S7 had had no previous attacks. This is still more striking in the case of general peritonitis. Of 35 cases in which allusion was made to the presence or absence of previous attacks, in no less than 31 the patients had not had appendicitis. Three patients had had one attack, and i patient had had two attacks. That is to say, in 88-6 per cent it was the first attack. Table D. — Cases of Abscess and General Peritonitis admitted to the London Hospital from July ist, 1900, to August 15TH, 1904, and their Relation to Previous Attacks of Appendicitis. Nnmber ol Cases Number of Previous Attacks of Appendicitis Not Stated None One Two Three or more Abscess . - - . General peritonitis 499 101 200 66 187 31 67 3 19 1 ^0 Total 600 266 218 70 ■ 20 26 These figures are, of course, small, and deductions from them must be made with some reserve ; but it is reasonable to assume that the adhesions which result from the first attack tend to limit the inflammation in subsequent ones to the immediate neighbourhood of the appendix. Whether a patient who has just recovered from an attack of appendicitis should have his appendix removed or not, depends upon the severity of the attack. If it was a very mild one, of brief duration, with little pyrexia or general disturbance, there is a considerable probability that the appeiidix will recover completely and bear no trace of the inflammation. Under these circumstances there is no reason to anticipate a recurrence, and therefore operation is not necessary unless a further attack develops. If, however, the patient has a APPENDICITIS 71 recurrence, the appendix should be removed whether the attack be a slight one or not. If it was a severe one, changes will probably take place in the appendix, resulting in a stricture, kinking, adhesions, etc., which predispose to a recur- rence, and therefore operation should be advised. An exception may perhaps be made where the patient has had numerous fairly acute attacks of appendicitis, perhaps six or seven, and each has been less severe than the preceding one. If these cases are operated upon, it is usual to find the appendix partially destroyed, great fibrous thickening of the submucous coat, and the lumen almost or entirely obliterated for a great part of its extent. Adhesions are commonly met with which shut off the appendix more or less completely from the surrounding peritoneal cavity. A patient with an appendix in this condition is unlikely to have a very serious attack, and therefore, if strongly opposed to operation, he may be treated on medical lines. At the same time one must bear in mind the pathological conditions in the upper abdomen which are frequently associated with, and apparently caused by, chronic inflam- mation of the appendix. If there are symptoms of dyspepsia the appendix should certainly be removed lest worse befall. Recurrence of Symptoms after Appendicectomy. — Sir Frederick Treves went fully into this question in 1905, and made a valuable contribution to the subject by analyzing the cases of 45 patients who consulted him because they were no better for the operation, or still had ' attacks ' which had been unaffected by the removal of the appendix. In the following table he gave a list of the patients who consulted him, and the varying conditions which gave rise to their symptoms. Table E. — Patients who Complained of Imperfect Relief after the Removal of the Appendix in the Quiescent Period. Appendix imperfectly removed ... - - 2 Ovarian trouble coexisting ------ 9 Persisting or relapsing colitis ... - - 8 Persisting local pain ....-- 7 Neurasthenia or hypochondriasis ----- 5 Continued attacks due to gall-stones - - - - 3 „ ,, colic - - - - - 2 „ ,, movable kidney - - - 2 ,, ,, stone in kidney - - - i ,, ,, an unexplained cause - - - i Tender mass in the right iliac fossa - - - ' 5 45 Reference to tliis table shows that in a large proportion of the cases, the symptoms were not caused by appendicitis, but by various other conditions such as gall-stones, colitis, etc., and consequently the failure of the operation was due to an incorrect diagnosis. In 2 cases the whole of the appendix had not been removed, and the patient had further attacks in the stump which was left. In 5 cases the symptoms were ascribed to neurasthenia and hypochondriasis. In 5 other cases a tender swelling appeared in the right iliac fossa some time after the operation. In 3 of them the tender swelling was a faBcal mass ; in I it was inflammatory, and disappeared in a few weeks ; in the remaining case it was due to tuberculous glands. At the request of Sir Frederick Treves I wrote to 363 London Hospital patients who had had the appendix removed in the quiescent stage. Among other questions, I asked if they had had any further attacks, resembling those which 72 INDEX OF PROGNOSIS they had had before the operation. There were 242 repUes: 231 said that they had been quite free from pain; 11, a proportion of 4-5 per cent, said that they had had further attacks. Among the patients who had the appendix removed during an operation for general peritonitis or abscess, the percentage was rather higher, as out of 107 patients who rephed, 6, or 5-6 per cent, complained. It is not surprising to find a higher percentage of imperfect reUef in the latter circumstances, on account of the gross intraperitoneal disturbance, and also because of the increased difficulty of removing the appendix in the case of an abscess, especially if there have been previous attacks. In 2 of the patients to whom I wrote, a second operation was necessary to remove the remains of an appendix which had been incompletely removed at the first operation ; in one of them, removal of the appendix was originally attempted during a quiescent period, in the other, during an operation for abscess. While giving adequate weight to the above investigations, it is important to remember that they were made nine years ago, and that since then we have made enormous strides in our knowledge of appendicitis, and in its diagnosis and treatment.* We may therefore reasonably suppose that a considerable propor- tion of the causes which were responsible for the lack of success of the operation, as illustrated by the table drawn up by Sir Frederick Treves, are no longer operative. Consequently, with proper care in the selection of cases, added to modern technique, the operation undertaken in the quiescent stage should be completely successful, and afiord entire rehef in probably not less than 97 per cent of them. Recurrence after an Abscess. — I now turn to those cases of appendix abscess in which the pus is evacuated but the appendix is not removed. In 1905, at the discussion before the Royal Medico-Chirurgical Society, the general feehng was that if a patient had an appendix abscess, his chances of having a further attack were very shght ; and it was even said, that if a concretion was found in the pus, there would be no further attacks. Credit must be given to Battle for so vigorously advocating removal of the appendix in all cases of abscess ; if it could not be done easily at the time the abscess was drained, he advised an operation during the quiescent stage. At the present time it is the usual practice, when operating upon an abscess, to remove the appendix unless there is great difficulty in doing so ; but eight years ago it was the rule to be content with opening the abscess, and not to remove the appendix unless it actually presented itself during the operation. From the statistics which were brought forward at the above meeting, I have been able to collect the following cases in which an abscess formed and was evacuated without the appendix being removed, and in which the question of further attacks was investigated. From St. George's Hospital there were 15 cases ; 2 of them had further attacks, after which the appendix was removed. Pearce Gould brought forward 71 cases: 41 occurred in his hospital and 30 in his private practice ; 4 of the former and i of the latter had suosequent attacks of appendicitis for which the appendix was removed. Battle operated on 54 cases of appendix abscess which recovered, and no less than 12 had further symptoms necessitating appendicectomy. Together this gives a total number of 140 cases, 19 of which, that is about 13-5 per cent, had further attacks. For the same meeting, I wrote to and had replies from 133 patients who had had an abscess or general peritonitis in whom the appendix had not been removed ; 21 of them said that they had had further attacks, a proportion of 14-6 per cent. * Lett, "The Present Position of Appendicitis," Lancet, 1914, Jan. 31, p. 295. APPENDICITIS 73 Taken by themselves, these replies would not be of much value, unsupported as they are by medical evidence, but the result coincides so closely with that obtained in the above 140 patients, 13-5 per cent of whom had so much trouble with the appendix after the abscess had been drained that a further operation was necessary, that their insertion here is justified. Hoffmann reported that out of 78 cases of appendix abscess, 44 had trouble subsequently in the form of abdominal disturbance or pain, and that in a certain proportion there were further definite attacks of appendicitis. An interesting paper was published by Dodds Parker in 191 2. He recorded 17 cases of appendicitis with abscess formation in which the appendix was removed when the attack had subsided. In none of these cases was the appendix destroyed or its lumen obliterated, but in all of them there were adhesions, kinks, and scars, which of course predisposed to further attacks. Sex. — It has long been recognized that the male sex is more liable to attacks of appendicitis than the female, and numerous statistics have been published to illustrate the incidence of appendicitis in the two sexes. In the 1905 series I found that of the 1000 cases, 682 were males and 318 females, the males forming 68-2 per cent of the total. Of the 898 cases which were operated upon in the London Hospital in 1912, 515 were males and 383 females, a percentage of 57-3. Added together, in 1898 cases there were 1197 males, that is, tyi per cent. This agrees closely with the results obtained by MacCarty, who compiled 2586 cases reported by four different writers, of which 64-7 per cent were males. In order to obtain still larger numbers, I collected all the cases admitted to the London Hospital during the years 1901-1912. I found that there were 3652 males and 2426 females, a total of 6078. This means that the male patients formed almost exactly 60 per cent of the cases, and coincides remarkably with Kelly's investigations, for he found that in the Johns Hopkins Hospital the proportion of men to women was as 60 to 40. The preponderance of the male sex is not limited to adults only ; the same holds good in the case of children. In 1912, 99 children were admitted to the London Hospital suffering from appendicitis ; 61 were boys and 38 girls, a male percentage of 61 •6. Why the male sex should be more subject to appendicitis than the female is not known, though numerous explanations have been offered, ranging from an alleged additional blood-supply in the female sex through a branch of the ovarian artery, to greater exposure to injury and the excessive use of tobacco in the male sex. As to the severity of the attack, although men are more frequently subject to appendicitis, the attacks appear to be more serious in the female sex, and are attended by a higher mortality ; for example, of the 515 men, 14 died ; of the 383 women, 16 died, giving a male mortality of 2-7 per cent, while the female mortality was 4-2 per cent. This suggests that although the male sex is more frequently affected, roughly in the proportion of 6 to 4, the attacks are more serious and more frequently fatal in the female sex. Age. — The age at which appendicitis occurs varies within wide limits, although, as we shall see presently, there is a very definite period of life when the disease is especially common. In the present series the youngest patient was 10 months old, and the oldest 72 years ; both recovered. The oldest patient, however, that I know of, was a gentleman of eighty-four, upon whom I operated and from whom I removed a gangrenous appendix. He made an uninterrupted recovery. On referring to Table F, it will be seen that of the 1000 cases, 117 occurred in children up to the age of ten, 339 between eleven and twenty, and 275 between twenty-one and thirty, that is, 614, or 61-4 per cent, occurred between the ages of eleven and thirty, and 731, or 73-1 per cent, before the age of thirty-one. 74 INDEX OF PROGNOSIS Table F. — Mortality of Appendicitis at Different Ages. Quiescent Inflamed Local Peritonitis Abscess General Peritonitis Total Mortal- ity Age R. D. R. D. R. D. R. D R. D. R. 110 330 265 159 71 33 D. per cent 0—10 11—20 21—30 31—40 41—50 Over 50 12 78 103 66 28 13 1 1 40 107 76 42 14 4 1 13 55 27 15 5 2 3 2 1 33 59 51 29 21 11 2 4 1 12 31 '8 7 3 3 4 5 4 1 2 7 9 10 1 2 3 6 2-7 3-6 0-6 2-7 8-3 Total 300 2 283 1 117 6 204 7 64 |16 968 32 3-2 R = liecovered. 1) = Died. As regards mortality : it has long been said that the mortality is especially great in the earlier and later periods of life, and it is interesting to see that the results obtained in the present series bear this out. Among 117 cases under eleven years of age there vi^ere 7 deaths, a mortality of 6 per cent. Between eleven and twenty there were 339 cases, with 9 deaths, a mortality of 2-7 per cent, and between twenty-one and thirty, 275 with 10 deaths, a mortality of 3-6 per cent. We next come to the period between thirty and fifty ; here the results are very remarkable, as in 233 cases there were only 3 deaths, giving the low mortality of 1-3 per cent. It is always dangerous to draw conclusions from statistics unless the figures are very large and all causes of error have been excluded as far as possible ; still, one cannot help feeling it is very suggestive that out of 233 cases there should only be a mortality of 1-3 per cent. Over the age of fifty, the numbers are so small as to be of little value. There were 36 patients, 3 of whom died, giving a mortality of 8-3 per cent. One is not surprised to find that the mortality in people of advanced years is greater than that in young people and those in the prime of life. It only stands to reason that a patient who is getting on in years, and is possibly troubled with some deficiency in the pulmonary, cardiac, or renal organs, should be more likely to fail to respond to treatment, and should succumb from heart failure or pulmonary complications. CHRONIC APPENDICITIS. Chronic Appendicitis and Conditions associated with it.— So far I have dealt only with the prognosis in acute cases. Chronic appendicitis must also be considered, not only in relation to the possibility of further acute attacks, but also in relation to other more remote effects. The so-called appendix dyspepsia is now a well-recognized clinical entity, and of late the medical profession has realized the frequency with which chronic inflammation of the appendix is associated with important pathological conditions in the upper abdomen. Appendix Dyspepsia. — It is now generally recognized that chronic inflammation of the appendix may give rise to symptoms simulating ulcer of the stomach or duodenum, or gall-stones ; and a definite diagnosis between these various conditions can be made in the great majority of the patients, if the case is properly investigated, and a full account of the symptoms obtained and thought- fully considered. The writings of Paterson and Moynihan should be consulted, particularly the article by Moynihan in the British Medical Journal, January 29th, 1910, and the article on " Appendix Gastralgia " in Paterson's book. APPENDICITIS, CHRONIC 75 The Surgery of the Stomach. I may, however, touch briefly on the principal features of this condition. The most frequent symptom is pain or discomfort in the epigastrium, coming on at a varying time after food, sometimes immedi- ately, in other cases not until two hours or more have elapsed. It is frequently associated with distention and regurgitation. Unlike gall-stones, the character of the food makes little difference. An important point of differentiation between the dyspepsia due to the disease of the appendix, and other kinds, is that in the former the symptoms are practically continuous with very little variation, whereas in the latter the patients nearly always have intervals of weeks, or even months, in which they are comparatively free from pain. Occasionally, but in my experience it is rather exceptional, the pain is referred from the epigastrium to the right iliac fossa ; tenderness in the right iliac fossa is occasionally met with, but may be entirely absent. Exercise such as cycling, and particularly golf, is liable to bring on the pain, or, if present, to aggravate it. Moynihan has drawn attention to the fact that pressure on the appendix region may produce epigastric discomfort. Conversely, I have had a number of patients who complained of pain in the right iliac fossa when pressure was made upon the epigastrium. A somewhat alarming symptom, which is by no means uncommon, and which I have met with in a fair proportion of my cases, is haematemesis. In addition to the fact that the appendix is found to be diseased, the proof that these symptoms are due to the disease of the appendix lies in the fact that after its removal all the symptoms subside and the patients become well. An interesting feature in these cases is the comparatively small number of patients who have had previous severe attacks of appendicitis, so that in many cases the patient has no reason to suppose that his appendix is at fault. Harold Barclay recently drew attention to this in an article in the American Journal of Surgery. In 41 cases he found only 5 with a direct history of previous attacks. Gastric and Duodenal Ulcer. — It would appear that appendix dyspepsia is a preliminary stage only, and that if it is neglected, gastric or duodenal ulcer may supervene. This is only reasonable when v/e consider that in many cases, on opening the abdomen, the pyloric portion of the stomach is seen to be in a condition of spasm (Moynihan) ; tlois causes delay in the emptying of the stomach and so predisposes to chronic catarrh. Then again, haematemesis is generally recognized as being by no means uncommon in appendix dyspepsia, and in one case Paterson observed multiple erosions of the mucous membrane of the stomach. That gastric and duodenal ulcers are associated with chronic disease of the appendix, cannot be denied. As long ago as 1908 Mohnert found that in 64 per cent of a series of gastric ulcer cases there were inflammatory changes in the appendix. Paterson says that among his cases of duodenal ulcer extending over a period of three years, there was obvious disease of the appendix in 66 per cent. Moynihan, taking a short series of 14 cases of duodenal ulcer, examined the appendix in 12, and in 80 per cent found evidence of long-standing disease in it. McCarty and McGrath report that in 52 opera- tions for gastric and duodenal ulcer, 26-9 per cent of the appendices which were removed were partially or completely obliterated. In my own experi- ence, it is the exception to find a normal appendix in the presence of a gastric or duodenal ulcer. Gall-stones. — These, too, apparently come into relation with chronic appen- dicitis. In several cases where the symptoms have been those of chronic cholecystitis I have found adhesions round the gall-bladder with some congestion of its mucous membrane, and a chronically diseased appendix. Here again, McCarty and McGrath have some very interesting statistics. In 57 autopsies 76 INDEX OF PROGNOSIS on cases of cholecystitis, the appendix was partially or completely obliterated in 52 per cent. They further draw attention to the fact that of 365 cases of chole- cystectomy, in 23-2 per cent the symptoms began at or under 25 years of age, a period when appendicitis is extremely common, and in 13 per cent there was a history of pain and soreness in the appendix region. The appendices were only removed in 59 of the above cases, but 69 per cent of these appendices showed undoubted signs of disease. They suggest that the sequence of events is, first, a chronic appendicitis ; secondly, cholecystitis ; and, finally, gall-stones. It is now generally recognized that the appendix may play an im.portant part in diseases of the upper abdomen, and that no operation for gastric or duodenal ulcer, cholecystitis, gall-stones, and possibly pancreatitis, is complete without examination of the appendix, and its removal if diseased. The explanation is not quite clear, though there are numerous theories. Payr and Mohnert think that a gastric ulcer may be caused by emboli from thrombosed veins in the appendix and its mesentery. Another explanation is that these lesions are the direct result of intestinal stasis, caused by adhesions and kinking of the intestine, the infection spreading along up the small intestine to the stomach and duodenum. This may be so, and the propounder of this theory. Sir Arbuthnot Lane, has explained the disappearance of the gastric or duodenal symptoms after appendicectomy on the ground that the removal of the appendix relieves the obstruction at the lower end of the ileum. Lane, however, considers that the appendicitis is a secondary and not a primary condition. It seems to me that the explanation may lie in the action of the ileo-colic sphincter. It is possible than an appendix which is in a state of chronic inflammation may so interfere with the ileo-caecal reflex, from the alteration in the character of its secretion, or from loss of contractile power in consequence of fibrosis or adhesions, that there is an abnormal delay in the passage of faeces from the small into the large intestine. MacEwen had the opportunity of watching a patient who lost the anterior wall of his caecum through an explosion. He observed that there was a considerable flow of alkaline, glairy mucus from the appendix orifice and caecal surface shortly after food was introduced into the stomach, and that it was greatly increased just before the contents of the ileum passed through the ileo-caecal valve into the caecum. Cannon found, in his experi- ments on cats, that if the caecum is irritated by the injection of croton oil, the passage of the effluent from the stomach to the intestine, and from the small intestine into the colon, is considerably delayed. In further support of this theory, we find that in many cases of appendix dyspepsia the duodenum is dilated. The experiments of Bond have clearly demonstrated that in the presence of obstruction, minute foreign bodies can be carried in the opposite direction to the normal flow in the case of mucous canals and gland ducts, and one may con- clude that in intestinal stasis, micro-organisms can ascend up the small intestine to the duodenum and thence to the stomach, or along the bile- ducts to the gall-bladder or to the pancreas. Whatever the value of these theories may be, the fact remains that a patient who is suffering from chronic inflammation of the appendix is liable to have gastric or duodenal ulcer, or gall-stones, quite apart from the danger of a further attack of appendicitis. The prognosis, therefore, for a patient who has had one attack of appendicitis is somewhat as follows : Over 50 per cent of patients have further attacks, and of these, 60 per cent have further attacks within twelve months, and 80 per cent within two years. There is also a possibility of appendix dyspepsia, gastric or duodenal ulcer, or gall-stones supervening. It is not possible to give ARSENIC POISONING 77 statistics to prove the frequency with which the latter complications arise. One can only say, in accordance with the statistics already referred to, that in probably 75 per cent of cases of gastric and duodenal ulcer the appendix is considerably diseased, and that in 175 cases of gall-stones and cholecystitis, McCarty and McGrath found the lumen of the appendix obliterated partially or completely in nearly 50 per cent, and consequently we may assume that there was evidence of disease, less pronounced, in considerably more. In addition, we have to remember the numerous cases of appendix dyspepsia which have come to operation before these serious complications have supervened. Colitis. — Lastly, there is a certain number of cases of cohtis which are the direct result of chronic inflammation of the appendix. It may be taken as a general rule that appendicectomy is indicated provided the colitis was immedi- ately preceded by a definite attack of appendicitis ; under these circumstances the prospect of a cure of the colitis is good. This favours the theory that the diseased appendix is constantly discharging colonies of virulent bacteria into the caecum which cause and keep up the colitis. If, on the other hand, the coUtis appeared first and the appendicitis appears to be secondary to it, there is little prospect of curing the colitis by removing the appendix. References. — Aldehoff, quoted by Hollander, Berlin, klin. Woch. 1910, i, loii ; Barclay, Amer. Jour. Surg. 1912, Aug. ; Battle, Med.-Chir. Trans. 1905, Ix.xxviii, 470; Battle and Corner, "The Surgery of the Diseases of the Vermiform Appendix," T910 ; Bidwell, Brit. Med. Jour. 1910, ii, 507 ; Bond, Brit. Med. Jour. 1913, i, 645 ; Brickner, Amer. Jour. Surg. 1910, xxiv, 208 ; Carless, Lancet, 1909, ii, 1540 ; Corner, Clin. Jour. 1912, May 29 ; Cosens, Lancet, 1909, ii, 1469 ; Denk, Beitr. z. klin. Chirurg. 1913, 481 ; Dieulafoy, Sent. Med. 1903, xlii, 341 ; Fairbank, Med. Press and Circ. 1912, i, 644 ; Von Frisch, Wien. klin. Woch., 1912, xxv, 30 ; Garre and Quincke, "The Surgery of the Lung," 1912, 196; Pearce Gould, Med.- Chirurg. Trans. 1905. Ixxxviii, 457 ; Hamilton, Brit. Med. Jour. 1912, i, 950 ; Hammersley, New Zealand Med. Jour. 1909, vii, 13 ; Hoffmann, Beitr. z. klin. Chirurg. 1912, Ixxix, 305 ; Hollander, Berlin, klin. Woch. 1910, i, loii ; Hunner, Jour. Amer. Med. Assoc. 1908, April 25, 1328 ; Karrenstein, quoted by Kiimmell, Langenheck Arch. f. klin. Chirurg., 1910, xcii, 371; Kelly and Hurdon, "The Vermiform Appendix and its Diseases," 1905 ; Klemm, Langenheck Arch. f. klin. Chirurg. xcv, 558 ; Mittheil. a. d. Grenzgeb. d. Med. u. Chir. 1906, xvi, 580 ; Korte, quoted by Hoffmann, Beit. z. klin. Chirurg. 1912, Ixsix, 305 ; Krogius, Langen- heck Arch. f. Chirurg. ,xcv, 759; Kiimmell, Langenheck Arch. f. Chirurg. 1910, xcii, 371 ; Lett, Med. -Chirurg. Trans. 1905, Ixxxviii, 545 ; McCarty and McGrath, Ann. of Surg. 1910, lii, 801 ; MacEwen, Lancet, 1904, ii, 995 ; McWilliams, Ann. of Surg. 1910, U, 909 ; Mohnert, Mittheil. a. d. Grenzgeb. d. Med. u. Chir. 1908, No. r8, 469 ; Moynihan, Brit. Med. Jour. 19 10, i, 241 ; Lancet, 1912, i, 9 ; Brit. Med. Jour. 1913, ii, 171 ; Ney, Johns Hop. Hosp. Bull. 1912, April, 123 ; Oehlecker, Berlin, klin. Woch. 1910, i, 578 ; Parker, Lancet, 1912, i, 350 ; Paterson, Lancet, 1911, i, 97 ; Med. Press and Circ. 1912, N.S., xciv, 63 ; " Surgery of the Stomach," 1913 ; Payr, Miinch. med. Woch. 1905, No. 17 ; Verhandl. d. deutsch. Gesellschaft f. Chir. xxxvi, 636 ; Douglas Powell, Med. -Chirurg. Trans. 1905, Ixxxviii, 459 ; Reichel, quoted by Hollander, Berlin, klin. Woch. 1910, i, ion ; Reavall, Eng. Mittheil. a. d. Gyncekol. Klin. 1908, vii, 18 ; Rheindorf, Med. klin. Woch. 1913, Jan. 12, 19, and 26 ; Rotter, Langenheck Arch f. klin. Chirurg. 1910, xciii, i ; Ruge, Langenheck Arch. f. klin. Chirurg. 1911, xciv, 711 ; Sasse, Langenheck Arch. f. Chirurg. igii, xciv, 549 ; Seelig, Ann. of Surg. 1908, xlviii, 388 ; Sprengel, Centr. f. Chirurg. 1911, xxxviii, 33 ; Still, " Common Disorders and Diseases of Childhood," 1912, 268-279 ; Telford, Lancet, 1910, ii, 1269 ; Treves, Med.- Ckirurg. Trans. 1888, 165; Med. -Chirurg. Trans. 1905, Ixxxviii. 431 ; Widal, Presse Med. igi2, Oct. 23, 872 : Wilms, Centr. f. Chirurg. 1909, No. 48, 166 ; Wilson, Brit. Med. Jour. 1912, i, 829; Woodforde, Proc. Roy. Soc. Med. 1910-1911, Sect. Stud. Dis. Child. 81. Hugh Lett. ARSENIC POISONING. — In the outlook of poisoning by arsenic, much depends on whether the poisoning is acute or chronic. In the former, the combination of violent purging with sanguineous stools, urgent vomiting, collapse, cyanosis, suppression of urine, convulsions, and coma, form a chnical grouping from which recovery is aU but hopeless. 78 INDEX OF PROGNOSIS If the case is less acute, it is important to bear in mind the fact that remissions may arise in the symptoms, leading to false hopes, and that such patients not infrequently pass into a fatal relapse. If the patient recovers, convalescence is frequently tedious, and later on, arsenical nervous phenomena may appear. The chronic form of poisoning may result from the continuous ingestion of the drug over long periods, or may follow a single large dose. The drug may, however, be taken in large quantities over very prolonged periods, as among the natives of Styria, without harmful effects arising. Signs and symptoms of peripheral neuritis have arisen as long as two months after a single large dose. Women are said to be more susceptible to nervous phenomena than men, though in both sexes advancing age increases the liability to affection of the nervous system. Children tolerate arsenic well. In chronic cases in which keratosis has appeared, it should be remembered that epithelial cancer sometimes develops. Apart from this, the skin lesions generally get well in time if the patient is removed from any further intake, although in some cases pigmentation may remain permanently. /. r. Charles. ARTERIAL TENSION, HIGH. — It is convenient to give some httle con- sideration to this subject as apart from that of arteriosclerosis, but most of the facts relating to this syndrome will be found under the latter heading. The pathological facts on which prognosis should be based are : (i) Renal disease is the cause of three-quarters of all cases of high tension ; (2) The tension cannot rise beyond a certain point without wearing out the circulatory tube, either at the cardiac or the peripheral end ; (3) The risks are therefore those of uraemia, cardiac failure, and cerebral haemorrhage. Janeway's analysis of too fatal cases of hypertension (170 mm. or over) showed that death was due more or less directly to cardiac failure in 36, to uraemia in a like number, and to cerebral haemorrhage in 14. In de Havilland Hall's 20 cases, on the other hand, there were 7 cardiac, 7 apoplectic, and only 3 uraemic deaths. The duration of life in Janeway's cases varied from four months to eleven years, and averaged a little less than four years. The particular kind of death did not have much bearing on the duration of life. The conditions on which prognosis is founded in individual cases are three : (i) The height of the pressure; (2) The cause or causes; and (3) The general symptoms. I. The Height of the Pressure. — The following facts illustrate the first point. Examination of a large series of insurance figures showed that the mortality in persons with a systolic pressure exceeding 150 mm. Hg was 35 per cent in excess of the average, while that in persons whose pressure was 170 or over was no less than four times as heavy as that of the average man. To quote de Havilland Hall again, he found that of a number of persons followed up for a definite period, the mortality rates worked out as follows : — Mortality According to Tension. Mortality Tension per cent Below 120 5-7 120-140 3-5 141-160 3-0 161-180 26-3 181-200 41-6 Over 200 53 ARTERIAL TENSION, HIGH 79 These figures suggest that pressures up to 160 in middle-aged people do not matter much, but that after that the prognosis grows rapidly worse as the figure rises. In assessing the importance of the actual systolic pressure, there are several modifying circumstances to be taken into consideration. The normal rises with advancing years. A rough and ready way of remembering this is to add the patient's years to 100, the result being his normal pressure ; thus, the pressure at the age of forty should be 140 ; this gives rather high results for the later decades, but otherwise it will serve. Again, sex makes a difference : the average tension is 10 or 20 mm. lower in a woman than in a man of the same age. In a nervous subject there is always a risk of getting too high a reading, and some instruments, such as the Pachon oscillometer, give artificially high results. We have not here entered into the question as to which is the more significant, rise in the systolic or in the diastohc pressure, because the whole matter is still unsettled, and for the present it is better to limit the term. ' high tension ' to cases of raised systolic pressure. It must also be remembered that a definitely rising pressure is of graver import than a stationary one, and that we should particularly fear those crises of hypertension that are liable to arise in cases of granular kidney, often without apparent cause, for they bring into the case a special risk of cerebral haemorrhage. Conversely, a fall in tension is anything but welcome when it is accompanied by threatenings of cardiac breakdown. 2. The Cause or Causes. — As to the importance of causes, it must never be forgotten that in the great majority of hyperpietics the kidneys are the seat of progressive disease. The more obvious these renal lesions are to the clinician, the worse the outlook. If, however, there are contributory causes such as excess in tobacco or food, too much stress, and so on — factors that are in some degree susceptible of removal — the prognosis is a little alleviated ; but it must be confessed that even when everything has been done that can be done, the high pressure tends still to persist and to rise relentlessly. 3. The General Symptoms. — There is no need to go fully into the symptoms, since the calamities that are to be anticipated— cardiac failure, uraemia, and cerebral haemorrhage — are dealt with in appropriate articles. The only point that need be made here is that each of these catastrophes is often foreshadowed by events which may appear trifling in themselves, but which have a great significance when looked at as foreshadowing the final downfall. The cardiac symptoms that belong to this category are those that indicate failure of contractility ; increasing breathlessness, periodic dyspnoea, swelling about the ankles, precordial pain on exertion, and the bruit de galop. The likelihood of an apoplectic seizure is also often hinted at, and not obscurely, by two sets of phenomena — haemorrhages elsewhere (nose, retina) and cerebral symptoms {headache, vertigo, mental obfuscation, transient palsies, and so on). The transient palsies are of the gravest significance : temporary aphasia, hemianopia, strabismus, hemiplegia, and such like, are to be accepted as very direct fore- warnings of danger in persons with a raised blood-pressure. Polyuria, early morning headache, and eye symptoms are, according to Janeway, precursors of uraemia. The effects of treatment on high tension are disappointing. In favourable cases dieting, purgation, and systematic moderate exercise, with restriction of mental stress, may keep the pressure from rising ; but once high pressures of 180 mm. and over are reached, it is almost impossible to get them down again. Even the nitrites are often ineffectual. The experiments of Matthew and others demonstrated this very clearly. They further proved that the most useful of the nitrites for continued reduction of high tension was erythrol tetranitrate. 8o INDEX OF PROGNOSIS but that, owing to the headache which this is apt to produce, it cannot often be used continuously. Under these circumstances sodium nitrite in frequently- repeated doses will be the most useful vasodilator, and it may be possible to efiect and to maintain a lowering of lo or 20 mm. The fall in pressure produced by nitroglycerin and by nitrite of amyl is too fleeting to be of service for reduction of a persistently high pressure. Potassium iodide cannot be relied on to depress tension, and the effect of venesection is also very brief. Carey F. Coombs. ARTERIOSCLEROSIS. General Outlook. — This is a most difficult matter to write about in a case of arteriosclerosis. It is inevitable that, in this article, there should be some over- lapping of others, that dealing wdth high blood-pressure in particular ; so far as may be, however, my purpose is to indicate what is to be feared for a patient in whom the arteries are found to be sclerosed. Now the practitioner's attention is directed to this condition under tAvo sets of circumstances. First, in the course of a general examination — for life insurance, for example — it is found that the radial arterj- is tortuous and hard, beaded it may be, the brachial artery unduly palpable, the abdominal aorta cord-like and throbbing ; in a word, general arteriosclerosis is accidentally discovered. In the second type of case, the patient complains of cerebral, cardiac, or peripheral symptoms, and the physical examination reveals the source of these in a progressive arterial degener- ation. In the first case, the disease is discovered at an early stage, before it has begun to produce tangible interferences with function ; in the second, these interferences have already begun. In anj' case, chronic arterial disease threatens life and health in one way, by spoiUng the nourishment of various organs and tissues; the three gross manifestations ' of this process are cerebral softening, cardiac failure, and senile gangrene. There is, of course, the risk of cerebral hsemorrhage to be considered ; but this is so closely connected with high blood- pressure that it will only receive brief comment in this article. In any given case, there are three things to consider : (i) The etiological factors ; (2) The stage of development to which the disease has attained ; and (3) Its distribution. I. Etiological Factors. — Confronted by arterial degeneration in a patient, we naturally want to know the reason ; and two aspects of this question present themselves to the mind. Sooner or later, arterial degeneration is the common lot of man, provided he Uves long enough ; in other words, the tunica media of the arterial tube tends ' normally ' towards decay after a certain age. It is said (Adami) that this downward process begins at about thirt\'-five ; at this time the katabohc leanings of the cells of the arterial media begin to gain the upper hand. Xow the rate of downward progress appears to depend on two sets of factors, the congenital and the acquired. Of these it is difficult to say which is cause and which effect : the writer inclines to the beUef that arterial degeneration is always the outcome of toxic agencies acting on a tissue, the tunica media, whose \Tilnerabilit^'- varies ^Aith certain inherited characteristics at present undefined. Of these toxic agencies, some, as we shall see, are perfectly obvious, others less so. It follows, therefore, that in estimating the prospects of arterial sclerosis in any given patient, we must take into consideration : first, the kind of arteries he inherits ; second, the existence or non-existence of any toxaemias to which his arterial decay may be partly ascribed. Congenital. — It is probable, though not proved, that a poorness of arterial make-up is inherent in certain families ; that, in these, the medial cell is particu- larly open to m.align influences. At all events, there are families whose mem- bers seem doomed to suffer earl}' arterial degeneration without obvious cause. ARTERIOSCLEROSIS 8i Assessment of the familial factor is conducted along obvious lines ; the age at death of the patient's forebears, their fitness for work during the decades when men commonly begin to wear out, the cause of death — all have to be passed under review. The kind of history to make a man repent his choice of ancestors is that in which generation after generation has decayed mentally at, or soon after, sixty, or in which a similar liability to cardiac breakdown has displayed itself. The family doctor often enjoys a great advantage here : he recollects how the father of the patient was an old man at fifty-five, and assesses the pros- pects of the present generation accordingly. The first definite question to be answered in any given case, then, refers to the quality of blood-vessel which the patient inherits. Acquired. — The acquired factors leading to arteriosclerosis are some of them obvious, while others are but dimly perceptible. Among the obvious ones are certain toxic substances, of which lead is the most conspicuous example. Some of the more obscure causes hang together in an indefinite kind of group : over- eating, excess in meat, mental or muscular stress, high arterial tension, renal disease. We ought to consider next, then, whether any such cause is discernible ; if so, whether it is operative at the time of examination or no ; and whether, if operative, it can be brought to an end. It is easy enough to ask these questions, and just as difficult to answer them categorically. Take the most definite of all, lead ; does it indeed act directly on the arterial media, or only through the renal lesions which it causes ? Perhaps the way to approach this from the prognostic view- point may best be illustrated by examples of the two extremes. A young man with abnormally palpable arteries, but no evidence of renal disease, may look forward with confidence to the future if he be removed forthwith from the risk of further poisoning. On the other hand, a man of sixty, with pronounced arteriosclerosis and quite definite signs of renal lesion, cannot expect any great improvement in his outlook, even though he leave his injurious work forthwith. This is tantamount to saying that the prognosis in a case of plumbism depends not merely on arterial, but also on other, lesions ; but that so far as the arterial changes are concerned, the fact that the cause is one where further operations can be prevented is all in favour of the patient. Of other definite chemical substances known or thought to act deleteriously on the arterial media, two of the luxuries of life come instantly to the mind, alcohol and tobacco. There is, at the present time, a tendency to behttle the part played by alcohol in the processes of arterial disease ; none the less, it is fair to console the arteriosclerotic patient, whose alcohohc excesses have been noteworthy, with the assurance that abstinence will be good for his arteries ; yet it is probable that the effect on the outlook is not great. As for tobacco, it is very difficult to see dayhght here. On the one hand, we have the well-known effect of nicotine on the arterial walls — a fact which Josue and others have used experimentally to such good purpose — backed up by many clinical experiences of coincidence between arterial disease and excess in tobacco ; on the other hand, there must be reckoned statements like those of Herz, of Vienna, who made a collective inquiry into the etiology of arteriosclerosis in Austria, and found that the disease was not particularly common, even in districts where the women smoke pipes, and the habit begins in childhood. It is, at any rate, permissible to forecast a good effect from cessation or moderation of smoking, where this has been exces- sive and no other factor is definitely discernible. The same may be said of tea- drinking in excess. Passing from these poisons, we come to those of definite bacterial origin. Among these, typhoid fever stands out prominently. Councilman's researches 6 82 INDEX OF PROGNOSIS showed that the arteries of persons who have had this disease are thicker than those of persons who have not. In sjrphihs, again, a similar change may be observed, quite apart from the local arteritis which is provoked by this infection. If, therefore, we find evidences of early arterial degeneration in a comparatively 3-oung subject who has had typhoid fever, their significance, so far as length of life is concerned, is probably shght ; that which caused them is no longer operative (always supposing there is no reason to believe the infection to be persistent). In the case of the syphihtic, on the other hand, the outlook is less reassuring, for it is not easy to be sure that the infection is no longer active. If the patient underwent thorough treatment, and if the Wassermann reaction be negative, it is probable that syphiUs is no longer operative as a cause of arteriosclerosis, the prognosis being good so far as this factor is concerned. Of the other infections we know less, and they do not enter into the assessment of expectation of life in arteriosclerosis. Yet another group of toxic agencies has to be considered, those of endogenous origin. Certain of these, which are relatively definite, may be considered first. Arterial disease is associated with glycosuria, and here the cause overshadows the effect, so far as prognosis is concerned ; we do not estimate the chances of our glycosuric patient in terms of his arteries, but in terms of his output of sugar and the degree to which this can be controlled. It may, however, be remarked that the progress of arterial change in such persons is relatively slow, and that the outlook is therefore better than in some types of arterial degeneration. Mitchell Bruce found that cardiovascular degeneration in glycosuria ran an average course of over twelve years from the onset of symptoms. That gout plays a part in causing aii:eriosclerosis is also clearly proved. If, therefore, an arterio- sclerotic patient be definitely gouty, and other causal factors are not apparent, the prognosis varies according to the amenability of the parent disorder ; should the gout yield to dietetic and other measures, the arterial changes will progress but slowly. These are well-defined morbid entities ; but they merge insensibly into other categories which are not so easy to understand — those of renal disease, mental and muscular stress, over-eating, and hypertension. So far as this article is concerned, the last of these may be dismissed in a word or two ; high tension is not a disease, but a symptom arising from a variety of causes, and when it coincides with arteriosclerosis, it is probable that the two constitute different aspects, the one anatomical and the other physiological, of one and the same process. In any event, it is more convenient to consider such cases under the caption of high tension, as I have done in the articles in this book. Arteriosclerosis as complicating renal disease will also be considered under the same heading. It is not quite proper, however, to dismiss all the factors named above in this way ; for though arteriosclerosis is seldom provoked by over-eating or stress, apart from high tension, yet this latter may be relatively shght, and the arterial change comparatively prominent. Excess in food is an extremely common and important cause of arterial degeneration ; this is often apparent in persons who eat large masses of food in general, and red meat in particular. There is no factor which can be cut out with greater confidence of bringing about improvement in the patient's condition ; consequently, the arteriosclerotic person who over-eats, and yet consents to a genuine correction of his evil ways, stands a far better chance than one who is incorrigible. As to stress, it is pretty clear that it is mental and not physical overstrain that tells ; indeed, as French has suggested, much of the premature arterial decay of city men is to be referred to overwork of some arteries (cerebral and ahmentar^'), in contrast •with underwork of those supplying the skeletal muscles ; and if such persons can be persuaded to work and eat less, and to take regular physical exercise, the ARTERIOSCLEROSIS 83 prognosis is thereby ameliorated. Finally, it is possible to analyze the stress factor a little further, for Mitchell Bruce distinguishes between emotional and intellectual expenditure, and finds that it is the former that is especially hard on the arteries. Now this brings us to the furthest point to which it is legitimate to press the toxic analogy ; it is probable that over-eating causes arteriosclerosis through the agency of toxins, and it is possible that stress, even of the emotions, acts in the same way, but it is also very certain that emotional strain is a matter of temperament. Here we come to the fact that there are cases of arterio- sclerosis in which it is possible to tell the patient that it is folly to continue to live as he is living — over-eating, under-exercised, constantly devoured by anxiety and excitement, — and to say that if these causes be removed his life will be prolonged, and arterial decay slowed down : and yet the patient may be so constituted temperamientaliy that he simply cannot stop. He may amend his diet ; he may even lessen his work and take to golf ; but he cannot stop worry- ing. Hence, temperament is an important etiological factor in the prognosis of arteriosclerosis ; it is a potent cause, and yet, at the same time, one which cannot be done away with, any more than it is possible for the Ethiopian to change his skin. In people of the worrying, anxious kind, therefore, arteriosclerotic changes are less easily checked, and, on that account, of graver import than in persons who take life quietly, and who will readily consent to profound altera- tions in their manner of living. Summing up what has been said as to the importance of etiology in prognosis, we find that arteriosclerosis is more likely to run a favourable course if it is largely dependent on some causal factor which can be removed. 2. Stage of Development. — -A second factor of importance, in arriving at a forecast of the future awaiting the arteriosclerotic person, is the stage at which it is first found that the vessels are not normal. It is tempting to divide the progress of arteriosclerosis into chapters, but this is of no value so far as our present purpose is concerned ; and the importance of the epoch at which the arteriosclerotic patient comes under observation is best realized by contrasting the outlook at the two extremes of the malady. Ignoring for the present the pre-sclerotic stage of Huchard, which is best considered under the caption of high blood-pressure, we find that the earliest stage of arteriosclerosis to come under notice is that in which thickening of the vessels is encountered accidentally, in persons who present themselves for examination on account of other symptoms or reasons. In such cases, there are no subjective evidences of arterial disease, or, at least, none that have struck the patient as noteworthy. Now, it would be rash in the extreme to offer a prognosis in such cases ; as a rule none is asked for, and even when it is, it is seldom that one can give an opinion that is of much value. In extreme cases, the gravity of the outlook is easily perceived: e.g., in a patient of forty who has arteries thicker than most men of sixty, and whose fore- bears have died young. Here the prognosis is clearly bad enough to justify a statement to that effect, if the physician thinks any good can be done by it ; if any contributory cause can be traced, such as excess in meat, it may, indeed, have _ a salutary effect on the patient if the prospects be hinted at, together with the amelioration that is likely to accrue from a reform of the diet. But in the majority of such cases, if we are asked for an opinion as to the patient's future by himself or his friends, and we have no evidences of arteriosclerosis apart from what can be felt with the finger, it is possible only to say frankly that the vessels are thicker than they ought to be ; that this is by no means a certain sign of curtailment of the expectation of life ; and that reasonable living is even more necessary than in the average individual, since this alone can avert such menace as is implied in the existence of arterial change. Sometimes it is possible to form 84 INDEX OF PROGNOSIS a rather more accurate opinion of the patient's chances by seeing him several times, at fairly long intervals, e.g., six months ; if such systematic observations enable one to detect the beginnings of visceral change, as a result of the arterial lesion, the task of prognosis is clarified. At the other extreme of the sclerotic process, the patient comes under observa- tion suffering from the organic effects of the disease. Of these effects, three stand out pre-eminent : cardiac failure, softening of the brain, and peripheral gangrene. Each of these will be considered under its appropriate heading, so that we need not regard them in detail, or from any point of view other than that of arteriosclerotic phenomena. From this standpoint, their importance is that they prove the disease to have reached an extreme stage — so extreme, that the vessels no longer perform their function of supplying nourishment to the organs dependent on them. Now the principle running through the whole prognosis of arteriosclerosis is its incurability ; the disease may be retarded, possibly arrested, but it is impossible to put the clock back. It follows, then, that these pheno- mena are evidences of the final development of incurable arterial disease ; and the prognosis, so far, at all events, as the injured parts are concerned, is unre- servedly bad. Between these two extremes there are all shades of cases in which there are symptoms referable to arterial disease. From the prognostic standpoint, these are chiefly of importance in so far as they prove that the disease has reached a stage at which it interferes Avith the nutrition of the parts supplied. Some of these phenomena are of special interest, and may therefore be considered in detail. The simplest to understand is transient dyskinesia of the limbs. The most familiar form of this is seen in the lower limb — an intermittent limp ; the legs are comfortable while at rest, and able to carry their owner for short distances, but after a walk of varying distance cramps come on, and the limb suddenly gives way, sometimes so suddenly that the patient falls to the ground. Similar troubles may afflict the arm, rendering it painful and useless when it is put to the performance of unusual tasks. Such phenomena are, perhaps, most clearly seen in obhterative arteritis (q.v.), but they do also occur in connection with ordinary arteriosclerosis. Their significance lies in the unmistakable evidence which they afford that the arterial disease has reached an advanced stage, and that absolute occlusion is not far off. Attacks which are probably similar in origin are seen in connection with the brain ; such are transient hemi- anopia, squint, aphasia, and even hemiplegia. These are to be regarded as evidences of advanced arterial disease, and as premonitions of permanent injury to the substance of the brain. The same may be said of angina pectoris, and the less definite grades of cardiac pain ; the coronary channels are becoming inade- quate to their duty of supplying blood to the myocardium. Attacks of abdo- minal pain, with meteorism, have been described as ' abdominal angina,' and referred to disease of the mesenteric vessels. All these paroxysmal phenomena are therefore of the gravest import, for they bespeak a stage of arterial disease which can scarcely go further without permanently cutting off the blood from the parts which the arteries supply. Apart from such attacks, however, there are less striking symptoms which, none the less, surely portend advance in the arteriosclerotic process to the point at which adequate blood-supply is threatened. Such are vertigo, stumbhng speech, slowed cerebration, persistent headache, and sleeplessness ; breathless- ness on exertion, puf&ness of the ankles, and muffling of the cardiac sounds ; impairment of sensation in the periphery of the limbs, and increasing muscular weakness. All these are to be interpreted as signs of progressive arterial degener- ation when they are associated wdth palpable thickening of the surface arteries ; ARTHRITIS, TUBERCULOUS 85 and, as such, they add to the gravity of the prognosis, for they show that the disease is becoming effective as a hindrance to the proper nutrition of the organs and tissues of the body. Summing up what has been said as to the significance of the stage of the disease in regard to prognosis, we find that arteriosclerosis tends to progress towards the point at which it cuts off blood-supply from certain parts of the body ; and that we must be on the look-out for evidences of the earlier phases of this interference with nutrition. 3. Distribution. — One other aspect of the disease must be taken into account in working out the prognosis of any given case, namely, the distribution of the arterial changes. It is obvious that these are of much greater significance when they attack the vessels responsible for nourishing a vital organ, such as the brain, than when it is the leg that is threatened. Arteriosclerotic lesions of the brain are more hopeless in regard to recovery than any others ; even in the most favourable cases of cerebral thrombosis of the senile type, the patient is never quite the same again, and usually his downfall is progressive and resistless. The cardiac lesions are less hopeless, perhaps, but more dangerous to life. Distinct evidences of abdominal arteriosclerosis are rare at any stage, and the data on which to base a general statement are, therefore, scanty ; but it can be safely said that such phenomena as do point to this form of the disease are only very rarely followed by grave consequences, such as mesenteric thrombosis. A last remark is this : that a calamity due to arterial degeneration in one part of the body predisposes to the occurrence of others. The most conspicuous example of this association is seen in the cerebral symptoms which are apt to follow close on cardiac breakdown due to arterial disease. Rest in bed pulls the heart through, but the brain remains injured. Summary. — In any individual case of arteriosclerosis, the factors to be con- sidered are : (i) The patient's arterial heritage ; (2) The presence of toxic or stress causes, and the possibility of their removal ; (3) The stage of the disease ; (4) Its distribution. Carey F. Coombs. ARTHRITIS, SEPTIC. — {See Joints, Injuries of.) ARTHRITIS, TUBERCULOUS. — We shall first examine some general con- siderations in the prognosis of tuberculous joint disease, and then discuss the end-results of the various methods of treatment for particular joints. General Outlook. — The following factors are of great importance in arriving at an accurate prognosis : The age of the patient ; the presence of phthisis or other lesions elsewhere ; the presence of septic infection ; the onset of acute general tuberculosis ; the social position and carefulness of parents. With regard to the age, we may say generally that children usually recover, while adults show Uttle tendency to improvement apart from excision of the joint, except in mild, early cases where the diagnosis is likely to be precarious. Concerning the second and third propositions, no comment is needed except to say that even septic sinuses do not necessarily make the prospects of recovery hopeless. Albuminoid disease is now rarely seen. The gravest risk is that of acute generalized tuberculosis, and the early signs of this, such as fever (not accounted for by the state of the joint), vomiting, drowsiness, etc., should be regarded as a warning that the end may be near. In early, well-treated cases, restoration of a movable joint is occasionally seen, but this is the exception and not the rule. In general, there is more or less complete fixation, especially if septic infection has supervened. Further, tuberculous hip leads, in many cases, to very decided shortening of the limb. 86 INDEX OF PROGNOSIS Although the majority of patients with a tuberculous joint eventually get ' cured,' it is important to realize the limitations with which the word should be used. Even when there is no pain, swelhng, or other symptom for years, it by no means proves that the bacilh are all dead. Strain, pregnancy or lactation, forcible bending of the joint by a bone-setter, or much more trivial causes, may lead to a recrudescence of the trouble. Hip-joint. — A few years ago, the eventual mortality of this disease was put at 30 per cent, but nowadays it is undoubtedly less. Watson Cheyne found a death-rate of 12 per cent in 77 cases, but some of the patients had phthisis ; excluding these, the fatalities amounted to 8 per cent. No cases were fatal which were aseptic throughout. The duration of treatment must be long. Thomas used to estimate that it took seven years to cure with his splint ; Cheyne considers this excessive. The amount of shortening is usually about one and a half inches ; it depends, of course, on the stage at which the disease can be brought to a standstill ; there will be no permanent shortening in quite early cases. The prognosis in relation to treatment is very important. Some evidence was advanced at a recent debate of the Royal Society of Medicine that tuberculin is helpful ; Butler Harris reported 10 cases improved by it ; Maynard Smith quoted 19, of which 16 were previously doing badly, where tuberculin rapidly improved all except 3. There is no doubt that, given prolonged earlj^ treatment in special institutions, the immense majority of children with tuberculous hips can be cured without operation, and may recover a fairly useful limb. Of 150 cases at the New York Cripple Hospital, 107 were cured with little or no deformity, although excision was only performed 4 times. At the Alexandra Hospital, London, 900 cases were treated without excision, and only 4 died (Bowlbj^). Gauvain reported a long series treated without operation at the Alton country cripple home with excellent results ; of 336 cases of tuberculosis of various joints, only i died. Of course, it is not possible to obtain results as good as these by conservative measures in ordinary hospital practice ; but very few British surgeons are disposed to regard excision with favour at the present time, except, perhaps, in adults. Stiles, one of the principal supporters of the formal excision, gives his results in the following table : — Results of Excision for Tuberculosis (Stiles.) Joint Excisions Good Useful Bad Am- putated Deaths Not traced Hip - Knee - Elbow Ankle 60 64 54 29 19 24 10 9 4 5 15 4 3 1 1 1 3 12 1 6 12 4 6 3 19 18 21 6 Total 207 62 28 6 22 25 64 It will be seen that the death-rate, immediate and remote, is high ; most of the fatalities were due to generahzed tuberculosis. Stiles's cases were all children. The average shortening was one and three-quarter inches ; the maximum was five and a half inches. Of the cases followed through, 23 out of 40 got a good or useful Umb. ARTHRITIS, TUBERCULOUS 87 Thompson gives results of 40 cases operated on at Guy's Hospital between 1896 and 1903 ; eventually, 6 of these died and 8 required amputation, so that 35 per cent were a failure ; in 11 cases sinuses were still present ; in 15 the disease had become inactive. Deformity was usually marked, but utility good ; there were 13 fixed joints, to mobile, and i flail-like. Seven were earning fair wages. We may conclude, therefore, that, after excision, a good result is likely to be obtained in only about half the cases. There is, again, a very real danger of lighting up fatal acute miliary tubercu- losis. Death took place from this cause, soon after the operation, in 2 of Stiles's and 3 of Watson Cheyne's cases. Konig has shown that, out of 18 patients with tuberculous hip who died of meningitis, death followed operation in 16. Knee-joint. — Figures relating to the prognosis of tuberculosis of the knee-joint treated conservatively do not appear to be available ; but a general opinion may be expressed that the prospects as to life are better than in tuberculosis of the hip, but the prospects as to local recovery scarcely so good. In adults, if there is well-marked swelling, and evidence of extensive disease in and about the joint, the prospects of recovery, apart from operation, are not promising ; but mild early cases without much pulpy swelling often do well. In Carre's clinic at Breslau and Bonn, the end-results of 86 cases treated conservatively (rest, heliotherapy, and iodoform injections) have been published by Els. Two-fifths of the patients were under ten years of age. Approximately half (51 per cent) obtained a good result ; 45 per cent were not satisfactory, and the rest died. We have some statistical evidence concerning the end-results of excision, both in children and adults. Stiles performs excision in children whenever the articular cartilages appear to be destroyed, or an abscess forms outside the joint. Arthrectomy is falling into disrepute, because the joint produced may be weak and painful. It will be observed that in 63 operations there were 4 deaths, one withm a month from generalized tuberculosis, and the others later ; i death was from measles. Of 45 cases followed through, 29 got a ' good ' or ' useful ' result, but subsequent amputation was necessary in 12. Of 30 joints examined, 29 were fixed and i slightly mobile. The two principal troubles are shortening and flexion. The average amount of shortening was a little over two inches ; in 5 cases it exceeded three inches ; a little shortening, up to one and a quarter inches, does not necessitate a high boot. In 5 cases a subsequent wedge-shaped resection was necessary on account of angular deformity, and in another there was flexion to ninety degrees. The results are not always as good as this. Elmslie, in a study of 89 cases of excision of the knee, found 3 with over six and a half inches of shortening and marked angulation, 25 had been subjected to re-excision, and 3 to a third excision. The results of excision in adults have been pubhshed by Seldowitsch, of St. Petersburg, as follows. In 57 cases followed through : 35 obtained firm, painless, bony ankylosis with excellent function ; 10 were improved ; 2 were no better ; 4 had subsequently to be amputated ; 6 died (pneumonia 2, general buberculosis 2, meningitis i, cachexia i). In the Breslau and Bonn series, excision was performed in 268 cases (114 under fifteen), the indications being evidence of bony disease complicated by abscesses or fistulas or severe contractures or luxations. The immediate results showed 2 per cent deaths, 88 per cent recoveries, 6 per cent little or no better, and 4 per cent needing amputation. Examined a year later, out of 188 cases, 14 had died, but 84 per cent showed a good result. We may conclude, therefore, that after excision for tuberculosis of the knee, about two-thirds, both children and adults, get a very good result, rather better INDEX OF PROGNOSIS in adults than children ; but that great skill and care are necessary in children, or the results may be deplorable. The mortality, immediate and remote, is about 8 per cent. Ankle and Foot. — In Stiles's series, 29 ankles were excised, 3 dying subse- quently. Out of 23 followed, 13 got a ' good ' or ' useful ' ankle, and 6 required amputation. The average shortening was three-quarters of an inch. Syring has published the results of a series of 222 cases of tuberculosis of the foot and ankle treated in Garre's cUnic at Breslau and Bonn, tabulated for the 1913 Congress. Conservative measures similar to those mentioned above for the knee-joint had to be given up in 114 cases, but in the remaining 108 they gave good results in 75 per cent, that is, about a third of the whole. Excision of the astragalus was adopted in 75 cases, of which 49 obtained a good, often a very good, result. The prospects of success are much better in children than in adults, but even over twenty years of age the majority did well. Amputation was necessary on 45 occasions ; of these, 30 were soon able to return to work. We may conclude, therefore, that conservative treatment of the foot and ankle may succeed in about a third of the cases, and excision in about two- thirds. Shoulder-joint. — Evidence concerning the exact prognosis is not forthcoming. Stiles operated on so few cases that he gives no figures. The majority of the cases occur in adults, and so it is not usually worth while to try prolonged rest, which may not succeed after all. Watson Cheyne, therefore, advocates excision in adults, except in mild early cases. A fairly mobile useful shoulder generally results, and the period of disabiUty is very greatly shortened. Elbow-joint. — Here the usefulness of the arm depends very much upon the position ; ankylosis at a wide angle is most inconvenient. In practice, a more useful joint is usually to be obtained by early operation, which will probably ensure mobility. This is especially true if abscesses or sinuses are present, because, in that case, very prolonged fixation would be necessary to get a cure by conservative means. According to figures quoted by Watson Cheyne, 75 per cent of the patients treated by excision get a good joint, and the remaining quarter may have a stiff or a flail joint in about equal proportions. Stiles excised the elbow 54 times ; 6 patients died subsequently (three months to two and a half years) of generahzed tuberculosis. Apart from these, 25 out of 27 obtained a ' good ' or ' useful ' joint ; in 10 there was considerable power and mobility, in 6 ankylosis, and 7 were flail. The shortening averaged one and a half inches. Only i patient required subsequent amputation. Wrist-joint. — In children, with proper conservative treatment, these cases practically all get well, mth some permanent stiffness (Marsh). In adults, also, the patient is likely to get the best results by prolonged fixation, except when the whole joint is badly disorganized, with septic sinuses. The hand left after excision is usually much crippled on account of the shortening of the bones compared with the tendons, and amputation is often preferable. Exact figures are not available. Dactylitis. — In children, in the great majority of cases, fixation and conserva- tive treatment end in a cure (Cheyne). Amputation is seldom required. In adults, the course is so slow and the prospect of benefit so uncertain that amputation is to be preferred. Saero-iliac Disease. — Although exact figures cannot be quoted, it is generally admitted that the prognosis in this afiection is grave. Most of the cases occur in adults, and phthisis is often present. The great majority die, after a chronic illness. In young subjects, recovery may occur, but often ^vith obUque deformity of the pelvis (Cheyne). ASCITES 89 Wheeler, of Dublin, points out that better results may be obtained by earher diagnosis, and that the sciatica and gluteal pain, together with a skiagram, give definite evidence before the classical signs develop. He obtained an excellent result by early operation in one case, and a fair result in another. References. — Watson Cheyne, Tuberculous Disease of Bones and Joints ; Stiles, Brit. Med. Jour. 1912, ii, 1356 (and discussion) ; Marsh, Joint Diseases ; Proc. Roy. Soc. Med. 1912, discussion, Children's Section, 65, 76 ; Sever, Jour. Amer. Med. Assoc. 1910, 2128 ; Thompson, Guy's Hasp. Rep. 1905 ; Els, Beitr. z. klin. Chir. 1913, Ixxxvii, 51 ; Syring, Ibid. 88. A. Rendle Short. ASCITES.— Since ascites is not a disease, but the result of various patho- logical conditions, its prognostic significance in any given case depends on its cause. As, however, it may be a late or even terminal phenomenon in some conditions, its recognition renders the prognosis of the causal disease very grave. The commonest condition associated with ascites is some form of heart disease ; out of 224 cases in which a quart or more of ascitic fluid was found after death, 89, or 39 per cent, were due to cardiac disease, the next most important cause being some form of intra-abdominal new growth, in 44, or 19-6 per cent (Cabot^). In adherent pericardium, ascites may be due to chronic peritonitis (polyorrhymenitis) , and then persists for long periods ; but in ordinary cases of chronic cardiac failure, the onset of ascites shows that the disease has reached an advanced stage. Again, in portal and hypertrophic biliary cirrhosis of the liver, in chronic splenic anaemia thus constituting Banti's disease, and in chronic malaria, the advent of ascites is a very grave indication. That the prognosis of ascites depends on the cause is shown by the different outlook in ascites due to malignant disease and to tuberculosis of the peritoneum respectively. The various forms of ascites are referred to incidentally throughout this article, but some of the more important forms will now be mentioned briefly. The three conditions — uncomplicated cirrhosis, cirrhosis complicated by simple chronic peritonitis, and simple chronic peritonitis — stand in this order as regards the gravity of the prognosis. Thus the average duration of life after the appearance of ascites in thirty-one cases of uncomplicated cirrhosis was 188 days ; in twelve cases of cirrhosis complicated with simple chronic peritonitis, 288 days ; and in nine cases of uncomplicated simple chronic peritonitis, 624 days (Ramsbottom^). In the ascitic form of tuberculous peritonitis, the outlook is better than in all other forms of ascites except those associated with the presence of an innocent uterine or ovarian tumour which can be removed. The ascites due to gummas in acquired syphilis of the liver rapidly diminishes with- out tapping under efficient treatment with iodides, and the prognosis is good. But in the rare cases of ascites due to inherited syphilis, whether in very early life or later, when the lesions of delayed inherited syphilis (gummas, cicatrices, and lardaceous disease) have developed, the outlook is very serious. As men- tioned elsewhere (see Liver, Cirrhosis of), cicatrices and so-called syphilitic cirrhosis are not influenced by antisyphilitic remedies. Medical Treatment. — The influence of diuretics on the prognosis depends on the effect they exert on the underlying cause. Thus, they may diminish or remove the ascites by improving the circulatory conditions in the cardiac or cardio-renal diseases which are responsible for the effusion, though even here their action is somewhat capricious and uncertain ; but in chronic peritonitis and malignant disease of the peritoneum, little benefit can be expected. Diuretics are disappointing in the presence of considerable ascites, and are often more effective shortly after paracentesis, when, from removal of pressure on the renal veins, the kidneys are better able to respond to stimulation. go INDEX OF PROGNOSIS A salt-free diet (dechlorinization) is more likely to do good in renal cases, and a restricted intake of iiuids (dry diet) should succeed better in cardiac and cardio-renal ascites than in other forms. Purgation is usually disappointing, though besides removing fluid it may exert a detoxicating action, especially in cirrhosis. Excessive purgation may seriously impair nutrition, and in the past such vigorous treatraent may have hastened the end. When ascites diminishes as the result of the administration of iodides, the underlying cause is almost certainly syphilis, and the prognosis is therefore very good. Operative Treatment. — In ascites associated with innocent ovarian or uterine tumours, operation renders the outlook extremely good ; but this association is not very frequent. Ascites was found in lo, or 50 per cent, of 20 cases of ovarian fibroma, in 31, or 7-9 per cent, of 391 multilocular ovarian cysts, and in 55, or 7 per cent, of uterine fibromyomas (Cabot^). In papilloma of the ovary ascites is frequent. In all these conditions removal of the tumour cures the ascites, and Cabot^ points out that it may also cure a concomitant pleural effusion. In the ascites of tuberculous peritonitis the question whether simple laparotomy or medical measures give the best results has been extensively discussed by surgeons and physicians, who have brought forward elaborate statistics to support their respective lines of treatment (vide Tuberculous Peritonitis). An obvious advantage of laparotomy is that a local focus of tuberculous disease which may give rise to re-infection and relapse after partial or apparent cure may thus be detected and removed. Out of W. Mayo's* 26 cases in which tuberculous Fallopian tubes were removed, 25 recovered permanently, and in 7 of these simple laparotomy had previously been performed from one to four times for the cure of tuberculous peritonitis. The operative treatment of the ascites of portal cirrhosis is referred to elsewhere {see Liver, Cirrhosis of). Paracentesis can hardly be regarded as a form of treatment which directly influences the prognosis of ascites ; it is a necessary means of obtaining relief from mechanical obstruction rather than a curative measure. The risk of peritoneal infection or haemorrhage (from wounds of the deep epigastric or other vessels), or of direct damage to the abdominal viscera from the insertion of a trocar and cannula, is almost negligible. Repeated paracentesis, however, may set up some chronic peritonitis, and so perpetuate ascites originally due to some other lesion, such as the backward pressure of heart disease. In hepatic cirrhosis, death from coma sometimes follows soon after tapping, but this is because the ascites is a terminal event, and is not a result of the paracentesis. Frequency of Tappings. — On the whole, frequent tappings are rather favour- able than otherwise, as they show that the condition is chronic and may thus exclude malignant disease. In chronic simple peritonitis in which ascitic life is longer than in other conditions, repeated paracentesis may be necessary ; an extreme instance of this is Rumpf's patient, who was tapped 301 times in sixteen years. Another remarkable example of ascitic life was that of a woman who was tapped 299 times in nine years, sometimes twice a week, the causal disease being papillomatous disease of the ovaries (Pye-Smith^). While rapid re-accumulation is not necessarily of evil omen, its occurrence in cirrhosis at such a rate as to require a fresh tapping after two or three days' interval, especially if accompanied by haematemesis and metena, may be due to throm- bosis of the portal vein, which is extremely likely to precipitate a fatal issue. Ascites may be a terminal event, and therefore of very grave significance. Thus, in uncomplicated cirrhosis, tapping is seldom required more than twice, and the prolongation of life is shorter than in cirrhosis complicated with chronic ASCITES 91 peritonitis, in which more tappings are required, and in chronic peritonitis. In some "cases of fatal cirrhosis, ascites does not require tapping. The prognosis, however, is not necessarily bad because tapping is not required, for in tuberculous peritonitis it is seldom called for, and in syphilitic disease of the liver, anti- syphilitic treatment may be followed by rapid disappearance of the fluid. The introduction into the peritoneal cavity at the end of paracentesis of a dilute solution of adrenin has in some instances prevented or delayed re-accumulation, but its action is not sufficiently constant to be relied upon. In Individual Cases. — Age bears on the prognosis in so far that, apart from cardiac disease, ascites in children is nearly always due to tuberculous peritonitis, in which the outlook is fairly good. The association of jaundice with ascites is seen in malignant disease and in cirrhosis, and is therefore a bad prognostic ; deep jaundice almost certainly points to malignant disease. The combination of ascites and oedema of the feet may precede the onset of ascites in cirrhosis, and is then a bad sign ; but in the backward pressure of heart disease this sequence is of comparatively little importance. Extensive ascites may induce oedema of the feet mechanically, by pressure on the inferior vena cava, and in rare instances gives rise to a pleural effusion (Caboti), and these results may disappear if the ascites is cured. The association of pleural and ascitic effusions should not necessarily cause more anxiety than the presence of ascites alone ; for it is sometimes seen in simple chronic peritonitis ; and cases of tuberculous peritonitis thus complicated may do well. On the other hand, it may occur in cirrhosis, usually from tuberculous pleurisy, and in widespread malignant disease. Fever is not uncommon at the onset of tuberculous peritonitis, and it is only when persistent that it causes serious anxiety as to the future of the case. In cirrhosis the onset of ascites with fever points to a rapid course or to some compli- cation, such as tuberculous infection, especially of the peritoneum. In ascites due to hepatic syphilis, any associated fever is easily removed by efficient antisyphilitic treatment. Albuminuria has not any special bearing on the prognosis of ascites ; for the ascites of chronic renal disease may clear up ; chronic simple peritonitis, in which ascites lasts for long periods, may be associated with chronic renal disease ; syphilis may give rise to both ascites and albumin- uria ; and in some instances albuminuria may be directly due to the pressure of the ascitic effusion on the renal veins. The presence of sugar in the ascitic fluid occurs in cases of cirrhosis with hemochromatosis, in which glycosuria usually supervenes about a year before death, and so is a bad prognostic ; but it is hardly likely to be noticed before glycosuria has been detected. The presence of melanin in the urine, which is easily established by the occurrence of a dark colour, either after the addition of nitric acid or of ferric chloride, proves that there is a malignant melanotic growth, almost certainly in the liver. Physical Characters of the Ascitic Fluid. — Clear ascitic fluid is met with both in conditions, such as hepatic cirrhosis, backward pressure from cardiac disease, and occasionally malignant growth, in which the outlook is grave, and also in tuberculous peritonitis, in which the prognosis is comparatively good. In cirrhosis there is often a yellow tint due to bile, and this may also occur in cardiac disease, so that this coloration is somewhat ominous. Generally speaking, without the assistance of a cytological examination (vide infra), these naked-eye appearances do not justify an opinion as to the prognosis. Turbid ascitic fluid points to subacute inflammation, and is also seen in less favourable cases of tuberculous peritonitis. In milky ascites the prognosis is grave ; out of 173 collected cases 116, or 67 per cent, proved fatal, the mortality for the 92 INDEX OF PROGNOSIS pseudo-chylous cases (70-4 per cent) being higher than that (66 per cent) of the chylous cases (Wallis and Scholberg^). Blood-stained ascites, which must be distinguished from an effusion of blood (hsemo-peritoneum), suggests intra-abdominal malignant disease, and so makes the outlook extremely grave ; but it may occur in portal cirrhosis, usually as the result of a previous tapping, and in association with ovarian cysts and uterine fibromyomas. Out of 31 cases of ascites due to ovarian cysts, 8 were blood-stained, and out of 55 cases of ascites due to uterine fibromyomas, 10 were blood-stained (Cabot). In these cases, the ascites can be permanently cured by removal of the innocent tumour. A blood-stained ascites therefore does not always cause grave anxiety-. A mucinoid ascites, which occurs in some cases of intra-abdominal malignant disease and also in association vAt\\. leaking ovarian cysts, renders the prognosis anxious but not certainly hopeless. Prognosis from Cytological Data. — A predominance of endothelial cells occurs in passive effusions, as in heart disease and cirrhosis, and, since ascites due to these causes is a late event, it is a somewhat grave sign. A high lymphocytosis usually points to tuberculous peritonitis, in which the outlook is comparatively favourable ; but in some cases of portal cirrhosis in which there is no evidence of tuberculosis in the abdominal cavity after death, lymphocytes are the pre- dominating cells. The presence of multinuclear cells and of atj^ical mitoses strongly suggests malignant disease of the peritoneum. Fragments of villous growth make the prognosis good, as their presence shows that the ascites is probably due to implantation of ovarian papilloma on the peritoneum ; for if the primary tumour is removed, the secondary implantations and the ascites disappear. If the opsonic index of the fluid for tubercle bacilli is lower than that of the blood, the cause is tuberculous peritonitis and the outlook fairly favourable, provided there is no reason to believe that the case is one of cirrhosis with superadded tuberculous infection. When the Wassermann reaction is better marked in the ascitic fluid than in the blood (Esmein and Parvu ') , the cause is syphilitic disease, and therefore likely to be cured by specific treatment. References. — ^Cabot, Amer. Jour. Med. Sci. Philad. 1912, clxiii, i ; ^Ramsbottom, Med. Chron. Manchester, 1906-7, xlv, 7 ; 3:\iayo, Jour. Amer. Med. Assoc. Chicago, 1904, xlix, 1157 ; *Pye-Smith, Trans. Path. Soc. 189s, xliv, iii ; ^Wallis and Scholberg, Quart. Jour. Med. Oxford, 1910-11, iv, 171 ; ^Esmein et Parvu, C.R. Soc. d. Biol. Paris, 1909, Ixvi, 159. H. D. Rolleston. ASTHMA, BRONCHIAL.. — This disease is not fatal in itself, but its complica- tions may shorten life. The paroxysm seldom if ever causes death, although there is at least one instance on record in which artificial respiration was re- quired. There are numerous cases of asthmatics having reached old age, but insurance records show that the majority do not live out their expectation. As a general rule, it may be stated that when the first attack takes place in early childhood there is a fair prospect that the disorder will cease when puberty is reached ; but a number of cases have occurred in which asthma first developed at the age of four or five and continued at intervals to the age of seventy or over. If middle age is not passed before the first attack occurs, there is alwaj's hope of a cure. After the age of forty-five, however, the tendency is usually towards a progressive increase in the severit}- of the symptoms. The disappearance of all symptoms does not necessarily mean a permanent cure, for the disorder may be absent for many years and then reappear. In estimating the prognosis in cases of asthma in which marked complications have not become estabhshed, the most important factor is the recognition of ATAXIAS 93 the cause in the particular patient. In some instances the paroxysms can be definitely associated with particular climates, or particular odours, or forms of dust. For example, some soldiers cannot be present when a horse is groomed, without suffering from an asthmatic attack ; other persons have a paroxysm when they sleep on a feather bed. When the exciting cause can be shown to be something which causes stimulation of an unduly sensitive nasal mucous membrane, the attacks can frequently be stopped altogether by appropriate treatment, provided that the patient has not been a sufferer for long, and has not acquired a ' habit.' In other cases, when it is impossible to remove the primary cause, treatment such as light cauterization of the nerve of the nasal septum appears to diminish the sensitiveness of the nasal mucous membrane, and to give rehef in a considerable proportion of cases. This reUef may be dramatic at times, but it would appear seldom to be permanent, although it may extend over several years. The use of intranasal remedies, such as dilute preparations of cocaine, often give relief for similar reasons, but they seldom if ever produce a permanent cure. At one time it was thought that the removal of gross abnormalities in the nose of asthmatic patients would be attended with excellent results. These expectations have not been confirmed, and it is doubtful whether success is obtained in more than five per cent of these operations, whereas in a not inconsiderable number the asthmatic attacks are aggravated. Further, it is a curious thing that if a polypus is removed before the light cauterization treatment, the symptoms may become worse ; whereas if the cauterization of the septal nerve precedes the removal of the polypus, good results m.ay be obtained. As a further argument of the importance of ascertaining the cause in each case, it should be mentioned that if the disorder appears to be associated definitely with gout, high blood-pressure, chronic constipation, or other pathological con- dition, appropriate treatment directed against the cause may do much to lessen the frequency of the attacks, although it seldom produces a lasting cure. In all well-established cases, we have to take the question of the family longevity into account in estimating the prognosis, but in every case the most important factors are the amount of emphysema, the degree of bronchial catarrh, and the condition of the right heart. These complications all increase the tendency to asthmatic attacks, which in turn increase the severity of the complications, and so the patient lives in a vicious circle. By the relief of complications much can be done to prolong Life. The introduction of appropriate vaccine treatment for bronchitis has helped to prolong the life of many asthmatics. In a number of instances considerable relief of the bronchial catarrh has been obtained, together with an increased immunity against particular organisms ; hence longer intervals occur between the attacks of bronchitis, and consequently there is greater freedom from the paroxysms. Again, the use of ' pressure baths ' for the treatment of emphysema has given considerable relief, and hence a longer life in some cases. In fact, it may be stated with some conviction that modern methods of treatment have tended, by the removal of the initial cause, or by the relief of serious complications, to do much to improve the general prognosis in persons suffering from asthma. It may be of interest to add, that a person who suffers from asthma seldom develops tuberculosis, cancer, or Bright's disease. Arthur Latham. ATAXIAS. Tabetic Ataxia. — As we have indicated elsewhere {see Tabes Dorsalis), ataxia is a relatively late symptom of tabes, and in a large proportion of tabetic cases, if the malady be recognized in the early stage, ataxia need never develop at all. 94 INDEX OF PROGNOSIS The symptom is best prevented by careful avoidence of physical over-exertion and by systematic exercises of the limbs, always stopping short of any sensation of fatigue. Once ataxia has supervened, its intensity is proportional to the muscular hypotonia, and to the degree of impairment of joint-sense and of kinaesthetic sense. The prospects of alleviation or cure of tabetic ataxia vary widely in different cases. The occurrence of optic atrophy seems to have a mitigating effect upon its incidence ; this, however, only applies to cases of moderate ataxia in which optic atrophy supervenes relatively early in the course of the disease. In some tabetic cases where ataxia has developed with great rapidity, rest in bed for a few weeks or months has a markedly beneficial effect ; and the patient, previously unable to walk without support, may spontaneously regain to a large extent his powers of progression. In other cases again, where the ataxia has been slowly and steadily getting worse, an acute intercurrent illness, confining the patient to bed, may rapidly aggravate all the symptoms, so that he may pass from the ataxic to the so-called paralytic or helpless stage. In the majority of cases, however, the ataxia is slowly and gradually progressive. What is the prospect of improvement in this class of tabetic patients ? Carefully devised exercises, under skilled supervision, can generally improve the ataxic symptoms, the amount of such improvement being dependent on the intelligence of the patient and upon the patience and ingenuity of the physician. It is not uncommon for a previously bedridden patient thus to regain the power of standing or even walking, with or without support. Or a patient in whom the gait is moderately ataxic may, as a result of these exercises, gain confidence to such a degree that he succeeds in correcting and concealing his ataxia, so as no longer to be an object of remark to the unskilled observer. Real cure of ataxia does not occur, but the acquisition of new modes of movement has a compensatory effect and may to a large extent conceal the old ataxia. Family and Hereditary Ataxia. — Whether this be the type known as Friedreich's, Marie's cerebellar type, or the intermediate spino-cerebellar variety, the ataxia has a slow and insidious onset in childhood and adolescence, the legs being affected earlier and more severely than the arms. The degenerative process being essentially progressive, the prognosis is unfavourable as regards relief of the ataxia, and it is futile to attempt re-educative exercises. The malady itself does not necessarily shorten life, and the patient may survive for many years, even when helplessly ataxic. The prognosis as to life depends upon the assiduity with which the patient is nursed and looked after, and upon the care with which intercurrent maladies can be avoided. Ataxia due to Focal Lesions of tlie Cerebellum. — This may be vascular in origin (as in thrombosis or haemorrhage), or inflammatory (as in abscess, acute encephal- itis or locaUzed meningitis), or associated with cerebeUar tumour. In such cases, the prognosis of the ataxia depends on whether the underlying cerebellar disease can be removed by surgical or medicinal means. If so, the ataxia may entirely disappear, even in cases where a considerable amount of cerebellar tissue has been permanently destroyed. Ataxia due to Focal Lesions elsewhere in the Brain. — In cases where ataxia is one of the symptoms of focal disease in other parts of the brain — e.g., in the corpora quadrigemina, optic thalamus, crura cerebri, etc., — the prognosis is, as a rule, unfavourable ; since, even if the lesion happens to be a stationary one, compensatory action by other parts of the brain does not, as a rule, occur. Purves Stewart. ATROPHY, MUSCULAR [See Muscular Atrophies.) BLADDER, CALCULUS OF 95 BERI-BERI. — The prognosis is variable, and in all countries the mortality is less now than it was a few years ago. Thus, in the Malay States, the mortality in the institutions used to be from 10 to 15 per cent, but in later years was only 2 to 4 per cent. Both higher and lower rates have been recorded, and in some outbreaks it has been 40 per cent or more. In others, where all the cases are of a mild type, it may be under 2 per cent. The larger the proportion of the ' wet ' variet}', the higher the mortaUty. Recovery, when it takes place, is usually complete ; but the restoration of the deep reflexes may be delayed, and in a small proportion of cases there is permanent loss of power of the extensor muscles. C. W. Daniels BLACKWATER FEVER. — This disease is variable in severity. Essentially an acute hemolytic process of doubtful causation, it may last for an hour or two, when it will be no more dangerous than a paroxysm of paroxj-smal haemoglobin- uria ; or it may last for three days or even more, when four-fifths of the blood in the vessels may be destroyed, and death occur from the anaemia. In other cases the continued fever, or sometimes h^-perpyrexia, may cause death in this anaemic condition. The cause of nearly four-fifths of the deaths is suppression of urine, due to blocking of the renal tubules in the kidneys, and particularly of the tubules in the pyramids. This process commences as soon as the urine becomes loaded with hsemolytic products, and the prognosis is in the main determined by the success of measures adopted from the onset of the disease and designed to prevent this occurrence. The risks from this cause, suppression, in cases treated from the onset, is much reduced, and in such cases the mortality is under 10 per cent. Where the tubules, or even a large proportion of them, become blocked, the outlook is most unfavourable. Usually death takes place within three days of the onset of suppression, but may be postponed for a week, or even more. In some cases the flow of urine is re-established as a result of the large quantities of fluid given in various ways. If the urine be of low specific gravity, it usually indicates that only a small portion of the kidney has resumed its functions, and death occurs. Operation, such as incision of the kidneys, may result in a flow of such urine, but these cases have so far all terminated fatally. Under modern methods of treatment the mortahty, including all cases, even those where treatment is not commenced earlj', is about 30 per cent. C. W. Dante s BLADDER, CALCULUS OF. — Stone in the bladder is a painful malady, and it is seldom that the disease is allowed to run its course without an attempt at relief by operation. There are, however, cases where the symptoms are comparatively sUght, so that the patient either disregards them, or knowing that a stone is present, prefers the pain or discomfort to the risk of operative interference. Such stones may remain in the bladder for fifteen or twenty years, or even longer, and reach a great size. Eventually, however, and usually at a very much shorter period than this, an unreUeved vesical calculus causes death, either by ascending pyelonephritis, or by back pressure causing dilata- tion of the Iddney and interstitial nephritis, or by a combination of the two. In the great majority of cases an operation is performed, and the prognosis of vesical calculus lies in the success or failure of the operative measures under- taken. The following factors are important : (i) The date of the operation ; (2) The presence of sepsis ; (3) The presence of bladder complications ; (4) The presence of kidney complications ; (5) The result of the operation. 96 INDEX OF PROGNOSIS 1. The Date of Operation. — When a small calculus is lodged in the bladder, its removal is a simple matter, and the danger to which the patient is exposed is very slight. The operation can be performed under local anaesthesia, so that the small danger of a general anaesthetic is avoided. An evacuating cannula and bulb may suffice to remove the calculus from the bladder, or the use of a small lithotrite may be necessary. There should be no mortality for such an operation. At a later stage, the size, number, and density of the stones, the presence of sepsis and of other complications, render the outlook for operation more serious. In the advanced stage, when the kidneys are diseased, operation of whatever kind is a serious undertaking, and is attended by a considerable mortality. 2. The Presence of Sepsis. — There are two classes of cases. In one, an aseptic calculus becomes infected either spontaneously or after the passage of instru- ments ; in the second, the calculus develops in a bladder already infected. The majority of calculi in the first class are composed mainly of oxalate of lime or uric acid, and they increase very slowly in size or number. When the urine becomes infected, and especially when the reaction of the urine becomes alkaline, a rapid increase in size takes place from the deposit of phosphates on the surface of the stone. Phosphatic calculi formed in an infected bladder develop very rapidly, a calculus of considerable size developing in a few weeks. Sepsis affects the prognosis in two ways. The mortality of operations on infected stones greatly exceeds that of operations on aseptic stones ; and secondly, the probability of recurrence after operation is much greater. 3. Bladder Complications. — A healthy bladder, or one with a moderate degree of cystitis, will permit of an easily performed and complete litholapaxy, the mortality of which is very low, and the probability of recurrence slight. When severe cystitis is present, and the bladder is acutely spasmodic, litholapaxy becomes difficult and may be impossible, and lithotomy becomes necessary, with a higher mortality. When the bladder is sacculated, or when a diverticulum is present, litholapaxy should not be performed, and suprapubic lithotomy is necessary. In such cases sepsis is always present, and it is very difficult and frequently impossible, to get rid of the infection. The prognosis is grave, for recurrence of the stone is probable, and ascending pyelonephritis may supervene. When a solitary diverticulum of large size is present, an operation for the removal of this will be necessary. New growths of the bladder occasionally complicate calculus. In such cases . the prognosis depends upon the nature of the growth, and upon the ability of the surgeon to diagnose its presence before attempting litholapaxy. Bilharzial disease of the bladder is a grave complication of stone, met with in countries where bilharziosis is rife. Septic complications are common, and fistulae follow cutting operations with great frequency. Perineal lithotomy is the operation usually chosen by those experienced in such cases. Enlargement of the prostate complicates vesical calculus by increasing the probability of renal complications, and if the obstruction is left untreated, by favouring recurrence of the stone. Litholapaxy is possible when there is a moderate enlargement of the prostate ; but it is unsafe, and may be mechanic- ally impossible, when the enlargement is pronounced. The proper treatment of stone in the bladder with enlarged prostate is suprapubic prostatectomy with removal of the calculus. 4. Kidney Complications. — Infection of the kidneys is the most serious compli- cation of vesical calculus, and is the commonest cause of death after operation, BLADDER, CALCULUS OF 97 or when no operation has been performed. The infection takes the form of a pyehtis in milder cases, and a pyelonephritis in the more severe. Stone in the kidney is a not infrequent complication. In many of these cases the stone in the bladder has developed on a small calculus passed from the kidney. In other cases the bladder is the seat of chronic cystitis from repeated descending infection from the kidney, and the vesical calculus forms in the infected bladder. Kidney symptoms may be absent or insignificant, and the presence of renal calculi and infection is very frequently overlooked. The prognosis in such cases is grave. An operation upon the kidney is required, in addition to that on the bladder, and nephrectomy may be necessary. In such a case the presence of cystitis, if this cannot be cured, is a menace to the remaining kidney, from ascending infection. 5. The Results of Operation. — The operation chosen, and the results of operation, depend upon the factors which have already been discussed above. Litbolapaxy is the operation of choice. Suprapubic lithotomy is performed when there are bladder complications, such as sacculation, diverticula, bladder spasm, enlargement of the prostate, intractable cystitis, new growth of the bladder ; when the size and hardness of the stone make crushing impossible ; or when septic renal complications render bladder drainage advisable. Perineal lithotomy is reserved for special cases, such as those with stone in the urethra complicating vesical calculus, and also for cases of bilharziosis. The mortality statistics of litholapaxy are much lower than those of lithotomy, but they hardly give a fair index of the relative gravity of the two operations ; for many surgeons reserve lithotomy for the more serious complicated cases, while performing litholapaxy in all simple ones. The following figures show the results of 1890 stone operations performed at St. Peter's Hospital from 1864 to 1914. Results of Operation for Stone in the Bladder. {St. Peter's Hospital, 1 864-1 91 4.) Date Operations Cured or lielieved Died Mortality per cent 18G4-73 118 100 18 15-25 1874-83 196 166 30 15-30 1884-93 362 332 30 8-29 1894-03 600 571 29 4-80 1904—13 578 559 19 3-28 1914 36 35 1 2-85 Statistics collected by Keegan of stone operations in India show that the mortality in 10,073 litholapaxies was 3-96 per cent ; in 7,201 cases of lateral lithotomy it was 11-02 per cent, and in 147 cases of suprapubic lithotomy, 42-17 per cent. In the Indore Charitable Hospital, Central India, in the period 1 881 to 1900, there were 500 litholapaxies in boys, with 11 deaths, a mortality of 2-2 per cent ; and 18 litholapaxies in young girls, all successful. The death-rate of litholapaxy in the hands of various surgeons is as follows : Guyon, 2-7 per cent ; Zuckerkandl, 3-6 per cent ; v. Frisch, 2-6 per cent ; Legueu, 2 per cent ; Freyer, 2-61 per cent. Watson collected from the litera- ture 17,736 cases of litholapaxy, with 426 deaths, a mortality of 2-4 per cent. The influence of age upon the result was shown by the following figures : Between one and fifteen years there were 2518 cases, with a mortality of 1-7 per 7 98 INDEX OF PROGNOSIS cent; between sixteen and fifty, 719 cases, with a mortality of i-6 per cent; over fifty there were 3395 cases, with a mortality of 4-4 per cent. The ■mortality of suprapubic lithotomy is much higher: Zuckerkandl, 13-5 per cent; v. Frisch, 12-7 per cent; Barling, 17-8 per cent; Dittel, 15-6 per cent; Preindelsberger, 12-9 per cent ; Guyon, 24-3 per cent ; Nicolich, 7-45 per cent ; Freyer, 12-75 per cent. Watson collected 3303 cases, with 436 deaths (13-2 per cent). The high mortality of suprapubic lithotomy, compared with litholapaxy, is due to the fact that all the grave cases were treated by lithotomy. When the same class of cases is treated by one or other operation, the results are less disproportionate. Thus Assenfeldt, in 460 cases of suprapubic lithotomy, found a death-rate of 3-6 per cent. Late Results of Operation. — Watson found 19 per cent of recurrence in 902 cases of litholapaxy, and in more than two-thirds of these the patients were fifty years of age or over. Zuckerkandl found 12 per cent of operated cases recurred. There is no difference in recurrence after the operation between lithotomy and litholapaxy, in the hands of an experienced surgeon. The use of the cystoscope immediately after the operation, or a few days later, checks the result, and provides against allowing the patient to depart with fragments unre moved. Recurrence takes place most frequently from new formations of phosphatic stone, usually in the subjects of enlarged prostate. Recurrence of oxalate of lime or of uric acid calculi is much less frequent, but may occur from the descent of calcuU from the kidney, or from new formation in the bladder. The latter is very rarely the result of fragments left behind at a crushing or cutting operation. The recurrent calculus, after removal of a uric acid or oxalate of lime calculus, may be phosphatic, and is due to changes in the urine. The effect of removal of an enlarged prostate upon the recurrence of calculi varies according to their composition and the state of the urine. Uric acid and oxalate of lime calculi rarely recur ; phosphatic calculi frequently. /. W. Thomson Walker. BLADDER, EXSTROPHY OF. — There is some variation in the degree of extroversion of the bladder. In the common form the anterior wall of the bladder is deficient, so that the bladder mucous membrane is exposed and bulges above the rudimentary penis, and the urine is discharged on the surface from the uncovered ureteral orifices. The conditions of existence are miserable in the extreme. There is continual escape of urine, saturating the clothes, and leading to inflammation and excoriation of the skin of the thighs and buttocks. The child lives in a pungent atmosphere arising from decomposing urine, and his life is a burden to himself and to those around him. Associated deformities such as hare-lip, cleft palate, and spina bifida may be present, and contribute to a fatal issue in infancy or early childhood. Progressive dilatation of the ureters and kidneys occurs. Ascending pyelo- nephritis is the commonest complication, and is the usual cause of death — ■which takes place, as a rule, during childhood or youth. Occasionally the patients survive till adult life, and even attain old age. A malignant growth jmay develop in the exposed bladder. The operations performed for extroversion of the bladder are numerous, and their number is an index of the poor results generally obtained. The principal symptoms against which treatment is directed are the incontinence of urine, the pain and discomfort, and the infection ; and by the success in abolishing these the value of the different operations may be measured. These operations will be considered in three groups, as follows : — BLADDER, EXSTROPHY OF 99 1. Autoplastic Repair of the Bladder. — The ingenuity of many surgeons, among whom are Roux, Sedillot, Billroth, Thiersch, Wood, Le Fort, and Legard, has been devoted to closing the bladder by flaps of skin ; and Pozzi, in addition, attempted to form a fibro- muscular shield in front of the recon- structed bladder, from the adjacent abdominal wall. The mortality of these procedures is not great, but the results are not satis- factory. There is frequently failure to obtain healing in even the most carefully planned operation, and many secondary operations are required. Occasionally the bladder is covered in at a single operation. The total gain in a successful operation of this nature is that the bladder mucous membrane is protected. The incontinence of urine continues, but the patient is enabled to wear a urinal, and thus some part of the misery is relieved. The infection, however, continues unabated, and a stone not infrequently develops in the partly recon- structed bladder. 2. Suture of the Margins of the Bladder, with or without Previous Operation on the Pelvic Girdle. — A few surgeons (Gerdy, Billroth) have endeavoured to close the gap by dissecting and suturing the edges of the bladder wall. This operation has, however, been attended by no success. In order to allow of the approach of the separated pubic bones, as a preliminary to closure of the bladder, Trendelenburg performed arthrotomy of the sacro-iliac articulations. The posterior ligaments of one synchondrosis are cut, and if this does not suffice to allow the pubic bones to come in contact, the other side is similarly treated, and the patient is suspended in a special apparatus for three or four months, when an attempt is made to close the bladder. The operation is a more serious one than any of the preceding, and the wings of the pelvis have been known to become separated again after some time. On the other hand, some successes have been obtained, and in three cases it has been claimed that the patient was continent after the operation. Estor states that continence has been obtained in 13 per cent of the cases operated upon by this method. Short of this the mucous membrane of the bladder is protected, with resulting improvement in the pain and inflammation. 3. Deviation of the Course of the Urine. — The number of operations of this nature is so great that only a few of the most successful can be discussed. a. Peter's Operation. — Catheters are placed in the ureters, which are dissected out, leaving a small ring of the vesical mucous membrane attached to each. The bladder is excised, and the rectum exposed extraperitoneally. The ureters are passed through the rectal wall, and the catheters are drawn through the anus, without suture. The catheters are left in position for several days. A disadvantage of this operation is that the sphincter action of the lower ureters is destroyed. In 4 cases, Peters obtained 2 good results, i failure, and i death from pyelonephritis. Sherman collected 11 cases operated by this method ; of these, only 2 died of pyelonephritis. b. Maydl's Operation. — The bladder is excised, leaving an area at the base which includes both ureteric orifices. The sigmoid colon is exposed, and the bladder base, bearing the ureteric orifices, implanted into this. Some surgeons have modified this by implantation into the rectum. The immediate mortality of Maydl's operation varies from 5-5 per cent (Josseraud, 18 cases) to 26-7 per cent (Katz, 57 cases). In Petersen's collection, 31 patients recovered from the operation : 2 of these died of pyelitis within a year ; while in 6 cases the operation was followed by fistula, which subsequently closed in every instance. Surgeons are by no means unanimous in regard to the protective power of the ureteric orifices, thus implanted, against ascending infection. In experi- INDEX OF PROGNOSIS mental work on dogs, the mortality due to ascending pj^elonephritis is very liigh. Clinically, some surgeons have recorded a high percentage of fatal cases from this cause. Pauchet, out of 4 cases, had 3 deaths from ascending infection, occurring after twelve, fourteen, and fifteen months respectively. On the other hand, cases have been recorded where the patients were in good health some years after the operation. Thus, Resigotte records a case alive and well after three years, Frank i after four years, Maydl 2 after four and iive years, Graubner and von Eiselsberg each i after five years, Ewald i after nine years, Estor I after seven years, Tuf&er i after seven years, Forgue i after eight years, Wolfler I after ten years, and Roux 2 after three and ten years respectively. The presence of urine in the rectum does not appear to have caused any reaction, and inflammation of the mucous membrane is very rare. After the operation continence is the rule. This may be established at once, or gradually develop. The rectum becomes dilated, and a considerable quantity of urine, which may be quite clear, is discharged voluntarily. Occasionally, for want of development of the perineal and anal muscles, continence is not established. This occurred in one case in Petersen's collection. The condition of the rectal sphincters should be carefully examined before embarking upon the operation. Maydl's operation is the most successful of any of those performed for extro- version of the bladder, and is the only one in which a considerable proportion of cases shows continence, together with disappearance of the pain and dis- comfort, and an absence of ascending infection. c. Soiibottine's Operation. — A rectovesical fistula is created, the rectum is opened along its posterior wall after removing the coccyx, and a broad vertical band of rectal wall, including the fistula, is raised on the anterior rectal wall, and the edges united so that a tube is formed, the orifice of which is within the anal sphincter. The gap in the anterior bladder wall is then closed. Of this operation Estor says that it is as efficient in obtaining continence as that of Maydl, and has the advantage of separating the urine from contact with fagcal matter. At the same time the operation is very complicated and may fail at some part. The infected bladder is retained, and may be a source of trouble from calculus or other cause. Further, damage is done to the anal sphincters, already'' weak in many cases. In creating the retrovesical fistula, the peritoneum may be opened and infected. Three cases operated on by Soubottine died of peritonitis. In the first 6 cases where the whole operation was performed at one sitting, 2 died ; whereas, in 10 cases in which a more recent operation in successive stages has been employed, all survived. The functional result has been very satisfactory in these 10 cases ; in all there has been voluntary micturition five or six times in twenty-four hours, the urine has remained clear, and ascending infection has not incurred. /. W. Thomson Walker. BLADDER, GROWTHS OF. — For the purpose of prognosis, growths of the bladder may be divided into two groups : (i) Papillomata or villous growths ; (2) Malignant growths. It is true that there are tumours which possess the characters of both of these groups, and it is admitted that papilloma of the bladder displays features that differ from simple growths elsewhere. The grouping is, nevertheless, a practical one, and will be used, while recognizing the pathological fallacies which underlie it. A number of varieties of growths, such as myoma, fibroma, and myxoma, are found, but so rarely that they do not merit special discussion. I. Papilloma. — Papillomata are generally regarded as benign growths. In the bladder, however, they show certain characters which give them a place BLADDER, GROWTHS OF somewhere between the well-defined benign and the clearly recognized malignant growths. They have a very pronounced tendency to become multiple ; the distribution of smaller papillomata around large growths, or of papillomata occurring at opposing points of contact of the bladder wall, suggest a special tendency to implantation ; there is also a very pronounced tendency to recur- rence of the tumours. A certain number of papillomatous growths, after retaining their benign characters for many years, infiltrate the submucous and muscular layers of the bladder wall, and show signs of true malignancy. In view of these facts, some authorities, such as Albarran and Imbert, and Brongersma, regard all papillomata of the bladder as malignant. The present writer looks upon these growths as pre-cancerous, and as occupying a position in regard to malignancy somewhat similar to that of leucoplakia of the tongue. The following are important points on which to base an estimate of the prognosis in a case of papilloma of the bladder. a. The Duration and Complications. — The history of a case of papilloma may extend over many years, an operation then having been performed. A duration of ten or fifteen years has frequently been recorded, and Albarran collected cases with a history of symptoms lasting twelve, fourteen, and thirty years. Certain complications may lead to a fatal result, and therefore increase the gravity of the prognosis. Excessive haemorrhage occurs in some papillomata. As a rule, the attacks of hsematuria are at first separated by long intervals (six months, or even one or several years), but gradually the intervals become shorter, and the attacks more prolonged and more severe. Profound anaemia may ensue, and indirectly lead to a fatal result. A serious complication of severe haemorrhage is the formation of masses of clot in the bladder. Retention of urine results from the inability of the bladder to expel the clots. The danger of infecting this clot-filled bladder by passing a catheter is extreme ; and if infection take place, severe cystitis and ascending pyelonephritis follow, and a fatal result is certain. Obstruction of the outlet of the bladder occurs when masses of papillomata are clustered round the internal meatus, or when a single papilloma with a long pedicle acts as a ball-valve. In such cases the bladder is trabeculated and sacculated, and the ureters and pelves of the kidneys are dilated. Infection of the bladder is specially liable to occur in such cases, and death from uraemia is a common result of injudicious instrumentation, or of radical operation. Infection of the bladder in papilloma rarely takes place spontaneously, and in this, papilloma differs from infiltrating growths of the bladder. The passage of an infected catheter or cystoscope is the usual cause. As already noted, it is specially liable to occur where obstruction is a feature of the case. The prognosis in a case of infected papillomatous bladder is very grave, since the infection is difficult to overcome ; and ascending pyelonephritis is a frequent and very fatal sequence. Exhaustion accounts for a large proportion of deaths. It results from con- stant irritation and broken rest, from septic absorption, and from frequently recurring haemorrhage. b. The Results of Operation. — The best results of operation are obtained in early cases where the growth is small, single, or in moderate numbers, the bladder aseptic, and the kidneys healthy. In order to operate in this early stage, it is absolutely necessary that those engaged in general practice should thoroughly grasp the grave significance of haematuria — the cardinal symptom of papilloma. It is unfortunate that the haematuria of vesical papilloma is unaccompanied by any other symptom, and that it is intermittent in character with, at first, prolonged intervals INDEX OF PROGNOSIS between the attacks. As a consequence, the patient, and not uncommonly his medical attendant also, looks upon the disappearance of the haematuria as indicating the cure of the complaint. It cannot be too frequently or too strongly urged that an attack of haematuria, however transient, is a matter of grave significance, and that the source of the haematuria must be traced and a definite diagnosis made ; and that for this purpose, in the great majority of cases, the cystoscope is necessary. The absence in the urine of cells derived from the surface of the papilloma, and the absence or presence of cells derived from the kidneys or bladder, are insufficient data on which to base a diagnosis, however definite the clinical pathologist's report or opinion may be. The prognosis for recurrence and for malignant transformation of the growth becomes graver as the duration of the papilloma is more prolonged. The following results of operation on the papilloma of the bladder may be noted : — Endovesical operations by means of the operation cystoscope have been used by some surgeons. Their use is limited to the most favourable types of bladder papilloma, when the bladder is tolerant of intravesical manipulation, and the papilloma is not too large or too extensive. Nitze recorded loi intra- vesical operations for papilloma, performed before 1902 ; of these, 71 cases remained without recurrence, there were 18 recurrences, and 12 cases could not be followed. Removal by suprapubic operation includes all classes of case. Rafin collected 265 cases, of which 21 died, a mortality of 8 per cent. He found, however, that the mortality improved considerably in recent cases ; thus, in the latest 156 cases, the death-rate was 3-8 per cent. An examination by this author of the remote results in 115 cases, showed 33 recurrences, or 28 per cent ; there were 82 cases without recurrence, at periods varying from one to five years ; in 18 cases there was no recurrence after a period of over three years. Recurrences of papilloma take place after considerable intervals, such as four, six, seven, or eight years after operation. According to Legueu, the patient can never consider himself completely free from the possibility of recurrence. As a rule, recurrence after operation in papilloma takes the form of multiple growths, at first of small size. The introduction of the high-frequency cauteri- zation of papillomatous growths, by Beer of New York, has greatly improved the prognosis in such cases. The bladder, after an operation for papilloma, should be examined at intervals of three months at first, and later, of six or twelve months, and on the first appearance of recurrence, the small papillomatous bud is destroyed with the high-frequency cautery. Sufficient time has not yet elapsed since the introduction of this method to gauge the full effect on prognosis. It is certain, however, that by this means the number of secondary open operations will be considerably diminished ; and, the treat- ment being applied in the earliest stage of a recurrence, the gravity of the procedure will be much less. A certain number of recurrent growths, after operation for papilloma, have proved to be mahgnant. Burckhardt found that of 15 cases operated on for papilloma, and in which the growth recurred, the recurrent growth was malignant in 3. 2. Malignant Growths. — The outlook in malignant growths of the bladder, when no radical operation is undertaken, is a certainly fatal one. The duration of the disease varies considerably. There are a number of cases where symptoms, such as haematuria, have existed for some years — as long as five BLADDER, GROWTHS OF 103 or even eight years — and then a rapid advance takes place, the growth infiltrates widely, forming metastases, and death quickly supervenes. In such cases the total duration of symptoms, up to the time of death, may reach eight to ten years. The most common type shows a steady advance of sym- ptoms, which terminate fatally in from one and a half to two years. Malignant growths of the bladder are, in their earlier stages, admirably suited for radical operation in proper hands. Spread to lymphatic glands, and metastatic deposits in distant parts, take place only in the latest stage ; and the prospect of cure by a well-timed and properly planned operation is, compared with malignant growths of other internal organs, extremely good. The following factors directly influence the prognosis by their effect on the result of operation. a. The Nature of the Growth.— -The different varieties of malignant growths of the bladder vary widely in their rapidity of growth and tendency to recurrence after operation. The most chronic in its growth, and the slowest to recur, is the epitheliomatous ulcer or cancroid, which forms a depressed ulcer, and has the structure of a squamous epithelioma. The nodular malignant growth varies considerably in its size, and also in the rapidity of its growth, and recurrence after removal ; histologically, these growths show either the characters of a spheroidal-celled carcinoma, or they are formed of papillo- matous tissues so closely welded together as to be almost unrecognizable. Some malignant papillomatous tumours show rapid and luxuriant growth, and very rapid recurrence after operation. b. The Extent of the Growth. — Extension of a bladder growth may be intra- vesical, intramural, perivesical, or there may be glandular involvement. The intravesical extension is gauged by means of the cystoscope. A malignant growth of very large size is seldom worth while operating upon with the view to radical cure, as it will certainly have passed beyond the limits of the bladder and formed deposits elsewhere. The particular size of the growth which experience has taught me is suitable for partial resection of the bladder does not exceed a walnut or the area of a two-shilling piece as seen by the cystoscope. The intramural spread is almost always more extensive than the intravesical extent would suggest ; it is best gauged by the finger, after opening the bladder. The perivesical spread can only be estimated at operation. Extensive intramural spread, and perivesical encroachment of the growth, render the case unsuitable for partial resection of the bladder wall, and therefore affect adversely the prognosis. c. The Position of the Growth. — A growth situated at or near the apex of the bladder is in the ideal position for resection. As the position of the growth, in different cases, approaches the base, it becomes less and less suitable for resection. The reason for this is not due to any increasing malignancy in growths at the lower part of the bladder, but to the closer relation to the ureters, the trigone, prostate, and urethra. If a clear exposure of the lower part of the tumour can be obtained, and the surgeon does not allow himself to be hampered by an attempt to avoid the ureters or trigone, the middle and even the lower parts of the bladder are still suitable for resection ; the lower part of the ureter being, if necessary, removed with the growth, and the stump implanted in the bladder wound. When the growth has encroached upon the trigone, or lies in close proximity to the urethral orifice, resection should not be performed. In 3 out of 5 of my cases of recurrence the growth was situated in close relation to the trigone and ureters, and in 2 of these the size was so considerable as to interfere with the manipulation at the lower part of the incision. I04 INDEX OF PROGNOSIS d. The Condition of the Bladder and Kidneys. — The greatest danger at the time of the operation, and after recovery from it, is sepsis. Mahgnant growths of the bladder have a special tendency to spontaneous infection. Over 40 per cent of all the cases that have come under my observation have presented the clinical picture of spontaneous cystitis, and were referred to me without a suspicion that a malignant growth underlay the cystitis. In 2 per cent of the cases the cystitis was so severe and persistent that opera- tion had to be refused on that account. Cystitis is not only a danger to the patient, from the pelvic cellulitis and other septic complications that may follow operation, but it gravely hampers the work of the surgeon, rendering the bladder cavity much smaller, and the bladder wall difficult to manipulate. Ascending pyelonephritis may be present before the operation, and accounts for some part of the operation mortality. It is a serious danger during the early part of convalescence when the case is already septic, and may cause death many months or some years after recovery from the operation. It is not more liable to occur when a ureter has been transplanted : in 10 of the author's cases, resection of the ureter and implantation in the wound was necessary ; in none of these cases did pyelonephritis develop. Results of Operation for Malignant Growths. Palliative Operations. — These occasionally become necessary in order to treat symptoms. Apart from the relief given in this way, no permanent benefit is obtained. The patients survive from three to nine months, or, less frequently, a year. Removal of the Tumour. — Removal only, without any attempt to remove the tissues round the tumour, does not appear to prolong life. Rafin collected 57 cases, with 8 deaths, or 14 per cent. Of the 49 survivals, only 38 were followed. The most part were dead, or suffering from recurrence, within a year ; 4 were dead of recurrence in one and a half, two and a half, or nine years ; 6 had not shown recurrence after periods of one, one and a quarter, two, four, and four and a half j^ears. Resection of the Bladder Wall. — i. Operation-mortality . — Rafin collected 96 cases, of which 21 died, a mortality of 21-8 per cent. Rovsing collected 16 cases, with 3 deaths, a mortality of 18-7 per cent. The following personal statistics may be noted :— Operator Cases Deaths Mortality per cent Brongersma - 36 Heresco ... 4 Zuckerkandl - - 8 Thomson Walker - 30 5 1 3 14 25 10 ii. End-results. — In 96 cases collected by Rafin, 75 survived the operation, but in only 52 was the late result known. Of these, 31 were followed till recur- rence appeared, or death, supervened ; this occurred in six months in 13 cases, twelve months in 11 cases, in the second year in i case, after three years in 2 cases, after four years in 2 cases. There were 21 cases without recurrence. Of these, 12 were followed for less than two years, while 9 were followed two years or over : 4 two years, i three years, i three and a quarter years, i four years, i five years, and i six years. BLADDER, TUBERCULOSIS OF 105 In Rovsing's collected cases, 13 survived operation. Of these, 4 cases died of recurrence from four and a half to nineteen months after operation, and i died of cerebral tumour. The following cases are known to have survived : 2 one year, i seventeen months, 2 three years, i six years. Brongersma gives the following results in his cases : 9 cases died from recur- rence or metastases under two years, i died some months after operation from pneumonia, 2 were still under treatment, 18 showed neither recurrence nor metastases at periods varying from some months to seven years. Kiimmel reports that of 47 cases of bladder resection for malignant growth, 10 are well after six and a half, eight, fifteen, and sixteen years, and i died of recurrence ten years after the operation. In 25 cases of resection by the author in which late information was obtained, there were 3 deaths from ascending pyelonephritis, and 6 recurrences, one of which was re-operated, and was well four years after the second operation. In 17 cases the patients were alive and without recurrence, as follows : six months after operation in 6 cases ; twelve months in 3 ; eighteen months in 6 ; two years in i ; and four and a half years in i. (Statistics, March, 191 1.) Total Extirpation of the Bladder [Cystectomy). — Of 39 cases collected from the literature, death occurred after the operation in 18, a mortality of 46- 1 per cent. Only 10 cases could be traced, and in only 2 of these was the period after the operation longer than fifteen months ; i was well five years afterwards (Hogge), and i sixteen years (Pawlik). Later statistics give an even higher mortality. Verhoogen and de Graeuwe collected 59 cases of total cystectomy, with an operation mortality of 52-7 per cent. Of the 27 cases that survived the operation, 6 died in the first year, 7 died before the third year, and only 2 survived more than three years. Cystectomy must, at the present time, be looked upon as a desperate measure which holds out little, if any, prospect of a cure. /. w. Thomson Walker. BLADDER, INJURIES OF. — {See Abdominal Injuries.) BLADDER, TUBERCULOSIS OF. — It is now well recognized that tuberculosis of the bladder is never, or only in the very rarest cases, primary, and that it results from extension of tuberculous infection from the kidney by way of the ureter, or from the prostate or seminal vesicles. This being the case, the prognosis depends largely upon that of tuberculosis of the kidney or genital organs ; and to these the reader is referred. {See Kidney, Tuberculosis of ; Epididymitis, Tuberculous.) There are, however, some points that may suitably be discussed here. I. The Course of Untreated or Unsuccessfully Treated Vesical Tuberculosis. — The course of tuberculous cystitis is slowly progressive, with periods of improve- ment and periods of relapse, dependent partly upon changes of diet and climate. At the commencement there may be a period of acute cystitis which subsides, a slight subacute cystitis persisting. More frequently, however, the onset is insidious, and the progress very gradual. After some years, the continual calls to micturate become very distressing, and the patient is worn out from loss of sleep. If septic complications are avoided, death takes place after some years from renal failure due to bilateral renal tuberculosis. More often there are septic complications, caused, almost invariably, by infection intro- duced by septic catheterization, or after drainage of the bladder by cystotomy. The condition of the patient, when this occurs, is distressing. There is constant desire to micturate, unsatisfied by the passage, with pain and scalding, of a few drops of urine every ten or fifteen ininutes. The frequency and irritation continue day and night. During the day some method of collection of the io6 INDEX OF PROGNOSIS urine becomes necessary, owing to the active incontinence which develops, and a rubber urinal is worn ; during the night the rest is broken by the constant calls, and bed-wetting is frequent. Secondary phosphatic calculi form in the bladder, and add to the pain and distress. Eventually, exhaustion combined with septic absorption bring about a fatal result, or ascending septic pyelo- nephritis may cut short the course of the disease. 2. The Origin of the Tuberculous Infection. — Where tuberculous cystitis is secondary to renal tuberculosis, the prognosis varies at different stages of the disease. In unilateral renal tuberculosis, tuberculous cystitis affects the prognosis but little. Removal of the tuberculous kidney is followed in most cases by a disappearance of the vesical infection, and the result is hastened by a course of tuberculin. It is a peculiarity of tuberculous cystitis, however, that even when the tuberculous infection has been quite cured, some increase in the frequency of micturition remains. Another point of interest in regard to these cases is that tuberculous ulceration of the bladder may be present, demonstrated by the cystoscope, and yet the urine be absolutely clear to the naked eye. In the later stages of renal tuberculosis, tuberculous cystitis is a serious complication, from the constant irritation and loss of sleep that it produces, and especially from the danger of sepsis and ascending pyelonephritis. In tuberculous cystitis secondary to tubercle of the prostate and seminal vesicles, the prognosis is not so good as in the early stage of renal tubercle. The results of treatment of the disease of the prostate and seminal vesicles by operation are not satisfactory, and septic complications are very frequent. Some cases react well to tuberculin, but in many the improvement is only partial and temporary. 3. The Results of Treatment. — Removal of the source of the tuberculous infection, as for instance the kidney, is the basis of treatment. Where this is impossible, as in bilateral renal tuberculosis, or when it has failed, as in per- sistent tuberculous cystitis after nephrectomy for unilateral renal tuberculosis, more direct measures are necessary. Tuberculin treatment is the most successful method, and the most favour- able cases are those where the original focus of tubercle has already been removed. Where the infection is mixed, vaccines should be used alternatively with the tuberculin injections. Local treatment by washing, or by instillation of various drugs, is highly recommended by some authorities. The best known of these methods is the repeated instillation of 5 per cent carbolic acid recommended by Rovsing. Good results are claimed for this treatment, but exact figures are not available. With all these methods there is a danger of introducing sepsis and producing a mixed infection. J. W. Thomson Walker. BONE TUMOURS. — We have to consider the following growths of bone : osteoma, chondroma, sarcoma, carcinoma, multiple myeloma, 'thyroid cancer,' and cysts. Epulis is discussed elsewhere {see Jaws, Growths of). Several of the above can be dismissed with a few words. Osteoma.— Ivory osteoma, usually arising about the orbits or on the jaw, is a progressive tumour of extremely slow but steady growth, and does no harm unless it presses on important structures. Cancellous osteomata and exostoses are usually capped by cartilage which ossifies at about twenty-one to twenty-four, when the growth of the skeleton ceases, so that the exostosis attains its maximum at that age. Large sessile cancellous osteomata may, however, go on growing. Complete removal is not followed by recurrence. BONE TUMOURS 107 Chondroma. — A pure chondroma, such as may be found on the fingers of young adults, grows slowly but progressively, and is not dangerous to life, and does not recur after removal. Large, rapidly-growing cartilaginous tumours on a bone are usually to be classed with the periosteal sarcomata undergoing degeneration, and are very malignant. Myeloid Sarcoma. — By this we mean a very vascular, usually deep-red, central tumour expanding the bone, containing a great number of giant cells under the microscope. It must be remembered that a central tumour of bone is not necessarily myeloid ; it may be a malignant sarcoma, but this is uncommon. The older literature, including much of that utilized in Butlin's Operative Surgery of Malignant Disease, is quite unreliable in its description of the exact nature of the growth. He collected from the literature the following cases of ' central sarcoma ' : — Humerus. — 10 cases ; 3 died of recurrence or metastasis (two of which were myeloid) ; 5 well, one to three years ; 2 well, over three years. In most of these, Berger's amputation was performed. Radius and Ulna. — 10 cases : i died of recurrence (probably not myeloid) ; 3 well, one to three years ; 6 well, over three years. Femur. — 14 cases : 5 died of metastasis (3 of these were myeloid) ; 2 recurred in situ ; 2 were well one to three years later ; 5 were well over three years. Nearly all these were treated by amputation. Tibia and Fibula. — 20 cases : 2 died of metastasis or recurrence (round-celled sarcoma, not myeloid) ; 9 well from one to three years ; 9 well over three years. Here again, nearly all were amputated. It will be observed, therefore, that in five cases myeloid gave rise to fatal metastases, but that 23 were well one to three years after, and a further 22 were well over three years. Coming to more modern investigation, we find that there is a general consensus of opinion that myeloid is practically an innocent tumour, and it is very unusual for metastasis to occur when the diagnosis has been made by a reliable microscopist. The writer knows of one recent case in which fatal secondaries appeared in the lung. On the other hand, Bloodgood reports that 18 cases seen by himself are all alive and well ; he added to this from the literature, and finds that of 26 treated by curetting out, 5 recurred, but none formed secondaries ; the other 21 were cured. Of 22 resected, i recurred and was amputated ; the rest did well. Eve reports 7 cases treated at the London Hospital by amputation, resection, or, in one case, scraping ; all were well from one and a half to ten years after. Eight cases treated in Bristol by resection or scraping out have all done well, except that local recurrence took place in two cases scraped out. We may conclude, therefore, that the risk of metastasis in the lungs exists, but is quite small, that inadequate local operations may be followed by recur- rence in situ, but that almost all cases can be cured by an adequate operation. Amputation is only occasionally necessary, as, for instance, if the bony shell over the growth is very thin, and so great a length would have to be resected as to make the limb useless. The operation mortality quoted by Butlin relates to ancient surgery ; nowa- days the risks are very small, probably not more than i or 2 per cent. Periosteal Sarcoma.- — It is difficult to obtain accurate accounts of the prognosis of this disease from the literature, because so many statistics are hopelessly vitiated by the inclusion of cases of myeloid, or what is described as " mixed round or spindle cells and giant cells," which usually means myeloid. io8 INDEX OF PROGNOSIS When this fallacy is eliminated, it becomes difficult to find cases of cure in patients with a genuine round- or spindle-celled sarcoma. The fiat bones give better results than the long bones. Kocher could only collect 15 instances of cure of periosteal sarcoma of the long bones, after amputation, in 1906. The more favourable statistics of Wyeth, Bergmann, and the Tubingen clinic, all include endosteal growths. Alexis Thomson records 5 periosteal sarcomas of the femur and 2 of the humerus treated by amputation (Berger's in the latter cases), but only one remained well, a femur patient being alive two and a half years after. Nancrede published, in 1909, the end-results of 65 cases of excision of the scapula for sarcoma. They were as follows : 10 cases insufficiently followed ; 35 cases died within two years ; 7 cases well over four years. Death usually took place within a year (26 cases). In one case recurrence was as late at five years after- wards. The writer has seen an unpublished case of mixed-celled sarcoma well more than three years after removal of the blade of the scapula. The operation mortality in Nancrede's series was about 10 per cent. Sarcoma of the Humerus is terribly malignant. The mortality of Berger's operation since 1887 is about 6 per cent (Chavasse, Barling, Dent, quoted by Butlin). The only case of cure mentioned by Butlin in which the diagnosis was microscopically confirmed, was a growth of the lower end of the humerus amputated in Gottingen, and well at least eight years afterwards. Sarcoma of the Femur is common, and very malignant. The mortality of amputation at the hip-joint was considered to be about 12 per cent, but is probably less at the present time. In Butlin's series of 68 cases, only 2 lived for three j'ears ; i of these had had a growth for seven years, and it is not certain that the other was a periosteal sarcoma. A case treated by local removal at the Bristol Royal Infirmary in 1910, associated with repeated fractures in 1904, 1906, and 1910, was seen apparently cured in September, 1913. The microscopical report, by a front-rank pathologist, was fibro-sarcoma. Sarcoma of the Tibia or Fibula. — In a series of 35 cases, ButHn found i alive and well after seven years, and 4 well between one and two years. The patient apparently cured had had the growth for eight years before operation. A case at the Bristol Royal Infirmary treated by amputation was quite weU when last seen, fifteen months later. Recurrence is not usual in the stump, but the patient dies of metastases in the chest, with groin glands also invaded in many cases. Sarcoma of the Skull. — Although of course the great majority of these cases are very unfavourable and proceed to a fatal termination in six to twelve months, with pressure on the brain, or an external fungating swelling, there are a few instances in which the growth appears to be less malignant in nature. One such, removed at the Bristol Royal Infirmary in 1904, recurred in 1908, and was then the size of a hen's egg ; it was again removed, and four years later the patient was known to be well, and is almost certainly still alive, though out of England. The microscopical diagnosis was fibro-sarcoma. In another case seen by the writer, the growth, a spindle-celled sarcoma, was stationary for five years (further history not known) after injections of Coley's fluid. Jacobson and Morris both record patients Hving for five or six years after the first appearance of the growth. Bergmann claims to have cured 5 (how long followed is not stated) out of 17 cases operated on. Some tumours of the skull are myeloid in nature, and may yield better results. Sarcoma and Carcinoma of the Jaws are discussed elsewhere {see Jaws, Growths of.) BONE TUMOURS 109 It will be gathered from the data given that sarcoma of the long bones is almost never cured by amputation, except when it is obviously very chronic, but that in the fiat bones there is some slight prospect of cure. The results in children are much the same as in adults. Rawling has collected cases in the literature of bone sarcoma affecting children under nine years. Of 59 cases, only i, a patient with congenital sarcoma of the scapula treated by local removal at five months, was followed up and found to be cured several years after. Two other methods of treatment call for some consideration. Coley's Fluid. — There are cases on record, one of which (a sarcoma of the orbit) the writer has seen, where a sarcoma has disappeared after an attack of erysipelas, and Coley has steadfastly maintained the value of his mixed toxins of erysipelas and Bacillus prodigiosus as a curative agency in sarcoma. Although the treatment was at first adversely reported on by an American surgical committee, Coley subsequently convinced its members and won them over to his side. The results in England are not so favourable as in America, but the writer has seen a patient with sarcoma of the temporal region, explored, microscoped, and found inoperable, cured and followed for many years after the treatment ; and a lad with sarcoma of the foot similarly treated has remained in statu quo for more than three years. There have been, of course, a number of failures besides. Coley claims to have cured, and followed up for three or more years, 4 cases of periosteal sarcoma of the femur and one of the tibia ; all except i femur case were also amputated. This patient eventually died, more than ten years after, of a mixed epithelioma-sarcoma in the scar of an x-Ta.y burn. Eve also reports a case of sarcoma of the femur amputated and treated by Coley's fluid, well frwo and a half years afterwards, but in 10 other cases the fluid did no good. In other situations (muscle, etc.), the injections are said to have cured over 100 cases of sarcoma, followed three years or more afterwards. In our opinion, the combination of amputation with Coley's fluid following, gives a patient the best chance, and of the two we have more faith in the injections for sarcoma of the long bones. Radium. — In one case known to the writer, radium treatment has a.rrested the growth of a sarcoma of the femur for over a year, but it is too soon yet to speak of radium cures. Carcinoma of Bone. — This is always secondary, usually to cancer of the breast, and is apt to lead, in the humerus, to spontaneous fracture, and in the spine to great pain and pressure on the cord. By this time this patient is nearly always within a few months of the inevitable end. Multiple Myeloma, Myelopathic Albumosuria, Kahler's Disease. — This disease, characterized by endosteal swellings in various bones and a peculiar albumose called Bence-Jones protein in the urine, is usually very malignant and runs a rapid course, killing the patient in about two years. The writer has seen a case, however, under the care of Mr. Hey Groves, in which the disease was arrested naturally, and the patient was living and well after many years, but severely crippled by badly united spontaneous fractures. " Thyroid Cancer." — In this curious condition a tumour appears on the skull or sternum, often pulsating, having the structure of thyroid tissue, and associated with an enlarged or cancerous thyroid. The English cases all died, but Goebel relates some successful removals of the growth in bone. Bone Cysts. — Cysts of bone are either of the nature of ostitis fibrosa which has developed central cystic cavities, or hydatid cysts, usually in the lumbar vertebra; or hip bone. INDEX OF PROGNOSIS Simple bone cysts of the former variety reach a certain size and then remain stationary throughout Hfe, giving rise sometimes to spontaneous fractures. Bloodgood reports the results of operation on 38 cases treated by curetting ; 2 died of hjemorrhage, in another amputation was necessary for the same reason, and the other 35 did well. Hydatid cysts of the spine are apt to enlarge progressively and press on the cord, but the results of operation are satisfactory. References. — Butlin, Operative Surgery of Malignant Disease, second ed. 1900 ; Bloodgood, Ann. Surg. 1910, lii, 145 ; Ibid. 1912, Ivi, 210 ; Eve, Lancet, 1912, ii, 1355 - Alexis Thomson, Edin. Med. Jour. 1907, Ixiv, 423; Nancrede, Ann. Surg. 1909, 1, i ; Rawling, Lancet, 1907, i, 352 ; Coley, Ann. Surg. 1907, xlv, 321 ; Colev, Proc. Roy. Sac. Med. 1910 (Surg. Sect.) i ; Goebel, Deut. Zeit. f. Chirurg. 1898 ; Groves, Ann. S»rg. 1913, Ivii, 163. A. Rendle Short. BRACHIAL PALSY.— (5ee Nerve Injuries.) BREAST, CANCER OF. Prognosis apart from Operation. — To foretell the duration of Hfe in a patient with breast cancer is one of the most difficult problems which can confront the medical man. Indeed in many cases no answer whatever can be given. This is not surprising when it is borne in mind that in the worst cases the disease may- run its course in three months, while at the other end of the scale the patient may live for thirty years or more -wdth a cancer which during the whole of that time shows some evidences of activity. But there are certain varieties of breast cancer in which a definite prognosis is possible. Acute Breast Cancer. — If the whole breast is involved in a large swelling which is everywhere adherent to the skin, if also the breast is fixed to the deep fascia, if enlarged hard glands are present in the axilla, and more especially if the skin over the tumour shows a red blush, it can be stated almost with certainty that the patient will be dead in six months, and that no operation is of the least use. Atrophic Scirrhus. — In certain cases in old people the nipple may be sHghtly in-drawn, or a definite local depression may make its appearance at some point in the skin over the breast, while the whole breast becomes somewhat shrunken ; no tumour can be felt in the breast, nor are the glands enlarged. Such a case is an example of atrophic scirrhus in its extreme form, and it is possible to assert that the patient will probably go on for a number of years without pain or trouble of any kind. Ultimately, however, and especially if the breast is too freely examined or massaged, it is probable that a tumour will develop, that the glands will become enlarged, and that the case will then slowly run the ordinary course of breast cancer. But if, as frequently happens, the patient is already old when the tumour is discovered, the probabihties are that she will die of some other condition. In the less tj'pical forms of atrophic scirrhus, a small hard lump is present which changes its character but httle for extensive periods of time. In such cases a prognosis of some years' duration of life, say up to ten, may be given with probable approach to accuracy. Carcinoma during Lactation. — If a breast cancer de\'elops during lactation, although it may make little progress so long as suckling is continued, it will probably grow rapidly Avhen the milk ceases to be secreted, and the prognosis is a bad one. Mastitic form of Carcinoma. — As a rule, cancer of the breast forms a rounded lump which bears no relation to the anatomical outlines of the lobes of the breast, but there are certain cases where the cancer commences throughout the BREAST. CANCER OF substance of one or more lobes. Such cases generally originate as a chronic mastitis. The tumour formed resembles, in its sector-shape, the thickenings of chronic mastitis ; that is to say, it marks out the limitations of one lobe or a group of lobes. A diagnosis may be difficult, but this question does not now concern us. It must be recognized that this form of carcinoma, perhaps owing to its multicentric or diffuse origin, is of particularly bad prognosis, and that recurrence is likely to take place within a year after operation. Duct Carcinoma. — The recent work of Mr. Lenthal Cheatle has shown that duct carcinoma is much commoner than has been supposed, and that it is probably almost as frequent as carcinoma originating in the acini ; but the typical form of duct carcinoma of the large ducts, which originates beneath the nipple in women of advanced years without causing retraction of the nipple, is a comparatively benign tumour and runs a somewhat slow course. The prognosis after operation is distinctly good. Ordinary Scirrhus. — It is only in the exceptional forms of breast cancer that a definite opinion as to duration of life can be expressed. In the ordinary scirrhus of the breast not operated upon, cases which are apparently similar may hve for varying periods. The younger, stouter, and more healthy-looking the patient, the shorter is life likely to be if no operation is performed. So long as the disease confines itself to the parietes of the body, and does not involve the visceral cavities, duration of life remains uncertain ; but from my experience I can state with some confidence that when there are visceral deposits, whether in the chest, abdomen, or head, the patient's life is unhkely to be prolonged more than a year. Many die within six months after the first onset of visceral deposit. Prognosis as regards Recovery from Operation. — Although the modern opera- tion for breast cancer is apparently a severe one, it does not produce marked shock if care is taken, especially in regard to preventing chill during the operation. Even old persons stand it well. Nevertheless, in hospital practice there is a definite death-rate, mainly due to the risk of infection arising from the collection of mixed surgical cases in one ward. This risk may be placed at from i to 2 per cent. My personal experience in hospital practice includes the loss of cases from influenza (at the time of an epidemic), erysipelas, broncho- pneumonia, and pulmonary embohsm. In a nursing home or private house, on the other hand, I have never lost a case, a fact which appears to show con- vincingly that the belief that a hospital is the safest place for operation is not borne out by experience. Prognosis as regards Recurrence after Operation. — It cannot be too strongly emphasized that the prognosis after an operation for breast cancer is largely dependent upon the thoroughness with which the operation is performed. Axillary recurrence, v/hich is hardly ever seen after a thorough operation, is common after the inadequate ones which are the far too frequent handiwork of the ' occasional ' surgeon. As regards operation statistics, it may be doubted whether they are of great ▼alue, since they depend so largely upon the stage at which the case is first seen, upon the mode of selection of cases regarded as suitable for operation, and upon the thoroughness of the operation. In my own series of cases, perhaps an unduly large proportion have been advanced ones ; moreover, no case, however late, has been refused operation if there seemed to be any reasonable prospect of benefit. Of the cases I have been able to trace, rather more than 50 per cent have remained free from recurrence for three years and upwards. It is probable that further improve- ment on these results must be sought in the better education of the public to INDEX OF PROGNOSIS a recognition of the early signs of cancer. It would not be fair to attempt to improve them by a more rigid selection of cases, for the practice of operation for statistics is now rightly condemned by surgical opinion. Included in my series are two cases, which were both absolutely inoperable by all ordinary rules, in which the patients were able to do full work for periods of five and two years respectively after the operation. Amongst the cases of cancer of the breast operated on by Dr. Halsted and his associates in the Johns Hopkins Hospital and other hospitals in Baltimore, the cures reckoned five years after the operation are about 40 per cent. If, however, the cancer is seen in such an early stage that the diagnosis can only be made by an exploratory incision, and if the complete operation followed immediately on the exploratory incision, 80 per cent of the patients remained well after five years. According to Bloodgood, who gives these statistics, the outlook is entirely different if the radical operation is not carried out at the same sitting as the exploratory one. Should an interval elapse between these two procedures, Bloodgood states that the probability of the five-year cure is reduced from 80 per cent to about 13 per cent. The experience of Bloodgood in this respect is not in accordance with my own. I do not believe there is much danger in the separation by a short interval between the exploratory and the radical operation, although it is desirable to combine the two. The most favourable indubitable statistics of the operation for breast cancer are those recently obtained by Professor W. R. Rodman, of Philadelphia, and brought forward by him at the London Clinical Congress of American Surgeons in August, 1914. These statistics refer to 50 private cases operated upon three or more years ago. Of this number, 13 are dead, i has a recurrence in the mediastinum after three years of apparent good health and is accordingly reckoned among the dead, and the remaining cases, constituting 72 per cent of the total, are well after three years. As Dr. Rodman says, these results could not be obtained in hospital practice. Private patients apply earher, offer better resistance, and will keep under observation indefinitely, thus permitting a second operation if necessary. Several of his cases have been saved by second opera- tion, a point in which his experience agrees with my own. Dr. Rodman adds that some of his cases were so early that a clinical diagnosis of cancer could not possibly be made until after histological examination. These results, which have not been equalled in this country, probably indicate that in the United States the public are better educated in regard to the danger of cancer, and dreading operation less, seek advice in an early stage of the disease. The further improvement of English results depends upon the education of the public in this direction. I may add that Dr. Rodman accepts my own conclusions as to the mode of dissemination of carcinoma, and that the operation he practises is in accordance with the conclusions of the permeation theory of dissemination. Prognosis after Recurrence. — It is too much the custom to abandon hope and sit with folded hands when, after an operation for breast cancer, recurrence has declared itself. It is true that in such cases the ultimate outlook is generally bad ; but if the recurrence is recognized promptly and treated vigorously, it may be possible to prolong the patient's life for at any rate some years. After the modern operation for breast cancer, recurrence, if it takes place, will usually be found in one of two places : either in the upper intercostal spaces — second, third, and fourth — originating from glands of the anterior mediastinum which were already infected at the time of the operation, or it may be found in the supraclavicular glands. Submammary, cutaneous and fascial, subclavian, or visceral recurrence may also occur. BREAST, CANCER OF 113 Intercostal Recurrence. — The first variety of return may be described as intercostal recurrence. It should be treated by the use of secondary x rays. An injection of a suspension of bismuth carbonate is made at the edge of the sternum in the infected space or spaces, and the area is subsequently vigorously ;i^-rayed. I have more than once seen the recurrence vanish under this treatment, which I have now used for over four years ; sometimes, on the other hand, the disease proceeds on its course unchecked. One of my patients with this apparently hopeless form of recurrence has now been well over three years since the ;t-ray treatment commenced. Treatment by radium may prove equally efficacious, or more so, but only time and experience can settle the point. Supraclavicular Recurrence. — If the patient is seen at regular intervals sub- sequently to the primary operation, and is carefully examined, recurrence in the supraclavicular glands will be detected at a time when the glands are still freely movable and not of great size. In these circumstances there can be no doubt whatever that the right treatment is operative ; but it is useless to perform a hmited form of operation restricted to the parts below the omohyoid. The whole of the posterior triangle must be cleared of its glands, from the mastoid process down to the sternoclavicular joint, and outwards as far as the edge of the trapezius. The tissues containing the glands should be removed in one piece. The operation required is an extensive one, and it is necessary to open the carotid sheath, and to carry the dissection down to the near neighbourhood of the thoracic duct, removing all the tissues between the sternomastoid and the scalenus anticus. The operation is not one which should be undertaken by the inexperienced. My experience shows that freedom for three years or more may be hoped for, and that almost always the patient will be freed from the terrible prospect of a mass of growth fixed to the brachial plexus and causing agonizing pain. If the disease returns, it is likely to do so in a painless form within the chest. The foregoing remarks apply to early supraclavicular recurrence. If the glands are large, and especially if they are fixed, an operation is rarely advisable, and if it is performed, local recurrence is very likely to take place. In this event the recurrence will be a diffuse one, and the patient's condition is rather aggra- vated than improved by the operation. Submammary Recurrence. — If after an operation nodules appear over a region corresponding to the area of contact of the breast with the chest wall, and if these nodules are adherent to the ribs and muscles but not to the skin, it may be inferred that at the time of the operation permeation had extended into the lymphatics of the intercostal muscles. Under these circumstances recurrence is of course inevitable, unless the prophylactic course of x rays is able to destroy the remaining cancerous foci. This form of recurrence, though unavoidable, is fortunately not common. It may be spoken of as submammary recurrence. Cutaneous and Fascial Recurrence. — The form of recurrence which follows inadequate operation for breast cancer is usually that known as local recurrence, in which nodules appear in or near the scar of the operation. If these nodules are cutaneous, i.e., fixed to the skin, they should be excised if they are near the scar ; but if they occur at the periphery of the field of operation, or are fixed to the deep fascia, they probably indicate inadequate removal of the deep fascia, with widespread and inoperable extension of the disease in that layer. Under these circumstances the only treatment is x rays, intensified by bismuth injec- tions, and the ultimate outlook is a bad one. Subclavian Recurrence. — When during an operation for breast cancer the subclavian glands are left behind, these glands are usually the seat of recur- 114 INDEX OF PROGNOSIS rence. This is a form which is extremely likely to occur in the practice of inexperienced operators. The subclavian glands are situated beneath the costocoracoid membrane, below the clavicle and above the pectorahs minor, at the extreme apex of the axilla. Recurrence in these glands is indicated by a lump deeply situated behind the pectoralis major and immediately below the clavicle. To this bone the lump may become adherent in the latest stage, simulating a deposit of cancer in the clavicle itself. The prognosis in subclavian recurrence is a very grave one, though operation, if undertaken early, and followed by vigorous radiation, is not entirely hopeless. Visceral Recurrence. — When signs of the return of the disease in the interior of the thorax or abdomen have made their appearance, it is possible to give a precise prognosis. Before the disease has reached the visceral cavities, a cautious man will often refuse to give any estimate of the duration of life ; it may vary from a few months to twenty or thirty years. When the signs of visceral return are manifest, it is an almost invariable rule that the patient will die within a period not exceeding a year, and not usually exceeding six months. In such cases treatment is of no avail, though it has appeared to me that sometimes open-air methods on the lines of sanatorium treatment for phthisis have some- what deferred the inevitable result. Influence of X-Ray Treatment on Prognosis, Prophylactic x rays. — A course of prophylactic x rays subsequent to the operation for breast cancer should never be omitted. It is known that, at any rate in some cases, x rays may cause the atrophy and disappearance of large masses of cancer cells. How much more effective, therefore, they must be when applied to small undetectable groups of cancer cells which may possibly lurk in the tissues subsequent to an operation for breast cancer, especially since by the removal of the breast these microscopic groups are brought nearer to the surface instead of being protected by the whole thickness of the breast. But the value of x rays does not rest on a priori considerations. My own experience conclusively proves their value. In my series of cases, only four or five times has recurrence been observed in the skin or subcutaneous tissues ; in all of these cases, with at most one exception, the patient for one reason or another had escaped the prophylactic course of x rays which I give to all my cases. The facts are rendered more striking when it is remembered how small a proportion the cases which escaped post-operative Ar-ray treatment bear to the total number of cases. , The value of x rays in the treatment of masses of cancer cells of macroscopic size is smaller, but an undoubted one ; such masses are usually accompanied by wide-spreading microscopic ramifications of the disease, which may very probably have extended deeply, e.g., to the pleura, beyond the range of x raj^s. Consequently, though these nodules may shrink or disappear in such cases, .r-ray treatment is usually only of temporary value. Secondary x rays. — Professor C. G. Barkla some years ago called attention to the fact that metalhc particles bombarded by x rays gave off secondary X rays. He suggested the possible therapeutic application of this observation, and for some years past I have been employing injections of bismuth carbonate in cases of breast cancer to intensify the action of x rays by acting as a secondary source of them. I am strongly of opinion that the method is a valuable one, and that in certain cases it entirely alters the prognosis. The most striking of my cases was that of a patient in whom, three years after the operation for breast cancer, intercostal recurrence showed itself. This form of recurrence, so far as my previous experience went, seemed absolutely hopeless. I injected .bismuth into the intercostal spaces, and ;i;-ray treatment was vigorously carried BREAST, CANCER OF 113 out by Mr. C. R. Lyster. The nodules completely disappeared, and at the present time (three years later) the patient remains quite well. Influence of Radium Treatment on Prognosis. — Speaking generally, and bearing in mind that radium has a purely local action of limited range, its field of usefulness in cancer of the breast is a very restricted one. This arises from the fact that, except in early cases for which operation is the only trustworthy treatment, the area of extension of the disease is too large to be dealt with by the amount of radium ordinarily available. Owing to this feature of the disease, X rays provide a more suitable form of radiation. Occasionally, however, radium may possess the advantage. Thus, for instance, in old persons too feeble for operation, radium may be buried in the primary growth as a preliminary to ;ir-ray treatment, especially if the growth is too massive to be penetrated by x rays from without. Radium is also suitable for the treatment of localized recurrent nodules which resist, or are not easily accessible to, x rays. Marked and complete retrogression may occur in local masses of cancer cells subjected to radium, but only in very rare cases can a cure of the disease be even hoped for — namely, in cases where such a single mass of cancer cells is the only focus of growth present, and is unaccompanied by microscopic extensions of the disease in other parts. Influence of Pleural Adhesions on Prognosis. — It is an interesting fact, and one which should be taken into account in estimating prognosis, that obhtera- tion of the pleural cavity checks dissemination to an appreciable extent. This I have been able to show by analysis of the statistics of the Middlesex Hospital cancer wards. Marked pleural adhesions were present in 37 of the 329 cases. Cancerous invasion of the pleura was present in only 11 of these 37 cases, or 30 per cent, while of the sum total of Middlesex Hospital cases 44 per cent showed pleural invasion. In 3 of these 11 cases the adherent pleura on the side of the growth had escaped invasion, while the opposite non-adherent pleura was cancerous. Doubt may at first appear to be thrown on this evidence of the protective action of an adherent pleura by the fact that only 30 per cent of the cases with pleural adhesions were absolutely free from metastases as compared with 33 per cent of the sum total of cases. But the protective action of an adherent pleura extends only to the thoracic cavity. It has been shown that in a large proportion of cases invasion of the abdomen occurs, not by way of the thorax, but directly through the epigastric parietes. Pleural adhesions do not check this process : perhaps, indeed, their resistance to the deep extension of the growth may accelerate the progress of fascial permeation, and so actually favour epigastric invasion. It is a most striking fact that 32 per cent of the 37 cases with marked pleural adhesions showed the abdomen invaded by cancer and the chest free, while only 12 per cent of a total of 329 cases showed a similar state of affairs. The converse difference is equally striking. While 22 per cent of the Middlesex Hospital necropsies show the thoracic cavity invaded and the abdomen free, only 5 per cent of the cases with pleural adhesions show a similar state of affairs. These facts are a strong indirect testimony both to the frequency of epigastric invasion and to the protection afforded by pleural adhesions to the thoracic cavity. Incidentally they provide a strong argument against the embolic theory, by showing that invasion of the abdomen and invasion of the thorax are independent events. The foregoing facts convey a therapeutic suggestion — namely, that if the pleural cavity on the affected side could be obliterated by artificially induced adhesions, hfe might be prolonged. Unfortunately, the injection of irritant fluids into the pleura is known to be attended by danger. In two cases in ii6 INDEX OF PROGNOSIS which there was evidence of early pleural involvement at the base of one lung I have injected radium emanation, and a sterilized suspension of bismuth car- bonate, respectively. In the latter case the injection was made as a preUminary to ;v-ray treatment. In neither case was a definitely favourable result attained. W- Sampson Handley- BREAST, SIMPLE DISEASES OF.— We shall consider the prognosis of : (i) Chronic mastitis ; (2) Tuberculosis ; (3) Fibro-adenoma ; and (4) Paget's disease of the nipple. None of these diseases involves any direct danger to life, and the interest of the prognosis centres around the possibility of the subsequent development of cancer. 1. Chronic Mastitis. — In young women this condition presents no immediate danger. After the age of forty, it is to be regarded with grave suspicion. Very convincing evidence has now accumulated to show that cancer of the breast, like cancer elsewhere, is invariably preceded by chronic inflammation. Bryant found a history of mastitis in 80 out of 360 cases of cancer. Microscopically, Beadles was able to demonstrate pre-existing mastitis in every one of 100 breasts removed for cancer at the Brompton Cancer Hospital, although in the majority of the cases no signs had been evident clinically. Quite apart from the possibility that mastitis may give rise to cancer, there is the very serious question of the uncertainty of the diagnosis of a lump in the breast. It is a sound surgical rule, at any rate after the age of thirty-five, that any lump in a woman's breast is better out than in. 2. Tuberculosis. — This is a very chronic disease, with no tendency to spon- taneous cure. The breast eventually becomes riddled with abscesses, and in about 20 per cent of cases, phthisis finally develops. It is wise, therefore, to effect an early clearance. 3. Fibro-adenoma. — Generally speaking, a mobile, well-encapsulated lump in a breast, confidently diagnosed as fibro-adenoma, is safe enough, and for years it does not alter in size. Microscopically, nowever, it is common to find that a recently observed tumour shows fibro-adenoma becoming malignant. There are a few cases on record of even old-standing and encapsulated swellings, undoubtedly innocent, eventually becoming carcinomatous. One of these is in the museum of St. Bartholomew's Hospital. Removal of a genuine fibro-adenoma, verified as such by the microscope, is very rarely followed by recurrence. 4. Paget's Disease of the Nipple. — This is not really a benign condition. If an apparent eczema of the nipple, in a woman over forty, fails to respond to treatment, and becomes red, raw, and angry, it is almost certain that the breast is already cancerous, though nothing can yet be felt. The tumour will become evident, generally in one to two years ; but in rare cases it may be delayed for ten years. Fortunately the cancer is often of a slow type. The prognosis is, therefore, that of scirrhus. Radium and x rays will frequently ameliorate the eczema, but will not prevent the onset of the cancer. a . Rendle Short. BRIGHT'S DISEASE.— (See Nephritis.) BRONCHIAL ASTHMA.— (See Asthma, Bronchial.) BRONCHIECTASIS. — When bronchiectasis is the sequel of measles or whooping-cough in childhood, and the dilatation moderate, recovery, often complete, is probably the rule rather than the exception, provided that death does not result owing to the severity of the primary disease. The more diffuse the bronchiectasis the worse is the prognosis, and consequently cases which are BRONCHI EC TA SIS 1 1 7 caused by pleural effusion, collapse of the lung, and especially unresolved pneumonia, usually run a shorter course than those due to chronic bronchitis. The disease in a few cases runs an acute febrile course ; but in the majority the tendency is towards chronicity, and instances are on record in which life was prolonged for forty to fifty years. The prognosis in an individual case is difficult, for it is hard to estimate the risk of the complications which are usually associated with a fatal termination. The more immediate modes of death are marasmus, bronchopneumonia with septic absorption, haemoptysis, pneumothorax, gangrene, tuberculosis, lardaceous disease, metastatic abscess (especially cerebral abscess), and cardiac and renal complications. In connection with this point, Lebert's figures of the effect of the disease on the general health in 80 cases are interesting : — Lebert's 80 Cases Showing the Effect of Bronchiectasis ON the General Health. Condition of Patient No. of Cases Percentage General good health .... Slight but distinct disturbance of health Marked disturbance without compUcation Marked diarrhoea with complications directly resulting from disease - . - - - Marked disturbance with accidental complications 17 28 15 3 *17 21 35 18 3 21 "The complications were : Kenal. 4 ; heart disease, 5 ; cancer of other organs than lungs, 4 ; tuberculosis, 1 ; pelTic abscess, 1 ; protracted whooping-cough, 1 ; chronic myelitis, 1. Lebert gave the following figures as representing the duration of the disease in 52 cases : Under one year, 2i'i per cent ; one to two years, yy per cent ; three to five years, 30-7 per cent ; six to ten years, i5"5 per cent ; over ten years, 25 per cent. In an individual case, the general nutrition and the amount of absorption of bacterial products, the age of the patient, the extent to which his financial and other circumstances allow for adequate protection and medical care, and the presence of complications, must be taken into account. If there is little evidence of absorption of bacterial products, if the patient is well nourished, and if he can be properly safeguarded, the prognosis is, on the whole, towards chronicity. When, however, the complications previously mentioned occur, and especially when there is septic absorption, the prognosis is grave. The effect of the absorp- tion of bacterial products upon the nutrition, and hence the tendency to fatal complications, has been diminished by the effective use of creosote baths. Again, suitable treatment by vaccines, though it does not cure the disease, in some instances does much to diminish the septic character of the expectoration, and may render it odourless. Further, vaccine treatment appears not infrequently to reduce the number of intercurrent attacks of bronchopneumonia, pleurisy, and bronchitis, which do so much to undermine the patient's powers of resistance. In generalized bronchiectasis, surgical measures are of no avail. Favourable results have been reported as the result of operation in cases in which there is a single dilatation, but in the majority even of these cases life is not prolonged by surgical means, and in not a few death may come sooner as the direct result. It is possible, however, that better result? will be obtained by more modern methods. Arthur Latham. INDEX OF PROGNOSIS BRONCHITIS. Acute Capillary Bronchitis. — This condition is always associated with some bronchopneumonia. It rarely attacks previously healthy persons, and is especially fatal to young children and old people. A severe attack in an infant may be fatal within twenty-four hours : an aged person may succumb in a few days. In estimating the prognosis, we have to take into account the general surround- ings and previous health of the patient. Unfavourable signs are failure of either the respiratory, circulatory, or nervous systems. Thus the outlook becomes grave if there is urgent dj'spnoea, lessening frequency of cough or cessation of expectoration owing to feebleness ; cyanosis or other signs of right heart failure ; delirium, coma, or convulsions. Acute Bronchitis of the Larger Tubes. — In mild cases the duration is as a rule from ten to fourteen days, but severe cases seldom last less than three to four weeks. Recovery is always slow if emphysema is present. There is a consider- able tendency towards relapse, and the precautions taken to avoid this have much influence on both the immediate and remote effects. The disease is rarely fatal, save in young children and old people, in the acute asthenic type, or when the disease is a complication of nephritis, heart disease, diabetes, chronic bronchitis associated \vith heart failure, or emphysema ; but the mortality is largely affected by adequate treatment. Signs of danger are : marked cyanosis, pulsating veins in the neck, great dyspnoea, short ineffective cough with cessa- tion of expectoration, rapid irregular pulse, cold clammy skin, and a tendency to sink down in the bed. Chronic Bronchitis of the Larger Tubes. — In young people marked im- provement often occurs, and in a fair proportion of cases all urgent symptoms eventually disappear. After middle age there are few recoveries. This is chiefly owing to the recurrence of acute attacks and the increase of emphj'sema, more especially when the disease is dependent upon or associated with cardiac or renal disease. The course of the disease is, however, usually prolonged. The intensity of the symptoms, and hence the duration of the disease, are much affected by climatic conditions and by the amount of care the patient can devote to his health. Much can be done by medical treatment, such as vaccine therapy, to ward off acute attacks and to lessen the cough and strain upon the heart, while pressure baths often have a favourable influence upon the emphysema. Plastic bronchitis affords a fairly good prognosis, and patients have been known to live for more than twenty-five years from the commencement of the symptoms. There is a tendency towards the development of ordinarj'- bronchitis with its usual complications, and cases are recorded in which the casts have led to sufiocation. Putrid bronchitis if due to simple catarrh is seldom dangerous to life, especially if appropriate vaccines are used ; but if due to other causes is usually fatal. Arthur Latham. BRONCHOPNEUMONIA. — This disease is always associated with some capillary bronchitis. The prognosis is grave in all severe cases, and the mortality may be as high as 30 or even 50 per cent. It is greatest in 3'oung children, and especially so below one year of age. In young infants, and in rickety or badly nourished children brought up under insanitary conditions, the probabiUty of a fatal termination is always considerable. This is especially true of broncho- pneumonia complicated by whooping-cough. The greater the extent of the disease, the graver is the outlook. Primary cases have a lower mortaUty than secondary ones : thus, bronchopneumonia following bronchitis has a mortality BULBAR PALSY 119 only half as great as bronchopneumonia following diphtheria. The chief immediate dangers are heart failure, convulsions, and hyperpyrexia : that is to say, the amount of toxaemia in relation to the patient's strength, and the extent of the disease, are the determining factors. Convulsions at the com- mencement of the disease have not so much significance as those at a later period. The character of the pulse is usually a better guide than the rate of breathing ; a feeble, rapid, and ' running ' pulse is of graver significance than rapid respiration. Bronchopneumonia may in a few cases lead to enlargement of the bronchial glands to a sufficient extent to be a source of trouble later on, to bronchiectasis, or to tuberculosis. As a general rule, bronchopneumonia which is an immediate sequel to an acute infection, such as diphtheria, is seldom if ever tuberculous, even though it runs a prolonged course and gives rise to great suspicion. On the other hand, a bronchopneumonia which commences more or less insidiously is often tuberculous in its origin and is then nearly always fatal. It is impossible to give the average duration of the disease, as cases vary so much according to the patient's previous condition and power of reaction. In all cases there is a great tendency towards relapse, and much care is required in convalescence, especially with regard to exposure. In my experience, the administration of 5 c.c. of fresh normal horse serum by the mouth in the early morning so long as fever continues has had a marked effect in reducing the mortality of this disease. Arthur Latham. BULBAR PALSY. — Chronic bulbar paralysis of nuclear origin is, pathologically, the same disease as progressive muscular atrophy (q.v.), but affecting the motor nuclei in the medulla. Its course is slow and insidious, and the prognosis is always unfavourable, most cases succumbing within a year, or at most two years, from the onset of the bulbar symptoms. Sometimes the disease appears to be retarded, or even, for a few months, temporarily arrested, by the hypodermic administration of strychnine in full doses. Sudden, so-called apoplectiform, bulbar palsy is always vascular in origin ; it is generally due to arterial ob.struction, and especially to syphilitic thrombosis. Where the bulbar palsy takes several hours, or even a few days, to develop (a less common occurrence), the condition is dependent upon acute inflammatory changes in the medullary nuclei, exactly similar to those which occur in the spinal cord in acute anterior poliomyelitis. The prognosis as to life in these two classes of bulbar paralysis is relatively good if the patient survives the acute stage, since the lesion is not a progressive one. The actual bulbar symptoms, however, remain stationary, for the nuclear disease is irreparable. Other cases of bulbar paralysis are due to infranuclear and extramedullar/ lesions, implicating the motor nerves of the bulb below their nuclei of origin. Such cases occur in tumours, and in chronic meningeal affections, syphilitic or tuberculous. The symptoms develop much more slowly, and are often asym- metrical, and even unilateral, in distribution. Save in the cases of syphilitic origin, the prospects are unfavourable. In Pseudo-bulbar Paralysis, where the patient has the same difficulty in articu- lation, deglutition, and phonation as in ordinary bulbar palsy, but without atrophy or fibrillary tremor of the affected muscles, the cause is entirely different. The lesion in such a case is a bilateral supranuclear one, situated in the pyramidal tracts. The common history is that of a patient who has had an ordinary attack of hemiplegia, without bulbar symptoms ; he may have repeated attacks of this sort on the same side, all without the slightest bulbar phenomenon ; at last, however, he has an attack of hemiplegia, slight or severe, on the opposite INDEX OF PROGNOSIS side; at once bulbar symptoms supervene, articulation becomes slurring, and deglutition becomes difficult. The sequence of events is so characteristic, that when we meet with a hemiplegic patient who has pseudo-bulbar symptoms, we can confidently diagnose a bilateral pyramidal lesion. The prognosis in pseudo- bulbar palsy is less grave, as regards life, than in true bulbar palsy ; since the pseudo-bulbar symptoms do not tend to get worse, and may even improve to a considerable extent. The real prognosis depends on the cause which has produced the bilateral hemiplegia. {See Strokes.) Purves Stewart. BURNS AND SCALDS. — A burn may of course vary in degree from the merest trivial accident to an inevitably fatal destruction of an enormous skin area ; but there are several points of importance which may guide us in prognosis. The Nature of the Burn. — Skin area, not depth, is the determinant of the prognosis, except of course in rare instances where the abdomen may be opened. Thus a burn of the sixth degree involving the foot and lower part of the leg is not so dangerous as a widespread burn of the second degree involving the trunk and limbs. Third degree burns, exposing the sensitive papillae of the dermis, are particularly depressing. It is probably true that burns of the abdomen are the most serious. If one half of the body surface is burnt, death is inevitable ; in the great majority of cases, a burn of one third will also be fatal. In hospital practice about a third of the cases admitted, die ; this of course varies with local custom, pressure on the beds, etc. Influence of Age. — Children and aged persons are decidedly the more liable to die from the shock of a burn. The Time Factor. — In the majority of the fatal cases, death takes place within forty-eight hours {128 out of 207 cases — Choyce), and no doubt most of these patients die from shock. Stupor, shallow breathing, prostration, and a quick weak pulse point to a probable fatal termination. There is, however, a curious group in which symptoms appear to be due, not to shock, but to some scorching change in the blood. Such cases may, for instance, develop signs of cardiac thrombosis two or three days after the accident, with dyspncea, pain over the heart, and very irregular pulse ; duodenal ulcer is probably another evidence of the same blood changes. Recurring vomiting may be due to a similar cause, and is of very grave import. If the patient survives the first few days, the prospect of recovery, apart from complications, depends upon how effectually suppuration can be controlled. Pneumonia, pericarditis, and nephritis appear to be due in nearly every case to pyaemia from suppuration. The Effect of Treatment. — There is no doubt that careful treatment may make all the difference between life and death in a considerable number of the cases. Extensive lesions of the skin do not produce shock in animals or in man under an anaesthetic, and the shock of a burn is due principally to pain, and can be controlled by efficient doses of morphia. The early dressings ought to be rendered painless by chloroform or morphia, for this reason. Warmth is a very important factor in saving the patient's life. The blood changes are probably beyond our control. The writer has shown that in some cases of severe burns the specific gravity of the blood is much raised, and the administration of saline is urgently indicated. If the burn is not so extensive as to be inevitably fatal, it is well worth while to take particular care to prevent sepsis later. If the injured area has been fouled, it should be surgically cleansed under an anaesthetic. Reliable anti- septics, like oil of eucalyptus (i in 20 in olive oil), improve the prognosis, and so CMCUM, TUBERCULOUS does a boracic bath applied for several hours daily ; but cases have undoubtedly- been lost by drug poisoning. The incessant vomiting and dermatitis of boric acid poisoning are not as well recognized as they should be. Complications. — Pneumonia, pericarditis, and nephritis can usually be prevented by proper asepsis. Duodenal ulcer does undoubtedly occur, usually a week or ten days after the burn, but it is rarer than was formerly supposed. Moynihan, in his classical study of duodenal ulcer, was able to find only the merest hand- ful of authentic cases. Out of 138 deaths from burns at St. Bartholomew's Hospital, Lockv/ood found only i duodenal ulcer, with 2 other cases showing punctiform haemorrhages. In a few rare instances the ulcer has caused death from perforation or haemorrhage. These ulcers are probably due to micro- scopical embolism of the duodenal arteries on account of the blood changes, followed by self-digestion by the juices of the stomach or pancreas. Tetanus is not very rare as a complication of a burn, and particularly if it is earth-infected. Fourth of July tetanus following burns from fireworks is well known in America. Patients with earth-infected burns ought probably to be given a prophylactic dose of antitetanic serum. Contraction with deformity is a very distressing late complication of burns. It only occurs if the whole thickness of the skin is destroyed. Something can be done to prevent it by liberal skin-grafting. The writer has seen one case in which it led to dislocation of the hip-joint. Keloid and epithelioma may develop in the scar of an old burn. X-ray burns appear to be particularly liable to undergo malignant changes, several members of our own profession having fallen victims. Scald of the Larynx. — Children who have been trying to drink from the spout of a kettle are liable to this accident. Unfortunately there may be no signs at all, or at most only a little hoarseness, for several hours, and lives have been lost by children being sent away from a hospital at this stage. A few hours later they are brought up again with laryngeal stridor, cyanosed, and struggling for breath, when even an immediate tracheotomy may be too late to save the situation. With proper supervision and prompt interference if necessary, there is no great danger. A. Rendle Short- CiECUM, TUBERCULOUS. — This somewhat uncommon disease is usually diagnosed as carcinoma, forming, as it does, a hard tumour-like mass in the caecum. We have not much information as to the natural course of the com- plaint. It is customary to remove the caecum. The mortality after removal by operation is given as follows : Of 58 cases in literature since 1900, 12 per cent died (Hartmann) ; of 130 other cases in literature, 30 per cent died after excision, and 17 per cent after short-circuiting (Nikoljski) ; of 46 cases of four surgeons since 1907, 25 per cent died (Finkelstein). The last figure is probably a fair approximation to the truth. If the patient survives operation, a cure usually results. References. — Finkelstein, Arch. f. klin. Chir., 1913, July, 936 ; Makins, Burghard's System of Operative Surgery. A. Rendle Short. CALCULI, PROSTATIC— (See Prostatic Calculi.) CALCULI, RENAL.~(5efi Kidney, Calculi of.) CALCULI, VESICAL.— (5ee Bladder, Calculi of.) CANCER. — {See Various Organs.) INDEX OF PROGNOSIS CANCRUM ORIS. — This term should not be used for cases of severe stomatitis unless there is black sloughing of the cheek. Interpreted in this way, the prognosis is very grave — it is given by Keen as 75 per cent. Death takes place within ten to fourteen days. Even if the child recovers, there is usually a horrible deformity which will require much skill and many operations to remedy. The outlook in a particular case depends on the extent of the sloughing and on the degree of toxaemia. If the patient is already worn out by measles or other illness, if there is a poisoned look, high fever, weak pulse, or coughing, death is almost inevitable. The best hope of recovery is in a case seen early, not extensive, promptly treated, and with little toxaemia. a. Rendle Short. CARBUNCLE. — Although usually not a dangerous disease, it must always be borne in mind that a large carbuncle involves serious danger to life when it occurs in a vascular part, such as the lip or face ; also in elderly, alcoholic, or broken-down individuals. Spreading in spite of treatment, delirium, pyaemic abscesses, or rigors all mean a grave prognosis. a. Rendle Short. CARCINOMA. — {See Various Organs.) CARDIAC SYPHILIS. — As this subject is largely covered elsewhere in this volume, by articles on aortic valvular disease, angina pectoris, and so on, a short note is added under this heading merely to co-ordinate the leading facts. The effects of syphiHs on the heart and aorta are threefold, in that the infection attacks the aortic wall, the aortic semilunar valves, and the myocardium itself through the medium of the coronary arteries. It is the relative severity of its attack on these three several parts of the circulatory apparatus that determines the prognosis. When it is the aorta that suffers most, and an aneurysm is produced, this throws so powerful an extracardiac bias into the situation that the whole outlook is practically conditional on the behaviour of the aneurysmal sac. Usually, therefore, when we speak of the prognosis in cardiac syphilis, it is of the valvular and myocardial lesions that we are thinking. Here it may- be remarked that timely recollection of the possibility of a syphilitic element in aortic regurgitation and obscure cases of angina and myocardial weakness, will stimulate investigation by means of the Wassermann reaction, searching for signs of cerebrospinal lesions, and so on, and the discovery of information that will be of the utmost service for prognosis as well as treatment. Prognosis as to Life. — The life prospects of these patients have been analyzed by Deneke, of Hamburg. He found that about half died within two years of the initial diagnosis ; about two-thirds within three years ; and about four-fifths within four years. It is true that these figures, dra.wn from the histories of 124 patients, do not exclude cases of aortic aneurysm ; but he shows that the outlook is only twice as bad when there is an aneurysm, with or without valvular incompetence, as it is in cases of aortitis without aneurysm ; and further, that the prognosis is nearly as bad in cases of valvular insufficiency without aneurysm as it is when aneurysm is present. Mitchell Bruce found that the average expectation of life in cardiac syphilis, from onset of symptoms to death, was between five and six years. The remarkable proneness of these cases to a sudden end is notorious. One of the physicians at whose feet the writer sat as a student used to emphasize this by telling stories of patients who had died on the doctor's doorstep, " with a gumma in the heart and an iodide prescription in the pocket." In 74 fatal cases observed by Deneke, the end was sudden in no less than 33 (24, if deaths from CELLULITIS 123 bursting aneurysms be excluded). Of Mitchell Bruce's cases of cardio-aortic syphilis, aneurysms excluded, 50 per cent died suddenly. This insecurity of life is due to the fact that, as Harlow Brooks and others have shown, gross myocardial lesions are to be found in a large majority of all cases of cardio-aortic syphilis. Apart from the development of aneurysm, the factors of danger in cardiac syphilis are, first, damage to the myocardium, and second, addition to its work by failure of the aortic valves. Of these the first is clearly the more important by far ; so that in seeking to form an opinion as to the prospects in any individual case, the most important data are those that bear on the condition of the cardiac muscle. The evidences of ventricular disease may be local or diffuse. The former class includes the signs of acute obstruction of a coronary artery or branch — development of a pericardial rub following a severe attack of precordial pain with faintness ; also signs of gradual coronary obstruction, or rather of its chief result, formation of an aneurysm of the heart ; and heart-block. Of these, the two first are the more immediately prophetic of sudden death ; and indeed there is nothing of more ominous significance in these cases than the appearance of a pericardial rub, even where this has been preceded by no other evidence of infarction. Anything indicative of coronary obstruction carries with it a threat of sudden death. With heart-block it is a little different, for its appearance can only endanger the patient's life if it is accompanied by syncopal or epileptiform attacks. Although the type of lesion conjured up in the mind by the term ' myocardial syphilis ' is focal, yet it must never be forgotten that those same focal lesions are merely the macroscopic expression of a widespread interference with the nutrition of the heart muscle by disease of the coronary arteries. Hence we must look out for and correctly interpret such symptoms as recurrent precordial pain on exertion, dyspnoea, puffiness of the ankles, alternating pulse : all these prove that the ventricular muscle is hard hit and likely to give out at no distant date. One other risk has to be borne in mind in cases of cardiac syphilis — that of the development of syphilitic lesions in other vital organs. One man recently under the writer's care with aortic dilatation and incom- petence, of luetic origin, died rather suddenly of a large cerebral thrombosis. Deneke found death due to extracardiac causes in about 20 per cent of his fatal cases. As to the result of treatment, Deneke found in his series that thorough treatment with antisyphilitic drugs doubled the patient's expectation of life. The best method of treatment is still a matter of some discussion ; from the prognostic point of view it may be said that, as far as is known, thorough treatment with mercury, either by inunction or injection, together with iodides, gives results as good as those following the use of salvarsan ; while most observers agree that the latter plan introduces a considerable element of risk, at all events in cases where the evidences of myocardial invasion are at all definite. Even those who advocate salvarsan say that repeated administration is essential and that mercury should be given as well ; so that it seems as if the prospect of radical cure were no brighter with this than with the older remedies adequately employed. Carey F. Coombs. CARIES OF THE SPINE.— (See Spinal Caries.) CELLULITIS. — The prognosis in cellulitis depends upon the location, the condition of the patient, and the extent of the disease. Of 889 cases at St. Bartholomew's Hospital, a good many years ago when the condition was commoner than it is now, 11 per cent died. 124 INDEX OF PROGNOSIS Cellulitis of the neck (angina ludovici) is still a very grave affection, if at all extensive, on account of the danger of oedema of the glottis and pressure on, or infection of, the air-passages. Unless promptly treated, it will usually be fatal. A cellulitis of the scalp is likely to cause fatal meningitis in some cases ; and cellulitis of the arm up to the elbow, or of the leg up to the knee, is a grave condition. If there is black slough, with emphysematous crackling, death will almost certainly take place. Other bad signs are pysemic abscesses or repeated rigors, delirium at night, or diarrhoea. An aged, broken down, or alcoholic person is not likely to recover from a severe attack of cellulitis. It is very doubtful if antistreptococcic serum saves many cases ; but proper evacuation of the sero-purulent fluid, hot soaking, and, if necessary, amputation of a limb are, of course, life-saving procedures. Stiffness of the tendons may be a serious after-trouble of cellulitis of the arm. A. Rendu Short. CEREBELLAR ABSCESS.— (5ee Intracranial Complications of Ear Disease.) CEREBRAL ABSCESS. — {See Intracranial Complications of Ear Disease.) CEREBRAL EMBOLISM, HEMORRHAGE, AND THROMBOSIS.— (5ee Strokes.) CEREBRAL TUMOUR, MEDICAL. — [See also Cerebral Tumour, Surgical.) — Once the diagnosis of intracranial tumour has been established, the prognosis must always be extremely grave. The duration of life, however, varies within the widest limits. Some patients die within a few days or weeks after the first appearance of symptoms, whilst others survive for two or three years, or even for ten or twenty, though this latter is uncommon. The danger of sudden ter- minal coma, with death from respiratory paralysis, has always to be borne in mind ; and although this termination may occur in tumours situated anywhere within the cranium, it is specially likely to happen when the growth is sub- tentorial in position. Tumours of the cerebellum, pons, and medulla are there- fore relatively more dangerous than those of the cerebrum, or those situated in the anterior or middle fossa of the cranial base. Frontal tumours have the longest survival period, as a rule. Sudden death may sometimes occur from spontaneous haemorrhage into a soft gliomatous tumour, from rupture of an aneurysm, or from a cysticercus suddenly blocking up the aqueduct of Sylvius or the fourth ventricle. In other cases, however, patients with symptoms of cerebral tumour show long remissions in their symptoms, or even complete intermissions, lasting months or perhaps years, during which many of the symptoms clear up, ultimately returning again and leading to a fatal termination. It is not uncommon for single symptoms, such as vomiting, visual troubles, fits, etc., to improve whilst the other phenomena persist. Such remissions and variations in the symptoms are partly explained by changes in the tumour itself. Sometimes a tumour changes its main direction of growth, so that parts of the brain which were originally directly compressed are, as it were, pushed aside, and are no longer directly attacked. In other cases, the tumour undergoes degenerative changes ; or it may for a time cease to grow. In others, again, a cystic growth (e.g., cysticercus) may undergo absorption of its contents. In still other cases, where CEREBRAL TUMOUR. SURGICAL 125 a comparatively small growth obstructs the downward current of cerebrospinal fluid through the ventricles, distending them and producing symptoms of severe intracranial pressure, — if the growth slightly alters its position, the ventricular outflow is again established and the acute symptoms subside. In some such cases of internal hydrocephalus, due to pressure from intracranial growths, the cerebrospinal fluid may even find an exit through the cribriform plate at the root of the nose, and produce a rhinorrhoea affording a spontaneous outflow for the dammed-up fluid, with a corresponding improvement in the symptoms. If a nasal discharge of this sort ceases, the symptoms of intracranial pressure return at once. Spontaneous cure of intracranial tumours is so rare as to be beyond the bounds of practical prognosis. It occurs now and then, however, in certain aneurysms, which become filled with blood-clot and then undergo obliteration. In certain parasitic cysts (e.g. cysticercus and echinococcus), the parasite may die and the cyst undergo absorption or calcification. Probably the least uncommon variety of spontaneous regression of an intracranial tumour is in the case of solitary tuberculomata, which may undergo partial absorption and calcification. Lastly, under the influence of antisyphilitic remedies, syphilitic gummata may undergo absorption and cure, provided that the syphiloma is still in the stage of cellular proliferation, and without degenerative or sclerotic changes ; in the latter case, a gumma will resist even the most energetic medicinal treatment. Intercurrent complications, rather than direct intracranial pressure by the tumour itself, may be the cause of death. Thus, respiratory complications are not uncommon, especially in the form of inhalation-pneumonia ; or a patient with a tuberculoma may have fulminating meningitis superadded ; or he may die from miUary tuberculosis. Purves Stewart. CEREBRAL TUMOUR, SURGICAL.— (See also Cerebral Tumour, Medical). — Two recent publications have thrown a great light upon the end-results of operation for this condition ; these are the report by Tooth of the figures for the National Hospital, Queen Square, and von Eiselsberg's account of the Vienna cases. Prognosis apart from Operation. — In the main, of course, the outlook is very gloomy, and the great majority of cases, after intolerable headache, blindness, mental impairment, various forms of paralysis, epilepsy, etc., die in the course of six months to five years. But to this generalization there are important exceptions. The duration, for instance, may be, and often is, much longer than that described. Many cases are on record in which symptoms of tumour lasted for ten or more years. Tooth, for instance, has found amongst the patients with cerebral tumour discharged from the National Hospital in Queen Square, London, fifty-one who were not operated on, but have survived, on an average, about seven years. About seventy others did not reply, and many are pro- bably dead. In estimating the prognosis, therefore, the length of time that has elapsed since symptoms were first noticed, up to the date of examination, is very important. The location also, is important. Tumours below the tentorium are always liable to cause sudden death by blocking the foramen magnum. Many cere- bellar ' tumours ' in children are tuberculous, and may lead to fatal tuberculous meningitis at any time. On the other hand, in adults, tumours of the cerebello- pontine angle and of the cerebellum may be innocent ; and Tooth reports 18 cases living, on an average, six years after the onset of symptoms. With reference to the possibility of cure, it is of course feasible to remove a gumma by early and efficient treatment with mercury and iodides ; but there is 126 INDEX OF PROGNOSIS a tendency to relapse, perhaps in some other part of the nervous system, and the scar may lead to paralysis, loss of sensation, or epilepsy. Apart from these cases, there are a fair number of instances known in which symptoms, apparently diagnostic of cerebral tumour, have ceased to advance, or even more or less completely disappeared. Some of these were probably cases of serous meningitis (Osier), and a similar confusion may arise in connection with growths of the spinal cord. The prognosis in individual cases must be founded principally upon the rate of progress of the symptoms up to the time of examination, and the diagnosis as to the exact nature and location of the growth. Signs of urgency, calling for operation if life is to be saved or made tolerable, are rapidly increasing blindness or optic neuritis, respiratory or cardiac distress, drowsiness or dullness, and intractable severe headache. Prognosis when treated by Operation. — It is only a minority of the cases that are suitable for any attempt at radical removal. Bruns could only attack 30 out of 100 cases seen by him, and only three or four of these were permanently cured. At the National Hospital for the Paralyzed and Epileptic, out of 497 patients with cerebral tumour, only 11 1 were treated by removal of the tumour (about a fifth). As both these series would probably include cases sent up specially for operation, the proportion amenable to surgical removal in ordinary practice may be even less. Operation Mortality. — Three operations have to be considered, decompression, exploration, and removal of the tumour. Decompression. — The mortality of this procedure is not negligibly small. In von Eiselberg's series, 6 out of 28 died within a month ; at Queen Square, 29 out of 80 were fatal in the same length of time. The results are usually very satisfactory in cases where there is a real rise of intracranial pressure, both in relieving headache and in saving the sight. Cerebral hernia may give trouble afterwards if the dura is opened. The eventual fatality from the continued growth of the tumour cannot, of course, be averted, though it may be postponed. Exploration. — The mortality of exploration at Queen Square was also heavy, 25 out of 74 dying within a month ; in von Eiselsberg's series, 16 died out of 35. The death-rate, then, is about 40 per cent. Removal of the Growth. — In the Queen Square series, 31 out of iii died within a month ; and in Vienna, 25 out of 100 ; so that the mortality is about 25 per cent. The danger is least with tumours of the cortex, and greatest with those of the cerebello-pontine angle ; in the latter case, more than half die. The causes of death are shock, cardiac or respiratory failure — which may come on a week or two after the operation, — septic meningitis, and occasionally pneumonia. Most of the extirpations (all in von Eiselsberg's series) were done in two stages. Of 168 cases at Vienna, 17 died as a result of the first stage. End-results. — Turning next to the end-results of operation, it will be observed that about a third of the cases at Queen Square, treated by extirpation of the growth, were alive and well some months or years afterwards ; but by no means all these were free from danger of recurrence. In von Eiselsberg's series, of t68 cases operated on, only 16 are described as cured, and 23 as improved, giving a total of only about a quarter of the whole. Kuttner's series is unduly favourable, in that cases of hydrocephalus and serous meningitis are included. CEREBRAL TUMOUR, SURGICAL 127 Results of Operation for Cerebral Tumour. I. — Tooth's Series, National Hospital for Paralyzed and Epileptic. CaseB observed AU Operations Removal (partial or complete) Exploration DECOUPItEBSIOH Cases Per cent Cases Died in am'ntb Alive and ■«eU* Cases Died in am'nth Cases Died in am'nth Frontal Central Temporal - Occipital Corona radiata - Pituitary Cerebellum - Extra-cerebellar - Pons - Various Not localized 96 66 47 14 13 14 74 44 41 49 40 70 54 30 7 6 4 33 36 4 18 3 73 83 64 50 46 28 44 82 10 7 31 30 7 2 1 4 11 24 1 9 1 1 1 1 4 13 1 13 9 4 4 t 17 14 14 3 2 14 1 1 7 1 5 4 1 1 5 1 1 7 22 10 9 2 3 8 11 3 10 2 7 2 5 1 2 7 5 Totals • 497 265 53 |m 31 37 74 25 80 29 "' Alive and well " includes some cases whera there Is no recent report. II. — Von Eiselsberg's Series, Vienna. (1901-1913). Died Cases End-results Location and Within a month Later Lost light Re. Progress Inter- Cured Better No better currence currence Extirpation of growth - 41 !l 10 — 1 9 6 3 3 Ligature of s angeioma 2 --- — — 1 1 H Incision of cyst 3 — 1 — 1 1 U ?^ Died of first stage Tumour not 6 — — — — — — — found - 23 9 — 2 1 Pituitary Body - 16 4 — — 12 Extirpation of growth - 5 1 3 — — 1 Incision of cyst 3 - - — — .-_ 3 ~ Meningitis ^H serosa - 3 — — 2 — 1 »h Died of first U stage Tumour not 9 — — — — — — found - 12 7 — 3 — 2 2 /Large* - 11 10 — — — 1 vS Small* 4 1 — — — 2 1 "< i Died of first ■S 1 stage - 2 — — — — — — — — ' Larger or smaller than • nut. INDEX OF PROGNOSIS III. — Kuttner's Series (1907-1912). Total operations, 72 ; mortality, 30-5 per cent ; tumour removed successfully in 22 cases. Of the twenty-two patients, 9 were alive three to six months after operation ; 5, one to two years after ; 4, two to three years after ; 2, three to four years after ; and 2, four to five years after. Functional results. — Of 22 cases, 10 are completely cured and back at work, but only 4 of these were true tumours ; the others were cases of hydrocephalus, serous meningitis, etc., with symptoms resembling tumour. Sight was restored to normal in 75 per cent. It must be remembered, however, that considerable temporary relief is often afforded to cases that afterwards recur and die. Innocent tumours, of course, give far better end-results than the commoner sarcomata and gliomata, which almost always recur. It is very seldom that removal will be successful if the symptoms have progressed rapidly before operation. Tooth, on the authority of the Oueen's Square results, advises that the surgeon should not attempt to remove red or purple diffuse growths, probably glioma or sarcoma ; nor yellow gelatinous or cystic degenerating gliomata, which become active if interfered with. Nor should he attack subcortical swellings, with the exception that cysts may be tapped. If the patient survives the operation, the best results are obtained in cases of tumours of the cerebello-pontine angle, which are usually innocent. Allen Starr finds records in the literature of 69 cases ' cured ' (up to three months) out of 162 operated on ; i was well after twelve years. Glioma of the cortex is exceedingly likely to return ; only one of the London cases was apparently cured. Unfortunately, after the removal of tumours of the cortex, patients maybe left with hemiplegia, aphasia, or mental impairment, if the Rolandic area or speech centres were involved. Summing up, we find that only about a fifth of the cases diagnosed as cerebral tumour are suitable for removal ; that a fourth of these will probably die of the operation ; that another fourth will be greatly improved, or cured ; whilst the remaining half will not be improved, or will die of recurrence. Thus, of 100 cases,''2o are extirpated, 5 die of the operation, 5 are improved or cured. Nevertheless, the headache and loss of sight are so distressing, that von Eiselsberg quotes Horsley with approval in the dictum that "it is inhuman not to operate on a patient with cerebral tumour " ; because a decompression, at least, is possible. References. — Tooth, Rep. of XVIIth Internat. Med. Congr. Sect, vii., 202 : Practi- tioner, 1914, April, 487 ; Von Eiselsberg and Ranzi, Archiv. f. klin. Chir. 1913, Sept. 309; Kuttner, Rev.de Chir. 1913, 646. A. Rendle Short. CERVICAL RIB. — In many cases cervical rib gives rise to no trouble at all ; this must be so, because though the condition is usually bilateral, the symptoms are almost invariably unilateral. There are three groups of sufferers ; those with pressure on nerve-roots, causing numbness, pain, anaesthesia or wasting ; those with narrowing of the artery, leading to pallor or blueness, and feeble circulation, or even gangrene ; and those with a pulsating tumour of the neck. There is said to be a tendency to phthisis, and an aneurysm of the subclavian has been induced. There is no tendency to spontaneous cure, but some improve- ment may follow rest. Effects of Removal. — There does not appear to be any mortality, so far, in the recorded cases. In 4 out of 21 operations collected by Eisendrath the pleura was accidentally opened, and Thorburn had the same accident in 2 out of 20 cases ; but no serious harm resulted. CHLOROSIS 129 End-results. — These are fairly satisfactory, but not invariably so. The writer has seen one patient who was operated on three times by various surgeons ; eventually she improved. Of the 21 cases in Eisendrath's series, 2 were no better. Sargent had i failure in 29 cases. In Thorburn's 20 patients, pain was relieved in four-fifths, and paralysis in half, of those suffering from it. Streissler sums up the results as follows : 77 per cent are cured ; 13 per cent improved ; 10 per cent not improved. Sometimes it is several months before the benefit is felt. References. — Thorburn and others, Proc. Roy. Soc. Med. 1913, vi, Clinic. Sect. 113 ; Eisendrath, Amer. Med. 1904, viii, 322 ; Streissler, Ergebn. d. Chir. u. Orthop. 1913, V. 280. A. Rendle Short. CHARCOT'S JOINTS. — There is, of course, no prospect of cure in these cases, but with care the joints may settle down and remain in statu quo for years. The writer has seen some excellent results following excision in suitable cases. A. Rendle Short. CHICKEN-POX. — This is a disease which is very rarely fatal, and one in which complications but seldom occur. During the eleven months, February 7, 1902, to January 6, 1903, 25,009 cases of chicken-pox were notified in London. There were, therefore, probably about 27,280 cases during the year 1902. During that year 32 deaths from chicken-pox were registered. Probably in not all of the cases was death strictly due to that disease. But even if it were, the fatality was only o-ii per cent. Of some hundreds of cases which have come under my observation, I have met with three in which death took place. In one case, a child of ten months, there were laryngeal symptoms, presumably due to vesicles in the larynx, which necessitated tracheotomy ; the wound became septic, and fatal bronchopneumonia supervened. The second case was one of varicella bullosa in a child aged one year. The third was a case of so-called varicella gangrenosa, also in a child aged one year. Varicella hsemorrhagica is invariably, and varicella bullosa occasionally, fatal. But both of these varieties of the disease, especially the former, are very rare. Varicella gangrenosa, which is a complication rather than a form of the disease, is more common, and is occasionally fatal, usually through some lung com- plication. The prognosis depends on the number of pocks which become gangrenous, and the age and physical condition of the patient. Should the larynx be invaded by the eruption — a very rare event — tracheotomy may be necessary, and this is an operation which is always attended by some risk, as in the case mentioned above. £•. p^. Goodall- CHLOROSIS. — In the average case of chlorosis, complete recovery may confidently be expected in from six weeks to four months. The greatest obstacle in the way of absolute cure is failure of the patient to persist with the necessary treatment. Symptoms disappear, and the patient's sense of well-being is so greatly increased that she fails to realize that complete health has not been regained. It cannot be too strongly insisted upon that the measure of recovery is not the patient's subjective sensations, or an appear- ance of health, but an examination of the blood. Any deficiency in the number of corpuscles, or percentage of haemoglobin, is to be regarded as a clamant indication for vigorous persistence in treatment. The reason for this is the great tendency of the disease to relapse. This may occur after complete recovery, but the conditions which arise as the result of incomplete cure make relapse almost certain. The patient has little or no discomfort. Her sense of well-being contrasts strongly with her previous 9 I30 INDEX OF PROGNOSIS breathlessness, palpitation, and headaches. She may now feel fit for exercise, work, or recreation formerly denied her. This is indulged in, although her blood is not yet a satisfactory medium for maintaining the respiration of the tissues. The deficiency can only be met by increased cardiac and respiratory action, the heart is strained, and in a very short time symptoms become as marked as ever. There is now, however, this important difference ; they are not nearly so readily curable. Another result of failure to attain complete recovery is that the patient becomes accustomed to a condition of health which is short of the normal standard. She becomes easily fatigued, listless, apathetic, even sulky, and often finds httle sympathy in her family circle. The more striking symptoms are not so much in evidence, and the result may be that the unfortunate patient's disability is attributed to an ungenerous disposition of mind rather than to a deficiency of haemoglobin in her blood. This type of semi-invahdism is a common result of ' home ' treatment. The occurrence of urgent symptoms or marked pallor leads to the purchase of a box of Blaud's pills or of some proprietary preparation of iron. As soon as the symptoms have subsided or the box has been emptied, the treatment, such as it is, stops, and the patient resumes her condition of semi-invahdism. With increasing years this state of affairs may be outgrown, but those cases of chlorosis in women of thirty and even forty 5'ears of age, which are exceedingly difficult to get well, are mainly recruited from this class. It may be noted that in chronic chlorosis, nutrition is deficient at a time of life when mind and body should be most active. Girls doing mental work are handicapped, so that they fail to profit to the fuU. by education, and among workers, chances of promotion may be lost during the period of life when they are most likely to present themselves. Over and above all this, such cases fall easy victims to intercurrent disease. Factors affecting Prognosis. — Age. — If the onset occurs at an early age, the illness is more likely to be severe and prolonged than if the first attack takes place at a later age. It may be noted that chlorosis practically never occurs for the first time after the age of twenty-three or twenty-four, so that when the condition is met with at a later age, it may safely be assumed that it is a relapse or recurrence of a previous attack, and that it will be more difficult to effect a complete cure. Heredity. — A family history of chlorosis is not necessarily an indication of any special prognostic significance, but if hereditary or family predisposition appears to be a causal factor of greater moment than stress of environment, then prognosis is so much the worse. Emotional Conditions. — As in other illnesses, the more definitely a removable cause can be ascertained, the greater is the likelihood of cure. The difficulty is, that a removal of the cause may not be practicable or possible. An unhappy love affair is proverbially difficult for any outsider to influence, and the most tactful physician is the one least likely to make the attempt to do so. Home- sickness is another potent cause of persistence of a chlorotic condition, and its removal, even when possible, may entail too great a sacrifice to be entertained unless the damage to health is very persistent or severe. Emotional con- ditions of many kinds may be antagonistic to the success of treatment, and in many instances, such as the recollection of a severe fright, they may be very difficult to overcome. Occupation. — A sedentary or otherwise unsuitable occupation may be the cause ■of persistence of anaemia, or of relapse after cure. It is often a difiicult problem for the physician to advise in regard to an occupation which may be congenial and inimical to health at the same time. Each case has to be judged on its merits. CHLOROSIS 131 The factors which will have to be balanced are the actual damage to health, the response to treatment, the probability of diminution of the chlorotic tendency as the patient grows older, and the amount of worry, either sentimental or financial, which a change of occupation may entail. Locality. — A change of neighbourhood may determine the onset of an attack of chlorosis. Curiously enough this effect sometimes follows a change from town or country to the seaside. Such cases readily yield to treatment and speedily become acchmatized. Marriage. — Chlorosis very rarely persists after marriage, but occasionally does so. Such cases are generally severe. In some instances there is a complete restoration of the blood to normal during pregnancy, and a relapse after the puerperium. In dealing with chlorosis, the ansemia which is often associated with illegitimate prep.nancy should be kept in mind. This anaemia may be true chlorosis, but is often secondary. Effect of Treatment. — Chlorosis is not one of the diseases in which difi&culties arise through the claims of alternative lines of treatment. There may be difficulties in the way, but the main indication is quite definite. That indication is the adequate administration of iron. The difficulties which may arise are the persistence of faulty conditions of life, or a disinclination or disability of the patient to take a satisfactory dietary, — carbohydrates, largely in the form of biscuits and sweets, being preferred to meat. In the severer cases, a speedy restoration in health cannot be expected unless the patient is confined to bed. It is our practice to advise every case with less than 60 per cent of haemoglobin to stay in bed till the percentage is well above that figure, and if we are asked how long the patient will be kept there, we may say three weeks. That period may be extended or shortened as the result of blood examination, but it is a fair average. Even the milder cases mend more rapidly in bed than when they are going about. Amelioration may be seriously delayed by the patient's inability to retain iron. Such cases are not common, especially if rest in bed be insisted on. Dyspepsia and constipation, when they are met with, may have to be treated before any iron therapy can be persisted in, and the time of cure is of course postponed. Very rarely, even when dyspeptic symptoms have been removed, iron is not well borne, and we may be obliged to fall back on one of the less irritating forms, such as the scale preparations, or one of the organic combinations. Neither will be found nearly so efficacious as the perchloride, carbonate, or reduced iron. Many of the organic preparations are useless; preparations of haemoglobin are notably valueless, and considering the minute traces of iron which they contain, this is not surprising. The great drawback to all organic compounds is their small proportion of iron, and their expense. Not much is gained as a rule by the addition of strychnine and other drugs to the prescription, unless there is some special indication for them. A little arsenic may be of use, when the count of red corpuscles is very low. When a case is complicated by considerable atony or dilatation of the heart, appropriate treatment is of course called for, and the question of prognosis then enters a somewhat wider sphere. We may remark, however, that cardiac atony or dilatation, due to chlorosis, is in nearly every case a readily curable condition. The idea that chlorosis depends on constipation is now exploded. Certain it is that chlorosis is not cured by purgatives, although they may play a useful part in its treatment. The view of Haldane and Lorrain Smith, that chlorosis is due to an increase of blood plasma, has led to a trial of therapeutic measures intended to deplete 132 INDEX OF PROGNOSIS the body fluids. Purgatives, diuretics, diaphoretics, and hot baths have been tried, but without good result, and the physician has been glad to fall back on treatment by iron. Attempts to influence chlorosis by bleeding, with the view of thereby stimulating the bone-marrow, have been made, but the results have not been satisfactory. It may be stated that when such measures are tried alone they fail, and when they are tried along with the administration of iron, the ensuing benefit is attributable to the iron. When iron is reasonably well tolerated and fails to cure anaemia, we may be assured that in 99 per cent of cases the anaemia is not chlorosis, and a revision of diagnosis is called for. Rheumatism, syphilis, and tuberculosis are among the most likely causes of confusion. Complications. — -Any anxiety that is ever occasioned by a case of chlorosis is much more likely to be due to the occurrence of a complication than to the disease itself. A connection between chlorosis and gastric ulcer is well recognized, but their exact relationship cannot be said to be well defined. A history of chlorosis in gastric ulcer is exceedingly common, and we have seen the symptoms of gastric ulcer arise in cases of chlorosis under actual observation. The occurrence of one or more of the symptoms of exophthalmic goitre during the course of chlorosis is probably too frequent to be a mere coincidence. Out of a series of 255 cases of chlorosis, quoted by von Noorden, 34 showed more than one of the symptoms of Graves's disease. The complication of outstanding importance in connection with chlorosis is venous thrombosis. It occurred in 6 out of 431 cases reported by von Erben, and in 5 out of 230 of von Noorden's histories. The thrombosis may occur in the femoral veins or in the arms, but unfortunately one of the commonest sites is in the cerebral sinuses. The occurrence of the latter is an experience not readily forgotten by the medical attendant. It is one of the catastrophes of medicine, and there is the danger that the symptoms may at first be attributed to hysteria. Nearly all post-mortem records of cases of chlorosis give venous thrombosis as the cause of death. Intercurrent Affections. — An important aspect of chlorosis is that it increases liability to all forms of infectious disease, and diminishes the patient's powers of resistance to them. G. L. Gulland. A. Goodall. CHOLECYSTITIS. — Cholecystitis may be diagnosed under the following circumstances : — Acute Suppurative Cholecystitis. — This may occur in connection with gall- stones {vide infra), as a sequel of typhoid fever, or apart from any known cause. In the post-typhoid cases, there are reports in the literature of 21 operations with 8 recoveries. Idiopathic cases are rare, and simulate appendicitis. The prognosis depends entirely on early diagnosis and operation ; granted this, the majority recover; otherwise nearly all die. Cholecystitis without Gall-stones, but causing Similar Symptoms. — This is by no means rare, and many of the patients are operated on and drained under the mistaken supposition that stones will be found. According to Stanton, of 98 such cases 46 were cured, 10 much better, 23 rather better, and 19 no better. These results are not nearly as good as in ordinary gall-stone cases. Empyema of the Gall-bladder. — This is usually due to impaction of a stone in the cystic duct, followed by infection. If an operation is performed early, the great majority do well after cholecystectomy. Cholecystitis with Gall-stones. — (See article on Gall-stones.) Septic infection greatly increases the risk of the operation for gall-stones ; at the CHOREA 133 Bristol Royal Infirmary 2 out of 9 such cases died, and in the Mayos' series 10 out of 61. The end-results are also less satisfactory. References. — Stanton, Joiir. Amer. Med. Assoc. 1911, Ivii, 441 ; Mayo, Ann. Surg. 1906, xliv, 209; Rendle Short, Bristol Med.-Chir, Jour. 1913, March, 34. A . Rendle Short. CHOLELITHIASIS.— (See Gall-stones.) CHOLERA. — There is always a large mortality — over 50 per cent — in the epidemics in Europe. It is less towards the end of an epidemic, but during the height thereof it is greater, sometimes much greater. '■ Rogers believes that a reduction in the mortality may be expected by the use of hypertonic saline injections and permanganates by the mouth. Out of 133 cases, he treated 39 in this manner with 9 deaths, or 23-1 per cent ; whilst in 94 not so treated there were 59 deaths, or 62-7 per cent. c. W. Daniels. CHOREA. — Prognosis is mainly concerned with childhood, although the occurrence of chorea in adolescence and in adult life is thoroughly recognized. It is interesting to notice in an out-patient department the manifestations that rheumatic children show when they are first brought to a hospital, and the result gives a rough practical idea of the relative frequency of the important ones. Thus in 500 cases, 248 suffered from arthritis and arthritic pains, 350 from morbus cordis, 245 from chorea, 137 from sore throat, and 39 showed nodules. It should be added that all cases of chorea were looked upon as rheumatic, an error probably on the safe side. Chorea is much more frequent in the female ; of 284 consecutive cases, 202 were females and 82 were males. This manifestation is very seldom directly fatal in childhood. Of the many hundreds that the writer has seen, only 2 have died from the severity of the movements, though some others have been desperately ill. So far, then, as the first problem in prognosis — the outlook for the particular attack — we may with confidence feel that it is good — a warning, let it be added, not to over-drug these patients. The duration of an attack is most uncertain. We may collect statistics and arrive at some such average time as six to eight weeks, but to apply any average to a particular case is as likely as not to result in failure. The liability to relapse is great, and there is a group of cases which seems to develop annually a fresh attack over a period of years. Of special interest is the fact that these attacks seem to come on almost spontaneously. With regard to this entire question of recurrence in rheumatism, it is remarkable how persis- tently an obvious event is demanded as an explanation for the occurrence ; yet who of us, with patients suffering from tuberculosis, would expect to find a clear-cut explanation for every lighting up of that infection ? Why should not also the rheumatic infection lie dormant in the system, as undoubtedly the tubercle bacillus does, and light up again under circumstances of climate and season which we cannot definitely ascertain ? The prognosis of chorea is intimately bound up with that of heart disease, for 217 consecutive cases showed obvious signs of organic heart disease in 122. Two points will, however, be emphasized here. Firstly, that recurrent chorea should always put us on guard for the develop- ment of mitral stenosis ; secondly, that this manifestation, if severe, is a very grave event when there is also severe carditis. When severe chorea develops at the height of a pericarditis, a fatal issue is frequent. In 20 fatal cases of acute cardiac rheumatism in which chorea was a prominent symptom, 14 died in their first attack, and in every case there was 134 INDEX OF PROGNOSIS pericarditis. Conversely, when, during a severe chorea, acute carditis develops, the prognosis is always grave. There are some cases of chorea in which perfect recovery is extremely slow, and it is doubtful whether, for some years, the child can be really said to be quite natural in its movements. Such cases may have exacerbations once or twice each year, and may be called examples of chronic chorea. Eventually they appear to get well, although the improvement is so gradual that it is difficult to define when the recovery occurs. The mental condition in some of these cases is considerably altered, and the writer has known several of them looked upon as mentally deficient. Children with chorea are often exceedingly unstable and emotional long after the move- ments have disappeared, and if in addition there has been practically no education, there is no doubt that the standard of intelligence in the most chronic cases is much lowered, and very possibly permanently damaged. As a rule, in ordinary cases, the intelligence is good, although the mental balance is always weak in the children who are the victims of severe chorea. We must remember that there are rare cases of tuberculous meningitis in which movements indistinguishable from rheumatic chorea occur ; the prognosis in such is, of course, hopeless. Mental delusions and hallucinations that occur in some cases pass away, as does also dumbness. In adult life, the predominance of chorea in the female still holds good, and the disease is more severe and certainly more fatal, although such an event is decidedly rare. The Guy's records quoted by Herbert French showed 3 deaths in 29 consecutive cases, a much higher proportion than occurs in childhood. The mental changes in the adult are likely to be more prominent than in the child, and may result in an actual dementia lasting for a considerable time, and some of these patients are indeed very close to the border of insanity. It must be remembered that chorea may sometimes begin at a very early age. The writer has had 3 cases in which the condition developed under three years of age. In all the very young cases he has seen there has also been cardiac disease, a point of great prognostic importance. The duration of an attack depends to some extent upon the mode of onset. The most acute cases in childhood often recover the most quickly ; the more chronic ones may linger on for months. Do any drugs alter the prognosis ? That careful and rational treatment improves the outlook is undoubted, but there seems no one drug that has yet been discovered which produces a certain curative action. On the other hand, the prognosis may be made much less favourable by reckless treatment. Severe arsenical neuritis is a terrible addition to the burden of the illness ; salicylate poisoning, or death from overdosage with chloral, are tragic events, but not unknown happenings. Chloretone may produce alarming symptoms in child- hood if given incautiously, but the intoxication is a passing one, and to this extent has little effect upon the prognosis. So far as the writer can ascertain, a good deal will depend in the question of prognosis upon the adaptation of the line of treatment to the individual and to the phase of the illness. Exceedingly severe physical and emotional storms if treated with arsenic will not derive benefit, but are assisted by nerve sedatives. A combination of the salicylates and bromides seems helpful to early rheumatic cases. Arsenic aids recovery when the temperature is normal, but the nervous system is obstinately unstable. Rest and absolute quiet — indispensable in the early stages — are often, towards the end of a long case, much inferior to cheerful, sensible company, and orderly exercises. F. /. Poynton. CLEFT PALATE 135 CHORION- EPITHELIOMA. — No type of malignant disease is found to present more marked variation in respect of its malignancy. On the one hand, death has followed growth and the performance of radical operation within the month ; while on the other hand, in some cases where operation has been delayed for more than a year after symptoms indicative of malignancy have occurred, yet the patient has been saved. Even when metastases have been left behind at the time of operation, recovery has taken place in a few cases. Cases are recorded in which spontaneous cure has occurred — where the diagnosis has rested upon the presence of vaginal nodules and masses of growth in the urethral veins, which have been subjected to microscopical examination. There is some evidence which suggests that cases following vesicular mole are less virulent than other forms. As the presence of hydatid mole has in many instances acted as a danger signal, it is likely that an ensuing chorion-epithelioma will be attacked at an earlier stage than a growth following upon normal preg- nancy or abortion. Further, the extreme difficulty of deciding when a hydatid mole has taken on a malignant character will often lead to radical operation earlier than absolutely necessary. All investigators are agreed as to the impossibility of deciding in borderline cases, and clinical observation and symptoms must be considered in forming an opinion. Teacher^ gives the following results in cases collected by him in the literature : Of 99 cases operated on, ii-i per cent died within a few days. Of 63 cases operated on, 13, or 20-6 per cent, were in good health and free from recurrence two years later. Two years may safely be taken as indicating a complete cure in these cases. Sepsis, or general dissemination, is the final stage in the disease ; but cases which were known to have had abdominal metastases and later to have had haemoptysis, suggesting the presence of deposits in the lungs, have yet in rare instances been recorded as recovering. Chorion-epithelioma of the Fallopian Tube. — The cases which appear to have originated in the Fallopian tube are, as might be expected, more serious than in the case of the uterus. In the first place the difficulty, almost the impossibility, of diagnosis, and in the next place the early dissemination which occurs, both militate against a favourable outlook. Bazy2 has collected 12 cases, with the following results : 2, not operated on, died ; of the other 10, who were operated on, 5 died soon after operation, 4 lived from two to four months, i was cured. In one case the growth was only the size of an early tubal gestation, for which indeed it was mistaken at the time of operation ; nevertheless the patient died in a few weeks with extensive metastases. In contrast to this is a case recorded by Phillips,^ who removed a chorion-epithelioma of the left tube, and later operated for metastases, removing the uterus and right appendage, but leaving behind a mass at the root of the mesentery which he took to be metastases in glands ; yet the patient recovered and was well two and a half years later. References. — '^Allbutt's System of GyncBCology , 1909, 407 ; "Ann. de Gyn. et d'Obsi. 1913, April ; ^Jour. Obst. and Gyn. 1911, ii, 299. Bryden Glendining. CIRRHOSIS.— (5ee Liver.) CLEFT PALATE. — In spite of the publication of some very important series of cases, well followed through and treated by various methods, we are still without reliable information on some necessary points. It would be very valuable, for instance, to have data for judging the mortality amongst cleft palate babies in the early years of life, before the age at which it has been 136 INDEX OF PROGNOSIS customary to operate. Sir Arbuthnot Lane claims that many lives are saved by closing the palate during the first few weeks after birth, because so many of these children would otherwise die, but this opinion is unsupported by figures and is open to grave doubt. Further, we do not know whether children, whose palates have been closed by a flap-operation, will eventually be able to speak well. At the exhibition of cases treated by various methods at the Royal Society of Medicine in 191 1, very few of those shown by the advocates of this procedure were old enough to talk, and their mouths showed a good deal of scarring in many cases, so that it was open to question if the very essential mobility of the soft palate would be obtained. On other points, however, we are now in possession of very excellent data. Four methods of treatment come up for discussion ; (i) Langenbeck' s , or the ordinary operation ; (2) Lane's turn-over flap method ; (3) Brophy's operation ; and (4) the Obturator method. I. Langenbeck's Operation. — Provided that care is exercised in the choice of time of operation, so that the child is in good health when it is performed, the immediate danger to life, in patients two years of age or older, is extremely small. Berry reports 154 cases without a death. The prospect of closure of the gap is good. Berry says that he has never seen a cleft which could not be closed by operation, provided that the parts had not been spoiled by a previous failure. In his list of 138 first operations, there were 109 in which complete union took place, or the hole left was only big enough to admit a probe and would probably close spontaneously. In 25 cases success was partial or a hole remained ; some of these were cured by a second operation. In 4 cases there was complete failure ; some of these also were remedied sub- sequently. Second operations gave 13 successes and 3 partial successes. The end-results as regards speech depend on many factors : the age at operation, the length and mobility of the soft palate, the intelligence of the child, and the care in after -training. In Berry's tables, the speech was investigated at least a year later in 97 cases ; it is described as good in 36, good, but certain letters still gave trouble, in 21, and fair or poor in 40 ; in many of these last there was very definite improvement, others were mentally defective, and the great majority had no proper training. The end-results of second operations were not so good ; out of 13 followed, 3 spoke well, 3 had trouble with certain letters, and 7 were only moderately improved. Langenbeck's Operation (Berry). Cases IJeatbs Union | Speech Complete or virtually com- plete Partial Failure Good Fairly yood Fair First operations - Second operations 138 16 109 13 25 3 4 36 3 21 3 40 7 2. Lane's Flap Operation. — At the meeting of the Royal Society of Medicine in 191 1, the principal exponents of this method were Sir Arbuthnot Lane, Hilton Fagge, and one of the former's house surgeons. Of Lane's operations, 369 were reported, with a mortality of about 6 per cent. Of these, 144 were first operations on children under twelve months, the majority being but a few weeks old. By this very early interference, such is the argument, COLITIS 137 shock is avoided, ill-development of the mouth and nasopharynx prevented, and children are saved who would otherwise die of malnutrition. Of these 144 cases, 18 (12-5 per cent) died in hospital. What eventually happened to the survivors is not, as a rule, known. Fagge reported 57 cases, of which 38 were under one year old. Of these, 3 died in hospital, and an attempt to follow up the others showed that 14 had died since. It is, therefore, by no means certain that the operation is life-saving ; probably the reverse is the truth. Goyder has operated on 30 cases, all but 3 by Lane's method. He failed to obtain complete closure at the primary operation in 7 cases. The end-results as regards speech are not known in a sufficient number of cases to justify deductions. In 15 cases investigated by Goyder, speech was good in 4, fair in 4, and poor in 7. Three of the 4 classed as good were still very young, and the final condition remains to be seen. Flap Operation. Lane, all cases ,, first operations — under one year old Fagge, all cases - „ first operations — under one year old 369 144 57 38 Deaths in Hospital 22 (=5-9 per cent) 18 (=12-5 per cent) 3 (=7'8 per cent) Died subsequently 14 (=37 per cent) 3. Brophy's Operation. — The essential point in this operation is to force the maxillae together by stout wires before the child is three months old. By this means it is usually possible to close a wide gap, the best results being obtained Avithin a few weeks of birth. Brophy claims to have treated 300 cases, with a mortality of only 3 per cent, but 5 out of 11 English cases died, and necrosis ensued in another. This operation can only be used when there is a complete cleft of the hard palate. Ulrich uses a somewhat similar method. He lost 2 out of 10 cases. 4. The Obturator. — It is easy to close the cleft in the hard palate by this means, but it is difficult or impossible to provide a movable soft palate controllable by muscles, and therefore speech is not greatly improved. The obturator is more useful in adults than in young children, who would require frequent changes, and might also get it impacted in the oesophagus. References. — Berry and Legg, Hare Lip and Cleft Palate, 1912 ; Proc. Roy. Soc. Med. 1911, iv, pt. 3, surgical section, 169 ; Goyder, Brit. Jour Surg. 1913-14, i, 259. A. Rendle Short. CLUB FOOT.— (See Talipes.) COLITIS.— Simple. — The prognosis is, as a rule, good, provided the condition is taken i n hand early. When very exceptionally acute, death may occur from exhaus- tion, toxcEmia, or collapse. Membranous. — This disease is, as a rule, chronic ; however, the majority of patients eventually recover, though some do not appear to be benefited by treatment. The outlook is better in men than in women. The complaint is not in itself fatal. The age of the patient has little influence on the course of the illness, nor has the presence of intestinal sand, which is not uncommon. 138 INDEX OF PROGNOSIS Ulcerative. — The outlook is exceedingly serious if the disease is in any way severe, many of the patients dying within the course of the first few months after presenting themselves for treatment. Grave symptoms are high fever, marked distention from flatus, severe haemorrhage, copious diarrhoea, exhaustion, and, more rarely, peritonitis. Death may occur in three or four days from the first onset of symptoms, and frequently occurs within the first two months. It must, however, be remembered that many of these patients give a history of previous attacks of diarrhoea, and if the onset of the illness is measured from the first of these, the duration is often many years. On the other hand, life may be prolonged with continuous subacute symptoms for upwards of two years, and in a small proportion of cases permanent cure apparently results from treatment, even when the disease has been very acute and severe. The vast majority of cases run their course either to death or recovery without complica- tions. Though perforative peritonitis may occur, it is much less common than might be supposed when the extensive area of ulcerated surface is taken into account. Hepatic abscess is very rare indeed. Pulmonary embolism sometimes kills. In cases which recover, there is little liability to obstruction of the bowels from cicatrization. The mortality is higher than in tropical dysentery ; thus death occurred in 40 out of 55 cases treated at Guy's ; 28 out of 32 at St. Bartholomew's ; 9 out of 19 at St. George's ; 8 out of 19 at St. Mary's ; 40 out of 80 at St. Thomas's. The mode of death in the St. Thomas's Hospital series was as follows : 8 children, all died from exhaustion following diarrhoea. Of 32 adults, 9 died from exhaustion following diarrhoea ; i from haemorrhage ; 8 from haemorrhage and diarrhoea ; i from hepatic abscess ; 6 from peritonitis after perforation ; 2 from peritonitis without perforation ; 5 from peritonitis following closure of .an artificial anus. At the present time there is not sufficient evidence upon which to base a prognosis from the predominant organism present in the evacuations, or from agglutination tests. The sex of the patient does not influence the outlook. It is questionable whether the use of vaccines materially modifies the prognosis. Improvement and sometimes cure have followed their use at times ; on the other hand, they have frequently no effect in arresting the course of the disease or preventing a fatal termination. Tropical Baeillary Dysentery [See also Dysentery). — This disease varies very greatly indeed in its virulence. Mild cases are rapidly cured and the prognosis is extremely good. The severity of the earliest symptoms forms an important guide. The mortality of epidemics of average severity, such as those which occur in Japan, is about 30 per cent. Convalescence is very liable to be slow, and a return of the symptoms not uncommon. A great deal depends on the time at which the illness first comes under treatment, for if taken in hand early the prognosis is good, while if neglected in the earUer stages it is very liable to become chronic with a poor outlook, A very guarded prognosis must be given if the temperature remains elevated. The presence of a leucocytosis is un- common, but even if it occurs in any given case, it does not necessarily involve a bad prognosis. The choleraic form of acute baeillary dysentery is usually fatal, but the prognosis appears to be decidedly improved since the introduction of the use of the intravenous hypertonic solution of Leonard Rogers (i.e., sodium chloride 120 gr., potassium chloride 6 gr., calcium chloride 4 gr., to a pint of water), combined with rectal injection of calcium permanganate (5 gr. to the pint). The chronic form generally gets well or ends fatally in the course of a few months, but may last for several years with relapses. A retracted abdomen. COLITIS 139 gross anaemia, emaciation, exhaustion, oedema of the extremities, offensive stools, are all bad signs. In rare cases the patient may succumb to haemorrhage. Perforation, peritonitis, and hepatic abscess are very unusual. Leonard Rogers says that in 125 post-mortem examinations on dysenteric cases in Calcutta, no case of portal pyaemia or serious hepatic complication was found in any of the bacillary cases, which numbered 36 per cent of the whole. He also points out that the mortality from bacillary dysentery among the Mecca pilgrims, which in 1909 was 64-4 per cent, was reduced by serum treatment in 1910 to IO-8 per cent. The inore frequent use of a Shiga, Flexner, or polyvalent antidysenteric serum promises to improve the outlook still further. Unfortunately the same cannot as yet be claimed for vaccine treatment. Leonard Rogers gives the following figures of the case mortality in India from 1906 to 1910 : British army, 2-93 per cent ; Indian arm}', 0-51 per cent ; Indian gaols, 5-29 per cent. Sprue. — The prognosis is very unsatisfactory unless the patient comes under treatment at the earliest possible moment. If the disease is of long standing, no recognized remedy has any very great influence on the course of the illness. Typical or severe mouth symptoms indicate, as a rule, an advanced state of the disease. In addition to the diarrhoea, the following are all bad signs : anaemia, diminution in the size of the liver, and emaciation. Many of the more acute cases succumb within eight to twelve months of the beginning of the trouble, but if they survive this period they tend to lapse into a very chronic condition, with a disease which lasts eight to ten years or even longer. The prognosis appears to be improved by residence in a temperate climate. Temporary improvements are often followed by relapses, even if the patient has made an apparent cure in a temperate climate. Amoebic Dysentery. — Children suffer from the disease less severely than adults, and natives of a place where amoebic dysentery is endemic are more easily treated satisfactorily than others. In acute dysentery, periods of apparent improvement, which are most delusive, sometimes occur, during which the stools become less frequent and offensive, and tenesmus much less marked. These periods of calm may be followed by severe relapse of symptoms. Marked prostration shoald cause a very guarded prognosis. In acute fulminating cases, peritonitis from perforation, gangrene of the gut, post-colic abscess, or exhaustion, may kill the patient even within a week or ten days from the onset. Severe haemorrhage may occur, but this is a very rare cause of death. The patient must not be regarded as out of danger because there is no fever, for many cases prove fatal without elevation of temperature. Palpable thickening of the bowel, most frequently felt over the caecum and sigmoid and often associated with great tenderness, may be present in severe cases. If more widespread thickening of the bowel can be felt, the case is generally one of the acute fulminating class, and the prognosis grave in the extreme. The mortality-rates vary from 20 per cent to 43 per cent ; but much depends on the stage at which the disease comes under treatment, and the particular type in any given case. Chronic amoebic dysentery may last for a year, and even then be liable to repeated relapses. The figures just quoted refer to the prognosis before the introduction of emetine. The outlook appears to have been wonderfully improved since Leonard Rogers introduced the method of the hypodermic administration of the soluble salts of emetine. Solutions of these salts may also be injected with very great success into amoebic abscess-cavities in liver or spleen. When no more amoebae I40 INDEX OF PROGNOSIS can be discovered in the stools, or not found at all owing to the closed nature of the lesion, the progress of the Leucoctyosis is most important, both from the point of view of prognosis and of continuance of the treatment. Absence of leucocytosis in acute amoebic dysentery is of bad omen, indicating extremely feeble resistance. In the case of a cured abscess, the leucocytosis should have disappeared in about a fortnight. With an uncomplicated intestinal lesion, it disappears much sooner. A case with over 30,000 leucocytes per c.mm. should be regarded with considerable gravity. Liver abscess may arise without dysenteric symptoms being evident. If, however, these are prominent, the prognosis is much worse, because there is then much more probability of the liver suppuration being multiple. Many of these cases are practically hopeless. If the abscess is single, and even of great size, it rarely destroys sufficient tissue to make recovery impossible. Secondary septic infection is very liable to follow an open operation, and this very frequently kills the patient if the abscess is large. Emetine, if used early enough, appears to prevent to a very great extent the hepatic complications, and to have a marked curative effect if they are already present. /. r Charles. COLON, CARCINOMA OF. — Compared with the average rate of growth of cancer elsewhere, carcinoma of the large intestine is not a particularly rapid or malignant type of the disease. It is certainly more favourable than cancer of the rectum. As Paul has pointed out, and contrary to the generally-received opinion, the hypertrophic form, in which a large tumour can be felt, is less rapidly fatal than the stenosing form, which causes chronic or acute intestinal obstruction. The duration of life, from the first onset of symptoms to the end, is usually from six months to two years, apart from treatment. In the great majority of cases the eventual fatality is due to an attack of acute obstruction ; less often, to cachexia ; and rarely, to perforative peritonitis. Marked ansemia and loss of flesh, or symptoms of obstruction, show that the end is not far off. Results of Surgical Treatment. — The mortality of operation depends very greatly on the state of the patient when the surgeon sees the case ; also, to some extent, on the method of intervention. If signs of acute obstruction are already present, the outlook is very grave, and all that can be done at the moment is a colostomy ; but occasionally the patient may recover sufficiently to allow of a subsequent radical operation. Cases with cachexia are already beyond hope of cure, though it may be possible to give some rehef. It will be perfectly evident, from the figures supplied, that a two-stage operation is decidedly the safer, probably giving a mortality of about 15 per cent. This refers to cases in which there is no acute obstruction present. By a two- stage operation is meant, either Paul's method, in which the growth is resected and a drainage tube tied into each end of the bowel at the first operation, the spur being reduced and the fistula closed subsequently ; or a preliminary colostomy, followed by resection and end-to-end union. The best results after the one-stage operation are from the Mayo clinic, where 8 died out of 61 operated on, or 13 per cent ; but in Finkelstein's series, including the patients of the Mayos and several other surgeons, the mortality in 209 cases is 29 per cent. Apart from acute obstruction cases, the mortality is given by various writers as follows : — COLON, CARCINOMA OF 141 Mortality of Operation for Carcinoma of Colon. Reporter Operation Cases Died per cent. /'*Finkelstein- Two-stage 142 16 J Paul - - - - 14 j Anschiitz 30 20 (^ *Moynihan - 32 15 f *Finkelstein- One-stage 209 29 J Anschiitz 20 55 1 *Moynihan - 68 32-3 l^Mavos - - - - 61 13 , *Hartmann - Stages not specified 143 33-5 1 St. Thomas's Hospital ,, ,, 58 39-5 < Voelcker 58 46-5 1 Caird - - - - ,, ,, 17 35-2 ^ Lausanne - " 28 10-0 * These are cases collected from the literature. Anschiitz's reports refer to cases in von Mikulicz's clinic up to 1907 ; Voelcker's to Czerny's clinic ; Moynihan's tables were published in 1906 ; Finkelstein's relate to the years 1907 to 191 2. Very probably several of the series taken from the literature include the same groups. Paul's cases are all from his private practice. The Lausanne series, published by Voichoud, relate to the years 1880- 1910. In 19 cases the operation was in one stage. End-results of Operation. — These are not unfavourable, provided, of course, that there were no secondary deposits at the time of intervention, and that the glands were removed. Various observers report as follows : — End-results of Operations for Carcinoma of Colon. Reporter Cases followed Alive and well Period Mayo - 16 9 Over three years Anschiitz - 27 14 ,, ,, Moynihan - 49* J 9 (22 One to three years Paul - 13t (1 Over tliree years One to three years Lausanne - 24 J 6 ( 8 Over three years Under three years * Three deaths were not due to cancer, t Two deaths were not due to cancer, We may conclude, therefore, that about half the patients are cured. Death from recurrence is often late. In 4 of Paul's cases it took place from two and a half to seven years after the operation. Palliative Operations include colostomy above the growth to relieve obstruc- tion, and a short-circuiting operation. Colostomy, in the presence of an acute obstruction, is, of course, a desperate performance, and frequently the patient does not rally. Of 64 cases in Paul's private practice in which this operation was performed for malignant disease, acute obstruction was present in 24, and 9 of these died soon afterwards. There were no fatalities in the absence of acute symptoms. 142 INDEX OF PROGNOSIS The survival afterwards is often surprisingly long, should the patient recover from the immediate efiects of the operation. Of Paul's 64 cases, 9 died shortly- after the operation ; 28 within a year ; 17 one to three or more 3-ears later ; TO were alive (all for more than a year and up to ten j-ears, except one. Some of these presumably had a resection performed later). It is not quite clear how many of these long-survival cases had a subsequent resection ; it cannot be many, as the total resections for cancer were only 14 in number. It is a mistake to suppose that these patients were necessarih^ left in a state of misery. Persons with a colostomy have frequently been able to get about their duties ; a lady has even acted as hostess through a London season, without serious inconvenience, wearing a colostomy belt. We have no adequate figures to show the risks or successes of short-circuiting operations in cases of cancer of the colon. To sum up, then, the mortality of the one-stage operation is 30 to 40 per cent ; of the two-stage operation about 16 per cent ; and about half the patients who survive will be cured. References. — Paul, Bnt. Med. Jour. iqi2, ii, 172; Moynihan, Abdominal Operations, 1906 ; Makins, " Cancer of Colon," Burghard's System of Operative Surgery ; Finkelstein, Archiv. f. klin. Chir. 1913, July, 936 ; Mayo, Ann. Surg. 1909, July, 200 ; Voichoud, Surg. Gyn. and Obst. 1914, ii, 248 (Summary). A. Rendle Short. CONCUSSION.— (5ee Head Injuries.) CONGENITAL DISLOCATION OF HIP. — Apart from surgical interference, the outlook in this deformity is not favourable. Natural cure appears to be unknown, although there are a few records of improvement in patients with partial dislocation or subluxation. In ordinary, the lameness, shortening, and difi&culty in walking increase rapidly during the years of growth, and even those children in whom the deformity is at first scarcely noticeable are eventually seriously crippled. In bilateral cases a good deal of spasm often develops, and the patient may become a chronic invaUd. We shall have to consider the results of two methods of treatment : (i) The open operation ; and (2) The " bloodless " reduction by Lorenz's method. 1. The Open Operation. — This is seldom performed now, though favoured by Burghard. There has been a considerable mortahty, and it is apt to cripple the muscles a good deal. Tubby has performed it 10 times ; 4 gave a good result, and 6 relapsed. 2. The Lorenz Operation. — This operation is only suitable within narrow age-Hmits, from four years old up to seven in bilateral, or ten in unilateral, cases. The risks are small. There is almost no mortality, 4 deaths in 1235 cases, according to Deutschlander — that is, about 0-3 per cent. Occasionally the femur may be fractured ; R. Jones mentions that he has seen this happen 4 times in 38 cases, and in the records of five Continental surgeons it appears 35 times in 856 cases (4 per cent). A transient paral3rsis sometimes follows the mani- pulation — 23 times in 755 French and German cases — but it soon clears up. The results obtained are almost always an improvement on the previous condition, and often terminate in a more or less perfect cure, but usually there is some slight deviation from the normal, such as a tendency to abduction. Putting the femur in place undoubtedly makes it grow ; Joachimstal used to reduce one leg at a time in bilateral cases, and found that the bone first replaced became longer than its fellow. It is difficult to tabulate the success of the operation, because writers classify their results so differently. Lorenz, dealing with 572 cases, claims a cure in 63 DIABETES INSIPIDUS 143 per cent ; his unilateral cases gave slightly better results. Hoffa gives only 30 per cent of 250 unilateral cases as showing real anatomical restoration, and only 7 per cent in 65 bilateral cases. Out of 49 treated by Narath, 18 gave an ideal result, 12 very good, 16 good, and 3 medium or bad. Stern quotes 2593 cases from the literature, with the following results : 4 per cent ideal anatom- ically and functionally ; 7 per cent ideal functionally ; 40 per cent good ; 12 per cent poor. All the figures given are previous to 1905 ; there has been some improvement in technique since that date. We may conclude that in careful hands, accustomed to the method, about half give a thoroughly good, almost ideal, result, and that about one in ten is a failure. References. — Tubby, Deformities, including Diseases of Bones and Joints, vol. i ; Stern, New York Med. Rec. 1906. ,j ^^^^^^^ gJ^^^^_ CONGENITAL MALFORMATIONS OF THE HEART. — [See Heart, CoNGENiTAi. Malformations of.) CONGENITAL STENOSIS OF THE PYLORUS.— (5ee Pylorus, Congenital Stenosis of.) CONTUSION OF ABDOMEN.— (5ee Abdominal Injuries.) CONVULSIONS, INFANTILE.— (See Infantile Convulsions.) COXA VARA. — Apart from treatment, the condition usually gets steadily worse, the shortening becoming more noticeable as growth proceeds. Rarely, the rickety form may improve ; Hoffa had a case in which the angle of the femur increased from 105° to 120° on one side, and 110° to 125° on the other, in three years. Rest and extension check the process, but do not rectify the deformity already present. The best results are obtained by subtrochanteric osteotomy, or better still by Whitman's method, that is, removal of a wedge with its apex at the lesser trochanter. Section of the neck of the femur is risky ; one death from sepsis is recorded, and two cases of necrosis of the severed head. Reference. — ^Tubby, Deformities, including Diseases of Bones and Joints, vol. 1. A. Rendle Short. CYSTITIS. — [See Pyelocystitis ; Bladder, Tuberculosis of.) CYSTS, PANCREATIC— (See Pancreatic Cysts.) DECIDUOMA MALIGNUM.— (See Chorion-epithelioma.) DELHI BOIL.— (See Tropical Fevers.) DEMENTIA. — (See Mental Diseases.) DENGUE.— (See Tropical Fevers.) DIABETES INSIPIDUS. — This name is applied to cases in which very large quantities of urine are passed without any signs pointing to disease of the kidneys. Little is known of the nature of the malady, though attempts have been made to differentiate certain types — hydruria, polyuria, phosphaluria, axoturia. 144 INDEX OF PROGNOSIS Hydruria or Polyuria. — This common form of the disease occurs chiefly in children, and more often in those of the poor. The condition may arise suddenly or gradually. No certain prognosis can be given until the course of the case has been carefully observed. Some cases continue for many years without giving rise to inconvenience, beyond the frequent micturition ; others terminate fatally within a few months. A sudden onset is more favourable than an insidious invasion, as the condition may subside as suddenly as it appeared ; cases of this kind associated with injuries to the head have the most hopeful outlook ; those which follow some shock are also likely to recover. Chronic cases, with insidious onset, and accompanied by wasting, loss of appetite, dryness of the skin, and increasing weakness, are likely to end fatally within five or six months ; those, however, which cause no symptoms may last long, sometimes exhibiting acute exacerbations and comparative remissions. Children of tuberculous parents usually do badly ; those presenting signs of a syphilitic taint may recover on appropriate treatment. In a certain proportion of cases, diabetes mellitus supervenes and proves fatal, while tuberculosis of the lungs may be the cause of death, as in the latter malady. Several different methods of treatment have been proposed, in comparatively recent years, which cause the general outlook in these cases to be better than formerly. One of these is the withdrawal of salt from the dietary, on the ground that the malady consists in an inability of the kidneys to excrete this substance except in extremely dilute solution, an enormous flow of water being thus necessitated. A connection has also been traced between diabetes insipidus and disturbance of the pituitary body, and the use of preparations of pituitary substance has seemed to modify the disease. It is stated that cases marked by infantilism, with headache and contracted visual fields, may be treated with an extract of the anterior lobe of the pituitary body ; cases with obesity, drowsiness, and, in females, amenorrhoea, with extract of the posterior lobe. The skull may be skiagraphed to endeavour to find evidence of alteration of the sella turcica. This method of treatment is, however, in its infancy, and nothing certain is known of its results. Azoturia. — Examination of the urine may show the continued passage of increased quantities of urea, the condition being usually accompanied by languor and aching in the loins, and sometimes by increased appetite as well as thirst. These cases generally do well if treated early by rest, change of scene, and hydro- therapy (Carlsbad, Homburg) . If neglected, the condition may pass into one of saccharine diabetes, or emaciation may supervene, and gradual or sudden death. Phosphaturia. — In some instances, which clinically resemble the above, the amount of phosphates contained in the urine is increased even more markedly than the urea. The patients are irritable, and suffer from digestive disturbances. The treatment is similar to that just described, and, if taken early, these patients do well. References. — Bradford, in Allbutt and Rolleston's System of Medicine, vol. iii, p. 212 ; Jewitt, Med. Record, 1914, 242. iy_ Cecil Bosanquet. DIABETES MELLITUS. — The true nature of diabetes, and its relationship to other forms of glycosuria, are still unknown, so that for practical purposes they must all be considered together. No useful distinction can be drawn between persistent glycosuria and mild diabetes mellitus, and from time to time apparently mild cases pass into the grave affection. With a view to prognosis, it may be most convenient to sketch the course of a few typical cases of varjdng severity, and then to endeavour to indicate points which may be used to assign individual patients to one or other group. DIABETES MELLITUS 145 Typical Varieties. — I. Alimentary Glycosuria. — A young or middle-aged man, feeling out of sorts after a copious meal accompanied by many ' sweets,' is examined by a doctor, and the urine is found to contain sugar. On the following day, this has disappeared. A similar experience subsequently, or a test-administration of glucose, proves him to be the subject of alimentary glycosuria. With a little care in avoiding dietary indiscretions, he remains free from any disturbance of health. In addition to this form of alimentary glycosuria, there are a number of cases of transient glycosuria which hardly amount to disease, and constitute no danger to life or health in themselves. Thus, closely allied to the alimentary form, but by some classed as a renal glycosuria, is the condition often seen in pregnant women, whose urine may from time to time contain small quantities of sugar (apart from their well-known lactosuria) which disappears after delivery [see below). Eaton and Woods state that similar glycosuria is common in infants. A form of glycosuria apparently associated with disorder of the liver, but possibly rather to be assigned to coincident pancreatic disturbance, occurs in alcoholic subjects. Quite large amounts of sugar may be present in the urine for a considerable period of time ; yet, on cutting off the supplies of intoxicants, complete recovery may take place. A somewhat similar recovery may occur in syphilitic subjects as a result of suitable treatment (mercury, iodide, salvarsan). It is wise, therefore, to withhold a definite opinion in regard to such persons until a suitable regimen has been adopted, and continued for some months. 2. Chronic Glycosuria [Chronic Diabetes). — A middle-aged man of sedentary habits, engrossed in business anxieties, stout of build, and with gouty tendencies, is found to suffer from glycosuria. On strict diet the sugar disappears, but the patient cannot tolerate strict dieting. On a diet containing a moderate amount of starchy materials he continues to pass 2 to 5 per cent of sugar, but suffers no apparent inconvenience, living to a fair age, and ultimately dying of cerebral hsemorrhage or arteriosclerotic heart failure. 3. Diabetes of Moderate Severity. — A middle-aged man notices that he is losing flesh and strength, while his urine is increased in quantity and he is unusually thirsty. On being questioned, he admits that he has not been well for the past year, and that the symptoms have gradually developed. The urine is found to contain a moderate amount of sugar. On a strict diet this gradually falls in amount and finally disappears, and it is ascertained that a small amount of carbohydrate can be allowed without the return of glycosuria. On a restricted diet he remains well for some months, but the glycosuria returns and a still more limited diet is necessitated. Later still, no reduction of carbohydrates is found to be efficient, and the urine always contains a considerable quantity of sugar. The patient perhaps suffers from itching of the skin, or from boils and pustules. Finally acetone and diacetic acid appear in the urine, perhaps accompanied by albumin and casts, and the patient dies comatose after an illness of seven or eight years. 4. Acute Diabetes. — A boy, aged ten to fourteen years, suffers from thirst, hunger, polyuria, and increasing weakness, all of which symptoms have arisen within the period of a week or ten days. When seen by the doctor, he is weak and drowsy, with a flushed face, and a red tongue covered on the dorsum with thick fur. His breath smells of acetone, and this substance, togetlier with diacetic acid and glucose, are present in tlie urine. On a diet containing a limited aniount of carbohydrate, aided by doses of liquor morphinas and administration of sodium bicarbonate, in draclim doses, by the rectum, he improves : the drowsi- ness passes off, the acetone bodies disappear from the urine, and the sugar 10 146 INDEX OF PROGNOSIS diminishes in amount, but does not disappear. On careful diet the boy remains comparatively well for six months, when the former symptoms return, to yield once more to treatment. A second period of comparative health is followed by a second relapse : treatment is ineffectual, air-hunger is noticed, and increasing drowsiness, deepening into coma and death. The whole illness has lasted a little over eighteen months from the first onset of symptoms. Coming to the cases which are usually classified as diabetes mellitus, no general rules as to probable duration can be laid down. Feilchenfeld found that, of 154 cases, 30 per cent lived over ten years after recognition of the malady. The shortest case which I have found recorded is that of a girl, aged seventeen, who developed acute diabetes after typhoid fever, and died in eleven days (Laache). Chronic cases may last over thirty years. It will be convenient to consider seriatim the various factors which influence the prognosis. Factors Influencing the Prognosis. — Age. — As a general statement, it may be said that the younger the patient the worse is the outlook. In infants and young children, the course of the disease is very rapid — seldom more than twelve to eighteen months. It is doubtful if recovery ever takes place in established cases, but Mason Knox, who collected 16 cases occurring within the first year of life, states that he found records of 2 recoveries. In rather older children, a similar brief course is common. In young adults, the outlook is scarcely better, a fatal termination almost invari- ably ensuing within two or three years. In those over twenty-five, the course is likely to be less rapid, and the patient may live seven or eight years if carefully looked after. In subjects over forty, the course of the affection is usually much more prolonged, a duration of ten to fifteen years being common. Acute cases are, however, to be encountered at almost all ages. Sex. — The outlook does not appear to be strikingly different in the two sexes ; but cases occurring in women about the climacteric are said to be specially amenable to treatment. It seems likely that they are often instances of glycos- iiria due to disturbance of internal secretions coincident with ovarian atrophy. Obesity. — Diabetes or glycosuria occurring in fat persons usually runs a slow course, often without much apparent disturbance of health, though various complications may be present from time to time. Hence the French have classified the disease into two forms, diabete gras and diabete maigre, the latter being the dangerous form. The stout diabetics often exhibit gouty symptoms, and perhaps more often die from arteriosclerosis or uraemia than from coma — the typical diabetic ending. They are also liable to cerebral haemorrhage. Social Position. — There is no doubt that persons who are well off, and thus able to carry out a strict regime of diet and mode of life, are more favourably placed than the poor, who cannot afford luxuries in the form of starch-free foods, rest, climatotherapy, and so forth. Acute rapidly fatal cases are rare among the upper classes. Cases in middle-aged persons of business habits, associated with some degree of worry and anxiety, often do well when these causes are eliminated by rest or retirement. Family History. — In a considerable number of cases, other members of the patients' families have suffered from diabetes. Some idea as to the probable severity or chronicity of the case may be gleaned from what has happened to the others ; but no great reliance can be placed on such evidence, as some cases in a family may be grave and others comparatively mild. Onset. — An acute onset with severe symptoms is of bad omen, whereas a .gradual increase, with periods of improvement or quiescence, points to a likeli- hood of a long course ; but such a rule is far from absolute. Some instances which follow an acute infective disease yield readily to treatment, while mild cases may DIABETES MELLITUS 147 develop into severe ones : this, however, according to von Noorden, is rare, at all events if patients submit to strict regimen. Cases associated with head injuries may completely recover ; they should probably be called glycosuria rather than diabetes. Symptoms. — Great thirst and increased appetite point to severe diabetes, but the absence of these symptoms does not necessarily imply that the affection is of mild type ; indeed, loss of appetite may be a bad sign if it has previously been large or moderate. Wasting is rapid in grave cases, and it is useful to weigh the patients regularly every week, as much information as to progress or retro- gression may be thus obtained ; a patient who is gaining weight is usually doing well. Constipation is usual, and may be difficult to treat, but does not necessarily affect the outlook. On the other hand, diarrhoea is a bad sign, and, if intractable, is often found to be a forerunner of coma. Severe epigastric pain is another warning signal which should not be neglected. Drowsiness may precede actual loss of consciousness by some days, and should always excite alarm. The smell of acetone in the breath may be the first warning of the grave intoxication which is accompanied by the presence of acetone bodies in the urine, but regular examination of the urine will always show the presence of traces of these substances in this secretion before it is noticeable elsewhere. It may be worth noting that acetonuria may be found apart from diabetes mellitus (cyclical vomiting of children, etc.), but it is always of serious import. The Urine. — ^The continued passage of very large quantities of urine is usually a sign of grave disease, and diminution in the amount passed is often an early sign of improvement. Very large amounts of sugar are also bad, but it cannot be said that the severity of the case is directly proportional to the saccharin output ; this varies with the diet taken and with other factors. Thus, the sugar may be much diminished, or actually disappear, just before the onset of coma; so that such an occurrence in the presence of grave symptoms is an alarming sign. In chronic senile cases, the percentage of sugar and its total amount are usually small. In the presence of intercurrent infective disease {see below), the sugar may diminish or disappear from the urine. The most important considera- tion in connection with the urinary sugar is the effect of restricted diet in reducing the quantity excreted. The usual procedure, in respect to cases seen for the first time, is to estimate the quantity of sugar passed for two or three days on a normal diet, and then gradually to reduce the amount of carbohydrate food, substituting such materials as casoid bread, gluten, saccharin, etc., for the ordinary bread, potatoes, sugar, etc., taken. When all starchy food has thus been withdrawn, the quantity of sugar in the urine is again estimated on three successive days. If no sugar is found, then small amounts of bread or potato are added to the diet until sugar once more appears. In this way the carbohydrate tolerance of the individual is estimated. If some 120 grams of carbohydrate can be taken in twenty-four hours without the appearance of • sugar in the urine, the case is a mild one, and the patient is likely to live for many years. If, on the other hand, no carbohydrate can be taken without glycosuria, the disease is likely to be serious, and if no restriction of diet causes disappearance of the sugar, the state of affairs is manifestly grave. (It need hardly be noted that, in all cases here dealt with, the sugar in question is glucose. Pentosuria is apparently a family or hereditary abnormality of metabolism, and is of no importance from a health point of view). Repetition of similar tests of tolerance during the progress of the case will indicate improvement or deterioration, according as the quantity ol: carbohydrate duly assimilated is greater or less than at first. In most cases, the degree of tolerance tends to fall as time goes on. The urine should be tested from time to time for the presence of acetone and INDEX OF PROGNOSIS diacetic acid. The ferric chloride test for the latter is simple, and usually sufficient for practical purposes, as the two bodies are generally present together. If they are found, the aspect of the case immediately assumes a graver character, as it evidently belongs to the class of severe diabetes and is likely to terminate sooner or later in coma. It must not, however, be assumed that this is imminent, for acetone bodies may appear and disappear for considerable periods of time without fatal issue. A definite increase in the amounts of acetone and diacetic acid excreted is a cause for anxiety, especially if the patient tends to be drowsy, or if the quantity of sugar diminishes concurrently. The appearance of any considerable amount of albumin in the urine is of bad omen, though small quantities may be found from time to time in chronic gouty cases without any serious effects resulting. If large numbers of casts are also found, the condition is serious, as this phenomenon often shortly precedes the fatal issue. Estimation of the ammonia-content of the urine is also of value in prognosis, any large increase in the normal quantity being associated with acetonuria, and being an indication of approaching coma. The skin in diabetes is usually dry : the occurrence of a tendency to sweat has been said to be a good sign, but it would be unwise to lay any stress on such a point. Pruritus seems to be more troublesome in chronic cases, especially in gouty subjects. Boils may be troublesome, but are not often of serious import. On the other hand, a large carbuncle is sometimes a grave complication, and may give rise to fatal septic intoxication and coma. Pigmentation of the skin in association with glycosuria is sometimes classed as a separate disease, hcsmochromatosis, or bronzed diabetes. The features are rather those of cirrhosis of the liver, a condition usually found in these subjects after death, which is usually due to intercurrent disease rather than to coma. The glycosuria may sometimes disappear while the other symptoms continue. The duration of the condition, after the phenomena have become well marked, may be from two to three years, but some patinets may succumb within a few months. Nervous System. — Loss of knee-jerks is commonly noticed in diabetes, and seems to be of no special importance as an indication of the severity of the disease. Neuralgia is a frequent trouble, especially in elderly subjects, but does not influence the general prognosis. It usually yields to rest in bed and regulation of the diet. Most of the sensory disturbances in diabetes are associated rather with vascular degeneration than with true peripheral neuritis, which is a rare complication. Coma. — Until recent years, the prognosis of diabetic coma was absolutely hopeless, patients invariably dying within a comparatively small number of hours after the condition originated. Even now, the outlook is so far desperate that a fatal termination to the disease is almost certain to ensue before many months after such an occurrence ; but in many instances the immediate fatality may be averted by treatment, at all events in the commencing stages of the condition. Recovery is certainly possible from a state of deep drowsiness and. practical unconsciousness with the typical symptoms of air-hunger, under the administration of large doses of bicarbonate or carbonate of soda, either in the form of enemata or by intravenous infusion. The administration of glucose itself by the rectum has also been employed in this condition, which is supposed to result from carbohydrate starvation. Gangrene. — Dry gangrene in diabetes is due to arterial disease, with consequent deficiency of the blood supply to the affected part. It is best treated expectantly, the limb being kept dry and, as far as possible, aseptic. The outlook is fairly good under these conditions. If the gangrene is moist, pointing to bacterial infection, amputation is necessary, and the outlook is bad. DIABETES MELLITUS 149 Cataract. — The appearance of cataract in an infant or young child is a sign of grave disease and of a rapidly fatal issue. In any acute case, operation is unadvisable. In chronic cases, in which the glycosuria is controlled by dieting, operation is often quite successful ; but there is always a danger of local haemor- rhage supervening. Intercurrent Disease. — Acute infective disease occurring in the course of diabetes is always a source of anxiety, as it may induce fatal coma. This is not, however, at all a necessary sequence, as diabetics may pass through severe illnesses and make satisfactory recoveries ; but the prognosis must always be guarded until complete convalescence. The effect produced on the glycosuria is variable. In some instances, the sugar disappears from the urine during fever ; or diminishes markedly ; in other cases, it is unaffected, or may even increase. A fatal diabetes may date from an attack of acute disease, such as enteric fever, though it is difficult to make sure that slight symptoms may not have existed previously, and been overlooked until the urine was tested regularly in the course of the infective disease. Pneumonia in diabetics is almost invariably fatal, gangrene of the lung being a frequent termination. Erysipelas and other troubles due to pyogenic organisms are also dangerous, owing to the diminished resistance shown by the tissues in these patients. Tuberculosis of the lungs is a common cause of death, constituting the most frequent termination after coma diabeticum. It is doubtful if recovery from this infection ever occurs in true diabetics, but its course may be prolonged for two, or even three, years. The sugar often tends to disappear from the urine as the pulmonary disease progresses. In grave cases, a fatal issue may occur in two or three months after signs are noticed in the chest. The prognosis in individual cases will depend on the rapidity of emaciation and on the progress of signs of destruction of the substance of the lungs. There may be fever of the usual hectic type, but in this, as in other infective disorders, cases are met with in which grave infections run their course with little or no elevation of temperature. Pregnancy . — The relationship of pregnancy to diabetes is not well understood. According to Franck, transitory glycosuria occurs in 40 per cent of all gravid women, and more persistent glycosuria in 10 to 12 per cent. Whitridge Williams believes that if the symptom occurs late in pregnancy, and the sugar is not more than 2 per cent, while there are no symptoms of ill-health, the condition is transitory and unimportant ; if it occurs early, or in larger amount, no prognosis should be given till delivery has taken place and the progress of affairs been observed. Diabetic patients may make good recoveries from the troubles of labour, or may die in coma. If the amount of sugar in the urine is large, and uncontrolled by diet, artificial labour should be induced. I have known a case in which glycosuria occurred in one pregnancy, with increased thirst and polyuria, to pass off after delivery, and return again with the next pregnancy, the case then becoming one of confirmed diabetes. A cautious prognosis is certainly necessary in all these cases. Surgical Operations. — Diabetics may make good recoveries from severe surgical procedures ; on the other hand, coma may ensue and prove fatal. This risk makes it wise to avoid all unnecessary operations of a trivial or cosmetic nature ; but dangerous conditions, such as appendicitis or cancer, which in themselves threaten life, should be treated without delay. A general anaesthetic, especially chloroform, is to be avoided if possible, local or spinal anaesthesia being preferred. Strict asepsis is of the greatest importance : the mortality of aseptic operations, in Karewski's experience, amounted to I4'7 per cent, that of septic operations to 26 per cent ; ti-8 of the former and 21-7 of the latter being due to coma. Shock is also to be avoided by all possible means, and it is wise to reduce the glycosuria I50 INDEX OF PROGNOSIS by diet, and to administer doses of bicarbonate of soda, before operation. Acetonuria is a contra-indication to surgical interference. Mode of Death. — The greater number of diabetics die ultimately from coma, this condition occurring in probably 90 per cent of the acute cases. In chronic diabetes this termination is less common, but can never be excluded. The next most common cause of death is tuberculosis of the lungs, which is also more frequent in young subjects with severe disease. Other causes of death are septic infection, as from carbuncle or erysipelas, cerebral hasmorrhage, uraemia as a sequel to albuminuria, gradual cardiac failure of arteriosclerotic type, and a peculiar form of sudden, or almost sudden, cardiac failure, possibly due to involve- ment of the myocardium. In some cases in which the symptoms of coma are present, the patient, nevertheless, retains actual consciousness until the end. References. — Eaton and Woods, Arch, of Pediat. 191 1, xxvii, 905 ; Feilchenfeld, Zeitschr. /. V ersicherungsmed. 1912, v, 33 ; Franck, Arch. f. experim. Pathol. 1913, Ixxii, 387 ; Laache, Med. Klin. 1910, vi, 503 : Lapersonne, Presse Med. 1910, xviii, 89 ; Karewski, Deut. med. Woch. 1914, No. i ; Whitridge WilHams, Amer. Jour. Med. Set. 1909, cxxxvii, I ; WUliamson, Practitioner, 1911, Ixxxvi, 821. iy_ Cecil Bosanquet. DIARRHCEA, INFANTILE. — Simple non-inflammatory diarrhaea is very much less serious than inflammatory diarrhoea due to enterocolitis. In this latter condition, high fever, constant vomiting, marked tenesmus, loss of elasticity of the skin, drowsiness, collapse, grave nervous symptoms associated with convulsions, are to be regarded as of the greatest gravity. Pulmonary catarrh with collapse of alveoli, and bronchopneumonia not infrequently arise during the iUness, rendering the outlook still more serious. If the temperature in the rectum reaches 105° the prognosis is verj^ bad, or if it runs up with a sudden leap from the normal to any great height. Exposure to chiU during the height of the attack is very likely to produce an exacerbation of all the symptoms. Summer Diarrhoea (Cholera Infantum). — In this complaint the prognosis is based on points similar to those mentioned above (enterocolitis). The younger the patient (ceteris paribus), the worse the prognosis. In the more chronic diarrhoeas of children, the incidence of oedema of the extremities is a sign of grave import, and so also is the onset of thrush in the mouth. J. ij. Charles. DILATATION OF THE STOMACH.— (See Stomach, Medical Affections of.) DIPHTHERIA. — The most important factors which govern the prognosis of this disease are : (i) The age of the patient ; (2) The site of the disease ; (3) The severity of the attack ; (4) The occurrence of certain complications ; (5) The treatment. I. Age of Patient. — The following table, based on 56,507 cases of diphtheria treated in the hospitals of the Metropolitan Asylums Board during the years 1900 to 1909, shows the importance of age as a factor in the case-mortality: — Fatality according to Age. Fatality Fatality Fatality per cent per cent per cent 0-1 34-0 0-5 15-7 25-30 1-3 1-2 22-7 5-10 8-3 3i-35 1-3 2-3 16-4 10-15 34 35-40 4 3-4 13-4 15-20 1-8 ; 40 and over 5 4-5 ]]-2 20-25 0-9 All ages 10-3 DIPHTHERIA 151 From ttiis table it appears that the disease is much more fatal in children than in adults; and that, up to twenty -five years of age, the younger the patient the greater is the risk to hfe. The large majority of these patients were treated with antitoxin: 2. Site of the Disease. — The most common sites are the fauces, nasal passages, and lavynx. The false membrane may be found on all these parts simultaneously, or may be limited to one of them. The more intimately adherent the false membrane is to the mucous surface, the more surely will absorption of toxin take place and toxaemia and its sequels occur. Now the false membrane is almost invariably attached very loosely to the nasal passages and to the larynx and trachea. Hence, toxaemia is seldom pronounced and is often absent in nasal and laryngeal diphtheria if the fauces are unaffected ; and it is the faucial form of the disease which affords the most striking examples of toxaemia. Diphtheria of the air-passages is, however, the most fatal of the three varieties under discussion, because of the mechanical obstruction to respiration to which it gives rise by the occlusion of the larynx, trachea, or bronchi. Simple nasal diphtheria is seldom fatal. The most serious cases are those in which the nose, throat, and windpipe are simultaneously involved. An estimate of the influence on prognosis of the involvement of the larynx may be derived from the statistics of the Asylums Board already quoted. During the ten years 1900 to 1909, the fatality of cases in which the larynx was not affected was 8-8 per cent; whereas in those in which it was affected (with or without involvement of the fauces) the fatality was 18-9 per cent. Of other forms of diphtheria, the vulval and cutaneous are the most serious, because they are prone to be accompanied by grave toxaemia. In ocular diph- theria there is considerable risk of loss or impairment of sight from damage to the eyeball. 3. Severity of the Attack. — Most laryngeal cases must be regarded as severe, because of the high fatality amongst them. Nearly half of them come to tracheotomy or intubation. In other forms of the disease, severity depends upon the degree of toxemia : this, in its turn, depends upon the extent and persistence of the false membrane. Albuminuria may be taken as a rough index of toxaemia ; the more lasting the albumin and the larger its amount, the more profound the toxaemia and the greater the chance of the occurrence of some untoward event. Early nephritis (blood and casts in the urine) is a most serious condition : fortunately, it is rare. The following symptoms of toxaemia are extremely grave : repeated vomiting ; scantiness of urine ; haemorrhages into the skin and subcutaneous tissue, and also from mucous membranes (unless from the nose only, in nasal diphtheria) ; an infrequent, feeble, and irregular pulse ; an ashen hue of the lips and extreme pallor. In most cases in which one or more of these symptoms are present the patient is evidently ill, even to the unpractised eye ; but occasionally, when there is progressive suppression of urine, with little or no vomiting, he may seem to be doing well, and even to be getting better. Other unfavourable symptoms are a blotchy erythematous rash, usually most pronounced on the extremities : enlargement of the liver ; and convulsions. 4. Complications. — Paralysis is the most frequent, as well as the most impor- tant, and occurs in about 16 per cent of the cases. It usually supervenes after the false membrane has disappeared, and when the patient may appear to have recovered from the attack of diphtheria. Hence it is important to know what forms of diphtheria it may follow. The lesions which give rise to paralysis are caused by the toxin ; so that the more to.xic the case, the higher the risk of palsy. In respect of the gravity of the paralysis itself, a fatal issue is the more to be 152 INDEX OF PROGNOSIS feared the earlier this compUcation arises and the more rapidly the various groups of muscles are involved. The outlook is grave if anj^ of the ordinan' muscles of respiration are affected, especially the diaphragm. Frequent vomiting is a serious sj^mptom. Paralysis is met with much more often in children than adults. Its termination is either by complete recovery or by death ; patients are never left permanently paralyzed. About 13 per cent of the cases are fatal. Heart Failure may occur, not onlj' in connection ■\\dth paralysis, but even in cases in which that complication has not supervened. Like palsy, it is to be anticipated most in the toxic form of the disease. Acute cardiac dilatation, especially when accompanied by precordial pain, is nearly alwaj-s fatal. Heart failure is prone to occur in patients who have been allowed to get up and about too soon after the false membrane has disappeared. Lobular pneumonia is the only other serious compHcation. It is found only in I or 2 per cent of the cases, and chiefly in those which have undergone tracheotomy. 5. Treatment. Antitoxin. — In cases not treated with antitoxic serum the prognosis is less favourable, ceteris paribus, than in those so treated. Amongst the antitoxin treated cases, those do best which are brought under treatment earliest. Of severe cases which receive the serum late, those have the best chance of recovery in which large doses (20,000 to 30,000 units) are given. The earlier the serum treatment is commenced, the less chance is there of the larynx becoming invaded, and of paralysis supervening. If paralj-sis does occur in a patient who has been treated with serum early, it is almost always very sUght. Convalescence is hastened in those who receive serum treatment at the begin- ning of the iUness. The following figures, from the 191 1 annual report of the Metropolitan Asylums Board, show the case-mortalit\'- per cent according to the day of disease upon which the serum treatment was commenced. Fatality according to day of Commencement OF Serum Treatment. 1 Cases Deaths Fatality per cent . 1st dav - 149 4 2-6 2nd „ - - 911 31 3-4 3rd „ - -• 981 88 8-9 4th ,, - - 707 89 12-5 5th „ and over 1 1116 150 13-4 Total 3864 362 9-3 Operation (Tracheotomy and Intubation). — In respect of recovery after tracheo- tomy, the prospect has very much improved since the introduction of the serum treatment. \Vhereas about 30 per cent used to recover, about 70 per cent are now cured. In some hospitals intubation is practised, usually to the partial exclusion of tracheotomy. It is impossible to compare satisfactorily the results of intubation with those of tracheotomy, because of the lack of parallel series of cases which can be fairly set against each other. During the seven years 1905 to 1911, 436 cases of larjmgeal diphtheria were submitted to operation at the Eastern Hospital, and of these 118 died, a fatality of 27 per cent. These cases can be arranged as follows : — DISSEMINATED SCLEROSIS 153 Fatality after Operation. Operation Cases Deaths Fatality 1 per cent Intubation only Intubation followed by tracheotomy Tracheotomy only 217 102 117 19 48 51 8-7 47-0 43-5 Total 436 118 27 It will be seen that 31 'g per cent of the intubated cases came to tracheotomy. The fatality of all the cases operated upon, viz., 27 per cent, compares favour- ably with the fatalit}^ about 30 per cent, of the tracheotomy cases at those hospitals in which intubation was not practised. The patient who is intubated recovers much more quickly than the patient who is submitted to tracheotomy. If a patient is intolerant of the intubation tube, and coughs it out frequently, tracheotomy should be performed : irritability of the larynx is prone to be followed by ulceration. But if membrane is coughed out with the tube, even though the latter is frequently expelled, resort should still be had to re-intubation until the membrane has disappeared. The longer the intubation tube is worn, the more likely is ulceration of the larynx to be set up. At the Eastern Hospital an intubation tube is seldom left in the larynx for more than twelve days ; consequently ulceration of the larj^nx is seldom met with. e. W. Goodall. DISLOCATIONS. — {See Joints, Injuries of.) DISSEMINATED SCLEROSIS. — The causation of this disease is undetermined as yet. The characteristic patches of sclerotic overgrowth of glia are secondary to an antecedent degeneration of the medullary sheaths. Why the medullary sheaths themselves should become degenerate is at present unknown. There is much, to be said in favour of a toxic origin for the malady, but until the toxin is actually identified, our treatment must remain frankly symptomatic. Early diagnosis is of great importance. If we can recognize the disease in its earliest stage, we save the patient from misdirected treatment. Thus, for example, some cases of disseminated sclerosis are mistaken for cerebrospinal syphilis, and are subjected to long and futile courses of antisyphilitic medication. Others are mistaken for tabes or other varieties of ataxia. Others, again, mistaken for cerebellar or cerebral tumour, have even been submitted to explora- tory operations. Most frequently of all, the remittent course of disseminated sclerosis causes it to be mistaken for hysteria ; and the patient is consequent!}' stimulated by encouraging suggestions to try and ' throw off ' her malady by an effort of will, and to undertake exercises of a fatiguing kind which probably hasten the progress of the disorder. The duration of the disease is uncertain. At the outset it should be remem- bered that, by itself, it is rarely fatal. The commonest course is a chronic one lasting for years, with occasional periods of remissions or arrest, during which marked improvement takes place, followed, after variable intervals, by further relapses. The remissions may amount to apparent cure. The longest remission with which I am acquainted occurred in the case of a woman who, at the age of twenty-three, had her first symptoms of the disease, consisting in complete 154 INDEX OF PROGNOSIS paraplegia, with loss of sphincter control, and with central scotoma due to retro- bulbar neuritis ; she recovered from this in six months. Three years later, she had another attack of visual trouble, with weakness of the right leg, lasting several months. She married at the age of twenty-nine and had four healthy children. For many years she led an active life, apparently in ordinary health. At the age of fifty-three — i.e., twenty-seven years after her second attack, — she again became weak in the right leg, and within three years developed the classical signs of disseminated sclerosis, including motor weakness, intention tremors, and the characteristic changes in the reflexes. At the age of sixty-eight — i.e. forty-five years after the first onset of the disease, — she is still alive, although the limbs are severely paralyzed and ataxic. Nevertheless she gets up to dinner daily, and is still able to go out driving. The next most common variety of the disease is that in which the symptoms, after slowly or rapidly attaining a degree of moderate severity, remain more or less stationary. The patient, although suffering from motor weakness and perhaps confined to bed, remains well-nourished ; and the general health is fairly well sustained, it may be for many years, until at last a final exacerbation of the disease occurs. A third variety is met with, where the patient has a series of attacks or exacerba- tions, consisting in transient blindness, diplopia, monoplegic or hemiplegic attacks, etc., clearing up in part, but leaving him in the intervals more and more paralyzed, each fresh exacerbation lowering the general level of strength, until the patient becomes bedridden, with contractures, sphincter trouble, etc. In such cases, careful attention is required to prevent cystitis and bed-sores, either of which complications may lead to a terminal toxaemia. Intercurrent pulmonarj- complications, tuberculous or pneumonic, may also prove fatal. Bulbar para- lysis, from the presence of a sclerotic area in the medulla, is a less common cause of death. To sum up, then, the prognosis in disseminated sclerosis, as regards cure, is unfavourable ; but, as regards duration, long remissions may occur, especially if the patient avoids physical or mental strain. In the later stages, when the patient has become bedridden, the duration of life depends on assiduous nursing, the prevention of bed-sores and of bladder infection, and the avoidance of pulmonary and other complications. The patient with disseminated sclerosis is not infrequently somewhat emotional, "with a tendency to smile and laugh on slight provocation ; but in uncomplicated cases there is rarely, if ever, any true intellectual deficiency. This fact is some- times of importance with regard to testamentary capacity. Purves Stewart. DRUG HABITS. — [See also Mental Diseases.) Opium. — Children are much more susceptible to the influence of opium than adults, but among the latter there is a very great personal factor as far as susceptibility is concerned. In acute poisoning, a cyanotic or ashy face covered with clammy sweat is of extremely grave, but not necessarily fatal, significance. It should be remembered that in the comatose condition, false appearances of improvement may occur which are very deceptive, the patient again relapsing into a fatal coma. Since death generally supervenes as the result of failure of respiration, an improvement in the depth of this, and in the colour of the skin, should be carefully looked for. Dilatation of the pupils, during deep coma, following on their contraction, is of the gravest import. Morphia. — In morphinism, much depends on the length of time the patient has been under the influence of the drug, and the dose taken. As much as 75 gr. has been tolerated by chronic morphinomaniacs in the course of twenty- DRUG HABITS 155 four hours. It is probably more difficult to break the habit in patients who take the drug hypodermically, than in those who take it in any other way. As in opium-eating, there is a very marked personal element in the amount which can be tolerated. Young people can stand larger doses over more prolonged periods without gross cachexia appearing than can the more elderly. The latter are more liable to feel the effects of the withdrawal of the drug in a greater degree. Chronic morphinomaniacs do not live to an old age and are very liable to be carried off by an attack of some relatively mild acute disease ; or if they escape this, they pass into a condition of extreme asthenia and emaciation, and die from sheer bodily debility. During treatment, the great danger is that of inducing a fatal collapse by too sudden withdrawal of the drug, while there are frequently periods, after cure has been apparently obtained, during which the patient suffers from intense craving for morphia ; the craving is less severe and not so constantly repeated as in the case of alcoholism or cocainism. These periods of craving may, however, recur for eighteen months to. two years after the cure. Heroin. — This is not a harmless drug, for a habit may be induced which, in severe cases, presents as much difficulty in escaping from as does the escape from the opium habit. Moreover, the patients may remain physical wrecks, with undermined constitutions and of no resisting power, even when they have been cured of their habit. Cocaine. — The prognosis of chronic cocainism is worse than in the case of morphinism, because the patients have no desire whatever, in the great majority of cases, to be delivered from their habits, and have a very great tendency to relapse immediately they are liberated from restraint. There is a greater destruction of the higher mental faculties than in the case of morphinism, and, if possible, the patients are even more inveterate liars. This renders treatment more difficult and prognosis worse. With the onset of marked emaciation, sunken eyes, tremors, hallucinations, and delusions of persecution, the prognosis is well-nigh hopeless. It produces destruction of its victim more quickly than opium or alcohol. Delusional insanity may develop very rapidly in chronic cocainism, and the delusions may remain for weeks after the drug has been entirely withdrawn. There is a strong personal idio- syncrasy to the effects of the drug. Chloral. — Full tolerance is not obtained even though the habit of taking this substance may have lasted for a long time. The great importance of this is that the usual dose, or even a smaller dose than usual, may be followed by a fatal result. The same remark holds good with reference to chloroform. Sulphonal. — The repeated ingestion of sulphonal may lead to very serious symptoms, because the drug has a cumulative action, being excreted slowly from the body. A dangerous sign is the onset of ha^matoporphyrinuria, evidenced by the appearance of red, pink, brown, or almost black urine. This danger is more marked in women than in men. When given continuously, sulphonal may produce sudden coma and death, but more often there are other warning symptoms such as hallucinations, mental confusion, exhaustion, nausea, tympanites, abdominal pain, cyanosis, coldness of the extremities. These may be followed by death from exhaustion in some cases. If any of these symptoms arise, the use of the drug must be immediately suspended ; but all danger is not then passed. Serious symptoms have arisen for the first time as long as nine days after the cessation of the administration of the drug. Trional and Tetronal may produce the same grouping of symptoms, including lijematoporphyrinuria, if given over a prolonged period. A large single dose is 156 INDEX OF PROGNOSIS not likely to produce them, as much as 120 gr. of trional having been taken without the onset of hasmatoporphyrinuria. /. r. Charles. DUODENAL ULCER (see also Stomach, Surgical Affections of). — Remembering that in many cases an ulcer of the duodenum is entirely latent as far as any manifestation is concerned, it is impossible to say how many get well unrecognized. Of those diagnosed, perforation is stated to occur in about 40 per cent, while more or less severe haemorrhage arises in from 30 to 40 per cent. In different series the mortality -rate from haemorrhage has varied from 13 up to 36 per cent. The possibility of complications, which include abscess (e.g., subphrenic), subsequent stenosis of the duodenum, stenosis of the common bile-duct, and secondary malignant disease, must be borne in mind in giving a prognosis. Relapses in duodenal ulcer occur with about the same frequency as in gastric ulcer. /. r Charles . DYSENTERY.— (5ee also Colitis.) Bacillary Form. — A group of many closely-allied bacilli, and some other bacilli not belonging to the group, are capable of causing dysentery, often in an epidemic form. Some outbreaks, particularly those in Indian prisons, are attended with a low case-mortality, 2 per cent or less, and the fatal cases occur mainly in debilitated persons or those suffering from chronic diseases ; when, however, the disease assumes a chronic form, a much worse prognosis has to be given. In other outbreaks, as those in camps in war, in asylums, and on board ship, the prognosis is unfavourable ; 50 to 80 per cent of the cases in some small outbreaks have terminated fatally, and a mortality of 20 per cent is common. In the war between Japan and China in 1894, there were among the Japanese 155,104 cases of dysentery with 38,094 deaths, or a mortality of 24-5 per cent, but many of these were complicated by beri-beri.^ Amoebic Form. — This form also varies greatly. It usually runs a chronic recurrent course lasting for years, but may be an acute febrile disease. The prognosis depends on the severity and duration of the disease, or on complica- tions ; the complication of most importance is acute hepatitis followed by liver abscess. The introduction of the treatment by salts of emetine has modified the prognosis both of the disease itself and the liability to liver abscess, and, after the occur- rence of liver abscess, of the mortality. Ipecacuanha as given previously had a similar effect, but the equivalent doses could not be tolerated, and therefore both the number of cases and the results were less marked. By the use of either preparation a smaller proportion of cases of hepatitis go on to abscess- formation. When an abscess has formed, it may burst naturally : into or through the lungs, when about 50 per cent recover ; or into the intestine, with a similar result ; if it opens into the pleura or peritoneum, even when operated on, the prognosis is more unfavourable. When an abscess is diagnosed and operated on, if it can be evacuated below the ribs the prognosis is more favourable than if the opening has to be made through the chest wall. The mortality, including all cases and various methods of treatment, varies between 10 and 20 per cent, but no doubt with the free use of emetine better results will be obtained. Davidson gives the mortality in the Indian Army, in 1901-3, as 286 out of 522 cases. C. W. Daniels- Reference. — ^Sandwith, Lancet. 1914, Sept. 5, et seq. DYSMENORRHCEA 157 DYSMENORRH(EA. I. Spasmodic. — This variety is the commonest, and in many ways the most troublesome. Great difficulty is experienced in giving an opinion as to the evolution of a case of spasmodic dysmenorrhoea. There are three points upon which the attention should be focussed : [a] The severity of the symptoms ; (6) The physical development and tone ; (c) The neurotic elem^ent. a. The Severity of Symptoms. — This must be gauged not only by subjective impressions, but also by an attempt to fix by other means the standards of expression of pain peculiar to the patient. In cases where the pain is severe, localized exactly in the hypogastrium, and lasts for a day or two with definite paroxysms, it is usually a waste of time to employ medicines ; on the other hand, where the symptoms do not appear intense, and the other features are good, it may be taken that in the majority of cases simple medical remedies, attention to physical hygiene, and sufficient rest, will be successful. b. Physical Development and Tone. — In the first place, dysmenorrhoea in the small infantile, or in the bicornuate, uterus is almost intractable to medical or lesser surgical measures (such as dilatation, which brings at most only temporary relief). In the majority of cases an extirpation is eventually required. Next, in cases with a conical cervix or with anteflexion, the results of medical treatment are small, while dilatation or incision of the cervix is permanently successful in at least 50 per cent of the cases, and in many more for a period of from one to five years. The failures are in many cases explained by faulty operation, in which the internal os escaped dilatation. Older gynaecologists are agreed that the use of the glass stem enhances the chance of cure in cases of anteflexion. In those cases in which there is no physical defect, attention should be paid to the general tone of the body ; many patients in weak health, physicalljr exhausted and anasmic, only require judicious correction of errors, and medical measures, in order to recover completely. c. The Neurotic Element. — The greatest difficulty will be found in estimating the proportion due to an underlying neurosis, and that due to the effect of continued dysmenorrhoea. The patients are usually thin, often the subjects of chronic arthritis and bad circulation. There is no doubt that the continued pain endured for years leads eventually to a lowered resistance, and a morbid fear of the forthcoming period, while relief is often found in alcohol, or in morphia injections. Under these circumstances it is rare for medical treatment alone to be successful, and cervical operations give as a rule but a temporary benefit. Reviewing, then, the prognosis of spasmodic dysmenorrhosa in general, it is seen that the greatest circumspection is required in forming an opinion. Beyond the special points detailed above, other factors are the age of the patient and the presence of sterility. Sterility is an indication for dilatation — and the results are perhaps best expressed in the following figures given by Brickner^: Of 38 patients suffering from dysmenorrhoea and sterility, only 27 per cent were cured of both the sterility and the dysmenorrhoea. The following figures also give some indication of the outlook in dysmenorrhoea generally. Findley- quotes Kelly as follows : Of 95 cases of dilatation, 18, or 19 per cent, were permanently relieved ; 14, or i^-j per cent, received great benefit ; and 7, or 7-4 per cent, were completely relieved for from one to twelve years, when, however, the pain returned. Brickner^ used Dudley's operation instead of dilatation in 73 cases — 42 for 158 INDEX OF PROGNOSIS dysmenorrhcea alone, and 38 for dysmenorrhoea with sterility — and obtained the following results : Of the 42 patients with dysmenorrhoea, 64-3 per cent were relieved; 33-3 were not relieved; and 2-4 per cent were worse; of the 38 patients Avith both dysmenorrhoea and sterility, 27 per cent were cured of both. 2. Membranous. — This much rarer condition is decidedly more grave in out- look ; it has not been successfully treated by drugs, and it nearly always recurs after dilatation and curettage. It is important to try to discover the presence of any pelvic disease ; thus, in a few cases operation has revealed a tuberculous condition of the appendages, associated with tuberculous endometritis, and hysterectomy has brought permanent relief. 3. Congestive. — This covers a wide field, and is after all but a symptom in the course of pelvic inflammatory disease or uterine displacement, so that it rarely requires consideration from the point of view of the dysmenorrhoea. Nothing, however, is more striking than the alleviation of the symptoms which results from the correct treatment of the underlying pathological lesion. References. — ^Surg. Gyn. and Obst. 1911, ii, Nov. ; ^Diseases of Women, 1914, 51. Bryden Glendining. EAR DISEASE, INTRACRANIAL COMPLICATIONS OF.— (See Intracranial Complications of Ear Disease.) ECLAMPSIA. Maternal Prognosis. In considering the prognosis as regards the mother in eclampsia, it is necessary to pay special attention to particular symptoms, and it is only at a comparatively late stage of the disease that it is possible to form an opinion. The general mortality in a large series of cases will be found to range round 25 per cent, but in a small series it may be reduced to 3 per cent, or even less. This does not so much indicate a marked superiority of one form of treatment over another as it points to the fact that the cases in one series have been mild and in another severe. While the majority of obstetricians are convinced that emptying the uterus as soon as convenient after the first convulsion is most important, there yet remain a number of physicians, especially among the senior members of the profession, who are in no way convinced that the results therefrom are an improvement upon the purely expectant methods of treatment of former years. Bumm^ believes that the quicker the uterus is emptied after the onset of fits the better the results, and he states that by adopting such a principle he is enabled to reduce the mortality from 25 or 30 per cent — repre- senting the results of expectant treatment — to 2 or 3 per cent. The Maternal Prognosis from the Clinical Aspect. — The prognosis varies directly with the period of onset of the fits. The figures compiled by Galabin^ from the records of the Guy's Charity are most striking in this respect : In cases beginning before the onset of labour, the mortality was 50 per cent ; in those beginning during labour, it was 25 per cent ; after delivery, 8 per cent. The number of fits and the interval between each fit are undoubtedly of im- portance. Rapidly recurring fits in which the interval becomes shorter and shorter will, as a rule, soon end in coma. Recovery has been recorded in a patient in whom 200 convulsions were reported. Some idea of the importance of the number of fits may be gained from the results of Csesarean section in this respect. Peterson^ records that in cases thus operated upon after i to 5 fits, the mortality was 15 per cent ; while in those operated upon after 6 fits had occurred, it was 30-3 per cent. That is to say, after the fifth fit the mortality is double. It would appear that the administration of chloroform or chloral has in many instances been of service in reducing the number of fits. ECLAMPSIA 150 The function of the urinary system is of the greatest importance in individual cases. Grave significance attaches to a marked diminution of the total quantity of urine' excreted in the twenty-four hours — especially when the small quantity becomes solid with albumin. Conversely, an increase in the daily quantity of urine is to be regarded as pointing to a favourable termination. Evidence of jaundice following the eclamptic convulsions must be taken to indicate considerable lesions in the liver. In these cases there is frequently a persistently raised temperature, a degree or two above normal, and a prolonged stage of coma. In the worst cases there is some haematuria, and small sub- cutaneous haemorrhages are seen. Deep coma accompanied by considerable elevation of the temperature will probably indicate cerebral lesions. Lastly, a point which is often overlooked, but which is of importance from the point of view of prognosis, is the fact that eclampsia renders the patient liable to haemorrhage during parturition and to septic infection during the puerperium, so that it must not be concluded that all danger is past because the fits have ceased. The Maternal Prognosis from the point of view of Treatment. — There is little doubt that injudicious treatment may be attended with disastrous results. First, with regard to expectant methods, it would appear inadvisable to persist in them if labour is not progressing and the fits continue. They are, of course, the only resource in post-partum cases, except where a marked drop in the urinary excretion renders it advisable to try decapsulation of the kidneys, an operation in which the mortality is at least 50 per cent. In the vast majority of cases, the problem resolves itself into deciding which is the best method of emptying the uterus under the circumstances. It is generally admitted at the present day that the best results will be obtained by that method in which the uterus is most rapidly emptied while at the same time the patient receives the least shock. It is assumed that emptying the uterus prevents further auto -intoxication from placental bodies ; on this assumption it is a priori probable that the best results would follow Csesarean section in all cases occurring before dilatation of the cervix. Unfortunately Caesarean section is regarded by most obstetricians as being too serious a pro- cedure except in special circumstances, and it must be admitted that the results liitherto have not been strikingly superior to those given by more conservative methods ; though it is undoubtedly true that the figures of Caesarean section represent a large proportion of very severe cases. Three methods of emptying the uterus require consideration : (i) Rapid dilatation of the cervix, with forceps delivery ; (2) Vaginal Caesarean section ; (3) Abdominal Caesarean section. 1. Rapid dilatation of the cervix is indicated in cases about terni, in which the cervix is readily dilatable. The results of this method of treatment have been published by Bossi* (who uses a special dilator), the maternal mortality being 14 out of 148 cases, or 9-45 per cent. These results are certainly good. Bossi's dilator has not become popular ^ however, owing to the risk of extensive laceration of the cervix ; so that dilatation with the hand is considered to be the safer method. 2. Vaginal CcBsarean section has given results which have not been uniformly good, owing to the fact that even after the lower segment has been incised it still remains to extract the child. Again, unless the cervix is already 'taken up,' the difficulty of the operation may be considerable. Routh^ has collected 15 cases performed by British operators, with 7 deaths, a mortality of 26-6 per cent. Beckmann,^ however, employing this method, has a mortality of 18 per cent. i6o INDEX OF PROGNOSIS 3. Abdominal Ccesarean section has been more extensively performed. It gives the best results in cases in whicli the cervix is rigid and it is thought advisable to empty the uterus at once. The figures of results varj^ considerably. Thus, Routh^ collected 105 cases by British operators, and found that there had been 50 deaths, a mortality of 47-6 per cent ; Peterson^ collected 283 cases from all over Europe and America, operated upon between 1908 and 1913, and found a mortality of 25-79 per cent ; still better results are shown in 91 cases operated on by thirteen different surgeons — a mortality, namely, of 18-63 P^r cent. FcETAL Prognosis. The later the onset of eclampsia and the less the number of fits that occur, the better the outlook becomes for the foetus. As regards treatment, there is no doubt that provided the child- is viable, abdominal Caesarean section offers a very much better prospect than an}^ other method. Thus, in Peterson's^ statistics of 248 cases, when only the viable children were taken into account, the foetal mortality was 9 per cent. Lichtenstein, in the Leipzic Klinik, grouping all methods of treatment, had a foetal mortality of 37-3 per cent in 94 cases; or counting only viable children, 21-3 per cent. Bossi* gives the foetal mortahty in 148 cases as 20-97 P^^ cent. References. — ^Bumm, " Die Behandlung der Eklampsie," Dent. med. Woch. 1907, xxxiii, 1945-1947 ; -Galabin and Blacker, Midivifery, 485 ; ^Peterson, Arner. Jour. Ohst. 1914, AprU ; *Bossi, 16th Intern. Cong. Med. (Sect. Obst. et Gyn.), Buda-pest, 1909 ; ^Routh; Jour. Obst. and Gyfi. 1911, Jan.; ^Beckm.d.nn, Mo nats. f.Geb. u. Gyn. 1913, ""■ ^' Bryden Glendining. ECTOPIC PREGNANCY. — The prognosis depends upon : (i) The method of ireatinent adopted ; (2) The stage of advancement of the pregnancy ; and (3) The condition of the patient when she comes tinder observation. I. The Method of Treatment. — It is now established beyond doubt that the best results are attained by immediate operation in all cases in which the gesta- tion has not advanced beyond the sixth month. The late Hamilton Bell, investigating cases from St. Thomas's Hospital, observed that many haematoceles due to ectopic gestation were completely absorbed, if left alone ; this is generally admitted, but the adoption of such a course is fraught with dangers which far outweigh the risks of surgical interference. The immediate dangers are : {a) That a further and possibly fatal haemorrhage may occur ; (6) That the hematocele may suppurate ; (c) That the gestation may be alive and secondarily implanted in the pelvis, when the surgeon will later be faced by the problem of dealing with an ectopic pregnancy advanced to the later months. Further, there are the disabilities that certainly accrue from the palliative treatment of ruptured ectopic pregnancies, in that adhesions of great variety and density are almost certainly formed. Some idea of the relative value of the two methods of treatment may be gathered from the following table, which is compiled from figures given by Findley-^ : — Treatment of Ectopic Pregnancy. Author Treatment Cases 241 82 130 63 Mortality Schauta - Schauta Fehling Kronig Expectant Operative Do. Do. per cent 68-8 2-4 2-3 ECZEMA AND ECZEMATOUS ERUPTIONS i6i 2. The Stage of Pregnancy. — The surgical difficulties increase with the advancement of the gestation. Thus, the operation is relatively simple when undertaken in the first three months. From thence onwards it becomes a more formidable procedure, because the increased size of the placenta and of the blood-vessels passing up to it, of necessity gives rise to profuse haemorrhage during its removal. So much is this the case in the later months of gestation that all authorities are agreed that in a pregnancy advanced beyond the sixth month it is wiser, whenever possible, to postpone any interference until after ' term ' ; at this epoch, with the advent of spurious labour and the death of the foetus, the subsidence of the placental circulation renders the removal of the foetus and the separation of the placenta a comparatively innocuous pro- ceeding, attended by inconsiderable loss of blood. It may, however, happen that the surgeon is forced to intervene during the later months of pregnancy, either by reason of rupture of the sac, or separation of the placenta, causing internal haemorrhage. The risk under these circum- stances is always considerable, and may be further aggravated by the site of the placental implantation. Thus, in intraligamentous pregnancy, practically the whole of the chorion is placentous, and its removal is accompanied by very great bleeding ; if, on the other hand, the surgeon contents himself with removing the foetus only, and trusts to the placenta to separate by necrotic disintegration, the possibility of septic infection further complicating the process is considerable . When, however, the gestation sac is intraperitoneal, the removal of the placenta is often more easily accomplished, and especially so when it is chiefly vascu- larized by omental vessels through the medium of adhesions. Finally, it is to be remembered that it is generally impossible to find peri- toneum with which to cover the site of implantation, and that the adherence of intestine or the formation of peritoneal bands is not uncommon ; in the former case an intestinal obstruction may occur, and has been recorded as the cause of death in several cases. 3. The Condition of the Patient when she comes under Treatment. — Opinion is mainly divided upon the question of immediate interference or waiting until the shock of haemorrhage has passed off. The preponderance of weight now inclines to the view that immediate operation as soon as the condition is diagnosed is attended by the better results. Efficient treatment of the shock and collapse from haemorrhage will perhaps again start bleeding, while the presence of the extravasated blood in the peritoneal cavity is to be regarded as a constant source of irritation. Further, the operation is itself so quickly performed in most cases, that the additional shock may be disregarded. Reference. — ^Findley, Diseases of Women, 1914, 172. Bryden Glendining. ECZEMA AND ECZEMATOUS ERUPTIONS.— It is impossible to lay down brief rules for prognosis in eczema, for under that name several conditions of widely diverse origin are included. The points which influence the prognosis, and the varieties, are as follows : — I. Eczema due to External Irritants. — Many conditions known as eczema are the result of the irritation of substances used in professions and trades. The possible irritants are so numerous that it would be out of place to enumerate them here. Certain soaps, soda, prolonged immersion in water, chemicals used in manufactures or medicinally applied, may all cause this type of eruption. Exposure to strong sunlight is sufficient to cause a dermatitis in some subjects. Certain plants act similarly. As a rule, on the removal of the patient from the source of irritation, this form of dermatitis yields rapidly to simple soothing applications. Recurrence is almost certain if the exposure to the irritant is II i62 INDEX OF PROGNOSIS repeated, and in many instances the skin becomes more and more easily affected as the attacks recur. In other instances a species of immunity may be acquired. 2. Parasitic 'Eczema.' — Under the name 'eczema' are included certain forms of eruption produced by ringworm fungi. These occur especially in the groin and on the extremities. They yield to antiparasitic remedies, and are discussed with the ringworms. The most rebellious cases are those in which the eruption occurs between the toes and on the adjacent part of the sole. 3. 'Seborrhoeic Eczema.' — This variety is associated with dandriff of the scalp and a greasy condition of the skin, and chiefly affects the middle line of the trunk, the face, and the flexures. It usually clears up rapidly under treatment by sulphur, resorcin, and salicylic acid, provided the condition of the scalp can be controlled. 4. Eczema of Infants. — This commonly involves the face. It usually begins in nurslings, and is often very intractable. An essential feature in successful treatment is the avoidance of scratching, which causes secondary pus-coccal infection. In most cases the dietary requires attention. The course is tedious, but the prognosis is good on the whole ; relapses, however, are common, especi- ally during the period of dentition. In a small proportion of cases seen in hospital practice the affection is persistent, or may for years merely show temporary remissions. 5. Eczema dependent upon Antecedent Conditions of the Skin. — The xero- dermatous and ichthyotic skin is very prone to eczema, which tends to recur every cold season. The eczema can usually be prevented by treating the congenital condition by regular bathing, and by the inunction of glycerin and water, or some oily preparation, daily ; this should be made part of the daily toilette. Varicose veins are a common cause of eczema, and the prognosis depends upon the possibility of the patient keeping the parts at rest. If this can be enforced the eczema soon yields to treatment. If the varices can be removed by operation, or if the limb can be properly supported by appropriate bandages, the eczema may be prevented, but relapses are exceedingly common. The senile skin is also prone to eczema, and very troublesome cases are met with in elderly subjects. The prognosis in these cases is usually unsatisfactory. 6. Eczema of Doubtful Origin. — In many cases we are at a loss to determine the cause of eczema. We may get evidence of gout, rheumatism, diabetes, renal disease ; or there may be some antecedent general illness ; or, again, we may be entirely unable to account for the condition. Here we have also to treat any general affection present, and the prognosis will depend in the naain upon our success in determining and dealing with the underlying cause. Local applications may frequently clear up an attack, and by dietetic measures, hydrotherapy, etc., we may reheve the affection of the skin ; but relapses are common unless the primary condition can be removed. /. h. Sequeira. EMPYEMA. — We have a fair amount of reliable material, gathered from a v/ide area, from which to judge of the prognosis of empyema, and the results of treatment show a remarkable constancy. Prognosis apart from Operation. — Apart from treatment by evacuation of the pus, death usually results from cachexia, after a long illness. A sudden fatality is not uncommon. Spontaneous cure, though unusual, is not impossible. The patient usually goes on for many weeks with fever, wasting, and signs in the chest ; at length the pus bursts, either through the chest- wall — commonly just •outside the apex-beat of the heart, — or it may be coughed up. This involves some risk of sudden death ; but if the immediate danger is survived, patients EMPYEMA 163 sometimes get well. Pneumothorax may result. Bursting through the chest- wall seldom results in cure ; a very persistent sinus generally remains. In both methods of natural cure, the lung is likely to have been long pressed upon, and so fail to expand properly, causing cirrhosis with cavities and chronic invalidism. Prognosis after Drainage Operations. — In older children and adults, the mortality after drainage operations seems, in hospital patients, to be very constant at about i in 5, as the following table shows : — Mortality after Drainage Operations. Reporter Lloyd Lord Schede . . . . . Lenharz Armitstadt Children's Hospital- St. Bartholomew's Hospital In the great majority of cases the operation involves removal of a piece of rib. Simple puncture, or insertion of a tube without rib resection, is very likely to be followed by re-accumulation of pus. The mortality is influenced by (i) The age of the patient ; (2) The bacteriology of the infection ; and (3) Whether the empyema is unilateral or bilateral. 1. Age. — In infants under two, there are many deaths. Natan reports 145 cases, mostly treated by a drainage operation, uith a death-rate of 64 per cent. Zybell considers that simple puncture, repeated when necessary, gives better results. His figures are: of 13 babies treated by puncture, 7 died; of 7 babies treated by drainage operation, 6 died. 2. Bacteriology.— With, reference to bacteriology, the tubercle bacillus, or an apparently sterile pus due to tuberculosis, makes the worst prognosis ; mixed infections are unfavourable ; the pneumococcus is favourable ; and, according to Lord, streptococcal cases do well. It is by no means certain, however, that Lord's opinion as to the benignity of the streptococcus will prove to be universally correct. Prognosis according to Bacteriology. Infection Eeporter Cases Cured No better Died ( Kiister 31 9 6 16 Tubercle ' Schede 45 10 — 35 I Lord 9 1* • — 8 Mixed infections - Lord 27 — — 5 Pneumococcus Lord 35 — — 4 Streptococcus Lord 17 — — 1 — — * Recovered with a sinus. 3. Double Empyema is a grave condition, but in pneumococcal cases probably about half recover. The two most favourable varieties of empyema are, the kind that arises with- out obvious cause in non-tuberculous subjects, and the post-pneumonic form. According to Lord, of 288 post-pneumonic cases, 13 per cent died, the period of illness averaging eighty-three days ; of loi idiopathic cases, 8 per cent died, the illness lasting, on an average, sixty-six days. i64 INDEX OF PROGNOSIS Grave types are those associated with pyaemia, subphrenic abscess, phthisis, or abscess of the lung. The operation itself is not altogether devoid of danger. Chloroform deaths are not very infrequent ; and there are about a dozen cases on record in which convulsions followed close upon the evacuation of the pus. Eventual Results.^Much depends upon early diagnosis and operation. If the lung has been compressed for weeks, it will probably fail to expand, and a persistent sinus will result, especially in tuberculous patients. A sinus, however, is by no means a death-warrant. Godlee writes of two of his operation cases who, wearing a tube, hved in moderately good health for many years, up to seventeen in one instance. Estlander's operation has a considerable mortality, perhaps about lo per cent ; but this varies much with the number of ribs that have to be resected and the condition of the patient's general health. Lord followed 13 cases of primary (idiopathic) empyema for a number of years ; 9 were well four years after, 2 died of lung troubles, and 2 of intercurrent disease. Of 26 post-pneumonic cases investigated five years later, 15 were well, i had phthisis, 2 had had hemoptysis, in i there was a persistent sinus, and 7 were dead, (4 of lung affections and 3 of intercurrent diseases). References. — Lord, " Empyema," Osier and McCrae's System of Medicine ; Werner, Deut. Zeitschr. f. Chirurg 1913, Sept., 419 ; Gee and Horder, AUbutt's System of Medicine, 1909 ed., v, 56 ; Zybell, Monatschr. f. Kinderh. 1912, xi. A. Rendle Short ENDOCARDITIS.— (See Rheumatic Peri-, Myo-, and Endocarditis.) ENDOCARDITIS, ULCERATIVE.— It may seem almost a waste of time to discuss the prognosis of so hopeless a disease ; but recent work has shown that the outlook is not quite uniformly desperate. The expectation of life, dating from the onset of symptoms, varies from a few days to two or even three years in the cases that end fatally, while complete recovery appears to occur in a small percentage. It is difficult to say exactly what that percentage is — probably less than five per cent achieve a real cure. It may even be objected that this is an unduly optimistic figure, but allowance is made in it for the fact that a more general practice of making cultures from the patient's blood is leading to the recognition of a number of comparatively benign cases — cases which might easily be mis-labelled chronic valvular disease, were it not for the application of laboratory methods. Death may be due to a variety of causes, the most important being cardiac failure, embohsm of brain, lung, or heart, uraemia, and general toxaemia. The cases in which recovery may ensue belong almost exclusively to one category. The discrimination between this and other tj^pes rests on clinical and bacteriological grounds. The symptoms that characterize this group of cases are such as suggest that the blood infection and its results are of a comparatively low virulence. Fever is moderate, and there may be afebrile intervals ; the patient wastes and loses colour, but often so gradually that it is difficult to persuade him into a prudent way of living ; there is usually a history of rheumatic infection, with well-marked signs of valvular disease ; painful, tender, erythema- tous plaques are common, especially on the fingers ; and the urine often contains evidences of active nephritis. When blood-cultures are made, the streptococcus which is described in Germany as 5. viridans, and classified by the St. Bartholomew's Hospital workers with the common streptococci of the ahmentary tract, is recovered. Sometimes the influenza bacillus is recovered from cases of a similar clinical type. The picture is that of chronic valvular disease, with evidences of a comparatively mild bacterisemia. ENTERITIS, TUBERCULOUS 165 At the other end of the scale are ranged those cases in which there is high fever with a wide daily swing, and often with rigors ; the evidences of cerebral poisoning — delirium and coma — dominate the clinical picture, and the signs of heart disease are unobtrusive — so much so that they may be overlooked altogether. From cases of this kind various organisms are recovered ; Staphylo- coccus aureus, Streptococcus pyogenes, pneumococcus, and gonococcus. The course is rapid, and invariably fatal. Between the two extremes, every grade of intensity may be encountered. If generalizations are permissible, it may be said that the discovery of the Staphylococcus aureus or of the Streptococcus pyogenes is a sure forewarning of a fatal issue after a short illness ; that infection with the pneumococcus or gonococcus is practically always fatal within a period of three months ; but that in those cases that are associated with Streptococcus viridans, B. influenzcB, or Staphylococcus albus, the possibility of recovery may be entertained. From the clinical standpoint, a serviceable general rule is that the more the case is like chronic valvular disease, the less hopeless is the outlook ; but that where the case is one of septicaemia, with little or no sign of cardiac disease, there is no hope of recovery. An equally unfavourable prognosis is to be given in those cases, seldom diagnosed during life it is true, where the cardiac infection is predisposed to by, and terminates, some chronic cachectic malady such as consumption, cancer, Bright's disease, or diabetes. The hopelessness of such conditions as these is too obvious to call for further comment. On the other hand, at least one case of recovery is on record in which the infective process had apparently attacked a congenitally malformed heart. Even in the comparatively benign cases, the course is usually run in six months ; and the chance of complete recovery is still so lamentably slender that it is not fair to hold it out as anything but a forlorn hope. Sudden death sometimes brings this disease to a close. Of Horder's 150 cases, 19 ended in this way. Embolism or haemorrhage into the brain, or embolism of the cardiac wall, may be responsible. Tearing of a diseased cusp, indicated by sudden change in the murmurs, with aggravation of the signs of cardiac embarrassment, may accelerate death greatly. Influence of Treatment on Prognosis. — Of this there is unfortunately little to be said. A very few cases are on record in which the application of specific remedies (autogenous vaccines and sera) has appeared to save life, so that it is perhaps fair to claim that cases in which treatment can be carried out along these lines stand a less negligible chance of cure than those in which it is not feasible. Carey F. Coombs. ENTERIC FEVER.— (5ee Typhoid Fever.) ENTERITIS, TUBERCULOUS. — Owing to the formation of adhesions, general septic peritonitis is less likely to occur in tuberculous than in other forms of ulceration of the small intestine, though this disaster is by no means unknown. Moreover, a general peritonitis may occur by organisms, e.g., B. coli, escaping into the general peritoneal cavity through a very much thinned intestinal wall, without actual perforation. More commonly, fistulous communi- cations are established into other parts of the intestine, or into localized abscesses. Strictures may arise from fibrotic healing of the ulcers, but it is rare for these to give rise to subsequent intestinal obstruction. Fatal haemor- rhage may occur. The ultimate prognosis depends, in the vast majority of cases, on the presence of tuberculosis elsewhere in the body. This is generally in the lungs, peritoneum, or mesenteric glands. /. R. Charles. 1 66 INDEX OF PROGNOSIS EPIDIDYMITIS, TUBERCULOUS. — It is difficult and unsatisfactory, in one respect, to discuss the prognosis of an affection which is probably, in the great maj ority of cases, only the most evident manifestation of an extensive involvement of the genito-urinary organs. It is obvious that the eventual outlook must usually depend more upon the state of the bladder, prostate, and kidneys, than upon the treatment of the testis. Tuberculosis of the urinary organs is discussed elsewhere. (See Kidney, Tuberculous, and Bladder, Tuberculous.) We shall here include tuberculous orchitis with epididymitis. It has been much debated whether an epididymitis is the primary manifesta- tion of tuberculosis in the genito-urinary organs ; but favour of late has rather been accorded to the opinion that, in most patients, the kidney, though it may show no signs itself, passes out living tubercle bacilli which invade the prostate, leading to a secondary infection of the vas, and then of the epididymis and testis. It is true that the finger, examining from the rectum, is frequently unable to feel anything in the prostate, but at autopsy this gland is always diseased ; it has lately been declared, contrary to the general teaching, that infection of the epididymis begins in the globus minor (that is, nearer the prostate) , not in the globus major. All this, of course, has an important bearing on prognosis. We have very little evidence as to the fate of a tuberculous testis left to itself. No doubt the immense majority of such cases perforate the skin and lead to chronic suppuration ; extension of the disease will also probably take place. A few non-operated cases go on without much change, or even with some improve- ment, under treatment with tuberculin ; but there is little prospect of a cure, and great risk of generalization. Results of Operative Removal. — We have to discuss the end-results of three methods of treatment by operation : removal of the epididymis, unilateral castration, and bilateral castration. The immediate mortality after operation is very small indeed. Some patients, however, fall victims to acute general tuberculosis within a few months. The proportion is given as 5-5 per cent by Barney. Much depends on the surgeon's judgement in accepting or rejecting the worst type of cases. End-results of Removal of Tuberculous Testis or Epididymis. Cases followed Cured Tuberculous elsewhere Died o( tubercu- losis Lungs Bladder other testis Various Barney* Von Bruns - - Simon Horwitz Bristol Royal Infirmary - 71 92 30 16 per cent 62 4f) 57-6 60 62 per cent 3 6 per cent 12 per cent 26 7 12 per cent 32 6-6 I per cent 5-5 35 "5 23-3 12 64 per cent of these cases followed less than a year. For determining the end-results, we have several valuable publications to guide us ; but the subject is complicated, and some of the statistics are scanty in detail or compiled too soon after the operation. Thus, Barney published in 1912 some American hospital figures ; but two-thirds of his 71 cases were followed less than a year, so that his rate of cure, 62 per cent, is high, and the after-fatalities, 5-5 per cent, are much too few. In many points, however, his results are interest- ing and valuable, as we shall see. EPIDIDYMITIS, TUBERCULOUS 167 Von Bruns and Simon publish statistics of patients traced from three years upwards. The first finds 46 per cent cured by unilateral castration, and 56 per cent by bilateral castration. Simon finds 57-6 per cent cured, and 35'8 per cent dying, out of 92 cases. Horwitz reports a small series, mostly followed for more than a year : 60 per cent were cured and 23-3 per cent died. At the Bristol Royal Infirmary, of 16 cases all followed over eighteen months, 10 were cured, i developed phthisis, 2 suffered from cystitis (present before operation), 2 developed tuberculosis of the other side, and 2 (including one of these last) died of pulmonary tuberculosis. We may conclude, therefore, that when followed for several years afterwards, perhaps rather more than half the cases are quite cured, and about 20 per cent die of tuberculosis elsewhere. The remainder continue to suffer from various tuberculous affections, such as cystitis, prostatic abscess, phthisis, etc., which were no doubt already present at the time of operation. In Barney's series, nearly half the patients had some evidence of tuberculosis elsewhere than in the testis when they were first seen ; in 63 per cent, the prostate or vesicute were affected. There is some evidence that these coincident manifestations of tubercle may improve after removal of the testis or epididymis. Thus, of the 63 per cent of cases with palpable nodules in the prostate or vesiculse before operation, Barney found that 18 per cent disappeared, leaving 45 per cent in statu quo. Recurrence in the other testis was observed in 2 out of 16 Bristol cases, in 29 per cent of von Bruns' series, and in 7 per cent of Horwtz's. It ma\'' be quite late ; in one of the Bristol cases it occurred six years after the first operation. Sexual power, according to Barney, was retained in 60 per cent of the cases ; but azoospermia was present in 11 out of 13. There are, however, plenty of instances recorded, i in the Bristol series, in which healthy children are born afterwards. The wife and child do not appear to be infected. Even bilateral castration has no demorahzing effect ; if performed before puberty, it arrests the development of the secondary sexual characters. The fatal cases die of general tuberculosis, phthisis, or uraemia from tuberculous kidneys. Results as regards Treatment. — ^With reference to the effects of treatment, we have to consider unilateral castration, bilateral castration, epididymectomy, and tuberculin. On paper, the results of epididymectomy are better than those of unilateral castration. Horv/itz gives i out of 11 dying after the former, and 6 out of 19 after the latter. Barney also claims greater success. This merely means, of course, that less extensive cases give better results than those in which the testis is already infected, but it affords justification for the practice of leaving the testis if it appears to be uninvolved. Double castration may be necessary, but it by no means makes a hopeless prognosis ; indeed, both von Bruns and Simon claim better results in these cases than in those in which only a unilateral castration was performed. Tuberculin appears to be of very decided value in the treatment of this and other tuberculous affections of the genito-urinary tract ; but its claims rest rather on individual reports than upon statistics. To recapitulate : Rather more than half the patients get quite well ; about 20 per cent die of tuberculosis elsewhere. Bilateral cases are no worse than unilateral in the eventual results. For early cases, epidid^miectomy is as satisfactory as castration. The operation often leads to improvement of the prostatic nodules, if present. The prognosis in individual cases depends far i68 INDEX OF PROGNOSIS more upon the tuberculosis of the bladder and other organs than upon the condition of the external genitals. References. — Barney, Boston Med. and Surg. Jour. 1912, clxvi, 409 ; Horwitz, Jour. Amer. Med. Set. 1902, xxxviii, 1607 ; von Bruns, Centr. f. Chir. 1901, Report of Congress, 119 ; Simon, ihid., 125. a. Rendle Short. EPILEPSY. The Prospects of Spontaneous Cure, i.e., cure without medicinal treatment, are so small as to be almost negligible, and therefore the occurrence even of a single epileptic fit calls for a prolonged and assiduous course of treatment. One epileptic fit favours the occurrence of another, since the fit increases the instability of the cerebral cortex. In female patients, puberty and the menopause, so far from exercising a beneficial influence on the fits, as has been popularly supposed, have quite a contrary effect. Both of these physiological crises are associated with profound disturbance of metabolic equilibrium, during which any irrita- bility of the cerebral cortex is more likely to be increased than diminished, and, in fact, puberty is a specially common time for epileptic fits to commence. Some- times infantile epilepsy ceases spontaneously at the age of four to five years, but this cannot be held out as a probability in any individual case. As a rule, the later in life the disease appears, the greater are the chances of spontaneous arrest. Marriage of an epileptic has no material influence on the disease, either beneficial or otherwise. Pregnancy sometimes arrests the fits temporarily, but they generally return after the pregnancy is over. The Danger to Life in idiopathic epilepsy is not great, despite the alarming appearances presented by the epileptic patient during the actual fit. Status epilepticus (where one fit follows another in rapid succession without the patient recovering consciousness between the individual fits of the series) is relatively rare, but it may be fatal from exhaustion and heart failure. The chief practical risk to life is that the epileptic patient may die accidentally, during a fit — -most commonly by drowning through falling into water, an inch or two being enough to prove fatal, since the fit prevents the patient from making any effort to save himself. Other epileptics may die from asphyxia, by rolling over on the face in bed during an attack. Others, again, may inhale food into the air-passages, if the fit occurs during a meal ; or vomited material may be re-inhaled, with the same result. These, however, are secondary ' accidents ' ; so also are the frequent injuries to the head and face sustained during falling, and the occasional burns which result from falling on to a fire. All of these ' accidents ' can be obviated only by close watching of the patient, and never, under any circumstances, leaving him unobserved. Prospects of Cure or Arrest by Treatment. — Epilepsy is one of the diseases in which medicinal treatment often succeeds in profoundly modifying the disease, either by diminishing or abolishing the attacks, or by altering the t^'pe of the paroxysms during the time that treatment is persevered with. The prognosis in an})- individual case depends largely upon the personal reaction of the patient to the remedies prescribed, and the assiduity with which these remedies are administered. Even where the fits do not entirely cease, treatment may some- times enable a patient to live an active and useful life in place of an existence which is distressing to the patient himself and to those on whom he is dependent. From a series of cases observed by Govv^ers, the following main conclusions were drawn in regard to factors affecting the outlook : — Age. — The younger the patient at the age of onset, the less is the prospect of cure. Cases beginning between the ages of ten and twenty have relatively the worst prognosis ; those beginning before the age of ten are somewhat more EPILEPSY 169 favourable. The most favourable are those which commence after the age of twenty (with the exception already referred to, viz., that cases beginning in women at the menopause have an unfavourable prognosis). Sex. — The prognosis is slightly better in males than in females, possibly owing to the intercurrent factors of menstruation and of the menopause in the female sex. Previous Duration of the Disease. — The shorter the duration, the brighter are the prospects of its yielding to treatment. Cases which have lasted for less than a year are the best of all : if the disease has existed for five years or less, the chances are only fair : if the fits have been occurring for more than five years, complete arrest is almost unattainable, and we usually have to be content with a mere diminution in their frequency. Intervals between Attacks. — Severe attacks, when occurring daily, are unlikely to be arrested. Attacks occurring at intervals longer than a month have the most hopeful prospect. Attacks occurring regularly once a month, in relation to a menstrual period — whether before, during, or after each period, — are relatively more difficult to arrest than those where the attacks occur at somewhat shorter, but irregular, intervals. The Waking or Sleeping State, during which the fits habitually occur, is of importance. If the attacks occur only in the waking state and not during sleep, or only during sleep but not when awake, the prospects are three times as bright as when they occur both asleep and awake. The prognosis is rather better in pure nocturnal than in pure diurnal epilepsy. The Major or Minor Character of the Fits has to be borne in mind. Major fits are much more easily influenced by treatment than minor fits. It is not un- common for the minor fits to persist, in spite of treatment, after the major fits have been completely arrested. The minor attacks may even become more frequent. Nevertheless, it is of supreme importance to persevere with treatment, since, if it be suspended, the major fits are almost certain to reappear. Hereditary Disposition to epilepsy, contrary to expectation, does not appear to render the epileptic patient less amenable to treatment. Gowers has been strongly impressed with the frequency with which hereditary cases responded successfully to treatment. Mental Change, whether dullness or irritability, is an unfavourable sign. We must bear in mind that some cases of apparent mental dullness in epilepsy may be due to excessive bromide medication. The Occurrence of an Aura appears to render the prognosis slightly more favour- able ; possibly because, in such cases, the patient may sometimes be trained by an effort of will to fight, during the time of the aura, against his threatened fit. The precise variety of aura appears to have but slight significance in this respect. The Apparent Exciting Cause of the first Fit is occasionally of importance with regard to prognosis. Thus, I remember one case in a young medical student, in whom a first and only epileptic fit occurred during the excitement of an election free-fight. The patient avoided exciting meetings thereafter, and never had another fit. I have also seen a number of cases, chiefly in adolescents, in whom some unusual article of diet (e.g., salmon, ice-cream, sausage, etc.) had been consumed at the meal immediately preceding each attack, and at no other time ; in others, each fit was preceded by a definite attack of constipation. Such classes of patients chiefly consisted of cases in which the fits occurred at long intervals of months, and even of several years. Attention to the diet and careful regulation of the bowels are of importance in every epileptic patient. Frequently, however, no constant exciting cause can be traced, and its presence or absence does not appear very materially to influence the prospect of cure. 170 INDEX OF PROGNOSIS The ultimate prognosis depends upon the patience and assiduity with which the patient and his friends can be induced to carry out the treatment. Treat- ment, dietetic, hygienic, and medicinal, must be persevered with for a long time after the fits have ceased. Two years without a fit is commonly agreed to be the shortest period that should elapse before treatment is relaxed. Even then, the bromide should not be withdrawn suddenly, but gradually, grain by grain, so as not to expose the brain to sudden stress. Purves Stewart. EPITHELIOMA OF LIP.— (See Lip, Cancer of.) EPITHELIOMA OF TONGUE.— (See Tongue, Cancer of.) EPULIS. — (See Jaws, Tumours of.) ERYSIPELAS. — -A simple attack of cutaneous erysipelas, in a healthy person, is almost free from danger. The inflammation usually lasts about a week. Recurrence is not uncommon in those cases which appear to be independent of a wound. Extensive cases, or those occurring in infants, the aged, sufferers from Bright's disease or diabetes, or alcoholics, are of much graver import. High fever and delirium, and the development of pyaemic abscesses, point to a probable fatal issue. The mortality in 875 cases at St. Bartholomew's Hospital, a good many years ago now, was 3'5 per cent, being rather heavier in males than females. When there was definite cellulitis as well as erysipelas, the mortality was much higher : II per cent in 889 cases. A. Rendle Short. ERYTHREMIA.— (See Polycythemia.) EXOPHTHALMIC GOITRE In this disease it will be necessary to investi- gate the results of various forms of medical treatment ; of surgical treatment ; the dangers to which the patients are liable ; and finally, the factors that make for a good or a bad prognosis. Results of Medical AND Surgical Treatment, Total Cases Died in H'pital Cases followed THSonoH PARTICULARS Total Much No Died thro' Better Better Better since per cent percent percent percent percent per cent /I. Hale White (hospital) 161 11 48 54 25 5 16 "^2. „ ,, (private) 55 54 64 17 6 13 3. Rogers (antithyroid serum) - 480 240(?) 30 20 34 16 Q 4. Jackson &Eastman(quin.HBr.) 56 56 76 13 11 g 5. Williarnson and Mackenzie - v6. Stoney (;v rays) 56 56 18 20 30 8 24 43 41 34 54 10 2* ^ Ti. Kocher (progressive Graves') 539 3 360t 45 41 8 6 < 2. Kuttner .... 64 17 37 34 36 17 14 " 3. Mayo (ligature of arteries) 225 2 115 2 48 9 Sit 9 « 4. Boisson (sympathectomy) 27 11 15 13 40 20 7 20 ,5 5- Guy's & St. Thomas's Hosp. - ^ U- Berry 23 33 13 8 61 31 28 11 — — 1 — — — — • Died of a subaequent operation; not improved by x rays. + Many of these had more than one operation. 4 Mo&t of these had a subsequent thyroidectomy. EXOPHTHALMIC GOITRE 171 Medical Treatment. — The tables that have been pubhshed, giving end-results, require examination before they can be generally accepted. Some authors are over-enthusiastic on behalf of a special mode of treatment ; others are meagre in details. Perhaps Hale White's^ statistics command most confidence, full particulars being given for each case, based almost entirely on a communi- cation from the patient herself or her medical attendant. The treatment was very diverse, including digitalis, belladonna, arsenic, thymus, Moebius' serum, and other drugs ; most of the private cases were ordered prolonged rest in bed, which Hale White considers of the first importance. It must be borne in mind that the mildest cases would not be adequately represented in these figures, as such would not be so likely to become hospital in-patients or to seek the consultant. It will be observed that about 11 per cent of Hale White's hospital cases died in the institution ; that of those followed through, more than half recovered more or less completely, a quarter improved, a few remained in statu quo, and about 16 per cent have since died. The private cases did decidedly better, about 64 per cent recovering, while only 13 per cent died subsequently. Most of these patients have been followed up for several j^ears. With reference to those who have died since, the mortahty appears to be about double that of healthy females of the same age. Rogers^ presents figures, without full details, illustrating the results obtained by the use of his antithyroid serum. No doubt rest and regimen must bear a share in the credit. The treatment does not appear to improve upon the success obtained by other methods. About 30 per cent are quite cured, and one-half altogether experience great improvement. The percentage of those not improved is high. Jackson and Eastman^ publish statistics of treatment by neutral quinine hydrobromide, in addition to rest and general supervision, and the percentage of cases cured or greatly benefited is high ; the details, however, are meagre. Data collected from the practice of Williamson and Mackenzie* are presented by the last named, a variety of methods of treatment having been followed. The results are not so good as Hale White's, only 18 per cent being cured and 20 per cent greatly improved, whereas the latter reports about 60 per cent recovered more or less completely There is no convincing evidence favouring any special drug treatment, and it would appear that of cases sufficiently ill to require hospital treatment or a specialist's opinion, about half get well or almost well, 20 per cent improve, about 10 per cent do not improve, and the mortality rate is about twice the normal. The end-results of ;ir-ray treatment^ compare favourably with other methods, but the figures are rather small, and only about half of the cases described as ' cured ' or ' almost cured ' had been followed for a year or longer ; it cannot therefore be regarded as proved that the x rays are a great advance on other treatment. In some reports they have not given particularly good results. Surgical Treatment. — This has made far more headway on the Continent and in America than in England, where it has been reserved for the worst, not to say totally unsuitable, type of cases, and is thus put to a severe test. Three operations are in current use : complete or partial excision of the sympathetic ganglia of the neck, or section of the connecting nerves ; ligature of the superior thyroid arteries ; and removal of one half of the thyroid gland. Data concerning cases of sympathectomy, followed up afterwards, and dealing only with instances of undoubted Graves's disease, are not easy to find. Boisson*^ has published a record of 15 answering to this description, of whom 2 were 172 INDEX OF PROGNOSIS cured and 6 greatly improved, but it is not clear that the benefit followed very closely on the operation. Out of 27 operated on, 3 died soon afterwards. The rationale of the treatment is open to doubt, and it is said that blindness may follow. Although the Mayos proceed to remove half the thyroid at a second operation if the first is not successful, they publish figures" giving the end-results of cases in which the treatment adopted has been ligature of the superior thyroid arteries. The details are scanty. The operation mortality was only 2 per cent. A few cases were cured ; about half were greatly improved, but about a third were either not improved or had to submit to the second operation of hemi- thyroidectomy. In the majority of Kocher's cases half the gland is removed. ^ He divides his patients into two groups ; in the first there are symptoms of h>'perthyroidism which are neither permanent nor progressive, associated with a parenchymatous or adenomatous goitre. Except that two patients died of pneumonia (out of 130), the results of operation were uniformly good. In the second group of 539 cases there were progressive S5anptoms of Graves's disease ; here the mortality was 3 per cent. He lays great stress on the use of a local anaesthetic. Although the majority of the patients had been suffering long and severely, nearly half were completely cured even when watched for many years, but they often required more than one operation, the first removal having proved too limited. The cases classed as ' better ' were able to earn their living ; these amounted to 41 per cent. Kuttner's * figures are about equally favourable, although he admits a much higher mortality (eleven out of sixty-four). In two London hospitals, Guy's and St. Thomas's, quoted by Hale White and Mackenzie, the results are less satisfactory, but it is probable that they represent a much severer type of case. One -third of the patients died, and although the majority of those who survived were improved, several were not benefited, and only one was absolutely cured. Berry, 1" however, has published a far more successful series of cases. He oper- ated on 28 patients, including one who died on the table before the first incision was made. Two others died within a few days ; 25 recovered well, and of these all were benefited, some to a most remarkable degree, but others relapsed. Every one of these patients had marked Graves's disease, with exophthalmos. The immediate dangers of operation are considerable. The patients take a general anaesthetic very badly, and a good many have died on the table ; on the other hand, the pitiable nervousness makes the strain of operation under local anaesthesia great, and Kocher admits that a considerable number are very much upset, with rapid pulse, fever, and other alarming symptoms. Again, patients with exophthalmic goitre have frequently an enlarged thymus, which may precipitate sudden death. Interference with the gland may lead to a pro- fuse outpouring of thyroid secretion into the veins, with symptoms of acute hyperthyroidism, including very rapid irregular pulse, fever, delirium, and increased exophthalmos : this maj'' end in death within a day or two. Crile's anoci-association methods, and the administration of large quantities of saline per rectum, help to avert these dangers. Occasionally tetany has followed, from injury or removal of the parathyroid glands. A comparison of the end-results of medical and surgical treatment, even if we neglect the London hospitals' records as abnormally bad and Kocher's first group as abnormally favourable, do not show any advantage gained by operation. One benefit, however, is not brought out by figures : the medical treatment is long and tedious, whilst the operation, if successful, leads to a much quicker cure. EXOPHTHALMIC GOITRE 173 To obtain best results from surgery, cases must be taken at the favourable time. As the Mayos and Berry have pointed out, the toxaemia advances to a certain degree, attains a maximum usually towards the end of the first year, and then subsides, and the proper time for interference is either early or late, but not at the height of the toxaemia. It is dangerous to operate on patients with a mark- edly dilated and irregular heart, great muscular prostration, great excitability, persistent albuminuria or glycosuria, or lymphocytosis with leucopenia. Great emaciation, however, is not a contra-indication per se. When there is doubt as to the patient's ability to stand an operation, it will be wise to content oneself with ligature of the superior thyroid arteries, proceeding to hemithyroidectomy at a later date if necessary. With these precautions, the present-day operative mortality is not above 10 per cent, and the Mayos have now had a consecutive series of 278 cases with- out a death. Sequelae. — Like other chronic invalids, patients are liable to various chest complaints, and also to profuse or uncontrollable diarrhcea. In many of Hale White's hospital cases, vomiting or diarrhoea was responsible for the fatal issue ; in his private practice, where the patient is more likely to be put to bed and to be suitably fed from the first, this complication was much less in evidence. Nervous Symptoms, such as delirium or coma, are not uncommon at the termination, and usually point to a rapid dissolution. Mania or melancholia may also occur. Cardiac dilatation is fairly frequent, and acute attacks may lead to sudden death. A mitral murmur may appear. Rarely, the exophthalmos so increases that ulceration of the cornea, or even blindness, may result, or the eye may be dislocated forwards on to the face. Glycosuria is not uncommon, and several of Hale White's cases died of diabetes. In other patients, intervals of hypothyroidisna (myxoedema) alternate with periods of hyperthyroidism. Relapse may occur even after many months or years of apparently perfect health. In one case known to the writer a relapse was induced after more than twelve years of entire freedom from symptoms ; the first attack was brought on by a head injury and the second by iodoform poisoning. In the great majority of instances, however, relapse does not occur if once complete freedom from symptoms is obtained for any length of time. Patients stand confinements very well, even if the disease is still present in mild degree. Many so-called relapses are really exacerbations of symptoms which had only partially subsided. Prognosis in Individual Cases. — In Hale White's tables, the cases are grouped according to the severity of the symptoms and the eventual result. We combine the hospital and the private patients here. Mild or Average Severe Very Severe Cases that have done well Cases moderately well, or better Cases that did not do well Total - 36 16 4 5f) 16 4 1 21 9 1 10 Many of Kocher's successful cases were very ill ; in one of these the eye- ball had prolapsed and had to be replaced, yet now the patient is quite weU, with no exophthalmos. Severity of the ordinary symptoms, then, does not make a bad prognosis. Cases that come on acutely usually get well rapidly, even if they become very ill for a time. 174 INDEX OF PROGNOSIS There are certain danger-signals. Diarrhcea and vomiting that do not yield soon to rest in bed and suitable feeding are of grave import. Delirium or coma usually heralds a rapidly fatal termination. The most significant sign is probably the wasting ; prognosis improves or depreciates with the patient's weight. Cases supervening on a chronic goitre are usually mild in type. It is almost impossible to foretell how long a patient will be ill. Six to eighteen months is a very ordinary time, but many cases drag on for years. When the weight is steadily falling, the outlook is less favourable ; when it is steadily rising, the patient is usually within a few months of the end of her troubles. A few cases are on record, especially in children, in which the symptoms came on rapidly in a day or two, and as suddenly disappeared after a few weeks or less. As a rule, children do better than adults, and women better than men. It is quite common for some degree of permanent indurative swelling of the thyroid and slight prominence of the eyes, due to fatty accumulation in the orbits, to persist even after recovery. References. — ^Hale White, Guy's Hospital Reports, vol. Ixv., 1911, p. i; ^Rogers, Annals of Surgery, Dec. 1909, p. 1023 ; ^Jackson and Eastman, Boston Med. and Surg. Journal, vol. 163, 1910, p. 419 ; *Mackenzie, Allbuit's System of Medicine, vol. iv. part i. P- 377 ; ^Stoney, British Medical Journal, 1912, ii. p. 476 ; *Boisson, Etude critique des interventions sur le sympathique cervical dans la nialadie de Basedow. Paris, H. Jouve, 1898; ^Mayo, Annals of Surgery, 1909, vol. i., p. 1018 ; *Kocher, Lancet, 1912, i. p. 576 ; *Kuttner, Revue de Chirurgie, 1911, p. 1031 ; ^"Berry, Lancet, 1913, i, pp. 583, 668. A. Rendle Short. EXTRA-UTERINE GESTATION.— (5ee Ectopic Pregnancy.) FACIAL PALSY. — [See Nerve Injuries.) FIBROIDS. — (See Uterus, Fibroids of.) FRACTURES. Simple Fractures. — Before entering on a detailed consideration of the end- results of various fractures, it may be well to emphasize the fact that surgeons and practitioners for some years have had a growing consciousness that the available methods of treatment have not always yielded results which can be described as satisfactory. It is platitudinous, but nevertheless true, to say that the utility of a bone after a solution of its continuity depends in a measure on the nature and extent of the traumatism. If this is severe, then a complete reconstitution with a good functional result cannot always be expected. It is quite obvious that there has been, and is, a constant effort to obtain good results on the non-operative side, operative methods apart for the moment, as witness the wonderful inventions which lumber up the splint rooms of hospitals, rusty worm-eaten evidences of the difficulty and disappointment which attend treatment. Nearly thirty years ago, M. Lucas-Championniere' began to issue his protest against rigid and prolonged splint or plaster fixation : he remained until his death the grand protagonist of the school of treatment by mobilization and massage. Few now apply this method in its entirety, but all recognize its great importance as an accessory to any mode of treatment. The extension methods of Bardenheuer are becoming more known in this country, and those who have mastered the application of the apparatus speak highly of the results. The nail- extension method of Steinmann would appear to take a place between non-operative and operative practice, but its employment does not seem to be sufficiently general at present to enable an opinion to be formed. FRACTURES 175 Ewald^ issues a word of caution in respect of this method ; he says that the results from the point of view of the fracture were satisfactory if not brilUant. He has used the nail in 29 cases of fracture of the lower limb; in 18 cases the perforations healed in from two to four weeks, but in 9 cases he has had an infection which lasted from five to twelve months, and in one case it was neces- sary to open an abscess at the end of two years. Ewald also warns us against using too large a nail in the calcaneum, and observes that the nail must be exactly in the middle of the bone or there is risk of fracture. A new school has evolved which contends that accurate anatomical reconsti- tution, and consequential good functional results, can best be achieved by operative treatment. This school, most ably led by Sir Arbuthnot Lane, Dr. Lambotte, and others, energetically rejects for many fractures the non-operative and the older operative methods, and bases its case on the application of a plate, screw, encircling wire, fixateur, or intramedullary splint to the fracture, accurately reduced by free incision. These differing systems of treatment show that all is not well and that prognosis must be guarded. The new light on the subject afforded by radiography and the enquiries under the Workmen's Compensation Acts reveal the good or bad results of the various methods. The report of the late Mr. Clinton Dent,^ " On the After- Effects of Injuries," in which he states that he had difficulty in remembering a case of Pott's or Dupuytren's fracture which had sufficiently recovered to resume police work, came as a shock to the profession. The universal desire for an inquiry into the ultimate results obtained in the treatment of simple fractures was voiced at the meeting of the Surgical Section of the British Medical Association in London, 1910. Pursuant to a resolution there passed, the Council of the Association appointed a Committee, whose report appeared in the British Medical Journal, November, 1912. In this report we have contrasted non-operative and operative methods, and it must form the basis of any discussion on the prognosis of fractures for some time to come. The number of cases on which the report is founded is 2940 ; this does not include the cases investigated abroad, which are set out separately. Amongst the important conclusions of the Committee, one finding stands out prominently, taking operative and non-operative cases together, namely, that if a good functional result is to follow, a good anatomical position must be attained. We find good functional use accruing in 90-7 per cent of cases when this latter is achieved. When the anatomical results are moderate or bad, we find only 29-7 per cent of good functional results. When the anatomical results are bad, we note 53-3 per cent of bad functional results. This shows the importance of endeavouring to obtain a good anatomical recon- stitution. A consideration of the age-group tables in the report affords further useful information. In the non-operative cases under 15 years of age there was a good functional result in 90-8 per cent, as compared with 45-4 per cent in cases over 15. In the operative cases belonging to the class in which operation was decided on at once and performed as soon as practicable, we find that under 15 years there was a good functional result in 93-6 per cent. In those over 15 years, operation gave a good functional result in 66-3 per cent. This shows the distinct superiority of operative as compared with non-operative methods. The operative cases are few relatively to the non-operative ; hence it is not advisable to dogmatize on the greater excellence of operative results. Still, it may be 176 INDEX OF PROGNOSIS assumed that as the older operative methods on the long bones, such as wiring, etc., become discarded, and more operative cases become available for com- parison, even better results may be looked for in the future. Dujarier* reports that in 32 cases of operative intervention for fractures of the leg, recent or old, he has not had a check ; all his patients are consolidated and walking. The operations were carried out between 1904 and 1912. Fredet^ records his experience of operation in 20 cases, following the technique of Lambotte ; he expresses himself as fully satisfied with the results. The method of inserting a bone-graft, generally from the tibia, in ununited fractures is coming into favour, due very largely to the peculiarly attractive advocacy of J. B. Murphy. Albee^ reports 15 successful cases. In Table VI of the Committee's report, given below, three fractures are considered, and the percentages of good functional results (apart from con- sideration of the anatomical result) are given. It will be seen that there is a diminishing number of good results in each group as age increases. In the words of the report, " there is a progressive depreciation of the functional result of non-operative treatment as age advances ; the older the patient the worse the result." Table VI. — Percentages of Good Functional Results for each Age Group. (Three Fractures.) Tibia AND Fi BULA. Radius AND Ulna. Pott's. Shafts. Shafts. Ages per cent Ages per cent Ages per cent 0-10 93 0-10 72 0-10 . 100 11-15 - - 95 11-15 52 11-15 - 100 16-20 - 81 16-20 50 16-20 - 50 21-25 - - 77 21-25 50 21-25 - 54 26-45 - - 65 26-45 28 26-45 - 54 46-60 - - 57 46-60 28 46-60 - 38 61- - - 50 61- - 30 In the tables which follow, when cases are spoken of as having a good anatomical and a good functional result, it means that the result is perfect, or nearly so. The result we should all aim at is a good anatomical and a good functional restoration of a limb. The percentage of these achieved by non-operative and operative treatment will be readily found in the tables, and those who require this high standard in their work will turn to the figures headed "Good Anatomical and Good Functional Results." In reference to the prognosis of fractures in the neighbourhood of joints, the recent important thesis of M. Siauve'' contains the following- cogent conclu- sions : — The prognosis of intra- and juxta-articular fractures is most grave. Those involving the ankle, wrist, and elbow have as a result more or less functional weakness, the cause of this being imperfect co-aptation of the fragments and the resulting exuberant or vicious callus which destroys the normal play of the articular surface. The insufficiency of ordinary treatment is thereby demon- strated. In the hands of specialists the ordinary measures may sometimes be sufficient, but no matter in whose hands, the results are often bad. Surgical treatment should be undertaken more often than is usually done. The reason this latter is not generally accepted is because the surgery of bones is far from having arrived at perfection, especially that which concerns articular and juxta- articular fractures. This method is capable of being perfected, and will be in the future. The usual methods have said their last word, and remain to-day as they have for long been — insufficient. FRACTURES 177 Whether or not these weighty words will be modified, the future experience of surgeons and practitioners alone will declare. For the present the older or non-operative methods remain " safe and serviceable." Truly the results are not of the best ; accurate reconstitution, at any rate in adults, cannot always be attained and maintained. Patients will be satisfied with fair functional results, and practitioners will hesitate to recommend a cutting operation. That the operative method offers the nearest approach to scientific accuracy in reconstruction there can be no doubt ; at present it is in the hands of experts, but with a more general diffusion of knowledge the treatment will be more widely applied. A criticism put forward by some opponents of the operative method, but which is not yet proved, is that there is greater delay in the process of consolida- tion than under non-operative methods. Even if this turned out in the event to be correct, it can hardly be a serious objection, as it would seem to be more important that a workman should return to work with a straight, well-reconsti- tuted limb, even after a somewhat longer convalescence, than to return earlier with an irregular and consequentially weak limb, with the greater probability of a breakdown. On examining the report of the Fractures Committee more closely, it will be seen that the non-operative treatment of fractures of the shafts of the long bones in children under 15 years (excepting fractures of both bones of the fore- arm) shows a high percentage of good results, so it appears that operation is not a necessity in children. The Committee points out that, as previously indicated, the operative cases submitted for examination were few in comparison with the non-operative cases, and that it is undesirable on this ground to arrive at a verdict as between operative and non-operative methods. But if we take the operative cases as they are set out, we find that in cases treated by immediate operation, the deleterious influence of age upon functional results is less marked. In most of the age groups, operative treatment gives a greater number of good results than non-operative treatment. Another very definite finding of the Committee is that operative treatment should not be regarded as a method to be employed in consequence of the failure of non-operative methods, as the results of secondary operations (that is to say, operations on (i) cases in which there has been failure to obtain and maintain accurate apposition by means of external mechanical appliances, or (2) cases of non-union, deficient or faulty union) compare very unfavourably with cases in which operation was carried out as soon as practicable after the accident. With regard to the important question of mortality, in fifteen hospitals 11,946 fractures of the long bones were treated non-operatively, giving a death-rate of I per cent. The majority of the deaths were due to age, disease, or associated injuries. The number of cases treated by operation was 1,040, giving a death- rate of 0-77 per cent. The causes which in the non-operative cases led to a fatal result caused death in 5 of the operative cases. The death-rate directly due to operation is then 0-3 per cent. Dr. Lambotte's death-rate in 567 operations is 1-5 per cent ; amongst these he includes operations for fracture-dislocation of the iliac bone, multiple fracture of the leg, double fracture of the femur, and a case of irreducible subtrochanteric obstetrical fracture of the femur in an infant six days old. Another case had appendicitis and evacuation of pus per anum. Most of the deaths are associated with the injuries, accidental or avoidable. We will now examine the Committee's report in some detail. 12 178 INDEX OF PROGNOSIS Femur. — Results of Non-operative and Immediate Operative Treatment of Fractures of Femur. 1 Good Poor Site of injury Treatment Cases anatomical and functional anatomical, good functional per cent per cent Neck . . - - -\ Non-operative - 91 16-4 9-8 Operative 1 100 — Separated epiphysis of head Non-operative - 9 44-4 22-2 ( Non-operative, all ages - 96 54-1 4-2 Upper third of shaft . Ditto, under 15 47 87 8 1 Operative (all under 15) - 3 100 — 1 Non-operative, all ages 436 67-8 13-2 Ditto, under 15 328 87 7-8 Mid. third of shaft " -, Operative, all ages - 27 92-5 i Ditto, under 15 25 96 — Lower third of shaft J Non-operative, all ages Ditto, under 15 104 50 58-6 86 15-3 8 1 Operative, under 20 - 2 50 — •i ( Non-operative, all ages 12 41-6. 8-3 Lower extremitj', J Ditto, under 15 2 100 involving knee -1 Operative 1 a moderate result only If we consider the figures of other authorities, we find Scudder^ reporting on 1 6 cases of fracture of the neck of the femur treated by traction and immobiliza- tion. The cases were examined two and a half to twenty-four and a half years after the accident ; ages between forty- two and over sixty ; 14 of the 16 had impairment of function; 2, that is, 12-5 per cent, gave good functional results. In Walker's^ report of 112 cases, 18 died within a week of admission to hospital, 32 not traced ; of the remaining 62, only 10 had completely recovered, that is, about 16 per cent of good functional results. Ashhurst and Newell^" give the end-results of 21 cases of fracture of the neck of the femur treated conserva- tively ; 5, or 23-8 per cent, had a perfect functional result. From this we conclude that 26 per cent of good functional results is the best we can expect from non-operative treatment in adults. Scudder's* statistics of 35 cases of fracture of the shaft of the femur treated non-operatively by Buck's extension, outside T splint, or long Desault apparatus and later plaster, show that of 16 cases between eighteen and forty-eight years, 5 had a perfect result ; in 5 cases, the average age being fifty-eight years, none had a functionally perfect result. Of 14 cases, the average age being seven and a half years, all had functionally perfect results ; 4 mention slight pain occasion- ally, and these have a little stiffness of the knee. This gives a good functional result in about 24 per cent over eighteen years. Lambotte's report shows 13 cases of immediate operation for fractures of the femur; 10 had a good anatomical and a good functional result, 2 a good anatomical and moderate or bad functional result. That is to say, a good functional result is achieved in 76-9 per cent of cases operated on. Walker^i records 21 cases of operation for fractured femur ; operation was only performed after the best efforts of conservative treatment had failed. The Lane technique was carried out, Semon extension apparatus and plaster case applied. No mortality or serious complication ; in one case the plate was removed for slight superficial suppuration. Improvement has resulted in every case. FRACTURES 179 Average Duration of Incapacity. Age Site of Injury Non-operative Immediate operation 1 Upper epiphysis and neck 26-5 weeks No record Under fifteen Shaft - - - - 16-5 „ 16-2 weeks years Lower extremity ]- 18-2 „ No record Lower epiphysis i Upper epiphysis and neck 53-2 ,, Over fifteen Shaft - - - - 33-6 „ 52 weeks years 1 Lower extremity Lower epiphysis I 18-7 „ 26 „ Permanent ( Upper epiphysis and neck Shaft - - - - 30 per cent 11-7 „ No record None incapacity over 15 years ( Lower extremity Lower epiphysis } - •• None The table of permanent incapacity is made up from 252 non-operative cases, and a very small number of operative cases, useless for purposes of comparison. Patella. — The prognosis in stellate and longitudinal or subaponeurotic fractures is usually good under early massage and movement treatment. Trans- verse fractures with separation or the interposition of aponeurotic tags between the fragments have a more serious outlook as regards restoration to full function. Helfericy^ (1899) quotes Bahr's report on 44 old cases averaging four years after the injury. In 42 some weakness remained, amounting to 35 per cent of working power ; this is 4-5 per cent good results. Bull's^^ report (1890) is a vast improvement ; 16 cases are recorded ; he states that 14 of these, or 87-5 per cent, had ' excellent ' results. They were all treated by plaster-of- Paris splints, with appropriate confinement of the fragments. Lucas-Championniere, who applied his method of massage and mobilization to most fractures, held that the treatment is only of exceptional application in fractures of the patella ; as a general rule, suture was his method of choice, for the reason that it brings about a definite anatomical restoration. Power's^* {1898) collection of 711 cases operated on, exhibits a mortality of 1-4 per cent. The late results showed 94 per cent of satisfactory results, 3 per cent had marked stiffness and disability, i per cent total ankylosis. Stimson^^ (1910) records 200 operative cases in two series. First series: 40 cases ; 2 became infected, with resulting stiffness. Second series : all recovered without accident, with good use of joint, 99 per cent good results. Lockwood^^ (191 1) reports 39 operations on 38 patients, ages twenty-two to sixty-three. The wires had to be taken out in 2 cases ; skiagrams were available in 12, and of these 11, or 91-6 per cent, had good bony union and good limbs. He IS strongly in favour of operation, as it gives better results in a shorter time. Delatour^'' (1914) gives an account of 99 operations: of these, 6 patients have useful joints, but with limited motion ; 40 have flexion to at least a right angle, and have perfectly useful joints. The remainder were not traced ; all had good motion to at least 45 degrees when they left hospital, and a satisfactory result was expected. There can be no doubt that in transverse fractures with separation, operation, apart from the definite though small risk of sepsis, will give the only chance of bony union, and so contribute materially to a good functional result. Under operative treatment the period of incapacity will be from two to three months ; under conservative treatment from six to twelve months. INDEX OF PROGNOSIS Constitutional disease or age may decisively iniiuence the selection of con- servative methods. Refracture. — Corner's^^ paper puts this matter very clearl}^. After stating that the patella is the most frequently refractured bone in the body, he points out that this occurs most often between the ages of thirty and forty. After operation, 69 per cent of refractures occur in the first year ; after non-operative treatment, 86 per cent of refractures occur after the first year. The percentage of refractures is approximately the same after operative as after non-operative treatment. Tibia and Fibula. — Results of Non-operative and Immediate Operative Treatment of Fractures. Good Poor Site of Injury Treatment Cases anatomical and anatomical, good Junctional functional per cent per cent ( Non-operative, all ages 424 74-4 10-7 Shaft of Tibia ■ Ditto, under 15 Operative 223 17 95 76-4 2 17-6 V Ditto, under 15 7 100 — Shaft of Fibula - 1 Non-operative, all ages Operative "1 70-5 100 3-9 Non-operative, all ages 548 44-4 25-6 Ditto, under 15 116 94 Both bones - Operative, all ages - 22 63-6 4-5 Ditto, under 15 2 100 — Non-operative, all ages 246 37-5 10-4 Pott's Fracture Ditto, under 15 8 87-5 12-5 Operative, all ages - 4 50 — ■ Lambotte's figures for immediate operative cases of fractured tibia show 5, with 4 good anatomical and good functional results, and one with moderate or bad anatomical and good functional result ; that is, 100 per cent of good functional results after operation. Lambotte's statistics of 18 cases of fracture of both bones show a good functional result by operation in 95 per cent. Of 35 cases operated on for failure to maintain apposition, non-union, defective or faulty union, 8 had a good anatomical and 21 had a good functional result; that is, a percentage of 60 good functional results. In Bardenheuer's account of 149 cases of ankle fractures generally, 77-2 per cent recovered before ninety-one days ; 20 had passed the fiftieth year ; half of these had fracture of both bones ; 19 of the 20 had become fit for work. Bardenheuer points out that this good result in older people should be taken as proof of the excellence of his extension bandage. Hitzrot^^ traced 64 non-operative cases of Pott's fracture one year after injury. Thirty-eight cases were under thirty -five years, and all had perfect functional results. Of 12 between thirty -five and fifty years, " function was perfect in all the cases, extension was normal, but there was distinct limitation of flexion in all." Of 14 between fifty-five and sixty-four 3'ears, " function was perfect in 4 only, 5 had practically a stiff joint. Flexion and extension were limited in all." Chaput,-" in a careful study of 30 cases of malleolar fractures treated non- operatively, notes only 7 good results (23-3 per cent), 4 fairly good, 9 moderate, and 10 bad. FRACTURES Of 6 cases where operation was undertaken after the failure of external mechanical methods, non-union, faulty or defective union, i had a good anato- mical and I a good functional result, 3 had a bad anatomical and 3 a bad functional result. Average Duration OF Incapacity. Age Site of Injury Kon-operative Immediate operation Shafts .... 12-8 weeks 9 weeks Under fifteen J Lower epiphysis, Pott's years \ fracture '>2 No record Over fifteen j Shafts .... 26-7 31-2 weeks Lower epiphysis, Pott's years [ fracture 23-7 14-5 Permanent ( Shaft . . . . 8"1 per cent 9 per cent incapacity over \ Lower epiphysis and Pott's fifteen years \ fracture 6 25 per cent bad results The non-operative cases number in all 797, and the immediate operative only 26, so the value of the table lies in the non-operative side. Astragalus. — The table constructed by G. Gayet^^ gives the results of the operative treatment of fractures of the astragalus. If there is no displacement, or if displacement and the fragments are easily reduced and maintain their position, massage and early movements will in all probability give a good r^ult. If there is much displacement of fragments, partial or complete removal of the bone will be required. Of 22 cases up to the age of sixty-four years in which complete removal of the bone was performed, 21 (95-9 per cent) gave a good result in the sense that the patient was able to return to his occupation ; the bad result was in a case operated on eight months after the fracture. Of 10 cases of partial removal, 1(10 per cent) only gave an excellent result, i a satisfactory result, and i returned to work, but was quickly fatigued. Cabot and Binney-- give figures in respect of 8 cases. There was a good result in 25 per cent and a bad result in 75 per cent, and they conclude that the results are distinctly worse than in fracture of the calcaneum. The average period of disability was about a year and a half. In making a prognosis from an x-TZ-Y photograph in cases of fracture of the astragalus, it is well to remember that the posterior surface of this bone has a small tubercle, the os trigonum, which occasionally has a separate existence and so simulates a fracture. Calcaneum. — Three forms of this fracture are recognized : (i) Posterior portion with iendo A chillis ; {2) Comminution of body ; (3) Sustentaculum tali. In the first form there is not usually much separation of the fragments ; but if there is, then operation and fixation by a screw will give the best results. In the second form, accurate anatomical reposition is not generally feasible. Operation may be required to remove fragments ; in any case the results are very unsatisfactory. In the third form, there generally results an amount of aversion and sinking of the inner border of the foot. In all the forms there frequently follows pain in the foot and difficulty in walking, consolidation of the fracture itself is much delayed, and no weight should be borne on the foot for at the least two months. Ely^^ records 12 cases of fracture of the calcaneum, and in i only was the result good (8-6 per cent). 1 82 INDEX OF PROGNOSIS Cabot and Binney's^^ statistics of 26 cases show good result in 50 per cent, fair in 38 per cent, and bad in 12 per cent. These good results seem to be quite above the average, and appear to be accounted for by the fact that 7 were heel-fragment cases, and that 5 of these had good, and i a fair result. The average duration of disability was about six months. This period appears short, probably on account of the number of heel-fragment cases in the series. Cuboid. — Fracture of this bone is rare, and there is not generally great dis- placement of fragments, though the fracture is usually a comminuted one. A good result may be expected. Tarsal Scaphoid. — Isolated fracture of this bone is not so ver^^ rare, and a considerable number of cases have been reported. It is difficult to maintain the fragments if much displaced, or even to reduce them ; but if this can be effected, then a good result vdW probably follow. In cases where the fragments cannot be reduced, removal by operation is indicated. Macausland and Wood-* report 2 cases of between five and six months' standing, of complete removal of the scaphoid for fracture, with a good functional result in both. Abadie and Rauge-^ report 28 cases ; of the 15 in which the result is men- tioned, 4 were operated on, and 3 of these had a good result; 11 were treated non-operadvely, and 3 had a good, 4 a moderate, and 4 a bad result. The tubercle of the scaphoid is occasionally fractured by muscular action, such as dancing, and a valgus condition may ensue. In forming an opinion from a radiograph, it is well not to overlook the occasional presence of a sesamoid bone in the tibialis posticus tendon ; it might be taken for a fracture of the scaphoid tubercle. Cuneiform Bones. — Fractures of these bones occur in association -with a crush of the foot, and the prognosis depends largely on the damage to other parts. If a readjustment can be made and the soft parts recover, then a fair result may be expected. Metatarsals. — Fractures of these bones may cause considerable disability in the use of the foot if a fair alignment of the bones cannot be achieved. It there is much displacement of the fragments, anatomical restoration and fixation by operation will give good results. Fractures united with marked upward or downward displacement frequently cause very definite disability. Fifth Metatarsal (Jones's fracture). — An indirect fracture which occurs by inversion, treading on the outer side of the foot ; the line of fracture is near the base. There is neither crepitus nor deformity. The diagnosis depends on the radiographs, and the prognosis is good. Fractures of the phalanges are frequently compound, and the prognosis depends largely on whether the wound infection is localized or becomes exten- sive, involving joints and tendon sheaths. In the former the result will be good, and in the latter great disability will ensue. Humerus. — -It wnH be observed from the table opposite that the results of fractured tuberosity are not good, and it seems reasonable to expect better in csises m which the fragment is separate if it is fixed into position by means of a screw. Seven cases of fracture of the surgical neck, 2 being under ten years, were treated by operation after failure of non-operative methods, faulty or defective union. In all, the results were good ; that is, 100 per cent good functional results. This seems to be specially good operative results for cases of this class. In 13 cases of fracture of the shaft in which operation was undertaken on account of failure of non-operative methods, faulty or defective union, 61-5 per cent had good functional results. FRACTURES 183 In 6 cases of supracondylar fracture, 2 being under ten years, in which opera- tion was undertaken for failure of non-operative methods, faulty or defective union, 33-3 per cent had good functional results. Six cases of separated lower epiphysis were operated on for the same reason ; I, or i6'6 per cent, had good functional result. In a case of fracture of the internal condyle in which operation was undertaken for failure of non-operative methods, the functional result was only moderate. Results of Non-operative and Immediate Operative Tre.\tment OF Fractures. Good Poor anatomica.! anatomical. Site of Injury Treatment Cases and functional good functional ^^ per cent per cent Anatomical Neck - -| Non-operative - Operative - - - - 5 2 80 100 — j Non-operative, under 20 - 5 80 20 Upper Epiphysis - - Operative, under 20 2 100 — Tuberosity Non-operative - 3 33 — ( Non-operative, all ages 37 40 17-5 1 Ditto, under 20 10 100 — Surgical Neck - - Operative, all ages - 6 60 — 1 Ditto, under 20 2 100 — f Non-operative, all ages 68 64-5 21-9 Shaft - - - -, Ditto, under 15 18 61 22 Operative, all ages 6 83-3 — Supracondvlar - \ Non-operative, all ages 17 41-1 11-1 Ditto, under 15 - 8 75 12-5 V Operative, under 15 - 1 100 — Lower Epiphysis - ■ Non-operative - Operative 50 14 44 57-1 22 71 Internal Condyle - - Non-operative, all ages Ditto, under 15 17 11 41-1 72-7 23-5 External Condyle - Non-operative, under 25 - 7 14-2 42-8 Musculospiral Paralysis occurs in from 4 to 8 per cent of cases of fractures of the humerus, being associated most frequently with fracture in the middle third of the shaft. The prognosis is fairly good after suture, or release, or both. Scudder and Paul's-* table of 11 cases treated by operation shows 8 cases of recovery of function — 72-2 per cent — -the shortest interval in the successful cases between the accident and the operation being three weeks, and the longest three years. Hitzrot's^^ statistics refer to 141 non-operative cases of fracture of the surgical neck of the humerus. Two were in children, i treated by non- operative and the other by operative methods ; both had perfect results. In the remaining 139 cases, hyperabduction to the amount of 5 per cent was lost in all except 2 ; external rotation to the amount of 5 to 10 per cent less than normal was present in all cases. The treatment adopted was :' Arm flexed and held in a sling, cushion in axilla, extension of from 5 to 10 lb. applied and allowed to hang for an hour. When fracture is reduced, shoulder plaster splints back and front down to wrist ; ;ir-ray control, splints on for three to live weeks, massage and movements at end of ten days, galvanic and faradic currents to deltoid. Lower End of Humerus. — There were 106 cases, all under ten years ; 51 cases of fracture of external condyle in children treated by hyperflexion for two weeks, then massage; in i, a fragment had to be removed ; all had 184 INDEX OF PROGNOSIS perfect return of function ; 54 cases of supracondylar fracture in children reduced under anaesthesia, arm fiexed at right angle or beyond ; two cases had musculospiral paralysis and were operated on, function becoming complete in twenty weeks in one case, in the other not so satisfactory, in thirty-six weeks. Of these cases, 50 had no perceptible deformity; function of the elbow joint was perfect in all cases. In 34 adult cases, 12 involved the external condyle; 1 1 were uncomplicated ; all treated by as much hyperflexion as possible ; no deformity resulted ; function excellent, but not perfect. Six cases of fracture of the internal condyle treated by reduction under ether and flexion ; function excellent in all, perfect in one. Fractures of the Elbow. — Andre Treves^' gives a careful account of the late results of 162 cases in children, as follows : — Site of Injury Under 5 years 5-10 years 10-15 years Eesults Supracondylic External condyle - Simple internal condyle T fracture Lower epiphysis 18 17 1 3 51 21 16 1 2 10 4 'I Perfect function in 88 per cent Excellent function 80 per cent Perfect function 61 per cent Satisfactory 50 per cent Perfect function 100 per cent Ten supracondylic cases had operations for defective union, and 6 for nerve injuries. Six internal condyle cases had operations for defective union, and 3 for nerve injuries. Thirteen fractures of the internal condyle with luxation had 10 perfect results — 70 per cent. These figures again show that good functional results are obtained in children by non-operative methods. Treves says that the treatment, save in supra- condylic by flexion where extension is required, and the supracondylic with lateral displacement where extension is admissible, should be by immobiliza- tion in flexion, the duration of immobilization being from eight to fifteen days, and not beyond three weeks. Early massage and movements are harmful, because they produce excessive callus in children, and besides, they are very painful. Average Duration of Incapacity. Under j fifteen years ( Over f fifteen years | Permanent j incapacity over - fifteen years t Site of Injury Anatomical neck and upper epiphysis Surgical neck and shaft Lower epiphysis and supracondylic - Anatomical neck and upper epiphysis Surgical neck and shaft Lower epiphysis and supracondylic - Anatomical neck and upper epiphysis Surgical neck and shaft Lower epiphysis and supracondylic - Kon-operative Immediate operatioa 8 weeks No record 10- ■) „ 26 weeks 13"5 ,, 8-7 „ 5-2 „ 8 27-6 „ 32-8 „ 17-1 „ 78 . „ 20 per cent None 10 8 % bad results 17 6 „ This point was noted in 92 non-operative cases and 11 operative cases, and, for what it is worth, shows operative treatment in a favourable light ; but the operation cases are too few to base a reliable opinion upon. FRACTURES 185 Radius and Ulna. — Results of Non-operative and Immediate Operative Treatment of Fractures of Radius and Ulna. Good Poor Site of Injury 1 reatment Cases and functional good functional Radius, upper epi- per cent per cent physis - Non -operative, under 15 2 50 ( Non-operative, all ages 45 53-1 12-7 Radius, shaft - - ' Ditto, under 15 Operative, all ages - 19 7 73-6 57-1 10-5 14-2 Ditto, under 15 4 75 25 Radius, lower epi-J physis - - - 1 Non-operative, all ages Ditto, under 15 15 11 66-6 03-6 13-3 9 Operative, under 10 - 1 100 — \ Non-operative, all ages 47 27-6 29-7 CoUes's - Ditto, under 15 4 100 — Operative 1 100 — Ulna, olecranon - 1 Non-operative, all ages Operative, all ages - 20 19 45 73-(> 311 5-2 ( Non-operative, all ages 18 77-7 ll-l Ulna, shaft Ditto, under 15 10 80 10 Operative 1 result not good — Ulna, lower epiphysis Non-operative 3 100 — ( Non-operative, all ages - 2 38 17-1 Radius and ulna - ' Ditto, under 15 76 63 — 1 Operative, all ages - 54 75 — Ditto, under 15 3 100 Hitzrot^^ records 15 cases of fracture of the head of the radius with little displacement; flexion and extension eventually became complete in all, but in II cases pronation and supination only half the normal. Of 4 cases with displacement of fragments, in 2 the head had to be removed in its entirety ; in the remaining 2 a broken fragment only was removed. The functional result was best in the cases in which the head was completely removed, and not good in the 2 cases of partial removal. In 10 cases of fracture of the neck of the radius of the transverse type half an inch below the head, 2 (20 per cent) had a good and 8 a moderate functional result. Average Duration of Incapacity. Under ( fifteen years Over j fifteen years ' Permanent i incapacity over-' fifteen vears Site of Injury Non-operative Immediate operative Radius and ulna 17-1 weeks 6 weeks CoUes's fracture 3-7 „ No record Radius and ulna 20-6 „ 19'4 weeks CoUes's fracture 17-1 „ — Radius and ulna (including lower epiphysis) - G per cent 8 per cent Colles's fracture 14-7 „ ~~~ These non-operative cases include 64 radius and ulna fractures and 34 Colles's, and the operative cases 25 radius and ulna and only i Colles's fracture. Arrest of growth of the radius is to be found as an end-result of separation of, or injury to, the lower radial epiphysis. Poland-'' records 17 out of a total of over 700 of these cases. He also notes INDEX OF PROGNOSIS 56 cases of arrest of growth after these injuries, the radial cases being the most numerous. Recently, 3 cases have come under my own observation ; the diminished length of the radius and the normal length of the ulna, gave the hand its characteristic deformity. In only i of these 3 was the functional result good. Table VII of the Report gives a summary of all fractures over fifteen years, and notes the average duration of incapacity. Duration of incapacity Percentage of cases of permanent incapacity Non-operative, 27'f) weeks Operative 27"3 ,, 9 per cent 7-8 Carpal Scaphoid. — Hitzrot^^ records 14 cases, 7 without displacement of fragments treated by a moulded anterior splint, fingers free, hand in slight radial deflection and extension, early massage, full movement in sixth week. The result was hyperextension limited in all, flexion in i, with pain on movement. In 3 cases Avith displacement of proximal fragment, the latter was removed by dorsal incision and treated as the foregoing ; result, extension two-thirds normal, flexion seven-eighths normal, deflection less than normal. Four cases with similar displacement associated with dislocation of the semi- lunar ; the fragment and the semilunar were removed in 3 ; the result was fair. In the fourth case the fragment of the scaphoid was removed, and an ineffectual attempt to reduce the semilunar was made ; the result at the end of nine weeks was a stifi wrist. The prognosis is not wholly good, though Cotton'^^ says that in 3 of his cases in which removal of fragments was done in uncomplicated fractures, the results were practically perfect. Lambotte^° thinks that in view of the unsatisfactory results ordinarily obtained, the fragments could be readily held together by a fine screw and a better result obtained. Campbelpi records 3 cases of fracture of the carpal scaphoid, with a lesion of the median nerve, which eventually made a good recovery as regards the nerve injury. In examining a radiograph for this fracture it is necessary to remember that in about i per cent of persons the scaphoid is normally divided into two parts in the course of developm.ent ; this might be mistaken for a fracture. Semilunar. — A number of cases of fracture of this bone have been recorded by Ebermayer,^- Finsterer,^^ and others. It is a compression fracture. The prognosis is not good as regards function ; the bone may require removal ou account of pain and diminished movements of the hand. Os Magnum. — Fractures of this bone are relatively rare. Harrigan^* has collected 6 authoritative cases, including one of his own ; in 2 only was the diagnosis confirmxed by ^r-rays. The results do not seem to be satisfactory. In none of the cases is it stated that a good result ensued. Fractures of the Trapezium, Trapezoid, Unciform, and Pisiform have been reported. They are important, for they are likely to be followed by anky- losis, so that the best results may be expected from elastic pressure, early passive movements, and massage. Metacarpals. — Fracture of the First Metacarpal. — This may occur at the distal end of the shaft or at the base. If good alignment can be achieved and maintained in these, a good result may be expected. Fracture at the Base (Bennett's Fracture). — An oblique fracture through the base. Good ana'tomical reposition is not always achieved, but very fair functional results may follow. FRACTURES 187 Lambotte^" has had a good result by fixing the fragment into position with a fine screw. Separation of the Basal Epiphysis of the first metacarpal occasionally occurs. In the two cases recorded by Coues^^ a good result followed. Fractures of the Shafts of the other metacarpals are apt to give serious trouble if a good alignment cannot be achieved ; if this is obtained and maintained, the results are good. In difficult cases, oblique fractures and such like, Lambotte recommends a small form of fixateur or a small plate, or cerclage, as giving good results. Fractures of the Heads (knuckle fracture; pugilists' fracture). — According to Cotton,-^ some deformity always remains, flexion may be impaired, function generally is good. He quotes a case in which there were sixteen of these fractures in both right and left hands without serious loss of function occurring, except in one knuckle. Fractures of the Phalanges usually unite well, and unless the crush, which is generally the cause, is severe, a good result follows moderate readjustment of the fragments. Fracture of the Sesamoid Bones of the thumb has been described by Preiser ; ^^ no bony union followed, but the functional result was good. Scapula. — Fractures of the Body are often multiple. Union takes place frequently with overlapping or exuberant callus, but generally speaking good functional results ensue. Cotton states that in his 10 cases the results were practically perfect. Acromion Fracture is rare. Union may be fibrous or bony ; in either case the functional results are nearly always good. Spine. — The edge may be broken, or the mass of bone, including the acromion, may be separated ; some deformity, but no permanent disability, results. Glenoid is rare except as an accompaniment of dislocation of the head of the humerus. It is possible that chipping off of the edges may predispose to recurrence of the dislocation. Coracoid. — The line of fracture is usually well behind the tip, but this may be split longitudinally. Union is seldom bony, but there is no displacement unless the coraco-clavicular ligaments are torn. Rarely is there any great functional disability. Neck. — The line of fracture is through the suprascapular notch to the axillary border. Bony union with some displacement is the rule. In the majority of cases good functional results ensue. Sternum, — Fractures of this bone are usually associated with damage to the intrathoracic or abdominal organs, and the prognosis may depend on the extent of injury there. Gurlt collected 98 cases, and of these 54 were simple cases; 46 recovered, 8 died, whilst of 44 cases complicated by severe injuries, only I recovered. Fracture of the Ensiform Cartilage may occur. It is sometimes followed by troublesome vomiting, which, in one of the 4 cases tabulated by Gurlt, persisted for two years and then ceased spontaneously. In three of the cases, vomiting ceased when the depressed cartilage was drawn forward. Clavicle. — These fractures usually unite well ; non-union is rare. The bond is firm at the end of four weeks. Displacement, deformity, and shortening are the rule. The amount of shortening may be as much as two inches. These conditions, however, do not follow in those cases in which the line of fracture is transverse and where displacement is absent at the beginning. Despite deformity and shortening, the functional usefulness of the arm is seldom much interfered with. INDEX OF PROGNOSIS The rare complications of this fracture which render the prognosis not good, are injuries to the subclavian artery and vein, brachial plexus, or lung, and pressure by exuberant callus. If operation is required for great deformity and failure of the usual treatment to maintain a correct position, or for other reasons, a screw driven in longitudinally, or cerclage (Lambotte's) or a fine Lane plate away from the skin, will give good results. Ribs. — Simple fractures without complications do very well. If excessive callus forms and persists, it may cause pressure on intercostal ner\^es, and per- sistent pain may follow. In old or feeble persons, the immediate outlook is more serious, pneumonia being the most dangerous sequela. Pelvis. — Fractures of the pelvis are not common, and the prognosis depends largely on the associated damage to pelvic viscera. Shock is a cause of death in many cases. If the patient recovers, there is frequently deformity, which, if it obstructs the pelvic outlet in females, may be a serious matter during parturition. On the other hand, in the lesser injuries, the results may be quite good. PauP' records a table of 54 cases, with a mortaUty of 50 per cent. Five lapar- otomies were done — four for ruptured bladder or rectum — and aU died. Four external urethrotomies were required ; two died. Estimation of Depreciation of Capacity for Work. On the Continent, in cases in which there is complete and permanent disable- ment, compensation is allowed equal to two-thirds of the wages earned. In the United Kingdom, half the average weekly wage is paid so long as there is incapacity for work. The worker will then thus receive his fuU compensation, so long as he is unable to do any work. The following table is after Brouardel,^* 100 being reckoned as the full estima- tion of depreciation. This figure is appUed to such cases as complete loss of vision or loss of the use of two limbs. The table will give a general idea of the depreciation in working capacity in the various permanent injuries, four tjrpes of workers being selected. The short notes which follow are intended to give a general idea as to the working capacity after injury of men who follow arduous occupations. The figures are taken from Brouardel, Rohmer^®, OUiveet Le Meignen^o, and others. Brouardel's Table I. Occupation Occupation specially specially Permanent Infirmities : Day requiring requiring Workers 100 indicates the maximum of loss labourers the use of the upper mbs the use of the lower limbs in the arts Right Upper Limb. Loss of the whole limb . - . - 70-80 70-80 50-70 70-90 Loss of the part below the elbow 70-80 70-80 50-60 70-90 Loss of the hand - - - . - 60-75 05-75 45-55 70-90 Loss of thumb - .... 2.0-35 25-35 15-25 40-55 Loss of index finger - . . - - 10-15 10-25 10-15 25-35 Loss of middle finger .... 10-15 10-15 .5-10 . 1.5-25 Loss of ring finger - ... 5-10 5-10 .5-10 1.5-20 Loss of little finger 5-10 .5-10 5-10 1.5-20 Complete ankylosis of shoulder 40-55 40-50 25-35 40-(;5 Incomplete ankylosis of shoulder according to the degree ..... 10-40 10^0 10-25 30-40 Complete ankylosis of elbow 30-40 30-35 10-25 35^5 Incomplete ankylosis of elbow according to degree - - - - . - 10-30 10-30 0-10 20-35 Complete ankylosis of ^^Tist 20-35 20-30 5-15 30-45 FRACTURES 189 Brouardel's Table II. Occupation Occupation specially specially Permanent Infirmities: Day requiring requu-ing Workers 100 indicates tlie maximum of loss. laboui-ers the use of the upper limb the use of the lower limb m the arts Left Upper Limb. Loss of the whole limb .... 60-70 60-70 40-50 70-80 Loss of the part below the elbow - 60-70 60-70 40-5U 70-80 Loss of the hand 55-65 55-65 30-40 70-80 Loss of the thumb . . . - - 15-25 15-25 10-25 25-40 Loss of index finger 5-15 5-15 5-15 15-25 Loss of middle finger .... 5-10 5-10 5-10 15-20 Loss of ring finger . - . - . 5-10 5-10 0-5 10-15 Loss of little finger .... 0-10 0-5 0-5 5-10 Complete ankylosis of shoulder 40-50 30-45 10-25 35-55 Incomplete ankylosis of shoulder~according to degree 10-40 10-30 0-10 10-35 Complete ankylosis of elbow 25-35 25-35 5-15 25-40 Incomplete ankylosis of elbow according to degree 5-25 5-25 0-5 10-25 Complete ankylosis of wrist 15-20 15-20 5-10 20-30 Incomplete ankylosis of wrist according to degree - 5-15 5-15 0-5 5-20 Brouardel's Table III. Occupation Occupation specially specially Permanent Infirmities: Day requiring requiring Workers 100 indicates the maximum of loss labourers the use of the upper limbs the use of the lower limbs in the arts Lower Limbs. Loss of the whole limb . . . - 50-75 50-75 70-90 50-75 Loss of the limb below the knee 50-70 50-70 60-80 50-70 Loss of the foot ..... 40-fiO 40-60 60-80 50-60 Loss of all the toes - . - . - 25-35 20-30 40-60 25-35 Loss of the great toe .... 15-20 10-20 20-40 15-20 Great shortening of the lower limb (above 5 cm.) 25-35 20-30 45-60 2.5-35 Slight shortening of the lower limb (below 5 cm.) up to 25 up to 20 up to 45 up to 25 Complete ankylosis of hip - - - . 30-45 30-45 60-80 30-35 Incomplete ankylosis of hip according to degree 10-30 10-30 40-60 10-30 Complete ankylosis of knee 20-30 20-30 40-60 20-30 Incomplete ankylosis of knee according to degree 10-20 10-20 30-40 10-20 Complete ankylosis of ankle 10-25 10-25 40-60 10-25 Incomplete ankylosis of ankle according to degree ....... 0-10 0-10 30-40 0-10 Fractures at the Upper End of the Femur \vliich result in non-union or exces- sive callus formation with interference with the movements of the joint, and ankylosis, may seriously depreciate a workman's earning capacity. He may be compelled to use a stick, or even a crutch, and he will in all probability be obliged to seek other employment if his usual work required the full use of his hip joint, as would be the case if the work involved climbing ladders, etc. Wasting of muscles is a frequent accompaniment of partial ankylosis, and adds I90 INDEX OF PROGNOSIS to the incapacity. Complete ankylosis of the hip may be valued at as much as 80 or even 90 per cent ; at an angle, 58 per cent ; atrophy of muscle, 33 per cent. If fixed in the flexed position, walking and standing will be interfered with ; and if the fixation is in the extended position, there may be a difficulty in sitting. It will probably take at least eight months before the patient is fit to begin work in an ordinary simple case of fracture of the neck ; this is presuming that the patient is not beyond middle age, and that there are no complications, such as arthritis, phlebitis, pseudarthrosis, etc. Fractures of the Shaft of the Femur may be followed by non-union and almost complete incapacity for work. Union with shortening and deformity is more common. In measuring the shortening it is well not to forget that there is sometimes a difference in the length of normal lower limbs. Some authorities state that this is as much as i cm., and the increase is generally'' in favour of the left limb, so that a shortening to this extent may be considered of no import- ance. OUive and le Meignen are of opinion that shortening below 3 cm. should not be compensated unless it is associated with other lesions. Brouardel reckons great shortening to be that above 5 cm., and values it up to 60 per cent. In the lesser degrees of shortening, a great amount of accommodation occurs, and this can be easily assisted by adding to the thickness of the sole of the boot. In the greater degrees, correction is difficult and the incapacity for work is considerable, save in those workers who can sit at their occupation. The foregoing remarks on shortening apply equally to fractures of the tibia and fibula. Angular deformity and excessive callus formation may prevent the full action of muscles. Pain will follow the involvement of nerves in callus, and it is frequenth^ a cause of incapacity in cases of union with overlapping or bowing of the limb ; standing for a length of time is sometimes impossible. If good alignment of the fragments is achieved, recovery will take place in four to six months ; in manj^ cases it will be as much as twelve. Fractures Involving the Knee Joint are sometimes followed by more or less ankylosis or weakness in the joint. If the ankylosis is in the straight position, the incapacity is about 40 per cent ; in the flexed position, according to degree, up to 50 per cent ; relaxed knee joint, 58 per cent. The insecurity here is most noticed in going up or down ladders or stairs. Marked wasting of the muscles of the thigh frequently follows injuries to the knee joint. In simple cases it generally takes from six to twelve months for full working capacity to be restored. Fractures of the Patella. — If bony union is achieved, the return to full function is the usual course. If the union is fibrous and there is not much separation of fragments, a useful, though not perfect, limb results. If there is much separation of fragments, a weak and flail-like limb -wdll result, Avith consequent incapacity, which may be as much as 50 per cent. Fractures of the Shafts of Tibia and Fibula, united with deformity or with painful callus, are often associated with thrombosis, swelling of the limb, and trophic troubles. If non-union occurs, the incapacity is great. If the fracture is in the upper end, involving the knee joint, the resulting condition maj?^ approxi- mate that found in fractures of the femur involving the knee joint (q.v.). If the fibula is fractured near the upper end, the peroneal nerve may be involved either in the fracture or in the resulting callus, and a condition of talipes equino- varus ensue, with incapacity for work. (For shortening, see Fracture of the Femur.) In favourable cases a worker is usually fit to return to work in three or four months. Fractures of the lower end of tlie tibia and fibula involving the ankle joint are FRACTURES 191 grave injuries, and very frequently result in serious incapacity. Deformity, a varying degree of ankylosis, and pain are the most frequent sequelae. If the foot is fixed at a right angle — the most favourable position — the incapacity may be from 15 to 20 per cent, according to the nature of the work. If fixed at an acute angle, or in an extended position, the incapacity may be as much as 60 per cent. The older the patient, the less is the chance of his being able to return to full work. The opinion of the late Mr. Clinton Dent, mentioned earlier, having reference to that picked body, the Metropolitan Police, shows how very serious these injuries are in persons whose occupation requires long standing or walking. Fractures involving the Tarsus and Metatarsus may sometimes cause perma- nent incapacity, occasionally equal to loss of the foot, on account of pain, swelling, and difficulty in walking, or standing for a long time. Flat-foot may ensue, and it is valued at from 30 to 50 per cent. Sometimes the strain on the sound foot occasioned by the weight of the body being thrown on it in an effort to save the injured foot, causes a condition of fiat-foot in a previously healthy foot. In metatarsal fractures, if there is much displacement of the fragments either in an upward or downward direction, the pressure of the workman's hard boot may cause very definite incapacity ; metatarsalgia may ensue. Fractures of the Toes rarely cause incapacity unless they become compound and septic. The loss of the great toe is estimated at from 10 to 20 per cent. The loss of a single phalanx does not cause any incapacity unless the scars are tender. The loss of several toes or all the toes may be estimated at from 20 to 30 per cent as a maximum. In many tarsal fractures it will be six to eight months before the patient is fit to undertake heavy work, or metatarsal fractures three to six months. Fractures about the Upper End of the Humerus may be followed by more or less ankylosis, and consequent limitation of movement, atroph}' of muscles, injury to the circumflex nerve, or chronic arthritis. Ankylosis may be estimated according to degree at from 50 to 60 per cent ; atrophy of muscles 28 to 58 per cent ; chronic arthritis 16 to 66 per cent. Arthritis may greatly delay recovery. Benign cases are well usually in two to four months, but severe ones may last as much as twelve months or more. Fractures of the Shaft of the Humerus may be followed by non-union (which is relatively frequent), faulty position, pain, and involvement of the musculo- spiral nerve in callus. Any of these may cause almost complete incapacity. In uncomplicated cases recovery is usually complete in three to four months. Fractures at the Lower End of the Humerus and Elbow Joint may be followed by complete or incomplete ankylosis, or loss of movements of pronation and .supination. Ankylosis in extension may be estimated at from 40 to 50 per cent ; in medium flexion, 33 to 40 per cent ; in acute flexion, 20 to 25 per cent. Loss of pronation and supination may be a serious disability, especially in skilled workers, mechanics, etc. Simple uncomplicated cases frequently recover full working capacity in three months. Fractures of the Radius and Ulna are sometimes followed by disability due to non-union or faulty union. In non-union the forearm is practically useless, and in faulty union there is frequently loss of pronation and supination. Fractures at the Lower End of the Radius and Ulna involving the Wrist Joint are sometimes followed by more or less ankylosis. Complete ankylosis of the wrist is estimated at from 25 to 33 per cent. Partial ankylosis may not interfere with working capacity except in specially skilled trades. In favourable cases, probably about three months may be reckoned as the period of recovery. 192 INDEX OF PROGNOSIS Fractures of the Carpus may cause ankylosis similar to that which follows fractures in the wrist joint. Simple cases recover in from one to three months; the lesser period will apply to those cases in which movements can be begun early. Fractures of the Metacarpus are not usually followed by any very great incapacity unless the bones are united with great displacement. Fractures of the Phalanges do not generally cause much disability. If the finger is ankylosed in a straight or flexed position, there will be interference with the full power of the hand, and amputation may be necessary to restore function. Loss of the thumb is the most important, as the hand is a forceps as well as a grasping instrument. If loss of a hand be reckoned at from 50 to 75 per cent, loss of the thumb will be equal to about one-third of this. Ankylosis of thumb joints, 25 to 33 per cent ; loss of a single phalanx of the thumb is a serious matter. Loss of index finger, 16 to 25 per cent. Ankylosis of index joints, 8 to 25 per cent ; loss of one or more phalanges of the index will equal one- to two-thirds of the total loss of the index. The estimation of the loss of the middle finger is about 8 to 16 per cent, and the loss of the ring finger is a little less. The loss of the little finger is valued just under the last two mentioned. Fractures of the Scapula. — If union is in a faulty position, so as to interfere with the movements of the shoulder or render these painful, the valuation of the incapacity is estimated at from 10 to 30 per cent. Most lesions about the shoulder are followed by an amount of wasting of muscle which frequently takes quite a long time to recover. Fractures of the Sternum. — In simple uncomplicated fractures the prognosis is usually good, though pain is sometimes persistent, but rarely wholly incapacitating. If the ensiform cartilage is driven inwards, an operation may be required to raise it. Remy*^ suggests 10 to 20 per cent valuation for a sinking in of the sternum without deep lesions. Fractures of the Clavicle usually result in some deformity; but if uncompli- cated by injury to adjacent parts, there is in most cases an excellent recovery. Non-union is rare, but if it occurs an operation will be necessary. Excessive callus formation may cause pressure symptoms, pain, and incapacitj'- for work. The estimation for imperfect recovery is from 16 to 50 per cent. In an ordinary case, about two months will elapse before full work can be undertaken. In severe cases it may be much longer. Fracture of the Ribs. — Uncomplicated fractures usually heal well, and there is generally very little incapacity for work afterwards. Sometimes faulty union and excessive callus formation may leave painful neuralgia as a result. If incapacity occurs on raising the arm, or is due to pain, it may be reckoned at from 20 to 50 per cent, or even more. Austrian statistics record 141 5 cases of fractured ribs ; of these, 806 have completely recovered in periods up to seven months. Fractures of the Pelvis, — Fractures of the pelvis are frequently complicated with fatal internal injuries. If recovery takes place, pain may be- persistent, or it may be elicited by movements, and as a consequence walking may be difficult. Simple fractures of the ilium may unite with deformity, causing very little incapacity . Fractures of the Sacrum may result in great incapacity, particularly if nerves are involved. References. — ^ Lucas -Championniere, Precis du TraUement des Fractures par le Massage et la Mobilisation, Paris, 1910 ; ^Ewald, Zenlr. f. Chir. No. 14, 1914, April 4 ; GALL-STONES 193 ^ClintoQ Dent, Clin. Jour. 1908, Oct. 7 ; ^Dujarier, Jour, de Chir. 1913, Sept. ; ^Pierre Fredet, Jour, de Chir- 1913, Sept.; ®Fred. H. AXh&e, Amer. Jour. Surg. 1914, Jan.; "Siauve," De Quelques Fractures Articulaires et J uxta-articiilaires " These de Lille, 1913 ; *Scudder, The Treatment of Fractures, 1905 ; ^Walker (New York), Ann. Surg. 1908, June; i^Ashhurst and Newell (Philadelphia), Ibid. 1908, Nov.; "John B. Walker, Ibid. 1912, Dec; ^^Helferich, "Fractures and Dislocations," Sydenham Soc. 1899; "Bull (New York), Med. Rec, 1890, Mar. 22; "Powers, Ami. Surg. 1898, July; ^^Stimson, A Practical Treatise on Fractures and Dislocations, 1910 ; ^*Lockwood, Brit. Med. Jour. 1911, Junes; ^'H. Beeckman Delatour, Ann. Surg. 1914, June; i^Comer, Ann. Surg. 1910, Nov. ; ^'Hitzrot, Ibid. 1912, Mar.; ^^Chaput, Les Fractures Malleolaires du Cotc-de-Pied, Paris ; ^^G. Gayet, Lyon Chir. 1909, June ; --Cabot and Binney, Ibid. ; ^Leonard W. Ely, Ann. Surg. 1907, Jan.; -^Macausland and Wood, Ibid. 1910, Dec. ; ^^Abadie et Range, Rev. de Chir. 1910, Sept. ; ^^Scudder and Paul, Ann. Surg. 1909, Dec. ; ^'Andre Treves, Etude stir les Fractures de I'Extremite Inferieure de V Humerus chez V Enfant, Paris, 191 1 ; ^^Poland, "Traumatic Separation of Epiphyses"; ^Cotton, Dislocations and Fractures, 1910 ; ^''Lambotte, Chirurgie Operatoire des Fractures, 1913 ; ^^W. A. Campbell, Lancet, 1912, ii, 1296 ; •'^Ebermaj'er, " Fortschr. a. d. Geb. Roentgenstrahlen," 1908 ; ^^Finisterer, Zentr. f. Chir. 1908 ; 3*A. H. Harrigan, Ann. Surg. 1908, Dec. ; ^*W. P. Coues, Ibid. 1912, Sept. ; ^^Preiser, Miinch. med. Woch. 1907; ^'Paul, Ibid. 1901, June; **Brouardel, Les Accidents du Travail ; ^^Rohmer, UEvaluation des Incapacifes Professionelles ; ^^Ollive et Le Meignen, Les Accidents du Tra,vail ; "Remy, UEvaluation des Incapacites Permanenfes. W. J. Greer. FRIEDREICH'S ATAXIA.— (5ee Ataxia.) FRONTAL SINUSITIS. — [See Nasal Accessory Sinusitis.) GALL-STONES. — We shall inquire [A) Into the prospect 0/ severe trouble arising from the presence of gall-stones; and (-B) Concerning the risks and benefits of the various forms of operation. A. The Prognosis of Gall-stones apart from Operation. — As is well known, gall-stones are very frequently found at the autopsy in cases where their presence was never suspected during life. They are said to be present in 4 per cent of all adult males and 20 per cent of all adult females, and are undoubtedly commoner in the obese. Only in about one-fifth of the cases are typical attacks of gall-stone colic recognized. As Moynihan has forcibly pointed out, this does not mean that the remaining four-fifths never have any symptoms. A large proportion of them have uneasy sensations of fullness, which may amount to agonizing attacks of pain, not in the right hypochondrium but in the stomach. It is not at all uncommon for a very exact mimicry of gastric ulcer to be the result, and it may even be supposed from the severity of the symptoms that the ulcer has perforated. In a number of these cases hyperchlorhydria is found, and some of them do actually develop a gastric ulcer in consequence. Gall-stone coh'c with or without jaundice, and gastric symptoms, are there- fore quite common evidences of the presence of calculi in the gall-bladder. There are a number of less frequent ill-effects. In about 20 per cent of the cases which are sufficiently severe to come into hospital for operation, a stone becomes impacted in the common bile-duct, and in a further 10 per cent in the cystic duct (Kehr, Mayos, the Bristol figures). Stone in the common duct causes persistent jaundice and pain, and sometimes febrile attacks ; stone in the cystic duct gives rise to dilatation of the gall-bladder, either simple (muco- cele) or infected (empyema of the gall-bladder). Another trouble resulting from gaU-stones may be a fistulous opening into the peritoneal cavity, some viscus, or on the skin surface. In Courvoisier's statistics collected from the literature, there were 184 cases of cutaneous fistula (usually at the umbilicus), 119 of perforation into the peritoneal cavity, 83 into the duodenum, 39 into the colon, 24 into the lung, and a very few each 194 INDEX OF PROGNOSIS into the stomach, kidney, and ureter. In 4 cases (one of whom was Ignatius Loyola) the inferior vena cava was opened by a gall-stone fistula. Acute cholecystitis is a quite common consequence of stones in the gall- bladder, and occasionally leads to perforation and peritonitis. Subphrenic abscess or abscess of the liver may also result. Intestinal obstruction due to gall-stones is rare, but many hundreds of cases are on record. Of 280 in the literature, 156 died (Martin), but literature statistics are seldom very valuable. Occasionally, adhesions around the bile- passages may lead to intestinal obstruction. Cancer of the bile-ducts or gall-bladder is a well-recognized consequence of the long-continued irritation of calcuU. We have some figures giving us an idea of the frequency of this result. Cancer was present in 18 out of 409 cases at the London Hospital, and 45 out of 333 cases at Guy's. The greater fre- quency is due to the older date of the statistics ; nowadays many more cases are operated on early. Combining these figures, we obtain a frequency of 8 per cent ; the ancient statistics of Riedel were as high as 28 per cent. It will be seen, however, that the danger of cancer is by no means negligible if even 8 per cent of patients with symptoms sufficiently severe to be operated upon already show it. Walton records 3, and Mayo Robson and Lawford Knaggs I each, cases in which cancer has supervened after operation, but this is evidently extremely rare. In the end-result statistics of Kehr, Davis, Arnsperger, McWilliams, Stanton, and the Bristol figures, comprising nearly a thousand in all, this sequel is not once mentioned. We conclude, therefore, that in the majority of cases the presence of gall- stones leads to some discomfort, which in about one-fifth of the cases is very severe, though it may be only temporary ; that of those who show marked signs about one-third eventually suffer from impaction of a gall-stone, or develop a fistula or acute cholecystitis demanding prompt interference ; that another 8 per cent go on to cancer of the bile-passages, and that a small proportion, perhaps i per cent, lose their hves from intestinal obstruction, perforative peritonitis, or subphrenic abscess. It is scarcely reaUzed by the profession that the prognosis of gall-stones, apart from treatment, is as grave as these facts prove. It will probably be admitted by nearly everyone that the prospects of permanent relief of symptoms by medical treatment — olive oil, salines, mineral waters and spa treatment, dieting, etc. — are very slight, and any patient who has had one attack of hepatic colic will most probably get others. Fortunately these are often at long intervals, so that life may be tolerable notwithstanding. B. The Prognosis of Operation for Gall-stones. — We shall consider, first, the operation mortality and its causes, and then the prospects of permanent cure. Table I. — The Operation Mortality for Gall-stones. All cases stones in GaU- bladder Duct cases Serious complications No. Died No. Died No. Died No. Died D'Arcy Power Kehr .... Mayo .... Bristol Royal Infirmary Arnsperger - Munro - - . - 73 1600 1500 84 230 200 per cent 23-3 16-5 4-4 13 6 -9 53 691 1164 31 per cent n-3 2-9 2-5 9-6 389 105 27 per cent 3-3 2-9 11 20 520 102 12 percent 55 44-6 24 42 GALL-STONES 195 I. Operation Mortality. — As a glance at Table I will show, it is impossible to give a figure for the death-rate of the operation for gall-stones which will not be utterly misleading if applied to particular cases without discrimination. Everything depends on the exact nature of the individual's condition. In absolutely straightforward, uncomplicated cases, the mortality is very low. D'Arcy Power records 27 such without a death ; Kehr collects statistics of 2494 operations of this type with a mortality of 3-6 per cent. On the other hand, in the presence of ' serious complications,' including cancer, peritonitis, infection with fever or pus, gastric ulcer, etc., most of the statistics range about 50 per cent. In Table I we are able to give in some detail four series of recent figures. D'Arcy Power quotes 73 cases under his observation in St. Bartholomew's Hospital from 1900 to 1912. The total mortality is high (23-3 per cent), because in England it is principally the severe or complicated cases that are sent to a hospital. He does not distinguish between stones in the gall-bladder and in the ducts. The Bristol Royal Infirmary figures, representing the practice of nine surgeons during the years 1900-1911, are very similar, but present a smaller proportion of serious complications, so that the total death-rate is much less. It will be observed that even in the absence of such serious comph- cations, about i in 10 die. Kehr, of Halberstadt, who performs an enormous number of operations for gall-stones, can quote 1600 cases, his total death-rate being rather higher than that in the Bristol series, but in uncomplicated cases his results are much better, the mortality being 2-9 percent when the stones are in the gall-bladder and 3-3 per cent if in the ducts. The statistics run over twenty years. The Mayos also record a long series, and they appear to deal with a much simpler type of case than the English or German material, so their total death- rate is only 4-4 per cent. Their figures in uncomplicated cases are a little better than Kehr's, and much better than the English. There is little doubt that when it becomes the rule to call in the surgeon early instead of late, the death-rate will fall considerably. In the Bristol figures, for instance, it was very remarkable to observe how the formation of adhesions affected the prognosis. Of 19 cases with extensive adhesions, 30 per cent died. In all the figures, the common-duct cases show a mortality rather higher than those with stones in the gall-bladder only. Cholecystectomy is more severe than cholecystotomy ; thus : — Cholecystotomy Cholecystectomy Mayo 845 cases; 2-1% died 319 cases; 31% died Kehr 307 cases; 2-2% died 384 cases ; 3-3% died The additional risk is due, not so much to the added severity of the operation, as to the fact that the necessity for removal shows a more complicated type of case, at any rate in the hands of the above-mentioned surgeons. Of 12 cases of stone impacted in the cystic duct in the Bristol series, none died. The causes of death are illustrated by the Bristol statistics : shock, 3 cases ; peritonitis, 3 ; gastric ulcer, 2 ; fatty heart (twenty-one days after), i ; pneu- monia, I ; cut portal vein, i ; intestinal obstruction, i. Cancer also accounts for some fatal results. A few jaundiced patients die of persistent haemorrhage. Some writers describe a post-operative cessation of the hepatic functions, characterized by absence of bile, fever, vomiting, and death. Both Kehr and 196 INDEX OF PROGNOSIS D'Arcy Power remark that the death-rate is much higher in males than females, being approximately double. 2. The Prospects of Cure.- — We have available several series of end-results of cases followed for periods varjdng from one to ten years after operation, and representing English, German, and American practice. Kehr and Davis also give figures, but the first are not followed long enough and the second are too vaguely expressed. In the table, aU forms of operation for gall-stones are classed together. Table II. — Prospects of Relief after Operation for Gall-stones. Author Number traced Cured Better Unrelieved Incisional Hernia Second Operation per cent per cent per cent per cent per cent Arnsperger - - - - 147 64-6 19-7 6-9 8-8 9 McWUliams - - - - 68 66-2 10 23 9 18 Stanton - . - 245 79 15 6 3 2 D'Arcy Power 20 70 — 20 10 Bristol Roj^al Infirmary 59 52-5 32-2 15-2 5 6-7 Arnsperger records the cases operated on at Heidelberg in the years 1907- 1909, it being customary to remove the gall-bladder. Both he and Davis specially warn against stitching the gall-bladder to the abdominal wall. It will be seen that about two-thirds of the patients were cured and only 6-9 per cent were unreKeved. McWilliams's figures are rather older (pubhshed in 1906), and there is a high proportion of cases not benefited, or requiring a second opera- tion. Stanton gives the end-results from Ochsner's chnic, where the results are much better, perhaps on account of earlier operation. D'Arcy Power's cases are few in number, and many of them were operated on late in the disease. The Bristol figures are from the same series as was quoted under the heading of mortahty, and show only about half cured, but another third improved ; perhaps the difference between this and the other reports is principally in the use of the word ' cured,' which in the Bristol table is taken to mean absolute freedom from symptoms. Taking all together, we may conclude that about 85 per cent are cured or relieved by operation, and the remainder, about 15 per cent, are not improved. What are the causes of lack of success ? PrincipaUy three : (a) Recurrence of the stones ; (&) Adhesions ; and (c) Incisional hernia. Second operations have often been performed, so that we are informed as to the relative frequency of these. Thus : — Arnsperger — gall-stones, 11 cases; McWUliams — „ 8 „ Stanton — ,, 8 ,, Bristol Roval Infirmary — ,, 1 ,, adhesions, 13 cases. 4 10 Adhesions, therefore, are rather commoner. It is very difficult to say whether the gall-stones are new formations, or stones overlooked and perhaps increased in size since the first operation ; probably the latter is more usual. Adhesions may produce symptoms exactly like hepatic cohc. Second operations in this class are not often successful. It is noteworthy that there is sometimes an attack of severe pain and jaundice soon after the operation, which therefore appears to have failed, followed by permanent cure. This is mentioned by Munro, and was seen in three Bristol cases. It is probably due to catarrh of the ducts. GANGRENE 197 Removal of the gall-bladder is not a certain preventive of re-formation of calculi ; Arnsperger relates three cases in which they recurred in the common duct. Incisional hernia is quite a common sequel, figures varying from 3 to 10 per cent. It often gives but little trouble. There is not much difference in the end-results whether the stones were in the gall-bladder, cystic duct, or common bile-duct. In Stanton's series, the common-duct cases gave the most failures, whereas in the Bristol series there were very few of these who did not get relief. The principal factor in deter- mining the end-result is the amount and density of adhesions found. In the Bristol cases with extensive adhesions, 6 out of 19 died and 36 per cent were unrelieved, whereas in the absence of adhesions only 10 per cent failed to obtain benefit. Stanton reports that of 107 uncomplicated cases of stones in the gall-bladder, only 5-4 per cent were unsatisfactory. We conclude, therefore, that in simple, early cases the mortality of operation is about 3 per cent, and that 90 to 95 per cent will be greatly benefited ; that in the type of case usually operated on in England after months or years of recurrent gall-stone colic, 10 per cent die and about 85 per cent of the survivors are relieved ; and that in cases with serious complications such as infection, perforation, cancer, etc., about 50 per cent die, and relief is likely to be incom- plete in most of the patients. It is evident, therefore, that to obtain the best results from the operation for gall-stones, it ought to be undertaken decidedly earlier than is now the custom. For this reason, the figures of a few enterprising American surgeons are better than those of average English practice. References. — Arnsperger, Milnch. med. Woch. 1912, lix, 6 ; Davis, Surg. Gyn. and Obst. 1912, XV, 27 ; Kehr, Milnch. med. Woch. 1910, s. 1986 ; Kehr, Deuxiime Congres de la Soc. Internal, de Chir. Rapp., 1908, ii, 422 ; Mayo, Ann. Surg, xliv, 1906, 209 ; McWilliams, N.Y. Med. Jour. 1906, Ixxxiii, 1109 ; Munro, Boslon Med. and Surg. Jour. 1909, clx, 359 ; D'Arcy Power, Brit. Jour. Surg. 1913, July, 21 ; Rendle Short, Bristol Med.-Chir. Jour. 1913, 34; Stanton, Jour. Amer. Med. Assoc. 1911, Ivii, 441 ; Walton, Ann. Surg, liv, 1911, 199. a. Rendle Short. GANGRENE. — The prognosis of this disease depends, of course, upon the cause of the gangrene. That due to malignant oedema is dealt with elsewhere {see CEdema, Malignant). Gangrene due to Raynaud's disease is likely to lead to loss of the finger-tips, but there is no danger to life. When due to frost-bite, to embolism of a main artery, or to injury, it will, of course, necessitate amputa- tion ; but there is no great danger of the gangrene spreading, or of life being imperilled unless, owing to delay, septic infection from the dead area takes place. We shall particularly consider here the outlook in cases of senile and diabetic gangrene : (i) In relation to the limb ; (2) In relation to the life of the patient ; and (3) In relation to the treatment. I. Prognosis as to the Limb. — It is often difficult to be sure exactly how much of a limb is irretrievably affected. Sometimes the skin turns black, but the deeper structures are living. When, however, the duskiness appears to be deep-seated, and the region, usually the foot, is painful or no longer sensitive to pressure, it is beyond recovery. If a line of demarcation forms, it is no use to expect, in senile or diabetic cases, that this will be the limit of the advance of the gangrene ; though in traumatic or embolic gangrene, or in cases of frost-bite, where the artery is blocked at a particular point, the disease does not usually spread above a line of demarcation. In senile cases, one only too often sees, after a while, a spreading duskiness even above the line, and the process gradually advances up the leg if it is allowed to do so. The writer recollects seeing in a ■workhouse an old pauper who developed gangrene of the toe, which extended, in the course of years, up the leg to the middle third of the thigh ; but for seven INDEX OF PROGNOSIS years he persistently refused amputation, and still retained possession of his dry, black, stinking leg ! Such a case is unusual ; most patients would have died of septic intoxication long before. In many cases it is possible to foretell how much of a limb is in danger by feeling how far down the arteries can be found pulsating, and by taking a skiagram to see how far up the vessels the calcareous changes extend. 2. Prognosis as to Life. — This is usually grave in an untreated case, and depends upon the rapidity of advance of the gangrene, the age and condition of the patient, and the degree of septic absorption. Much sugar in the urine makes the outlook more ominous, and if there is a good deal of fever, and the dead area is moist, nothing but early amputation is likely to save the patient's life. 3. Prognosis as influenced by Treatment. — ^It is quite useless, in a senile or diabetic case, to amputate at the site of any line of demarcation that may have formed. Nor has the operation of raaking an anastomosis between the femoral artery and vein met with success, save in a very few exceptional cases. The treatment remaining, therefore, is to amputate through the lower third of the thigh ; or, in early cases with pervious arteries, at the site of election. The amputation conducted under such circumstances is by no means a trifling risk. Of 39 cases so treated at two London hospitals, the Middlesex and St. Thomas's, from 1907 to 1911, 16 died shortly afterwards, a mortality of 41 per cent. A. Rendle Short. GASTRIC ULCER. — {See Stomach, Medical and Surgical Diseases of.) GASTRITIS. — [See Stomach, Medical Affections of.) GENERAL PARALYSIS OF THE INSANE.— (5ee Mental Diseases.) GENU VALGUM. — In young children with rickety deformities, this condition may improve in the course of years, with splints and a more suitable dietary ; but in older children and young adults the deviation of the knees is hkely to be permanent, and may increase up to the age at which growth ceases. The success of treatment depends much on the technical skill of the individual surgeon, but it is usually possible to obtain an excellent result at a smaU risk by the Macewen operation, or by taking a wedge out of the tibia. A. Rendle Short. GENU VARUM.— (5ee Rickets.) GLANDERS. Acute Glanders. — This is an extremely fatal disease ; the mortality is over 90 per cent. Death occurs in from one to three weeks. Only if the lesion is localized and no internal organ is affected can a favourable termination be hoped for. The appearance of a pustular eruption is highly ominous. Chronic Glanders. — Half of these cases are fatal. In this form, also, so long as the disease is localized and the internal organs are not attacked, recovery may result. But the course of the disease is always tedious, and tlie patient is always subject to the risk of the occurrence of an acute attack. e. W. Goodall. GLYCOSURIA. — {See Diabetes Mellitus.) GOITRE. — Swellings of the thyroid gland may be due to a variety of causes, of which the following are the most important : (i) Parenchymatous goitre : (2) Adenomatous and Cystic goitre; (3) Papuliferous goitre; (4) Malignant goitre ; (5) Exophthalmic goitre. GOITRE 199 1. Parenchymatous Goitre usually attacks older children or young adults, advances to a certain extent, and then becomes stationary for the rest of the patient's life. Not uncommonly, however, it may resume growth and produce marked pressure symptoms, even in adults. Sometimes a goitre appears rapidly and increases at a great rate, causing considerable dyspnoea. 2. Adenomatous and Cystic Goitre do not usually show the same tendency to arrest, but very gradually increase in size. Htemorrhage into a cyst may bring on urgent dyspnoea. The prognosis as regards life in these three conditions is almost always favour- able. Suffocation from pressure on the trachea only in quite rare cases comes on so rapidly as to be dangerous. Apart from operation, of course, some patients would pass gradually into a very grave condition from lateral compression of the air-passages. A few simple goitres in elderly persons assume malignant characters. Spontaneous cure is not to be hoped for, except in quite recent cases in young adults or children. Iodides or thyroid extract will aid in bringing this about, but if the swelling has persisted many months they usually fail. It is often desirable to change the drinking-water supply. In rare cases of goitre the internal secretion of the thyroid becomes deficient, and myxoedema ensues. More commonly it is excessive, with mild symptoms of Graves's disease. The children of goitrous mothers suffering from deficient thjn-oid secretion are apt to be goitrous. Congenital swelling of the thyroid is almost invariably associated with goitre in the mother, and the child may be a cretin. In the great majority of cases of goitre in women there is no thyroid insufficiency, and the children are therefore normal. The prognosis after treatment by operation is very favourable. Only a small proportion of cases of goitre need be operated on, marked deformity or dyspnoea being the principal indications, and " there is never too much dyspnoea " for the operation to be done (Berry). The operation mortality is very low. At the Bristol Royal Infirmary during the paist three and a half years, 59 operations have been done without a death. Kocher's mortality is 3 in 1000. Of 267 innocent cases. Berry lost 3, 2 dying of heart failure and i of pleurisy following a wound of the larynx. A general anaesthetic, usually open ether, was used. None of his cases developed tetany or myxoedema, which in the early days, when all or nearly all the thyroid gland was removed, were both fairly frequent. Tetany is not entirely banished, however, as a number of modern operators have been less fortunate than Mr. Berry, and can report a case or two. It appears to be due to removal of the principal functioning parathyroid glands lying behind the thyroid. It is not usually very serious, even if it does occur. The end-results, provided an adequate removal is made, are most satisfactory. In Mr. Berry's tables, 222 out of 274 are perfectly cured as far as the goitre is concerned (traced from one to five years, very few less than one year). In two cases the growth, though innocent, is extending, and in one stridor persists. The others are either lost sight of, or some swelling remains. 3. Papilliferous Goitre is by no means so favourable in its prognosis. It is not a malignant growth, but there is a considerable tendency to recurrence. Five patients came under Mr. Berry's care ; i is lost sight of, and 2 were cured, but in 2 others the growth continued enlarging and they returned for operation after operation for several years. 4. Malignant Goitre is uncommon, and the prognosis is very grave indeed, both as regards the immediate and the ultimate results. It invades the larynx and INDEX OF PROGNOSIS its nerves early, and causes secondary glands in the neck. Of 7 cases in Mr. Berry's statistics, 3 died after the operation, i is lost sight of, and the other 3 died of recurrence twelve, fourteen, and sixteen months later. 5. Exophthalmic Goitre. — This is discussed elsewhere (see Exophthalmic Goitre). Referexce. — Berry, Proc. Roy. Soc. Med. {Surg. Sect.), 1908, i, pt.3, 21. A. Rendle Short. GONORRHCEA. — The principal object in the treatment of gonorrhoea is to prevent the spread of the infection to the posterior urethra, since there is no prospect of serious complications if the disease is confined to the anterior part of the urethral mucous membrane. Formerly it was recommended that local treatment should be postponed until the subsidence of the acute stage — a most pernicious doctrine, as the gonococcus was thereby enabled to make its progress unchecked into the posterior part of the urethra. If the patient is seen in the incipient stage of the disease, attempts may be made to abort it, and to destroy the gonococcus before it has had time to spread far down the urethra. This is best effected in the following manner. The anterior urethra is first cocainized by a solution of cocaine and adrenalin, and a urethro- scopic tube subsequently introduced to its full extent ; down this tube a pledget of cotton-wool saturated with a solution of nitrate of silver 10 gr. to i oz. should be introduced on a holder, and the whole of the anterior urethra thoroughly swabbed out. The reaction may be severe, but it usually subsides in a short time, leaving a watery discharge which clears up in three or four days. But it is seldom that the disease can thus be attacked in its early stages, and when once the prostatic urethra has been invaded by the gonococcus, the patient is liable to complications, and a guarded prognosis must be given. When the whole urethra is infected, treatment by irrigation or injections must be adopted ; the modifications of nitrate of silver, such as protargol, argyrol, argaldin, or ichthargan, have a destructive effect on the gonococcus, and should be employed as long as that organism is present in the discharge ; astringent injections, such as sulphate, permanganate, or sulphocarbolate of zinc, may be used alternately with the silver salts ; at the same time a rigid abstinence from alcoholic liquors should be enforced, and no violent exercise should be taken. A long continuance of the discharge or frequent infections may give rise to peri- urethral thickening, which contracting forms a stricture, the dilatation of which will often be followed by a cessation of the discharge. If the posterior urethra is attacked, the complications to which the patient is liable are more numerous and more serious, and will necessitate a guarded prognosis as regards ultimate cure. Epididymitis is a most serious complication, since by it the function of the testicle may be destroyed, and cases of double epididymitis must be looked upon with gravity, since this condition is responsible for a large number of cases of sterility. With a view to preventing this possible contingency, the most careful treatment is required until all traces of the thickening of the epididymis have subsided ; this is effected by means of pressure and heat, best applied by means of a JuUien's bandage. No positive opinion as to the patient's matri- monial prospects should be given until an examination of the semen has been made and the presence of active spermatozoa ascertained. Prostatitis, either acute or chronic, is a further complication of the disease ; the prognosis of acute prostatitis is good, and the condition usually subsides in a week or ten days, though it may form an abscess which will require to be opened. Chronic prostatitis is a common complication of a posterior gonorrhoea, is a most difficult condition to treat satisfactorily, and is responsible for a large GONORRHCEA number of cases of sexual hj'pochondriasis. Massage of the prostate gland per rectum, and subsequent instillations into the prostatic urethra of 20 min. of solution of nitrate of silver, 5 to 20 gr. to i oz., by means of a Guyon's syringe, is the treatment from which the most satisfactory results may be expected. Seminal vesicuUtis is a not infrequent concomitant of chronic prostatitis, and may yield to similar treatment, though massage of the seminal vesicles is a more difficult procedure than is that of the prostate. In this condition, catheterization of the common ejaculatory ducts through the urethroscopic tube has been recommended and carried out with success, but this is a process of considerable difficulty, and one requiring much technical skill. Gonorrhceal cystitis is another complication of a posterior gonorrhoea, and is commonly located at the neck of the bladder, although the whole of the vesical mucous membrane may be affected. Treatment by rest in bed, by the administration of balsamics, urotropine, and helmitol internally, and later by irrigations of the bladder with weak antiseptic solutions, will usually ensure the disappearance of this symptom, but occasionally the infection spreads upwards to the pelvis of the kidney, a region in which local applications are not available except by means of the ureteric catheter. Gonorrhceal ophthalmia in the new-born or in the adult is a most serious comphcation, but is one which usually yields to treatment by local applications of nitrate of silver solutions or its modifications, such as protargol, followed by astringent lotions and the application of boracic lotion. The prophylactic treatment of the sound eye is a necessary accompaniment of the treatment. Ophthalmia neonatorum is a disease which should be averted bj^ prophylactic measures, but is a condition which when recognized early should yield to applica- tions of solutions of nitrate of silver or of its compounds. In addition to the complications of gonorrhoea due to a direct infection with the gonococcus, there may be a systemic infection from that organism or from its toxins, giving rise to gonorrhceal arthritis, keratoses, irido-choroiditis, endo- carditis, pericarditis, peritonitis, pleurisy, and meningitis, really forms of gonor- rhceal septicagmia. It is in the sj^stemic manifestations of gonorrhoea rather than in the local ones that vaccine therapy is chiefly indicated, though it has been found to be beneficial in all stages of the disease. Either stock or autogenous vaccines may be used, but in either case their introduction is liable to be followed by both local and general reactions, the local ones manifesting themselves in redness and swelling at the site of injection, and the constitutional ones in rise of temperature and in an increase of pain in the region affected by the gonorrhceal invasion. In our experience, rectal injections of antistreptococcic serum yield most satisfactory results in cases of gonorrhceal arthritis or other forms of septicajmia, 10 c.c. of the serum being introduced per rectum daily for a fortnight or three weeks. The prognosis in gonorrhceal arthritis must be a very guarded one, as, in a certain proportion of cases, the affected joints are permanently injured, and some limitation of movement will be the result. In addition to the vaccine treatment, local measures such as Bier's passive congestion may be tried, and in the case of the knee joint, early aspiration may be practised, followed by counter-irritation and passive movement. Excision of the seminal vesicles has been attended with success in cases of gonorrhceal arthritis on the assumption that in the vesiculoe is situated the focus of systemic infection, and in justification of this somewhat severe operation it is undoubtedly the case that seminal vesiculitis is a frequent accompaniment of gonorrhceal arthritis. /. Ernest Lane. INDEX OF PROGNOSIS GONORRHCEA IN THE FEMALE. — Before considering the results of infection in particular sites, it will be well to make a few observations on gonor- rhoea irrespective of the locahzation. Speaking generally, the ill effects are less obvious than in the case of the male, but are even more disastrous and serious, especially when — as happens in at least 50 per cent of all cases — the infection reaches the cervix and is an ascending one. Considerable lesions in the urinary tract are decidedly exceptional. The lower genital tract is little liable to severe gonococcal lesions, and when attacked readily recovers. In the first week or two after infection, no definite opinion concerning the ultimate prognosis can be made in individual cases ; under palliative treatment the mischief has become localized at the end of a fortnight, and the prognosis varies with the lesion then present and its site. Gonorrhcea and Sterility. — It is estimated that 70 per cent of all sterile marriages are the result of gonorrhcea, either in the husband, the wife, or both. Of women who have had gonorrhoea, it is found that 30 per cent are sterile. ' One-child ' sterility is pretty generally regarded as resulting from the exten- sion of gonorrhoeal infection during the puerperium. Giles^ found that in the cases he operated upon for pelvic inflammation or tubal disease who were under forty years of age and married, 25 per cent subse- quently became pregnant. Of these, 19 women had 25 children, and 5 other women had miscarriages. Norris^ records that in 68 cases treated surgically, but none of which was sterilized, 17 of those under forty years of age became pregnant, and 4 others had miscarriages. The chance of infecting the child when gonorrhoeal women bear children is to be regarded as serious. It is variously estimated that 10 to 30 per cent of all blindness in the world results from this cause. Prognosis as affected by Treatment. — Chief interest in the treatment of gonorrhoea centres round the different methods adopted — whether reliance is to be placed upon vaccines, or whether the older methods of local applications and douches are to be almost the only hope of the physician. Concerning the value of vaccines, the widest variation in opinion is found, both as to their use in general and in localized lesions. The weight of opinion tends to the views that chronic lesions react better than acute ; that success is more likely to follow their administration in general infections than in localized lesions ; that the vulvovaginitis of children is benefited ; and that many cases of chronic arthritis react to vaccines. Pelvic disease of the tubes or peritoneum does not react to vaccine treatment. Prognosis in Particular Sites. Vulvovaginitis. — The infection in children is usually acute, and would appear to react better to vaccines than to simple palUative naeasures. The following table is taken from Norris, and gives the result of vaccine treatment ; the second series in each instance was reported after an interval of five years : — Results of Palliative and of Vaccine Treatment OF Vulvovaginitis in Children. Reporter Cases Cured Improved Not benefited Butler^ Butler* Hamilton^ - Hamilton* - 12 25 67 84 10 76 2 25 6i 1 5 (&31ost) GONORRHCEA IN THE FEMALE 203 Hamilton® shows the comparative results obtained in gonorrhoeal vaginitis of the adult, according as douching or vaccine therapy was employed, and the duration of treatment. Respective Results of Irrigation and Vaccine Treatment OF Vaginitis in Adults. — [Hamilton.) Treatment Cases Cured Not cured Lost Cured Irrigation Vaccines 260 84 158 76 53 5 49 3 per cent 60 90 Average length of time under treatment by irrigation, 101 months. Average length of time under treatment by vaccines, 17 months. The results in the above tables must be taken as much above the average, and unlikely to follow the administration of stock vaccines. Condylomata. — The treatment of condylomata is in general uniformly good, although the larger masses require more extensive cauterization, often at repeated intervals. Bartholin's Gland. — Once infection of the gland has occurred, treatment has to be prolonged. Often an apparent cure results, within a month or two, in a recrudescence of inflammation and swelhng, with or without discharge. In the more stubborn cases a Bartholinian cyst or abscess develops ; the results of treatment by excision leave nothing to be desired. Urethritis and Cystitis. — Although by accurate examination it can be deter- mined that at least 50 per cent of all cases of gonorrhoea show the diplococcus present in the urethra, it is in comparatively few instances that symptoms indicative of urethritis, and still more rarely of cystitis, result from gonorrhoeal infection. In all cases simple medical measures, such as local applications and irrigations, are successful. Stricture is exceedingly rare as a result. Herman^ was able to collect only eight cases from the medical literature, and it is doubt- ful if all of these were certainly gonorrhoeal. Balsamic remedies such as cubebs and copaiba are of no use in women. Alcohol and sexual irritation are con- ducive to a recrudescence. In rare instances the infection lodges in Skene's tubules, and there is formed a peri-urethral abscess, which is readily and efficiently treated by surgical means. Gonorrhoeal pyelitis has occurred following a cystitis, but is rare. Cervix. — The cervix is one of the most unfortunate sites in which to have the infection localized, owing to the depth of gland tissue and the coating of mucus ; most remedial applications entirely fail of their object. Figures as to the relative value of the different treatments are lacking. The application of caustic chemicals, or even of the actual cautery, when persisted in over a long time and with care, appears to end more or less successfully in the majority of cases, but the treatment may be necessary for months and even years. The number of cases of cervicitis in which vaccines have been employed are few, but in some cases in which local applications have failed, the result of a vaccine has been good. Finally, in certain cases when the mucosa extroverts and a definite erosion results, it will be found that the best results follow surgical measures. Whatever measures are adopted, there usually results a mild chronic cervi- citis, perhaps owing to a superimposed pyogenic infection, with a degree of leucorrhoea which may be intermittent or vary in intensity from time to time. 204 INDEX OF PROGNOSIS Uterus. — Endometritis is usually obscured by the associated pelvic inflamma- tion. The condition ends in a few cases in a chronic metritis leading to fibrosis of the uterus. Salpingitis and Pelvic Inflammation. — In the acute, and more especially in the subacute, stages, opinion is divided as to the value of rest and medical therapeutics ; all are agreed that many cases which now come to operation might have been cured by purely medical means if the treatment had been continued some time longer. This is borne out by figures from Prochownick which we shall quote presently, and a rough comparison may be made with the results of operative treatment. Kronig (quoted by Stoehler^) states that of 38 cases treated entirely by palliative measures, 32 were able to go about their work after a varying period of treatment by rest. The most valuable figures are those of Prochownick® ; he treated his cases with surgical measures when necessary, and sent many to a sanatorium for further treatment when thought advisable, and above all, the cases treated were all watched for at least five years : Of 420 cases treated, he records 160. or 38 per cent, of permanent cures ; without any operation the permanent cures were 80, or 19 per cent. Of the 160 cures, 70 per cent were treated for over four weeks — some of them for six weeks — and later sent to a sanatorium. Of the 160 cures, 85, or 55 per cent, remained well after the one course of treatment ; 27 remained well after a second course of treatment ; 16, or 10 per cent, had pus collections which were evacuated ; 10 required operation for adhesions from tliree to five years after treatment (no tube or parts being removed). Giles, ^practising conservative surgery, had the following results : cases treated, 132; cured, 120. These figures are perhaps optimistic. Many said to be cured suffer from adhesions, producing abdominal pain of greater or less severity. Even after operation, adhesions are re-formed. Where both appendages are diseased and extensive peritoneal inflammation exists, it is important that the uterus be either fixed forward or removed ; there are numerous instances of surgical measures being regarded as a failure owing to retro- displacement with fixation of the uterus subsequently arising. As regards vaccine treatment, Heymann and Moos'^" used vaccines in 44 cases of acute tubal infection. The results were very good in 27 per cent, fair in 41 per cent, and a failure in 20 per cent. All treatment was supplemented by local measures, so that it is not obvious how much is directly attributable to vaccines. In 9 cases of chronic tubal infection there were 7 distinct failures. They state that vaccines were also found useless in cer\dcal and urethral infections. Peritonitis. — In the pelvic peritonitis which follows acute gonorrhoeal infec- tion, the results of surgical interference are so uniformJy good in the early stages, that palliative measures are seldom continued when there is any fear of the peritonitis becoming general. The result of operation in the general peritonitis that ensues upon the rupture of a tube is more serious, as the following figures show. Bovec,^^ 56 cases : 24 recovered, 32 died. Bonney,^^ 45 cases : 23 recovered, 22 died. Further, the earlier the operation the better the prognosis. Of those operated on during the first twelve hours, 14 recovered, 6 died ; after twenty-four hours, I recovered, none died ; after forty-eight hours, i recovered, 4 died. Arthritis. — Norris" makes the following observations as to the prognosis in joint lesions. In the acute form of the disease the occurrence of suppuration and the GOUT 205 destruction in part of the joint is not infrequent ; and in the chronic type partial ankylosis is rarer in the case of children. Serous effusions limited to intra-articular structures do best, but even in these relapses are frequent. Norris,^ quoting and summarizing the results obtained by a whole series of authors, gives the following figures respecting the results of vaccine treatment — 211 cases : 84 cured, 102 improved, 25 not benefited. Heymann and Moos^" think vaccines of great benefit ; in 6 cases the results were : 2 very good, 3 good, i failure. The opinion appears general that medical and local applications should be continued during the administration of vaccines in all cases. Puerperal Infection. — Findley^^ states that i case in every 6 is due to gonor- rhoea. The puerperal infection rarely causes death, but it is often complicated by the presence of streptococci. Often the infection recurs in each puerperium and runs a similar course, lasting a few days, with high temperature and slight discharge ; occasionally the fever is more prolonged. The more common end-result is a one-child sterility or a pyosalpinx. References. — ^Jour. Obst. and Gyn. 1910, March ; ^Norris, Gonorrhcza in Women, 1913 \^Pract. 1905, 589 ; *Jour. Ainer. Med. Assoc. 1910, U, 1301 ; ^Infect. Dis. 1908, v. 158 ; ^Jour. Amer.Med. Assoc. 1910,1196; ''Trans. Obst. Soc. London, xxix ; ^Monats. f. Geb. u. Gyn. 1903, xvii ; * Ibid. 1909, No. 20, 453 ; ^'^Monats. f. Geb. u. Gyn. 1913, Hft. 5 ; "Swrg. Gyn. and Obst. 1910, x, 405 ; ^^Ibid. 1909, ix, 542 ; ^^Diseases of Women, 1914. Bryden Glendining. GOUT. Acute Gout. — The danger to life in an acute attack is practically negligible unless acute inflammatory changes are set up in internal organs, as a result of chill or injudicious treatment of the articular lesion. Violent cerebral, gastric, or cardiac symptoms may be set up in this way, and then the immediate outlook becomes very grave indeed. The predominant symptoms indicating these changes are severe headache and violent delirium, acute epigastric pain associated with obstinate vomiting, and signs of acute pericarditis with a rapid, intermittent pulse and a tendency to syncope. The prognosis is worse if there is a strong hereditary history, and if the attack occurs early in life. Chronic Gout. — As a rule, in this condition, the main danger lies in the gradual onset of complications, the most important of which are in the renal and cardio- vascular systems. Of the former, the contracted gouty granular kidney has to be considered. The prognosis in this is probably ranch the same whether it is produced by the gouty diathesis, or by any other etiological factor. It leads to death mainly along three lines, viz., firstly, by cardiovascular change ; secondly, by the incidence of superadded, often terminal, infections ; and thirdly, by uraemic manifestations. From an analysis made by the writer from post- mortem hospital records of 156 consecutive cases of patients who died with chronic interstitial nephritis, the following figures showing the causes of death were obtained : uraemia, 21 ; cerebral haemorrhage, 41 ; cardiac failure, 14 ; cardiac failure associated with much bronchitis, 7 ; the supervention of acute nephritis with oedema of the lungs, 2 ; supervention of acute nephritis with uraemia, 2 ; cerebral thrombosis, 4 ; aneurysm, 2 ; oedema of lungs, 2 ; sub- dural haemorrhage, i. Death occurred in a large number as the result of superadded terminal infections, thus : 28 died from lobar pneumonia, 3 from bronchopneumonia, 4 from pericarditis, 4 from phthisis, 4 from empyema, 2 from general miliary tuberculosis, i from the combination of pericarditis, pleurisy, peritonitis, and pneumonia, i from pericarditis with pleurisy, i from pleurisy alone, and i each from pneumonia and empyema, pneumonia and pericarditis, and pul- monary gangrene. 2o6 INDEX OF PROGNOSIS The following percentages are obtained from these figures : death from uraemia, 147 per cent ; from indirect changes in other organs, 46-2 per cent ; from secondary infections, 33'3 per cent ; accidental causes, e.g., carcinonaa, poisons, 5 "8 per cent. The possibility of the incidence of a gouty venous thrombosis, with the occurrence of pulmonary embolism leading to a fatal result, must always be borne in mind. In spite of all these dangers, the members of a gouty family are frequently long livers. With reference to the prognostic value of changes in the fundus, a renal retinitis has the same serious significance as in other forms of nephritis, but a unilateral haemorrhagic retinitis, with extravasations of blood which may burst into the vitreous, sometimes occurs. These haemorrhages are most probably due to thrombosis of the retinal vein and do not carry the same outlook as renal retinitis. It is too early to say whether the prognosis of the vascular and other lesions in gout will be materially modified by the use of radium, emanations, or by thorium. /. R. Charles. HiEMATOCELE, PELVIC. — {See Ectopic Pregnancy.) H.ffiMATOMA, ARTERIAL. — Recent rupture of an artery, subcutaneously or after a punctured wound, is a very serious injury which urgently demands surgical interference to prevent gangrene or fatal loss of blood. There has been some difference of opinion as to which operative procedure will lead to the best results. Thus Guibe has collected from the literature 78 cases of rupture of the axillary vessels in association with dislocation of the shoulder, 57 being due to efforts at reduction, especially by extension or the heel-in-axilla methods. One would have expected that incision and tying the vessel would have given better results than ligature of the subclavian, and it also allows of reduction of the dislocation ; but in the records the incision method shows a mortality of 31 per cent and 44 gangrened, whilst ligature of the subclavian cured 80 per cent and only 20 per cent became gangrenous. The figures are, however, too few to prove the point, and go back into the pre-antiseptic era. A larger and more reliable body of statistics, which we owe to the researches of Monod and Vanwerts, show that the best results in every situation were obtained by restorative methods or by compression of the feeding artery, opening the haematoma and ligature in situ. The results are shown in this table : — Method Cases Cured Died Gangrene Failed Proximal Ligature Incision . . . . . Obliterative Aneurysmorrhaphy - Conservative operations 41 157 1 39 per cent 60-5 81-5 100 87 per cent 14-6 10 5 per cent 7 '5 6-5 5 per cent 12 1-2 "5 With reference to the individual vessels, the same writers relate 17 cases of injury to the Carotid, of which 6 died and 4 developed cerebral troubles. Four cases of wound of the Brachial artery and vein all did well. Although ligature of the Femoral artery has a bad reputation for causing gangrene, only 2 out of 56 showed this complication, and in one of these the vein was injured. In 9 cases the artery and vein were both tied without causing gangrene. Most of these, however, were superficial femoral cases. HEMOPHILIA 207 The Popliteal was much more disastrous ; 9 out of 14 were gangrenous before operation, and 4 more became so afterwards. In several of these the vein was also injured. References. — Guibe, Rev. cle Chir. 1911, 580; Monod and Vanwerts, Ibid. 1911, 663. A. Rendle Short. HAEMOPHILIA. — It may be well to make it clear at the outset what we understand by this condition. It may be defined as a disease, usually congenital, characterized by a tendency to haemorrhage, which may be spontaneous or in connection with wounds or injuries. The disease affects males in the great majority of instances, and the usual history is that the tendency is transmitted through the females, who are not themselves bleeders. Bullock and Fildes have gone so far as to deny the existence of de novo cases, or of definite symptoms appearing, in the female. We are inclined to think they have arrived at this conclusion by the somewhat arbitrary course of disparaging, or disregarding, evidence to the contrary, and we may say at once that we have seen and treated patients whose history and symptoms have convinced us that cases without hemophilic ancestry do occur, and that severe haemophilia may affect females. Prognosis may be considered, (i) from the point of view of the expectation of life or recovery of the patient; and (2), in view of the hereditary aspects of the disease, as regards the chances of a patient transmitting it to posterity. I. Prognosis as regards Patient. — This is always grave, especially in young subjects. As a rule, the condition does not show itself within the first twelve months of life. Some cases, however, are fatal shortly after birth from bleeding of the umbilical cord ; the bleeding may be immediate or may not begin till the third day or later ; it may be arrested, but is sometimes fatal within twenty- four hours. The risk to life diminishes after early childhood. The child and his attendants learn to appreciate the danger of even slight knocks or scratches ; and the essential defect seems to lessen. The seriousness of the outlook is illus- trated by Grandidier's statistics. Out of 152 boy haemophilics, 81 died before the end of the seventh year. The longer a patient lives the greater is his chance of outgrowing the tendency. In many of the surviving cases it has disappeared at the age of twenty or thirty ; but other cases reach a ripe old age and exhibit symptoms to the end. It cannot be said that much can be done by treatment to diminish the tendency to bleeding. The administration of lime has been lauded, but Addis has thrown grave doubt on the scientific reasoning on which this treatment is based ; he holds that enough ionisable calcium to affect clotting cannot be absorbed. Definite improvement has followed the administration of horse serum. The administration is made intravenously, since the elastic recoil of the venous wall and skin form an efficient bar to local bleeding. The injection of Witte's peptone has not been tried often enough for conclusions regarding its efficacy to be stated. It is indeed a matter of great difiiculty to form an opinion regarding the efficacy of any line of general treatment, since the tendency to bleeding shows such extraordinary variations in the same patient at different times. After a serious or even dangerous haemorrhage, the coagulability of the blood may increase to a degree approaching or reaching that of health, and this result may be ascribed to the last line of treatment employed. Residence in a warm climate seems to diminish the hsemorrhagic tendency in some instances. There is no doubt that prognosis in haemophilia has improved, owing to recent discoveries in connection with the coagulation of the blood. These have resulted 2o8 INDEX OF PROGNOSIS in the addition to our armamentarium of the means of dealing locally with acces- sible haemorrhages, means which were not previously available. Addis has shown that the diminished coagulability of the blood is due to a great delay in the interaction between prothrombin and lime, which forms thrombin. The throm- bokinase which is supplied by the damaged tissues may be washed away in the blood, escaping from the wound before it has had time to cause the prothrombin and lime to unite to form the thrombin which determines the change from fibrinogen to fibrin. The existence of a layer of fibrin on the edges of a wound may indeed play an important part in preventing access of thrombokinase to a bleeding point in the centre of the wound. The indication in such a case, therefore, is to remove coagula from a wound which is still bleeding and apply to it an abundance of thrombokinase. Thrombokinase can be obtained by making an extract of chopped thymus or testis with o-g per cent saline solution to which a trace of sodium, carbonate has been added. BuswelP has stated that a powerful extract of thrombokinase can be made by washing sheep's fibrin in tap-water till it is haemoglobin-free, and then kneading about 20 grams of the wet fibrin in 300 c.c. of distilled water. So far as we are aware, this extract has not been tried in practice. These physiological styptics are more efficacious than those which depend on astringent or escharotic action, and moreover their use is not followed by the danger of recurrence of the haemorrhage which sometimes takes place when an eschar separates. Haemorrhages are not alone dangerous qua haemorrhage. Adherent clots in the posterior nares and among the teeth, and the presence of decomposing blood in the stomach and bowel, may lead to great discomfort, and sometimes to marasmus and death. Haemorrhages, and haemo-serous effusions into joints, are not dangerous to life, but may lead to permanent incapacity. They are often imperfectly absorbed, and frequently recur, with the result that adhesions, erosions, and osteo- arthritis, with subsequent ankylosis of varying degree, may be occasioned. Cases of fracture in haemophilia have been recorded. A large effusion takes place, but satisfactory union usually occurs. Menstruation and parturition in non-haemophilic females of bleeder stock arc not associated with special danger. Even female bleeders seem frequently to escape serious consequences at these times, but in some cases menstruation is a recurring anxiety ; in the case of one young lady under our observation, a fatal result from naenorrhagia has been very narrowly escaped on three separate occasions. Between these serious episodes there have been intervals of months or years when menstruation has given comparatively little trouble, although the susceptibility to bruising and accidental bleedings has persisted. The examination of the blood is of comparatively little service in estimating prognosis in haemophilia. We have never found the great reduction of poly- morphonuclear leucocytes which has been described by authors, and in particular by Wright, and if it be remembered that many persons in perfect health never have more than 6000 leucocytes per c.mm., even the majority of Wright's own figures are not particularly low. An estimation of the coagulability of the blood is sometimes of more service ; but when bleeding is in evidence, we may take it for granted that coagulation time is prolonged, and when bleeding is absent, the coagulation time in a bleeder may be no longer than in a healthy person. An estimate of coagulation time might conceivably be usefully made before HEMORRHOIDS 209 a hsemophilic entered upon some special undertaking, such as a journey ; but data regarding the coagulation time oefore haemorrhages are very scanty. The onset of spontaneous haemorrhage, or of increased liability to traumatic haemorrhage, is sometimes preceded by prodromal symptoms. Headache, nervous irritability and lassitude, and sometimes even convulsions, may occur; but whether these are associated with an actual diminution of coagulability is a matter of inference rather than of observation. In other cases, a special feeling of well-being may precede a spontaneous haemorrhage. To sum up, the expectation of life in the case of a young bleeder is poor. It is probably diminished by 50 per cent. This state of affairs lessens with advancing age. The necessity for constant care, the occurrence of joint-effusions and their results, and the incidence of spontaneous haemorrhages, reduce all but the slightest cases of haemophilia to a condition of at least semi-invalidism. The danger of bleeding from accessible sites may be greatly diminished by the use of physiological styptics. 2. Transmission of the Disease. — The females of hasmophilic stock are fertile beyond the ordinary, and a study of the genealogy of haemophilic families shows clearly that the great majority of the male offspring of the women, whether the latter are themselves bleeders or not, are likely to be haemophilics. Women of haemophilic stock should therefore be advised not to reproduce their species. A male bleeder is obviously not a fit and proper person to assume the responsi- bilities of parentage ; and apart from his personal disabiUty, there is a definite, though comparatively slight, probability that he may propagate bleeders. The question of marriage in non-hasmophilic males of a bleeder stock is more difficult. The man is under no personal disability, but there is rather more than a moderate risk that he may transmit the disease. We have published a genealogy in which a non-bleeder male of hasmophilic stock had two sons who died of haemophilia. His non-haemophiUc daughter was twice married and had haemophilic offspring by both husbands. One of her sons, a non-bleeder, married a healthy woman and had two sons who died of the disease. Reference. — ^Joiir. Physiol. 1913. G. L. Gulland- A. Goodall. HEMORRHOIDS. — A patient suffering from ' an attack of piles ' frequently asks whether he is likely to get better without operation. The answer depends on the condition found. Thrombosis of an external pile, which is very painful for a few days, usually gets quite well, and there may never be any further trouble. Bleeding piles can fairly often be relieved, rather than cured, by dieting, purgatives, and local applications. Strangulated prolapsed piles, in rare cases, cure themselves, after a painful illness, by gangrene. A patient's life is very seldom in danger from haemorrhoids, but fatal embolism from a thrombosed pile has been recorded, and the bleeding, if unchecked, might even threaten Ufe. The prospect of cure by injection of carbolic acid into the pile, or ionization, is always uncertain. Results of Operation. — There are three operations in common use — namely, the hgature, the clamp and cautery, and the Whitehead operations. Mortality. — This is as low as that of any operation can be. Swinford Edwards and other surgeons have treated thousands of cases without a death. At St. Mark's Hospital, in forty years up to 1896, the mortality was i in 670 ; after- wards there were no deaths in many years. After-discomfort varies with the method of operating. Pain is least with the clamp and cautery method, most after ligature. Stay in hospital was, on an 14 INDEX OF PROGNOSIS average, ten days after the clamp and cautery, twenty-one after ligature, and twenty-six after Whitehead's operation. The two principal after-troubles are stenosis and recurrence. Stenosis is unknown after the cautery operation ; it occurs in slight degree, which is of no importance, after about a third of the ligature cases and half of the Whitehead cases. Stricture requiring treatment was met \\'ith in 8 out of loo patients on whom Whitehead's operation had been performed. Recurrence is extremely rare if an efficient operation is performed in the first place ; the writer has never met with a case. The end-results of piles operations are almost invariably extremely satisfactory. In eighteen months, at St. Mark's Hospital for diseases of the rectum, only 2 recurrences were seen, one after two years and the other after eighteen. The three operations ought not to be regarded as mutualty antagonistic. The clamp and cautery is best for cases where there are only a few piles not involving the skin, because burns of the skin are painful. Whitehead's method is to be reserved for uncommon cases where the whole anal canal is a mass of piles. References. — Anderson, Brit. Med. Jour. 1913, ii, 1478 ; Swinford Edwards, Burghard's System of Operative Surgery ; Cripps, Diseases of the Rectum and Anus. A. Rendle Short. HEAD INJURIES. — The prognosis of a number of conditions will here be considered under one heading, because it is so difficult to distinguish between them in practice. The aphorism of Hippocrates still holds good : " There is no head injury so trivial that it should be despised, or so serious that it should be despaired of." That the prognosis after a severe head injury is very uncertain is evidenced by the excellent hospital rule always to admit such cases, if possible, as a precau- tionary measure ; it is quite impossible to tell what the outcome may be at the first examination. Every surgeon knows of patients lying deeply comatose, who appeared to be marked for death, who have recovered ; and, on the other hand, how often has a resident imperilled his reputation by sending away a patient with apparently nothing the matter, who subsequently died. The three main causes of death after this latter mistake are the oncoming of intracranial haemorrhage, spreading oedema, or meningitis. We shall consider : (i) The mortality of various head injuries ; (2) The material for giving a prognosis in particular cases ; and (3) The possible sequelcs. Mortality of Head Injuries. Cases Deaths Mortality per ceut [ Phelps 28fi 176 61 Fractured base 1 Rawling "" Battle Anderson 205 168 89 54 44 32 58 33 57 I Phelps 116 41 34 Fractured vertex - \ Rawling \ Anderson 88 29 37 72 46 64 Pistol-shot wounds of brain - Phelps 126 120 95 Extradural haemorrhage with J Bowen - "1 (with operation) 36 14 38 no brain injurv 25 3 12 Extradural haemorrhage with ( Bowen - 36 30 83 serious brain injury - ■( (with operation) 26 20 77 I. Mortality of Head Injuries. — It is of no value to quote hospital statistics of mortality amongst head injuries in general, because practice differs so much HEAD INJURIES as to what type of case is admitted and what sent away. A few well-defined groups, however, furnish valuable information. We have figures for the death- rate in cases of fractured base, fractured vertex, pistol-shot injury, and extra- dural haemorrhage. Rawling's cases are taken from the records of St. Bartholomew's Hospital, Anderson's from the Cook County Hospital, and Bowen's from those of Guy's Hospital. It will be observed that the figures for fractured base vary ; in English practice the mortality is probably under 50 per cent. Fractured vertex is less dangerous ; about one-third die. Out of 137 cases of pistol-shot of the brain reported in a New York newspaper for one year, 6 recovered after operation. Of 51 cases of extradural haemorrhage treated by operation, 23 died, that is, less than half. 2. Data for Prognosis. — As above remarked, prognosis is absolutely impossible at the first time of seeing, unless the patient is obviously moribund ; and even if consciousness has not been lost, one dare not say that the injury is trivial. The great majority of fatal cases die within forty-eight hours, and after a week has elapsed, death is extremely improbable ; but even then there is a remote risk. Unconsciousness. — The degree, depth, or prolongation of primary unconscious- ness, taken apart from other signs, is of very small value in giving a prognosis. If other signs are favourable, recovery will almost certainly occur, even if the patient is still unconscious at the end of the third or fourth day or later (Phelps) . Nor will such patients necessarily have grave after-symptoms, if properly treated. On the other hand, recurring unconsciousness, after a more or less lucid interval, is of very grave import, denoting intracranial haemorrhage ; and apart from successful operation, as in cases of middle meningeal rupture, the patient will almost certainly die in a few hours or days. The temperature is another sign of great value (Phelps). If it is very subnormal from the first, and shows no tendency to rise, the patient is likely to die outright of shock. Again, if at any time it rises rapidly, death is probable. Recovery never occurred in Phelps's cases when 105° was reached, and very few survived whose temperature rose above 104°. A pulse which is slow and full, or very quick and feeble, is generally rather ominous ; the former usually indicates cerebral compression. Hemiplegia is a grave sign, if it comes on from the first ; it makes it probable that the cerebral cortex is lacerated. Depressed fracture of the skull is a much less grave injury in young children than in adults. Escape of cerebrospinal fluid from one ear, in Rawling's cases, did not make the prognosis of fractured base worse ; escape from both ears had a mortality of 66 per cent. Septic complications render the death of the patient certain if the meninges are involved or a subcranial abscess forms, and therefore all cases with an open wound communicating with a fractured skull are in danger for a week or more. Late deaths are due to sepsis in most instances, but it is extraordinary how long a person may live with a haemorrhage which eventually proves fatal. Two cases have come under the writer's notice in which the patients remained in a variable, but rather stupefied, condition for more than a month after an injury, to the occiput in the one, and to the spine in the other — each dying at last of intracranial haemorrhage, apparently dating from the time of the accident, and not repeated since. Concussion. — A few autopsies on men and animals have been recorded showing that it is possible for death to result from simple concussion, without any signs of injury post mortem. INDEX OF PROGNOSIS Gunshot or pistol-shot injuries are almost invariably fatal. Occasionally a bullet of low velocity, traversing the frontal or the occipital cortex, fails to kill the patient at the time. Of 40 cases coming under Phelps's care, 15 died within an hour, 7 died under twelve hours, 10 between fifteen hours and forty days, and 8 apparently recovered. Even so, there is a great probability that, sooner or later, days, weeks, months, or years afterwards, an abscess will form if the bullet is retained, and lead to a fatal result. Bullets in the brain practically never remain quiescent in perpetuo. 3. Eventual Results of Head Injuries. — Within a few days of the accident, the condition called cerebral irritation may come on, in severe cases, and last for a week or two. Nerve injuries associated with a fractured bone may be immediate or remote ; in either case they usually clear up. Those cases in which the paralysis does not appear for a few days, are always well in two or three months ; in a few of the nerve injuries seen immediately after the accident, the lesion is permanent. The nerves most commonlj' involved are the second, seventh, and eighth. A rare sequela of head injury is rupture of the internal carotid artery into the cavernous sinus, causing pulsating exophthalmos. Another rare inj ury is traumatic cephalhydrocele. Functional defects of the brain are the most important sequelse of a head injury. It is well known that persistent headache or neuralgia, vertigo, loss of memory, mental enfeeblement, or traumatic epilepsy may follow such an injury, and may persecute the patient for the rest of his life. Sometimes he becomes very sensitive to the effects of a hot sun, or easily upset by a little alcohol. Crisp English followed up a number of cases of head injury treated at St. George's Hospital, and obtained the following results, with which the statistics of Rawling closely agree. No effects Slight Marked eSeots In 100 cases of fractured skull - - - - 31 50 19 In 100 cases of concussion, compresssion, laceration 48 42 10 In the fracture series, 52 out of 86 were earning their old wages, 6 were totally disabled, and the rest partially. In the second series, 63 out of 78 earned their old wages, 3 were totally disabled, and the rest partially. The old and the young suffered most. These unfortunate end-results can be averted to a large extent by proper treatment at the time of the original injury. Patients, especially of the hospital class, are usually allowed to go back to work too soon. Every case of head injury ought to be kept quiet in bed on fluid diet until the dazed look of the face has passed off, the blood-pressure has risen to normal, and the patient does not sweat, or become giddy, on attempting to get up. After a prolonged unconscious- ness, lasting hours, the patient ought to lead a quiet life for many months. These conditions being observed, even severe head injuries seldom leave any permanent trouble. Traumatic Epilepsy. — In most cases, this is evidence of some organic lesion, such as a depressed fracture, scar in the meninges, old blood-clot, or tear of the cortex, but sometimes nothing can be found. The results of operation are not very successful ; if a definite cause can be removed the outlook is better. Much depends upon keeping the patient absolutely quiet for months after the operation. Rawling records 20 cases of his own, of which 2 v.'ere cured, 14 markedly improved, and 4 not improved. Gushing gives figures as follows : free from attacks, 12 ; attacks less frequent, 30 ; no improvement, 17 ; died of status epilepticus, 2. References. — Phelps, Traumatic Injuries of the Brain ; Rawling, The Surgery of the Skull and Brain ; Crisp English, Lancet, 1904 ; Anderson, Surg., Gyn. and Obst. 1914, 522. A. Rcndle Short. HERNIA 213 HERNIA. — Common as this disease is, it is extraordinary how difficult it is to find reUable reports in the hterature as to the end-results of different methods of treatment, in an adequate number of cases. This is particularly true with reference to femoral and umbilical hernia, where a prolonged search of the surgical records of many countries has been almost barren of result. The Spontaneous Cure of Hernia. — In young children, up to the age of four years, it is undoubtedly possible to cure some cases, probably only a minority, by the use of a truss. If this is to be efficient, the hernia must never be allowed to come down, or all the benefit previously obtained is lost. What usually happens, no doubt, is that the sac becomes very narrow, and it may well be that heavy straining in adult life would reopen it. On this point we lack evidence. But it is quite certain that occasionally the neck of the sac may be obliterated. This has been verified by subsequent operation in one or two cases. In older children, or adults, cure of a hernia by any other means than an operation is so rare as to be practically negligible. Femoral hernia in infants is seldom cured by a truss. The great majority' of cases of umbilical hernia in infants disappear after a year or so, if a pad and bandage is worn. We do not know if they ever come back again in middle life. The Danger of Strangulation. — It is very difficult to estimate the frequency with which a hernia becomes strangulated. Macready puts it at i'6 per cent. The proportion of cases of strangulated to those of reducible inguinal hernia, seen at a hospital, is perhaps about i in 20 ; it is mere conjecture what proportion of the herniated members of the community who depend upon hospitals for surgery present themselves at those institutions for examination, but probably nowadays it is from a quarter to a half, which agrees pretty well with Macready 's opinion. Femoral and umbilical hernias become, in proportion, much more frequently strangulated. The risks of strangulation in persons who neglect treatment year after year, and neither have an operation nor wear a truss, must be much higher than 1-6 per cent, because this diminishing class furnishes the majority of the strangulation cases. It is a mere guess, but such a patient's prospects of calamity are probably 30 to 50 per cent in the long run, especially in the femoral and umbilical varieties. The Results of Operation. — We shall have to consider, (i) The operation mortality ; and (2) The prospects of cure or relapse. I. The Operation Mortality. — This is, of course, very low nowadays. A few years back it was by no means inconsiderable ; in four London hospitals in 1890 it was as high as 6 per cent. To-day, however, it is only from 0-25 to 0-5 per cent in adults, and a little higher in infants (Bull and Coley). Brenner, of Vienna (1906), quotes 2000 cases with 5 deaths (0-25 per cent). Pott's enormous figures, running into thousands, for the years 1895 to 1903, show : inguinal hernia, 0*7 per cent died ; femoral hernia, 0-5 per cent died ; ventral hernia, I -I per cent died. Fatalities are due to sepsis, pneumonia, anaesthetic calamities, and totally extraneous occurrences. Thus, the writer lost a patient who developed tj'-phoid fever ; four or five instances are known in which the femoral vessels have been injured, and some of these have been fatal ; deaths have resulted from wounding the' bladder in the sac, its presence not having been recognized by the operator. The writer has also heard of urureported cases in which fatal intestinal obstruction followed, due in one instance to imprisonment of a loop of bowel by the inverted sac in Kocher's operation, and in another to the intes- tines becoming entangled in adhesions about a filigree. 214 INDEX OF PROGNOSIS 2. The prospects of Cure after Operation. a. Inguinal Hernia.- — The introduction of the Bassini method has greatly im- proved the results in adults. The older methods gave as high a proportion of relapses as 30 to 40 per cent (Bull and Coley). Simple ligature of the sac, without slitting up the external oblique, in adults, was followed by recurrence in nearly 30 per cent of the cases (Pott). In children, however, it is almost always successful ; Kellock had no failures in 52 cases. The Bassini operation gives much better results. Pott's huge collection of German figures, published in 1903, shows about 10 per cent of recurrences, but other results are much more favourable. Simmonds gives the statistics for 1905 for Massachusetts Hospital, the cases being examined in 1909 ; in 113 cases followed, there were 7 per cent of relapses. Dreesman, 1913, quotes only 2'5 per cent out of 403 operations. Bull and Coley quote less than i per cent, but a large number of their patients were children. The true figure, nowadays, is probably about i in 20. If relapse is going to occur, it will usually be in the first year. Kocher's operation gives equally good results, according to Pott's figures. b. Femoral Hernia. — According to Bull and Coley, there were no relapses in 125 cases of operation for femoral hernia, but this merely means that no patients returned to them ; they did not examine, or hear from, those alleged to be cured. Pott's figures are by no means flattering to surgery ; of 158 cases operated on before 1903, without closure of the ring, more than a third recurred, and when the ring was sutured, nearly 30 per cent relapsed. At the Bristol Royal Infirmary, of 41 cases treated by various methods, 30 were well from eighteen months to four years afterwards, and 11 had relapsed, that is, 27 per cent. Making use of the new method of closing the ring above Poupart's ligament, C. A. Morton found 7 cases free from recurrence, and Fagge had 3 failures after 18 operations. Cures AFTER Various Operations for Hern [A. iNGflN'At. Fl- MORAL Reporteb Bassini Kocher Simple ligature of sac Ring not closed Ring closed Closure above Poupart's lig. Cases Cured Cases 1 Cured Cases Cured Cases Cured Cases Cured Cases Cured percent per cent percent percent percent percent Pott - 1851 90-1 376 92-5 1419 71-6 158 63-3 155 71-6 Bull & Colev - 837 99 Kellock (chil- dren) b'l 100 Simmonds - 113 93 Dreesman 403 97-5 Fagge ; Morton 20 88 Bristol Royal Infirmary - 41 cases, 73 per cent cured c. Umbilical or Incisional Hernia. — The results in these cases appear to be less satisfactory than in either of the others, and failures are often seen in Enghsh hospital practice after operations by the older methods. Of 86 cases followed through by Pott, 54-7 per cent were cured, but nearly half relapsed. Capelle's figures for 35 cases are rather better. Probably the newer methods, the fihgree operation and the transverse line of suturing, will show improvement on these results. At the Bristol Royal Infirmary, of 9 cases of umbihcal hernia followed eighteen months to four years, 5 were cured and 4 relapsed. HERNIA, STRANGULATED 215 References. — Pott, Deut. zeit. f. Chir. 1903, Ixx ; Bull and Coley, Jour. Amer. Med. Assoc. 1907, xlix, ioi7; Kellock, Proc. Roy. Soc. Med. 1912, pt. iii., surg. sect., 26 ; Simmonds, Boston Med. and Surg. Jour, igio, clxii, 847 ; Capelle, Beitr. z, klin. Chir. 1909, Ixiii, 264 ; Fagge, Proc. Roy. Soc. Med. 1911, surg. sect., 165. A. Rendle Short. HERNIA, STRANGULATED.— If we use the term in its strict sense, excluding cases in which the herniated loop of bowel is merely obstructed by fasces, strangu- lated hernia, apart from treatment, is practically a death-warrant. It would be impossible nowadays to obtain figures showing in how many patients the hernia would discharge its contents through the skin, and so save life at the expense of a fascal fistula. In the great majority of cases in which this happens, death nevertheless supervenes, and until this release occurs the patient's condition is most pitiable, on account of burrowing abscesses and very violent and extensive dermatitis set up by the irritation of the contents of the small intestine. The percentage of spontaneous cures in cases of strangulated hernia is said to be about 2 per cent (Coley, in Keen's Surgery). Gangrene of the Gut. — The occurrence of this complication depends upon three factors : the tightness of the constriction, the length of time that the hernia has been strangulated, and the situation. In a series observed during five years at St. Thomas's Hospital, Corner found gangrene in 4 per cent of the inguinal, 10 per cent of the femoral, and 25 per cent of the cases of strangulated umbilical hernia. Usually it takes about three days to develop ; there are, however, very many recorded instances in which gangrene has supervened in a day. Out of 119 cases of strangulated hernia at the Bristol Royal Infirmary, 2 had become gangrenous in less than twenty-four hours, and i in less than twelve hours ; there is a case in the literature which gangrened in four hours. Of course, gangrene makes the prognosis as to life much graver. Duration of Life and Cause of Deatti. — Apart from operation, the average duration of life, according to old figures supplied by Macready, is about seven to ten days. It may be much shorter ; there are many recorded instances of a fatal issue within twenty-four hours, and two have been known to die within a couple of hours. The cause of death is usually peritonitis ; next to this, profound toxaemia. Others die of various lung complications, either from inhalation of foul vomit, or from embolic pyaemia. Treatment by Taxis. — In the days of pre-antiseptic surgery, prolonged and vigorous taxis was employed in almost all cases. Of course it frequently failed, and recovery by no means always took place even when it succeeded in reducing the hernia. Thus, according to Frickhoffer (1861), of 300 cases of strangulated femoral hernia reduced by taxis, 14-9 per cent died, and of 518 cases of strangu- lated inguinal hernia, 7-8 per cent died. The deaths were due to reduction of gangrenous gut, rupture of the gut, reduction en masse (or reduction into another sac), pre-existing peritonitis, or paralysis of the bowel. Nowadays, taxis is only employed with gentleness, and for a few minutes, in early cases ; in late cases, it is usually possible to tell almost immediately by the feel that taxis would be hopeless. Probably, if seen within a few hours, the majority of strangulated inguinal or umbilical hernias, if previously reducible, could be safely treated by taxis, though of course a subsequent radical cure would be desirable. In young children, the writer has had considerable success in getting back a hernia strangulated less than twelve hours by tying the child in bed in an inverted position and giving chloral. This is often valuable, as it allows an immediate operation to be converted into a routine one. 2l6 INDEX OF PROGNOSIS Used only in early cases, for a short time, and with a light hand, taxis is not likely to cause any damage, and if the bowel can be returned the patient will almost certainly get well. I have seen profuse bloody diarrhoea follow. Of 24 cases reduced by taxis at the Bristol Royal Infirmary since 1900, every one recovered. Treatment by Operation. — One of the oldest of surgical operations, herniotomy for strangulated hernia has improved immensely in its results of late years. Between 1836 and 1841, of 183 herniotomies in Paris, 62'2 per cent died. Between 1869 and 1888, of 283 herniotomies for strangulated inguinal hernia in four London hospitals, 59 per cent died. At the present time, the results may be gathered from the following table : — • Results of Operation for Strangulated Hernia. INGUINAI. Femoral. Umbilical Obiueatok Hospital CaseB Died Per cent Cases Died Per cent Cases Died Per cent Cases Died Per cent St. Thomas's, 1 1907 to 1911 Middlesex, 2 1907 to 1911 - Bristol Royal In- firmary, 1900 to 1912 - 111 37 119 21 8 22 — 103 29 96 24 3 14 30 11 11 14 2 2 — 2 3 3 — Total - 267 51 19 228 41 18 52 18 34-5 5 3 60 It will be observed that the mortality for inguinal and femoral hernia is approximately the same, a little under 20 per cent ; that umbilical hernia is decidedly worse, and that in the majority of obturator hernias the patients die. This agrees well with the experience of seven German writers quoted by Meyer^ ; out of 1429 cases of various hernise strangulated, 20-7 per cent died ; in 56 cases of obturator hernia, Meyer reports 32 deaths, that is, 57 per cent. We have next to consider the results of operation under certain special conditions. The Age of the Patient. — All writers agree that the prognosis is much more grave in elderly persons. Children usually do well. According to Collins,* the mortality in 1902 was 23 per cent, but it is now 3 to 10 per cent, given early inter- ference. Of 12 cases in infants under two years of age treated by operation at the Bristol Royal Infirmary, every one recovered. The Time of Operation. — It is no doubt true, in the main, that good results depend on early operation. Macread}?^^ calculates from 129 cases :- — Operation within 24 hours ,> 24-48 „ 48-72 „ „ after 72 ,, 12-5 26-1 36-3 44 per cent died It is a remarkable fact, however, in the figures of the Bristol Royal Infirmary, that the correspondence is b]/- no means so close as might have been expected. After three or more days of strangulation, 55 cases (25 inguinal, 30 femoral) were operated on ; of these, 9 died, that is, 16 per cent, or positively fewer than those operated on early ! It would be most calamitous, of course, to use this as an HEART, CHRONIC VALVULAR DISEASE OF 217 argument for delay. The truth of the matter is that cases with marked sym- 13toms are Ukely to obtain help and get treated early, whereas there is a type of strangulation which comes on more quietly and is not so rapidly fatal. The best results, of course, were obtained by operation within twenty-four hours. Of 88 such cases at the Bristol Royal Infirmary (femoral and inguinal), only 7 died, that is, 8 per cent, instead of the general average of nearly 20 per cent. These 7 cases mostly showed gangrenous gut, and some of them were very aged. The Various Methods of dealing ivith Gangrenous Gut. — When gangrenous gut is found at operation, two courses are open. We may either resect the loop, including any dilated paralyzed coils on its proximal side, or we may content ourselves with making an artificial anus. From a study of the literature and hospital records, Hesse*' gives the results as follows : — Operation Cases Died Per cent Artificial anus Resection of loop 604 860 382 71-3 44'3 It must not be concluded from these figures, however, that resection is invariably the best treatment. No doubt the higher mortality is partly due to the fact that the very worst cases were treated by making an artificial anus. Like all hterature figures, the results are probably shown in an unduly favourable light, owing to the pubhcation of successes and suppression of failures. Of 30 cases recently seen at St. Thomas' HospitaP : — 18 were treated by resection ; 8 cured, 10 died. 10 ,, enterostomy ; 1 cured, 9 died. 2 ,, invagination ; 2 cured, died. Prognosis in Individual Cases. — Before operation, the principal guides to an accurate prognosis are the age of the patient, the degree of collapse, and especially the nature of the vomit. If the latter consists of foul jejunal contents, the outlook is grave ; if it is definitely fsecal in odour, the patient is nearly always doomed. Evidence of peritonitis makes an almost hopeless prognosis ; so does a sense of rupture with sudden cessation of the pain. At operation, a Richter's hernia makes for a rather worse prognosis ; and, of course, the presence of gangrene is very ominous. Meyer reports 252 German cases in which gangrene was found ; the death-rate in various statistics was from 50 to 85 per cent. After operation, persistent vomiting is a grave sign ; it may mean paralysis of the gut. Som.etimes washing out the stomach may give great relief if the vomiting is only due to jejunal contents therein. Pituitary extract, physo- stigmine, salines, or hormonal may overcome the paralysis of the loop of bowel. As already stated, strangulated umbilical hernia is worse than femoral or inguinal, partly because the patient is likely to be old, fat, or bronchitic, and also because there is a tendency to consider it as merely obstructed, and so to delay treatment. Strangulated obturator hernia is dangerous because it is often diagnosed late. References. — ^St. Thomas's. Hasp. Rep. ; 'Middlesex Hasp. Rep. ; ^Meyer, Arch, f. klin. Chir. IQ14, ciii. 497; ^Collins, Ann. Surg. 1913, Ivii, 188; ^Macready, Treatise on Ruptures ; ^Hesse, Beit. z. klin. Chir. 1907, iv, i ; 'Corner, Lancet, igoS, i, 1692. A. Rcndle Short. HEART-BLOCK. — {See Pulse, Irregularities of the.) HEART, CHRONIC VALVULAR DISEASE OF— The outlook in chronic valvular disease is notoriously obscure, and the new light which is breaking in hardly warrants didactic statements. Recent work teaches us that it is a 2i8 INDEX OF PROGNOSIS misconception to regard a lesion of the valves as constituting a true morbid entity. The three great causes of valvular disease — rheumatic infection, syphilis, and atheroma — whenever they injure the valves, damage the even more important myocardium at the same time. In a few years from now we shall speak of cardiac rheumatism or cardiac syphihs as the disease, and mitral obstruction and aortic insufficiency as symptoms, or at most phases, of those diseases. A book of this kind is, however, not the place for intro- ducing a sweeping change of terminology, and the more usual plan of dividing valvular diseases along anatomical hnes \^ill be followed. Even so, however, it soon proves impossible to exclude etiological considerations. Mitral Regurgitation, for instance, is notoriously a symptom which it is customary to treat of as if it were a disease. The available evidence teaches that generally, if not always, it is myocardial and not endocardial disease that makes the mitral valve incompetent. Stiffening of the mitral cusps causes obstruction, not incompetence ; myocardial disease promotes stretching of the mitral ring to the point at which it becomes incompetent. The course of the mitral defect is therefore in the main that of the myocardial lesion that is responsible for it. The diagnosis of mitral incompetence rests on the presence of a sj^stohc bruit at the apex, providing the possibihty of the latter ha\dng an exocardiac origin has been excluded. What does the discovery of this murmur portend ? As we have already seen, mitral regurgitation is one result of myocardial atony ; with one important exception, to be mentioned presently, this is its whole significance. Clearly, then, we have first to ask ourselves what is the morbid process that is injmring the muscular walls of the heart and making them atonic. In many cases it is, of course, some temporary anaemia or toxeemia of the whole economy, such as chlorosis or pernicious anaemia on the one hand, or diphtheria or typhoid fever on the other, that is attacking the myocardium among other organs. Here the prognostic import of mitral incompetency is small ; since it furnishes some proof that the heart is attacked, it cannot be said to have no importance whatever ; but the fact that there is a mitral systohc murmur adds nothing at all to the gravitj^ of the prognosis. If in diseases of this general kind the patient's death is to be through his heart, it ^^dll not be because the mitral ring is so weakened that the valve leaks ; it ^^•ill be because the more important function of contractility is impaired, and experience teaches that atony of the mitral ring, as revealed by the mitral regurgitant murmur, is no index at all of interference with contractility. When we come to those diseases in which the heart is picked out for attack by the morbid process (syphihs, alcohohsm., arteriosclerosis) — processes, too, which last till and tend towards death — a little more weight attaches to the presence of mitral incompetence. As in the group of conditions considered above, it is one more proof of the fact that the heart is really injured. But a greater importance than this is often claimed for the mitral regurgitant murmur. It is said — Here is a heart that from now onwards has to bear the disadvantages of a mitral valve that does not allow the left auricle and its tributary pulmonary veins to be drained. These drawbacks are alleged to be imperfect aeration of the blood that is passing through the lesser circuit, and extra work for the right heart. These ideas are worth considering : if, in a case of chronic myo- cardial disease belonging to any of the types named above, there be found a mitral regurgitant murmur, it does imply some liability to pulmonary stasis ; and if the second sound at the pulmonic cartilage be accentuated, this hability is probably being incurred. In fact, it is not too much to say that the best way of measuring the amount of stress imposed on the lesser circuit by mitral leakage HEART, CHRONIC VALVULAR DISEASE OF 219 is by observation of the degree of accentuation of the puhnonary second sound. Over against the evils attendant on the mitral defect in such a case there are, on the other hand, certain considerations which suggest that the supervention of mitral regurgitation may give actual relief where, as in many cases of chronic myocardial disease, the contractile power of the left ventricle seems to be giving out. Under such circumstances the fact that a little blood leaks back into the left auricle is no doubt bad for the pulmonary system ; but the harm done in this way is outweighed by the relief afforded to the wearing-out ventricle, in that its systolic task is a little lightened. Therefore one need not be perturbed because a cardiosclerotic with angina and breathlessness develops a mitral systolic bruit ; it is quite likely that relief from pain and other symptoms may follow. In all such cases as these, the prognosis is really that of the disease itself ; the mitral leak is but one, and by no means the most important, feature. We said above that, with one reservation, mitral regurgitation is an expression of myocardial atony and no more. This one reservation has to be made in regard to mitral disease due to rheumatism of the heart. Here the mitral apparatus is doubly afflicted ; the myocardial lesions, which always occur in every case of active carditis, and often persist when the acute phenomena have died down, favour stretching of the ring, while in practically every case each of the recurring phases of active infection adds something to the inflamma- tory fibrosis of the mitral curtains — a fibrosis which, once established, never disappears. The active phases are more or less limited to the first twenty years of life ; the lesions of the valves and pericardium that are established during these years remain, while the myocardial lesions recover to a variable degree. So far as the mitral regurgitant bruit is concerned, then, we have to find out to what extent it points to muscular damage that will pass away, and to what extent to valvular fibrosis that will tend to get worse. In the writer's view, the myocardial factor in rheumatic mitral incompetence is far more important than the endocardial ; this view is chiefly based on post-mortem evidence. It is, however, probable that the more stiffened the mitral curtains, the louder and harsher the mitral murmur. It is further true that the presence and per- sistence of this murmur are evidence of the presence and persistence of organic disease of the heart. Kemp's recent inquiry into the subsequent course of the cardiac complications of acute rheumatism shows that the mitral systolic bruit which is so prominent a characteristic of such attacks disappears during or after convalescence in about one-third of the cases. The writer's experience is roughly confirmatory of this ; but it also shows that a bruit which has persisted for a year after it was first established is not likely to clear up. The great hindrances to the disappearance of this bruit are recurrent attacks of rheumatic carditis (in children, so often overlooked at the time) and inadequate care after obvious attacks have occurred. The latter point is responsible for the very definite contrast that exists between the behaviour of the convalescent rheumatic heart in children of the hospital class and in those who are more happily circumstanced. The former point is probably responsible for the fact that in adults, whose attacks of rheumatism are more likely to be articular than in children, and who are less liable to relapse, a permanent systolic murmur is not such a common feature as it is in the rheumatic child. Even in cases where the apical sj^stolic bruit has disappeared, it is well to remember that the patient is not yet out of the wood. Either with or without obvious relapse, it may reappear, or a presystolic murmur may develop. Prolonged absence of all signs of mitral regurgitation does not prove that the mitral curtains are normal ; a process of inflammatory sclerosis may be going forward through a stage of latency to the point at which it causes signs of obstruction. INDEX OF PROGNOSIS As for the actual harm which mitral regurgitation of rheumatic origin does to the rest of the heart, this is slight compared with the other lesions of the heart which are present in any case of rheumatic heart disease with signs of mitral reflux. It is true that in these cases the pulmonic second sound is nearly always unusually emphatic, but this must not be ascribed solely to the effect of mitral insufficiency in raising the tension in the lesser circuit ; the fact that the conus arteriosus dexter is uncovered is of equal importance, as it brings the diastohc snap of the pulmonary valves nearer to the observer. The importance of the signs of mitral leakage is indirect ; their presence proves that the heart has been injured by the rheumatic infection, and their persistence proves that those injuries have not disappeared, and that there is still a hkehhood of permanent cardiac disablement. The harsher the murmur, the greater the probability of this persistent type of disease ; but even in those cases where a loud, harsh systohc murmur at the apex persists into adult life, it is of more importance to note the size of the ventricles and to estimate their functional efficiency than to bother oneself unduly about the intensity and line of spread of the apical bruit. To sum up : Mitral regurgitation is a symptom of various disorders and diseases of the heart, and not a disease of itself. Its prognostic significance lies in the light which it throws on the course of the underlying condition. Mitral Stenosis, on the other hand, is a distinct clinical and pathological entity. The cases that usually bear this label are in reality cases of rheumatic heart disease that have escaped the earlier dangers of the disease and its compli- cations, and have survived into the residual or terminal stage. There are certain fundamental facts on a realization of which prognosis must rest. 1. Recovery is impossible. The fibrotic deformity of the curtains, the essential fact of the disease, cannot be caused to disappear by any means in our power. As they are, so they will remain to the end. Prognosis is therefore concerned solely with questions as to the patient's chances of survival. 2. The average age at death in a series of 35 cases of pure mitral stenosis examined post mortem at the Bristol General Hospital was 39-2. Probably this figure is low : an undue proportion of patients with acute reinfection, as well as of those exposed to abnormal stress, is sure to be included in a hospital series. In 6 cases there was evidence of recent rheumatic inflammation of the heart in addition to the mitral stenosis ; in this series the average age at death was 30 , while in 8 cases in which the scarred mitral valves had become the seat of an ulcerative endocarditis the average age at death was 31. The average age in the first class would probably be lower if one were able to include those cases in which fresh rheumatic infection has occurred but without producing any gross naked-eye change. In such, microscopical examination discovers signs of acute myocarditis. Post-mortem data therefore show that (a) Mitral stenosis shortens life by twenty to thirty years ; {b) The mechanical effects of the lesion are responsible for the end in a majority of cases ; (c) Two complications, fresh rheumatic infection and ulcerative endocarditis, occur in a small number, bringing about a fatal termination earlier by a decade than would have been the case otherwise. 3. The average age of the onset of symptoms, in those cases where it has been possible to inquire into this rather vague point, has been 26. From this it seems that the average expectation of life from the onset of symptoms is about 13 years. The actual date at which the cardiac lesion is first established cannot be ascertained in a vast majority of cases. The rheumatic process is so insidious in its beginnings that these usually go undetected. It is, however, certain, from those cases that can be studied from the beginning, that the foundations of the valvular lesion are laid in nearly every instance before the age of 16. HEART, CHRONIC VALVULAR DISEASE OF 221 4. There is, then, a prodromal stage during wliich the mitral orifice is becoming narrowed. How can this narrowing be foretold ? In any given case of rheumatic carditis the signs most distinctly indicative of stiffening of the mitral cusps are persistent harshness and loudness of the systolic apical murmur, if one be present ; sharp accentuation of the first sound at the apex ; doubling of the second sound at the apex, if that doubling be constant and definite ; and the existence of a constant mid-diastolic bruit at the apex. If these phenomena persist for months, uninfluenced by rest, one is justified in most instances in regarding the case as on the road to mitral stenosis. Once established, the course of mitral stenosis is towards cardiac failure. As we have seen, this end may be forestalled by other happenings. The sclerosed, vascularized valve may become the home of other organisms, and the super- vention of any blood infection, such as pneumonia or puerperal septicaemia, is more to be feared in the subject of chronic mitral disease than in others. Actual evidences of ulcerative endocarditis — swinging temperature, sweats, petechije, wasting, hsematuria, and so on — should never be forgotten in the examination of cases of chronic mitral obstruction. If signs of this complication are found, the outlook is well-nigh hopeless ; death is probable within the year {see Endocarditis, Ulcerative). The supervention of a fresh attack of rheumatic carditis is not so immediately dangerous. In the presence of polyarthritis, or chorea, or subcutaneous nodes, one should look out for pericarditis, dilatation of the heart, or fever persisting after subsidence of the outward and visible evidences of active rheumatic infection. These indicate fresh carditis, inevitable results of which are temporary impairment of the myocardium and permanent addition to the mitral fibrosis. For these two reasons rheumatic reinfection of the patient with mitral stenosis must always be regarded with respect ; every such attack tends to shorten the patient's life. One other accident may intervene to accelerate the patient's gradual progress to the grave — that of cerebral embolism. This occurs in a small number of cases ; Bradshaw found that 6 out of 77 cases of mitral stenosis ended so. Apart from the symptoms that point to emboUsm of other organs, no warning is given of this calamity. It rarely occurs except in persons with marked evidence of circulatory embarrassment, save when it is due to malignant endocarditis engrafted on the fibrotic lesion. The presence or absence of symptoms of active infection will serve to distinguish between the embolism that arises from thisl cause, and that which is due to detachment of clot from the mass in the left auricle. In the latter case, if the end is to be fatal it comes at once ; in the former, the immediate shock of the embolism may pass away, and yet death may follow after a short interval from the later effects of the infection of the interior of the skull which is imphed in an embolism of this type. In either case the majority of cases of cerebral embolism compUcating mitral stenosis do not end abruptly. The non-infective embolus that fails to kill establishes a hemi- plegia which is never completely recovered from. In a large majority of all cases of mitral stenosis death is due to gradual cardiac failure. The forces responsible for this are two. The heart, and especially the left auricle, is asked to do more work by reason of the valvular obstruction ; and gradually increasing venous stasis undermines the nutrition of the cardiac, and particularly the auricular, musculature. An unconquerable vicious circle is thus established. The results are pulmonary engorgement, auricular breakdown, and ultimate ventricular failure. The first of these threatens death by pre- disposing to bronchitis, suffocative oedema, and multiple infarction of the lungs ; and for these reasons dullness at the bases, signs of bronchial and alveolar catarrh, and haemoptysis are bad features of the case. Auricular failure can INDEX OF PROGNOSIS only kill in so far as it predisposes to the other fatal factors ; that it lends itself to pulmonary hyperjemia is obvious, but it is not always realized how much the importance of auricular breakdown lies in its capacity for vexing the ventricles. The auricular contraction is not a vital function — the circulation can go on without it, for ventricular diastole will drain the auricles ; but ventricular systole must go on — for if it stops, life stops too. Now, auricular failure contributes to the ultimate downfall of the ventricular function in two ways. The overworked, underfed auricle goes into fibrillation ; instead of handing down a regular series of stimuli to the ventricle at the rate of, say, 80 to the minute, it pours down stimuli into the ventricle in a disorderly and incessant stream, which escape into the latter chamber as fast as the auriculo-ventricular connections will transmit them. The result is that the ventricle is stimulated to contract more often than is necessary, and in so disorderly a fashion that contractile substance cannot be built up on the ordinary rhythmic plan — a fact which cannot but indicate some waste of energy. -Left auricular asystole also adds directly to the work of the right ventricle, and thus increases the probability of its failure. It also helps to overthrow the ventricular functions by increasing venous stasis, and so damaging the nutrition of the ventricular musculature. There are thus three things to take note of if we are seeking to ascertain how near the patient is to auricular, and thence to ventricular, breakdown : (i) Pitch of stasis ; (2) Condition of auricles ; (3) Condition of ventricles. 1. Pitch of Stasis is to be measured by certain sj^mptoms : dyspnoea and cyanosis afford our best means of raeasuring it in the earlier stages ; later we may be guided also by the total daily output of urine, the presence or absence of hepatic enlargement, the size of the veins in the neck, and the occurrence of oedema (though this is quite a late feature of mitral stenosis). 2. The Condition of the Auricles may be judged from data bearing on (a) their size, (p) their functional integrity. a. Increase in the size of the auricles is a bad feature of mitral stenosis as far as it goes, but it matters less than the more positive and direct evidences of impaired function. Dilatation of the right auricle is indicated by duUness filhng in the cardio-hepatic angle ; skiagraphy is also of service, and it is even more so in the examination of the deep and inaccessible left auricle. The pressure signs that may arise from extreme dilatation of the left auricle (left recurrent laryngeal palsy, dysphagia, etc.) are all of serious prognostic import. b. The signs of the previous class are less frequent and less ready to hand than the evidences of impaired auricular function. By far the most important of these is the totally irregular pulse, which is a constant feature of auricular fibrillation. The reasons why this upset of rhythm is bad for the heart's working have been stated above, but it must be remembered that the inception of this form of arrhythmia marks two things : the arrival of the auricle at an advanced stage of degeneration, and the addition of a new disability to the disadvantages under which the ventricles are working. In 26 cases under the writer's care the average age at which this form of arrhythmia was first detected was about forty, a httle in excess, that is to say, of the average age at death in these cases. This proves that the totally irregular pulse — or rather, the fibrillation which underlies it — is a terminal phase in those cases of mitral stenosis that have escaped the more summary modes of termination. The patient may hve on for years, if he is careful, after this has developed ; in rare instances he may even be able to go to work and lead a fairly active life ; but it will be on condition that he remains in the doctor's hands and submits to his advice for the rest of his days. Total arrh^-thmia nearly always marks the beginning of total invalidism. The HEART, CHRONIC VALVULAR DISEASE OF 223 expectation of life from its onset varies from a few months to ten years, or even longer in very fortunate cases, the average expectation being about five years. The factors making for long life in such circumstances are a good ventricle and a quiet life. For this reason older persons often do better than younger ones ; in the latter the irregular pulse begins before the ventricle has had time to recover from the direct infective injuries of the first two decades, and moreover they are less willing to go softly for the rest of their days than are those who have reached years of discretion. The other evidences of auricular failure are as a rule masked by this very striking arrhythmia ; nevertheless, they may be found if they are looked for, and they are not without importance. Decrease in intensity of a previously loud presystolic murmur, and lessening of the a wave as compared with the c wave m the jugular curve, both show that the auricular systole is becoming less effective. With the onset of total arrhythmia, both murmur and a wave disappear entirely. In cases of mitral stenosis of long standing, with much dyspnoea and cyanosis, the appearance of many auricular extrasystoles in the pulse curves is often a forewarning of imminent fibrillation. 3. The Condition of the Ventricles. — Ventricular failure is likely to occur earlier in patients with dilatation of the ventricle, in those who have chronic bronchitis, in persons with high arterial tension (not an uncommon accom- paniment of mitral stenosis), and in those who are prevented from giving themselves a due amount of rest. The last phase is one of intense hyperasmia of the lungs, with or without infarction ; to this stasis, failure of vis a tergo, as well as increased resistance in front, is contributory. Two symptoms that may appear at this late stage are worthy of separate mention in regard to prognosis — haemoptysis and vomiting. The former is never fatal of itself, and its significance differs in different cases. There is a constant slight weeping from the lung which does not betoken dangerous pulmonary congestion ; it comes on early in the case, and may continue intermittently for weeks. There is, on the other hand, a more acute and intense type of haemoptysis which, if accompanied by respiratory embarrassment and even by pain in the chest, points to the occurrence of infarction. This is evidence of a more serious state of affairs, and death may follow soon. But people never bleed to death from the lungs in mitral stenosis, nor do they drown in their own blood as in tuberculous haemoptysis. Vomiting may be ceaseless and intractable in this last stage of the disease ; it may even kill the patient. One final cause of death in mitral stenosis, rare indeed but yet worth bearing in mind, is cerebral haemorrhage. The reason lies in the association that some- times exists between mitral stenosis and granular kidney, and the consequent occasional association between ixiitral stenosis and high tension. It is a rare coincidence, yet so important that the possibility of its occurrence should not be overlooked. The risks of sudden death in mitral stenosis are small. The cerebral lesions, embolism and haemorrhage, are possible causes, and the writer has known at least one death in early mitral stenosis which occurred without warning. Possibly this was due to recurrent acute carditis, but there was no autopsj'. At any rate, sudden death from cardiac failure is so rare in mitral stenosis that patients may be assured that the risk is almost non-existent. As for the effect of treatment on the prognosis, the most conspicuous benefit to be derived is that which those enjoy who can and will consent to limit their activities. With regard to the amount of activity that may be safely allowed, there is of course no fixed rule ; but the patient may, if he must, be allowed to undertake such work as does not cause him to become breathless. The writer 224 INDEX OF PROGNOSIS has under observation at the present time five or six men with advanced mitral stenosis ; one is employed as a gardener, another intermittently as a plasterer, a third as a tanyard labourer, and so on. These men are better off earning a little money than starving in idleness. Women do a little better than men, and if their circumstances are comfortable and easy they do better than those who are compelled by want of help to do heavy housework and to undertake personal responsibility for large families. Pregnancy makes the symptoms worse for the time being, and introduces a small risk of reawakening of the rheumatic infection. French and Hicks found that in only 28 per cent of a large series of cases of mitral stenosis in married women was there any direct relation between pregnancy and heart failure ; and in nearly all of these it took several pregnancies to bring on symptoms. It is only in extreme cases that the patient has to be prematurely delivered on account of the aggravating eifect of pregnancy on the symptoms. In such cases as require this extreme step, its consequences are often disappointingly small, the patient being but little relieved ; but on the other hand, the patient suffers no ill consequences from the strain of parturition, whether it be normal or induced, providing it be not unduly protracted ; or perhaps it would be more correct to say that the ill-effects of that strain are more than counter- balanced by the relief afforded by the emptying of the uterus and the removal of the impediment to breathing which the fuU uterus offers. In French and Hicks's cases there was no single example of death during labour, and in only 14 per cent of those whose symptoms of heart failure began during pregnancy, did the woman die within three months of dehvery ; and the percentage of abortions was even smaller (5-5 per cent). Of other points regarding treatment in its effect on prognosis, there is all too little to be said. The future hope in mitral stenosis lies in prevention and not in treatment. One observation is worth attention — the remarkable benefit experienced from the use of digitahs by patients with mitral stenosis and total arrhythmia. Armed with this drug, and after a period of complete rest, patients recover and retain their capacity for work in a most gratifying way. If this line of treatment — rest and digitalis — fails in a week to slow the pulse and alleviate the dyspnoea and other symptoms, in a case of mitral stenosis with total arrhythmia, the patient is in a hopeless case and cannot survive long. If, however, the treatment gives relief, it is probable that he will regain to some small extent his capacity for getting about and even for work ; though, as we have already remarked, he will still have to regard himself as in need of continued medical care. Patients who are urgently dyspnoeic, blue, and dropsical, are sometimes relieved to an astonishing extent by venesection, a procedure which seems to give cardiac tonics a better chance of helping the patient, as well as affording direct rehef . Leeching may have a similar effect. The value of opium in giving the patient rest may also be mentioned. The outlook in mitral stenosis is discovered, therefore, by assessing its effects on the functions of the rest of the circulatory apparatus, especially the left auricle and the lesser circulation. Aortic Regurgitation is the outcome of several morbid processes, which may act together but much more often operate singly. The prognosis varies widely according to the causation. This is chiefly because different causes affect the myocardium in varying degree. Syphilis injures it profoundly and progressively ; arteriosclerosis as progressively, but less profoundly and rapidly ; rheumatism attacks the myocardium severely, but for the most part its effects are transient, though liable to repetition. The prognosis in any given case exhibiting the HEART, CHRONIC VALVULAR DISEASE OF 225 signs and symptoms of aortic regurgitation depends also on the degree to which the valves are injured, and the extent of the secondary effects of these injuries on the general efficiency of the circulatory apparatus. In the syphihtic cases the expectation of life from the onset of symptoms is about five years, if we exclude cases in which syphilitic infection of the aorta has led to the formation of an aneurysm as well as to valvular disease. In cases of the latter type the prognosis is even worse. In the rheumatic cases the prognosis is much better. This is not seen so well in mere averages of duration of life after onset of symptoms and the like, as in a consideration of a few typical cases. Out of a group of seven fatal cases seen by the writer in recent years, the youngest died at 13 in an acute attack of carditis, in which the aortic lesions had little or no effect in bringing about the fatal issue ; while the oldest was a man of 45, whose ventricular contractility had been failing for years. Of the rest, two died at 19 and 29 respectively, in what seemed to be an acute phase of rheumatic carditis ; two others at 35 and 37 of ventricular failure, and the fifth at 29 of malignant endocarditis engrafted on the old valvular lesion. Thus the various risks of rheumatic disease of the aortic valves are exemplified : acute injury of the myocardium by recurrence of the acute infective process, progressive ventricular failure, and ulcerative endocarditis. This third risk is of course much less often encountered than the other two, so that those who are fortunate enough to escape at last from the years in which the rheumatic infection is active, and who are also able in later years to avoid ventricular overstrain, may look forward to a possibility of long life. To quote examples, the writer has under his care a man of 44 whose rheumatic aortic lesion led to an almost complete breakdown seven years ago ; warned by this, he exchanged a laborious occupation for a lighter one, and is at present good for some years as far as one can judge. The writer also knows two members of the profession who live active and responsible lives in spite of rheumatic aortic incompetence borne in each case for a number of years. A third ill-defined group consists of those cases in which the aortic incom- petence is one aspect of a cardiosclerotic process of the senile or atheromatous type. When the syphihtic factor has been rigorously excluded, this class is probably a small one, and no statistics are available. Experience shows, however, that the course is slower than in the syphilitic cases, but more rapid than the rheumatic ones that have survived into the fourth and fifth decades. Turning to the clinical features of each individual case, we must find out, first, how badly the valves leak, and secondly, how well the heart bears its abnormal burden. As to the extent of valvular injury, the direct physical signs are of less value than those which point to the effects of the leak on the peripheral circulation. The loudness of the regurgitant murmur and the extent of the area over which it is heard teach us nothing as to the degree to which the valve is rendered incompetent : except in this indirect way, that if the bruit be heard loudest at or above the aortic cartilage there is most likely some dilatation of the aorta, and the prognosis is worse, since dilatation of the aorta belongs to the cases that are syphilitic in origin or severe in degree. The effect of the leak on the peripheral circulation is best measured by observing the pulse-pressure — i.e., the difference between the systolic and the diastolic pressure. For the sake of accuracy it is well to measure this with the sphygmomanometer in every case ; but even where this is not immediately feasible, a rough estimate of the circulatory disability may be arrived at by noting the amount of visible pulsation, and especially the amount of visible capillary pulsation. The wider the swing between maximal (systohc) and minimal (diastolic) fiUing of the peripheral vessels, the greater the amount of reflux and the worse the prognosis. A similar 15 226 INDEX OF PROGNOSIS conclusion is to be drawn from the prevalence of any of those symptoms (head- ache, dizziness, nose-bleeding, visual disturbances, etc.) that indicate unsteadiness in the supply of blood to the systemic organs ; the more marked these are, the worse is the leak and the graver the prognosis. Even more important than the state of the peripheral circulation, however, is the condition of the rayocardium. How far is it able to meet this very direct and very considerable task that is thrust upon it ? Here a knowledge of the etiology is indispensable, and it is especially important to ascertain whether or not there is a syphiUtic factor. A search for evidences of cerebrospinal syphilis, and an examination of the blood by the Wassermann method, should not be forgotten here. The discovery of the syphilitic factor makes the prognosis worse, because it impUes an attack on the myocardium by a progressive and practically invincible process. If the case be one of rheumatic disease of the aortic valves, the most serious risk to which the myocardium is exposed is that of re-invasion by the rheumatic process ; this danger becomes less with advancing years, and after the age of thirty it is remote. Of the cardiosclerotic cases nothing need be said, but that the same morbid process that has led to calci- fication of the aortic valves is sure to interfere more or less with the nutrition of the cardiac wall, and to do so, though slowly, yet progressively. Not only etiology, but also symptomatology, come under review in finding out what chance the left ventricle has of coping with the extra burden thrown on it by the failure of the aortic valves. In this form, of valvular disease the danger-signals to be anticipated are those phenomena that point to exhaustion of ventricular contractility. There are three factors at work, the combined eflEorts of which are sure to undermine the efficiency of the ventricular contrac- tions in the long run : the myocardial lesions of the causal disease, which have just been discussed ; the persistent overstress to which the ventricle is exposed by the valvular leak ; and interference with the myocardial nutrition by the disturbance in the peripheral blood-supply, which tells on this as on every other systemic tissue. Failure of contractihty is therefore probable in all cases except those in which the first of these factors, the etiological one, has done its worst in early life and become inoperative later — ^i.e., in the rheumatic cases. It is for this reason that cardiac pain, dyspnoea, and cedema — all of them evidences of failing contractile force — are of more significance than any physical signs in aortic disease of long standing. For the same reason the alternating pulse is a very grave sign in such cases. Among the physical signs, those which point to progressive increase in the size of the ventricle, and loss of strength in the first sound at the apex, are of most significance. Anyttdng suggestive of gross myocardial change (coronary thrombosis or embolism, rupture of the heart, formation of a cardiac aneurysm) is of course of almost immediately fatal import. Rupture of a valve, on the other hand, though it adds at once to the patient's discomforts and disabilities, does not by any means kill at once. The writer has recently seen two cases, in the one of which the man was alive and at work till about seven years after the rupture seems to have occurred, while in the other a year had elapsed and the patient was still working. The opening which a sclerosed valve offers to the various organisms capable of setting up an ulcerative endocarditis needs not to be enlarged upon ; the supervention of septicaemic symptoms in a case of chronic disease of the aortic cusps will readily suggest the appropriate diagnosis and prognosis [see Ulcerative Endocarditis). The possibility of other lethal lesions should never be overlooked, especially in the syphilitic cases (aneurysm, cerebrospinal syphihs). The liability to sudden death of persons carrying a leaking aortic valve is almost proverbial. Indeed, this risk has been rather over-emphasized. Yet HEART, CHRONIC VALVULAR DISEASE OF 227 when we consider the double attack to which the ventricle is exposed in this form of valvular disease — the direct injury of the myocardium that is inflicted by that which causes the valvular lesion, and the less direct effects of overstrain resulting from the incompetence of the valve — it is not to be wondered at that this should be, above all others, that lesion which best and oftenest exemplifies the disastrous effects of exhausted ventricular contractility. In the syphilitic cases, if those which are terminated by rupture of an aneurysmal sac be excluded, death comes suddenly in nearly 40 per cent ; in the rheumatic cases, the writer had only two out of ten fatalities that could by any means be called sudden. Syphilis is more likely to cause sudden death than rheumatism, because of its more enduring and progressive interference with the nutrition of the myocardium. In many of the cases that end with unexpected abruptness, this catastrophe might have been foreseen and possibly averted if more weight had been given to the symptoms of faihng contractility that were present. As for the effect of treatment, the results of antisyphilitic measures call for brief comment. No immediate and complete cures of aortic valvular disease can yet be placed to the credit of salvarsan ; and as it is generally acknowledged that in the presence of cardiac disease the use of this medicament is not entirely free from risk, it is best to rely on mercury and iodide, the prolonged use of which (and especially the former) does indubitably ameliorate symptoms, as much, no doubt, by its action on the myocardium as by any effect on the valvular lesion itself. In the rheumatic cases the estabhshment of a quiet way of life is amply justified by its results. Complete cure is excessively unlikely, but it does occasionally come about. Signs disappear, and symptoms also. Possibly in such cases dilatation of the aortic ring has played an important part in rendering the valve incompetent, and its recovery of tone has restored its functional integrity to the valve. It is so unlikely and so unforeseeable that it cannot be looked for with any confidence, but the fact that it does occur, if it be borne in mind, will serve to colour one's view of the disease. Lastly, it should be recollected that, in spite of its dangerous nature, in spite of the variety of ways in which it may end life, the possession of an incompetent aortic valve is not incompatible with a long life. The writer has already given instances of this, and there are various remarkable examples scattered through the literature ; one, for instance, in which a man who was known at 13 to have aortic valvular disease, was still carrying it with comparative comfort and freedom from symptoms at 66. Aortic Stenosis presents three classes of cases to be considered. The first consists of those patients in whom the obstruction appears to develop slowly, the symptoms being first noticed at or about the age of 30, without obvious cause, apart from rheumatism in a few cases, and without accompanying signs of aortic regurgitation. This is a small group of cases, and the prognosis is nearly always bad ; the patient rarely passes the age of 40. In a second group, the patient has already distinct evidences of aortic incompetence, when the signs of aortic obstruction become superadded. The result is a modification of the peripheral phenomena; the pulse loses its collapsing character, and so on. The effect on the prognosis in such cases is not as bad as one might assume at first sight, for the peripheral effects of the obstruction neutralize those of the regurgitation to some extent. Often the patient is actually more comfortable for the change. It is only in cases of severe valvular change that this sequence is encountered, so that the regurgitation is generally free and the symptoms are pronounced. The mitigation of the symptoms, which ensues upon the super- vention of stenosis, affords the patient real relief, and delivers his ventricle from 228 INDEX OF PROGNOSIS over-distention in diastole, thus diminishing the load which has to be hfted by each systole : so that, for the time at least, the heart's work is eased. Of course, the ultimate prognosis is not good, but it is not so bad as in the first group. In the third group are collected those cases of stenosis developing slowly in persons of 50 or over, thanks to a gradual calcification of the aortic cusps. Here the morbid process is a very slow one, and though the coronary arteries may be damaged at the same time, the myocardium yields but slowly, and the patient may attain to old age. In individual cases of aortic stenosis there are two things to be assessed — the degree of obstruction and the condition of the left ventricular myocardium. The former is determined by observation of the type of pulse rather than by the physical signs, though the prominence of the thrill and murmur must also be given some weight. The more characteristically flattened the pulse-wave, the worse for the patient. As for the state of the ventricular muscle, this is revealed by an examination of the functions ; pain, dyspnoea, alternating pulse, and other evidences of failing contractility are ominous signs. Treatment has little effect, even in the syphilitic cases. Combined Aortic and Mitral Valvular Disease is encountered in two sets of cases. In the first the rheumatic inflammation which injured the one set of valves did the same by the other; in the second, ventricular dilatation, con- sequent on aortic insufficiency and diastolic overfilling, has stretched the mitral ring and made the valve incompetent. In the first class of case, the signs of mitral stenosis are added to indefinite evidences of aortic regurgitation ; or it may be that the aortic lesion is pronounced and the mitral signs are vague ; while in a few there are pronounced evidences of both. In any such case the gravity of the outlook is greater than in the presence of a single lesion, partly because the mechanical disabilities of the one lesion are added to those of the other, and partly because the presence of severe and widespread endocardial lesions in post-rheumatic heart disease argues the presence of diffuse and severe myocardial damage. In the second group of cases the supervention of mitral incompetence in an aortic case is evidence of severe embarrassment of the left ventricle, and therefore of bad omen. Acquired Lesions of the Tricuspid Valve. — The prognosis in these lesions is based on the fact that they never occur alone. Tricuspid Incompetence is so common that some writers regard it as one of the normal functions of the tricuspid apparatus to open but under stress and relieve a distended right ventricle by permitting a certain amount of back-flow into the distensible liver and venous system. Whether this is going rather far or not, evidence does not at present allow us to decide ; but there are certain facts available. First, such diseases as mitral stenosis, cardiosclerosis, and chronic bronchitis with emphysema, diseases which encourage hyperaemia and stasis in the blood-channels that course through the lungs, lead at last to persistent over-stretching of the right auriculo-ventricular communication and render its valvular apparatus permanently incompetent. Second, the clinical evidences of this persistent incompetence are mainly those of venous stasis in the sj^stemic circulation — big veins in the neck, enlargement of the liver, diminution in the output of urine, dropsy, and so on. Third, the more pronounced and persistent these symptoms, the worse the outlook ; partly because the condition of venous stasis thus perpetuated undermines the nutrition and efficiency of various vital tissues, the myocardium itself among them, but also because the presence of extreme and permanent tricuspid failure proves the existence of a proportionately severe hindrance to the drainage of the lesser circuit into the left heart. The presence or absence of a tricuspid systolic murmur makes little or no difference HEART, CHRONIC VALVULAR DISEASE OF 229 to prognosis, at any rate as compared with the significance of the symptoms mentioned. In the first place, it is not easy to decide whether or no the bruit is tricuspid at all ; in the second, the valve may be grossly incompetent without any murmur being audible. Tricuspid stenosis, if acquired, is always the outcome of rheumatic carditis, and as such is little more than an unusual feature in a common type of case. The tricuspid curtains are found thickened and stift'ened in a small percentage of cases of mitral stenosis coming to autopsy, but it is only in a very few of these that the presence of such a coincidence of lesions can be diagnosed. When the diagnosis can be made, the patient's prospects are a good deal worse than in an uncomplicated case of mitral stenosis. According to Newton Pitt's figures, the duration of symptoms does not usually exceed five years, and about half the cases fail to survive the age of 30. The fiver pulsation, sufficiently developed to yield a clear three-wave phlebogram, which has by some been regarded as a sign of tricuspid obstruction, is sometimes encountered apart from this condition ; but even so, it is a valuable proof of advanced engorgement of the right auricle, and as such is a bad sign. Acquired Pulmonary Lesions. — These are so rare that they may be quickly dismissed. Pulmonary Stenosis is of course rarely diagnosed as an acquired lesion ; it runs a short course, the length of which may best be gauged by observation of the state of the right ventricle. As in the corresponding congenital malformation, the patient is specially liable to contract, and die of, phthisis. Pulmonary Regurgitation, due to inflammation of the pulmonic semilunar cusps, is a very rare lesion ; the diagnosis is a bold one, but if it has been made it carries with it a bad prognosis. More common is that insufficiency of the pulmonary valves which may develop in advanced mitral stenosis as a result of the great rise of pressure in the pulmonary artery. It is extremely hard in many supposed cases of this condition to be sure that we are not deaUng with that very frequent result of rheumatic carditis, aortic and mitral valvular disease combined ; but if this can be excluded and the diagnosis of secondary pulmonary insufficiency substantiated, it may be regarded as a bad sign in a case of mitral stenosis. It proves the existence of a high degree of circulatory obstruction ; and it also threatens overloading of the right ventricle. As a matter of fact, its prognostic importance is not as great as inight be expected, for it is only in cases of mitral stenosis that are obviously advanced, that one ventures on a diagnosis of secondary pulmonary regurgitation. In conclusion, the general principles of prognosis in chronic valvular disease may be briefly re-stated. 1. The valvular lesion is but a part of the picture ; it is the observer's duty to discover as far as possible the state of the whole heart, and of all the organs. 2. The outlook depends ultimately on the balance struck between valvular disability and myocardial capacity. To what extent is the latter capable of rising to the occasion ? 3. This question is best answered, speaking generally, by an intelligent exploration of the symptoms, and a search for evidences of myocardial ex- haustion. 4. It is particularly important to see what effect a period of rest has in restoring myocardial efflcicHcy before giving an unqualified prognosis in an apparently bad case. Carey F. Coombs. 230 INDEX OF PROGNOSIS HEART, CONGENITAL MALFORMATIONS OF.— In forecasting the future of a child or young adult who has been found to suffer from a developmental fault of the heart, the questions that have to be answered are. How long is he likely to live ? and Is there any chance of a useful career for him ? It would be possible to answer both of these questions with considerably more precision and confidence if it were possible in every case to discover the actual nature of the malformation. Unfortunately, such detailed accuracy is out of reach in very many cases, so that one's prognosis is founded on a varying admixture of knowledge of the defect present and the average duration of life in such cases, with observation of the symptoms as indices of the extent to which the efficient working of the heart is threatened by the disabilities imposed upon it by the errors in development. Average Expectation of Life in various Defects. — The following facts and figures are collected from the writings of Peacock, Maude Abbott, and others. The- lesion which is most readily, and therefore most often, diagnosed is pulmonary stenosis. Patients have been known to reach a good age with this defect, even after an active life. The writer recalls several such — a railway porter who at twenty-three was just beginning to be dyspnoeic, a cook who at thirty-seven showed her first signs of broken compensation, and a lady of over forty who leads a fairly active life. One case is on record in which the patient reached the age of fifty-two. These, however, are the exceptions. The average age at death in pulmonary stenosis is nine and in pulmonary atresia three. The co-existence of other lesions is a matter of some weight. Of cases in which an autopsy has been made, 56 per cent of those in which there was no associated defect of other parts of the heart ended fatally within the first two decades of life ; of those in which pulmonary stenosis was coincident with a defective auricular, but a perfect ventricular, septum, the percentage was almost the same ; of those in which there was an associated defect of the ventricular but none of the auricular septum, only 9 survived the age of twenty ; and of those in whom there were faults in both septa, none passed that age. Patency of the foramen ovale, without other defect, is a common and un- important fault, but it is rarely diagnosed, so that we are thus deprived of the pleasure we might otherwise enjoy of giving a favourable prognosis in the great majority of these cases. Patients with this fault have lived a normal life without knowing that there was anything wrong with them. The same is probably true of limited defects of the septum ventriculorum ; and since this is more readily detected it offers some small scope for the exercise of optimism, if one can be sure that no other defect of a more serious nature co-exists. Even when the septal faults are extreme and the heart is three-chambered, middle life may be reached. Of the other defects, congenital atresia of the tricuspid valve is apparently incompatible with survival beyond the first year of life. Only one-seventh of the cases in which a transposition of the great arterial trunks was found post mortem had passed the age of five. Patency of the ductus arteriosus, if uncomplicated by other deformities, is compatible with the attainment of middle life and fair activity. Coarctation of the aorta may remain latent throughout a normal life, being discovered only at the autopsy. Of the cases verified post mortem, 14 per cent passed the age of fifty. The gross defects of position, those in which the heart lies exposed owing to a thoracic defect, are incompatible with more than a ievr days of extra-uterine life, though one case is described in which life was apparently maintained for a few days by the expedient of oiling the heart every three hours. HEART, WOUNDS OF 231 Transposition of the heart, on the other hand, makes no difference whatever to the subject's expectation of Hfe, and the heart may even He wthin the abdomen, as in Deschamps' famous soldier, without being seriously incommoded. Significance of Symptoms. — There are two chief ways in which a malformation of the heart may be responsible for the patient's death : cardiac failure and intercurrent infections. The patient's liability to the former is directly depen- dent on the extent to which the cardiac defect embarrasses his systohc efficiency ; and in cases where the fault is on the right side of the heart, as it is in the great majority, this may roughly be measured by the degree of interference with the oxygenation of the blood. Thus, the more cyanosed the patient is, the worse the prognosis ; and the same generalization holds good for other evidences of imperfect aeration, such as clubbing of the fingers, dyspnoea, stunted growth, and polycythsemia. Of the intercurrent infections to which these unfortunate persons are prone, the most important are malignant endocarditis and certain pulmonary infections (tuberculosis and bronchopneumonia). The malformed heart seems to offer a ready home for streptococci and other organisms concerned in the production of ulcers of the endocardium ; and though there is some evidence that acute inflammatory lesions of the developmentally crippled heart may recover, it must be acknowledged that this is a very remote possibility. Consequently, anyone with a congenital heart lesion who presents the symptoms and signs of an acute blood infection, with or without evidences of embolism, is in a bad way. The vulnerability to tuberculosis is greater in those patients who have survived the first decade ; when contracted it runs a rapid course. The risk of this and the other pulmonary infections is of course increased if the patient's circumstances do not admit of his living a protected and sheltered life. Among the causes of death in cases of congenital heart disease, the possible importance of associated malformation in other organs must not be quite lost sight of. One of the writer's patients had pulmonary stenosis and Mongohan idiocy, but his death was apparently due to the toxic effects of a congenital dilatation of the colon. Sudden death is not a very common event in congenital heart disease, but cases of all kinds may end thus. It is impossible to lay down any rules for the foretelhng of such an event ; and with a malady which is already so crippMng to the patient's usefulness, it is probably better to say nothing about it. In patients with a patency of the interventricular septum and drainage of both ventricles by one arterial trunk, sudden attacks of dyspnoea and cyanosis are apt to cause great alarm ; here it is possible to assure the relatives that avoidance of the provocative factor (which is usually easy to discern) will ward off further attacks. To sum up, the prognosis in congenital cardiac defect is arrived at by making a diagnosis of the actual condition present as far as possible, and by filHng in the gaps by assessment of the degree of cardiac embarrassment as revealed by the symptoms. Carey F. Coombs. HEART, WOUNDS OF.— Until Rehn, of Frankfurt, in 1897, pubhshed his classical and successful case of suture of a wound of the heart, the injury was regarded as mortal, and treatment was in the clouds. To-day there are scores of recoveries on record. In England, where the promiscuous use of the knife as a means of setthng quarrels is not so common as on the Continent, the published cases are very few, and the writer is only aware of one success (Somerville). No doubt the immense majority of cases of wound of the heart are fatal within a few minutes, if not instantly, and this is especially true of gunshot wounds. 232 INDEX OF PROGNOSIS Even when thus produced, however, death may be delayed. In the very desk on which this is being written there reposes a pistol used by a suicide to shoot himself through the ventricle (verified at autopsy) ; as this did not have the desired effect, he afterwards turned the weapon upon his temple, and died of a pistol-shot through the brain. The cause of death in stab-wounds is not cardiac shock. The heart both of animals and man will withstand extraordinary ill-usage. The fatality is due to the mechanical obstruction of the diastole by effusion of blood into the pericardial sac. A heart which has almost or quite stopped beating has been restored by aspiration of the blood in the sac, and this should be borne in mind in deahng with patients apparently dead. ^>^ Turning to the records of operation, there are in the literature up to igi2 about 239 cases treated by suture, whereof 140 died and 99 recovered, a death-rate of 58-5'per cent. Probably the true death-rate is a little higher, some failures being likely to pass unreported. Success depends upon several factors. 1. It is essential, of course, that operation should be very prompt. 2. The mode of obtaining access is important. A flap with the hinge external is less likely to cause fatal double pneumothorax than one with the hinge internal. The stab wound has usually opened one pleura already. 3. Wounds of the auricle appear to be less dangerous than wounds of the ventricle. In Peck's series, the results were as follows : — Mortality in Wounds of Heart. Region Cases Died Mortality Auricles Left Ventricle Right Ventricle 11 74 69 4 45 48 per cent 36 HI 70 Death usually occurs on the table, or shortly afterwards ; but some cases ha\'e developed aneurysm (9 on record) or leakage of the suture line ; and suppuration has been responsible for some deaths, especially if the pericardial sac was drained. References. — Peck, Ann. Surg. 1909, 1, loi ; Pool, Ibid. 1912, Iv, 485. A. Rendle Short. HIGH TENSION, ARTERIAL.— (See Arterial Tension, High.) HIP, CONGENITAL DISLOCATION OF.— {See Congenital Dislocation of Hip.) HIP, TUBERCULOUS. — {See Arthritis, Tuberculous.) HODGKIN'S DISEASE.— (See Lymphadenoma.) HYDATID DISEASE. — Hydatid disease of the liver and other viscera in the upper abdomen will here be considered. Prognosis apart from Treatment. — The condition may last for many years without giving rise to trouble ; RoUeston mentions a patient who had been tapped for hydatid twenty years before, and in whom the cyst had recurred. But a hydatid large enough to be diagnosed is always a source of danger to the host, the principal risks being rupture and suppuration. HYDRONEPHROSIS 233 Rupture may be sudden, or a gradual leakage. Sudden rupture is often fatal. According to Cyr : from rupture into the peritoneal cavity, 90 per cent die ; into the pleural cavity, 80 per cent ; bile-ducts, 70 per cent ; bronchi, 57 per cent ; stomach, 40 per cent ; intestines, 15 per cent ; on the surface, 3 per cent. Occasionally the cyst may burst into the pericardium or inferior vena cava ; these are usually fatal accidents. If leakage takes place into the peritoneal ca\ity, an immense number of hydatids may keep on growing in the abdomen and pelvis. The writer has seen a patient whose abdomen had to be opened again and again for obstruction and pelvic pressure. Suppuration produces a large abscess of the liver which, apart from treatment, is likely to be fatal. Results of Treatment. — The principal methods of treatment are by aspiration and by enucleation of the cyst. Aspiration has the advantage of simplicity, but not of safety. Leakage through the puncture may follow and give rise to peritonitis or to dissemination, and there are cases on record where fatal haemorrhage has resulted. Although this treatment is often successful, the parasite is not always killed, and may grow again. Enucleation is both more certain and less risky. It is well to inject the cavity of the hydatid with a little corrosive subhmate solution to kill the scoUces and prevent dissemination if any fluid is spilled. Both after aspiration and after enucleation, but especially the former, curious symptoms, called by the French ' intoxication hydatique,' may be met with In the milder cases there is no m^ore than an attack of urticaria. In severe cases, which are however very rare, there may be collapse, convulsions, dyspncea, and death ^vithin a few hours, without urticaria. Inasmuch as this result has been met with even when it is certain that very little of the fluid could have been spilled, it is probably a variety of anaphylaxis. References. — RoUeston, Diseases of the Liver, Gall-bladder, and Bile-ducts, 1912, 410 ; Deve, Rev. de Chir. 1911, 513. A. Rendle Short. HYDRONEPHROSIS. — Prognosis in regard to Ufa in hydronephrosis depends on the following factors : (i) The nature of the obstruction ; (2) The condition of the second kidney ; (3) The presence of complications ; (4) The success of operative measures. I. The Nature of the Obstruction. — Hydronephrosis may be due to malignant disease of the bladder or other pelvic organ. In such cases the dilatation of the kidney is moderate in degree, and there is rarely the development of a large abdominal swelling. The obstruction is, however, bilateral, and on that account, as wall be seen later, the prognosis is grave. The chief factor governing the prognosis is, however, the malignancy of the growth causing the obstruc- tion. The growth in such cases is extensive, and from the point of view of radical cure is inoperable. The condition develops most frequently in maUgnant disease of the bladder, causing obstruction to the ureteral orifices. It is seldom that this stage is reached without sepsis being superadded, and pyonephrosis results. In malignant growths of the pelvic organs obstruction of the ureters takes place less frequently. It is surprising how the ureter may be surrounded by malignant growth and still remain pervious. Congenital hydronephrosis is usually due to obstruction in the urethra, although occasionally no obstruction can be discovered. The resulting dilata- tion of the kidney is bilateral, and the prognosis is very grave, death taking place soon after Isirth in most cases. Occasionally congenital hydronephrosis is unilateral, but in these cases other congenital lesions are usually present, such as cleft palate, congenital atony of the colon, or other conditions, which contribute to a fatal result in early life. 234 INDEX OF PROGNOSIS 2. The Condition of tlie Second Kidney. — This factor, which governs the prognosis in all diseases causing destruction of the kidney tissue, is especially important in hydronephrosis. a. Bilateral Hydronephrosis. — Of the various diseases which ma}^ affect the second kidney when one kidney is hydronephrotic, hydronephrosis is the most common. About two-thirds of cases of hydronephrosis are bilateral. In 665 collected cases, Newman found 217 unilateral and 448 bilateral. Bilateral hydronephrosis is a progressive and fatal disease. "When the obstruction remains unrelieved, death takes place after a period which varies greatly, but which always extends to several years. The cause of death is destruction of kidney tissue and resulting urjemia. The picture presented by the patient is one of gradual failure of the renal function. There is progres- sive emaciation, listlessness, headache, thirst, loss of appetite, and, in the later stages, vomiting v^dth complete anorexia, and recurring attacks of ureemia. The temperature, apart from intercurrent infection, is subnormal throughout. In some cases of bilateral hydronephrosis, few symptoms are observed until the very latest stages. A patient may have two hydronephrotic kidneys which form large abnormal tumours easily recognized by the eye, and appearing at different times or simultaneously, and yet present no symptom of renal failure, and enjoy good, if not robust, health. There is, however, the certainty that the balance of renal secretion may easily be upset by a chill or other cause, and death takes place rapidly from uraemia ; or that, if the recurring obstruc- tion remains unreheved, slow progressive renal failure will eventually supervene. The prognosis in bilateral hydronephrosis depends also upon the cause. Con- genital hj'dronephrosis, and hydronephrosis due to malignant growths in the pelvic organs, are, as already stated, beyond surgical aid, and are invariably fatal. Where the obstruction is remediable, as in urethral obstruction, stone, obstructing bands, vessels, valves, kinks, etc., the prognosis depends upon how far the destruction of renal tissues has been allowed to progress before operation ; in other words, upon the ability of the medical attendant to make an early diagnosis. The results of operation will be referred to later. b. Other Diseases of the Second Kidney. — In 8 collected cases of anuria following operation upon a hydronephrotic kidney, the second kidney was hydronephrotic in 2, atrophic in 2, the seat of nephritis in 2, and there was no second kidney in 2 cases. The prognosis in all these cases, apart from any operation, is very grave, and the fatal issue cannot be long delayed. 3. The Occurrence of Complications. a. Infection. — The most common complication is infection of the hydro- nephrosis, and this has an important bearing on the form of operation, and on the ultimate result of the disease. A hydronephrosis is dangerous to life merely from the destruction of kidney tissue. If infection is added, this destruction takes place more rapidly and completely, and further, the danger of absorption from a large pus-containing cavity is superadded. A very considerable proportion of cases of hj'dronephrosis eventually become infected. The entrance of bacteria may take place by way of the urethra and bladder after catheterization, but much more frequently the infection is haematogenous in origin. Whether infection takes place directly through the wall of the hydronephrosis from the overhang and occasionally densely adherent bowel, is not certainly known. It appears likely that infection may take this route. It may be of a mild character, so that the contents of the dilated kidney are cloudy, and the deposit small in amount ; such an infection does not endanger life from absorption, or militate against the success of plastic opera- tions on the kidney. On the other hand, the infection may take a more active HYDRONEPHROSIS 235 form, and the dilated kidney contain a large quantity of pus, while there are a high swinging temperature and other signs of toxaemia. The prognosis in such a case is much more grave, death taking place in unrelieved cases from toxic absorption, or from this combined with uraemia. It is rarely possible to operate in such cases with the object of preserving the remaining kidney sub- stance, and the choice lies between a palliative nephrotomy and nephrectomy. b. Rupture of Hydronephrosis.— This is by no means common, and is almost invariably the result of injury, although this may occasionally be of a trifling character. In children, rupture into the peritoneal cavity may take place, causing fatal peritonitis ; in the adult the rupture is extraperitoneal, and may cause death from suppression of urine. Recovery may, however, follow prompt operation. c. TJrcemia. — This is the last stage of hydronephrosis when the second kidney is absent, or so far diseased as to be incapable of performing the renal function. 4. The Success of Operative Measures. — The success*, or failure of operation for the removal of obstruction in the urethra, bladder, or renal pelvis depends upon the nature of the obstruction. Nephrotomy has been performed in congenital bilateral hydronephrosis, without averting a fatal result. It may be used as a preliminary to plastic operation on the kidney. Nephropexy, nephrolithotomy, the removal of bands and of aberrant renal vessels, and plastic operations on the renal pelvis, its outlet, and the ureter, may be required. The degree of success attending any of these operations depends upon the early diagnosis of hydronephrosis. It is now possible by means of p5'-elography to make a diagnosis before the kidney has reached such a size that enlargement can be detected on palpation of the abdomen. If this is done and the obstruc- tion remedied, the kidney can be saved with little damage to its secreting substance. In the later stage of hydronephrosis, when a palpable tumour can be detected in the abdomen, the kidney tissue is expanded and much destroyed. The removal of the obstruction does not restore the kidney to its normal state, and only saves what remains of the secreting substance. In the fully developed hydronephrosis, when the layer of kidney tissue is reduced to half an inch or less in thickness, the organ still retains a considerable degree of functional power. I have operated on both kidneys in a case of bilateral hydronephrosis, when each organ was reduced to a thin shell, and the patient is well and without renal symptoms four and a half years after the operation. There are cases of bilateral advanced hydronephrosis in which the patient has lived for many years, and there are other cases where a solitary kidney has been converted into a hydronephrotic sac, and yet carried on a renal function sufficient to maintain life. Schloffer collected 86 plastic operations with the following results : — Operation Cases Deaths Failures Section of valves Uretero-pyeloplasty Uretero-pyeloneostomy Lateral anastomosis (ureter) Plastic operation in renal pelvis .... Pyeloplication Orthopajdic resection - Combined operations - 12 18 19 13 1 4 8 11 1 1 2 2 1 3 4 fi 3 1 86 7 17 235 INDEX OF PROGNOSIS Nephrostomy, or incision and drainage of the sac, without any attempt to overcome the cause of the obstruction, is sometimes performed. It is said to have resulted, in from 30 to 45 per cent of cases, in re-estabhshment of the flow of urine through the ureter and heahng of the nephrostomy wound ; in the remaining cases a fistula persisted. Primary'' nephrectomy is only indicated when the sac is very large and its wall so thin and fibrous that no renal tissue is present, and should only be undertaken when it can be proved that a second kidney is present and efficient. Kiimmel performed nephrectomy on 35 cases of unilateral hydronephrosis, with. I death, and the late results of the operation were uniformly good. /. W. Thomson Walker. IDIOCY. — {See Mental Diseases.) IMPERFORATE ANUS. — [See Anus, Imperforate.) INFANTILE CONVULSIONS. — Convulsive attacks, with symptoms more or less resembling those of epilepsy, may occur in infants of various ages. Here, as in aU other diseases, the prognosis depends upon the accuracy of diagnosis of the underlying cause. In newly-born children, con\ailsions may occur immediately after birth, or within a few days. They are specially common after a prolonged and difficult labour, and first-bom children are, therefore, more hable to such convulsions than later-born children. In these birth -convulsions, the convulsive movements, if hmited to one side, are strongly suggestive of a cortical haemorrhage, generally from rupture of meningeal veins. If such hemorrhage be so severe as to produce structural changes in the cerebral cortex, the unilateral convulsions are likely to be followed by permanent hemiplegia, more or less profound. Bilateral cortical hsemorrhages, from the same causation, produce bilateral symptoms of the same kind, and are amongst the commonest causes of bilateral hemiplegia (diplegia). As birth-haemorrhages are generally situated on the vertex, the cortical centres which are situated nearest to the middle hne — ^i.e., the centres for the lower hmbs — are most severely affected ; hence the resulting hemiplegia or diplegia is usually most intense in the legs. Other newly-born children suffer from convulsions which are apparently the result of excessive venosit}^, or other morbid condition, of the blood, without actual cortical haemorrhage. Such children are cyanosed, and may be severely convulsed, but the convulsions do not show the same constant commencement on the same side ; they vary in their mode of onset, starting sometimes on one side, sometimes on another. In such cases, the prognosis as to the absence of subsequent paralysis is better than in persistently unilateral convulsions. Many cases of generahzed con\Tilsions occur later in infancy, independent of any evidence of difficult labour. Such cases are most commonly toxic in origin, e.g., during attacks of diarrhoea from dietetic faults. In these cases, if the gastro- intestinal irritation be treated by suitable food and intestinal antiseptics, the convulsions rapidly subside ; nor do they tend to recur or to have any paralytic sequelae. Still later in infancy, at the age of eight or nine months, we meet with so-called ' teething convulsions.' Doubtless the irritation of the first dentition is an exciting factor, but the predisposing and underlying cause is usually rickets. Convulsions in rickety children are generally bilateral. In severe cases, they may resemble an epileptic fit ; in other cases, the symptoms are much less severe, consisting in sudden pallor of the face and lips, with fixation of the ej^es, and some- times transitory squint, the limbs and trunk meanwhile becoming rigid ; in other INFANTILE PARALYSIS 237 cases again, clonic movements appear, especially in the face, hands and feet. Whatever be the particular variety of symptoms present, they are always bila- teral. Unilateral spasms generally indicate focal disease, and have an entirely different prognosis. The onset of any acute fever in an infant may be accompanied by convulsions ; these are generalized and bilateral, and do not tend to recur after the temperature has become normal. Even in the absence of fever, conditions of temporary cyanosis — e.g., during a paroxysm of whooping-cough — may cause a generalized convulsive attack. Convulsions of unilateral distribution, often associated with high temperature and delirium, indicate a localized cortical lesion of some sort, most commonly due to the virus of acute polio-encephalitis. If the morbid process destroys a portion of the motor cortex, it is followed by a corresponding permanent hemiplegia or monoplegia of the face, arm, or leg, as the case may be, such weakness varying in intensity from a sUght paresis to a profound hemiplegia. Moreover, in this variety of infantile hemiplegia, there is a subsequent tendency to recurrent- convulsions on the hemiplegic side of the body. In the convulsions of meningitis — tuberculous, meningococcal, etc. — the prognosis is that of the underlying disease. In cases of this sort, examin?tion of the cerebrospinal fluid gives us valuable diagnostic and prognostic indications. {See Meningitis.) Purves Stewart. INFANTILE DIARRHCEA.— (See Diarrhoea, Infantile.) INFANTILE PARALYSIS. — Pohomyehtis anterior used to be regarded as a disease per se, but recent observations have now established the fact that it is but one variety of a wider-spread malady of infective origin, which attacks the central nervous system and its meninges, having a selective action upon the motor nerve- cells. When the brain cortex is affected, we call the disease polio-encephahtis superior ; when the motor nuclei in the bulb are attacked, we call it poho- encephalitis inferior ; and when the anterior cornua of the spinal cord are affected, we term it pohomyehtis anterior. Polio-encephalo-myelitis, then, is a febrile disease. It has an incubation period of six to eight days, and a febrile phase lasting about three or four days. The muscular paralysis appears during the stage of pyrexia. If the cortical motor cells are affected (polio-encephalitis superior), there are usually convulsions at the start ; these subside, and may leave the child monoplegic, hemiplegic, or diplegic, according to the extent of permanent cortical destruction. If the cells of the spinal cord are mainly attacked (poliomyelitis anterior), there is a widespread flaccid paralysis of the trunk and limbs, varying in distribution in different cases, and corresponding to the extent of grey matter that is affected. The initial paralysis reaches its maximum in a few hours, and is always more widespread than the permanent residuum of muscular atrophy ; for many of the nerve-cells during the acute stage of the disease are merely affected by inflam- matory and cedematous changes, and if there is nothing beyond an inflammatory oedema, there is a possibihty that the cells may still recover. If, however, some of the nerve-cells are actually destroyed by the inflammatory process, as is generally the case, the corresponding muscle-fibres undergo permanent atrophy and paralysis. It v.dll be seen, from what we have said, that the prognosis of this disease differs according to the stage at which it comes under observation. During the acute febrile stage, if there is no implication of the vital medullary centres, and the patient survives, the probabilities are that the paralysis will, in 238 INDEX OF PROGNOSIS time, clear up to a certain extent. It is even possible that if the cells have been merely oedematous, and not actually destroyed, they may all recover, and the initial flaccid paralysis or paresis of the limbs or trunk clear up completely. This, however, is uncommon, and it is more usual to find that, whilst some muscles re- cover, other muscle-groups remain feeble and undergo wasting, indicating that destructive changes have occurred in the anterior cornual cells. When the acute febrile stage has passed off, the question of the amount of permanent recovery arises. This question is best answered by a consideration of the electrical reactions of the affected muscles, especially the faradic reactions. We wait until ten days, at least, have elapsed from the time of onset of the paralysis, in order to allow time for degenerative changes in the nerve-cells and muscle-fibres to be recognizable. After ten days or a fortnight, when some of the muscles have recovered voluntary power, whilst others are still flaccid and paralyzed, we proceed to examine these paralyzed muscles electrically. Those which still react to faradism will ultimately recover, those in which faradic excitability is lost will probably remain permanently paralyzed. Other muscles, again, show mere diminution in faradic response ; these will recover to some extent. The recovery of those muscles which are recoverable will be hastened by assiduous skilled massage and passive movements. If the patient is already in the chronic stage by the time he comes under observation, we have now to deal with the relics of an antecedent disease. Presuming that all the surviving muscles have been brought to their maximum development by a preliminary course of suitable massage and electrical treat- ment, lasting six months or longer, we have now to consider the prospects of preventing or diminishing deformities, and of enabling the patient to make some use of his paralyzed limb. This is largely a matter for the ingenuity of the orthopaedic expert. When the limb is flaccid and flail-like, the question of fixation of certain joints arises. This can sometimes be accomplished by arthrodesis; at other times by the application of a light splint, preferably made of celluloid. In other cases again, where the muscles on one aspect of a joint are paralyzed, whilst their antagonists are still active, transplantation of the insertions of muscles or tendons from the healthy to the paralyzed aspect of the joint, together with division or lengthening of shortened tendons, may serve to restore a certain measure of useful mobility to a joint, and to correct deformities. Surgical measures, however, should not be thought of until the limb has had a previous thorough course of massage and passive movements for several months at least. It is astonishing how often a limb, which at first seemed hopelessly paralyzed, recovers part of its motor power, without the necessity for surgical interference. {See also Talipes.) Purves Stewart. INFERIOR VENA CAVA, WOUNDS OF. — The inferior vena cava is occasion- ally ruptured by contusion of the abdomen, and this is a cause of very rapid death. The writer has seen one such case. The effusion of blood was very small, but apparently the heart failed because it received an inadequate quantity. The inferior vena cava has several times been torn in removing a right kidney. Albarran considers that the best treatment is to ligature it ; he collects from the hterature records of 5 cures and 2 deaths following this procedure. A. Rendle Short. INFLUENZA. — The prognosis in influenza depends primarily on the virulence of the organism, which varies greatly in different epidemics. Uncomplicated influenza is rarely dangerous to life. The mortality in the epidemic of 1889- 1890 was in Munich o-6 per cent, in Mecklenburg-Schwerin 1-2 per cent, in Leipzig 0-5 per cent, in the German army 01 per cent, in fifteen Swiss towns INFLUENZA 239 o-i per cent. These figures do not include cases of death from influenzal pneu- monia. The mortality from this varies from 15 to 26 per cent. The increase in the general mortality-rate during an epidemic of influenza is chiefly due to increased mortality from acute diseases of the respiratory organs, and to a rise in the death-rate of pulmonary tuberculosis. In the whole of Germany during the epidemic of 1 889-1 890, about 66,000 succumbed. Owing to the more malignant character of subsequent epidemics both in England and Germany, the death-rates were higher. Thus, deaths from influenza in London from January to March, 1890, were 558 ; from May to July, 1891, 2104 ; from January to March, 1892, 2078. The influenzal bacilli may remain for a long time in the sputum in phthisical cases, especially in patients with pulmonary cavitation, whereas they generally disappear after a few days in a typical acute case arising in a previously healthy person. In some cases the initial symptoms are extremely severe and sudden in onset. For example, the disease may be ushered in with convulsions, coma, severe vertigo, or even acute mental symptoms, and yet the patient may be well in a few days. As a rule, after an uncomplicated attack, the patient passes through a rapid convalescence ; but in other cases, when the course of the illness has been apparently in all respects identical, convalescence is extremely long and tedious, owing to great debility, loss of energy both bodily and mental, insomnia, anorexia, and gastric disturbance. Influenza is prone to relapse after a few days' interval, and not very infrequently the relapse is much more serious than the original attack. Moreover, pulmonary trouble, which was at first absent, may now supervene. With reference to the pulmonary form, in addition to the prognostic points common to any form of pneumonia, a guarded prognosis should be given even when the temperature has fallen to normal, as it is not very unusual to have a second or even a third pneumonic attack following closely one on the other. A particularly fatal form is that of acute hypersemia of the lungs, associated with dyspnoea and cyanosis, sometimes with sanguineous sputum, but without pneumonic change. Such patients very often die after a few days with cardiac asthenia and tachycardia. In some cases, resolution of the pneumonic lung may be delayed for weeks, sometimes even for months, after which the lung may become completely clear. It is well, therefore, not to be too premature in asserting that the patient is suffering from an indurative pneumonia, or, if the lesion happens to be at the apex, that the patient is becoming tuberculous. On the other hand, an influenzal infection certainly does not infrequently pave the way for a tuberculous lesion. Further, latent phthisis may become active, and healing foci break out afresh. Phthisical patients show a special predisposition to influenza, and influenzal patients to an increase of any tuberculous lesion present. With reference to the prognosis of influenzal encephalitis, it is usual for the resulting paralysis to clear up entirely if the patient does not succumb to the severity of the attack. The prognosis is grave in cases, which generally occur in children, which assume all the characters of meningitis, including con- vulsions, headache, vomiting, coma, cervical rigidity, strabismus, mydriasis, inequality of pupils, grinding of teeth, bradycardia, and irregular respiration. According to some authors, the prognosis of influenzal epilepsy is decidedly better than in many other forms. The prognosis of uncomplicated influenzal psychosis is as a rule favourable, but it may last for weeks, or even months. Influenza occasionally exerts its influence almost entirely on the heart, and when this occurs the outlook is very grave. There is a great tendency to syncope. 240 INDEX OF PROGNOSIS the pulse is rapid, irregular, and feeble, with pallor, precordial distress, and sometimes sweating. When recovery takes place, convalescence is extremely tedious as a rule, and is associated with prolonged disturbance of the heart's action: this is generally rapid and irregular, though sometimes bradycardia with intermittent action persists. An attack of influenza influences patients suffering from diabetes very unfavourably, and they not infrequently die in coma. It may also lead to abortion in a pregnant woman, and in this way render the prognosis exceedingly grave if pneumonia is also present. In some rare cases, repeated rigors occur throughout the course of the illness. These may arise without the formation of pus, pneumonia, or obvious visceral changes, and although the prognosis must be guarded, owing to the severity of the cases, too gloomy an outlook should not be given. j. 7j. Charles. INSANITY.— (See Mental Diseases.) INTESTINAL OBSTRUCTION.— Under this heading we shall include cases of acute intestinal obstruction due to cancer, faecal impaction, bands, apertures, Meckel's diverticulum, and volvulus. Intussusception, strangulated hernia, and chronic obstruction due to cancer of the colon or rectum, are dealt with in other articles. The most essential element in the prognosis is to make a careful distinction between faecal impaction and organic obstruction. Many cases of simple impac- tion recover with ordinary treatment such as purgatives and enemata ; when organic obstruction is present, recovery apart from operation is next to impossible. In practice, however, the distinction between the two may be extremely difficult, and most surgeons have seen a patient refuse a laparotomy, and recover never- theless. Of course, if a mass of hard faeces can be felt in the rectum or colon, or if copious enemata immediately bring away a large evacuation, the diagnosis is clear. The difficult cases are constipated elderly people with a swollen or fat abdomen in which nothing can be felt, who have vomited once or twice, and are not relieved by enemata. It is much safer to explore the abdomen, if enemata fail and nothing can be felt in the rectum, without waiting to see if spontaneous recovery will take place. It is probable that in a few rare instances the bowel has escaped, by some lucky accident, from an organic strangulation ; but almost invariably it is paralyzed soon after it becomes ensnared. Still, these occurrences will lead a practitioner who values his reputation not to be too ' cock-sure ' in threatening death to a patient who refuses operation. The practical rule, however, is that if repeated enemata fail, and vomiting, abdominal pain and distention, and constipation are present, death within a few days is all but certain, apart from operation. One ought not to wait for faecal vomiting ; that is a death-door phenomenon. Patients with foul vomit may recover after operation ; those with vomit smelling of faeces, very, very seldom. The most common cause of death is toxaemia, then peritonitis, and occasionally lung complications. Death on the table from inhaling foul vomit is by no means a negligible cause of fatality. Results of Operation. — It is not easy to gauge accurately the present-day mortality of intestinal obstruction treated by surgical means ; cases are operated on at all stages, for so many types of obstruction, and in so many different ways. Some statistics, such as McClannan's, are complicated by the inclusion of an unspecified number of strangulated hernia cases. The most reUable figures available are the records for the years 1887 to 1907 from St. Thomas's Hospital, and those published by Gibson, though they are by no means recent. By a INTESTINAL OBSTRUCTION 241 combined study of the literature and hospital reports, Gibson published in 1910 the results of 646 cases, whereof 312 died, that is, 47 per cent. This includes patients with intussusception, but does not include cancer. Treves (1899) and Moynihan (1906) both agree that the actual mortality is probably 50 per cent, but Moynihan declares that this is a reproach, and that " anything over 10 per cent is the mortality of delay." In the St. Thomas's figures the death-rate in simple cases was 56-7 per cent, and in inahgnant cases 65 per cent. How much the time of operation influences the death-rate is shown by Gibson's figures, as given in the following table (the figures do not include intussusception, hernia, or cancer). Mortality according to Day of Operation. Day of Operation Cases Died Percentage First - - - - 16 6 . 37 Second 44 17 38-5 Third - 61 25 41 Fourth - - . 70 27 38-5 Fifth - - - - 62 30 48 Sixth - . - - 44 29 66 Seventh 28 15 53-5 Later - - - - 107 59 55 The Varieties of Obstruction. — We must now take up each form of obstruc- tion separately. Fcecal impaction and foreign bodies produce a form of obstruction which is relatively favourable, and which will usually yield to simple measures such as enemata. Death from faecal impaction is very unusual, unless the patient is utterly neglected. It is astonishing how long they may survive without an action of the bowels ; one patient, reported by Harris, was seen fifty-three days after the last evacuation ! Obstruction by bands or kinks is not favourable, because the small intestine is involved. The higher the block, the worse the outlook. According to Treves, the average length of life is about five days, the extremes being eight hours and twenty days. In Gibson's 186 cases, 41 per cent died. The treatment was usually division of the band ; on 17 occasions resection was necessary ; and an artificial anus was made in 22. Practically all these last died. Of 102 cases at St. Thomas's, 35 recovered and 67 died. Volvulus, when not treated by operation, has an average duration of six days, the extremes being sixty-four hours and twenty days (Treves). Corner and Sargent, reporting on 57 cases from St. Thomas's Hospital over many years, found 19 recoveries and 21 deaths. Gibson gives the death-rate as 54 per cent : when the loop was untwisted, 31 out of 79 died ; when resected, 13 out of 16 ; when an artificial anus was made, the fatahties amounted to 16 out of 20. Finsterer, using the published records of various German and Austrian surgeons, believes that resection gives better results than detorsion. In his whole series (up to 1912) of no cases, 37 per cent died; resection and imme- diate end-to-end anastomosis had a mortality, if the gut was not gangrenous, of only 7 per cent in 29 cases. It is difficult to accept tliis as a fair representation, however. Most surgeons consider end-to-end anastomosis in the presence of acute obstruction very dangerous. Finsterer's cases probably include a dispro- portionate number of pubhshed successes. 16 242 INDEX OF PROGNOSIS Jankowski has reported 5 cases of volvulus of the caecum, of which 2 were cured and 3 died ; he also reported 48 cases of volvulus of the pelvic colon operated on in Riga during ten years (1903-1913). The results are shown in the following table : — Results of Operation for Volvulus of the Pelvic Colon (Jankowski). Operation Cases Cured Died Detorsion and fixation of mesocolon - Enterotomy and fixation Short-circuiting (caecum to rectum) Resection of loop ----- Gangrene already present 11 4 6 3 24 11 3 1 2 2 1 5 1 22 Gall-stone impaction, for some reason or other, is not as favourable as one would have thought. In Gibson's series of 40 cases, 57 per cent died ; and in two long lists of 280 and 105 respectively, quoted by Treves in 1899, the mortality was about the same [see Gall-stones). These statistics are all somewhat ancient. Meckel's diverticulum caused obstruction in 42 of Gibson's cases, and 62 per cent died. Division or excision was practised 30 times, with 17 deaths ; resection of bowel 5 times, with 4 deaths ; and an artificial anus was made in 4 cases, with 3 deaths. At St. Thomas's Hospital, 14 out of 22 died. Mortality according to Form of Obstruction (Gibson.). Cause of obstruction Foreign bodies Bands Volvulus - - Gall-stone impaction Meckel's diverticulum Bowel snared in openings or fossae per cent 16 25 186 41 121 54 40 57 ■ 42 62 34 62 Results of Operation for Intestinal Obstruction at St. Thomas's Hospital, 1887-1907. Nature Total Recovered Died Mortality per cent Intussusception . . . . Volvulus - - _ - Broad peritoneal adhesions Cicatricial bands . . - - Mesenteric holes . . - - Meckel's diverticulum Cicatricial stricture Gall-stone impaction Various - - - - 202 29 60 42 9 5 26 109 10 24 11 8 1 1 9 93 19 3() 31 5 14 8 4 17 46 65-5 60 74 100 64 89 80 65 Malignant disease of bowel - 400 137 173 48 227 89 56-7 65 INTRACRANIAL COMPLICATIONS OF EAR DISEASE 243 Incarceration in openings or retroperitoneal hernia is also a serious condition. In Gibson's series of 34 cases, 62 per cent died. During the past eight years, however, of 15 cases found in the hterature, 10 were cured by operation, including one of my own. A cancerous growth is, unhappily, one of the commonest forms of acute intestinal obstruction. At St. Thomas's Hospital, out of 137 such cases, 65 per cent died. The growth in the great majority was situated in the sigmoid or rectum. In Paul's series of 24 private cases, treated by colostomy, 9 were fatal. Of 23 cases at the Bristol Royal Infirmary all suffering from acute obstruction, and excluding patients with a band, hernia, gall-stone, volvulus, or intussuscep- tion, 6 died ; these were nearly all suffering from cancer of the bowel treated by colostomy. (For further progress of the cases, see Colon, Carcinoma of.) The Prognosis in Individual Cases.^There is a remarkable sex difference ; the mortality in women is only 33 per cent, against 54 per cent in males (Gibson). This is difficult to explain. The principal factors in judging the prognosis in any particular case are (i) The time of operation ; (2) The nature and frequency of the vomiting ; and (3) The presence or absence of gangrene when the abdomen is opened. 1. The importance of early operation has already been emphasized. The first two days are relatively favourable ; after the fifth day the chances are against survival. 2. The nature and frequency of the vomiting is very important. A high-up obstruction, near the duodenum, causes very frequent and urgent vomiting, without much distention of the abdomen, and the vomit becomes foul but not fscal ; these cases are very fatal unless operated on early. When the obstruc- tion is low down in the colon or rectum, vomiting is late and infrequent, and there is more time before the patient passes bej^ond the reach of surgical help. If the vomit becomes foul, the outlook is grave ; if fscal, it is almost hopeless. 3. // a gangrenous area is found at the operation, the chances of recovery are small, but not hopeless. A ' chesty ' patient, or one suffering from grave toxaemia, is not likely to be saved, and the advent of peritonitis is practically a death-warrant. The method of giving the anaesthetic and of conducting the operation counts for something. If there is incessant vomiting or bronchitis, intraspinal or local anaesthesia is probably safer. It is very important to operate quickly, and to empty the distended, paralyzed coils of bowel by Moynihan's tube or some similar device. Physostigmine salicylate and pituitary extract will probably reduce the mortality a little by averting post-operative intestinal palsy. References.— Gibson, Ann. Surg. 1900, xxxii, 486; Treves, Intestinal Obstruction, 1899 ; Moynihan, Abdominal Operations, 1906 ; Finsterer, Arch. f. klin. Chir. 19 12, 010 ; Paul, Brit. Med. Jour. 1912, ii, 172 ; Jankowski, Deut. Zeits. f. Chir. 1913, Sept. ; ^'lakins, Burghard's System of Operative Surgery, ii, 521. A. Rendle Short. INTESTINE, INJURIES OY.—{See Abdominal Injuries.) INTRACRANIAL COMPLICATIONS OF EAR DISEASE.— It is stated" by Haseler that of 81,684 cases of suppurative otitis media, 116 died of various intracranial complications (lateral sinus thrombosis 48, meningitis 40, abscess 28), a percentage of about 0-14. Some London figures agree with this. The risk, therefore, is about i in 700. It is very difficult to find in the literature a sufficient number of reliable records by which we may judge the prognosis of these affections. Some statistics arc altogether too favourable ; in others a few successes have been reported and 244 INDEX OF PROGNOSIS many failures overlooked. It must be remembered that, in practice, two intra- cranial complications often exist together, and obscure both the diagnosis and the prognosis. Lateral Sinus Thrombosis. — Apart from operation, these patients nearly all die of pyaemia or meningitis, the duration of life varying from two to six weeks. Natural recovery does occasionally take place, but it is rare ; the writer has seen one case. The prognosis depends upon early operation, but patients may occa- sionally be saved even after abscesses have formed in the lungs. According to Hunter Tod, about a third of the patients operated on recover. Macewen's results were much better than this (20 out of 28). At the Bristol Royal Infirmary, 5 patients out of 1 1 recovered ; some of the fatal cases had an abscess as well. No doubt earlier diagnosis would improve the prospects very much. I have interviewed three patients some years afterwards. One was quite cured ; another suffered for months from pyaemia, and then recovered except for otorrhcea ; the tliird complained of persistent giddiness, due to labyrinthitis. Extradural Abscess. — All five of Macewen's cases recovered ; but in practice many of these patients die, in spite of operation. Abscess of the Cerebellum or Temporosphenoidal Lobe. — Unfortunately the difficulties of diagnosis, especially of cerebellar abscess, are very great. The classical signs, nystagmus, ataxia, or atonia, are very frequently absent ; optic neuritis is inconstant ; and the subnormal temperature is only present in about half the cases. At the Bristol Royal Infirmary during ten years, 6 cases of cerebellar abscess were missed, but of 8 cases of temporosphenoidal abscess a successful diagnosis was made in every instance. In our experience, the main point in the prognosis is to operate within three days of the onset of drowsiness (not coma). Of ^ cases so treated, 3 recovered ; later than the third day none recovered. The prognosis after operation is very much better in temporosphenoidal than in cerebellar abscess. Once again Macewen's results are much better than those ordinarily obtained ; but according to the statistics of Henke and of the Bristol Royal Infirmary, from a third to half of the patients may be saved in cerebral cases, and a quarter or less (7 out of 28 in Politzer's clinic) of the sufferers from cerebellar abscess. Of 100 patients treated at the London Hospital during ten years, 20 temporosphenoidal and 10 cerebellar cases recovered ; probably this is abnormally bad. Milligan's series of 27 operations for cerebellar abscess at Manchester during ten years is very gratifying, 17 being saved and 10 djdng. After operation the patient may remain in a drowsy state for days, and yet recover if the pulse and temperature are normal ; but symptoms often return and end fatally. If the patient recovers, there is some fear of persistent liability to convulsions ; the writer has seen one such case. Mortality in Cases of Intracranial Complications of Ear Disease treated by operation. Lateral Sinus - Thrombosis Ceeebeal Abscess Cerebellak abscess Cases Deaths KecoY- eries Cases Deaths Eeoov- eries Cases Deaths Recov- eries Macewen . - - - Henke - .... Bristol Royal Infirmary - Politzer's Clinic Milligan - 28 11 8 6 20 5 9 37 10 I 20 7 8 17 3 4 10 4 28 27 9 4 21 10 4 1 7 17 INT USS USCEPTION 245 Meningitis. — The onset of evidence of meningitis (head-retraction, Kernig's sign, nerve-palsies, irregular fever) is usually a death warrant, but a few cases have undoubtedly been saved. Macewen operated on 6 out of 12 cases where there was intracranial meningitis only, and saved them all ; only i out of 6 patients with cerebrospinal meningitis recovered. The writer has seen a case saved by operation and drainage, combined with repeated lumbar puncture. Urotropine probably helps. References. — Macewen, Pyogenic Diseases of the Brain and Spinal Cord ; Neumann, Cerebellar Abscess (Lake's translation) ; Hunter Tod, " Intracranial Complications of Ear Disease," Burghard's System of Operative Surgery, iv, 429 ; Milligan, Brit. Med. Jour. 1914, ii, 833. ^. Rendle Short. INTUSSUSCEPTION.— It will be necessary to consider, first, the acute intussusceptions, usually of children ; and, secondly, the chronic intussuscep- tions of adults. Acute Intussusception. — There is a natural cure of intussusception by sloughing of the intussusceptum. It is very difficult to arrive at any idea of its true frequency. Wiggins (quoted by Childe) puts the spontaneous cures at approximately i per cent ; but there is always the probability that such a curiosity would turn up witk undue frequency in the medical literature. The main point is that it is an event of excessive rarity in infancy ; only 8 per cent of the recorded cases were in children under eight years of age. In adults it is not so very infrequent, and the slough may come away several weeks afterwards. A few cases die (said to be 3 per cent) even after passage of the slough. Apart from this very exceptional occurrence, the average length of life, in infants, is about three days. Cases have died within nine hours. Three or four reports in the literature appear to suggest that an intussusception may in very rare cases reduce itself spontaneously. Cure by Injection of Water is now attempted by very few surgeons, because it often fails even in early cases, and it is impossible to tell for inany hours whether it has succeeded or not, so that the necessary operation may be dangerously delayed. Clubbe, of Sydney, tried it in 138 cases, but it was only successful in 14 of these. In Copenhagen, it is apparently the routine to treat cases of intussusception by injection of water under an ansesthetic, even two or three days after the onset. Koch and Oerum have furnished details of 397 cases, 60 per cent under twelve months old, treated between 1880 and 1909. One to two pints are injected with an enema syringe, and then taxis is used. Deep anassthesia is required. In 2 cases the bowel was ruptured. In the worst cases only, a pri- mary operation is performed. If the injection fails, a secondary operation is undertaken. Results of Treatment in Copenhagen by Injection under Chloroform. Cases Cured by injection Failed and had operation Total Cured Total Lived Died Died Under 12 months Over 12 months 187 114 87 (i5 13 24 39 10 100 89 87 25 Total 301 152 37 55 189 = 03 % 112 = 37% Set forth as they are in the authors' tables, the results of injection of course appear to be much better than those of operation. We have recalculated the 246 INDEX OF PROGNOSIS figures according to the data furnished, so as to be able to compare the conse- quences with those of the English school of practice. It will be observed, first, that about half the cases are capable of cure by injection and taxis under an anaesthetic, but secondly, that the eventual results are not so good as the figures furnished by St. Bartholomew's Hospital or by Clubbe. When it is remembered that the injection method was only used for the more favourable type of patients, and that in 65 graver cases primary opera- tion was performed, it is clear that the Danish figures do not establish a powerful argument for bloodless measures. It must further be borne in mind that perhaps a few recoveries were not cases of intussusception at all. If it is pos- sible to administer an anaesthetic, it is usually also possible to operate. Reduction of the Intussusception by Operation is the routine treatment. Judging by the published statistics, about two-thirds of the cases recover and one-third die. Records are given in the table of 59 children treated by reduction at St. Bartholomew's Hospital from 1901 to 1911, 124 cases operated on by Clubbe, and 46 cases of all ages similarly treated at the Bristol Royal Infirmary from 1903 to 1912. The St. Thomas's Hospital figures are less favourable, but they go back to 1887. Table of Cases of Acute Intussusception treated by Laparotomy and Reduction. St. Bartholomew's Hospital* Clubbet Bristol Royal Infirmaryf - St. Thomas's Hospitalf 59 116 46 202 46 = 78% 83 = 73% 28 = 61% 109 = 54% 13 = 22% 00 2tD /Q 18 = 39% 93 = 46% 60 73'3 57-5 26-6 •Children only. tAU ages. The success of treatment depends principally upon early diagnosis. Childe quotes 123 Glasgow cases, of which — Operation within 6 hours gave . . 60 per cent cured. 6 to 12 hours gave ,, ,. 12 to 24 ,, ,, ., 24 to 48 ,, ,, Acute cases operated on after forty-eight hours nearly all die, but there is a more chronic type, in which the results are fairly favourable; thus, 8 out of 12 such at St. Bartholomew's recovered. The higher death-rate within the first six hours than in the next six -hourly period is a common phenomenon in the records of abdominal surgery ; it must not be used as a plea for delay, as it means no more than that the ultra- acute cases are soonest diagnosed. Prognosis in older persons is worse than in infants ; thus, in the St. Bartholomew's Hospital series, of the patients over two years, 9 out of 19 died, and of those under two, only 24 out of 68. Treatment by Resection is a last-resort method, and usually leads to a fatal result. There are a few instances of successes on record. At the discussion in 1910 at the Royal Society of Medicine, 4 cures were mentioned, 2 aged two and four respectively, at the Queen's Hospital for Children, and i aged seven months at Great Ormond Street, under spinal analgesia. Clubbe reports a recovery in a child of eleven months ; 7 other resected cases all died. The writer has seen a recovery in a young man with acute intussusception, in whom five feet of gut were resected by Hey Groves. Four out of 24 resection cases, all patients over a year old, recovered in the Copenhagen series. JAWS, TUMOURS OF 247 Relapse is uncommon. The only case which has come under the writer's notice is one in which an appendicostomy was performed, partly for feeding purposes, and partly to prevent relapse ! Prognosis in Individual Cases depends largely upon the length of time before treatment is instituted ; over twenty-four hours turns the chances against the child. Much vomiting, listlessness and lack of interest, and a depressed fonta- nelle are all grave signs. There does not appear to be much evidence that one anatomical variety of acute intussusception is more dangerous than another. Chronic Intussusception. — This rare disease is usually of grave import, because it is likely to be diagnosed late, and reduction will probably be impossible. Of 6 cases treated by resection at St. Bartholomew's Hospital (1873-1908), i recovered and 5 died. Maxwell, of Formosa, reports 6 cases there, whereof 3, treated by lateral anas- tomosis, recovered, and 3 died. The writer has seen i case which was resected, but died. It would, therefore, appear to be better to leave the intussusception and do a short-circuiting lateral anastomosis. References. — Clubbe, On Intussusception; Childe, "Diseases of Children," Proc. Roy. Soc. Med. 1910, vol. iii, pt. i, 165; Eccles, St. Bart.'s Hosp. Rep. 1911, 97 i Maxwell, Ibid. 1908, 153; Koch and Oerum, Edin. Med. Jour. 1912, ix, 227; Makins, Burghard's System of Operative Surgery, Vol. ii, 521. A. Rendle Short. ISCHiEMIC CONTRACTURE.— (See Muscular Atrophies.) JAWS, TUMOURS OF.— Although there is no reason to believe that there is any difference between the prognosis of growths of the upper and of the lower jaws, we shall follow the example of most writers, and discuss them separately, at least as far as malignant disease is concerned. Epulis. — There is some difference of opinion as to what is meant by a ' simple ' epulis. Under this name the older writers described what they took to be a fibroma. According to Eve, out of 17 cases microscoped at the London Hospital, 2 were fibrosarcoma, 8 were myeloid, and 7 were granulation tissue ; he doubts, therefore, whether there is any such thing as a fibrous epulis. In Kiihner's series, out of 30 microscoped there were 2 fibromas ; of the remainder, 20 proved to be myeloid, 7 sarcoma, and i granulation tissue. Both these statistics refer to surgical clinics ; in the reports of dental clinics, where the smaller and more chronic growths are likely to be seen, fibrous epulis is much commoner. If, then, we take epulis to mean a tumour of the gum, the majority of the cases will be myeloid or fibrosarcoma. Nevertheless, the end-results appear to be very satisfactory if an efficient operation is done in the first place — that is, if a small margin of healthy bone is removed together with the growth. It is not usually necessary to divide the lower jaw, or to encroach on the antrum, but even if this has to be done, as in a case of the writer's, it is remarkable how the antrum fills up in time, so that a small addition to a dental plate closes it effectually. The operation has almost no mortality. End-results of Operation for Epulis. Keporter Cases Died of operation Relapsed Eve, London Hospital Kuhner, TiJbingen clinic :50 7i) 6 7 Of the 7 recurrences at the Tiibingen clinic, 5 were cured by a second operation ; in 2 patients death followed recurrence. The microscopical 248 INDEX OF PROGNOSIS findings in 30 of the cases are quoted above. We have evidence, therefore, that even a so-called niaUgnant epuhs can usually be cured by a small operation — namely, removal of the portion of the alveolar process containing it. Tumours of the Upper Jaw. — Coming now to the consideration of tumours involving the body of the jaw, or growing from the antrum, we find a very much graver state of affairs. There are a number of published records on which to base an opinion as to the prognosis, mostly German and derived from a study of the end-results in various university chnics. These growths are nearly all cancer or sarcoma, and apart from operation are as a rule fatal in from one to three years. The usual treatment is by partial or complete removal of the maxilla. Gland-involvement appears to be late and infrequent, so that it is not usually necessary to clear the lymphatic area in the neck. The mortality of removal of the superior maxilla is undoubtedly high. The figures for three London hospitals from 18S6 to 1897 give a death-rate of only 12-6 per cent in 127 cases, but this probably includes a good many partial operations. The carefully described records of Eve, Butlin, and the Gottingen clinic under Koenig, running up to 1S97, are more worthy of confidence, and these show a mortality of i5-6, 28'5, and 32 per cent respectively. Eve's figures are more recent (1907), and he practises a preliminary laryngotomy. Kronlein's estimate from the hterature since 1875 is probably the most reUable figure we have for present-day surgery, and we therefore conclude that the mortality is about one in four or five. A partial resection is, of course, less dangerous. The fatalities are usually from pulmonarj^ comphcations. Operation-mortality and End-results of Removal OF Superior Maxilla for Malignant Growths. Reporter Cases ! Operation- mortality per cent Cases foUowed Cured Recurred Eve - - ' - Butlin - - - - Kronleia (literature) Three London hospitals Greifswald clinic Estlander's clinic - Gottingen clinic BerUn clinic Von Bergmann's clinic - Erlangen clinic 12 14 158 127 72 16-6 28-5 21-5 12-6 32 10 12 1 49 i 47 1 21 17 5 2 16 5 6 1 5 17 10 33 42 15 16 Total 173 85 (or 22 per cent 138 (or 78 per cent* Turning now to the prospects of cure, we find here also plenty of room for improvement. Buthn records 10 cases, of which 5 recurred, 2 were alive and well less than three years, and 3 were aUve and well more than three years afterwards — but in one of these the diagnosis was doubtful ; two patients ^vitl^ epithehoma appeared to be cured, though the orbital plate was left. In the Greifswald chnic no cases out of 17, at the Erlangen chnic i out of 16, and in Estlander's clinic 2 out of 12, were successful. At von Bergmann's chnic 13 cases of epithehoma were operated on without success ; but of 8 cases of sarcoma, 6 were apparently cured. In the Berlin chnic only 5 out of 47 were cured by JOINTS, INJURIES OF 249 a total resection ; but when partial removal could be practised, half the patients were cured. The most detailed figures available, albeit rather old now, are from the Gottingen cUnic up to 1S97, where, of cases recovering from the operation, 16 out of 49 were apparently cured ; of these, 14 were followed over three years (up to eighteen years in one instance), and 2 less than three years. The micro- scopical report on these 16 growths showed 8 epithelioma, 4 myeloid, 3 sarcoma, and I endothelioma. In the cancerous cases the orbital plate was always removed, because it was found that recurrence followed if tliis was not done. In non- cancerous cases the plate was sometimes left ; of 13 such, i died of the operation, 7 recurred, and 5 were apparently cured (2 under, 3 over, three years). We may conclude, therefore, that in cases of malignant disease calling for removal of the upper jaw, about i in 5 is likely to be cured. The cancer cases are more serious than those with sarcoma or myeloid. In the great majority, recurrence takes place within four months, and death in a year. A serious deformity is, of course, left by the operation, and an artificial jaw will be required. Also, if the orbital plate is removed, the eye may drop and cause diplopia. To summarize, we may estimate that of 100 patients with growths of the upper jaw treated by operation, about 22 will die of the surgical procedure, and about 16 will obtain lasting cure — rather more in the sarcomatous group and rather less in the cancerous. Tumours of the Lower Jaw.^ — The material for judging the prognosis in this variety of malignant disease is old and inadequate. Butlin has collected the records of 60 cases of excision of the lower jaw, with 8 fatalities. The growths which call for the operation are periosteal sarcoma, myeloid sarcoma, and epithelial odontome. Of 11 cases of periosteal sarcoma collected from the literature by Butlin, i was well nearly three years after, i died of pneumonia within a year, and 9 recuiTcd. Of 43 cases of m^^eloid, 8 died of the operation, 2 recurred, 30 were not followed up, and 13 were ' cured ' — but only 4 of these were followed three years. Here again, grave deformity follows the operation, but it can be remedied by the application of a dental prosthesis, even to such a degree that the patient may be able to bite an apple ; or a piece of rib may be grafted in. References. — Eve, Brit. Med. Jour. 1907, i, 1525 ; ButUn, The Operative Surgery of Malignant Disease, 2nd ed., 1900 ; Fagge, "Diseases of the Jaws," Burghard's System of operative Surgery. ^_ ^^^^^^ ^hort. JOINTS, INJURIES OF {see also Knee- Joint, Injuries of; Congenital Dislocation of Hip). — We shall treat the subject under three headings : (i) Sprains ; (2) Dislocations ; and (3) Perforating wounds. I. Sprains. — -An ordinary sprained ankle, wrist, or other joint, given proper treatment such as rest, cold, and compression at first, and massage and move- ments later, will recover completely in a month or two. Trifling injuries will be well in a correspondingly shorter time. There are, however, certain excep- tions to the rule. The first of these is the sprain-fracture. Not at all an uncommon injury is a so-called sprained wrist accompanied by a fracture of one of the carpal bones, notably the scaphoid. This accounts for a large proportion of those cases in which pain, stiffness, or discomfort persists for j^ears. The diagnosis is made, even after a long interval, by skiagram. If recognized early, something may be done to avert the prolonged disability, by advising against all movement, and fixing the wrist in a splint for a month, taking care to reduce any deformity, if necessary by open operation. 250 INDEX OF PROGNOSIS A second obstacle in the way of a confident prognosis is the possibiUty of the development of some form of arthritis. Rarely, tuberculous joint-disease may follow the injury. More often, and especially in the shoulder, a traumatic arthritis may make itself evident a few weeks after the sprain ; there is marked teinderness over the coracoid, and limitation of movement in all directions. It is very important not to attempt to treat this condition by forcible movement, or it may go on to permanent incapacity. The proper treatment is rest. But in any case the trouble is likely to remain for a long time, and there will prob- ably be some loss of range of movement. A third source of disappointment is the formation of adhesions. This can and ought to be prevented by early recognition of the nature of the limitation of movement. It calls for exercises, and if necessary the breaking down of the adhesions under gas. In the case of the shoulder joint, there is no tenderness on direct pressure over the coracoid, and movements are more painful in one direction than in another. This distinguishes it from the arthritis just de- scribed. No joint ought to be moved whilst there is still synovitis, heat, or redness in or about it. Given early diagnosis, including a skiagram, and proper treatment, the sur- geon is able to give a fairly accurate prognosis, except for the unknown factor of arthritis ; this cannot be foretold, but it may only too probably occur if the patient is known to be ' gouty ' or ' rheumatic ' in the old-fashioned sense. Aged persons usually do not recover well. 2. Dislocations. — Apart from treatment, a dislocation is bound to lead to a great deal of disability ; but in the case of the shoulder joint, in young adults at any rate, a very fair degree of usefulness is often recovered. Late excision for unreduced dislocation, or operative replacement, gives results much less favourable than those of immediate bloodless reduction, but some- times a very fairly useful joint is obtained, and, at the shoulder, rotation even may be preserved. Scudder and Barney^ report ii cases of unreduced disloca- tion of the shoulder treated by excision and examined several years afterwards. Of these, rather more than half obtained a fair, but not perfect, result. There was always marked limitation of movement. The best success was obtained in a child. Immediate reduction by manipulation is, of course, the best treatment when possible, and in the majority of cases leads in the course of two or three months to a perfect cure, at any rate in patients under thirty, and given proper treat- ment after reduction. Of i6 adult cases of dislocation of the shoulder investi- gated as to the end-results at the London Hospital,^ lo obtained a good result, 5 fair, and i bad. Elbow cases in children may be said to do very well ; in middle-aged or elderly people there will probably be some permanent limitation of movement. A too favourable prognosis, however, has to be guarded against, because each of the complicating factors which we have passed in review as spoiling the pros- pects of a cure after a sprain may also be operative after a dislocation. There are two other unfavourable conditions to be added to the list : first, after some dislocations, and especially those of the hip, the muscles may be so torn as to lead to permanent lameness ; and second, dislocations of the shoulder, jaw, patella, and clavicle sometimes show a remarkable tendency to relapse. In the case of the clavicle and patella relapse is not very serious, but it may become a great nuisance to the patient if the jaw or the shoulder keeps on getting out of joint. It is related that a certain famous barrister was subject to the former affliction, and used sometimes to be taken when in the act of addressing ' my lord ' or the jury : onwhicn occasions he used to envelop his face in a hand- KIDNEY, NEW GROWTHS OF 251 kerchief as though overcome by emotion, and hurry from the court. He acquired the reputation of being full of sympathy for the woes of his clients. Recurrent dislocation of the shoulder is prone to occur in epileptics. Thomas^ has recently published a series of iS shoulders treated by taking a reef in the capsule. In 13 of these a cure was obtained ; in 3 others a further dislocation occurred, but only as a result of severe injury, such as in wrestling ; in 2 cases the operation was not successful. Thomas makes use of a posterior approach to the joint. 3. Perforating Wounds. — Given immediate diagnosis, and thorough cleansing and drainage within a few hours, more or less perfect recovery can usually be obtained, with at worst a certain amount of stiffness. Many wounds of joints do not lead to suppuration, and the prognosis is then approximately that of a sprain. But if septic arthritis makes its appearance — usually by the third or fourth day — the outlook as regards the joint is grave indeed, and even the patient's life may be in jeopardy. Repeated incisions for drainage may fail to give relief, pyaemia often supervenes, and at last in despair both patient and surgeon are glad to end the struggle by an amputation. If this is avoided, bony ankylosis will probably take place, with or without dis- placement. References. — ^Scudder and Barney, ^ mm. Surg. 1909, xlix,' 696 ; ^Warren, Lancet, 1909, ii, 138, 2ig ; .^Thomas, Surg. Gyn. and Obst. 1914, xviii, 107. ^, Rendle Short. JOINTS, TUBERCULOUS. — [See Arthritis, Tuberculous.) KALA-AZAR.— (5ee Tropical Fevers.) KIDNEY, INJURIES OF.— (See Abdominal Injuries.) KIDNEY, MOVABLE.— (See Movable Kidney.) KIDNEY, NEW GROWTHS OF. — The following factors are important in considering the prognosis of renal new growths : — I. The Malignancy of Kidney Growths. — A small number of benign tumours have been described in the kidney. Some of these, however, are known to develop malignant characters at a later date. The v/riter has removed a kidney, the seat of extensive malignant growth, from a patient who for over five years had passed in the urine portions of papillomatous growth from the renal pelvis which were examined by an eminent pathologist and pronounced non-malignant. Cases of papilloma of the renal pelvis are on record where symptoms had been present for twenty years, and nine and a half years, before operation. The writer also knows of a case where a growth, after removal, was published as an adenoma of the kidney ; the patient afterwards developed multiple bony metastases, from which he died within two years. The number of growths that remain benign must be quite insignificant. All new growths of the kidney should therefore be looked upon cUnically as malignant. Some variation is said to exist in regard to the relative malignancy of the different forms of mahgnant growths of the kidney, and an opinion based on this might be given after removal and examination of the kidney. Hypernephroma is believed to be less rapid in its course as compared with sarcoma and carcinoma of the kidney. It is, however, unwise to make definite statements based upon the liistological varieties. The new growths grouped under the name of hypernephroma show, in some cases, a rapidity of local spread and metastatic deposit that is not exceeded by any of the other forms of renal growth. 252 INDEX OF PROGNOSIS 2. The Duration of the Disease. — Cases are recorded where symptoms had been present for eight (Kronlein), twelve (Israel), and fifteen (Loumeau) years before operation was performed. The average duration of the illness from the commencement of the symptoms to the fatal issue is, however, much less than this. It was three and a quarter years in 32 cases collected by Garceau, and two and a half years in 40 cases collected by Richards, while Keen, Pfahler, and Ellis found an average of two and three quarter years. The duration of the disease is shortened by the appearance of metastases. When extensive metastases are present in vital organs, such as the lungs or liver, the patient will only survive a few months. 3. Results of Operation. a. Immediate Results. — The operative mortalitj^ including under this head deaths occurring immediately, or any time during the first two months after the operation, has been much reduced during the last decade ; but it still remains high compared ^\•ith nephrectomy performed for other diseases. Bloch reports Israel's cases of nephrectomy for malignant growth. There were 124 cases with 28 deaths, an operative mortality of 22-2 per cent. Garceau collected 143 nephrectomies for gro\rth, with 33 deaths, a mortahty of 23 per cent. The mortahty, however, was under this figure in cases operated in the last ten years. Shock, collapse from haemorrhage, and cardiac failure were the causes of death. Braasch records a primary death-rate of 11 per cent in the Mayo cUnic. b. Remote Results. — The remote results of operation upon kidney growths are to a large extent dependent upon an early date of operation and the thoroughness with which the operation is performed. Certain conditions of the growth facilitate early recognition, or militate against a timely diagnosis. A tumour situated in the lower pole of the kidne}^ is in a position favourable for an early diagnosis by palpation. Israel recorded a case where a tumour in this position, the size of a nut, was diagnosed. On the other hand, a gro^^'th situated in the upper pole is concealed beneath the ribs, and usually reaches a considerable size before it can be detected on palpation. The first change that can be noticed in such cases is a pushing down of the kidney, which is felt lower than normal. The occurrence of haematuria is another factor in early diag- nosis. It is present in 90 per cent of adult cases. Where it is absent, diagnosis is not likely to be made until a later stage, when the size of the growth attracts attention. The form of haematuria is intermittent, and there may be long intervals between the attacks. The significance of this form of haematuria is frequently not recognized bj' those in general practice in this country, the disappearance of the symptom being sometimes regarded as an indication of cure. Until the practitioner recognizes to the full the importance of haematuria as a symptom, and insists upon every case being carefully investigated by •cystoscopy, catheterization of the ureters, and, if necessary, by radiography, the time for early diagnosis and favourable operation in a large proportion of cases will pass unheeded, and the prognosis, on tJiis account, will remain very grave. The operation performed for growths of the kidney should aim at the removal of the perirenal fat and the lymphatics included in the perirenal fascia, which should, if possible, remain unopened, and should be traced to the great vessels. A collection by Watson and Cunningham of 143 nephrectomies for malignant growth of the kidney showed the following results : Death from operation, 33 ; death later, after operation, 43 ; survival, 31 ; not stated, 36. The 43 cases that died later, after an operatiori, were distributed as follows : one year or under, 22 ; one to two years, 11 ; two to three j-ears, 6 ; three to KIDNEY, NEW GROWTHS OF 253 four years, i ; four to five years, i ; seven to eight years, i ; ten to eleven years, i. Death, these authors note, has occurred from metastases ten years after operation, the patient having enjoyed perfect health in the interval. The following were the periods of survival after operation in the 31 cases that remained well : one year or under, 9 ; one to two years, 6 ; two to three years, 7 ; three to four years, 2 ; four to five years, 3 ; five to six years, 2 ; six to seven years, i ; nine to ten years, i. Bloch describes the late results of Israel's cases of nephrectomy for malignant growth in 124 cases, of which 93 survived the operation ; at a two years' limit, 26 remained well and 3 died of accidental diseases ; thus, of all the patients who survived the operation 32-6 per cent, and of all the operated cases 27-7 per cent, remained well. At the end of five years, 19 patients were known to be well. This writer remarks that the permanent results of nephrectomy for renal growths are better than those of the operation for stomach and rectal carcinoma, and quite as good as those for mammary carcinoma. Braasch states that the results in the Mayo clinic showed 10 per cent of cures at the end of five years. In 20 cases recorded by Rafin, 10 remained well for longer than three years. 4. Age. — The statistics already quoted are for new growths of the kidne)^ in adults. In children, a number of factors combine to make the operation mortality higher, and render the probability of recurrence greater. Hsematuria occurs in only about 16 per cent of cases, and is rarely present until after an abdominal tumour is discovered. As a result, diagnosis is only made after the growth has assumed considerable dimensions. It follows that the operation is always of a formidable character, while the age of the patient renders him less able to withstand heroic surgical procedures. Walker puts the general mortality in children from operation and recurrence at 93-22 per cent. Albarran and Imbert give the mortality from operation as 25 to 30 per cent, Simon at 32 per cent, and Lecene as low as 12-44 P^^ cent. Recurrence in patients surviving the operation takes place, according to Albarran and Imbert, in 81 per cent of cases, and Simon states the percentage of recurrences at 67. Recurrence usually takes place rapidly, and appears within the first year. Occasionally, however, it may be delayed, and cases where the growth reappeared three, four, and even five years after operation are on record. Simon has collected 11 cases in good health a year or more after operation, among which the longest were — Israel five years, Doderlein four years, Schmidt three years, and Shend and Rovsing each two years. Recently Bastianelli recorded a case well four years after operation. The longest survival of which I have definite information is a case operated upon by Mr. J. D. Malcolm in November, 1S92, which was well in February, 191 1, eighteen years and three months after operation. Abbe, of New York, recorded two cases of prolonged survival ; in one the patient died of new growth of the remaining kidney four and a half years after operation ; the other patient was alive and well over ten years after operation. Notwithstanding such results, the prognosis in children is very grave, and some surgeons even advise against operation. 5. Clinical Points in estimating Prognosis. — The important points to take into consideration are the probability of spread beyond the capsule, the forma- tion of metastases, the general condition of the patient, and the condition of the second kidney. Spread beyond the capsule is indicated when the kidney is fixed, or is very irregular in outline. Free mobility is a favourable sign, but a large renal growth which is fixed to the liver or diaphragm shows a considerable range of 254 INDEX OF PROGNOSIS vertical mobility with respiration. A large growth may appear fixed, yet be confined within the capsule of the kidney ; but the detection of fixity in* a small renal growth is significant of perirenal spread. Pain, constant or localized, or radiating along nerves, indicates nerve pressure outside the kidney. Renal colic from clot obstruction should be carefully distinguished from this. The appearance of varicocele on the side of the growth is due to the engorge- ment of the perirenal veins, but does not necessarily indicate spread of the growth beyond the kidney. It disappears after nephrectomy, and should not be considered a contra-indication to operation. Hochenegg states that if the varicocele does not disappear in the genupectoral position, it is due to compression of enlarged glands, and the growth is inoperable. Metastases are most commonly deposited in the lungs, liver, lymph glands, and bones, and careful examination of these, including radiographic examina- tion, should be made. Cachexia rarely appears unless the growth is advanced, and has spread beyond the kidney. The cardiac muscle is frequently afiected by toxins from the growth, and cardiac failure immediately, or some time after operation, is not uncommon. Dilatation of the heart, with a feeble, irregular, unequal pulse, is a contra-indication for operation. As regards the second kidney, the urine should be obtained and examined. A trace of albumin and a few tube casts are frequently present, and they dis- appear after nephrectomy ; but if these are signs of advanced nephritis, and of a reduced renal function, operation is contra-indicated. Bilateral growths are rare. They occur especially in childhood. / . W. Thomson Walker. KIDNEY, POLYCYSTIC. — This condition is almost invariably bilateral. Luzzato collected 226 cases, of which only 41 were unilateral ; Lejars found only 2 out of 63 cases were unilateral, and Ritchie only 2 out of 72 post- mortems. The disease is invariably fatal, but the duration may extend over many years. Josseraud found that the age at death in 187 cases was as follows :— Age 10—20 years 20—30 ,, 30—40 ,, 40-50 „ Cases 2 13 26 69 50 — 60 years 60-70 „ 70-80 ,, 80-90 „ 47 17 11 Nephrectomy has a very high mortality. Seiber found an operation mortality of 32-7 per cent in 60 cases. Of the 41 cases that survived the operation, only 8 were known to be alive after three years. The longest survivals were 4 after three years, i after eight years, i after six years, and 2 after seven years. /. W. Thomson Walker. KIDNEY, TUBERCULOSIS OF. — Primary tuberculosis of the kidney is said to be present when the kidney is the part of the urinary system first affected. It is obvious, however, that, unlike the lung or bowel, the kidney cannot be directly infected by the tubercle bacillus from without, but must always receive the infection secondarily from some tuberculous focus elsewhere in the body. The nature and activit}'^ of this extrarenal tuberculous focus has a considerable influence upon the prognosis. In the majority of cases of renal tuberculosis that come before the surgeon, either no other tuberculous focus can be found, or, it one exists, it is quiescent or obsolete. In most cases no other lesion can be discovered clinically. Post- KIDNEY, TUBERCULOSIS OF 255 mortem evidence goes to show, however, that in such cases the primary focus lies in a tuberculous bronchial or mediastinal lymphatic gland. In other cases there is evidence of old-standing but apparently long-quiescent tuberculous disease of bones, such as Pott's curvature, or old sinuses connected with bones, or there are ankylosed joints, or a foot has been amputated, or a knee excised. In such cases the tuberculosis of the kidney may be considered on its own merits, for the other foci affect hardly at all the future progress of the disease. In a smaller number of cases there is active tuberculous disease in some other part of the body. A typical example of this is active pulmonary tuberculosis. Here the prognosis is dominated by the pulmonary condition. In such cases the outlook is very grave, and the patient usually succumbs in about two years, though occasionally after symptoms of only a few months' duration. Less unfavourable cases are those in which the active tuberculosis is in a position where radical treatment is possible, such as the foot, the epididymis, or the cervical glands. When, however, there are found a number of foci of tubercle distributed over the body — as, for instance, where there is renal tuberculosis, bilateral tuberculous epididymitis, tubercle of a joint, and possibly evidence of bygone tubercle of the lung — the resistance is so low that the results of operation are unfavourable, while the outlook under general treatment is very grave. Renal tuberculosis with tuberculous epididymitis is not uncommon, and is not usually so serious. Radical operation may be successful in per- manently curing the disease. In the remarks which follow, renal tuberculosis is considered as primary in the kidney, with no active tuberculous lesions elsewhere, unless specially mentioned. 1. Can Tubercle of the Kidney Heal Spontaneously? — A few observers hold the view that a kidney which has been the seat of tuberculous disease may heal spontaneously ; but the great majority of those competent to judge believe that when tuberculous disease attacks a kidney, it is not arrested until the organ is totally destroyed. In support of the view that spontaneous healing may occur, fibrous scars, some of which show cretaceous deposit, have occasionally been observed. It is not certain that such scars are of tuberculous origin, but even should this be so, the few cases that have been recorded suffice to show that such an out- come is rare. A portion of the kidney affected with tubercle may be shut ofE from the rest of the organ by occlusion of that segment of the pelvis, and chnically, this corresponds to a disappearance of the pus and tubercle bacilli from the urine. After a time, however, another part of the kidney is infected, and symptoms reappear. It is not unusual to find, at operation, that one part of the kidney, corresponding to a division of the pelvis, is distended with tuberculous material, and is isolated by occlusion of the outlet, while more recent active tubercle is seen in the open part of the kidney. Finally, the whole kidney may be distended with fluid or with semi-solid tuberculous material, and the ureter be thick and occluded, so that the entire organ is destroyed and shut off (closed tubercle). The tuberculous disease here is quiescent or obsolete. It may be stated that, short of complete destruction of the organ, tuberculous disease of the kidney does not, with the rarest excep- tions, heal spontaneously. 2. Is Tuberculosis of the Kidney Unilateral or Bilateral ? — Renal tuberculosis is unilateral in the earlier, and very frequently bilateral in the late, stage. This accounts for some discrepancy between the statistics of different observers. Kronlein states that 92 per cent, Albarran 80 per cent, Brongersnia 86 per cent, and Legueu 85 per cent of cases are unilateral, and clinical evidence 256 INDEX OF PROGNOSIS obtained by catheterization of the ureters, and the results of nephrectomy, certainly support this view. Such statements must always be subject to the qualifiGation that they apply to the early stage. In the late stage the disease, in a large proportion of the cases, is bilateral. Post-mortem statistics given by Gaultier show 57 per cent, by Isermeyer 62 per cent, and by Halle and Motz 33 per cent bilateral. Whe7ice does the Second Kidney derive its Infection P Do the bacteria come from the same focus as those that infected the first kidney ? Direct evidence on this point is very difficult to obtain, but the results of nephrectomy in unilateral renal tuberculosis show that the second kidney is infected, not froni the original primary focus, but from the first kidney. During the first two years after nephrectomy for tuberculous kidney, there is a mortality of io-6 per cent from tuberculosis of the remaining kidney. The tuberculous disease in the great majority of these cases, if not in all, was present at the time of the nephrectomy. If the mortality due to tuberculosis of the second kidnev after surviving two years be examined, it is found to be only 3 per cent. If this figure be compared with the 33 to 62 per cent of infection of the second kidney with tubercle where no operation has been performed, the influence of nephrectomy upon the prevention of tubercle of the second kidney will be realized. 3. The Introduction of Sepsis. — Infection of a tuberculous kidney with pyo- genic organisms may result from olood-borne bacteria, but more frequently it is an ascending infection up the ureter from a bladder infected by catheteriza- tion. Pyonephrosis very frequently develops, and the patient is dangerously ill. Nephrotomy obviates the urgent symptoms, and should the second kidney be healthy, nephrectomy can be performed at a later date with a good prospect of success. If the bladder is infected, there is a danger of ascending pyelonephritis of the remaining kidney. 4. Results of Medicinal, Climatic, and Tuberculin Treatment. The administration of drugs has no effect upon the progress of the disease, but symptoms such as pain and bladder irritation can be ameliorated. A climate which is warm and dry, with an even temperature, moderates some of the more distressing bladder symptoms which accompany renal tuberculosis ; but climatic treatment does not permanently influence the pro- gress of the disease. Tuberculin treatment gives varying results. In some cases of unilateral renal tuberculosis, with or without involvement of the bladder, considerable benefit has resulted from prolonged administration of tuberculin. After one or two years, tubercle bacilli and all signs of inflammation have disappeared from the urine, and there has been no immediate recrudescence of symptoms. Informa- tion obtained by the cystoscope and by operation upon such cases shows that the tuberculous focus has become isolated by occlusion of a part of the renal pelvis, or of the entire pelvis, by closure of the ureter. The recrudescence of the tuberculous disease in other parts of the kidney or urinary tract is to be expected in such cases, and it is a mistake to suppose that the temporary dis- appearance of signs in the urine, and of symptoms, means a permanent cure. In bilateral renal tuberculosis, tuberculin has a more legitimate field, for curative operation cannot be undertaken. Undoubted improvement takes place in a good proportion of cases under tuberculin treatment, but I have not seen any case of cure. In cases where there is tuberculosis of one kidney v.^ith tuberculous foci in other parts, tuberculin treatment is often of service, either in combination with nephrectomy, or apart from operation. After nephrectomy, tuberculin treatment of genital tuberculosis is likely to be successful. KIDNEY, TUBERCULOSIS OF 257 When tuberculosis of the kidney occurs with active tuberculosis of the lungs, bones, and joints, tuberculin treatment does not give encouraging results. In some cases an improvement in the renal disease takes place ; but the extra- renal foci are frequently unaffected, or may even appear to increase under the treatment. In estimating progress in the treatment of tuberculosis of the kidney by tuberculin, attention should be paid to the increase or decrease of body weight, the general feeling of vigour, the effect on pain, frequency of micturition, tenderness and enlargement of the kidney, and haematuria. Where vesical symptoms are present, the amelioration of these frequently provides a striking demonstration of improvement. The specific gravity and pigmentation of the urine increase as the renal condition improves. The quantity of pus, and the presence and numbers of tubercle bacilli, are critical tests of progress. 5. Immediate Results of Operation. — Nephrectomy in the early stage of renal tuberculosis is the only method by which a cure can be assured, and the operation is indicated whenever the diagnosis of unilateral tuberculosis is made. A preliminary to modern operative treatment of renal tuberculosis is the examination of a specimen of the urine of the second kidney, obtained by catheterization of the ureter. Nephrectomy, as a curative operation, depends upon the absence of the tubercle bacillus and the proof of a satisfactory renal function, as shown by the examination of this specimen. If this is not carried out, the death-rate of nephrectomy reverts to that of the older statistics (25 per cent), and patients who would have lived for some years under palliative treatment, die from anuria after the operation. Brongersma collected 515 cases operated by various surgeons, with a mortality of 7-18 per cent. He states that when only the statistics of surgeons who use modern methods of diagnosis as a routine measure are taken, the mortality of nephrectomy for unilateral renal tuberculosis falls to 2-85 per cent. A series of statistics published in 191 1 shows the following figures : — Israel Wildbolz - Asakura Andre Von Frisch- /1023 (collected) \ 170 (personal) 13y 70 100 10 to 15 per cent 15 / 71 per cent I. (up to four years) 15 per cent 6. Late Results of Operation. — The after-history of 369 patients on whom nephrectomy was performed for primary tuberculosis shows that death occurred after a considerable interval in 56 (15-2 per cent). In these cases the interval varied from one or two to fourteen or sixteen years. In 329 cases of nephrectomy, 35 (io-6 per cent) of the patients died during the first two years ; in these cases the fatal result was due to a spread of the tuberculous process. Of 184 patients surviving two years after nephrectomy for tuberculosis, only 6 (3'2 per cent) died of tuberculosis later. It may be stated, therefore, that there is a risk amounting to io-6 per cent of the patient dying of tuberculosis during the first two years, and a risk of 3-2 per cent of a fatal result from tuberculosis after this. /. w. Thomson Walker. 17 258 INDEX OF PROGNOSIS KIDNEY AND URETER, CALCULUS OF.— In the early stage of calculous disease of the kidney, there is a danger of a small stone becoming impacted in the ureter and causing anuria. In the later phase, sepsis and uraemia are the chief conditions to be feared. The following factors are intimately con- cerned vsdth these dangers, and are therefore important in estimating the prognosis : (i) The size and number of calculi ; (2) Unilateral and bilateral calculi ; (3) Asepsis and infection ; (4) Results of operation ; (5) Recurrence after removal : (6) Calculous anuria. I. The Size and Number of Calculi. — In the earljr stage, a primarj^ calculus of the kidney is single and small, and the kidney is health}^ or nearly so. Slight interstitial and parenchymatous changes, described by Albarran under the name of diathetic nephritis, may be present, but it is probable that if the calculus is removed thus early, no serious permanent damage to the kidney will remain. At this stage the chief danger is impaction of the calculus in the pelvic outlet, or in the ureter, during an attempt to expel it. When the obstruction is incom- plete or recurrent, a hydronephrosis results. When the impaction is sudden, and obstruction complete, there is danger of anuria (calculous anuria) resulting. The prognosis in these conditions is discussed elsewhere. As the calculus increases in size, pressure upon the kidne}^ substance causes interstitial nephritis and atrophy, until eventually, in the case of a very large calculus, the kidney substance is reduced to a mere shell. The renal function is now carried out entirely by the second kidney, and if this should fail, uraemia follows. At any period in the history of a renal calculus, but especially when the stone becomes larger, or there are a number of calculi present, there is a risk of infection being superadded. The infection usually occurs spontaneously^ and the path by which it arrives is the blood-stream (haematogenous infection). Occasionally it follows septic catheterization and washing out the bladder (ascending infection). The influence of this comphcation on the prognosis will be discussed later. Removal of a calculus in the early, small, aseptic stage can be performed without great destruction of renal tissue, and "will prevent this complication. The use of the x rays in diseases of the urinary organs has been the means of greatly improving the prognosis in calculus of the Iddney and ureter. In the early stage, a small stone will throw a shadow on the ;i;-ray plate, and its exact position is demonstrated. It is thus possible to operate with certaintj-, and to extract the calculus with a minii ium amount of destruction of kidney tissue. WTien multiple calculi are present, '-.heir number and position are accurately shown on the plate, and each shado ' is accounted for at the operation by a corresponding stone. The danger of overlooking a small calculus is thereby greatly reduced. By means of the x-ray plate, the operative measures required can usually be planned beforehand. Thoroughness and rapidity of operating are thus facilitated. When the calculus lies in the ureter, it frequentl}- happens that the symptoms afford no guide to the exact position of the impacted stone. In such a case an exploratorvi- operation, which may be of very formidable character, is avoided by the discovery of a shadow in the line of the ureter on the x-TSLY plate. From the foregoing it may be stated, that a good prognosis is justified when the calculus is single, aseptic, and of small size, although the condition is not ■without some immediate risk of calculous anuria. The piognosis is much less favourable, and may be very grave, when calculi are large, multiple, and septic. KIDNEY AND URETER, CALCULUS OF 259 2. Unilateral and Bilateral Calculi. — -When one kidney contains a calculus, the most frequent form of disease that affects the second kidney is the develop- ment of a calculus in this side also. In the early stage of calculous disease, bilateral calculi are not very common ; but in the late stage, the second kidney is frequently the seat of calculus. Israel found bilateral calculi in 27 per cent, Grau in i6-6 per cent, Kiister in 11-78 per cent, and Morris in 10 per cent of cases operated ; while Legueu found calculi in both kidneys in 50 per cent of 76 post-mortem cases. The latter may be taken to represent the late stage of the disease, while the former gives an indication of the frequency of bilateral calculi in the early stage. With the more general use and the development of radiography, the diagnosis of stone in the kidney is being made at an earlier date, and the number of bilateral calculi is likely to be reduced. The significance of bilateral calculi depends upon the extent of the disease and the presence of sepsis. The development of calculi in the second kidney, when one organ is already affected, is a grave complication. There are cases where small aseptic calculi are formed in each kidney, and passed at intervals. In such cases the kidneys appear to suffer little change, so long as the calculi pass freely along the ureters. The danger of anuria from impaction of a calculus is, however, much greater, the prognosis after operation graver, and the course of the disease shorter than in unilateral calculus. When one kidney is the seat of a large calculus or of multiple calculi and the second kidney contains a small calculus, when large calculi are present in both kidneys, and when bilateral calculi are infected, the prognosis is very grave. Nephrectomy in any of these conditions is unwise, and a permanent cure after removal of the calculi is unlikely. In very large bilateral calculi it is a question if the patient will not live longer and in greater comfort without operation. In such cases, recurrence of stone after removal is frequent, and at each operation there is very considerable destruction of renal tissue. The mortality of nephrolithotomy in bilateral calculus is much higher than in unilateral. In 22 collected cases of calculous disease where fatal anuria followed opera- tion, there were calculi in the second kidney in 12, atrophy and degeneration in 4, the organ was the seat of fatty disease in 2, amyloid disease in i, hydro- nephrosis in 2, and interstitial nephritis in i. In order that the prognosis may be estimated in any case of renal calculus, a careful examination must be made of the second kidney and ureter by means of the X rays ; and the condition of the urine, and the activity of the renal function of the second organ, must be ascertained by examination of the urine, and by the use of the tests of the renal function after catheterization of the ureter. Kiister reports 20 cases of operation on bilateral calculi, in 10 of which a good result followed ; fistula persisted in 3 cases, and there were 7 deaths from uraemia. Legueu had 8 double operations ; of these, i died of uraemia, and 7 recovered. Of the 7 survivors, 2 died of uraemia within a year. 3. Asepsis and Infection. — At some period in the history of unoperated calculus, infection occurs. In some rare cases, large bilateral calculi develop in both kidneys and run their course till the final anuria, with nothing more than the very niildest infection of the urine occurring. Usually, however, the urine is contaminated with B. coli communis, or with a mixed infection. In some cases calculi develop in an alread}^ infected kidney. The prognosis in infected calculus is much graver than when the Iddnej^ remains aseptic. The mortality of operation is higher, the probabilit}'^ of recurrence is greater, and the destruction of kidney tissue is much more rapid. 26o INDEX OF PROGNOSIS Legueu quotes the following statistics in regard to stone operations on aseptic and on infected kidneys : — Nephrolithotomy in Healthy or Slightly Infected Kidneys. Reporter Cases Deaths Brongersma 17 Nicolich 18 Zuckerkandl 8 2 Rovsing 115 7 Kapsammer 21 2 Israel 61 9 Kiister 1()0 15 Legueu 20 2 Total 420 37 (or 8'8 per cent) Nephrolithotomy in Infected Kidneys. Eeporter Cases Deaths Schmieden - Kiister Brongersma Nicolich Legueu 211 251 2 4 5 43 50 2 3 1 Total 473 109 (or 23 per cent) 4. Results of Operation. — The results of operation for renal calculus are governed by a number of factors, such as the size and number of the stones, the condition of the second kidney, the presence or absence of sepsis, the operation performed ; and, it may be added, the experience and skill of the operator, for a successful operation may demand a high degree of both. Some of these have already been discussed, while others require no elabora- tion. It remains to compare the results of the different operations under varying conditions. The operations performed for renal calculus are {a) nephrolithotomy,, (b) pyelolithotomy, and (c) nephrectomy. a. Nephrolithotomy. — The results of nephrolithotomy are largely influenced by the presence or absence of sepsis previous to the operation. Some authorities, notably Morris, regard as cases of nephrolithotomy only those in which the kidney is healthy and there is no infection. Most surgeons look upon all cases of removal of calculi from the kidney as cases of nephrolithotomy. The results in cases uncomplicated by sepsis or dilatation show a very low death-rate. Watson collected 135 cases with 3 deaths (2-2 per cent), and Rovsing 115 cases with 7 deaths (6-o8 per cent). Other results have already been quoted. In infected cases the mortality is high, as the results of Schmieden (20-3 per cent) show. After nephrolithotomy the wound usually heals rapidly, even when mild infection has been present. In infected cases a fistula may persist. KIDNEY AND URETER, CALCULUS OF 261 and this is occasionally due to calculi having been left in the kidney pelvis, or to ureteral obstruction. In Schmieden's cases (infected) a fistula followed the operation in 22-2 per cent, while in Watson's collection (infected and non- infected) there were fistulas in 8 per cent. b. Pyelolithotomy . — This operation is confined to a small class of cases where there is a small or moderate-sized calculus occupjang the renal pelvis or calices, or where the pedicle is comparatively long and the loin not too deep. In Schmieden's statistics there are 54 cases of pyelolithotomy, of which 36 (66-7 per cent) were completely healed. There were 12 (22-2 per cent) recoveries with fistula, and 6 (ii-i per cent) died. In the writer's experience, the percentage of fistula following nephrolithotomy and pyelolithotomy, given in the statistics quoted, is much too high. c. Nephrectomy. — Nephrectomy for calculus is, compared with the operations already discussed, a rare operation, and is reserved for cases where uncontrol- lable haemorrhage occurs during nephrolithotomy, where the calculi are very numerous and large, and where the kidney is atrophied or destroyed by dilata- tion or suppuration, or where a malignant growth complicates the calculus. Secondary nephrectomy may be called for in urinary fistula, recurrence of stone, or prolonged renal suppuration. The conditions under which the opera- tion is performed are, therefore, of a serious nature, and the outlook is very grave. The following statistics were collected by Watson : primary nephrectomy, 136 cases, 41 deaths (30-1 per cent) ; secondary nephrectomy, 33 cases, 6 deaths (i8-i per cent). 5. Recurrence after Removal. — The recurrence of calculi in the kidney after an operation for their removal depends upon a number of factors. Incomplete removal of the stone or stones at the operation is a frequent cause. A deep loin with a narrow space between the rib and iliac crest ; a large, fleshy kidney with a short, inelastic pedicle ; multiple calculi ; an inefficient A'-ray examina- tion ; nervousness and inexperience on the part of the operator : these are factors which have an important bearing on the incomplete removal of stones. Occasionally an aseptic, single, hard stone may be chipped in removal, and the tiny fragment form the nucleus of a fresh concretion. This is much more likely to occur where the calculi are multiple and crumbling. Sepsis is a prolific source of recurrence, phosphatic stones being rapidly re-formed even after complete removal. The repeated formation of oxalate- of-lime stones, and of uric-acid stones, either after expulsion along the ureter and discharge from the bladder, or after operation, is the unfortunate habit of some patients, and the underlying diathetic condition is very difficult, and sometimes impossible, to control. 6. Calculous Anuria. — Calculous anuria results from the impaction of a small stone in the ureter of one kidney, the second kidney being absent, atrophied, or diseased in varying degree. Rarely the ureters of two functional kidneys are simultaneously blocked by calculi. If the anuria is untreated by operation, death occurs in 71 per cent of cases according to Legueu, and in 67 per cent according to Donnadieu. It takes place usually about the tenth or twelfth da}-, after two or three days of uraemia symptoms. In cases that have recovered, the date of spontaneous relief was the third day in i, the fifth to the tenth in 10, the thirteenth in i, the fourteenth in i, the fifteenth in i, and later than the fifteenth in 2. Operation should be performed at the earliest possible moment in all cases of calculous anuria. It has been held that the operation may be delayed until the fifth or sixth day, as uraemic symptoms rarely supervene before that 262 INDEX OF PROGNOSIS time. This delay could only be justified by a large proportion of spontaneous recoveries, and such does not exist. Death, if it take place, is a result, not of the operation, but of the condition for which the operation was performed. Huck's statistics show that the mortality rises each day that operation is delayed. Before the fourth day there is a mortalit}^ of 25 per cent, before the fifth day of 30-7 per cent, and before the sixth day of 42-1 per cent. The presence of uraemic symptoms does not contra-indicate operation ; successful cases of operation under these conditions have been recorded. Watson collected 205 cases of calculous anuria, and found the following results of treatment : — Treated without operation, no; deaths, 80; mortality, 72-7 per cent. Treated by operation, 95 ; deaths, 44 ; mortality, 46-3 per cent. These results are capable of great improvement if the necessity for early and rapid operation is fully realized. /. w. Thomson Walker. KNEE JOINT, INJURIES OF THE.— Year by year we obtain a more complete knowledge of the many various consequences of an injury to the knee joint, and we are gradually becoming more accurate in our prognosis and treatment. Fractures of the patella and long bones are considered elsewhere. We have here to discuss the outlook in the following conditions : (i) Synovitis and hismarthrosis ; (2) Ruptured ligaments ; (3) Dislocation of the knee or of the patella ; (4) Recurrent disability [internal derangement of the knee joint) ; (5) Per- forating wounds. I. Synovitis and Haemarthrosis. — The signs of these conditions are well known ; but it is often impossible at first to decide whether the effusion consti- tutes the whole trouble, or whether there is also some injury to bone, ligaments, or cartilages ; and the prognosis depends principally on this very point. In all but the slightest cases a skiagram should be obtained to show any bony lesion, such as a fracture of the patella or of the condyles, separation of the tibial spine, or a foreign body composed of bone and cartilage dislodged from a condyle. Marked lateral mobility with a tender area over the site of rupture points to tearing of the lateral hgaments. Rupture of the ligamentum patellae is usually obvious, and the patient is powerless to extend the knee. Antero-posterior mobility, either in extreme flexion or extension, is a sign of tearing of the crucial ligaments. When any evidence is obtained of one or another of these injuries, it is necessary to expect a prolonged disability and perhaps an imperfect final result. Even when no special signs are present beyond the synovitis, it is impossible to promise a complete permanent recovery, because there may be bruising or tearing of a semilunar cartilage. Apart from this, however, it is usual for a simple synovitis of the knee to be restored to normal in a month in mild cases, and in two to three months in severe cases, assuming that the treatment is efficient — rest and cold applica- tions or pressure at first, followed by massage, and when the acute inflammatory signs pass off, exercises and liniments. If considerable effusion comes on within an hour of the injury, and especially if there is deep ecchymosis of the skin appearing a day or two later, it is probable that the joint contains blood, and this is apt to absorb badly and to leave a permanent stiffness. This result is only too often seen in a hasmophihac knee. It must be borne in mind in giving a prognosis that in rare instances tubercu- losis, osteo- arthritis, or acute epiphysitis passing into acute necrosis may follow an injury ; but in the first and last of these, the original mischief is seldom severe enough to cause synovitis. KNEE JOINT, INJURIES OF THE 263 2. Ruptured Ligaments. — The special signs of these injuries are as follows : — Ruptured Ligamentnin Patella;. — A gap between the patella and tubercle of the tibia, inability to extend the knee. Ruptured Lateral Ligaments. — Excessive lateral mobility ; tenderness over the torn ligament. Ruptured Crucial Ligaments. — If complete, antero-posterior mobility in extreme flexion or extension. If incomplete, persistent inability to flex to a right angle, even after synovitis has cleared up. Any of these signs would lead the surgeon to give a guarded prognosis ; recovery will take several months, and there will often be some permanent disability, happily seldom preventing the patient from walking. Several weeks' fixation will be necessary to allow of sound healing. 3. Dislocations. — Partial or complete dislocation of the knee, a rare accident, is necessarily accompanied by tearing of the important ligaments on which the integrity of the joint depends, and it is therefore bound to be many months before restoration to the normal can take place. Usually there is some per- manent weakness and limitation of movement, not sufficient to prevent the patient from walking. Dislocation of the Patella, especially the outward dislocation, is unfortunately liable to relapse, especially in patients with genu valgum, and various methods of operative treatment have been devised for the relief of this condition, but none are very satisfactory. The disability is usually not serious, even if the patella is left unreduced. 4. Internal Derangement of the Knee. — This convenient term includes those cases in which, nearly always as a sequel to some acute or chronic injury in the first place, the joint repeatedly gives way, locks, or suffers from recurrent attacks of pain and synovitis whenever it is wrenched or twisted. Very similar symptoms may be due to one of four conditions, arranged in order of frequency : [a) A torn, folded, or loose semilunar cartilage ; {b) A loose body (bone, cartilage, fibrous tag, old clot) ; (c) Nothing obviously wrong ; or {d) Hypertrophied synovial fringes or alar ligaments. It is sometimes possible to make the diagnosis without opening the joint. A very definite history of locking, with a tender spot, and perhaps a depression over the internal semilunar cartilage, suggest that it is at fault ; loose bodies can often be felt both by patient and surgeon, and if bony, a skiagram will reveal them. The prognosis in internal derangement of the knee joint has to be considered under the headings of non-operative and operative. It is agreed that many cases, apparently of this disease, can be restored to fair comfort without operation, by massage and rest immediately following the first occurrence of the trouble. Sir William Bennett found it necessary to operate on only 123 out of 500 patients. But it is seldom that the knee can be trusted for football or other violent exercises ; also, if two or three recurrences take place, non-operative treatment will scarcely succeed in restoring the joint to normal, though a good form of knee-truss may prevent severe attacks of pain and synovitis. The end-results after operation have been studied by D'Arcy Power in 89 patients at St. Bartholomew's Hospital. Of these it was found by correspond- ence that : — 73 had no recurrence of attacks. 50 regarded the knee as good as the other. yy reported movements perfect. 68 had no change in shape ; and 43 found the knee painless, whereas 11 had some aching in wet weather, and 35 always had pain. 264 INDEX OF PROGNOSIS Many were well enough to play football again. The writer has investigated the after-history of 40 cases operated on at the Bristol Royal Infirmary. In aU of these, at least six months had elapsed since the operation, and in all but 6, at least a year. Of 56 operations, none died, and since rubber gloves were introduced, only i case out of 47 suppurated, the patient having taken off his dressings and fiingered the wound. He finished with a stiff, swollen knee. End-results of Operation for Internal Derangement of Knee. Lesion No- of cases Excellent Good Fair Bad Cartilage torn or very loose Loose bodies Nothing abnormal, or cartilage (?) loose Synovial fringes - - - - - Notes of lesion inadequate - 17 7 8 3 5 16 2 4 I 1 2 2 1 1 2 1 1 1 1 1 1 Total 40 1 2.0 7 1 4 j 4 \ It will be observed that when there was a definite lesion of the semilunar cartilages the results are almost uniformly excellent. Six patients are able to play foot- ball again, and several are miners ; one does his work with comfort after having parted with both his internal semilunar cartilages. In every case the injured cartilage was removed ; stitching in place usually leads to recurrence. It had been performed elsewhere in one of our patients, but he had to come to have the cartilage excised. The cases of loose body, though few could be traced, are decidedly less satisfactory. Apparently a loose body means an osteo -arthritic joint in most cases, which relapses after the operation, and in one of our series a second loose body was removed two years afterwards. When nothing abnormal is found, removal of the internal semilunar cartilage nevertheless gave a good result in 6 out of 8 of our cases. In another patient, the after-history suggests that a loose body was overlooked. We may conclude on the whole that the operation for internal derangement, provided asepsis is secured, is usually followed by the happiest results, except in the loose-body cases, where the outlook is not so certainly favourable. 5. Perforating Wounds of the Knee. — The vital element in the prognosis after this injury is, of course, the occurrence of suppuration, and its degree. Provided that this can be avoided, the joint will be restored to normal in a few weeks. If suppuration take place, there will probably be one or two months spent in bed, and a permanently stiff knee following, though fortunately it is usually not painful. In a small proportion of the cases the inflammatory reaction is violent, and the patient suffers a desperate illness, with, it may be, the formation of pyaemic abscesses and occasionally a fatal result. This would nearly always be averted by early and efficient cleansmg and drainage. In such bad cases, . the knee may ankylose at right angles and remain painful ; the writer recollects seeing one patient who, after many operations and narrowly escaping death from pyaemia, finally had to suffer amputation. References. — D'Arcy Power, Brit. Med. Jour. 1911, i, 61 ; A. Rendle Short, Bristol Med.-Chir. Jour. 1912, 52. A . Rendle Short. KNEE, TUBERCULOUS. — {See Arthritis, Tuberculous.) LARYNX, CARCINOMA OF 265 LARYNX, CARCINOMA OF. — In this disease it is necessary to divide cases into the two following classes : — 1. Intrinsic, i.e., those arising from the vocal cords true and false, the inter- arytenoid region, the ventricles and the subglottic region. 2. Extrinsic, i.e., those springing from the upper aperture of the larynx and from the back of the cricoid cartilage. I. Intrinsic Carcinoma is not very malignant in type. Owing to the arrangement of the lymphatics within the larynx, which do not communicate with those of surrounding parts, but empty into a pair of small glands on either side, glandular infection is uncommon and metastases so rare as to be practically non-existent. Growth is often slow and, in the absence of treatment, cases have been recorded in which life has been prolonged for ten^ and thirteen- years res- pectively. Treatment is essentially surgical, and consists in either intralaryngular removal through the natural passages, or opening the larynx by thyro-fissure. The former operation is generally condemned, and no statistics are available, although 7 cases of removal with no recurrence for three years are reported by Frankel,* while in 5 cases operated on by Schmiegelow^ recurrence took place in 3. Removal of intrinsic laryngeal carcinoma by thyro-fissure is probably now the most successful operation in the surgery of malignant disease. Only recent figures must be considered, as, owing to improvements in technique, results have become better of late years. Results of Thyro-fissure in Laryngeal Carcinoma. Died from Well from Well for Local cases operation 1-3 years over 3 years Recurrence Tillev 5 1 1 3 Semon" 25 1 4 14 3 Jackson 14 7 4 3 StClair Thomson - 10 4 4 Butlin 21 1 — — — Koschier 5 i 4 — — Schmiegelow 20 4 9 — — Total - 100 8 29 25 8 Thus, in loo operations, the mortality as a result of operation was 8 per cent. Of 79 cases observed for over i year, there was no recurrence in 54, or 68 per cent ; while in 38 cases observed for more than 3 years, a cure was established in 25, or 65 per cent. Semon^ has given reasons for considering that if recurrence has not taken place in one year it will not do so. Thus the results show an operative mortality of 8 per cent, v/ith cure in either 65 per cent or 68 per cent, compared with figures for amputation of the breast of an operative mortality of 5 per cent and a cure in 42 per cent.* As a result of this operation, owing to the formation of a cicatricial band to replace the cord which has been removed, the patient is as a rule left with a fair voice. Thus in 20 cases operated on by Semon, the voice was good in 11, fair in 5, and only a whisper in 4 cases, while Jackson states that in all his cases the voice was fair except where recurrence had taken place. 2. Extrinsic Carcinoma has a very much more serious prognosis. The disease 266 INDEX OF PROGNOSIS spreads to surrounding parts, glandular infection occurs early, and life is seldom prolonged beyond three years without operation, death usually taking place from aspiration pneumonia. Operation is the only treatment which holds out any hope of cure ; a large number of cases, however, do not come under observation until too late a stage. The operation consists of a partial or complete laryngectomy, frequently accompanied by removal of a portion of the oesophagus or pharynx. The great risk of the operation is aspiration pneumonia, but this risk has been diminished recently owing to the method of shutting off the tracheal opening from the septic pharyngeal discharges. In all cases, the glands on either side should be removed with the larynx, as recurrence in glands is the most frequent form met with after operation. I have placed together figures for partial and complete removal of the lar^mx, as from the point of view of prognosis before operation, one frequently cannot tell how much of the larynx it will be necessary to remove. Partial or Complete Laryngectomy. Reporter Number of Cases Koschier - 13 Schmiegelow 9 Semon 5 Gluck 84 J ackson 8 Crile 24 Butlin 7 Delavan - 56 Death from. operation 6 1 5 2 1 29 4 1 3 * Appt'oximate only. Thus, of 193 cases operated on, the mortality as a result of the operation v/as 44, or 22" 7 per cent, while as a result of operation on 119 cases, a cure was obtained in 28, or 23-5 per cent. Von Bruns' gives, as a result of figures collected for complete laryngec- tomy since 1890, an operative mortality of 19 per cent, with a freedom from recurrence of 28 per cent in cases observed less than one year after operation, of 16 per cent from one to three years after, and of 10 per cent over tliree years after. Therefore an operation with a mortality of about one-fifth of the cases gives a prospect of a more or less permanent cure in about a like number. As a result of this operation, except in a few cases in which only a very partial removal of the larynx has been performed, the patient is speechless. A faint whisper may be developed by using the air in the pharynx, but at the best this is only intelligible to those who are in constant contact with the individual. In addition, especially if the pharynx has been much encroached on by the opera- tion, there may be some considerable difficulty in swallowing. There is also, owing to the impossibility of an effective cough without a larjmx, an increased liability to bronchial and pulmonary afiections, and the impossi- bility of fixing the chest by closing the glottis makes manual labour difficult if not impossible. All these disadvantages may cause a condition of great mental depression. In considering the advisability of this mutilating operation, however, it must be remembered that the condition of a patient dying of a laryngeal carcinoma LARYNX, PAPILLOMA OF 267 is a wretched one. Frequently there is great dyspnoea and dysphagia, and a paUiative tracheotomy becomes necessary. References. — ^Gluck, Jour. Laryngol. xviii. 484 ; -Smith, Laryngoscope, 1910, Feb. ; ^Frankel, — V. Bergmann, System of Surgery, ii. 241 : *Arch. Laryngol. u. Rhinol. 1910 ; ^Jour. Laryngol. 1903, Sept. 473 ; ®Von Bergmann, System of Surgery, ii. 602 ; ''Handbuch der Pract. Chir.irg. 1907. ^ j y^yiaJit. LARYNX, PAPILLOMA OF. — This condition usually arises in infancy or childhood. In the absence of treatment the growths may persist for a prolonged period. As a rule, at some time, frequently about puberty, the growths will spontaneously disappear. This does not, however, always take place, and cases have been recorded in which the condition persisted for thirty^ and thirty-live^ years. The alternative treatments are : — 1. Surgical, [a) Local removal through the natural passages. (6) Removal by opening the larynx from the exterior, (c) Tracheotomy. 2. Medical. The internal administration of calcined magnesia in large doses. 3. Radium applications. The great risk of the condition is asphyxia, and many of the cases have to be tracheotomized for acute dyspnoea when first seen. 1. Surgical. — • a. Local Removal through the Normal Passages. — This is the treatment now most comimonly adopted, the operation being performed by the direct method, and frequently accompanied by the application of the cautery or caustics to the base of the growths. It will relieve the symptoms for a time, but the growths almost always recur and the operation has to be repeated many times until eventually recurrence ceases. A case has been recorded in which opera- tion was performed 47 times.' It is almost without risk to life. b. Removal by Thyro-fissure. — This method, formerly much employed, is little used now. It gives no greater security against recurrence than the former method, although a greater risk to life is incurred. It is too serious an operation to be lightly repeated, although a case is recorded in which it was repeated 17 times without a cure.* c. Tracheotomy. — In a large number of cases this has to be performed as a matter of urgency. It has also been thought that it will produce a cure by giving rest to the larynx, but it is doubtful if this is so ; thus, cases have been recorded in which the growths persisted for fifteen^ and thirty-five® years, in spite of this operation. 2. Medical. — Calcined Alagnesia. — The administration of this remedy in large doses has been recently tried. Cures are recorded by Claone,' Dortu and Masini, a total of 5 cases, all of which had been under treatment by other methods. Rose,"* however, reports failure in 2 cases. The method is therefore on its trial. 3. Radium. — This has been tried on 2 cases recently by Delavan^ and Abbe,^" with complete success. Harris^i has collected records of 13 cases treated by him.self and others. In all the growths disappeared, but recurrence took place in 3. Thus radium, if obtainable, would seem to give the best hope of an immediate cure. Calcined magnesia may cure in some cases, and can do no harm. Tracheo- tomy is often necessary, but will not cure of itself. Local removal is almost without risk, and can be repeated. It is impossible in any given case to say when cure will occur. References. — ^Packard, Ann. of Otol. Rhinol. and Laryngol. 1910, Sept. ; ^Masini, Boll, delle Mai. dclV Oreichio, 1912, March, 49 ; 'Tilley, Jour. Laryngol. xxvii, 218 ; 268 INDEX OF PROGNOSIS *Semon, Proc. Laryngol. Soc. Land. 1894, Jan. i, 62 ; *Blondian, Presse Oto-Laryngol. Beige, 1910, July ; ®Masini, ibid. ; 'Claone, Ann. des Mai. de I'Oreille, etc. xxxvi, pt. I ; SRose, Jour. Laryngol. 1913, June, 318 ; ^Delavan, Ann. of Otol. Rhinol., etc. 1910, Sept. ; ^°Ann. Surg. 1912, Sept. 470 ; ^ ^Harris, Int. Congress of Medicine, 1913. A. J. Wright. LARYNX, TUBERCULOSIS OF. — Laryngeal phthisis is for all practical purposes only a complication of pulmonary tuberculosis, and the prognosis is essentially that of the lung condition. The laryngeal disease usually occurs when the pulmonary condition is advanced, and the prognosis is always grave, the mortality being probably about 90 per cent. Although the laryngeal and lung conditions usually progress or improve together, not infrequently cases are seen in which the larynx will improve under treatment while the lung gets worse, and the converse. The situation of the disease in the larynx is of importance, those cases in which the epiglottis is involved having the worst prognosis, partly because of the dysphagia and consequent difficulty in taking food, and partly because epiglottic involvement usually occurs when the lungs are extensively diseased. Lake and BarwelP give the following figures of the number of deaths taking place while the cases were under observation : — ■ Mortality in Laryngeal TXTBERCULOSIS. Location of disease Number of cases Deaths Proportion Epiglottis Arytenoids Vocal cords alone 72 148 35 11 16 1 lin6i 1 in9| 1 in 35 The results of general treatment are those of pulmonary tuberculosis, except that the prognosis is always rendered worse by the presence of laryngeal disease. Sanatorium figures are unreliable in this respect, as the majority of laryngeal cases have pulmonary disease too far advanced for sanatorium treatment. Cases of healing of the larynx under tuberculin are given by Wilkinson, Parker, and Blumenfeld,^ and the latter gives the number healed by this treatment as about 5 per cent. The following tveaUnents are directed solely to the healing of the laryngeal disease : — Silence, the use of various pigments and caustics, Pfannenstill's nascent iodine method, the galvano-cautery, diathermy and the x rays, the removal of disease with punch-forceps and curettes, and major operations such as tracheo- tomy and laryngectomy. For the relief of the most distressing symptom, dysphagia, without any idea of cure, amputation of the epiglottis and the blocking or section of the internal laryngeal nerve have been employed. Silence, in conjunction with sanatorium treatment, has met with some success. Felix Semon^ and Bardswell* have recorded 7 and 6 cases respectively in which healing of the laryngeal condition took place under these conditions. StClair Thomson^ records arrest of the laryngeal disease in 37 out of 178 cases (20-7 per cent) with sanatorium treatment and voice rest, aided in 15 of them by local applications of the galvano-cautery. These were all selected cases. The use of lactic acid and other pigments is less employed than formerly, and although isolated cases of healing have been described, they are few, and no statistics are available. Pfannenstill's nascent iodine method," in which the patient inspires ozone LARYNX, TUBERCULOSIS OF 269 while taking large doses of iodides, has been employed on only a limited number of cases. The inventor has cured 2 patients on whom he tried the method, and Tidestrom obtained healing in 8 out of 12 cases ; but Stangenberg only found slight improvement in i case out of 4 treated, so that the method is at present on its trial. The galvano-cautery' also produced healing in a number of isolated instances. A'-rays and diathermy have only been used in experimental cases. The active local treatment by punches and curettes has been largely employed. Heryng, in the treatment of 252 cases, obtained healing lasting for from one to six years in 20 cases, or 7-8 per cent; and Barwell, out of 211 cases, obtained healing in 20 per cent, but these cases were only watched for a short period and were not seen after leaving hospital. Major operations are seldom employed, and the results have usually been disastrous. Gluck gives : — Major Operations. Operation Number of cases Healed Died Tracheotomy - * Hemilaryngectomy Laryngectomy 7 2 20 1 2 4 9 6 13 Grunwald, of 64 collected cases of laryngostomy, found that only 8 per cent were alive a short time after operation. Amputation of the epiglottis, in cases in which it is ulcerated and the cause of dysphagia, will usually reheve this symptom, and is an operation without risk to life. Amputation of Epiglottis. Halt Lockard Moeller 24 151 25 Relief of dysphagia per cent 100 100 The relief of pain by the section of the superior laryngeal nerve, or by injecting alcohol into the nerve in order to block it, has been successfully and largely used recently, and no risk seems to accompany this method. The relief of pain, in the case of alcohol injection, usually lasts about thirty days, and the injection can be repeated. Alcohol Injection of Superior Laryngeal Nerve. Number of cases Success in Logan Turner Fetterold Helot Bertran and Castillo Grant - - 1 15 3 6 2 1 14 3 6 2 Total 27 2« 270 INDEX OF PROGNOSIS Blumenthal has recorded 2 successful cases of section of the nerve. Thus larv'ngeal tuberculosis is a serious complication of a serious disease. Cases with epiglottic involvement bear the worst prognosis. Cases in which the lung condition remains stationary, or improves, will usually heal with silence and sc'natorium treatment. Galvano-cautery and minor operative measures may assist healing. Major operative measures are disastrous. Eemoval of the epiglottis and blocking of the superior laryngeal nerve give certain relief of dysphagia, without risk, in suitable cases. Referenxes. — ^'■Lake and Barwell, Laryngeal Phthisis, 1905 ; ^Zeifs. f. Laryngol. iv. 4 ; ^Semon, Brit. Med. Jour. 1906, ii. 1623 ; *Bardswell, Brit. Med. Jour. 1907, i, 1350 ; ^StClair Thomson, Brit. Med. Jour. 1914, April 11 ; ^Hygeia, 19 10, Nos. 5 and 6 ; 'Siebenmann, V erhandlungen des Vereins deiitscher Laryngologen, 1909. A. J. Wright. LATERAL SINUS THROMBOSIS.— (5ee Intracranial Complications of Ear Disease). LEAD POISONING. — Metallic lead and practicalh' aU its salts are poisonous. Even the sulphate and chromate are soluble in the gastric juice, and it has been found that the addition of i per cent peptone increases the solubihty of the metal and of white lead. Probably the most harmful compound is Pb,,0, while there is only one insoluble and therefore harmless salt, viz., the sulphide. The mechanical as well as the chemical composition of the salt has some bearing on prognosis, for a less soluble salt may be more dangerous than one which is more soluble but less easil}' powdered. Individual susceptibility is very marked ; e.g., one man in a white-lead factory began to have symptoms in two weeks, and died of acute plumbism after five and a half months' work. In the same factory was a man who had worked in white lead for thirty-two years, and had felt no ill effects. Probably about a quarter of all workers are not suscep- tible. There appears also to be a family susceptibihty ; hence the son of a lead-poisoned father and mother should avoid all work connected with lead. Females are more susceptible than males, especially if they are anaemic. The disease is liable to be very much more severe, if there is a constant absorption of small quantities of the poison over a lengthened period, than if a large quantity is taken on a single occasion. Further, when lead is absorbed into the respira- tory tract by inhalations, the onset of the symptoms is frequently earlier, and they are of a more severe character, than when it is absorbed from the alimentary tract. In connection with the length of time of exposure necessary before symptoms arise, A. Hamilton, in an analj'sis of 120 cases, found i case of paralysis at the end of one week's work, x case of colic at the end of one week's work, I case of cohc with neuritis after three days ; 8 of the workers be- came ill in less than two weeks, 36 in less than a month, and 89 in less than a year. Recurrences have a worse prognosis than first attacks. Lead, once absorbed into the system, may remain latent for long periods, and then make itself felt. The symptoms of lead poisoning may therefore develop for the first time after a man has given up all lead work for some months, and in certain cases even a few jj-ears have inter^'ened before the manifestation of the symptoms. One attack predisposes to another. It is not possible, however, to assert positively that a patient has entirely'- recovered from an acute attack, as insidious disease in some of the internal viscera, such as kidneys or liver, may have been initiated. With reference to the prognosis of lead colic, the outlook is as a rule very good, provided there is no gross organic disease ; but if the colic is exceedingly severe, the patient may die during an attack. LEUCOCYTHMMIA 271 Cerebral symptoms are dangerous, especially if the patient becomes comatose. Epileptiform fits may follow each other in rapid succession and prove fatal. If the patient gets over these attacks, recovery may be far from complete, and blindness and aphasia may follow. The mental condition may also be permanently deranged, or memory be extremely defective ; lead may be responsible for a condition closely resembling general paralysis. As a rule, however, the onset is much more rapid, and the prognosis very much better, for very considerable improvement may occur even in the third stage, the gait improving, paralysis diminishing, and the intellectual faculties and speech becoming more clear. Much mental irritation, however, generally persists even in the most favourable cases. Haemo-retinitis may occur with, or apart from, these cerebral symptoms. About 50 per cent of those who develop this eye trouble get permanent optic atrophy. In the hsemo-muscular form, the prognosis as to ultimate recovery depends much on the intensity and duration of the paralysis, whether or not there is persistent atrophy, and on the state of the electrical reactions. Paralysis of the deltoid, biceps, brachialis anticus and supinator longus occurs in the long-estabhshed cases, and hence the prognosis is worse in this form than in the usual forearm type. In very severe cases paralysis may extend to the muscles of the larynx, the diaphragm, and even the intercostals, and so prove fatal from failure of respiration. In plumbic pseudo-tabes, recovery is sometimes remarkably rapid, even when inco-ordination, loss of muscle sense, and ataxy have been marked. The chronic cachectic form undermines the general resistance of the body, rendering it more prone to intercurrent infections. It shortens life by inducing chronic disease of the internal viscera, more especially of the kidneys, arteries, and heart. It also predisposes to gout in all its various manifestations. Lastly, plumbism leads to abortion, with its own dangers. /. R. Charles. LEISHMANIASIS.— (See Tropical Fevers.) LEPROSY.- — This disease may become stationary in either the anaesthetic or tubercular form, and though tissues which have been destroj^ed are not renewed, still the patient niay remain in good health for thirty years or more ; it may run a rapid course and become generalized, so that the patient dies in two or three years from leprotic septicaemia ; or more frequently there is slow progress, and death occurs from intercurrent disease, of which dysentery, diarrhoea, or pulmonary complications are the most common. The duration of life is shorter in the tubercular form (seven to eight years, as a rule) than in anaesthetic or nerve leprosy (ten to twelve years). C. W. Daniels. LEUCOCYTHffiMIA. — No question regarding leukaemia can be discussed without some preliminary understanding regarding terminology. It has been customary to classify cases into the splenomeduUary and lymphatic types. It is now recognized that the enlargement of the spleen is a passive process, and consequently the first form is often spoken of as medullary or myelogenous. In recent years there has been a growing tendency to distinguish between ordinary large and small lymphocytes, on the one hand, and large and small myeloblasts on the other. These latter can be demonstrated, by special methods, to have a more regular chromatin network and more nucleoli than the lymphocytes, and they are regarded as the precursors of the granular mj^elocytes, neutrophil, eosinophil and basophil, which in turn develop into polymorpho- nuclear leucocytes with the corresponding type of granules. 272 INDEX OF PROGNOSIS It is unnecessary for our present purpose to discuss the relationship of these cells, but it is necessary to point out that cases of ' myeloblastic ' leukaemia are not infrequently recorded as myelogenous. We are not disposed to quarrel with this, but if such a description leads to the beUef that these ' myeloblast ' leukaemias are to be classed in the same category as the granular leukaemias as regards symptoms or prognosis, then either the description is unfortunate or the belief is wrong. We may perhaps best get over the difficulty by classifying the leukaemias in terms of the characters of the preponderating cells, as regards the presence or absence of granules. If the cells which are unduly increased are non-granular, it is a matter of little practical importance whether they are to be labelled lymphoc^'tes or myeloblasts. We thus have to deal with (i) Lymphatic {non-granular) leukcBmia. This is usually acute, rarely chronic. (2) Medullary (granular) leukcBmia. This is usually chronic, very rarely acute. (3) ' Mixed ' forms. (4) Chloroma. I. Lymphatic LeukaBmia.- — The great majority of cases run an acute course. An early fatal result is the usual outcome, the only exception being the very occasional transition of a case from the acute to the chronic type of the disease. Some cases end fatally within forty-eight hours of coming under observa- tion ; the greatest number die between the fourteenth and thirtieth day, and an intermediate number live for from three to six months. Among the symptoms which indicate an early termination are suddenness of onset and high temperature. The early onset of haemorrhages is a serious symptom. Once a case shows a definite tendency to bleeding, an early fatal termination is practically certain. A single haemorrhage from the nose or other mucous membrane has not such serious significance, but when bleeding from both nose and gums, haematemesis, or hematuria have appeared, it is likely to be persistent. Purpura may occur, and a hypodermic injection may lead to the formation of a hasmatoma. Advanc- ing anaemia is another very grave omen. The anaemia is not merely due to the haemorrhages, but to the unchecked proliferation of lymphocytes in the bone- marrow. The onset of diarrhoea weakens the patient, but in the absence of more serious symptoms it is not of much significance in this form of the disease. Attacks of pneumonia or pleurisy may occur, and may determine an early fatal issue in a case which otherwise might have lasted a few months. Rupture of the spleen is a contingency which has occurred. Local necroses, ulceration, and the formation of diphtheritic membranes on the gums or cheeks, may lead to a condition of profound toxaemia. Haemorrhages into the eye or ear may lead to blindness or deafness. Little significance can be attached to changes in the leucocyte count. It is certain that a falling count is no indication of improvement. A falling lympho- cyte percentage would be a favourable omen, but we have never known it take place. No known form of treatment has any beneficial influence on the course of the acute cases. .X'-ray application does harm. In the chronic form, the spleen is enlarged and there is also great enlargement of the lymphatic glands. Indeed, the enlargement, especially that of the spleen, may be taken as an index of the previous duration of the case. The liver also enlarges, and lymphomata may occur in the skin and elsewhere. The counts in the chronic form are much larger, as a rule, than in the acute, but the actual figures have little relationship to the course of the disease. A fatal result is sooner or later to be expected. Duration in most cases does not exceed a year, but chronic cases lasting for several years are not unknown. LEUCOCYTHMMIA 273 Advancing anaemia, cachexia, intercurrent affection, or the onset of haemorrhages and acute symptoms, may bring about the end. On the other hand, a few cases undergo remission and may have a precarious existence for a few years. In the remissions the leucocyte count falls, but, as a rule, the lymphocyte percentage remains unduly high. We have, however, notes of one case, a miner, aged sixty-nine, in whose case a remission appeared to be complete. The application of x rays in chronic lymphatic leukaemia occasionally does good, and has not the harmful influence it exerts in acute cases. Arsenic appears to do good. We have seen remissions follow the use of naphthalene tetra- chloride. 2. Medullary Leuksemia. — Prognosis is absolutely unfavourable. In the usual chronic form, it is difficult to make any statement about duration on account of the insidious onset. Most cases are likely to live for at least six months after they first come under observation. They probably all die within five years. The course of the disease is not uniformly downwards, and remissions and relapses are often seen. When remissions occur, the spleen usually diminishes in size and the leucocyte count falls, but the blood-picture generally retains its pathological quahtative features. In some cases, symptoms ameliorate without improvement of any kind in the blood or in the size of the spleen. The subject of myelocythaemia is liable to many disabilities. Fatal haemorrhage has been known to follow such contingencies as an abortion or the extraction of a tooth. Diarrhcea may be a troublesome symptom, and may persist to such an extent as to shorten life. Pressure by enlarged glands on important organs may give rise to serious symptoms. Intercurrent disease may have a remarkable influence on the blood-picture. The leucocyte count may fall to normal as the result of an attack of influenza, and in some cases the count becomes subnormal. Such complications do not much influence the general course of the disease. The more serious complications of a chronic disease, such as pneumonia and pleurisy, are uncommon in myelocythaemia, possibly on account of the large number of polynuclear cells in the blood. Myelocythaemia occasionally runs a very acute course. In these ca.ses the duration is from fourteen days to eleven months. Effect of Treatment. — In x rays we have a powerful agent for combating the symptoms of myelocythaemia. Their effect is not curative, but the excessive output of leucocytes may be temporarily checked, the organs are probably freed to some extent from the packing of their substance with white cells, and their functions are for the time being improved. The treatment may succeed in establishing remissions on successive occasions, but sooner or later its power fails. In all cases the application must be closely checked by the examination, not only of the leucocytes, but of the red cells also. It is possible to carry on the process of irradiation to such an extent as to exhaust the marrow. In many cases toxic symptoms follow the use of x rays. The administration of arsenic is another measure which has a beneficial influ- ence on the disease. The patient who is in a position to submit to a combined treatment by x rays and arsenic has a better chance of a moderate prolonga- tion of life than a patient not so favour?bly circumstanced; the organic pre- parations of arsenic offer no special advantages. Salvarsan has no good influence on the course of the disease. Some strikingly good results have recently been recorded as the result of treatment by benzol in capsules. We have not shared such favourable experience, and consider that the treatment by benzol has more risks, and confers less benefit, than treatment by at rays and arsenic. 18 274 INDEX OF PROGNOSIS 3. Mixed Forms. — ^Mixed leukaemia may arise in two ways : — a. In lymphatic leukaemia, a considerable number of myelocytes may make their appearance. This is the result of marrow disturbance ; the lymphocyte proliferation acts as a stimulus to the parts of the marrow not yet affected. A large number of nucleated red cells generally appear in the blood at the same time. The advent of the myelocytes does not very materially influence prognosis. Any significance which may be attached to their presence is certainly not favourable. b. In medullary leukemia, the blood-picture may become mixed by the failure of the marrow to elaborate the granulations in the cells before they pass into the blood. In this way a larger number of lymphocytes (myeloblasts) than usual are present in the films. A high percentage of non-granular leucocytes in a case of myelocythaemia adds to the gravity of the outlook. 4. Chloroma. — This condition may be regarded as leucocythasmia associated with the formation of green-coloured tumours, particularly in connection with periosteum. Prognosis is quite hopeless. In a general way the outlook is the same as in simple leukaemia of corresponding type, but owing to the tumour- formation, the likelihood of pressure-symptoms arising is much greater. There is also a tendency to more rapid emaciation. In no form of leuksemia is any good result to be expected from splenectomy. The patients in whom the operation has been performed rarely recover from it, and if they do, the course of the disease is not influenced. g. L Gulland. A. Goodall. LICHEN PLANUS. — It is difficult to lay down any criteria on which to base a prognosis in this disease. Except in a few cases of acute type which develop rapidly and tend to clear up in a few weeks, lichen planus is apt to be progressive, and may last for many months. Its course may be shortened by treatment, and the most important point in the successful management of the severe cases is absolute rest, both mental and bodily. Chronic patches of the disease are best treated by the x rays, or by radium applied on a flat plate. The affection may run a relapsing course, but when once it has cleared up it shows much less tendency to recurrence than psoriasis. The writer has, hov/ever, seen a few cases in which the disease has recurred after intervals of from two to four years. /. H. Sequeira. LIP, CANCER OF. — As is well known, this is one of the least malignant varieties of epithelioma, but there are cases even of this disease in which the prognosis may be very grave from the first. Prognosis apart from Operation. — Probably every case would at last prove fatal but the rate of progress is extraordinarily variable. Sometimes death follows within a few months ; in other cases the growth may last for 10 years or more. Probably the average duration is about two or three years. Extensive foul ulceration of the lip, face, and jaw takes place, and the glands in the neck enlarge extremely and may suppurate. Death is usually due to lung troubles. In 34 autopsies, Rowntree found bronchitis, pneumonia, or gangrene of the lung recorded in 29. Metastases in the viscera are uncommon ; Rowntree mentions four in the lung, three each in the kidney and liver, and one each in the thyroid, larynx, brain, adrenal, heart, pancreas, and femur. The writer has seen large metastases in the ovaries, more than six years after the original growth in the lip of a woman who smoked a clay pipe. Mortality of Operation. — The operation death-rate nowadays is very low, even if the glands are removed. None died out of seventy cases operated on at the Bristol Royal Infirmary. Old German statistics give a mortahty of 7 per cent, but they go back to pre-antiseptic daj^s. LIP, CANCER OF 275 Results of Operation for Epithelioma of Lips. Reporter or Hospital Operation Died of operation Cases followed Time followed ' Cured' Eecurred or Dead per cent years per cent per cent Worner, Bruns' Klinik (pre 1886) - 896 7 424 3 38 62 Fricke, Konig's Klinik (1874-96) - 114 7 106 3 66* 34 tBristolRoyalInfirmary(i 890-191 2) ia) Lips only removed (6) Palpable glands; lips and glands removed 70 29 11 2 2 69 27 31 73 (c) Lips and glands removed ; glands not palpable Mayo clinic : (a) All cases ; glands cleared - - — 12 99 2 1-2 83 84 17 16 (h) Glands showed cancer — — 12 1-2 50 50 Bloodgood : (a) Glands not cleared - (h) Glands cleared — — — 10 5 70 30 I. Microscopically cancerous — — 12 5 50 50 2. Not cancerous — — 21 5 95 5 * III 17 of these, patient followed for less than 3 years. t In 3 of these, patient followed for less than 2 years. t The Prospect of Cure. — It will be observed that even the methods of pre- antiseptic surgery were able to report about 38 per cent cured, and at a later period the proportion rose to 66 per cent. No doubt with modern methods even better results can be obtained. Out of 52 cases treated by operation and followed up afterwards in the Bristol series, 33 (63 per cent) were well two years after. Admittedly, two years is rather early to judge of success; but out of a dozen in whom the neck was cleared although no glands could be felt, 83 per cent were free from recurrence. When lip only was removed, 69 per cent were well. The figures are, however, small. Beckman has reported the figures for the Mayo clinic, but unfortunately some of the cases have only been followed a year, though the majority are over two years. In 84 per cent, out of 99 cases, a ' cure ' was obtained ; in all these the glands were removed. Bloodgood has followed a series for five years, and finds that clearing the neck improves the prognosis. Where the glands were found to be cancerous, 6 out of 12 where cured ; when not cancerous, 20 out of 21. It is quite clear that when the glands are already palpably enlarged, the out- look is very much graver. Only 3 out of 11 of our cases were alive and well two years after, and in none of these were the enlarged glands proved by the microscope to be cancerous, although the growth on the lip showed as typical epithelioma in section. When the glands show cancer microscopically, both Beckman's and Bloodgood's figures show that half the cases may be cured. We conclude, then, that if the neck glands are not enlarged, the prospect of cure is probably about 80 per cent if the neck is cleared and a free removal made of the growth in the lip. Recurrences in the lip are often amenable to treatment, and 3 out of 7 of our Bristol cases did well. Even if a cure is not effected, the patient is relieved of what might afterwards be a foul growth, unless, of course, it recurs in the lip. Date and Place of Recurrence. — Of 25 recurrences in the Bristol series, 13 affected the lip (often glands as well), and 12 only the glands. Wider removal, therefore, is still called for. In our cases, recurrence in the neck was usually 276 INDEX OF PROGNOSIS within six months, but, according to Rowntree's statistics, the average was seventeen months. This is probably too long. The growth may come back again in the hp after a great lapse of time. According to Rowntree's tables, the average is twenty-four months. We had cases three, six, and even twenty-four years after the original operation ; Rowntree records one sixteen years after. In the Bristol Royal Infirmary statistics, death in the failed cases took place about eighteen months after operation. One survived for three years ; another died in five weeks. Referemces.— Rowntree, Middlesex Hospital Reports, 1906, vLt, iiS ; ButUn, Oper- ative Surgery of Malignant Disease, 1900, p. 103 ; A. Rendle Short, Brit. Med. Jour. 1910, ii, 426 (an amplified account is here utilized) ; Beckman, Jour. Okla. St. M. Assoc. 1913, vi, p. 185 ; Bloodgood, Surg. Gyn. and Obst. 1914, April, p. 404. A. Rendle Short. LIVER ABSCESS.— (.See Dysentery.) LIVER, ACUTE YELLOW ATROPHY OF.— Until recently, this disease was regarded as necessarily fatal, because the diagnosis was considered to be established only by death or necropsy. It is now recognized that cases presenting the acute symptoms, but not terminating fatally until several months later, show areas of hyperplasia of the liver cells which compensate for the areas of acute atrophy and thus enable life to be maintained. These cases, called sub- acute atrophy from their duration, are examples of partial recovery from the disease, and as this compensatory hj^erplasia has been seen in cases sur\dving for months and years, the possibility of permanent recovery cannot be denied ; but in the absence of exact confirmation, scepticism as to their nature may be expressed, though a fatal issue would have silenced any doubts. I have seen two such cases. There is still much critical reserve about the acceptance of such conclusions, for though in 1880 Wickham Legg^ collected twenty-eight reputed cures, F. W. White^ in 1908 estimated the recoveries at about the same figure. Recently it has been suggested that acute yellow atrophy is due to the same causes as those of epidemic infective jaundice acting on a liver weakened by some temporary strain or inherently weak (Cockayne).^ Medical Treatment. — Recovery has been recorded after repeated transfusions of saline solution in a few cases, and the treatment of acid intoxication hy trans- fusion with sodium bicarbonate and enemas containing sugar should improve the outlook. In one case to which I gave horse serum which has an autolytic action, on the ground that the hepatic change is due to autolysis, recovery- followed ; but it is obvious that no real conclusions can be based on an isolated observ'ation. Efficient prophylactic treatment in cases which may possibly pass into acute 3'ellow atrophy'- has some bearing on the prognosis. Thus, jaundice in pregnant women should contra-indicate chloroform anssthesia in childbirth, and the use of chloral and chloretone, as chloroform causes autolysis of the liver cells, and should call for the prevention of acidosis and constipation. The benign jaundice which may occur in secondary sj^hLhs readily yields to mercury, and this method of treatm.ent may therefore be regarded as a means of preventing the onset of the rare sequel, acute yellow atrophy. In a certain number of cases, of which Parkes Weber* has collected fifty-three, acute yellow atrophy supervenes in the course of secondary syphilis, and may thus be compared with acute myelitis in similar circumstances. It is much commoner in women than in men, and may follow the specific jaundice occasionally seen in secondary syphilis. The available observations show that the Treponema pallidum is not present in the liver of syphihtic acute atrophy, and the hepatic change therefore LIVER, CIRRHOSIS OF 277 appears to be due to poisons manufactured elsewhere and conveyed to the liver. If this is true, mercurial treatm.ent should cut short the supply of poisons and so improve the prognosis, but I cannot bring any figures to substantiate this. Prognosis in Individual Cases. — Although it be admitted that the disease is not invariably fatal, the outlook in any given case is very gloom5^ It is worst in pregnant women. Children, probably from their greater power of repair, show the changes of subacute atrophy more often than adults do, and the prognosis is therefore less grave in them. Special Danger Signals. — Rapid diminution of the liver dullness, evidence of grave renal changes as shown by blood-casts and albumin in the urine, acidosis, a hsemorrhagic tendency, the early onset of severe nervous symptoms, coma, and a very high or very low temperature, show that a fatal termination is near. References. — ^^Wickham Leg?, Bile, Jaundice, and Bilious Diseases, 1880,' p. 676; ^F. W. White, Boston Med. and Surp. Jour. igo8, clviii, 729 : ^Cockayne, Quart. Jour. Med. Oxford, 1912-13 vi, i ; *F. P. Weber, Proc. Roy. Soc. Med. 1909, ii (Path. Sec.'), 113. H. D. Rolleston. LIVER, CIRRHOSIS OF. — Under this heading the following forms of cirrhosis will be considered : (i) Portal ; {2) Biliary, {a) hypertrophic, {b) obstructive ; and (3) Syphilitic. I. Portal Cirrhosis. (Synonyms: Multilobular, 'Alcoholic,' Laennec's cirrhosis). The subject wUl be treated in the following order : first, some general con- siderations on the prognosis of the disease, then the prognosis of hagmatemesis, of jaundice, and of ascites and its treatment, then the influence of treatment generally on prognosis, and lastly, the prognosis in individual cases. The hepatic change is often latent, for in about half the cases in which a cirrhotic liver is found at necropsy, death is due to other causes. The prognosis is thus much better than in biliary cirrhosis. Taking into account the greater frequency of cirrhosis in males, the disease is less often latent in females, possibly because alcohoUsm when once established is even more difficult to control than in males. In adults, a comparatively early age appears to be favourable as regards greater tendency to improvement, provided alcoholic excess be stopped, probably because the nutrition is better preserved and compensatory processes are more readily effected. Thus the average age of 37 patients in which temporary or prolonged improvement occurred was thirty-nine years (Cheadle),^ which is about ten years less than the average age of fatal cases of cirrhosis. In children the prognosis is generally considered to be very grave ; but from a study of 74 cases of cirrhosis due to alcohol, E. Jones- concludes that " the prognosis is better in children than in adults when the condition is slightly marked, but worse when definite symptoms of hepatic inadequacy have set in." Haeraatemesis occurs in about one-quarter of the cases, is usually an early symptom, and is directly fatal in only some 5 per cent of the cases dying from the effects of cirrhosis. In Preble's^ 60 collected cases of fatal gastro-intestinal haemorrhage in cirrhosis, death followed a single hjemorrhage in a third of the cases. As h^ematemesis may induce the patient to alter his habits of life at a comparatively early period of the disease, it is possible that in this way it exerts a favourable influence on the course of the disease. When, as occasionally happens, haematemesis occurs late in the disease and in the presence of ascites, the outlook is very gloomy. The occurrence of general haemorrhages is always a grave sign. 278 INDEX OF PROGNOSIS Jaundice, which occurs at some time or another in rather more than a third of all the cases, may be due to several causes, and the prognosis varies accordingly. Often it is transient, and of the form usually spoken of as catarrhal, or it may be slight, without bilirubin in the urine. In these circumstances it does not exert any appreciable influence on the prognosis. On the other hand, the onset of jaundice in the late stages, or when accompanied by fever, multiple hasmor- rhages, and nervous symptoms, is a very grave indication ; cases of this character may run an acute course, and are more often seen in comparatively young subjects who have been drinking heavil3^ Ascites. — The onset of ascites always makes the outlook bad. It is true that ascites may be due to factors associated with cirrhosis, especially chronic peritonitis, and that the prognosis is then not nearly so grave as in ascites due to uncomplicated cirrhosis. But when ascites first appears, it is seldom possible to distinguish between these two conditions, though the presence of oedema of the feet before the onset of ascites is in favour of uncomplicated cirrhosis. As time goes on, a decision can be arrived at on the ground that frequent tappings are required in ascites due to chronic peritonitis complicating cirrhosis, whereas in uncomplicated cirrhosis this is not the case. These points are borne out by the following statistics of Ramsbottom* : in 31 cases of uncomplicated cirrhosis, the interval between the onset of ascites and death was on an average 188 days, the average number of tappings two, and the interval between the first tapping and death 46 days ; whereas in 12 cases of cirrhosis associated with chronic peritonitis, the interval between the onset of ascites and death was on an average 394-6 days, the average number of tappings 6-7, and the interval between the first tapping and death 288 days. For statistical purposes, cases in which the condition of the liver and peritoneum has been examined must be emploj^ed, for in cases which recover it is obvious that some doubt as to the underlying condition must remain. But recovery certainly occurs after one or more tappings in patients who appear to have cirrhosis ; this has also been confirmed in cases which have proved fatal from other causes, years after the disappearance of ascites. The Influence of Paracentesis. — Although the prolongation of life after tapping first became necessary was only 46 days in 31 cases of uncomplicated cirrhosis (Ramsbottom), there is no reason to believe that tapping per se accelerates the end, for with the present aseptic methods, the risk of infection of the peritoneum is practically neghgible as compared with the discomfort and bad effects due to pressure on other organs exerted by an unreUeved ascites. In Individual Cases of Ascites. — The prognosis is rendered gloomy when ascites is preceded by great tympanitic distention, or by oedema of the legs, as these show that there is grave toxaemia ; by the occurrence of fever synchronously with the onset of ascites, as this may be due to some complication, such as tuber- culosis of the peritoneum or other parts ; by concomitant haematemesis or melaena ; or by such rapid re-accumulation after tapping as to require its repetition in two or three days, as these events may indicate thrombosis of the portal vein. Surgical Treatment of Ascites of cirrhosis has taken several forms, of which the production of vascular peritoneal adhesions, or the Talma-IMorison operation, is the best known. The operation is contra-indicated in an advanced stage of the disease with much toxaemia, by considerable jaundice, and by definite cardiac or renal disease. On the basis of cases observed in Calcutta, Rogers* considers that leucocytosis renders any operation inadvisable. The prognosis is influenced by the stage at which the operation is performed. But it might be urged that cases in the earlier stages are those which might recover if left to nature. LIVER, CIRRHOSIS OF 279 From analysis of 227 cases, Sinclair Whites estimated that 37 per cent were cured and 13 per cent improved, whereas Willems^ concluded that only 4 per cent out of 250 cases were really successful. Other operations, such as introducing the omentum into a subcutaneous pocket in the abdominal wall (Narath), or establishing permanent drainage of the ascitic fluid into the subcutaneous tissues of the abdomen (Paterson) or thigh through the femoral ring (Wynter and Handley), entail much less operative shock and have been successful in some cases. Possibly the mechanism by which improvement results is on the same lines as in ' autoserotherapy, ' or the injection of ascitic fluid, after its removal, into the abdominal wall ; by injecting 3 dr. every other day, Vitry and Sezary^ induced profuse diuresis and cure of the ascites. Of Routte's operation, which consists in making an anastomosis between the peritoneal cavity and the internal saphenous vein, Celso^ in 191 1 collected 10 cases, of which 2 only were successful. In Egyptian splenomegaly, which, as in Banti's disease, becomes complicated by hepatic cirrhosis, splenectomy, or removal of the supposed focus of the disease, has been employed as a curative measure in the early stages when there is evidence of only moderate hepatic cirrhosis (Richards and Day^"). It is not advisable when ascites or jaundice has appeared. This surgical procedure, therefore, improves the prognosis, but the disease is not the same as ordinary cirrhosis. Splenectomy in 7 cases of cirrhosis in France proved fatal in 2 (JuUien^^), and at present appears a risky and heroic procedure. The Effect of Treatment is greatly influenced by the period of the disease at which it is undertaken, and thus depends on early diagnosis. Haematemesis, the earliest symptom of striking importance, may, under efficient treatment, temperance, and care in diet, be succeeded by years of life, and the underljdng cirrhosis may remain permanently latent. But the disease is compensated, not cured, and the compensatory mechanisms may fail ; the hyperplastic areas of liver cells may degenerate, or the dilated oesophageal veins may rupture and give rise to hsematemesis. In Individual Cases. — An advanced state of the disease, with emaciation, is obviously ominous. Fever points either to a rapidly progressive change in the liver or to the presence of some complication, such as tuberculosis, and is there- fore a bad prognostic. The onset of drowsiness is a most grave sign, as showing that lethal coma due to hepatic toxaemia is imminent. The gravity of ascites, oedema of the feet, and multiple haemorrhages has been referred to already. The size of the liver, if taken alone, is not of much value in prognosis, for though an enlarged liver due to compensatory hyperplasia is found in latent cases, enlargement also occurs in cases running an acute course, and may be temporary and due to recent alcoholic excess. The general symptoms must also be taken into account ; in the absence of well-marked gastro-intestinal symptoms, a large liver is a favourable sign, and vice versa. Since the spleen is usually large and palpable in progressive and acute cases, and comparatively small in latent cirrhosis, the association of a large liver and spleen is less favour- able than a large liver without a palpable spleen. Occasional glycosuria after indulgence in alcohol or a large amount of sugar has no special bearing on the prognosis. But in the cirrhosis of haemochromatosis, in which diabetes may result, death usually occurs within a year after the onset of glycosuria. The presence of diacetic acid in the urine, which is rare in ordinary cirrhosis, shows the presence of acidosis, and is therefore ominous. Very well- marked anaemia is a grave sign, and, from his experience in Calcutta, which has not been confirmed for this country, Rogers^ considers that a high leucocytosis is a bad sign. 28o INDEX OF PROGNOSIS 2. Biliary Cirrhosis. a. HypertropMc Biliary or Hanot's Cirrhosis is always, or nearly always, fatal. It runs a chronic course with exacerbations, and may last as long as ten or more years, but the average duration is about five years, and acute cases terminating within two 5-ears from the onset are sometimes seen. In India, especially in Calcutta, there is a form of endemic cirrhosis clinically somewhat resembling the biliary cirrhosis of Europe, which attacks infants. It is probably different in origin, and is conceivably aUied to kala-azar. It runs a more rapid course than ordinary bHiary cirrhosis, and it is said that 95 per cent of the cases in Calcutta terminate fatally before the end of the second year of hfe (Ghose^^), Aji endemic form of intercellular cirrhosis characterized by jaundice, fever, ascites, enlargement of the Hver but not of the spleen, and by a rapid course in six to eight months, is said to occur in Mexico City (Carmono y VaUei^). Influence of Treatment. — A quiet life in a healthy sunny place, with protection from cold %\T.nds and damp, wiU prolong Life. Calomel has been stated to exert a really beneficial influence on the disease and to cause the jaundice to disappear, but more evidence is necessary' before this can be accepted. Surgical Treatment. — Drainage of the gall-bladder has been stated to give good results; out of 17 cases, 13 were reheved (Greenough^'^). But some at any rate of these cases may have been examples of chronic infection of the bniary tract rather than of Hanot's cirrhosis. In Individual Cases. — The patient's general nutrition, inasmuch as it indicates the progress of the malady, naturally influences the prognosis as regards prolonga- tion of life. Clubbing of the fingers is only met vdth in long-standing cases, and therefore shows that the course of the disease has been slow. Wasting and the recurrence of the febrile exacerbations or crises at shortened inter\'als indicate that the disease is advancing rapidly. The onset of %^-idespread haemor- rhages and the appearance of ascites and oedema of the legs are very grave indications, and the occurrence of compUcations such as pneumonia and peri- tonitis are most serious. Erysipelas, however, may not be fatal, pro\dded the urinary excretion is well maintained. b. Obstructive Biliary Cirrhosis. — Fibrosis of the hver ma}' be associated with obstruction of the larger bile-ducts. Thus, in congenital obhteration of the bile- ducts, cirrhosis of the hver is constant ; and in some cases of chronic obstruction of the ducts by gall-stones, there is increase of fibrous tissue in the hver. The prognosis of such cirrhosis is largely bound up -wdth that of the associated con- dition, and cannot be considered independently. Thus, in congenital obhteration of the ducts the outlook is hopeless, and death nearly always occurs before the eighth month of life. In gall-stone obstruction operation may, if the hepatic fibrosis has not become excessive, lead to a cure ; but niuch enlargement of the liver and the presence of secondary fibrosis add to the gra\dty of the outlook in gall-stone obstruction and render operation more anxious than in cases not so comphcated. 3. Syphilitic Cirrhosis. In acquired syphilis it is probable that an intercellular cirrhosis, resembling the well-known lesion in the congenital form, occurs ; but opportunities for verifying its presence are very rare. It is possible that it may be a causal factor in the benign jaundice of secondary syphilis, and that when excessive it may lead to acute yellow atrophy — a very rare event (see Liver, Acute Yellow Atrophy of). The prognosis of intercellular cirrhosis in adults, assuming that it occurs, is very good as regards the immediate future, for LUPUS ERYTHEMATOSUS jaundice and acute yellow atrophy very seldom follow. It is, however, reason- able to beUeve that, if untreated, gummatous change would be more likely to supervene. Syphilitic Cicatrices. — The deformed and widely-fissured or ' botryoid ' liver, due to contraction of gummas and syphilitic cicatrices, is often called ' syphilitic cirrhosis,' and no doubt has a superficial resemblance to a coarsely lobulated portal cirrhosis. But it would be more accurately described as syphilitic ' fibrosis ' than ' cirrhosis.' The prognosis of syphUis of the liver is discussed elsewhere (see also Ascites), but it is important to remember that whereas gummas melt away under efficient treatment, cicatrices are not affected. Antisyphilitic measures are therefore disappointing, and in addition misleading, if failure to obtain a good result be regarded as necessarily eliminating the existence of syphilitic change in the liver. Parasyphilitic Portal Cirrhosis. — By this is meant the occurrence of portal cirrhosis in a liver which, having formerly been affected with intercellular cirrhosis, is left mth its resistance so weakened that portal cirrhosis is easily induced. This probably explains some cases of portal cirrhosis in early life, and possibly, though this is difficult to establish, some cases in adults. The prognosis is bad, and is much the same as in ordinary cirrhosis in early life. As the lesion is parasyphilitic, and comparable to tabes, in that though not syphilitic it is favoured by syphilization of the soil, no real benefit can be anticipated from antisyphilitic treatment. Intercellular Cirrhosis of Congenital Syphilis. — Prompt and efficient anti- syphilitic treatment has a most important bearing on the prognosis, not only in curing the condition at the time, but in preventing the occurrence of the delaj^ed congenital lesions such as gummas and lardaceous change. In individual cases the outlook depends on the general condition of the patient, and on the degree of enlargement of the liver and spleen, which may be regarded as an index of the severity of the infection. General haBmorrhages and jaundice, which are often due to secondary infection, are very grave signs. Cases with ascites, which is very rare except with infants born with the disease in an advanced stage, are nearly always fatal. The earlier in life the general manifestations of hereditary syphilis appear, the graver the outlook. References. — ^^W. B. Cheadle, Some Cirrhoses of the Liver, p. 72, 1900 ; ^E. Jones, Brit. Jour. Child. Dis. 1907, iv, i ; ^Preble, Amer. Jour. Med. Sci. Philad. 1900, cxix, 263 ; *Ramsbottom, Med. Chron. Manchester, 1906-7, xlv, 7 ; °L. Rogers, Lancet, 1912, xi, 355 ; ^Sinclair White, Brit. Med. Jour. 1906, ii, 1287; 'Willems, Rev. de Chir. Paris, 1904, xxiv, 606 ; ^Vitry et Sezary, Rev. de Med. Paris, 1913, xxxiii, 86 ; ^Celso, Morgagni, Milano, 1911, R. iv, liii, 675; ^"Richards and Day, Trans. Soc. Trap. Med. 1912, v, 33 ; ^^Jullien, Arch. Prov. de Chir. Paris, 1911, xx, 90 ; ^^Gbose, Lancet, 1895, i, 321 ; ^"Carmono y Valle, Gaz. Hebd. de Med. Paris, 1897, N.S., xi, 873 ; "Greenough, Amer. Jour. Med. Sci. 1902, cxxiv, 979- ^. 2). Rolleston. LIVER, INJURIES OF.— (See Abdominal Injuries.) LOCOMOTOR ATAXY.— (5ee Tabes Dorsalis.) LUNACY.— (See IMental Diseases.) LUPUS ERYTHEMATOSUS.— There are two types of this disease :— (i) Acute, and (2) Chronic. I. Acute. — In this form the lesions are erythematous, with little or no obvious infiltration. The eruption develops rapidly, involving both flush areas of the cheeks, the root of the nose, the backs of the fingers and hands, sometimes the elbows, knees, and ankles, and rarely, the trunk. The patients are nearly all young girls or young women. \Vhen pyrexia and general symptoms exist, the prognosis 282 INDEX OF PROGNOSIS is unfavourable, and I have seen several cases end fatally. The mortahty is about 15 per cent. The fatal issue may be due to pneumonia, acute nephritis, or pulmonary tuberculosis. In some instances the eruption is haemorrhagic, and this factor is of grave omen. The prognosis depends mainly upon the general symptoms, and upon the pulmonary and renal condition. In many cases the disease can be controlled, and sometimes cured, by large doses of quinine ; but relapses are common. 2. Chronic. — In this more common locahzed form, the lesions are of limited area, slowly spreading from one or more foci on the cheeks, nose, ears, or scalp, or rarely, the trunk. The patches are infiltrated, red, and more or less scaly or crusted, with a tendency to produce scars in their centre and to spread peripherally. Beginning in adolescence or early adult hfe, the disease has many variations in its activity, and may last for many years. Even when the lesions are quite removed by treatment, or heal spontaneously, it is impossible to promise a permanent cure. The chronic scaly patches are removed temporarily by appUcations of carbonic-acid snow, by scarification, and by the local apphcation of caustics such as iodine, but recurrence is the rule. These recurrences are more common in the winter months and in the spring. Residence in a warm dry climate prevents relapses, but a return to a humid region is almost invariably followed by a recrudescence of the eruption. We are in complete ignorance of the cause of the disease, but attention directed to the general health, and the administration of quinine and tonics, are of service. IMany cases gradually improve with the lapse of time, but cases in which the disease has been present for twenty or thirty years are not uncommon. Epithelioma is a rare complication. In two cases which I have seen, it has followed prolonged ;ir-ray treatment. /. H. Sequeira. LUPUS VULGARIS. — The prognosis in a case of lupus vulgaris depends on : (i) The presence or absence of disease of the mucous membranes ; (2) The extent of the cutaneous affection ; (3) The character of the lesions, whether ulcerated or non-ulcerated ; (4) The general condition of the patient, and the conditions under which he lives, as regards the supply of proper nourishment, the hygiene of the home etc. ; and (5) The treatment. 1. Involvement of the Mucous Membranes. — This occurs i 1 43 per cent of the cases seen at the London Hospital, and the presence of disease in the nasal cavit\% on the palate, on the gums or the lips, or in the pharynx or larynx, materially increases the difficulty of treatment, and necessitates a guarded prognosis. It is my experience also that one is more likely to get pulmonary affection in the cases in v.'hich the upper air-pass? ges are involved. Where, however, the diseased areas in the nose are within reach, and can be thoroughly destroyed by the curette, cautery, or caustics, or combinations of treatment of this kind, a cure is frequently effected ; but if the surgeon is unable to remove the disease entirely, relapses in situ, with secondary involvement of the skin, are the rule. Where the cartilages of the septum and alse are involved, the outlook as regards permanent cure is less hopeful. The use of nascent iodine (Pfannenstill method) after operation is of great assistance in preventing recurrence in the intranasal cases. In lupus of the gums, lips, and pharjmx, the prognosis depends upon the thorough eradication of all the foci by the cautery, or the application of caustics, such as iodine (1-5). 2. The Extent of the Cutaneous Affection. — The size of the area involved depends, of course, in the main upon the duration of the disease, and therefore LUPUS VULGARIS 28^ upon early diagnosis. Large single areas require prolonged treatment, but if of the dry type, the prognosis is not materially influenced. Multiple lesions scattered about the face, limbs, and trunk, such as occur after the acute exanthems, do not yield so readily as the extensive single-focus cases, but many of the foci may heal spontaneously if they are of small size. 3. The Character of the Lesions — Ulcerative or Non-ulcerative. — The dry, non- ulcerative form responds most readily to the Finsen treatment, and the most permanent results, with the least deformity, are obtained in it. A'-ray treatment IS extremely tedious in this variety, and cure can only be effected at the risk of •producing a telangiectatic scar, which may become epitheliomatous. The ulcerative form responds readily to treatment by local antiseptics, followed by exposures to the x rays. Relapses are, however, more common, and there is greater disfigurement. 4. The General Health of the Patient and the Conditions under which he lives are of great importance. The resistance of the individual to the tuberculous process obviously depends to a large extent upon his general health and upon a sufficiency of good food, fresh air, and proper hygiene. Where these are unsatis- factory, as in the ill-fed children of our large cities, the effects of efficient local treatment are often nullified. 5. The Treatment. — Complete excision of the affected area with a good margin of skin around, and the removal of a sufficiency of the subjacent tissue, give admirable results ; grafts may be applied where the area is extensive. Lang, of Vienna, has reported a remarkable series of results. In many cases the operator does not go deeply enough, and, on the face, the fear of increasing the deformity is an ever-present drawback ; the result is that patients return with deep-seated nodules which can be seen through the graft. These, I find, are extremely difficult to destroy, except by puncturing with the cautery. Where the lupus occurs in regions in which the character of the scar is of Httle moment, the method of excision is to be advised, as giving excellent results with the minimum loss of time over treatment The Finsen treatment is especially indicated where the lesions are of moderate size, and on the face or exposed parts. The permanency of the results is now assured by a lengthy experience. I have nearly 100 cases which have been cured by this method, and which have been free from recurrence for ten years. Of 1039 completed cases treated in the Finsen light department at the London Hospital during thirteen years : 544 were free from recurrence for from three to thirteen years; 186 had been well for less than three years; 117 patients require occasional treatment (the}' have never been free from recurrence for a long period, but are able to follow their employment) ; in 161 cases we were only able to report improvement (these patients had usually had extensive disease before treatment was begun, or there had been severe affection of the mucous membranes of the nose, nasopharynx, or buccal cavity) ; only 31 cases were found to be uninfluenced by treatment. It should be mentioned that these results were not entirely due to the light treatment, as ulcerated areas received preliminary applications of the x rays, and the nasal, palate, and buccal cases received special treatment, either by operation or the application of strong antiseptics and caustics. I should like to take this opportunity of protesting against the prolonged treatment of lupus, especially of the dry forms, by the x ra^'S. I have seen a large number of cases in which several hundreds of applications of the rays have been made. The results in some instances have been satisfactory as regards the disappearance of the lupus, though the scar was an ugly one. This, however, is of sm'all moment in comparison with the grave complication of epithelioma. Chronic 284 INDEX OF PROGNOSIS lupus is followed in about 2 per cent of the cases by epithelioma, but prolonged treatment by the x rays unquestionably increases the liabihty to cancer, and I regret to say that I have seen cases in which the prolonged radiation has without doubt been the cause of this grave complication. Treatment of lupus by tubercuhn is unsatisfactory. In some cases of the ulcerative type, and in many cases of scrofulodermia, improvement follows the careful exhibition of this remedy ; but care is required, for there is no doubt that its uncontrolled administration has been followed by an aggravation of the disease, and also by the stimulation of latent pulmonary foci. Lupus is not in itself a fatal disease, but in cases in which the nose, pharynx, and larynx are affected, there is considerable risk of pulmonary comphcations ; 6 of my 544 patients cured of lupus died from pulmonary tuberculosis, and 7 others died while under treatment. Tuberculous meningitis also developed in 2 cases while the patients were undergoing the Finsen light treatment. /. H. Sequeira. LYMPHADENITIS, TUBERCULOUS.— We shall confine ourselves in this article to tuberculosis of the glands of the neck. The problems which present themselves are : (i) The prospects apart froin radical removal ; (2) The mortality of operation ; and (3) The end-results of cases operated on. I. Prospects apart from Radical Removal; or, in other words, the effects of medical and general treatment. Included under this heading are cases in which the bursting of an abscess may be hastened by incision. We have to ask what prospect there is of natural cure, and what is the danger of tuberculosis arising elsewhere. Reliable statistics of a sufficient number of cases are not abundant ; but we may probably accept Wohlgemuth's figures as sho-wing that about 24 per cent are permanently cured. The majority either advance and retrogress alternately ; or remain stationary for many years (the glands often becoming calcareous) ; or, more commonly, softening eventually takes place, and an abscess bursts through the skin, often discharging for a long time, and leaving an ugly scar. In children, the majority of the cases eventually break do\vn ; in adults, the glands have often been present for a long time already, and frequently show no tendency to change further. Given the best possible conditions, fresh air, good food, etc., the results would no doubt be better. Sea air, especially that of the Kent coast, has a great reputation in this particular complaint. But even under the best circumstances a considerable number of the cases come, or ought to come, to operation. Tuhercidin. — The value of tubercuhn is not yet definitely determined by statistics, but it often appears to help. Jones has published a study of 79 cases treated at St. Mary's Hospital inoculation departm.ent : he describes 27 as cured, 21 as much better, iS better, 8 not improved, and 4 worse ; it is not stated how long they were observed. About half had had a previous operation. Patients under ten and over twenty did well ; those between ten and twentj^ did poorly. We may conclude, therefore, that, given the best conditions, about a quarter are likely to be cured apart from operation ; that the majority can be improved for a time, or brought into a comparatively quiescent state ; but that many of these will eventually suppurate ; and further, that tuberculin is probably helpful. Recurrence Elsewhere. — As to the danger that tuberculosis may develop else- where, the figures obtained by Demme from the Children's Hospital at Berne, where cases could be followed up for many years, even as long as twenty, are probably the most reliable we have : of 692 cases treated without operation, 145 eventually developed phthisis, or 21 per cent, and 57 developed tuberculosis elsewhere, or 8 per cent, a total of 29 per cent. LYMPHADENITIS, TUBERCULOUS 285 It does not follow, of course, that this was always due to self-infection from the tuberculous glands of the neck. Prognosis in Individual Cases. — If the glands are already softening, cure will only result by the long and uncertain process of external discharge. The ability to obtain fresh air and good food, and the response to a few months of this treatment, are the principal guides to prognosis. 2. Mortality of Operation. — This must be very small indeed. Of 649 cases at the Mayo clinic, none died of the operation ; the nearest approach was a fatahty, four weeks afterwards, from generahzed tuberculosis. Dowd had 2 deaths in 465 operations. We may take it, then, that, apart from the irreducible minimum of surgical calamities, such as anaesthetic deaths, status lymphaticus, etc., the danger is practically nil. Nerves may be cut, but it is very unusual for section even of such important structures as the vagus or spinal accessory to give rise to any permanent trouble ; nor does Ugature of the jugular vein appear to do any harm. Cutting the thoracic duct is another harmless bogey. 3. End-results of Operation. — It is difficult to quote figures as to prospects of permanent cure, because operators differ so much in the thoroughness of their methods. Local Recurrence. — The number of local recurrences is given by different collectors of statistics as follows : Wohlgemuth, 30 per cent ; Dowd, 25 per cent out of 100 cases ; Judd, 8-6 per cent out of 649 cases in the Mayo clinic ; Miiller, I3'4 per cent out of 67 cases. Wohlgemuth's records are getting old now, and are probably much too high. The true recurrence rate, judging by what is seen in ordinary hospital practice, is probably about i in 5 or 6, and it would be less if a more complete clearance of glands were made in the first place. Some writers attach great importance to removing enlarged tonsils and carious teeth, as a considerable help in preventing recurrence. Recurrence Elsewhere. — Another inquiry must be made concerning the prospects of subsequent development of tuberculosis elsewhere after removal of glands from the neck. Von Xoorden quotes 149 cases, followed from three to sixteen years after operation, whereof 28 per cent showed evidence of tuberculosis in other organs. Bios watched 160 cases for three to twelve years ; 26 per cent developed phthisis, and 14 per cent tuberculosis elsewhere. Dowd, on the other hand, found only i case of tuberculosis of the lung and 3 of bone disease following on 100 operations, but his end-results are not so late as the others. Judd, reporting on 649 cases from the Mayo clinic, found that 19 afterwards died of phthisis and 9 of tuberculosis elsewhere ; at the time of operation, only 10 were known to be consumptive. MiiUer found that 6 out of 67 cases eventually died of tuberculosis. From these figures we may conclude that removal of the glands is by no means a sure preventive of further tuberculous mischief. It looks, at first sight, as though operation were of no value in averting such mischief, because there is very little difference between the figures quoted for tuberculosis developing elsewhere in the medical and surgical groups. In each group, probably about I case in 4 will eventually show signs of phthisis, bone disease, etc. ; but it m-ust be remembered, of course, that the non-operated group mostly includes the milder types of the disease, and the operated group the severer types, in which a much larger proportion of cases of dissemination might have been expected. References. — Judd, Ann. Surg. 1910, Hi, 758 ; Attridge, Surg. Gynaecol, and Obst. 1908, vii, 885 ; Jones, Brtt. Med. Jour. IQ09, ii, 531 ; Miiller, Ann. Surg. 1913, Iviii, 433. A. Rendle Short. 286 INDEX OF PROGNOSIS LYMPH ADENOMA. — In considering the prognosis of lymphadenoma, it is important to understand exactly what is meant by that name. Until 1901-2, when the histological work of Andrewes, Reed, and others definitel}'- established the structural characters of lymphadenoma, cases of lymphatic glandular enlarge- ment which did not fit into any other group, and would now be spoken of as lymphocytoma or pseudo-leukaemia, were often included ; and at an earlier period, confusion occurred with some forms of sarcoma, of leuksemia, and of tuberculosis. At the present time, microscopic examination of a gland should be regarded as essential to a diagnosis of lymphadenoma, and for strictly accurate statistics only cases, such as Longcope's collectioni of 86, in which this has been done, can be accepted. Othermse, cases of tuberculous large-celled hyper- plasia of lymphatic glands might be thought to be examples of lymphadenoma cured by operation. True lymphadenoma appears to be invariably fatal sooner or later. The duration of life after the onset of symptoms varies considerably ; the rare acute form may run its course in some weeks or a few months, but usually the disease proves fatal within three years ; thus, out of 49 cases followed to their termin- ation, Longcope found that 34, or 69-4 per cent, died ■\\ithin two years, but 2 survived for seven years and another for six years. The question of prognosis is therefore concerned with the duration of life rather than with recovery. The usual course of the disease is that the glandular enlargement is at first and for a considerable time local, and with periods of quiescence or remission is slowly progressive, and that eventually it generalizes more or less rapidly and is then accompanied by fever. When the local phase is latent or possibly absent, the disease appears acute from the start. Medical Treatment. — Arsenic has a marked effect in reducing the size of the glands, and may apparently bring about a long intermission in the course of the disease. Organic compounds of arsenic such as atoxjd, orsudan, and salvarsan have also been employed. Salvarsan produces a rapid and striking effect, but it should not be used in debilitated patients late in the course of the disease. Arsenic does not act equally well on all cases of lymphadenoma ; sometimes it fails to exert any influence ; and although it may be most successful for a time, it may lose its effect and no longer control the glandular enlargement ; or in a case in which the glands have become normal after the use of arsenic, a recur- rence is quite uninfluenced by arsenic. In this connection it is possible that in its progress the disease undergoes some alteration in character, such as trans- formation into sarcoma (Yamasaki-, Karsners), or that some secondary infection of the glands has occurred. X rays prolong life but do not destroy the unknown cause of the disease ; this is shown by the occurrence of relapses. Soft glands containing much cellular elements, and the spleen, diminish in size, but hard fibrous glands are unchanged. According to McNalty,* x rays do not influence cases with the relapsing t}^e of fever. In some cases, although diminution in size follows x-ra.y treatment, the glandular enlargement recurs very rapidh^ when the exposures are discontinued (Morton, 5 Reid^). The application of x rays may induce a grave toxemia and, as shown experimentally, normal lymphoid tissue may be extensively destroyed and grave damage be done. In 42 collected cases Pancoast^ found that a ' symptomatic cure ' occurred in 18, improvement in 14, and no change or slight improvement only in 10. A further report on 27 of these cases showed that 17 had died of the disease, 3 from toxaemia ascribed to x-ray treatment, and that 2 more would shortly succumb ; 7 were well three or four years after the first symptomatic cure, and i a year after ; but 4 of these 8 had had relapses. Thus, as a cure for three or four years was obtained in 25 per cent of the cases, the influence of x rays on prognosis is extremely good. LYMPH ADENOMA 287 Surgical Treatment is only admissible in the early stage when the disease is localized to a group of superficial glands, as in the neck. From a priori considerations it is perfectly logical to remove the primary focus so as to prevent generalization ; in some instances this has been thought to delay the course of the disease. In a case under my care there was an interval of five years between operation and death. On the other hand, it is often impossible to remove all the glands involved when the parts are exposed, and in some instances recurrence and generalization occur rapidly after operation ; the later event, however, is not necessarily due to operation, as it may have begun before the surgical procedure. It is possible that ;r-ray exposures soon after operation might be beneficial by acting on the inoperable glands. Although operation may be desirable to relieve pressure symptoms or to prevent deformity, its influence from a prognostic point of view is probably bad. Prognosis in Individual Cases. — The prospect of life varies according to the stage and site of the disease ; when it is confined to a single group of glands, two, three, or even more years may elapse before death, provided pressure is not exerted on some important structure such as the trachea or bronchi. In the late stage, when generahzation has taken place, the end is nearer, but considerable variations are met with. Thus, a mediastinal growth may, by mechanical pressure, precipitate the end. Intrathoracic and intra-abdominal lymphadenoma is more rapidly fatal than widespread superficial glandular implication. This is incidentally shown by the figures given belov/ in connection with the bearing of relapsing fever on the prognosis. Fever of one form or another almost always occurs in the course of the disease, and generally speaking its presence points to an advanced stage with generalization of the disease. The average duration of life after the onset of the relapsing type of fever is about seven and a half months (Batty ShawS), but cases have been known to last more than a year. The cases which present the relapsing form of fever appear to run a more rapid course than others. In 27 cases of lymphadenoma with relapsing fever collected by McNalty,* the extremes of life from the onset of the glandular enlargement were five weeks and four years, and the average 12-7 months ; or excluding 3 exceptional cases with durations of two and a half, three, and four years, 9-3 months. In 18 out of these 27 cases in which the superficial glands were enlarged, the average duration was 14-6 months, or excluding the 3 cases of exceptionally long duration, ten months. In 7 cases in which the internal glands only were affected, the duration was eight months. Haemorrhages and a grave secondary anaemia show that the end is near. There seems some evidence to believe that a decided leucopenia and a small number of platelets in the blood (Buntings) indicate a late stage of the disease. Pruritus, which is rather a rare symptom, has appeared to me to be associated with a rapid course of the disease. 10 Disappearance of glandular enlargement is not necessarily a good sign, for the disease may advance in the internal organs while the superficial lymphatic glands are disappearing. Further, although the amount of growth left is small, the patient may pass into an extremely aucemic and cachectic condition and die. I have seen this after prolonged ;tr-ray treatment. The appearance of complica- tions, of which tuberculosis is the most frequent, renders the prognosis very grave. References. — ^Longcope, System of Medicine (Osier and McCrae), 1909, vi, 475 ; ^Yamasaki, Zeits. /. Heilk. 1904, xxv, 269 : ^Karsner, Arch. Int. Med. Chicago, 1910, vi, 175; *McNalty, Quart. Jour. Med. Oxford, 1911-12, v, 76; "Morton, Proc. Roy. Sac. Med. 1910, iii (Electro-therapeut. Scot.), 134 ; ®Reid, Proc. Roy. Soc. Med. 1910, iii (Electro-therapeut. Sect.), 133 ; 'Pancoast, Univ. Penn. Med. Bull. Philad. 1906-7, xix, 282 ; ^H. Batty Shaw, Edin. Med. Jour. 1901, N.S., x, 501 ; ^Bunting, Johns Hop. Hosp. Bull. 1911, xxii, 369 ; ^"Rolleston, Practitioner, 1911, Ixxxvi, 505. H. D. Rolleston. INDEX OF PROGNOSIS LYMPHATIC FISTULA,— (5ee Thoracic Duct, Wounds of.) MADURA FOOT (Mycetoma). — This disease usually remains localized, and slowly progresses if the affected part is not amputated ; but it is not directly fatal, and in only one recorded case has it become generalized. c. W. Daniels. MALARIA.-^Here is an instance where the prognosis depends largely on early diagnosis. Most of the deaths occur either in undiagnosed cases, or in others where severe complications such as cerebral crises are present when treatment is commenced, or where there is pre-existing disease or organic change. In England, at the Albert Dock Hospital, 436 cases of malaria have been diagnosed during the last ten years, and 4 patients have died. The case- mortahty was therefore o-gi per cent. Of these four cases, two were not diagnosed as malaria (being thought to be hsemorrhagic pancreatitis, and asthma and bronchitis, respectively), and each of the other two was admitted comatose in a cerebral crisis. Probably if the diagnosis had been made early, and treatment commenced at once, these four would not have died. The total number of deaths in any malarial country is large. In some of these the diagnosis is open to question ; in many there has been no antimalarial treatment ; and amongst natives the majority of cases are neglected. A certain increase should perhaps be made in the death-rate owing to the fact that malaria predisposes to intercurrent diseases such as dysentery and tubercu- losis, and in persons with a fatty or a poisoned heart, as in beri-beri, it may by direct toxic effect cause a fatal termination of these diseases. Where the vessels are atheromatous, cerebral haemorrhage may occur as a result of the high blood- pressure common in some cases of malaria. Premature labour and abortion are not uncommon, either as a result of the disease or of injudicious treatment with quinine. Still-births and high infantile mortality are not infrequent in parturient women with malaria. c. W. Daniels. MANIA. — [See Mental Diseases.) MEASLES. — The most important points to which attention must be paid in the prognosis of measles are — (i) The age of the patient ; (2) The presence of certain complications ; (3) Certain special symptoms ; (4) The social status of the patient ; and (5) The virulence of the epidemic. I. Age. — It can with confidence be stated in general terms that the younger the patient the worse the prognosis, but that only for patients under two years of age is it really serious. The exact gravity of the prognosis when considered from this point of view varies with the character of the epidemic and the circum- stances of the patient. The fullest figures bearing on the subject are those from the city of Aberdeen, where measles was a notifiable disease for the twenty years 1883 to 1902. During that period 40,374 cases were notified, and there were 1346 deaths. For all ages and for the whole period the fatahty was thus 3-3 per cent. The table on the opposite page shows the fatality at different age- periods. From this it is seen that the fatality is considerable, and highest in infants under one, and next high in those between one and two. After that age it drops considerably, and remains low at all other ages. It is possible that the Aberdeen notifications contained a considerable number . of cases of rubella. As the latter disease is very rarely fatal, its inclusion in notifications of measles would cause the fatality from this disease to appear to be lower than it really is. MEASLES 289 Fatality according to Age (Aberdeen). Age Fatality Age Fatality per cent per cent Under 1 13-9 9-10 0-6 1-2 lO'O 10-11 0-2 2-3 34 11-12 0-0 3-4 1-6 12-13 0-0 4-5 0-9 13-14 1-2 5-fi 0-7 14-15 0-0 <;-7 0-5 15-25 0-9 7-8 0-5 25-60 0-6 8-9 04 GO & over 0-0 The only statistics available in which corrections for errors of diagnosis have been made are those of various hospitals. But inasmuch as the worst cases*are, as a rule, sent to hospital, while the less serious are treated at home, the fatality of cases treated in hospitals is usually high. The following table shows the cases admitted into the hospitals of the Metropolitan Asylums Board during the two years igii and 1912, with the number of deaths and fatalitj' per cent: — j Fatality according to Age (Metropolitan Asylums Board). Age Cases Deaths Fatality per cent Under i 667 152 22-7 1-2 1738 366 21-0 2-3 1355 148 10-9 3-4 1186 96 8-0 4-5 997 61 6-1 Under 5 5943 823 13-8 5-10 1325 27 2-0 10-15 114 2 1-7 1.5-20 27 0-0 20 & over 49 0-0 Total . . 7458 852 114 The figures in this table bear out the statement made above as to the diminution of the fatality with the increasing age of the patient. Sex makes no difference in the prognosis. 2. Complications. — Lung Affections. — By far the most formidable, as well as the most frequent, complication is bronchopneumonia. It accounts for a large majority of the deaths from measles. During the three years 191T-12-13 there were 1882 cases of measles under treatment at the Eastern Hospital, and in 293, or 15-5 per cent, of the cases bronchopneumonia supervened. Of the 293 cases, 210, or 71-6 per cent, were fatal. Besides these there were 17 fatal cases of bronchitis. The total number of measles deaths for the three years was 292 ; so that in 777 per cent of the fatal cases death was due to acute bronchitis or bronchopneumonia. These figures suffice to indicate the gravity of pulmonary complications. 19 290 INDEX OF PROGNOSIS Cancrum Oris and Acute Tuberculosis are extremely serious. Fortunately they are relatively uncommon. Chronic and latent tuberculous lesions are prone to be stirred into activity by an attack of measles. Secondary Inflammation of the Fauces should be regarded with apprehension. Not infrequently it results in extensive ulceration and septicaemia. Implication of the Larynx occurs in between 4 and 5 per cent of the cases. The prognostic significance depends on the period during which it arises. There is less cause for alarm when it occurs during the initial period, before the appearance of the rash, than when it sets in as the latter is fading, or during convalescence. The laryngeal symptoms of the initial period are usually due to simple laryngitis, and in many cases subside when the rash comes out. Late laryngeal symptoms betoken either diphtheria or laryngeal ulceration, both of which conditions are serious, but especially the former. Indeed, hardly a more for- midable combination of acute infectious diseases is to be found than that of diphtheria and measles. But even non-diphtheritic inflammation of the larynx is a very serious complication. During the three years igii to 19x3 there were 78 cases of laryngitis or ulceration of the larynx at the Eastern Hospital. Of these, 30 were fatal, or 38-4 per cent. In a considerable number of the cases intubation or tracheotomy was necessary. Bronchopneumonia, too, is not uncommon in the laryngeal cases. The incidence of laryngeal comphcations varies in different years. The 78 cases were distributed amongst the three years, as follows : 1911, 30 cases with 17 deaths ; 1912, 28 with 6 deaths ; 1913, 20 with 7 deaths. Eye Affections. — The eye is prone to become inflamed in measles. This complication occurred in nearly 4 per cent of the cases at the Eastern Hospital. Usually the inflammation is limited to the conjunctiva, but occasionally the cornea is involved, in which case an ulcer and an opacity may result. But these sequelae are rarely seen in cases in which early and assiduous treatment has been applied. One form of ophthalmia is particularly dangerous — namely, that in which not only the conjunctiva, but also the eyehds are inflamed. There is usually brawny swelling, and the lids are with difficulty separated. These are the cases in which loss of sight results sometimes, even though every attempt is made to save the eye. Otitis Media occurs in from 11 to 14 per cent of cases treated in hospital. The prognosis is much the same as in scarlet fever. 3. Special Symptoms. — If the respiration becomes hurried and the lips and extremities cyanotic before the rash comes out, the prognosis is grave. When convulsions occur, recovery seldom takes place. Should pulmonary symptoms not clear up within two or three weeks of their onset (which is mostly while the rash is out) , tuberculous disease should be suspected. Progressive wasting with pyrexia, with or without diarrhoea, is also suggestive of the same disease. Frequent vomiting and diarrhoea are ominous, especially if they come on early in the disease and are accompanied by a fall of temperature and other signs of collapse. 4. The Social Status of the Patient. — It is a matter of common observation that measles is much more fatal amongst the poor than the well-to-do. Perhaps, indeed, in no other acute infectious disease, with the exception of whooping- cough, is this class-distinction more marked. In Aberdeen it was found, during the twenty years aheady referred to, that the fatality varied inversely with the number of rooms occupied by the famfly in which the cases occurred. Thus, in one-roomed houses it was nearly 7 per cent ; in two-roomed, 3 ; in three- roomed, just under 2 ; and in four and five-roomed, less than i. The average fatality for all houses was 24 per cent. MELANOTIC SARCOMA 291 5. Virulence of the Epidemic. — The effect of this has also been shown by the Aberdeen figures. In that city the fatality from measles varied from o to 25 per cent in different years. E. W. Goodall. MELANCHOLIA.— (See Mental Diseases.) MELANOTIC SARCOMA. — The prognosis in this dreaded form of mahgnant disease has been depicted as black as the characteristic nodules of the malady, a view which requires some modification. Melanotic sarcoma, broadly speaking, arises either in the choroid coat of the eye, or in the skin. In the latter situation it originates either from a congenital pigmented mole, or in rare cases from punctured wounds, which presumably carry a group of the pigmented connective-tissue cells of the skin into a situation favourable to their proliferative activity. The duration of life in melanotic sarcoma is usually about two to three years. The disease is generally painless until towards the end, but subcutaneous deposits of the disease, when ulcerated, become painful. The patient is usually able to go about and follow his occupation without any feeling of illness until a few rhonths before death. Lymphatic oedema of the affected limb then begins to manifest itself if the disease has begun on one of the extremities, or the deposits in the internal organs — and especially in the liver, which may attain an enormous size — interfere by pressure with the activities of the vital organs, and cause serous effusions which are the usual proximate cause of death. On the whole, melanotic sarcoma is a very merciful form of malignant disease. As stated in my Hunterian lectures on melanotic growths, I have obtained strong microscopic evidence that the process of dissemination in malignant melanoma, just as in breast cancer, is primarily one of centrifugal lymphatic permeation. There is, it is true, strong evidence from the results of necropsies that in many cases the blood-vessels are the channels of spread in the later stages of dissemination. The crucial point to settle as determining the prospects of surgical interference in malignant melanoma is this : At what period is lymphatic dissemination supplemented or replaced by blood dissemination ? When once viable fragments of the growth are launched into the blood-stream the surgeon's hand is paralyzed, and the patient must depend entirely on the natural forces, always inadequate, and frequently altogether absent, which tend to the destruc- tion of the embolized fragments. Fortunately it would appear that, as a general rule, blood invasion does not take place at an early stage. This is indicated prima facie by the comparatively long average duration of the disease, which has been estimated at three years ; if malignant cells reach the blood in the early stage of the disease, the natural powers of resistance must inhibit their further development, or obviously the patient would succumb within a few months. In the second place, cases of death from intercurrent disease occur, in which lymphatic dissemination sufficiently widespread to be inoperable is seen, unaccompanied by evidence of blood dissemination. Lastly, most extensive lymphatic distribution of the disease may take place in the glands, the subcutaneous tissues, and upon the serous membranes, without any of the nodular visceral metastases which are the usual result of blood embolism. In the museum of Guy's Hospital there is a specimen which bears very directly on this point. It is a kidney, itself entirely free from disease so far as the naked eye can see, but embedded in a mass of melanotic growth which is replacing the perinephric fat. It appears certain that, as frequently happens in breast cancer, the perinephric growth originated from malignant infection of the lumbar glands. If this is the case, it is evident that 292 INDEX OF PROGNOSIS widespread lymphatic dissemination may occur in melanotic sarcoma, without obvious evidence in the kidneys of embohc blood invasion. To sum up, pathology indicates that if the operation for melanotic sarcoma is rightly planned, its prospects should not be so hopeless as is generally assumed. The principles upon which the excision of a mahgnant melanoma should be carried out are, in my opinion, as follows : A circular incision should be made through the skin round the tumour, at what is judged by present standards to be a safe and practicable distance. The incision, situated as a rule about an inch from the edge of the tumour, should be just deep enough to expose the sub- cutaneous fat. If necessary, two radial hnear incisions extending from the circular one should be made on opposite sides of the tumour in order to facihtate the elevation of the sldn flaps, which forms the next step. The skin, with a thin attached layer of subcutaneous fat, is now to be separated from the deeper structures for about two inches in all directions round the skin incision. At the extreme base of the elevated skin flaps a ring incision down to the muscles surrounds and isolates the area of deep fascia and overlying deeper subcutaneous fat to be removed. The fascial area is next to be dissected up centripetaUy from the muscles beneath, to a Hne which corresponds vnth. that of the circular skin incision. Finally, the whole mass with the growth at its centre is removed by scooping out with a knife a circular area of the muscle immediately subjacent to the growth. The edges of the wound are to be brought together as conveni- ence dictates. Writing in 1903, Eve^ said : " The removal of the nearest chain of lymphatic glands, whether palpably enlarged or not, should never be omitted ; for it may be taken as a matter of certainty that in a great majority of cases they are infected." In the same paper. Eve enforces this lesson by recording a case of melanoma of the palm in which, although the axillary glands were not palpably enlarged, they were infected even to the naked eye. Yet Acton,^ writing in 1905, found in nearly every case of which the records were available, that the primary growth was removed and the lymphatic glands were left. Admitting the imperative need for removal of the lymphatic glands as a part of the first operation, it must be remarked that in cases which show palpable enlargement of these glands, simple excision of the glands is hkely to be quite useless. I have shown that permeation of the lymphatic plexus of the deep fascia soon takes place around the infected glands, just as it occurs round the primary tumour. The excision of the glands must therefore be carried out on exactly the same principles as the excision of the primary tumour — that is to say, a large circular area of the surrounding deep fascia must be exposed, dissected up from its circumference towards the infected glands, and removed in one piece with them. In late cases it may even be right to remove an area of skin over the infected glands, but such cases are probably inoperable. Lastly — and this is most important — the apparently healthy set of glands above those obviously enlarged should be completely removed. The case which follows illustrates the successful application of these principles. Miss C, age 40, was sent to me by Dr. Burstal, of Staines, on October 21, 1909. In Septem.ber, 1907, Dr. Moreton Palmer removed an ulcerated papilloma which had been present on the dorsum of the left -wTist for three or four years. In September, igo8, some small lumps were removed just above the epitrochlear gland. These lumps were subcutaneous, and were not glandular. A week or two later, a small dark nodule appeared just below the incision. It was removed under local anaesthesia, and was reported by the Clinical Research Association as a malignant melanoma. Subsequently, the patient suffered much pain in the bicipital region, thought to be due to an involve- ment of nerves in the scar. On examination, I found a vague induration running up the brachial vessels about the middle of the upper arm, midway between the axilla and the scar of the second operation, and it appeared probable that the growth was recurrent MELANOTIC SARCOMA 293 in this situation ; moreover, a large gland, nearly as big as a chestnut, could be felt in the axilla. I therefore advised a thorough operation, which should include removal of the supraclavicular glands, clearing of the axilla, and excision of the deep fascia extending from the axilla almost to the elbow. The patient consented to undergo the operation, and was admitted to the Bolingbroke Hospital. A semilunar flap of skin, involving most of the inner aspect of the arm, was turned backwards, and the deep fascia was widely removed, with exposure of the brachial vessels and accompanying nerves. The axilla was next opened by a prolongation into its fornix of the first incision, and was completely cleared of its fat and glands, which were removed in continuity with the deep fascia of the inner side of the arm. The supraclavicular triangle was now cleared of its fat and glands through a separate incision. The patient made a good recovery from the operation. About a year later, a recurrent nodule appeared over the lower part of the triceps at the back of the arm. It was excised on December 15, 1909, and on section was a typical sarcoma, unpigmented and degenerate at the centre. (It is well known that unpigmented metastases are not rare in melanotic sarcoma.) Since this time the patient has remained well, and the neuralgic pains from which she suffered in the arm have greatly improved, especially since a visit to Sidmouth, where she had hot sea-bathing treatment. The absence of any sign of recurrence up to the present time, a period of over four years, encourages me to hope that in this case a permanent cure has been obtained. In this connection I may repeat what I said in my Hunteriau lectures in 1907 : " The methods still employed in dealing with melanotic growths of the skin are precisely those which years ago gave such deplorably bad results in the treatment of carcinoma of the breast. Formerly the tumour, with a small circumferential area of skin, was cut out from the breast, and the axillary glands were removed, if at all, only when palpably enlarged. Even when the glands were excised, the surrounding zone of permeated lymphatics in the breast, in the deep fascia, and in the muscles, w-as left intact to reproduce the disease. Nowadays, the improved operation for breast cancer produces prolonged or permanent immunity in about 50 per cent of cases. And upon the evidence I have laid before you, I venture to predict that the apphcation of more thorough and scientific methods to the surgery of cutaneous melanomata will produce a corresponding, though perhaps a smaller, improvement in the results of operation." I trust that the case I have recorded is the beginning of the fulfilment of the prediction then made, though, owing to the fortunate rarity of the disease, the evidence can only accumulate very slowly. Only one other opportunity has occurred to me of applying the principles w-hich I advocate in the treatment of melanotic sarcoma. The case was that of a middle-aged man lying in the inoperable cancer wards of the Middlesex Hospital, with a small, non-pigmented, pedunculated growth of the foot, and a mass of confluent and adherent melanotic inguinal glands. I had no sanguine expecta- tion that he would escape local recurrence after the removal of these glands, but since only slightly-enlarged glands could be felt above Poupart's ligament, I thought it worth while to attempt radical treatment. After removing the primary growth, I excised the inguinal glands with a large area of fascia. I then divided Poupart's ligament, and removed the glands along the external iliac vessels nearly as high as the bifurcation of the aorta. But even the highest glands which I could reach already showed signs of early malignant deposit, and it was impossible to carry out the principle which I believe to be so important, namely, the removal of the apparently uninfected set of glands above those enlarged. I was not surprised that this patient retmrned a few months later with inoperable recurrence in the region of Poupart's ligament. To sum up, the prognosis in melanotic sarcoma is not nearly so bad as it has been represented, provided that the disease is recognized early, and that it is operated upon on the lines indicated by the pathological evidence of its mode of spread. References. — ^ Eve, " A Lecture on Melanoma," Practitioner, 1903, Feb. ; ^ H. W. Aeton, Middlesex Hosp. Jour. 1905. W. Sampson Handlcy. 294 INDEX OF PROGNOSIS MENINGITIS. Meningococcal Meningitis (sporadic). — In this form, where the diagnosis can generally be clinched by the demonstration in the cerebrospinal fluid of the characteristic diplococcus, the prognosis as to life is relatively more favourable than in other forms of meningitis. Thus, in the 94 cases collected by Lee and Bachow, 50 per cent of the patients admitted to hospital survived ; but, of these, only some 15 per cent recovered completely, the rest being left with hydro- cephalus, blindness, or varying degrees of mental deficiency, sometimes amounting to idiocy. The results of intrathecal injection of antimeningococcal serum are less striking than in the epidemic variety of the disease. Nevertheless, lumbar puncture — by relieving the intracranial pressure — and the administration of the above-mentioned serum, when available, will sometimes turn the balance and may save a patient who would otherwise die. The prognosis as to the future mental condition of those patients who survive should be guarded. Even after an apparently complete recovery from all the meningeal symptoms, it may be found that the child's subsequent mental development is arrested or delayed. Further, a considerable proportion of the cases which survive develop hydrocephalus, probably due to adhesive obstruction in the foramen of Monro or in the other foramina in the neighbourhood of the fourth ventricle, thereby preventing the downward flow of fluid from the ventricles into the spinal theca. Other patients, again, become permanently blind or deaf from inflammatory changes in the optic or auditory nerves. Meningococcal Meningitis (epidemic). — The prognosis in cases of this type, untreated by serum, is extremely bad. According to the statistics of Flexner, the mortality is usually from 80 to 90 per cent, and never less than 70 per cent. Since the introduction of serum treatment by intrathecal injection, however, the gross mortality of cases thus treated has fallen to a remarkable extent. Thus, out of 1295 serum- treated cases collected by Flexner, 893 recovered and 402 died, a mortality of 31 per cent. The earlier in the disease the specific treat- ment is begun, the better are the prospects, as shown by the following table of 121 1 cases :— Mortality According to Time of Serum Treatment. Period of Disease Number of Cases Mortality per cent Within first three days Fourth to seventh day Later than seventh day 199 346 666 18 27 ;3(; The mortality amongst infants under two years of age is usually very higli, rarely being less than 90 per cent, according to Flexner. But of 125 serum- treated infants under one year, 63 recovered and 62 died ; of 21 infants injected within the first seven days, 1 7 recovered and only 4 died, a mortality of less than 20 per cent. Whereas recovery is a gradual process, lasting about four weeks, in the small proportion of epidemic cases which spontaneously survive: in serum- treated cases, on the other hand, recovery by crisis is not uncommon, and the duration of the disease averages only about eleven days. Pneumococcal Meningitis, etc. — Pneumococcal meningitis may occur as a primary malady, or it may be secondary to pneumococcal infection of other MENINGITIS 295 parts of the body, especially after empyema or otitis media. Untreated cases are practically always fatal. Lumbar puncture undoubtedly relieves symptoms, and may in some cases turn the balance in favour of recovery. The same remark applies to Streptococcal and Staphylococcal, and also to Influenzal, Typhoidal , and Gonococcal meningitis. I myself observed a case of gonococcal meningitis in a young man aged twenty-nine, in whom, three weeks after the urethral infection, gonococcal arthritis developed in the knee and hand. Three weeks later — i.e., six weeks after the original infection, — he developed all the signs of meningitis. The cerebrospinal fluid was turbid, with a large deposit of pus. Antigonococcal serum was injected intrathecally, and, on three subsequent occasions within a week, antimeningococcal serum. After a temporary relapse, the patient ultimately made a complete recovery in about three months. Tuberculous Meningitis. — Here the prognosis is always grave. Once the diagnosis has been established, by the presence of headache, vomiting, convul- sions, stupor, by the occurrence of a pleocytosis of the cerebrospinal fluid, and, most conclusive of all, by the discovery of tubercle bacilli in the fluid, we must be very guarded in our prognosis. The prospects of recovery depend upon various factors. If the disease be limited to a small part of the meninges, and if there be no extension into the substance of the brain, there is still a possibility of recovery. If, however, the meningitis be widespread, and accompanied by numerous signs of focal brain affection, the hope of recovery is almost nil. The occurrence of glycosuria is of bad omen ; when present, it generally presages death within two or three days. In making our prognosis in any individual case of meningitis, from whatever cause, we have to bear in mind that the immediate causes of death are two in number : first, mechanical distention of the cerebral ventricles (acute hydro- cephalus) ; and second, toxaemia resulting from the products of the infective organism. The toxaemic element, unfortunately, is not at present directly amenable to treatment ; but if this factor be not too intense, we may, by relieving the mechanical distention, sometimes save the patient's life. This is best done by early and repeated lumbar punctures. After withdrawing cerebrospinal fluid until the intrathecal pressure falls to normal, we generally obtain distinct improvement in the clinical symptoms, so that the coma or stupor clears up, temporarily at least, and the headache and vomiting are relieved. By repeated lumbar punctures at intervals of one or two days, life may thus be prolonged, and cure may even result. I may quote a case of my own, a young man of twenty- two, with headache, vomiting, stupor, head retraction, absent knee-jerks, etc., in whom a patch of chronic lupus on one leg gave clinical evidence of tuberculous infection, and in whom the cerebrospinal fluid contained no fewer than 3467 lymphocytes per c.mm. Repeated lumbar punctures, five in all, about once a week, produced not only disappearance of all the clinical symptoms, but the pleocytosis of the cerebrospinal fluid fell successively to 827, 787, 36, and 16 cells per c.mm., and the patient made a perfect recovery. Such cases, it must be admitted, are the exception, but the fact that they do occur must modify the view hitherto almost universally held, that the result must certainly be fatal, once the diagnosis of tuberculous meningitis is established. Meningism is a condition in which the patient, usually a child, either during the course of some specific fever or in any febrile condition, develops many of the clinical phenomena of meningitis, but where the cerebrospinal fluid withdiawn by lumbar puncture contains neither excess of cells nor organisms. It is more frequent in children with a tuberculous diathesis, and may thus raise the suspicion of tuberculous meningitis. The symptoms rapidly clear up after the lumbar puncture. Ptirves Stewart. 296 INDEX OF PROGNOSIS MENTAL DISEASES. — Prognosis in mental diseases is afiected not only by the nature and causes of the particular maladies, but also largely by the special anatomical construction and physiological functions of the brain. A correct prognosis is easj^ in some forms of disease, for instance, in many forms of skin disease. But in dealing with an organ such as the brain, the most important in the bod}'- in its constitution and functions, the most highly integrated, the most complex, and the most sensitive to the effects of every environment outside the body, and to everything that takes place in its own working, it would be unreasonable to expect a very definite prognosis in most cases when it becomes diseased or disordered. Especially when its highest function of mind is disturbed, the difficulty of saying whether it wiU again resume its normal condition is often extreme. In addition to physical conditions of disorder, we are face to face with an entirely different set of conditions, viz., states of con- sciousness, intelligence, emotion, and passion. Disturbance of each of these may not only be a result of brain disease, but they may be its causes, and they may also act as a means of cure. Mental diseases are unquestionably the most difficult department of medicine. The higher forms of the brain cell, being the vehicle of mind, are Nature's last and greatest effort in the evolutionary process which has been going on during the past aeons of time. The full know- ledge, treatment, and cure of these will be the high-water mark of medicine. Every such cell carries, in its molecular structure and in its biochemical mode of action, the organic memories of its ancestral cells, and with those memories it becomes subject to ancestral reversions and weaknesses. How subtle and imponderable must be the changes which cause the mild emotional depression perhaps felt in the morning and gone within an hour ! Yet that depression in a more marked form may constitute a mental disease. The human brain is a cosmos in which are represented the working and the condition of every other organ in the body. There are few diseases to which the mind is subject where some organ or function of the body is not also disturbed, and there are many cases where, as a result of mental disease, we have also peripheral bodily disturb- ances. There are, however, some cases of mental disease where we cannot, by anAJ- means at present at our disposal, discover any bodily symptom what- ever, the mind cell alone seeming to be affected, and where the prognosis seems to depend on mental means of cure alone. Prognosis in such cases must depend on reactions to mental stimuli, but it may be said generally that prognosis depends chiefly on bodil}' reactions to environment, diet, and medicine. If those reactions are favourable and there is no organic brain disease, the prognosis is usually good. The subjective state of the patient must always be taken into account, and especially his feelings of optimism, his belief that he will overcome the disease, and his power of will to fight against it. Personal equations of all sorts come in both in regard to the doctor and the nurses, as well as the patient himself, for cure and prognosis. The prognosis in mental disease must depend chief!}' on the twelve following considerations, namely : — 1. The causes of the disease. 2. Its form and symptoms. 3. Its previous duration. 4. The brain heredity of the patient. 5. The possibilit}' of response and reaction of the mental and bodily symptoms to suitable treatment, especially to the restoration of sleep. 6. The sequence of the mental and bodily changes that have taken place during the attack. 7. The period of life of the patient. MENTAL DISEASES 297 8. The existence or not of signs of organic disease in the brain cells. 9. The existence or not of certain abnormal bodily conformations and stigmata. 10. The tendency or not that may exist to relapse and recurrence of the symptoms. 11. The completeness or incompleteness of the improvement in the attack under treatment. 12. The temperament and race of the patient. It need hardly be said that in almost every case both the mental and bodily symptoms present at the time, and that have existed during the attack, must be taken into account in any attempt to predict the course and duration of unsoundness of mind. In one case the mental symptoms will give better indications for prognosis, while in another the bodily symptoms, or the absence of them, will be more to be relied on. The really scientific study of mental diseases onh?- began in the end of the eighteenth, and the first part of the nineteenth, centuries. The physiology of the brain and its minute structure were only able to be scientifically studied well into the nineteenth centurj^ and without the knowledge gained by this study a scientific psj^chiatry could not have been attained. The classification of mental diseases and defects was at first founded on mental symptoms alone. It consisted of four varieties, namely : mania, or states of mental exaltation ; melancholia, or states of emotional depression ; dementia, or conditions of permanent mental enfeeblement coming on in a brain that had once been normal ; and idiocy, or congenital forms of mental weakness. During the latter part of the nineteenth century an enormous number of varieties of mental disease have been segregated, their foundation in different cases being etio- logical, pathological, and psychological. Some of these varieties, like general paralysis, must be permanent. Many of them are obviously transitory and experimental. Prognosis must depend to a large extent on a true classification, where that is possible, and in the present article I shall adopt the varieties which seem to me to have a scientific and practical basis. Early in the scientific study of mental diseases attempts were made in this, country, on the Continent, and in America, to draw up statistical tables showing the number of recoveries, the number of deaths, the liability to relapse, and the duration of the attacks, but in all these insanity was regarded as a whole, and its forms and varieties were not taken account of. The science of n?edical statistics was then in its infancy, and the registers of the various existing mental hospitals were very imperfectly kept, while there were no available facts to be obtained from records of private practice. Esquirol in France, Jacobi in Germany, and especially Thurnam in England, were the pioneers in the statistical department of prognosis in mental diseases. Farr helped greatly by pointing out the errors of previous writers and in laying the foundatipn of general medical statistics on scientific principles. The figures and the general results of these authorities need not be discussed in detail in this article, as the chief aim of this work is not statistical but clinical, and to help the practi- tioner of medicine. Thurnam sums up the general results of the treatment of insanity in institutions in his time, that is, about 1845, in this way : " A proportion of much less than 40 per cent of recoveries on the admissions is, under ordinary circumstances, to be regarded as a low proportion, and one much exceeding 45 per cent is a high proportion." He says, in regard to the mortality rate among the mentally afflicted, " a mortality that exceeds 9 or 10 per cent is decidedly unfavourable," and one wliich is less than 7 per cent is "highly favourable," in asylums where all classes are treated. In regard to pauper 298 INDEX OF PROGNOSIS asylums a mortality which exceeds 12 or 13 per cent is "a very unfavour- able one," and one which is much less than 10 per cent is "highly favourable." Since that time the rate of mortality has remained nearly stationary, in spite of the fact that far more cases of senile breakdown and organic brain disease with resulting mental symptoms are now certified as insane. My personal experience of the recovery rate in 11,346 patients treated by me in the Roj-al Edinburgh Asylum during the thirty 3'ears 1874-1903, was that 39-4 per cent of them recovered. They included every variety of mental disease and defect which can be certified under the Scottish Lunacy Laws as unsoundness of mind or idiocy, but the number of cases of idiocy or congenital imbecility was com- paratively small. I shall have in the course of this article to refer to the recovery rate in the various forms of mental disease which have been under my care in two mental hospitals and in my private practice. The figures from the Royal Edinburgh Asylum have this advantage over those of county asylums and the registered hospitals of England, that they comprise the whole population and are not confined to the rate-paid class as in the county borough and district asylums, or the class in a better social position who can afford to pay for their maintenance as in the registered hospitals. They also have this advantage, that they comprise the period (fifty years ago) when the number and variety of persons counted as technically insane and certified as such for institutions, was more restricted than in the older times, and also the more recent years, when undoubtedly an extension has been given to the meaning of the term ' insanit}'.' Fifty years ago, before the Government grant was given towards the partial maintenance of every pauper patient, it was not so common as it is now to send to mental hospitals patients who suffered from various fornis of senile decaj-, paralysis, and other incurable brain diseases. This is now done for two reasons : first, the great convenience and the real benefit to such help- less persons of being properly treated in the hospital wards of county asylums ; second, the change of opinion that has taken place in regard to its being a discredit, if not a disgrace, to have a relation in a mental hospital. The general effect of this change of opinion and practice has been to reduce the percentage of recoveries in British institutions. There has been, however, another tendency in the opposite direction, namelj-, to send cases at an earlier period of their disease, and to send more transitory and alcoholic cases, both of whom are apt to recover soon. In considering the statistics of institutions and of certified patients, this fact must be kept in mind, that mental disease in all civilized countries is not looked at and defined through the clinical symptoms present and from a scientific point of view, but largely through the provisions of the Lunacy Statutes. In this respect mental disease differs from all other diseases. An important series of tables are given in the Reports of the Scottish Board of Lunacy for 1S98 and 1913 (the 40th and 55th Reports), showing the ' progressive history ' of 385S patients for fifteen 3-ears after admission into mental hospitals. These throw a valuable but not a complete light on the prognosis of mental diseases, in regard to recovery and mortality. Of the patients of all classes, ages, and forms of mental disease, admitted into Scottish asylums in 1868 and 1S98, the chief results in the fifteen years are as follows : there were 2252 ' recoveries,' or 58-6 per cent of the whole. But those included repeated recoveries in many of the patients. In fact, there were 1230 readmis- sions to the institutions, most of which resulted from relapses into mental disease, and some had such relapses several times. Some of the readitussions were, no doubt, of the 781 who had left the institution not recovered. On the hypothesis that one-fourth of the ' recoveries ' had been those of relapsed cases or of the previously discharged non-recovered, it would show a recover)' rate of 43 per cent. MENTAL DISEASES 299 The deaths during the fifteen years amounted to 1361, or 35 per cent of the total admissions. One of the most striking and instructive facts about these tables is this, that it was in the first two years after admission that the greater number of the recoveries, the relapses, and the deaths took place. In fact, the general results of the mental attacks showed themselves in that time. Seventy per cent of the recoveries occurred then, 60 per cent of the readmissions, and 45 per cent of the deaths. Unfortunately these tables do not show how many of the recoveries relapsed into insanity. If the returns had shown how many of those who recovered had relapsed, and how many times, their value would have been enormously increased. If the heading after the first column had been ' Relapsed after Recovery,' instead of ' Readmitted,' this result would have been obtained. At the end of the fifteen years there were 694 patients of the 3,858, or 17-9 per cent, left uncured in the institutions. An enormous ' movement of the population ' takes place, in fact, among the insane as compared with the general population, as might have been expected. In addition to the twelve general considerations which I have mentioned, there are many particular symptoms and indications which apply in all cases of mental disease in forming a prognosis, some of which I shall describe. Most of them are of importance in determining this particularly difficult point. We ask in every case of mental disease, when trjdng to solve the question of its chances of recovery, How did the disease come on ? Had it the characters of a sudden brain explosion, a cloud coming into a clear sky, or was it a gradual evolution of mental symptoms beginning with slight psychical changes and evolving gradually from these into a more acute and marked disease ? In making inquiries to determine this important point, we have to go into the normal psychology and mental habit of the man or woman. For instance, we have to inquire into the ordinary strength and the indications of the social instinct. This differs widely in different individuals ; but if we find that the patient became, at a certain period, considerably anterior to the mental attack, less inclined to mix with his fellows in social intercourse, to be more self-con- tained, more reticent, more secluded in his habits, and that this gradually went on to an active dislike of social intercourse, this becoming a real pain to the man ; if this went on further to a morbid suspicion of others, a misinter- pretation of their conduct in regard to him, passing into organized and fixed insane delusion, leading perhaps to assaults or homicidal attacks on others — this whole sequence of changes in the social instinct, if it took years to accom- plish, would lead to an extremely bad prognosis of the case, while if somewhat the same symptoms were rapid in their course and sequence, say within a few months from their beginning to their full mental development, they might not mean anything like so grave an outlook for recovery. Taking another form, of mental disease, namely, that characterized chietl>- by maniacal excitement with emotional elevation, the outlook in such a case differs greatly according to the innate and original qualities of the brain that suffers from it. If we have a case, let us say, with a bad mental or neurotic heredity, where during childhood there have been convulsions, night terrors, or other such signs of brain instability, and if we have, during the developmental period of the brain, tendencies to delirium or even short attacks of maniacal or depressed conditions or periods of lethargy and stupidity, the prognosis even in such a case need not be unfavourable, at all events until after twenty- five or thirty years of age. 300 INDEX OF PROGNOSIS The various epochs of life also, and their effects on the mental condition of men and women, cannot be left out of account in the prognosis of any of the diseases to which they are specially subject, but especially if those diseases are mental in character. Each epoch of life has its distinctive physiological and psychological characteristics. The prevailing dynamical and trophic activities are different at different times of life. The child period, when growth in bulk is the characteristic, the onset of sex, child-bearing, the decadence of power which marks the climacteric and old age, have all to be taken into consideration in prognosis. In almost any case of insanity we cannot dissociate the normal from the abnormal psychology — one influences the other. The insanity is often an evolution of the natural temperament. The same symptoms occurring at twenty-five and at seventy may mean a quite different prognosis in the two cases. The time element in all forms of mental disease is of the greatest importance ; in fact, in many cases this determines the prognosis. It may be laid down as an almost universal axioni that the chances of recovery diminish after the first year in the ratio of the duration of the attack, except where the epochs of life of which I have been speaking come in. We never give up hope of recovery in such cases until the particular epoch during which the attack has begun is passed. Different mental symptoms also afiect the time limit differently. For instance, I was in the habit of laying down to my students this dictum : " Never give up hope in the case of melancholia while the depression of mind lasts." It is different with conditions of exaltation. If they persist for over a year or two, and take on the signs of chronic mania, the prognosis is bad ; if symptoms of general enfeeblement of mind come on and last, say, for a year, the prognosis is almost hopeless. The same rule applies to conditions where we have regular periodic recurrences of the mental symptoms. If such persist for over a year or two they certainly make the prognosis bad. The typical instance oi a recurring and alternating insanity is folie circulaire, and that is now regarded as mostly incurable. There are certain gross diseases of the brain, such as certain forms of apoplexy and paralysis, wliich on their first onset are apt to be accompanied by mental symptoms ; some of those are recovered from ; at all events, the patients partially improve in mind, in such a way that they can no longer be regarded as technically insane ; but if such mental symptoms persist more than, let us say, six months, the prognosis is unfavour- able. The same rule applies to many of the cases of insanity caused by alcohol, opium, and other toxins. If the mind is disordered as the result of an acute toxin such as influenza, we expect it to be very short in duration. Acuteness of symptoms is very apt to be considered by relations to be a bad sign in regard to the prospects of recovery. That is not so. I alwaj'-s like an acute case of any kind where organic brain disease does not exist, and tell the relations that it is one of the best signs that the case will recover quickly and perfectly. For instance, one of the acutest of all forms of insanity is that caused by child-birth, and yet none recover so certainly, quickly, and completely. There is, of course, 'a greater risk of death in the acute cases, and this should always be explained to relations. Eight per cent of all cases of acute mania die of the disease, and the mortality in puerperal insanity is even greater. Facial Expression in Prognosis.^ — The mental expression of the face and eyes in most cases of mental disease should be carefully observed. It is changed for the worse, and in some of its more acute varieties it is so changed that the man is almost unrecognizable by his friends. The only exceptions to this are in the case of persons who are, by temperament and natural disposition, slow, stupid, and lethargic. I have seen many such who, during a mild attack of MENTAL DISEASES 301 mental exaltation, were brighter and better looking than ever they were in their lives. There are only two facial disturbances of a decided kind that 1 think are unfavourable in prognosis. Those are the heavy wiped-out expression of the face and eyes in the young man, and particularly in the 3'oung woman, who, towards the end of an attack of adolescent insanity, has passed, or is passing, into dementia. The other is the cunning, suspicious expression of the patient who suffers from paranoia of the persecutory type. All the ordinary disturbances of expression but these, however extreme they are, may be recovered from, and the patient resume his normal appearance. The muscular expression of the emotions is not sufficiently realized in mental practice. There are fifty mind and eye muscles, not including all those of speech, the action of which make all the difference in their mental expressions between one man and another. They are extremely small in size, but they are innervated to an enormous degree. Their motor ner^^es together are as bulky as those of the arm muscles, wliich weigh a hundred times as much. It is only when those mind-muscles of expression and eye show a certain disturbed mode of action which lasts for a long time, that such changes indicate a bad prognosis. Commonly they change quicklj^ from good to bad expressions, and vice versa. Causation and Prognosis. — The cause or causes of a mental attack have often much relation to the prognosis in the case. The causes which may determine an attack of mental disease are almost innumerable, and I cannot in this article refer to all of them. Commonly, when the history of a case is gone into, one finds that there existed more than one cause of the attack. There is often a predisposing, an exciting, and a proximate cause. For instance, a man ma}- have a bad brain heredity as a predisposing cause, may have taken alcohol to excess as an exciting cause, and had a fall on the head as the proximate cause of his attack. Then in some cases there are even more than one exciting cause. I shall further on refer to heredity, which is the chief and most common of all the predisposing causes. There is a strong natural craving to find a cause for such a tragic event in life as an attack of mental disease. Relatives will press their doctor on this point very unduly, and if a cause can be assigned there is very often a sense of relief and a more hopeful feeling as to the chances of recovery. I often hear this remark : "I feel happier now I know the cause of the illness." The relations of our patients are exceedingly apt to assign causes which by no possibility can be the real ones. The causes which a mother will assign for idiocy in her child may be almost grotesque in their unreality. To account for a mental attack, relations nearly always seek a mental or a moral cause. In reality we know that only about one-fourth of all the cases of mental disease are due to mental causes, the other three-fourths resulting from bodily causes. Looking over the tables of the causes of the diseases which are usually attached to the annual reports of our large mental hospitals does not always help us ver^'- much. iVIany of the terms are too general to be of any scientific or prognostic use. It may be assumed generally that a cause, or what may be reasonably assumed to be a cause, of a mental attack, will be less likel}^ to produce an incurable brain malady if it is removable. Taking such causes as toxins affecting the higher brain cells, most of them either exhaust their action on the brain quickly, or an immunity is set up, or they can be more or less counteracted by suitable treat- ment. I take as examples, cases of mental disease caused by or following the action of the influenza poison or sj'philis or alcohol. These together cover a very considerable part of the era of mental disturbances. Then there are causes which are in their nature transitory, such as child-birth, many forms of bodily disease and exhaustion, surgical operations, etc. In regard to the mental INDEX OF PROGNOSIS and moral causes of psychical disease, many of them soon exhaust their dele- terious action, or can be counteracted by changes of circumstances and environ- ment ; of such are overwork, some forms of domestic worries, love affairs, and mental shocks. On the other hand, there are causes that are almost necessarily irremovable, which therefore lead to a bad prognosis, such things, for instance, as traumatic injuries to the head, senility, alcoholic excess so long-continued that the organic structure of the cells or vessels are changed, gross cerebral disease, epilepsy, etc. The mental symptoms may not be the main or original element in the case. They may be so secondary to bodily disease that the prognosis may depend almost entirely on the nature of such bodily causes. I would take as an example cases dependent on heart or uterine disease, on cancer, on diabetes, or on pernicious anaemia. Finally, the innate vulnerability and power of resistance of brain have to be taken into account when estimating prognosis in regard to causation. One brain raay be upset by a cause which in another would produce no serious result at all. The unstable and vulnerable brain mav, however, throw off bad effects far more readily and quickly than the more stable brain. Our modern methods of examination have enabled us to discover changes in the spinal fluid and blood and micro-organisms which are very valuable in regard to the prognosis in some cases. Response to Treatment. — Every medical man is influenced in his prognosis by the effects of his treatment, using treatment in its larger sense of environment, nursing, and diet, and not confining it to drug treatment alone. If a patient, for instance, falls into depression of mind on account of unfavourable or local •circumstances, and when he is sent away for a change at once begins to brighten and have his attention taken up with his new surroundings, it is necessarily a favourable sign in prognosis ; or if, in any case, we have to do with thinness and general want of nutrition in a patient suffering from any form of mental disturb- ance, and our efforts to increase his weight by diet or drugs or change of air are successful, we think better of his chances of recover}^ I have sometimes watched with so much anxiety the putting on of the first pound or two of weight in a patient whom I was treating, that my whole outlook became more optimistic when that took place. Insomnia, so very common a symptoni in most cases of mental disease, both as preliminary to and during the disease, gives us the greatest anxiety in regard to the effects of treatment. It is so very intractable, in some cases, that we feel the patient cannot recover his mental balance until it is subdued. Nothing is more exhaustive to the higher mental functions of the brain than prolonged insomnia. If by drugs, by change of air, by medical treatment, we find that the normal periodicity in the occurrence of sleep is restored, we feel that the patient will almost certainly recover in due time. Volumes have been written as to what sleep is, and as to the best methods of restoring it when insomnia is present, but we all feel that as yet neither of those problems has passed into the region of scientific certainty. We do surely know that sleep is the greatest and most important of all the examples of periodicity in the physiological and mental life of a human being. We also know that it is Nature's most important method of resting the higher functions of the brain and of restoring to a proper state of nutrition the brain cells. Everyone who has thought about the subject realizes that the ph3^siological unconsciousness of sleep is quite as mysterious as the occurrence of any mental disease whatever. Dreaming is the nearest physiological analogy to insanity. I believe that when we discover the secret of sleep it will lead to the discovery of the prevention of much mental disease. Mental Hospital. — The response, favourable or otherwise, to the removal of a patient to a mental hospital undoubtedly affects prognosis in his case. MENTAL DISEASES 303 Unfortunately, the ideas of many of the pubUc regarding mental hospitals, and the feelings of repulsion and distress which those ideas have produced, in some cases tend to counteract the good effects of the control, discipline, regime, and medical treatment which are given in such institutions. Happil}' such wrong ideas are now undergoing a marked change, and a great many patients are willing to place themselves under treatment voluntarily in mental hospitals. This is the most satisfactory method of all in the cases where it is suitable. Unfortunately, the majority of cases of mental disease do not recog- nize they are ill, and therefore resent such treatment as being unjustifiable. But if a patient shows a marked betterment during his first month's residence in the hospital, it improves the prognosis in the case very much. Before going to such a hospital, the doctor has commonly to make the likelihood of an improved prognosis if sent there his chief argument for that course being adopted, and undoubtedly in the larger number of cases such a prognosis is justified by the results. Unfortunately, at present, the risk of danger to him- self or others is rather too much of an element for the sending of patients to mental hospitals. In reality the great reason should be the improved chances of recovery and the impossibility among the poor of securing proper treatment otherwise. There are a certain number of cases where the prognosis is distinctly improved by removing patients from mental hospitals to other environments. This occurs sometimes in a too prolonged convalescence, where such a change restores the interests in life and stimulates the patients to a greater amount of self- control. Speaking generally, however, I am of opinion that the best chance of complete recovery and of non-recurrence of the disease is secured by the patient's residence in the hospital until such recovery has not only taken place, but may be said to be established. Langer of Recurrence. — In many forms of ordinary disease the patients are liable to a recurrence at some time or other after recovery has taken place. Gout, rheumatism, bronchitis are common examples of this tendency. Mental disease is liable to recur in at least 20 per cent of those who have recovered, and in many cases this tendency occurs over and over again. There are a certain number of cases where the more frequent the occurrence the greater the danger is of a final incurability, but this does not apply to all of them. I have known many cases recover and relapse on very many occasions, the recoveries being good ones while they lasted, and the patient able to take his place in society and do his usual work. The classic case of Charles Lamb and his sister is an example. In many cases that have this tendency, the treating of the symptoms in time, before they have developed into serious mental disease, is the great principle to be adopted. Cure the insomnia, restore the nutrition, give a chance for brain rest, change the current of ideas and thoughts, remove causes of irritation or exhaustion, give a fillip to the mental life, are all modes of effective treatment, and they improve prognosis in most cases. Statistically the danger of recurrence is scientifically brought out in the Scottish statistics referred to on page 298. Heredity as an Element in Prognosis, — The influence of a bad heredity in making any man or woman liable to mental disease has always been taken into account by those with experience in the medical profession. It was evident, on even casual observation, that some families were more liable to such diseases than others. Of recent years much more careful clinical and statistical know- ledge on this point has been obtained. The ordinary methods of scientific statistics, and those of biometrics, have been called in to attain accuracy, with much, but not as yet complete, success. Dr. Karl Pearson and Dr. Mott arc 304 INDEX OF PROGNOSIS the latest authorities on this important subject, and their work has undoubtedly advanced our knowledge. For myself I have much more faith in what may be called the clinico-statistical methods of Dr. Mott than those of the purely mathematical methods of Dr. Karl Pearson. Two things I would especially impress on the readers of this article in regard to heredity are these : The worst and the most direct heredity need not imply the occurrence of mental disease in any family, and the existence of heredity, even strong heredity, does not necessarily imply incurability in any case. We are nowadays continually asked about the liabilities to mental and nervous disease in certain families where there are intentions of marriage, proposals of insurance, uncertainties about taking to certain occupations or professions, and thoughts of going to live in certain climates. This reading of the horoscope of human beings is, or ought to be, a department of prognosis, and as our scientific knowledge increases it will become an extremely important part. It is already affecting the great science of education in a marked degree. It is affecting certain acts of the legislature that relate to social questions. It may be said to be affecting men's views of ethics and of human conduct. It has also a relation to literature, especially in history and biography. Long ago, in reading Carlyle's biography of Frederick the Great, one was impressed by the fact that that shrewd writer devoted his first volume entirely to Frederick's ancestry and relations, their history and characters. He did not use the word heredity, but that volume is a treatise on the subject notwithstanding. The keynote of the new science of eugenics depends on heredity, and as a result of the perfecting of that science, prognosis, in a large sense, will be made far more accurate. It may be described indeed as the most comprehensive field of prognosis at present in existence, for all its aims consist of looking to the future in human life. In the prognosis of mental diseases it is to be remembered that it is not the special mental defect or disturbance that is inherited, but a general defect of brain nutrition, or an instability of action in the higher brain cells, or a deficiency of resistance against toxins or against mentally upsetting causes. Heredity may consist, and in many cases of mental disease at the adolescent period does consist, of a want of ability to adjust the action of the brain cells — the vehicles of mind — to the more complicated and evolved life of civilized man as compared with that of primitive ancestors. Dr. Mercier says : " The stability or instability of a person's highest nervous arrangements depends primarily and chiefly on inheritance." Without evil mental heredity there would be very little unsoundness of mind in the world. It is one of the chief problems of psychiatry. In considering the heredity of any case of mental disease with a view to prognosis, we must inevitably consider whether the defects in fathers or mothers, if any such exist, were personally acquired, or derived from an ancestry further back. To a large extent the belief as to the non-transmissibility of any personally-acquired characters held the field till lately, but a newer generation of scientists are of opinion that, in certain circum- stances, they may be transmitted. Professor Cossar Ewart, a great authority, as the result of practical experiments, says that " the germ cells are liable to be influenced by fever and other forms of disease that, for the time being, diminish the vitality of the parents," and we have also the great authority of Darwin, Maudsley, and Hertwig for holding the same views. If we find, in addition to a bad hereditary history, that there are bodily abnor- malities in our patients, which we now call ' stigmata of degeneration,' the prognosis is considerably worsened. In inquiring into the heredity of any case, we must take into account not only mental but also neurological facts, MENTAL DISEASES 305 such as epilepsy, malformations, convulsions, chorea, asthma, stammering, hysteria, and many other such allied diseases. One law of mental heredity laid down by me long ago, and now fully confirmed on larger statistics by Dr. Mott, is that any mental defect in ancestry is liable to occur at an earlier age in posterity than the age in which it occurred in parents. It is also a fact that the maternal heredity towards mental and other nervous diseases is stronger than the paternal, and the mental defects tend to cross the sexes from mother to son, etc. It is also certain that while a strong heredity does not imply incurability to any one attack, yet it does produce a greater tendency to recurrence of the disease ; and, finally, as a most important consideration in prognosis, few of us now doubt that in a vast number of cases a bad heredity can be counteracted, in some degree at least, or modified, by favourable environ- ments and modes of life. The Age of the Patients. — Youth, in mental diseases, as in all others, is a favourable element in prognosis, ceteris paribus. Some mental diseases, such as senile dementia, are incurable simply because the patient is old. Some others are apt to recover because they occur in the developmental period of life. Nature always tends towards nealth if she has a fair chance. Some diseases, such as choreic insanity, will almost necessarily recover because they are developmental in their character. Completeness of the Recovery. — The prognosis in all our cases largely depends on whether the attack has been absolutely and completely recovered from. In mental disease, unfortunately, there are apt to be left certain of the slighter peculiarities of character and conduct. These, if they persist too long, are liable to become brain habits difficult to get rid of. Temperament. — The original temperament of the patient, to a certain extent, determines the prognosis of his attack if he falls into certain forms of mental disease. Melancholia in a markedly melancholic temperament is not so curable as in a sanguine temperament. Mania is not so curable in the case of aa excitable, boisterous, nervous temperament as in a man with an ordinary- average working brain. Conditions of Simple Mental Depression and Elevation — Manic-depressive Insanity. "Whatever classification of mental disease may ultimately be adopted, I am satisfied that there are certain morbid conditions which for the general practitioner and the relatives of patients it will always be necessary to reckon with and to treat as distinct forms of disease. The chief of these are states of mental depression and mental elevation with diminished self-control. From the earliest times in the history of medicine these have been recognized. The terms melancholia and mania have become a part, not only of medical books, but of popular language and of literature. The conditions I am to describe are those which are apt to come under the notice of the medical practitioner in his ordinary work, commonly before a specialist is called in. It is essential, therefore, that right conceptions regarding their nature, causes, risks, prognosis, and treatment should be held by every doctor. Especially when they exist in a minor degree and constitute what we now call the ' borderland,' it is important that they should be subjected to the right kind of treatment, and that their prognosis should be well considered. I believe if proper treatment is carried out they may be arrested in many cases, and recoveries may be brought about before they reach their more serious stages, the necessity of being placed in mental hospitals thus being avoided. I shall refer both to my experience in treating 20 3o6 INDEX OF PROGNOSIS them in a mental hospital, and also as a consulting physician where I had to advise as to their treatment in private houses, in rooms, or in nursing homes. Among the practical classifications adopted in most mental hospitals, conditions of depression are usually assorted into the varieties of simple, hypochondriacal^ delusional, suicidal, resistive, excited, and stuperose. The cases of simple melancholia are those which the general practitioner of medicine sees most of from start to finish. It is the most rational of all the insanities. The patients themselves and their relations usually object to its being called mental disease at all. They talk of it as ' nervous depression,' ' melancholy,' ' low spirits,' being ' out of sorts,' and being ' run down.' I am not of course alluding to the cases of mere physiological depression of mind from natural emotional causes. Mere physiological melancholy might be defined as a sense of ill-being and a feeling of mental pain, with no real perversion of the normal reasoning power, no morbid loss of self-control, no impulses towards suicide, the power of working not being abolished, and the ordinary interests of life only lessened, not destroyed. The simple melancholia, whose prognosis I am to treat of, is a really pathological condition of the brain cortex accompanied by mental pain, emotional depression, a sense of ill-being more intense than melancholy, with some loss of self-control or volitional power, perhaps a tendency to delusion of a depressed character, the power of doing ordinary work being greatly diminished or abolished, the interests of life interfered with, and with discoverable bodily symptoms in nine cases out of ten. In the examination of such cases the patient himself is of the greatest assist- ance, because he knows he is ill, sometimes perhaps exaggerating his symptoms. The patient's ' objective consciousness ' is morbidly acute, while his ' sub- jective consciousness ' is exaggerated. Such a patient is usually run-down in body, and has had some physical or mental antecedents which have been the cause of his trouble. There is usually more or less insomnia. The patient has either a jaded or a more or less irritable feeling, his work instead of being a pleasure is a conscious toil, he has a sense of ill-being, the opposite of that normal sense of well-being which is to all mankind the best proof of health. The nutrition of the body is lowered ; commonly there is want of appetite and constipation. The depression is nearly always worst in the morning. This is a fact well worth keeping in mind in treatment and prognosis, for certain measures can often be taken to rouse the brain from this morning depression into somewhat normal action. It is not often kept in mind that sleep, in addition to the marvellous condition of unconsciousness which accompanies it, does so alter the working of the higher cortical cells or their capillary circulation that they do not resume work for a little time after sleep is past. In a minor degree this is a common enough thing in people who are far from being mentally diseased. Although the definition of this simple state of melancholia cannot be exact, it having no definite boundary lines from either sanity on the one hand, or the more severe varieties of the disease on the other, we can for practical purposes ask : What are its chances of recovery and its general prognosis, its liability to relapse, and the fear, if any, of a fatal result } The general pro- gnosis is unquestionably a favourable one ; but in order to give a statistical basis for that opinion I shall take my experience during the last ten years I was Physician-Superintendent of the Royal Edinburgh Mental Hospital, from 1897 till 1908. I must explain that while this condition of simple melancholia may usually be quite well treated at home if the patient's finances admit of it, that is expensive if practicable. For the poor and the ' lower middle class,' most of the cases have to be sent to mental hospitals, on account of there MENTAL DISEASES 307 being no means of proper treatment, and of the patients not being able to earn their own livelihood. In the ten years I had under my care altogether 4319 cases of mental disease. Of those, 414, or 15 per cent, say one- seventh, were cases of simple melancholia. It is therefore one of the most frequent of all the varieties of mental disorder. Of the 414 cases, 225 recovered, or 54'3 per cent. Considering that two-thirds of the remainder were discharged (technically relieved), and one-third of those probably completed their recovery after their return home, I think it would be a reasonably correct estimate to say that 70 per cent is the chance of making a recovery in this class. The rest of the cases, the 30 per cent, passed either into the more severe varieties of melancholia or into dementia, while a few died. Less than i per cent died, and that was through the exhaustion of acuter symptoms coming on, or through their becoming so low in nutrition that intercurrent diseases, such as phthisis, pneumonia, etc., carried them off. I may say very few of those cases of simple melancholia were really suicidal. All the suicidal cases, or rather the worst of them, I included under the separate heading of suicidal melancholia, but no doubt the general idea that life is not worth having, and some little risk of suicide, was present in some of them. It is interesting to compare all the eases of melancholia, the simple and the more severe, as to prognosis, with the special group that I have called simple. There were altogether 1465 cases grouped under melancholia, including the simple variety, and of the total number 43'7 per cent recovered. Adding the proportion of the relieved, which is not so great as in the siniple variety alone, the general prognosis as to recovery in conditions of depression of mind suffici- ently severe to be sent to institutions may be put down at about 55 per cent. Duration. — Patients themselves and their relations are commonly very urgent, not only as to whether recovery will take place, but how long the symptoms will last. This is the most difficult part of the prognosis in all mental cases. The grounds for giving a time limit are always somewhat un- certain ; the data are commonly insufficient. Simple melancholia, however mild in its symptoms, is not one of the mental disorders that we expect to pass off suddenly ; its recovery is usually gradual, and we cannot count on a case recovering speedily because its symptoms are specially mild. There are some cases of simple melancholia that recover within three months, but taking them all, their duration is over that time. We may, however, reasonably expect a recovery in this disease within six months from its beginning. Only about 10 per cent persist for over a year before recovery. Certainly three-fourths of the recoveries take place in that time. Its symptoms are so mild in many cases that it is difficult to say when a complete recovery has taken place. In the above estimate of recovery I assume that the patient has been for a month free from any symptoms of mental depression before the statistics are drawn up. Simple melancholia is one of the diseases from which a complete recovery is not only possible, but is likely to occur. Indications of Improvetnent. — In nearly all cases of melancholia the symptoms are worst in the morning and forenoon, while the patients improve towards afternoon and evening. It may be held to be a good sign when the evening remissions are complete, the patient feeling quite well ; and if along with this the morning exacerbation is not so severe as at the beginning of the disease, it is also a good indication. In most cases of melancholia the patients are not able to follow their usual occupation or any occupation in a continuous and efficient way, or if they do some work it is done with little interest and somewhat forced. It is always a good sign when a patient is able to resume any kind of occupation for any part of the day. We often treat such patients by keeping 3o8 INDEX OF PROGNOSIS them in bed at first. If that has a good effect, it is a good sign as making for recovery. I constantly find, in the case of women who have been accustomed to that form of employment, that simple knitting is a most excellent occupation, being simple, not requiring any great amount of attention, and implying some muscular effort. When the patients become more inclined for active outdoor exercise it is always a good sign. If the stimu- lating nerve tonics, which we usually employ as a remedy in such cases, mani- festly have an effect for good on the brain action, it is a good sign. Above all, if the patients gain weight steadily, and if their appetites and digestion improve, it is a favourable sign. Constipation being a frequent accompaniment of melancholia, it always means a general betterment when the bowels resume their normal action. If the skin becomes softer and the perspiration more normal, it may be looked upon as favourable in prognosis. If the patients have had, as most of them have, an idea that they will not and cannot get better, and cease to be obsessed in this way, and begin to believe that there is a hope of their recovery, it is a sure sign that they are on the way to recovery. It is one of the great means of mental treatment to assure every melancholic patient that he will certainly get better, and I am in the habit of telling my nurses to reiterate this to every such patient at least a dozen times a day. This is a legitimate ' mind-cure.' If the patient has been restless and that symptom diminishes, it is a good sign. If there had been any tendency to delusion and that diminishes in force, it is also a good indication that recovery is soon going to take place. There is a symptom which I have often noticed in cases of melancholia. The patients, during the earlier part of the disease, are often abnormally deficient in will-power and are too calm in temper. If a stage of irritability comes on I look on it as a good sign. I had one patient whom I was always glad to hear using strong language. I knew then that he was going to recover. The conscious sense of organic well-being is the last to come, that being the best subjective sign of health. A symptom worthy of observation is the return of minor neuroses or ailments to which the patient may have been subject, e.g., headaches, asthma, skin troubles, etc. When these are seen it is a good sign of approaching mental recovery. If a patient has had a quick and irritable pulse, and that disappears, it is a good sign. Unfavourable Indications. — The following symptoms are those which make the prognosis more uncertain or entirely unfavourable. If the onset of the depression has been exceedingly slow and gradual, and its symptoms more and more serious in their development, if there is a gradual decay of bodily vigour, like a premature old age, and a persistent loss of nutritive tone and bodily weight that will not jdeld to diet and treatment, it is a bad sign. If hallucina- tions of hearing come on, we do not like it. If there are convulsive attacks or slight shocks of paralysis, we know that organic disease of the brain cells has set in and that there is little hope of mental recovery, but I have seen many exceptions to this. If the patient in facial expression takes on a prematurely old appearance it is not a good sign, or if the emotional depression of face and eye gets permanently fixed without any smile, or if muscular expressions of mental pain come on, such as wringing of the hands, groaning, etc., or if a suicidal tendency develops and gets extremely intense, those are bad signs. If there are proofs of marked arteriosclerosis or other vascular degenerations, they add much gravity to the prognosis. If there is seen a general weakening of the mental power, the memory, power of attention, and interest in life, the patients becoming somewhat facile and too content, it is an indication that dementia is threatened, but simple melancholia is of all mental diseases one of those least subject to pass into dementia. As I have mentioned, however, MENTAL DISEASES 309 hope of recovery should be entertained so long as anything like decided depres- sion of mind exists, even for years. I have known a case of melancholia recover after twenty years. If the disease has come on during, or in consequence of, an epoch in life, like adolescence, pregnancy, or the climacteric, recovery may be looked upon as more likely when such an epoch has passed away. Senility is not in itself an absolute bar to recovery. I shall refer to the fact, when 1 speak of senile insanitj^, that its melancholic forms recover in a reasonable proportion of the cases. Periodicity and Recurrence. — The patients themselves and their relations are nearly always anxious as to whether the trouble is likely to return. The prognosis in regard to this must be somewhat guarded in all forms of mental disease, which, taken all together, recur in about 20 per cent of the recoveries. Simple melanchoha is not a disorder that is specially apt to recur unless the temperament of the patient is an extremely sensitive one. A certain mental hyper-sensitiveness of disposition is, in my opinion, the psychological basis on which most cases of melancholia are implanted. It may be put down, in fact, as its chief predisposing cause. This hyper-sensitiveness is so extreme in some cases that its unfortunate possessors may be said to be always on the verge of simple depression of mind. I had a lady patient once who was liable to be thrown into such a condition on almost the slightest occasion of worr5% distress, disappointment, or loss. She had several attacks when she lost relations, she had one when her favourite dog died, and she could never stand a too exciting sermon at church. Some persons with a strong neurotic heredity of brain are liable to depression during the epochs of life I have referred to. Some people are liable to an attack whenever they overwork themselves, mentally or physically, whenever they have an attack of indigestion, or whenever they are ' run down.' Taking simple melancholia as a whole, the liability to recurrence or periodicity may be put down at about 15 per cent of all the cases. It is always a right thing for the doctor, when he is in attendance on such a case, to assure his patient that there is no chance of recurrence if he will keep his health in good condition and adopt means of treatment at the very earliest stage, or if he should feel the least symptom of depression, loss of weight, or sleeplessness. I advise most of my melancholic recoveries to weigh themselves regularly. It is to be kept in mind that the slighter forms of depres- sion are liable to occur as preludes to most other forms of insanity, and during the very first part of those attacks the doctor has to think of this in his prognosis. Other Forms of Melancholia As I mentioned, melancholia occurs in the proportion of 35 per cent of all the cases of insanity sent to institutions. Taking all the cases who consult doctors privately on account of mental symptoms, I would say that mental depression stands in the proportion of at least 80 per cent. The general prognosis of all forms of melancholia is repre- sented by the 43-7 per cent which I have referred to. While the simple melan- cholia of which I have treated is by far the most curable variety, it is not the only one that is curable. Suicide. — First let ns look at the most serious of all the complications of melancholia, namely, the suicidal impulse. This is so common that it exists in lesser or greater degi-ee in about four-fifths of all the cases of melancholia, but, in great intensity and constituting a serious risk, it only applies to two- fifths of the cases, and those we classify as emphatically the suicidal variety. It is a common idea that when a patient is strongly suicidal he is therefore incurable. This is certainly not a correct view. Its gravity and its risks should not make one take a despairing view of even a verj^ suicidal case. They recover in as great a proportion as the ordinary cases if we exclude the simple variety. INDEX OF PROGNOSIS Delusional Melancholia. — The next variety of melancholia, which we call the delusional fonn, is much more serious than the suicidal in the prognosis. By this term is not meant melancholia with delusions. It is used to indicate that varietur of the disease in which a delusion or delusions are from the beginning the most prominent symptom, in which they remain throughout the disease of the same nature, giving the attack a distinctive character, being what are called fixed delusions, in contradistinction to milder delusions that change in kind, or subject, or degree. The relatives of such patients are apt to call it the cause of the disease, when scientifically it is merely the most marked symptom. The real disease consists of the depression, the mental pain which is at the bottom of the delusion and underhes all the other symptoms. In such a case of delusional melancholia the prognosis is undoubtedly unfavourable, especially if the delusions last for over the first six months of the case. The delusional cases constitute about 25 per cent of the melancholies. The delusional and the suicidal symptoms may combine in the same case, and this constitutes a grave prognosis. Homicidal feelings and attempts sometimes occur in melancholia, and consti- tute a grave element in the prognosis, without, however, indicating incurability. I have known many cases of simple melancholia with vague homicidal feelings, but the real danger of homicide is found chiefly in the excited variety' of which I am about to speak, and at the beginning of the attack. Excited and Resistive Melancholia. — Extreme agitation and excitement as a part of the disease may be the distinguishing characteristic of an attack from the beginning till near the end of its course, or it may occur as one stage in its complete clinical history. The patients in such cases rush about, may be violent to those about them, wander ceaselessly, walk up and down, and cannot sit still for any length of time, roll about on the floor, bite their finger-nails, or wring their hands, or shout, or groan, and weep loudh% or tear their clothes. In short, the muscular expressions of the per\'ading morbid emotion are strong and uncontrollable by their wills. This really constitutes the worst varietv- of the disease, and by far the most difficult to manage, rendering institution treatment necessary in almost all the cases. The presence of this agitation is determined either by the intensity of the disease or the temperament of the patient. The Celtic races are apt to show it more than the Teutonic. Delirium. trem.ens in the acute form may be taken clrnicall}- as representing excited melancholia. There are apt to be hallucinations of the senses in this form, and a toxic element in the etiolog}'. Along with excitement, or, in some cases, without much motor excitement, there are cases of melancholia which are intensely obstinate and resistive in their conduct. Thej- will not go to bed, they wUl not undress, they will not do what they are wanted to, and some of them are stuperose in their character. The expression of face in those cases is utterly changed from the normal. The excited and resistive varieties constitute what is often called ' acute ' melan- choUa. The prognosis in such cases is worse than in any form of the disease. It is apt to run on into a chronic condition, or the patient dies of exhaustion. Certainly not more than one-fourth of such cases recover. Those forms are often associated also with a strong suicidal tendencj'. Hypochondriacal Melancholia. — A somewhat distinctive form of the disease is characterized by hj-pochondriacal sj-mptoms in which the mental pain has a certain want of intensity, and takes the form of fancies which centre round the patient's own health. He thinks he is all out of sorts, that his digestion is -vvTong, that his stomach is all out of order, that his heart is weak, that he is certainly going to die of paralysis or some other trouble which is really imaginary. There MENTAL DISEASES 311 are no limits to the fancies of the hjrpochondriac. Now this class of symptom adds considerably to the gravity of the prognosis. Such patients are not apt to recover quickly, and more than one-half of them do not recover at all. They are a very troublesome class to the doctor, because the patient is con- tinually wanting to see him and pour out accounts of his imaginary illnesses to him. Although what the patient complains of may be perfectly unreal as real objective facts, 5'et they represent an organic sense of ill-being and are quite real to his consciousness. There is little risk of suicide in the prognosis in those cases, except in the very worst class of them. Suicide is often talked of and threatened, but seldom carried out. In ordinary cases of melanchoUa, when a patient is deeply depressed, he says little about suicide but thinks a great deal of it. Those are the really dangerous cases. When a man is constantly talking of suicide, as sometimes in the hypochondriac, there is certainly very much less risk of his committing the act ; but still I have known it occur even when it had been much spoken of previously. States of Depression as seen in Private Practice. — The statistics of these conditions as met with in private and consultation practice are perhaps more instructive to the general practitioner than those of institutions, even if they are not quite so exact. The patients are mostly in the early stages of the disease, and they are still living under the ordinary home conditions of treating disease. They are in every way more analogous to cases in ordinary practice. As the results of such treatment are not to be found in the text-books, I give them here. I have taken the last 200 consecutive cases that I have seen in consultation and have analyzed them. I find of the 200 there were 104 who laboured under depression of mind, who mostly knew they were ill and had themselves desired or were persuaded to consult a mental specialist for their symptoms. I usually had the advantage too — a great one — of getting the previously acquired know- ledge of the family doctor as to the patient's previous history and mental symptoms that had appeared. I was not able to follow the mental history of all those patients — that is one of the disadvantages of a consultant. At least 21 of them thus passed out of my medical knowledge. But I know that 88 of the 104 were said to have 'recovered,' that is a total recovery-rate of 84 per cent. That represents the curability of the present attack in the milder cases of melancholia. If one relied on this experience, conditions of depression would seem to be a very curable disease indeed. But I knew many of them would be likely to relapse, some of them over and over again. My inquiries into that point brought out this fact. I ascertained that 36 of them had recurrences or relapses, and I have no doubt that number does not represent the full facts. Deducting this 36 from the 88 ' recoveries,' it leaves a proportion of exactly one-half as being possible permanent recoveries. The relapses did not take place in many of the patients for years, so that in those cases the ' recoveries ' were just as real as recoveries from gout or rheumatism and many other diseases often are. I knew that at least ten of those relapses passed into folie circulaire, or dementia, or other incurable mental states. Almost all those patients were in comfortable circumstances, so that they could afford to obtain skilled nursing, changes of environment, etc. Melancholia is apt to be the first form of mental disturbance when it occurs in any family up to that time free from it. Being the sanest form of mental disturbance, it is the most curable and the least damaging to the brain when it is recovered from. Premonitory Symptoms. — In the early stages of melancholia, the patients very frequently have a sense of impending danger, of loss of self-control, and 312 INDEX OF PROGNOSIS that they may take away their own lives. This feeling causes great distress, and aggravates the painful s^onptoms of the disease very much. It is certainly a symptom that is not to be disregarded in the prognosis, and especially in regard to the precautions to be taken. The patient perhaps does not speak of it to anyone but his doctor. Relatives usually pooh-pooh the S3rmptom as not being worth taking much notice of, because the patient at the time is self-controUed, and can pull himself together and look ver\' much as usual in the presence of strangers. One of the dif&culties of its treatment and prognosis is this, that constant watching, though it ma^^ be necessary' in many cases, may add greatly to the patient's depression, thus aggravating the disease ; the watching against the symptom, in short, acts as a continual suggestion that it is present. There are three kinds of cases which, in my experience, make it almost impossible to provide absolutely against attempts at suicide. Those are, first, these latent early cases, and secondly, those where, during the course of the disease, explosions, as it were, of suicidal impulse come on suddenly %\'ithout any preUminary symptoms. The third is where the patient exhibits extreme cunning in concealing his impulses and extreme determination in carr^dng them out. As regards the doctor in attendance, wherever there is any suicidal impulse, or any reasonable chnical risk of it, he is bound to take precautions and to intimate its existence, in an earnest, impressive way, to the nurses and attendants and to the responsible relatives of the patient. CoNDiTioxs OF Mental Exaltation — ;\L\xia. Both the symptoms and the prognosis are different where we have emotional and intellectual exaltation as the chief symptom, as compared with the depression of which I have been speaking. Exaltation in any form is a more insane sj^mptom than the milder degrees of depression. The patients usually do not recognize they are HI, as the melanchohcs so frequently do. There are conditions of what may be called physiological exaltation, as in healthy childhood. A grown-up man or woman who behaved like such a child would be in a condition of mental disorder. Then there is the natural exaltation of feeUng resulting from good news or good fortune. This maj', in some cases, pass into pathological exaltation in certain temperaments. A certain transitory kind of morbid elevation is apt to occur as a comphcation of fevers and other diseases in children of a strongly neurotic temperament. We think differenth* of conditions of depression and of exaltation. The former we are apt to think of chiefly from the patient's own subjective point of view, the latter from the objective evidences of his conduct and speech. There are certain conditions of exaltation where joy, pleasure, and happiness are the characteristic emotional states, and there are others where rage, discontent, and irritability are its chief manifestations. Most cases of mania are accompanied by ' excitement,' that is, have visible muscular acts as its sj^mptoms, whereas, in simple melanchoUa, no such excitement need be present. As a clinical fact, mania divides itself into varieties, just as melancholia does, and the character of those varieties markedly affects the prognosis in individual cases. The chief of those varieties are the simple, the acute, the delusional, and the chronic. Simple Exaltation. — I had under my care, during the ten years 1S9S-1907, in the Royal Edinburgh Mental Hospital, 800 cases of simple mania out of 1754 maniacal cases altogether, and, of that Soo, 348 recovered, giving a favourable prognosis of 43 '5 per cent. In addition to those recoveries, a certain number more were discharged relieved, some of whom no doubt completed their recov- eries after leaving the institution, but there were not nearly so many of such MENTAL DISEASES 313 relieved patients among them as among the melancholies. I think if 5 per cent were added to the 43 5 per cent of recoveries, it would represent the total curability of conditions of exaltation so marked as to be certified insane. This gives a prognosis in such states of 10-5 per cent less than that an^ong the depressed, in the simple varieties of the disease. In the general outlook of a patient who suffers from morbid mental exaltation, there are different risks and different things to be considered from those suffering from depression. An exalted patient will commonh' not commit suicide, or think of it. He will attract more attention from others of an unfavouraole kind ; he will be looked on as more of a ' fool.' He will have far more chance of losing any work or situation he has, he wiU. be more likely to ruin himself by foohsh action or speculation, he will run more risk of getting into the hands of the pubhc authorities, and he will be far more apt to produce disturbances in his family and social relations. The greatest of all human faculties, that of will-power and self-control, is very much more weakened. His moral sense is lessened in such a way that he is liable to commit acts of immorality ; the conventionalities of life are lessened in him, and he sets them aside. In his dress, and in the company he keeps, he changes his normal habits. He is much more frequently, and is sooner, certified to be insane and sent to an institution for care and treatment, and from the beginning this contingency is to be kept in mind by the doctor and explained to his relations. It is more easy to persuade relatives that this step is necessar}- than in the case of depression of mind. Mental exaltation is not so apt to be gradual in its beginnings as depression. It comes to a head faster. There are fewer cases of simple mania out of the total number of cases of exalta- tion as compared with melancholia. It is characterized less by nutritional defects. The man suffering from simple mania eats weU, sometimes excessively, and keeps up his strength. His temperature is shghtl}- higher than the melan- cholic. Instead of putting him to bed and giving him rest and massage as a form of treatment, we tend in most cases to give him a great deal of exercise in the fresh air, to put him to dig, or to send him away on a walking or bicycling tour with his attendant or a friend. We are far less sure of what he wull do and of how the case will turn out than where we have simple depression. Comparing simple exaltation with all the other forms of mania, the percentage of recoveries is only about 3 per cent greater, thus showing that there is not so great a difference between simple mania and its other forms as between simple melancholia and other forms of depression. It is in fact not so curable a disease. The brain is more disturbed in its action and not so liable to recover when exaltation is present as when the disturbance consists of depression. The 414 cases of simple depression sent to the institution in the ten years, as compared with the 800 cases of simple exaltation, is not a proof, in my opinion, that the exalted conditions are more frequent, but that they are of a character that cannot readily be managed at home and are therefore sent to asylums much more frequently. Recurrence. — I have no quite definite statistics showing the liability to recur- rence in cases of simple mania, but my opinion is decided that it is more liable to recurrence, and certainly it is more liable to pass into other and deeper forms of mental disease, than states of depression. Acute Mania. — This state, being the most vivid and dramatic of all forms of mental disease, is very often taken as the t>-pe of all the insanities. It is the ' raving madness ' of literature. It is the least rational, the least conscious, the most noisy, and most unmanageable of all the forms except general paralysis. Unfortunately, being thus so very distinctive, it has affected the conception, the treatment, and the prognosis of all forms of mental disease in a very 314 INDEX OF PROGNOSIS unfavourable way until recent times. The man in the street thinks of every- case of mental disease as of this type. Its treatment in old times consisted of manacles, chains, darkness, and stripes, and its prognosis was usually put down as entirely hopeless. It is not really a common variety of mental disease, for, out of 2377 admissions into the Royal Edinburgh Mental Hospital during the seven years 1874-1880, only 297, or about 8 per cent, were so classified. Acute mania begins in various ways, sometimes by the condition of simple mania, but often quite suddenly. At times it has the melancholic prelude to which I have alluded. Bodily symptoms are more apt to be present than in most varieties of insanity except general paralysis. The temperature is raised, weight is rapidly lost, and great exhaustion occurs in a short time in most cases. The prognosis as regards recovery is not nearly so bad as was formerly thought. My experience was that 60 per cent of the asylum cases recovered, yj per cent died, 32^ passed into chronic mania and dementia. This liability to a fatal issue is greater than in any other form of mental disease except puerperal insanity and general paralysis. There is no form of mental disease where there is more liability to the brain losing its higher powers of mind and sinking into an incurable mental condition. That in fact is the greatest risk of all, and the greatest anxiety to the doctor who is responsible for its treatment. There is a very acute form of mental disease, called by many authors ' delirious mania,' or acute delirium, which clinically may be reckoned as the worst type of acute mania. In that form the prognosis, in regard both to recovery and to death, is verj' much worse than in ordinary acute mania. Some authors say that delirious mania is almost invariably fatal, but that is not my experience. In some books this is called typho-mania. The present opinion in psychiatry tends to put down almost all cases of delirious mania, and many of acute mania, as being forms of brain toxaemia, although no specific organism has as yet been detected. Certainly the high temperature, and many of the other symptoms, point to a toxin whose action has focussed itself, as it were, on the higher cortical brain cells. Good Indications for Prognosis. — If the disease has come on suddenly, if the great organic functions of the body are not especially affected, these are of course good signs. If the stomach and bowels and digestion are acting in a normal way. if the heart's action is not unduly weakened, if the temperature does not rise above 101°, if the common sensation is not unduly impaired, if the mucous membranes of the mouth and throat are not dry, if weight is not lost at the rate of more than four pounds a week, and if the general strength shows no sign of exhaustion during the first fortnight, then we may have good hopes of the patient's ultimate recovery under proper treatment. If the patients begin rapidly to put on weight, it is perhaps the most favourable bodily sign of approaching recovery that can appear. If the disease does not last in its acute form more than a month, if there are no signs of a general enfeeblement of mind after the first six or twelve months, if there is no tendency to fixed delusion, those are all good indications in the prognosis. Nowadays we commonly put our acutely maniacal patients to bed for the first few weeks, and if this is success- ful in calming them, we look on it as a favourable indication. If prolonged bathing treatment is adopted, and the patients submit to this quietly and are the better for it, that shows that the attack will probably be recovered from. If this treatment by warm baths, with perhaps the use of mild sedatives, has the result of soothing the patients' excitement in a marked way, their recovery will probably be speedy. If the habits are not very uncleanly and improve under care it is a good sign. Unfavourable Indications. — If the temperature is persistently over 101°, if the loss in weight amounts, as I have seen in some cases, to fourteen pounds in a MENTAL DISEASES 315 week, if the mucous membranes are persistently dry, if there is a ' muttering delirium ' at night, and if there are marked signs of general exhaustion with heart failure, these are all unfavourable indications as to recovery and life. Some cases of acute mania die from exhaustion in spite of everything that can be done, and some of these die very quickly and suddenly, within the first fortnight. We now think that in such cases the toxaemia has been of a very acute character. If there have been hallucinations of the senses and they show a tendency to persist, it is an unfavourable sign. If the acute symptoms are entirely intractable and go on for perhaps a year without much change, we fear that it may pass into chronic mania. But the result which we dread above all things is that of dementia, of which I have spoken, and the early symptoms of this consist of a diminution of the active maniacal symptoms, a blurring and deterioration of the expression in the face and eye, a lack of the power of atten- tion to what is going on, a want of interest in the people about him, or in suitable occupation, a persistent lack of orientation, and a lowered emotional condition, with a loss of social instinct and the persistence of very dirty habits- — all these are unfavourable indications for complete recovery, especially if the patient is in the period of adolescence. They mean that the brain cells are undergoing demonstrable deterioration or atrophy. This affects at least 50 per cent of all the cells in bad cases. Tendency to Recurrence or Complete Recovery. — Acute mania is a condition which is not apt to recur, and when it has been of short duration it may be completely recovered from and leave the brain and the man in a normal condition. Chronic Mania. — This is really, as to its symptoms, acute mania somewhat modified in certain particulars and running a chronic course. I put down the time limit here as twelve months, but there are undoubtedly some cases of acute mania who recover after that time. Chronic mania is an incurable disease, but many patients live a long time suffering from this condition. There is a spice of enfeeblement of mind in chronic mania, the memory is impaired, the habits and fine feelings are degraded or dulled, the emotional power and social instinct are usually almost paralyzed, and the power of attention usually much lessened, although some patients are extremely sharp and observant. Delusional Mania. — Some cases of mania have from the beginning a strong and fixed delusional element on which the symptoms of excitement seem to hang. A man believes that he has been persecuted by his relations and friends, and he seems to get excited in consequence of this delusion. I had a patient who shouted, scolded, and was violent, almost all day, alleging as the reason of her conduct that her children were below the boards of the lioor, and that she heard them constantly being tortured by villains who were killing them. The prognosis in this form of mania is certainly unfavourable, though individual cases sometimes recover. It is often accompanied by vivid hallucinations both of hearing and sight, and these are unfavourable, particularly the auditory hallucinations if they last long. Mania in all its Forms. — Statistics. Taking every form of morbid mental exaltation, I had 1757 cases in the Royal Edinburgh Asyluin during the ten years I have referred to, of which 715 recovered, which gives a percentage of 40-7, being 3 per cent less than that of melancholia, and I think that the patients who were discharged relieved did not recover at home in anything like the same proportion as the melancholies did. About 5 per cent may be added to the 40-7, making about 45 per cent as a general prognostic chance in mania. The whole number of cases of mania were 1757, as compared with the 1465 melan- cholies, during the ten years; but, as 1 have stated, this does not represent the real liability to depression and exaltation of mind in the population. 3i6 INDEX OF PROGNOSIS Turning to conditions of morbid exaltation seen in private practice, I had 31 of these out of 200 consecutive cases, or 12 per cent, contrasting thus with the 52 per cent of cases of depression. Twelve of the 31 recovered, a percentage of 39, as compared with the 88 per cent of the melancholies. I ascertained that 5 out of the 12 recoveries had relapses, or 41 per cent, which is the same proportion as the melancholies. The lesser number of elevated cases I saw as compared with the depressed may not necessarily prove a lesser occur- rence of morbid elevation in the brain working of the community, but to the fact that patients suffering from mania are not so apt to come or be brought to a consultant. They usually do not recognize they are iU, and they are so decidedl}^ more insane that they are much more apt to be removed to mental hospitals at once. The lesser percentage of recoveries I met with in private practice among the cases of mania may be partly accounted for through the greater mildness and manageability of the symptoms in melanchoha, so that many more of them could be treated at their homes or in rooms during the curable stage of their attacks. 'Manic-depressive' Mental Disease. — All. authors on mental diseases had noticed a certain relationship between cases of mania and melancholia. I stated in my " Clinical Lectures " that " there exists in the majority of nearly all the acute cases, at some time or other, in some form or degree, in some stage of the disease, a tendency to alternation, periodicity of symptoms, remissions, or recurring relapses." I\Iy statistics showed that about 44 per cent of all my cases of insanity showed those characteristics, but, by confining ourselves to cases of mania and melancholia, at least 46 per cent had those characteristics. All phj^sicians in charge of mental hospitals knew that certain cases of mania maght become depressed, and vice versa, during the same attack, also that a patient might come in at one time with mania and his next attack would be melancholia. We all considered that those two conditions had a certain relationship to each other, but it was reserved for Kraepehn, of INIunich, to throw the two conditions into one for purposes of classification and call it ' manic-depressive insanity.' He maintkined that a very large number of cases of either condition actually had some symptoms of the other, if the whole mental life were taken into consideration. His subsequent experience and more careful study of the subject has led him to the belief that there are practically no cases of mania that have not had a melanchohc phase, and that there are perhaps a few more, but not m.a.ny, cases of melanchoha that have not a maniacal phase. His general conclusion from those facts is that, in essential nature and as forming the basis of a true classi- fication, they all ought to be thrown together and called by one term — not two. That there is a great deal in this view few of us doubt, but our experience as to the almost universal frequency of the association of the two conditions has not been the same as that of Kraepelin. Either we have not observed those phases, or Kraepelin has been biassed and has seen slight depressions and elevations which have not been visible to most psycMatrists. From a clinical point of view, especially as to treatment and management, a case of depression is largely different from one of mania, and, as we have seen, the prognosis is different. One can scarcely imagine telling the relatives of a tj-pical case of simple depression of mind that it is one of ' manic-depressive insanity.' It would obviously be more satisfactory and intelligible to both the medical attendant and to the relations to call it a case of mental depression. The psychological, and especially the emotional condition, in the two varieties is so essentially different and opposite that, even from a scientific view, Kraepelin's classification does not seem altogether satisfactory. It is only in the verv- decided cases, where the depressed and elevated states alternate regularl}^ and ha\'e a definite and MENTAL DISEASES 317 calculable relationship to each other, that we are bound to regard them as different phases of the same brain condition. The general prognosis in Kraepelin's manic-depressive insanity is represented, according to my experience, by a 42 per cent recovery-rate in the cases treated in institutions, and if we add 8 per cent for recoveries at home, we arrive at a prognostic chance of 50 per cent. States of Marked and Regular Alternation and Periodicity — ' Folic Circulairc' — This is not the place to go into the most interesting subject of the physiological periodicity of function in all living creatures, except in so far as it relates to prognosis in raental diseases. The two most marked periodicities in man are sleep and the processes of reproduction. Both are disturbed in mental disease, and disturbances in both markedly affect its symptoms and prognosis. We cannot dissociate the physiological periodicities from the pathological alternations and similar changes in disease. Many recurrences and changes in mental disturbances are accounted for by reference to the physiological periodicities, especially in youth, when we have to do with sex and menstruation. An attack of mental depression or of elevation may be a pathological representative of the physiological effects of menstruation. If we have such a pathological mental periodicity established, as a morbid habit it is very difficult to get rid of, as might have been expected from this relationship to a physiological process. The prognosis therefore becomes bad in such a case. There is no doubt that when we have a neurotic diathesis and a bad brain heredity we are more apt to have an exaggeration of the physiologcal periodi- cities in the direction of disease. Everybody who observes men and women from a psychological point of view knows that the slight morning change of mental condition, as compared with the evening, which may be said to be physiological, is greatly exaggerated in the neurotic subject, taking the form of a regular morning depression or want of power of energizing, or some vague feeling of organic discomfort. Few men and women of the finer and more sensitive artistic temperament but experience some such feeling, and we have seen that simple melancholia often has the same features. The periodicities of morning and evening temperature are markedly altered in the acute insanities. There is no more common symptom in all forms of recent mental disease than insomnia, which means the ceasing of a brain periodicity. Seasonal periodicities exhibit themselves in many of the neurotic and the insane. They are not always in the same condition of mind in the spring as in summer. Some such people are subject to moods, cravings, obsessions, and tempers periodically. There are many persons whose mental life is one long alternation of action and reaction, activity and torpor, as if by a natural law of their organization. There are very few of the neuroses, in addition to the mental disturbances, that are not more or less periodic ; for instance, neuralgia, asthma, megrim, and, above all, epilepsy. There is a form of mental disease, called folic circulairc, first described by French medical authors, in which, when it occurs in a typical form, there are weeks or months, or even, in some cases, years of morbid depression, followed by somewhat the same periods of morbid elevation, and then by a condition which is practically sanity. This sequence, forming a kind of circle with three sections, goes on during the whole life-time of the patient in most cases. Once fairly established the prognosis is extremely bad. In my experience there are not more than 5 per cent of recoveries. The terminations of this disease, other than those few cases of recovery, are : first, exhaustion during the maniacal phase of the disease ; second, death iiora old age at the usual periods of life ; third, a sort of settling down into either a milder form of periodicity or into a stuperose condition during old age. Nearly 20 per cent undergo this change. Very few 3i8 INDEX OF PROGNOSIS indeed of such cases pass into dementia, however acute the elevated phases may have been. In the majority of cases of my ' adolescent insanity ' there is a tendency to remission and periodicity before either recovery or dementia set in, and w^e must be very careful in the diagnosis and prognosis not to pronounce them cases of folie circulaire. In fact, we must have several years' duration and very many successive and regular states of alternation before we definitely make the diagnosis. Patients suffering from folie circulaire usually live long. The acuter cases are very troublesome, and usually need institution treatment, but there are many people in the world who have what is virtually a very mild form of folie circulaire, and during the elevated periods do uncommonly good and sometimes brilliant work, and during the depressed periods are simply ' lazy,' stupid, and inactive. They do not need to be put under care at all. I could quote from literature many examples of men who put out their best work during periods of slight mental exaltation. The favourable indications in folie circulaire, in the rare cases where such are met with, are a lengthening in the periods covered by the whole circle, a mitigation in their character, and an improved self-control during the period of elevation, the depression being less intense and the elevation less maniacal. I have been in the habit of trying in the early stages of folie circulaire to control and stop the elevation by the use of the bromides, sometimes combined with sulphonal and cannabis indica. I think I can say that in a certain number of cases this has been done and the morbid mental brain habit has been, as it were, stopped. This is worth trying, but I can recall one or two cases where the result of this treatment has been that the patients sink into a kind of lethargy and do not come out of it, ceasing to have any elevations and depressions. On inquiring into family history we find that cases of folie circulaire have nearly always a mental or a neurotic family history. It is found in a typical form more frequently in members of ' old ' families, and many such families have had other members of great intellectual distinction. Delusional Conditions — Monomania, Paranoia. — Delusion is a term which is not easy of definition. It has a popular and a medical meaning. If any man or woman has a fixed belief in something that would be incredible to people of the same class, education, or race as the person who expresses it, this belief persisting in spite of proof to the contrary, we say he or she has a fixed delusion. If such a delusion continues month by month and year by year, the prognosis is extremely unfavourable. It is only in exceptional cases that such persons recover and do good work in the world. The fixity in such cases is the character which means the incurability. Such false beliefs and delusions may assume almost every character. They may refer to the patient himself, his health, his organic and primary instincts, such as sex, food, and social relations, or they may be of a general and impersonal nature, referring to society, to other individuals, to political matters, etc. They may or may not be accom- panied by hallucinations of the senses, but if they are so it is a particularly incurable sign. A man's whole mental life may be of a delusional character, or it may refer to one subject alone, in which case it is called monomania. Delusional conditions are usually divided psychologically into two kinds, one of elevation and often unreasonable happiness, the other of persecution, suspicion, unseen agencies, and irritability, danger, and general unhappiness in life. Delusional insanity is often founded on the temperament of the individual. Vain men fall into the delusion that they are much more able or hold higher positions than is the case. Suspicious men get to believe that their relatives and friends or society are persecuting them. MENTAL DISEASES 319 A modern psychiatrist, when he is consulted about a case where there is a tendency to insane delusion, or where there are hallucinations of recent origin, first looks out for some bodily cause of this brain and mental change. He endeavours to ascertain whether there is any toxin circulating in the brain from without the body or from within. It is one of the common results of the excessive use of alcohol, to find delusions of suspicion and hallucinations of the senses. The syphilitic poison often produces the same result. I believe the toxic eiJects of the breaking down of the tubercle bacilli in phthisical patients sometimes causes mental disturbances through their action on the brain cells — a condition which I have called ' phthisical insanity.' There is a rare but well-known form of mental disturbance which is liable to occur during attacks of acute rheumatism, which is undoubtedly caused by the rheumatic poison or micro-organism. There are also the myxoedematous and exophthalmic forms of mental disturbance. I would advise every medical practitioner not to come to an absolutely unfavour- able prognosis in cases of delusional insanity before he has made a thorough inves- tigation into such possible bodily causes for the disease and estimated the chances of counteracting or getting rid of them. No doubt toxins may have the effect of damaging the brain cells irretrievably, but in some cases of delusion they may be counteracted, and in that way the patient cured if taken in time. Of recent years many of our younger psychiatrists have been trying the effects of various serums and vaccines used in the early stages of such cases, as cures and counter- actives, but their success has not as yet been great. This is a field, however, from which we hope much in the more acute toxaemias, but I cannot say that in the cases of paranoia there has been as yet much success except in certain cases of syphilitic origin, and then I have seen marked benefit, and even cure, by the use of antisyphilitic remedies, combined of course with moral and mental treatment, occupation, changes of environment, etc. There are now a considerable number of cases on record where a condition of fixed delusion was caused by traumatic injury to the head, and where surgical operation by trephining cured the disease. There is a legal aspect of insane delusion, as there may be in most forms of mental disease, where we have homicide, suicide, and serious bodily injuries, done as the result of delusions. It is often important to be able to give evidence that such cases are the result of mental disease. There are a certain number of the cases of paranoia where delusions are concealed, and their presence is even consistent with occupying positions of responsibility and doing good work in the world. In such cases the prognosis specially applies where wills are made and are influenced by the delusions present in the patient's mind. I have been frequently consulted about persons with delusions but who have exhibited them to no one except their nearest relations. Magnan, of Paris, has described a " progressive systematized delusional insanity," characterized by four stages : (i) Insane interpretations and slight depression ; (2) Ideas of persecution, with hallucinations of hearing ; (3) Delu- sions of grandeur, and (4) Dementia. My experience is that this systematic course, while it undoubtedly is seen in some cases, is a rare one. Delusional insanity is sometimes a part of that ' degeneracy ' and ' hysteria ' which Max Nordau so vividly describes as influencing our present-day literature and art. If this is so, and where it exists, it is certainly an incurable human tendency. Defective Control, Insane Impulse, Insanity without Delusion, Exaltation, De- pression, or Enfeeblement. — There can be no doubt that man's power of will, his self-control, and his ability through the exercise of his vohtion to regulate his conduct so that he lives within the limits of the law and of good morals, is his highest faculty. When this great power fails in a marked degree and men and 320 INDEX OF PROGNOSIS women act from pure unreasoning impulse, and especially if such action is sudden and explosive, it undoubtedly means disease. Under the influence of such uncontrollable impulses suicide and homicide are sometimes committed, and many crimes and anti-social acts result. Such loss or weakening of the power of mental inhibition must, however, be very marked to class it as a disease. After all, control in all men is a question of degree. Mental inhibition is a faculty which does not exist in early childhood, and it grows during childhood and adolescence just as bodily powers and faculties develop. A careful study of different children shows that there is an extraordinary difference between the degree and the development of this power in different children of the same ages. That development is, or should be, associated with a growing sense of right and wrong, and of duty in regard to parents, relations, society, and the Almighty. There are cases where such power of action and such a sense of right and wrong is never developed at all. We now call such ' moral imbecility,' and for the first tim'^ this condition has lately been recognized in Bills before Parliament, and statutory provisions are now proposed for the care of such persons, just as we have similar provisions for the care of the insane. The Royal Commission on the Care and Control of the Feeble-minded thus defined such moral imbeciles : " Persons who, from an early age, display some mental defect, coupled with strong vicious or criminal propensities, on which punishment has little or no deterrent effect." It will be observed that the words " mental defect " are used by the Commissioners, and it is quite true that there is a real mental defect which, in most cases, involves the intelligence and the emotions ; but there is a condition of loss of will-power^.and moral sense in a few grown-up men and women without intellectual impairment. Some such are sometimes extremely acute intellectually, and use that ability to the detriment of society. They have been called " congenital and instinctive criminals." Most fortunately for society such persons are rare. When this condition of moral and inhibitory defect exists, after a careful inquiry, and after taking into account the effects of bad enviroment, bad example, and no moral teaching, its subjects may be pro- nounced as quite incurable. Society must forcibly segregate them, as indeed is proposed in the Report of the Commission I have referred to. They usually come out of insane ancestry. Dipsomania. — The most common, and to society the most troublesome, of those uncontrollable impulses and moral defects is that of craving for alcohol, opium, cocaine, and such drugs. They have been called ' dipsomania,' ' morphino- mania,' etc. There are many fornis of drunkenness, some of which are curable, but the true dipsomania is, in ninety-nine cases out of a hundred, an incurable malady. It is a real disease. It is often recurrent and periodic in its symptoms, and a careful psychological study of a number of cases has led many physicians, myself among the number, to the conclusion that one usually finds associated with the drink-craving more or less of a real mental weakness in character, in intellect, and common-sense, as well as will-power. The effects of the excessive use of alcohol have been so injurious to society that many Government Commissions have been appointed to investigate the causes and to suggest remedies, while books without number by doctors and laymen have been written on the subject. 1 was lately a member of a Departmental Committee which investigated the subject of inebriety and its social consequences. We heard many witnesses who had had every sort of social experience. I was greatly impressed with this fact, that the opinion of the public in this matter is now so advanced that we could get no witnesses to contest the thesis that the principle of the liberty of the subject should be set aside when we have to deal with certain forms of inebriety. Even distinguished witnesses from the legal profession, whose duty it is to protect the MENTAL DISEASES 321 liberty of the subject, admitted that some statutory provisions must be made to control persons suffering from dipsomania and certain kinds of inebriety. Until the legislature finds time and has inclination to pass such measures, the prognosis of such diseases is mostly hopeless. The exceptions of recovery only prove the rule. Those exceptions, in my experience, apply only to such cases, and they are very few, who lose the drink craving at about the age of thirty or so, from some sort of physiological change which has taken place in their brain action at that time, but even when they recover they are not usually good for much as citizens. I shall speak of the prognosis of alcoholism — an entirely different disease from dipsomania — later on. The forms which defective inhibition, insane impulse, and explosive conduct may take are innumerable — destructiveness, fire-raising, satyriasis, kleptomania, suicide, homicide, etc. The medico-legal aspect of all those tendencies is extremely important, and we must sometimes be prepared to state on oath in the courts our views of prognosis in regard to them. As a class it is unfavourable. Conditions of Mental Confusion and Stupor. — I have already referred to the stuporose conditions as sometimes forming a part of the sequence of clinical symptoms in melancholia, but there are conditions of stupor and confusion, not associated with melancholia or mania, that form of themselves a symptoma- tological group of mental disease. A certain amount of confusion may be present in almost any form of insanity, but it may also exist per se. Typical cases of stupor are characterized by negative symptoms. There is no exhibition of active mind at all present, there is no mental reflex as the result of any mental or bodily excitant, and there are many bodily symptoms which show that the higher brain cells are almost in a condition of suspended function. There are certain striking bodily symptoms in typical cases of mental stupor which are always of importance in prognosis. The circulation is very disturbed, so that the capillaries have lost their tone, the extremities look blue and feel cold, the whole action of the central nervous system is, to a certain extent, lowered and devitalized, the ordinary motor reflexes are sometimes almost abolished, and the general effect is very alarming to the non-medical mind. The relatives think that a person in such condition is pretty sure to die. The voluntary motor system is found to be in three conditions in different cases : (i) Passive and unresistive (' anergic ' stupor) ; (2) Cataleptic, with a decided tendency to keep fixed attitudes, and the muscles ' waxy ' ; (3) Resistive, so that a strong resistance is made to change of positions, to walking, etc. Now none of these necessarily mean a bad prognosis. They may be all recovered from in time and with proper treatment. Most of the cases of stupor occur before the age of thirty. They are sometimes mixed up with hysterical symptoms. In the cataleptic and non-resistive condition there is no expression of the face or eye whatever. In many of the resistive cases there is a marked melancholic expression. It has been called melancholia attonita. While many of the cases result from purely bodily causes of exhaustion, many of them are also the result of terrible mental shocks. A few of the cases of stupor die, in spite of all treatment, of exhaustion and inanition. As a group, however, they recover in the proportion of 50 per cent, but there is an unfortunate tendency in about 30 per cent to pass into dementia, and those Kraepelin would call dementia prcBcox (see p. 335). Stupor sometimes occurs as a phase in cases of mania or melancholia ; and at the end of a pro- longed attack of acute mania, in a young person, there may be a stage of stupor which may closely imitate true incurable dementia. One must be careful not to give an unfavourable prognosis in such cases. Some authors use the term ' primary dementia ' to describe certain cases 21 322 INDEX OF PROGNOSIS of stupor. I altogether object to the use of the term ' dementia ' except to describe incurable conditions of mental enfeeblement. It is also sometimes called ' confusional insanity,' but confusion requires to be present in an extreme degree for it to be called stupor, although psychologically and physiologically the two conditions have a close relationship, and the one may be simply an aggravated degree of the other. In some few cases of stupor we may have sudden, automatic, causeless impulses or explosions, like a mental epilepsy. Such symptoms do not necessarily indicate a bad prognosis. States of Mental Enfeeblement. Dementia. — While the term ' mental enfeeblement ' may be used in a semi - popular sense, the term ' dementia ' should only be applied to a condition of weakness of mind in regard to memory, power of attention, interest in the outside world, power of reasoning and of emotion, these in by far the larger number of cases occurring as a secondary condition to some more or less acute form of mental disease. Mental exaltations, especially acute mania, are the most common preludes to a condition of dementia, but there are a \ery few cases where a slow, progressive enfeeblement occurs in young people, just as senile dotage slowly draws on as a physiological process. Formerly we were apt to think that the cell- damage, caused by toxins, and in acute mania, produced a state of damage in those cells with a tendency to atrophy ; but further study of the subject has shown that the primary state of morbid exaltation and the secondary condition of mental deterioration and ceU-death are really parts of the same process and are the result of a possible toxaemia with a strong hereditary tendency towards mental disease. We find that by far the greater number of cases of dementia occur as a sequel to and a part of adolescent insanity, occurring before the age of twenty-five. I have sometimes called it a ' postponed imbecility.' Unfortunately, in secondary dementia the prognosis is always bad. The patient in fact cannot recover, because 50 per cent of the higher brain cells in the higher and anterior parts of the cortex have undergone a process of atrophy or degeneration, as can now be demonstrated microscopically. Dements may live for a long time, in the less marked cases even to an extreme old age, but there is always a tendency for them to be unduly unresistive to the ordinary causes of disease and death. In the older mental hospitals, where there was overcrowding and imperfect ventilation, and where the diet was not as carefuUy attended to as it is now, 30 per cent used to die of phthisis pulmonalis. In many cases of secondary dementia the ' stigmata of degeneration,' to which I shall presently' allude as being present in congenital enfeeblement, are found. Conditions of Congenital Mental Weakness. Amentia. — In the process of growth and development of the brain there is liable to occur an arrest, either in utero, or in the first five years of life. This results in a mental enfeeblement, a.n incapacity for education, and most frequently also in changes from the normal appearance, strength, and power of the body generally, or of some of its chief organs. Of recent years these conditions have attracted great social attention, and have been subject to an inquiry by a Royal Commission, as previously stated. By scientific observers, conditions of idiocy and congenital mental defect have been classified in various elaborate ways, etiologically, symptomatologically, and pathologically. Several observers, especially of the Italian school, have been inclined to put down a considerable proportion of them to ante-natal toxic conditions. This, though undoubtedly applying to some of them, has not yet been proved to be their cause in by far the majority of cases. The Royal Commission to which I have referred classified them into : — I. Idiots, i.e., persons so deeply defective in mind from birth, or from an early age, that they are unable to guard themselves from common physical dangers. MENTAL DISEASES 323 such as, in the case of young children, would prevent their parents from leaving them alone. 2. Imbeciles, i.e., persons who are capable of guarding themselves from common physical dangers, but who are incapable of earning their own Uving by reason of mental defect existing from birth or from an early age. 3. The Feeble-minded, i.e., persons who may be capable of earning a living under favourable circumstances, but are incapable, from mental defect existing from birth, or from an early age, {a) of competing on equal terms with their normal fellows, or [b) of managing themselves and their affairs with ordinary prudence. They add a fourth class, moral imbeciles, the class of which I have already spoken. This classification is, as will be readily seen, largely founded on administrative grounds, for the purpose of enabling the legislature to adopt different measures and to provide different kinds of institutions for those classes of defectives. Looking at the whole class from a prognostic point of view, it may be said that they are all incurable. Idiocy is not only incurable, but is only improvable to a limited extent, in regard to the habits and ways of the patients, by placing them in institutions and by special treatment. Their lives may thus be rendered somewhat more human than if left alone, and undoubtedly may be prolonged. As showing the fact that, in this condition, not only the brain and mind are defective, but the whole nutrition of the body is weakened, it is found that about two-thirds of all the idiots are subject to, or die of, tuberculous disease. The second class, of ' imbeciles,' are educable, in special institutions and by special means, to a considerable extent ; but there is a limit to this, and all their lives they will require to be cared for by others. It is now proposed to provide special institutions for such care at the public expense, as a great philan- thropic measure, for all of them who have not means to provide such care for themselves. Undoubtedly, the imbecile may be enabled to lead a happier life and to live longer through such special care. The third class, of the ' feeble minded.' often called 'defectives,' have attracted more public interest than the other two classes, because they are nearer ordinary humanity, and some of them exhibit special capacities, e.g., in music and mechanical work, etc., in a stronger degree than even average humanity. There is a great social and eugenic question connected with this class also, namely, the risk of their propagation, the liability of some of the female defectives to fall into the ranks of prostitution, and other social and moral risks to which society is liable through their existence. The educability of many of them, during childhood and youth, is such, that a few may be made self-supporting members of society, but always need some supervision. None of them can ever attain the position of a responsible citizen The whole question of prognosis is mixed up, in conditions of congenital en-' feeblement, with legislative, social, and educative measures on their special behoof, and improvement can only be attained at the best in the great majority of cases. The few cases which are really restored to mental capacity are those resulting from gross pathological conditions, capable of recovery and cure, like hydrocephalus and traumatic injury to the brain. Stigmata of Degeneration. — There are certain kinds of bodily and mental abnormalities, that are found in most congenital cases, which are of im- portance, both in diagnosis and in prognosis. These have been called ' stigmata of degeneration.' They assume innumerable forms. The bones of the head may be so altered that they make it abnormal in shape, and so alter the expression of face, producing the effect of ' ugliness.' Mal- formations of the hard palate are the most frequent of all the bodily stigmata. 324 INDEX OF PROGNOSIS It may have a " V " shape or a saddle shape, or it may be cleft. The teeth may alter in their number or shape or disposition ; the bones of the thorax may be affected so that we have pigeon-breast. The fingers may be short or irregular ; the hand may be of that shape that we now call ' neurotic' There may be supernumerary fingers or toes or club-feet. The organs of special sense, especially the eyes and the external ear, may be abnormal ; asymmetry or attached lobes occur. The angle of the eyelids may droop so as to produce a Mongolian appear- ance. The heart, the stomach, the bowels, the tongue, the genito-urinary system, may all be abnormal. There may be a general arrest of bodily function producing ' infantilism ' and dwarfishness. The general power of expressing emotion in the face may fail. Certain mental stigmata also are liable to appear. Arrested, or postponed, or unrelational development of the mental faculties is common. Speech may be defective or postponed in coming on. The power of reasoning may not be absent, but so disturbed that the victims are never able to draw right conclusions from premises, however obvious they may be. There are cases where the memory is so prodigious that whole pages of a book can be repeated after once reading it. Many cases of an abnormal power of calculation are on record. All these things give a bad prognosis in any case. They are found, but not so frequently, in some cases of adolescent insanity, and are extremely common among developmental epileptics. Cretinism — Thyroid. — There is one class of imbecile children where the prognosis is not always unfavourable, viz., the cretins, and those in which the thyroid gland is affected in its functions. Many of these are either cured or markedly benefited by the administration of thyroid gland. Many physicians now try thyroid administration experimentally whenever they have an idiot or imbecile to treat, and occasionally great improvement is thus attained. General Paralysis. — We now come to one of the most interesting of all the forms of combined brain and mental disease — general paralysis. Its prognosis has this profound interest, that whUe as yet there is an almost infinitesimal record of recovery, there is a strong feeling, founded on the facts of its etiology, and of the results of recent developments in vaccine and other treatment, that its cure will become possible when our knowledge in regard to it still further increases, and that it may be prevented by an early cure of all cases of syphilis. The chief difficulty in this disease is not its prognosis, but its correct diagnosis in the early stages. In addition to the well-known clinical symptoms of the disease, the Wassermann reaction has now taken a definite place as perhaps the most important of all in confirmation of the diagnosis. The disease may now be said, almost definitely, to have sjrphilis as its predisposing cause. Whether there is not another and proximate cause in syphilized subjects to account for the disease is as yet in doubt. Considering that it only occurs in from 2 to 4 per cent of those who have acquired syphilis, and that it is not amenable to antisyphilitic remedies, it seems to me that there must be another etiological element, probably in the shape of some specific micro-organism. Dr. Ford Robertson, who has worked long and arduously at this subject, is of this opinion, and he believed, at one time, that a form of diphtheroid organism, wliich he called the Bacillus paralyticans, was the proximate cause of the disease ; but this has not as yet been confirmed. He has certainly been able to produce a morbid condition of the brain in some of the lower animals which, in symptoms and pathological appearance, closely resembles the disease, by using injections of cultivations of bacilli from general paralytic patients. The duration of general paralysis, from its beginning, varies from a few months to over twenty years, but the average duration of life is a little under three years. MENTAL DISEASES 325 One of the great things to remember in general paralysis is that no prognosis is justifiable until the disease has been definitely ascertained to exist. Further, there must be a combination of mental and bodily symptoms present. Certain mental and bodily conditions closely resembling general paralysis, produced by alcohol, syphilis, epilepsy, trauma, organic brain disease, acute mania, and chorea, must be eliminated before any diagnosis or prognosis is come to. There are certain symptoms which at present usually mean a short duration of the disease. These are extreme acuteness of symptoms at the onset, congestive attacks, and rapid development of the three stages one after the other. There are other symptoms which indicate that the case will probably last long. These are a slow, insidious onset of mental enfeeblement, freedom from maniacal symptoms with ambitious delusions, the prolongation of the first stage, and the occurrence of what appear to be remissions in the course of the disease. We now recognize that, in addition to the classical three stages of the disease, there is a preliminary or prodromal stage, but the symptoms of this are as yet so uncertain that we must on no account give a bad prognosis because of any such apparent prodromal symptoms. The application of the Wasser- mann test will, however, in the future, help us greatly in regard to the prognosis by determining the character of such preliminary stages. The great hope for the future in regard to general paralysis is that it will be altogether prevented by the early cure of syphilis in all cases. Syphilitic Mental Symptoms. — There are conditions of mental disease due to the direct action of syphilis on the brain, its neuroglia, its membranes, or its vessels, apart from general paralysis. The prognosis, in many of such cases, is exceedingly good, if treated in time. It is in these cases, rather than in general paralysis, that salvarsan comes in as a mode of treatment, and the Wassermann reaction as a means of diagnosis. If mental symptoms occur during the second stage of the disease they are, in nearly all cases, curable under the proper treat- ment of the disease. These secondary mental symptoms are, however, very rare. The most common form of syphilitic insanity is caused by various forms of vascular disease. Those may occur in any degree. Sometimes they are extremely localized. Usually they are slow in their course. They are very difi&cult to diagnose during the first, which is undoubtedly the most curable, stage. If we have marked motor paralysis, indicating serious damage to the motor centres, the symptoms may be arrested, but we can seldom hope for cure. In such cases I have frequently known the patient recover in regard to his mental condition, but still remain more or less paralytic and live for many years. The occurrence of convulsions, which usually take the form of Jacksonian epilepsy, does not necessarily indicate a bad prognosis if proper treatment is adopted. I can recall a case where, as a young man, the patient had both slight local paralysis and Jacksonian epilepsy, but who lived for fifty years and did good work during most of that time. There was no progression of the symptoms in his case. There is a form of what I believe to be syphilitic insanity which has, at first and often for many years, no bodily symptoms except hallucinations of hearing, the mental symptoms being morbid suspicions and tendencies to impulsive violence. If such cases are diagnosed and treated by antisyphilitic measures very early, I have seen recovery take place ; but if really established, the outlook is very hopeless ; it becomes an ordinary case of delusional insanity. Such cases usually have a bad heredity, and the syphilitic brain poisoning seems to light up this heredity into actual mental disease, just as an excessive use of alcohol might have done, without causing very marked damage that can be detected microscopically after death. 326 INDEX OF PROGNOSIS We see a few cases of acute mental disease resulting from syphilitic meningitis, from gummata causing pressure and taking the form of local convulsions and acute mania. This, if detected early enough, is amenable to treatment by the iodides in very large doses. The risk of death is, however, very great. The actual number of cases of syphilitic mental disease is very small, in my experience being only one-half per cent out of 3145 cases of mental disease altogether. No doubt, in minor forms treated and cured out of institutions they are much more common, and, with the Wassermann reaction and the use of salvarsan, we should expect syphilis to be much more curable and free from mental complications. Alcoholism and Alcoholic Mental Disease. The excessive use of alcohol is statistically the most frequent cause of mental disease in this country. Its incidence ranges between 6 to 25 per cent of the cases sent to institutions. It acts both as a predisposing, exciting, or proximate cause in different cases. Alcoholic mental disease takes very different forms in different cases, according to the kinds of alcoholic liquor used and the way in which it has been taken. Its prognosis may in different cases be absolutely bad, or in the highest degree favourable. Its forms and characters range from acute delirium tremens on to complete dementia, from cases where its bodily symptoms are the most important, to others where there are scarcely any bodily symptoms present at all. It is therefore necessary, in considering its prognosis, to take its forms into account. I find that out of the 11,346 cases of mental disease sent to the Royal Edinburgh Asylum in the thirty years 1874-1903, there were 1644 cases diagnosed as the insanity of alcoholism., a percentage of 14-5 ; 5540 cases were men and 5806 were women. The percentage of alcoholics among the men was i8-5 per cent, and among the women 12-9 per cent. Delirium Tremens, if caused by the stronger liquors, recovers in at least 80 per cent of the cases, 10 per cent dying, and other 10 per cent passing into the more prolonged insanities with hallucinations and a doubtful chance of recovery. It is now stated by recent authors on alcoholism, like Dr. Hare, that delirium tremens should be preventable altogether if proper measures are taken when it is threatened or when its symptoms first appear. Hare calls delirium tremens an ' abstinence symptom,' and he believes Janregg's theory of the real cause being a hypothetical substance called an ' anti-alcohol.' He strongly advocates its abortive treatment. This is carried out by not depriving the patient of alcohol suddenly, and giving it either by the stomach or by inhalation with oxygen, carrying out this treatment with ' adequate ' quantities until the patient begins to improve. He states that not only is the disease better treated, if ' aborted ' in this way, but the risk of death is less, and the risk of such complications as pneumonia is much lessened. I should like to see the term delirium tremens abolished and ' acute alcoholism ' substituted for it. Patients not only recover from this disease but. Hare says, there is little risk of relapse, unless alcohol is again taken to, which, most unfortunately, is very apt to be the case. When the temperature falls, and the power of sleep is restored, the patient may be pronounced on the way to convalescence. Mania a Potu. — This is really a transitory alcoholic deUrium to which patients of a certain neurotic type of brain are subject from a bout of drinking, or, in some cases, from even small quantities of alcohol. It does not imply previous alcoholic habit, and its symptoms almost invariably pass off in a few days. Its occurrence means that the patient subject to it should never taste alcohol in any shape or form. MENTAL DISEASES 327 Chronic Alcoholism. — When we pass from these two forms of alcohoHc mental disturbance to chronic alcohoUsm, the question of prognosis worsens in a very- marked degree. While chronic alcoholism varies in most of its symptoms, according to the constitution of the patient, to the time during which excessive alcohol has been taken, and to the kind of liquor used, it invariably has symptoms, bodily and mental, of a much graver nature, and in most of the cases there are, after death, demonstrable changes in the brain cells, their vessels, neuroglia, or envelopes. In most cases there are motor symptoms, these taking, in some cases, the form of general convulsions, in others tremulousness, sensory symptoms, slow motor paralysis, or muscular inco-ordination. The working of the mind- muscles in the face, as shown by the facial and eye expression, is invariably deteriorated in chronic alcoholism. Mentally, the patients have either morbid suspicions and fears, or hallucinations of hearing. There is always also moral deterioration, loss of self-respect, and of truthfulness and of feelings of honour. The memory for recent events is, in the more chronic cases, impaired. There is often insomnia, the speech is often blurred, inco-ordinated, or thick. The spinal reflexes are often abolished. There is sometimes peripheral neuritis. The patients have always lost some of their inhibitory power, and in some cases there are tendencies both to suicide and homicide as well as to other morbidly impulsive acts. As to the prognosis of chronic alcoholism, it is, in most cases, bad, on account of the organic lesions of the brain to which I have referred, and the fixed and strong habit of excessive use of drink ; but in my experience a certain number of the cases, with even marked symptoms, get better if properly treated. The length of time the patient has drunk excessively, and the duration of marked mental symptoms, are the two circumstances on which prognosis must chiefly depend. If the patient has been a chronic drunkard for many years, and if the mental symptoms are comparatively recent, and have in them some of the characters of acute alcoholism, then the prognosis may not be absolutely bad. I have seen some even unfavourable cases improve so much under the use of iodide treatment that they were no longer technically insane ; but, in most of the cases who thus improve, a careful psychological analysis of the patient's mental and moral faculties, and especially of his power of mental inhibition, will show that there is some deterioration as compared with his normal condition. There are a few cases in which, when the chief symptoms of chronic alcoholism have disappeared, there also disappears the craving for drink, but I think this results more from a certain lowering of nervous and mental action than from a recovery in self-control. Complete recovery is usually a long process when it occurs. Alcoholic Dementia and Degeneration. — Patients who have taken alcohol in excess for many years are liable to a general lowering of the mental condition, to a diminished power of initiative and action, and especially to defects of memory that are very characteristic. The expression of the face and eyes are altered and deteriorated, and the man is not at all ' the same ' as he was. There need not have existed, in such cases, any previous form of acute alcoholism or insanity. I need hardly say that this condition is entirely hope- less in regard to the prognosis, and the older the man is, the worse the outlook. Such a condition seems to bring on senile dotage prematurely. The brain cells are hopelessly degenerated. ' Respectable ' Excess. — To anyone accustomed to observe carefully the expression of the face and the intimate psychology of some of his friends and acquaintances who take much liquor, there are minor mental degenerations to be seen as the result, not of constant drunkenness, but of what has been really excess in the habitual use of alcohol, though it may not have been counted 328 INDEX OF PROGNOSIS very unusual. They were respectable drinkers. The finer traits of mind and character get lost. There is a coarsening of the moral tone, a lack of energy and activity in life; selfishness and egoism are seen in too marked a degree. Now in the very beginning of this condition, if a man has judicious friends and a firm doctor, so that he is persuaded to abandon entirely the use of alcohol, to take a great deal of exercise, and resort to outdoor games, these suspicious symptoms may entirely disappear and the man may become his old self. I have seen many such cases. I have already treated of dipsomania as one of the forms of defective inhibi- tion. Morbid Cravings for Various Drugs. — Opium, chloral, cocaine, and various other drugs of the nerve-stimulant or nerve-sedative type may be taken to such excess that they become a morbid habit and virtually forms of mental disease. It may be said that in regard to most of them the habit may be broken and the patient cured, for the time being, but only through outside control and special treatment. The patients are not able, of their own accord, to cure themselves and abandon those drugs. The opium habit is the most common, and if long continued is more liable to end in death than any other, through stomach irritation and incapacity to receive food. My experience, however, is that the cocaine habit is really the most difficult to break, and the most apt to return. Cocaine is, in fact, the most fascinating and the most powerful destroyer of human inhibition of any substance known to us. I have seen a complete cure of the opium habit after thirty years' duration. I have never seen a cure of the cocaine habit at all. Special institution treatment is necessary in by far the majority of cases of the drug habit, though, where the means allow, a doctor's house or a home with special nursing may be effectual. The prognosis in the opium habit depends on (i) The patient's resolution to undergo treatment ; (2) His response to treatment in its early stages. During the gradual tapering down of the drug, which is the method now always practised, there is intense misery and prostration. If the sickness, diarrhoea, and consequent exhaustion are extreme, the patient may die, or the treatment may even, in a few cases, have to be stopped to save his life. The Mental Symptoms of Organic Brain Diseases. — When we have attacks of apoplexy or hemiplegia, especially in advanced life, they are almost invariably accompanied by mental symptoms. The same thing occurs as the result of tumours, atrophies, and many gross forms of brain degeneration. Those symptoms sometimes take the form of morbid excitement, but in essence they are an enfeeblement of mind. We find, in a large number of such cases, an emotionalism, a childishness, a morbid suspiciousness, a loss of will-power, a diminished power of work, and a lessened mental energy. These symptoms do not, in most cases, constitute an insanity in the popular sense. The mental symptoms are apt to be more acute in the early stages of most organic diseases, and more those of enfeeblement in the later stages, especially in paralysis with softening of the brain. If we have an embolism of one of the smaller brain arteries in a young person, it may produce local paralysis without almost any mental symptoms after the first few weeks, and the same is seen in syphilitic vascular disease. Taking the statistics of the Royal Edinburgh Mental Hospital for the nine years 1874-1882, we had, out of 3145 admissions, 91, or 3 per cent, of this kind of mental disease, which means that the mental s^'mptoms in those were of a marked type. Of these 91 cases, 17, or almost 19 per cent, recovered. I do not say that all the recoveries were so perfect that the subjects of them were not handicapped in some way, but this favourable result, I confess. MENTAL DISEASES 329 surprised me. I had expected a considerably less ' recovery ' rate. The treatment really consists in proper nursing and non-stimulating diet, and if the patient improves within the first month, his chances of at least a partial mental recovery are good, but it will probably be slow. The patient's age is perhaps the most important thing in forming the prognosis. If his age is great and there are signs of arterial degeneration, it is bad. Epileptic Unsoundness of Mind. — Epilepsy is unfortunately associated with mental disturbances or mental defect in a very large proportion of cases. Those disturbances and defects assume a great variety of forms, and their degrees and intensity are strikingly different. For prognostic purposes we have to divide epileptic unsoundness into three groups : (i) Mental defect as an almost universal accompaniment of the disease when it occurs before seven years of age ; (2) Mental defects and disturbances, when they arise during the developmental period between seven and twenty-five years of age, the largest number of cases occurring during this period, and the most typical mental effects being then seen ; (3) Epilepsy occurring in the fully developed and senile periods. The defects in the first period are those of mental deficiency from a retarded development of brain, and the prognosis is the same as in idiocy and imbecility. It may be said to be hopeless if the fits are frequent and regular in course, but there are a few cases of convulsions of the infrequent and sporadic character, at that period of life, in whom the brain and mental development is not very seriously arrested or retarded. The epilepsy of this period of life is, in most cases, accompanied by such abnormalities and stigmata as I have described in idiocy. We look on the mental defects, the bodily stigmata, and the fits, as being all effects of the common factor of arrest in brain growth and develop- ment. As a matter of fact, however, the occurrence of epilepsy is a very unfavourable factor as regards educability and improvement in the mental condition, either when carried out in the form of special training in institutions or at home. Any improvement thus produced is apt to be arrested and put back by the frequent occurrence of the fits. The second form of epilepsy may be consistent with technical soundness of mind between the fits, especially during the earlier part of the disease, but the general tendency is towards mental deterioration when it is long continued, and there is always a danger of the occurrence of conditions of mania, often of a very severe type, and of delusional conditions connected with the fits. The prognosis is not absolutely bad, for there are men and women who have occasional sporadic fits during many years, or during the whole life-time, without the occurrence of technical insanity or even marked mental deterioration. Efficient work in life may be done in those cases, but a careful observation of the character and whole life-history of the epileptic who is reckoned sane, is apt to result in the conclusion that even in them there are apt to be slight abnor- malities in the emotions and character. The occurrence of epileptic fits at very rare intervals may, however, be compatible with great mental power, and even with genius. It is usually said, but the statement lacks definite scientific proof, that Julius Caesar, Mahomet, and Napoleon were subject to such attacks. The mental symptoms in ordinary epilepsy usually occur after one or more fits. In such cases, the symptoms are acute and often extremely violent, sometimes with attempts at homicide. The epileptic maniac is an extremely dangerous man. These acute mental symptoms commonly occur within twenty-four hours of the convulsions. There are many epileptics who are subject to mental disturbances as a prelude to the fits. These show themselves 330 INDEX OF PROGNOSIS a day or two before the convulsions occur, and, in many cases, the mental symptoms cease, apparently as the result of the fit. There are a few cases where a mental disturbance will, as it were, take the place of the fits ; this is the mental epilepsy, the false consciousness, the epilepsia larvee of the French. If epilepsy persists year by year there is almost always a mental deterioration, a loss of memory, a change of affection, a blunting of the finer feelings, a morbid egoism and selfishness, all these symptoms getting worse as time goes on. This is, in fact, an epileptic dementia. The prognosis in this second class of epileptics is extremely bad in regard to complete recovery. Attention to the health and diet, abstinence from alcohol, a routine life of work in the fresh air, and a steady use of the bromides, in suitable cases, will undoubtedly, in most cases, result in a diminution in the number of attacks and in an enormous modification, for the better, of the acuter mental symptoms. I used to have, in the Ro3'al Edinburgh Asylum, a steady average of thirteen epileptics sent to the institution every year, and of about forty constant residents, and after I put the greater number of them on constant doses of from 25 to 50 gr. of bromide of potassium every twenty-four hours, the acuter forms of epileptic mania practically ceased, and I was able, in ten years, out of 115 admissions, to discharge 22, or 19 p3r cent, as ' recovered ' mentally. This gives, however, too favourable a prognostic result, because, if the patient who has been certified as insane in an institution remains mentally free from technical insanity for twelve months, although he is still an epileptic and subject to mental attacks, we must legally discharge him as recovered from his mental disease, and many of these recoveries were contingent on their regularly using the bromides, which, by the way, it is extremely difficult to get carried out when a patient feels himself pretty well and does not have the fits for a certain time. Statistics show that 51 per cent of all epilepsy comes on before fourteen years of age, and 95 per cent before twenty-five. This fact clearly shows its definite relationship to the early period of life and brain development. The Royal Commission to which I have alluded gives some statistics in regard to epilepsy. It quotes one estimate as being one sane epileptic per thousand of the population. This would make the number in the country 45,216, but another investigator gives the number as only 19,516 for England and Wales. Such a discrepancy shows that these estimates are unreliable. The estimate of the Commissioners in regard to insane epileptics in asylums and workhouses, or in the general population, is that their number amounts to one in ten thousand, or 4521. As an actual matter of fact there are 11,078 epileptics out of an insane popu- lation in the county and borough asylums of England. My estimate is that there are 100,000 epileptics, sane and insane, in Great Britain and Ireland. The prevalence of epilepsy in difierent counties and districts of England differs enormously. It may be said that in those agricultural counties of Eng- land which are largely beer- or cider-drinking, the proportion of epileptics in the mental hospitals is much greater than in the manufacturing counties and large cities, and amounts to 11 per cent of aU the admissions to county asylums. In the large cities of England they amount to 8 per cent, and in Scotland to about 4 per cent of the admissions. It is a curious fact, as illus- trating the possibility of treating epileptics and epileptic insanity at home, and in private houses, where there are sufficient means, that the proportion of epileptics among private patients in mental hospitals is enormously less than among the rate-paid class of insane. In regard to the third class of epileptic insane, where the disease has come on after twenty-five years of age, which amounts to 5 per cent of the total number, it is, to a large extent, the result of excessive alcohol or traumatism or vascular MENTAL DISEASES 331 disease in old age. The prognosis in many such cases is more favourable than in the cases that have occurred before twentj^-five. I have no actual statistics, but I would give it at about 30 per cent if treatment has been begun at once. In dealing with the prognosis of epileptic mental disease one must not leave out of account the fact that most epileptics are exceedingly apt to have an uncon- trollable craving for alcohol, and that, under the influence of alcohol, they become far more dangerous and homicidal. It is well known that, of the number of homicides committed in the country, a certain proportion of the murderers are epileptics. Any medical man having an epileptic to treat should certainly point out this note of possible danger in every case. Mental Diseases Associated with Childbirth. The mental affections connected with childbirth have been naturally assorted into those which are liable to occur during pregnancy, those which occur soon after, and as the result of, confinement, and those that occur during nursing. By far the most important and the most frequent of these is puerperal insanity, which term is somewhat artificially restricted to apply to cases occurring within the first six weeks after delivery. This does not present the same symptoms in all the cases, but the larger number and, as it were, the general type, consists of those occurring within the first fortnight after delivery. This type is about the acutest form of mental disease ever met with, and the m.ost deadly, always excepting general paralysis. The temperature is high, rising sometimes to 106°. The pulse is extremely weak and thready, the patient looks extremely exhausted, the lochia cease, the mucous membranes are apt to be dry, the eyes are brilliant, and the bodily condition is one of great exhaustion and obvious risk. The mental symptoms are of the acutest type. The attention cannot be fixed, the patient is in a condition approaching delirium. She takes no notice of, and has no interest in, her baby ; she gets violent and may have to be held in bed ; she will not take food ; and, above all, we have the gravest symptom that can occur in mental disease, she may try to injure her baby or put an end to her own life. Now this condition resembles a toxaemia so closely that it is difficult to believe it is not of that character ; but no specific organism has been yet detected, though diphtheroid and other micro-organisms have been found, especially in the urine, but some recent authors deny its toxic character. Looking at it from a clinical point of view, such acute cases certainly seem the result of some toxic poison. Their prognosis in regard to recovery is extremely good. They not only recover quickly, most of them within three months, but the recovery is a complete one, not subject to relapse. But there is one distinct risk in such acute cases, and that is of death, especially when the temperature goes much above 102°. The death-rate in these amounts to over 10 per cent. My experience is that the test of the risk of death is found in the temperature above all other symptoms. I have found that over 80 per cent of such acute cases recover. They are subject to intercurrent diseases — septic inflammation of the womb and its surroundings, meningeal inflammation, and incidentally mammary abscess. As might have been expected, heredity comes in as a predisposing cause of mental disease after confinement, as it does in most other cases. There is a type of puerperal mental disease of a milder type than that which I have described, constituting about one-half of the cases. In these, the sym- ptoms are all milder, without much tendency to an abnormally high temperature, and with the risk of death greatly diminished. These recover in the proportion of about 70 per cent, some of them running on into chronic insanity and dementia. They do not recover quite so quickly as the very acute cases of the disease, taking sometimes six months to get better ; but in the milder, as in the 332 INDEX OF PROGNOSIS acuter cases, the risk of the mother injuring the child has to be kept in mind in every case, and the nurses and relations must be seriously warned on that point. Lactational Insanity. — When a woman, in addition to having a child, fulfils the natural duty of nursing it, and she is perhaps not strong in general health, and in poor circumstances implying hard work and insufficient nourishment, she may, if there is any innate liability to the neuroses or to insanity, become affected in mind during such nursing. We call this ' lactational insanity.' It is apt to be an anaemic disease attended by exhaustion of body and depression of mind. The mental symptoms are usually preceded by headaches, flashes of light, feelings of exhaustion, and irritability. If these are seen and treated in time, the chances are that no mental symptoms will supervene. When they do appear, the risk of suicide should be kept in mind. In some cases the symptoms are those of mania. My experience is that over 77 per cent of the lactational cases recover, but the recovery takes a longer time than in the puerperal cases, because the general strength has run down to a greater degree. Lactational insanity seldom occurs among the better-off classes, the reason being, no doubt, that they have proper nourishment and are not being over-worked while they are nursing their children. With proper nursing and good food we should not lose a lactational case. Most of them respond to such treatment at once. The Mental Disturbances of Pregnancy. — This is a rare form of mental disease. The symptoms are usually mild depression, but there is always a risk of this depression leading to suicide. Most cases of the mental disease of pregnancy have a bad neurotic heredity. The worst class of cases, those sent to mental hospitals, only recover in the proportion of 60 per cent, and of those who do not recover, a large number pass rapidly into dementia. Women are more liable to have mental symptoms during the first than subsequent pregnancies, especially if they are over thirty-five. As a question of prognosis, the treat- ment of serious mental symptoms, occurring during early pregnancy, by abortion or premature labour, is now a measure to be seriously faced by the medical man. For myself, I am of opinion that this should be done after consulting with another medical man, and with the full written consent of the husband or nearest relation. It gives a better chance to the mother, which is the first consideration, and it prevents the entrance into the world of a human being who would be extremely liable to be mentally affected. Dr. Routh describes the ' Toxaemias of Pregnancy.' No doubt these, in predisposed subjects, account for some of the insanities. The mental disturbances connected with childbirth occur in the proportion of 5 per cent puerperal, 4 per cent lactational, and i per cent pregnancy, in Edinburgh. In Cumberland and Westmorland my experiences for the ten years 1863-73 is that they occurred in the proportion of 17J per cent of all the female cases. When they recover they remain well mentally with very small chance of relapse, except those who have subsequent childbirths. The Epochal Mental Disturbances. In addition to the mental disorders of which I have spoken, connected with childbirth, certain other epochs of life are subject to mental disturbances of a somewhat characteristic kind, with many distinctive symptoms and marked differences in their prognosis. In the ordinary man and woman, with a reasonably good heredity, the various eras and epochs of life are passed through without much risk of mental upset. It is different with those of the neurotic and psycho- pathic constitution. The physiological characteristics are, in them, more MENTAL DISEASES 333 liable to pass into pathological states. Each era of life has its own normal psychology, and the passing from one into the other may quite naturally be expected to have some influence on the mental working. The epochal psychoses will always be co-related to the epochal neuroses by the thoughtful physician, and we know that the ' critical ' periods of life are often attended with nervous as well as mental symptoms. Childhood, Boyhood and Girlhood.^This era has a singularly characteristic psychology, and is very free from such mental disturbances as can be rightly called insanitJ^ When such disturbances are seen they usually take the form of short attacks of maniacal elevation resembling delirium, which soon pass off, but may recur a few times before final recovery. A very few indeed have attacks of depression of mind which are apt to be recurrent. There are some children, always those of the neurotic diathesis, who, whenever they become feverish from any cause, are extremely liable to become delirious. Even temperatures under 100° may cause severe delirium in them. It may be said that the mental disturbances of children, except those in the very early periods of life which are either syphilitic or of the nature of idiocy and other mental arrestments, are curable, and are speedily recovered from. Left to nature, or with the use of mild sedatives such as the bromide of ammonium, they speedily return to their normal state. Puberty and Adolescent Mental Disturbances. — The great physiological and mental changes that take place at puberty and go on for ten years, through the period of adolescence, are attended with more serious mental and nervous risks than any of the epochs of life, except childbirth. It is unfortunately true that the prognosis is very serious in many of those cases. At least 30 per cent of the mental cases ultimately fall into that state of mental deterioration and death which I have described under dementia and dementia prascox. The chief and the most characteristic phases of the mental disturbances at puberty, and more especially during adolescence, are a tendency to attacks of naaniacal excitement, often very acute in character, each individual attack not lasting long, and when it abates, recovery seeming to have taken place. But those attacks have a tendency to return, often many times ; in fact, adolescent insanity, as I have called it, is especially a periodic and recurrent form. In forming a prognosis of this form of mental disturbance it is, in the first place, necessary to observe whether the patient is averagely developed and has no bodily stigmata of degeneration. These, unquestionably, may be bad signs in regard to recovery. If, in addition, he has been somewhat backward in mental development or prone to undue excitability, or has shown defects in morals and character in a marked degree, if he has been ' thoughtless ' and not very educable, then the outlook is not very good, but not necessarily very bad. Even cases with such characters recover in many instances. If, on the contrary, he has been well developed and normal up to the time of the attack, in body and mind, if the attack has been of manic-depressive character, and if, after the first, we notice that the subsequent attacks are less acute and shorter in duration, we are entitled to form a favourable prognosis. As a matter of fact, mental disease of marked character does not occur so frequently until a later period of adolescence, namely from seventeen to twenty-five. I have always held and thought that the liability to such attacks was coincident, in persons with a bad heredity, with, not the actual gain in weight of the brain, which has virtually ceased before that time, but with its development in its highest function of mentalization. One need not be a physiologist or a psychologist to realize how momentous, during this time of life, are the subtle changes in brain working which mean full reasoning power, large powers of self-control and moral feeling, 334 INDEX OF PROGNOSIS development in a normal form of the religious instincts, proper regulation of sex feelings, appreciation of the higher forms of literature, and manliness and womanliness of the best type. All these have not usually come to perfection at the age of seventeen ; they are, or should be, by twenty-five. A moment's consideration shows that in the formation of a brain vehicle for these qualities, so momentous to a successful life, a certain strain is put on the organ and its higher cells. Now the period of this strain is the period of liability to adolescent insanity. If one closely notices the bodily developments at this time of life, we see marked changes in the direction of attaining the mental and bodily ideals of man and woman. The form takes on a manly type, the beard grows, and the voice completes the change that has begun at puberty. In the woman, the form rounds up towards the ideal type of beauty, the mammse develop, and the whole woman is perfected. Now, if we find those changes taking place normally during the time that a patient is subject to these recurrent attacks of mental excitement, then we form a favourable prognosis. Nature has in such adolescents gone through the strain laid on her, and there is a reasonable probability that the tendency to mental disturbance has passed, at aU events until child-bearing or the climacteric occurs. In a certain proportion of the cases of adolescent mental disturbance (about 22 per cent), it takes the form of depression that is also apt to abate and recur, though not quite in the same degree as the acutely excited cases. The prognosis in the melancholic cases is better than those of mania. Taking the whole of the mental disturbances of adolescence into account, they recover at the rate of 60 per cent ; but limiting oneself to the depressed cases, the rate of recovery is about 10 per cent more. Instead of exaltation or depression, we meet with stuporose, confusional, and lethargic symptoms, sometimes, too, with catalepsy and ' trance.' The prognosis is not so good in such patients, but is by no means very bad. The worst class of symptoms in regard to prognosis are those which Kraepelin selects as constituting his dementia praecox, of which I shaU speak presently. I had always held that the man who could tell us in the early stages of any case of adolescent insanity the symptoms which indicated incurability, would add greatly to our exact knowledge of psychiatry, and I welcomed Kraepelin's induction accordingly. There is an undoubted liability to a recurrence of mental disturbance in those who have had an attack at adolescence and have recovered. Tracing them through their whole lives I find that nearly 20 per cent are liable to a recurrence in some form or other. The gravest aspect of adolescent insanity is that, in about one-third of the cases, instead of recovering, they pass slowly into dementia. Nature has not been able to bear the strain of the period of complete development, and the young man or woman virtually dies as regards all the highest qualities of mind. I believe that, in most of those, dementia is inevitable from the beginning. No methods of prophylaxis or treatment would have had much effect in saving their mental life. It is this fact that makes me look on them as having some analogy to the cases of congenital imbecility in which a mental death has taken place in the earliest periods of life. The brain of the imbecile has been ' unfit ' from the beginning, the brain of the adolescent was fit up to twenty, and then became unfit from some deeply-seated hereditary cause. In addition to imbecility and adolescent insanity, we notice during brain development a series of lesser mental and moral changes, states of perverse conduct and peculiarities, which are due to the same hereditary defects, and are, in many ways, of the same essential nature as technical mental disease. Those MENTAL DISEASES 335 frequently occur at earlier ages than adolescent insanity, sometimes even before puberty. They consist, in some cases, of stupidity and lethargy, in others of perversions of the social instincts, in others of causeless aversions to father, mother, or other near relations. Some show their peculiarities in an abnormal intolerance of control, incompatibihty of temper, and, in some, in immoralities and criminal acts. It is a striking fact that one-half of all convictions for crime are found in offenders under the age of twenty-five. There are many cases of the morbid impulsiveness, the losses of control, and the tendencies to drink which I have described that occur at that age. Most of such cases are ascribed simply to bad conduct, which the parent and the schoolmaster usually treat bj' punishments. A few of such cases recover from those mental and moral peculiarities towards the end of adolescence, but unfortunately the outlook is bad in most of them, and they remain, so long as they live, the bad citizens, the skeletons in families, and the criminals of society. Dementia Praecox. — Since I first segregated those forms of insanity just described and called them ' Adolescent Insanity,' Kraepelin, of Munich, has segregated a group of mental cases occurring about the same age, which he has called ' Dementia Praecox,' and holds they form a distinct variety of mental disease, with distinctive symptoms and history. That term covers the un- favourable region of adolescent insanity. Those who recover, Kraepelin would include in his 'Manic-depressive Insanity.' The chief features of dementia praecox are that it begins slowly over a period of years, and the patient shows his disorder more by what he does than by what he says and thinks. He shows odd or bizarre conduct. The emotional tone is blunted and changed. There is a peculiar loss of consistency between ideation, emotion, and will. The will-power is per\'erted or lost, the conduct is automatic, there are what is called negativism, ' stereotypism,' apathy, mannerisms, and indifference to personal appearance. The patient often has hallucinations, and is completely changed in character. Ivraepelin divides the cases into three forms : ( i ) The ' Katatonic,' (2) 'Hebephrenic,' and (3) 'Paranoid.' All three varieties are unfavourable as to prognosis, but the first and second are better in this respect than the third. Many of the katatonic are those which I have described under ' Stupor,' and we have seen that the chances of recovery are on the w-hole favourable in this form. But all forms tend to be deteriorating psychoses. If rightly diagnosed, aU cases of dementia praecox should be incurable. The Mental Disturbances of Decadence — The Climacteric, and Senility. — When we come to that period at which men and women turn the corner of life, when they pass into the first stage of decadence and involution, and particularly when they arrive at its later stages, in old age, some of them are Uable to certain forms of mental disturbance, the symptoms of which are markedly different from those in the earlier periods of life. The pathological in them has a close relationship and resemblance to the physio- logical characteristics of those eras of life. The passions of life have lost their intensit}', its ideals and emotions are less keen, the driving power of sex and all that it imphes in life is fading away or is past, the general result being that when the mind becomes unsound it tends towards melancholy, to a want of interest in life, to a tedium vitce, and a general diminution in originating and energizing power. There are bodily changes pointing to the same general result. The red corpuscles of the blood markedly diminish in number, certain glands lessen in bulk, the countenance and eye are less mobile and expressive ; poetry, fiction, and love tales cease to have the power to set the brain on fire. The general social instincts remain, but they assume different forms from those of youth. The subtle interest of the society of the other sex is less overmastering. 336 INDEX OF PROGNOSIS Friendship and comradeship take the place of love of the fervid sort. The climacteric period begins in the woman earlier than in man, and its signs are more marked ; but it also occurs in man at a later period of life, and in a less marked form. The ' grand climacteric ' of the Romans may be put down in man as occurring at about the age of sixty-three. In some of the lowest animals reproduction is at once followed by death ; in man the loss of the power of repro- duction is followed by a lessened mental and bodily intensity. The symptoms of climacteric unsoundness of mind in five cases out of six takes a melancholic character. The sleep becomes broken, the appetite for food is less intense, the skin gets muddy, the patient has fears and fancies, sometimes of an intense character. She is often terrified that she will lose control over herself or even commit suicide. She blames herself for all those feelings, and this is a cause of distress. Work is difficult. In some cases there are hallucinations of hearing. In men, initiation, courage, and mental aggressiveness are lessened. There is often a tincture of hypochondria in the mental symptoms, and a feeling that life is no longer worth having. The prognosis in those conditions is not so unfavourable as is commonly supposed. It must be kept in mind that the epoch is not a sudden one. It begins slowly, and it takes several years, at least five in most cases, to get com- pleted. In women 57 per cent recover, but in men only 31 per cent. I do not give up hope of recovery in a climacteric case for at least five years. The signs of recovery are a return to a reasonable enjoyment of life, but with less intensity in it. Weight should be gained, fat should be put on, the sleep should become normal. The post-climacteric happiness and power of work are not as great as in the former life, but there are many women of the nervous tempera- ment who experience a quiet comfort and happiness which they have never enjoyed before. The storms of life are, as it were, past; the patients have sailed into smooth water. During the climacteric, whether normal or abnormal in its character, I have a profound belief in changes of environment, and especially in living in the fresh air. Suicidal feelings must be carefully looked for in both sexes, because, though these are not usually intense, yet there are exceptions to this rule. There are a few cases of climacteric unsoundness in both sexes that assume the exalted form ; agitated melancholia also occurs. My experience is that the more acute and decided the mental symptoms are, the less chance there is of recovery. When those acute symptoms abate, the patients are apt to pass into a senile condition before the usual age of dotage. Old Age. — The normal psychology of old age has been frequently depicted , from Shakespeare's King Lear onwards, but an exact scientific record which takes into account, not only the heredity of mental breakdown, but the heredity in regard to long life, has not been made as yet ; especially the brain point of view : its vascular and its cellular elements have not been taken into account as they should have been. Many cases of breakdown in old age are primarily due to vascular conditions and consequently insufficient blood-supply to the nerve cells. Atheroma and arteriosclerosis are both very common in all degrees, in old people. Sometimes they are general, sometimes localized. The blood- pressure is always increased in old age on account of the loss of elasticity in the arteries. The brain at that time, neither in its vessels nor its cells, can stand too much alcohol, though the immediate effect of that substance is often cheering and comforting. Heredity comes in as a predisposing cause of senile changes in an apparently less degree than in any other forms of mental unsoundness except general paralysis ; but the facts about heredity are further back and more apt to be forgotten. Senile insanity is apt to assume one of three forms : either a melancholia like the climacteric form, or a maniacal period of excitement, or a MENTAL DISEASES 337 condition of senile dementia which may be the termination of the other two forms. My experience, from the study of hundreds of cases of senile insanity, is that about one-third of them were of the depressed type, and of these 30 per cent recovered, some of them completely, and in others, all the acute sym- ptoms passed away, so that they could return to their homes. This form of the disease does not necessarily end in either dementia or death. One-tenth of the cases had acute attacks of excitement, in fact, in many cases, acute mania. Some of these were short sharp brain storms preceding death, or outbursts of delirious excitement accompanying the break-up of the organism. They are exceedingly apt to precede attacks of paralysis, and most of them are accompanied, if not caused, by vascular disease. While few of these recover, yet this som.etimes happens, but in an imperfect degree. In regard to cases of simple senile dementia or aggravated dotage, these are not commonly sent to institutions, and, if possible, should not be so sent. As might be expected, the cases of senile mental depression that occur in the earlier semle stages, that is, from seventy to seventy-five, are apt to show less arterial disease, and therefore recovery takes place in a real and complete form. The risk of speedy death in most of them is considerable. Thirty per cent die as the result of their attacks, one-half of them being within the first six months of a residence in institutions. The acuter class of cases is extremely difficult to manage on account of the sleeplessness and restlessness. It needs the very best nursing arrangements to cope with them, and if they are not provided the risk of death is very great. Exhaustion, bedsores, gangrene, paralysis, are all common. I have commonly found that the mUder degrees of senile excitement may in the beginning be effectually treated by small doses of the bromide of potassium and sulphonal, beginning with not more than five grains of the sulphonal and ten grains of the bromide twice a day at the most, and as an occasional night sedative. If a case responds to this, and the acute restlessness subsides, with a reasonable amount of sleep at night, the patient is manifestly much the better for it. It gives him the brain rest that is so much needed in these cases, and it should not interfere with the appetite. After a week or two the medicines should frequently be omitted experimentally to see if the patient can do without them. Insomnia notoriously, in many cases, becomes a brain habit, and by breaking the habit and re-forming the habit of sleeping, the patient may often go on without sedatives or hypnotics. It is always desirable, if there are means and proper nursing, and arrangements can be provided, that an old man or woman should stay at home and not be sent to an institution. This seems somehow to be the natural right of any citizen, and is almost always greatly appreciated by near relations. There are some senile cases, however, even at the advanced ages, whose symptoms are so acute, so troublesome, and so exhausting to all who have to do with them, that institution treatment is necessary ; but all good institutions now have hospital wards where the arrangements are specially adapted to treat such cases. Rarer Etiological and Clinical Forms of Mental Disease. In addition to these etiological and clinical forms of mental disease, of a somewhat definite type, there are many others of a less common kind : — Mental Symptoms from Influenza. — Since the year 1890, when the first great wave of influenza swept over the country, there have been a large number of cases where the primary disease was complicated by nervous and mental symptoms. In fact, it may be said that every attack of influenza in some way 22 338 INDEX OF PROGNOSIS or in some degree lowers the nervous tone, either during the attack or after- wards. These results often assume the form of depression of spirits, and a lessening of the nervous energy, which lasts for weeks and sometimes for months after the actual disease has passed away. Many of us who have had severe attacks of influenza feel that we have been the worse for it permanently. I have been in the habit of saying that influenza has left the nervous and mental tone of Europe and America lower by many degrees than it found it. Some of the cases of melancholia were very marked in both their bodily and mental symptoms. They had depression of mind, lethargy, a feeling that life was scarcely worth having, anaemia, want of appetite, digestive troubles, or loss of weight. I do not say that there is any post-influenzic insanity of a special type. I have seen the motor energy of the body affected so that it simulated early general paralysis. I have seen the memory markedly affected for many months. I have seen cases where a drink craving was established for the first time. The treatment of all these conditions is very well known — rest, mostly in bed, tonics, change of air, careful attention to diet, and freedom from business anxiety. Most of the influenzic cases recover after a few weeks and respond to treatment readily. The great thing is to keep up the treatment and the regime for a considerable time after the symptoms seem to have passed away. I observed a curious fact, which may be a coincidence, that after the great epidemic of influenza of 1890, which affected almost everyone, the general type of mental disease sent to the Royal Edinburgh Asylum, which admits all classes of society, became more of a melancholic type than it had previously been. Before that, states of morbid elevation prevailed largely over those of depression. Since that time the melancholies have almost equalled in number the maniacal cases, and in some years have exceeded them. Diabetic Mental Symptoms. — A very large number of the cases of diabetes have some mental or nervous symptom in addition to the liability to diabetic coma. It usually takes the form of depression, irritability, and incapacity to do the usual amount of work, mental or bodily. I have seen acute cases of melancholia arising in diabetes, who mostly died of the attack. The treatment of these nervous and mental affections is that of diabetes, and the prognosis is certainly very unfavourable. Blight's Disease with Mental Symptoms. — A few cases of Bright's disease show marked mental symptoms, usually of the toxic character. It begins with irritability and moroseness, passing into acutely maniacal symptoms with periods of delirium. This condition I look on as an equivalent of the convulsions that are common in the disease, probably determined by the fact that the patients had a bad neurotic heredity which rendered them more than normally liable to be affected by any toxin in their higher cortical regions. Phthisical Insanity. — The early, and what used to be called the prodromal stage of phthisis is, in a certain number of cases, accompanied by somewhat distinctive mental symptoms : suspicion, slight mental enf eeblement, unsociable- ness, mild attacks of excitement, incapacity to follow regular employment, with digestive and nutritional weakness, which I called " Phthisical Insanity." My study of this condition led me to believe that about 3 per cent of the cases sent to mental hospitals were of tliis character. I used to think that it was a very incurable form of mental affection, but the modern treatment of phthisis, when applied to those cases, results in a larger number of cures than I used to see. I now believe that the cause of such mental disturbances is due to the toxic influence of the tubercle bacfllus on the brain in persons specially predisposed to mental disease. The recovery-rate of this psychosis under the present treat- ment of phthisis may be put down as about 50 per cent. MENTAL DISEASES 339 Mental Symptoms in Acute Rheumatism and Chorea. — In a few cases of the typical acute rheumatism which we used to see before the saUcyUc treatment was introduced, the patients would suddenly become very acutely maniacal, this being accompanied with an extremely active form of chorea. The rheumatic temperature would keep up during this state, while the joint affections would cease. Most of the cases recovered, but in a few death took place during such acute attacks. I have no doubt whatever that these resulted from a metastasis of the rheumatic toxin or micro-organism from the joints to the spinal cord and brain cortex. It was very relapsing in character, in this way following the lines of uncomplicated rheumatism. Its treatment is that of the acute rheu- matism, by salicylates, etc. Too few cases have been put on record to give reliable statistics of curability. My impression is that such cases are far less frequently seen now under the modern treatment of acute rheumatic fever than formerly. The ordinary chorea of early adolescence is complicated in a few cases by a delirium accompanying the inco-ordinated muscular movements. The patients first show depression and then this delirious mania, which may be accompanied by acts of violence and suicide. Most of such cases recover, but there are a few who die of exhaustion. The treatment is that of chorea plus the employment of hypnotics and nerve sedatives. We may have to resort to hyoscine in some of the cases, and its effects, by diminishing the motor symptoms, often give extreme relief, for the time being at least. Most of the cases recover soon and have no relapses. Masturbational Mental Symptoms. — The habit of masturbation is a frequent accompaniment of many forms of mental disease, and in that case it always aggravates the mental symptoms, tending to produce mental irritability and confusion. On the whole it worsens the prognosis if persistent. There is in addition a distinct form of insanity associated with and caused by masturbation. This is not, however, nearly so common as is popularly and even medically supposed. It is far more frequently a symptom than a cause, and when present it is not nearly so incurable a malady as is imagined. My experience is that 35 per cent of my cases of the disease made good and mostly permanent recoveries under right bodily, mental, and moral treatment. Some of those cases had a tinge of congenital mental weakness which was, of course, incurable. Myxoedema and Exophthalmic Goitre.— The mental symptoms which are liable to accompany these two conditions are fairly well known. In both cases they often become so severe that patients have to be sent for treatment to mental hospitals ; at least that was so in the case of myxoedema before its treatment by thyroid extract was discovered. The symptoms are in some cases depression, and in some, exaltation of mind, but they all have tendencies to hallucinations of hearing. They all have a lowered vasomotor tone, a slowness in the reaction time, and a general lethargy of voluntary movement. All the cases I have had since the thyroid treatment was discovered have recovered. The mental symptoms in exophthalmic goitre are irritability, a tendency to delusions of suspicion, and, in the worst cases, acute mania of an extremely fatal character. Accompanying such mental symptoms are the usual bodily signs of the disease. We are yet waiting the entirely satisfactory treatment for the disease. A surgical removal of part of the thyroid gland has lately been reported by several surgeons to have good results. The Delirium of Young Children. — The delirium to which all children are liable from high temperatures and toxic causes is, in some cases, so intense and prolonged as to become a cause of anxiety. Such delirious conditions mean that the children affected by them are of an extremely neurotic temperament, 34° INDEX OF PROGNOSIS this complicating almost every form, of disease to which they are liable. It means also that such children should be specially cared for in after life with a view to antagonizing the effects of their temperament. The fact should be taken into consideration in many cases in education, selecting employments, etc. The Mental Symptoms of Lead and Arsenical Poisoning. — The salts of these two metals, when slowly absorbed into the system by painters and those who have drunk much beer adulterated with arsenic, are liable to cause mental symptoms which may go on to coma. Hallucinations, morbid elevation, maniacal attacks, and delusions of persecution are the chief symptoms. There have been cases of coma and death following such symptoms, but most of the cases will recover if proper treatment is applied in time. The General Prognosis in Persons with a Mental and Neurotic Heredity but no actual Mental Symptoms. The change from a potentiality and tendency into an actual mental disease is always an uncertain matter on account of the absence of reliable statistics and of scientific prognostic indications, as well as by the fact that the tendencies to actual disease through hereditary defects vary so infinitely in their strength in different cases. The risks of the occurrence of mental disease in many persons are a question constantly referred to doctors nowadays, but it is rare that a certain prognosis can be given in any individual case. So much depends on the circumstances and environment of the person, on his employment, on his innate vitaUty and general health, and on his habits of life, as well as on his heredity, that our con- clusions are made uncertain in most cases. On the one hand a certain amount of bad heredity exists in so many families that we must not draw too fine a line, and on the other the evil consequences to the individual, to the family, and the race may be so great that we must not shirk from pointing out the obvious risks. There are in fact prognostic risks that may be taken by any man or woman in choosing a profession, in choosing a residence, or in getting married, but on the other hand there are risks that no prudent and conscien- tious man or woman should take. The chief consideration which should guide the medical adviser are the strength and directness of the evil heredity and the constitution of the person about whom our advice is sought. In every case I would say to the applicant for advice that our present knowledge of heredity is defective and uncertain, so that we may be mistaken in our conclusions. The following, I would say, are the most relevant facts, so far as our present knowledge goes : — 1. Mental disease in the father or mother implies a considerable and necessary risk in the offspring. 2. The risk is greater from the father to the daughter or from the mother to the son, especially if there are also bodily or mental likenesses. 3. On the whole there is more risk from the maternal side. 4. If mental disease has been common ' in the family,' the risks are the greater. 5. If the person about whom our advice is asked is obviously ' neurotic ' in constitution, and has ' stigmata of degeneration,' bodily or mental, the risks are thereby accentuated. 6. If the general health has been much below par, especially during the period of development, the risks are greater. 7. If any developmental diseases have occurred, such as convulsions, asthma, chorea, severe hysteria, tubercular affections, etc., even though they may have been recovered from, the risk is greater. MIGRAINE 341 8. If mental affections have appeared, in near relations, in the early periods of'hfe, the risks are far greater than if they have appeared later on. 9. Many of the neuroses, notoriously epilepsy, occurring in ancestry, are' liable to be ' transformed ' into mental attacks in descendants — mental attacks are, in fact, their ' equivalents,' looked at from the hereditary point of view. 10. Alcohohc, sjrphilitic (including general paralysis), traumatic, and toxsemic mental attacks may not necessarily imply any mental hereditary element. 11. In some cases mental attacks will appear in members of a family with an entirely clean bill of health so far as the facts are ascertainable. T. S. Clouston. MEDITERRANEAN FEVER.— (5ee Tropical Fevers.) MERCURIALISM. — Patients who are affected with tremor as the result of inhaling mercury vapour may not suffer from any other manifestation. - Removal from the influence of the poison may be followed by rapid recovery, though in some cases the tremor never entirely passes away, and may remain with undiminished intensity. Nervous symptoms rarely follow the medicinal use of mercurial salts, but arise most frequently in those who work with the metal. Weakly people suffer much more severely than the robust, and there is a very marked individual susceptibility. The symptoms may arise for the first time when an interval has elapsed since the last exposure. With regard to oral administration, it is stated that the taking of 3 gr. of perchloride of mercury has been followed by death. On the other hand, a case has been recorded in which extensive alveolar necrosis and parenchymatous nephritis followed the ingestion of 7^^ gr. of perchloride of mercury, and in spite of this the patient eventually recovered. Of the more acute manifestations, the following justify a very grave prognosis : oedema of the glottis may rapidly follow a large concentrated dose, leading to speedy death from asphyxia ; severe gastro-intestinal disturbance with frequent Tomiting of blood-tinged material, diarrhoea with bloody evacuations ; exten- sive stomatitis followed by sloughing of the gums and the inside of the cheeks, and sudden collapse, and, in somewhat less acute cases, marked cachexia with oedema round the ankles. The prognosis is much worse if there is any coincident nephritis. Some patients die with acute cerebral symptoms, beginning perhaps with hallucinations, passing on to a stage with epileptiform convulsions, or acute mania. Chronic mercurialism in women favours miscarriage and the birth of still- born children. In both sexes it undermines the resistance of the body and paves the way for phthisis, or some acute infection. /. R. Charles. MIGRAINE. — Migraine, with its characteristic paroxysmal headaches, generally unilateral, frequently preceded by the well-known visual phenomena, and usually culminating in vomiting, does not involve any direct danger to life. Migraine is a family disease, which generally appears in childhood, and sub- sequently recurs, often with remarkable periodicity, at intervals of about three or four weeks throughout adult life, ultimately tending to disappear in old age. In women, the attacks are specially hable to occur towards the end of each menstrual period. In addition to the natural tendency to spontaneous recur- rence, there are frequently sources of peripheral irritation which precipitate or aggravate an attack at the end of a particular cycle of time in each patient's case. Sometimes the recognition and correction of such accessory factors as errors of refraction (these should always be looked for), nasal or dental abnormalities. 342 INDEX OF PROGNOSIS gouty diathesis, etc., may produce a remarkable diminution both in the frequency and in the severity of the attacks ; but the disease is essentially a hereditarj^ and constitutional one, and therefore entire cessation of the attacks is not to be expected. Gowers thinks that cases in which the face becomes cold and pinched during the attack have a more favourable prognosis, as regards mitigation of the attacks, than when the face is flushed at the onset of the paroxysms ; but it is difficult to be sure of this. Purves Stewart. MITRAL DISEASE. — {See Heart, Valvular Disease of.) MOLES (Simple). — These tumours are congenital local defects of development in the skin. They are characterized b}- warty overgrowth of the papiUae, and often by the presence of hair, but above aU by the presence in them of groups of chromatophores or pigmented connective-tissue cells, which give to the mole its characteristic dark colour. In certain moles pigment is absent. The prognosis is good. There are few indi\-iduals who do not possess them. But in two contingencies their potential mahgnancy may awake. If the mole is subjected to any injury, and especially to chronic irritation such as chafing, melanotic sarcoma may supervene, heralded by increase in size and elevation, and by repeated bleeding, followed by enlargement of glands. The second contingency is injudicious treatment. Caustics and partial excision are most dangerous. Either a mole must be severely let alone, or it must be treated, like the aspiring relatives of an Oriental despot, by complete extirpation. Clean excision with the knife should alwaj^s be performed when the mole displays signs of activity, and in any case if it is subject to chronic irritation, as on the sole of the foot, the inner side of the thigh, the neighbourhood of the anus, or in the region of the coUar. w. Sampson Hundley. MOLES, VESICULAR. — The dangers of a vesicular mole are : (i) Excessive hcBmorrhage due to partial separation of the mole ; (2) Perforation or rupture of the uterus by the mole ; (3) The coincident or subsequent development of chorio- carcinoma. 1. Excessive Haemorrhage. — Great bleeding may be caused by a vesicular mole, but it is rare for a patient to die from this cause alone. Even after apparently complete spontaneous extrusion, it is usual for bleeding to go on and necessitate uterine exploration. All vesicular moles should of course be removed surgically. More than this: even after apparently complete natural expulsion, it is safest to explore the uterus, so as to be sure that no fragments remain capable of giving rise to chorio-carcinoma subsequently. The removal of a vesicular mole is accompanied by a great deal of bleeding, but not as a rule sufficient to give rise to anxiet\^ because the hsemorrhage provokes surgical interference before the patient's condition has become alarming. External haemorrhage is most marked in the non-mahgnant variety of these moles, and indicates an attempt on the part of the uterus to expel the mass. In some cases this is successfully accompUshed ; but more commonly only a portion of the gro%vth is extruded, because the adhesion of the viUi to the uterine wall is generally far firmer than obtains in normal pregnancy. 2. Perforation or Rupture of the Uterus. — Instances have been recorded many times, but the event is relativelj- rare. In a certain proportion of cases the chorionic vilh penetrate deeply into the wall, even to the peritoneal surface, and in such cases the risk of perforation during exploration or curettage is MOVABLE KIDNEY 343 evident ; while it is in such cases that spontaneous rupture occurs — during the contractions of the uterus in the attempt to expel the mole. The internal hasmorrhage in such cases has often proved fatal. 3. The Coincident Development of Chorion-epithelioma. — This is an eventuahty for which one must always be on the look-out. Findley,^ in an analysis of 210 cases of hydatid mole, found that 16 per cent became malignant. It has occurred much more commonly after a vesicular mole than after normal preg- nancy or ordinary abortion. The earlier writers found that vesicular mole pre- ceded chorion-epithelioma in 50 per cent of the cases ; but in later researches the percentage is somewhat lower. These growths are known as malignant moles, and the prognosis is correspondingly grave. It follows that every case of vesicular mole must be watched for at least a month or two after treatment, in order to adopt energetic measures in the presence of untoward symptoms. Unfortunately, it happens that no great reliance can be placed upon the histological features of the chorionic villi in vesicular degeneration as giving indications of malignancy. Complications. — Finally, a few of the rarer complications of vesicular degenera- tion are vomiting, albuminuria, and even eclampsia and sepsis. In these cases a condition of lowered resistance ensues in which a haemorrhage may be attended by a rapidly fatal result, or in which a septic infection is prone to develop. Figures relating to the effect of molar pregnancies upon fertility are lacking, but there exist numerous observations in which pregnancy has supervened not once, but on several occasions. It is even asserted that sterility is rare after a molar pregnancy. Once a hydatid mole has been successfully cleared out, there are no remote effects to be feared beyond the possibility of subsequent chorion-epithelioma developing. Mortality. — From all causes Brindeau^ states that the mortaUty in vesicular mole is about 15 per cent of the cases. In the figures of Findley,^ representing 210 cases collected from the Litera- ture, there were 49 deaths, a mortality of about 25 per cent. Of this number, 32 died from malignant degeneration, or 16 per cent; 7 died from haemor- rhage, or 4 per cent ; 4 from septic peritonitis, or 2 per cent ; i from general sepsis, I from uraemia, i from endocarditis, i from meningitis, and 2 from unknown causes. References. — ^Diseases of Women, 1914, 174 ; "La Pratique de VArt de V Accouche- ment, 1914. Bryden Glendining. MORPHIA HABIT.—' (See Drug Habits.) MOUTH, CANCER OF.— (See Tongue, Cancer of). MOVABLE KIDNEY. — We have to consider the outlook from the patient's point of view, first, apart from operation, and secondly, when operated on by some of the niany methods now in use. It is well known that the doctor often finds a movable kidney in the course of a routine examination, when there have been no special symptoms connected with it, and it frequently happens that nothing is ever heard about it. On the other hand, severe pain or a wearying sense of drag may make the patient's life a misery. A number of secondary consequences may appear. I. Dietl's Crises. — These are violent attacks of pain, with haematuria, due to kinking of the pedicle. 344 INDEX OF PROGNOSIS 2. Intermittent Hydronephrosis. — A swelling raay be felt in the loin, which periodically disappears, and a large quantity of watery urine is passed. This may be due to other causes than kinking of the ureter by a movable kidney. 3. Secondary Gastric Symptoms. — It has recently been recognized that all the symptoms of gastric ulcer (pain, vomiting, hsematemesis, hyperchlorhydria, etc.) may be induced as a reflex from movable kidney as weU as from other abdominal conditions, such as appendicitis and gall-stones. Indeed, the hyperchlorhydria may actually lead to the development of a gastric ulcer. Of 38 cases of movable kidney operated on at the Bristol Royal Infirmary, 5 developed sooner or later a gastric ulcer, one of which perforated fatally. In another case a patient was explored for gastric symptoms and nothing was found, so the kidney was fixed, great improvement resulting. 4. Mental Disturbance. — According to Suckling, 40 per cent of all women attending a neurological clinic have a movable kidney, and their nervous symptoms are reUeved by its fixation, so that he takes it to be causative. The great majority of English surgeons, however, do not think it justifiable to operate unless there is definite evidence of local symptoms referable to the kidney. The prospects of cure by various forms of pads, belts, and corsets are difficult to estimate. Treves states that nineteen cases out of twenty obtain some relief from Ernst's apparatus, and that it may be left off after two years, but other experience is much less favourable, and the patients frequently declare that the pain is no better, or that the pressure is intolerable. Results of Operation for Movable Kidney. — The death-rate is not very serious. Edebohls collected records of 846 cases from the literature, with a mortality of 1-65 per cent. Billington has operated on 515 patients, of whom 4 died. At two Bristol hospitals there was i death (from sloughing of the wound) in 104 cases. Probably the mortality is between i and 2 per cent. ReUable end-results are not easy to obtain, most authors giving very inadequate details, or only following the cases for a few months. Keen mentions 116 patients whose condition was investigated afterwards, but in some cases this was only three months after the operation. He found 58 per cent cured, 13 per cent better, and 20 per cent without rehef ; but details are lacking. Wilson and Howell examined 41 cases who had had various operations at St. Bartholomew's Hospital at least a year previously. Twelve were quite cured and 8 greatly improved ; 9 were no better. The acute cases did better than the chronic. In several patients the kidney had broken loose again, but nevertheless there was considerable relief. BilUngton has followed up two series of his end-results. In the first, 87 cases were communicated with at least a year after the operation ; 60 per cent were almost or quite cured, 20 per cent much better, 10 per cent better, and 10 per cent no better. In a second series, 7 out of 92 patients were reported by their doctors to be no better ; the rest were cured or improved. Billington, how- ever, operates on a type of patient that most surgeons would not consider to be sufficiently disabled by the symptoms of movable kidney per se to warrant surgical intervention, for instance, neurasthenics and even lunatics. His results are therefore not comparable with those of others. His method of operating is to make a sUng out of the capsule of the kidney, combined with Goelet's sutures. Rovsing, of Copenhagen, reports on a series of cases operated on from one to twelve years previously. Out of these, 107 were cases of uncomphcated movable kidney, whereof 85 per cent were quite cured, 9 per cent better, 4 per cent no better, and 2 died of the operation. In 64 cases complicated by pyelitis, MOVABLE KIDNEY 345 appendicitis, or gastric ulcer, 50 per cent were cured, 25 per cent better, 22 per cent no better, and 3 per cent died of the operation. The method was to make a sling out of the capsule. It is probable that patients with mild symptoms, as most surgeons would judge them, were submitted to operation. Mills has collected the results of nephropexy at the General Hospital, Bir- mingham. He investigated 57 cases up to four years afterwards, and found that 33 per cent were cured, 10 per cent better, 57 per cent no better. In 23 per cent the kidney was again movable. The method of fixation varied. He points out that the patients cured were all characterized before operation by a very significant feature, that the symptoms were relieved when they lay down. Thomson Walker lays stress on the same observation. At the discussion by the Royal Society of Medicine in 1914, the registrars of three London hospitals presented reports on 83 patients two or more years after operation. Of these, 52 per cent were cured or greatly improved, 12 per cent better, and 36 per cent no better. End-results of Operation for Movable Kidney. Reporter Cases lollowed Cured or nearly cured Better No better per cent per cent per cent Wilson and Howell - 41 49 29 22 Billington . - - . Rovsing — 87 60 30 10 (a) Uncomplicated - (b) Complicated Mills .... 107 64 57 85 50 33 9 25 10 4 22 57 3 London hospitals - 2 Bristol hospitals 83 69 52 58 12 18 36 24 The writer has investigated the end-results of 69 operations at two Bristol hospitals under the care of various surgeons. Of these, 40 were cured as far as the kidney trouble was concerned, but some still had indigestion, or pain in the other kidney; 16 were not improved. Several of these were undoubtedly incorrectly diagnosed ; one proved afterwards to have a dilated stomach. Another suffered from intermittent hydronephrosis. In 6 cases the kidney appears to have broken loose again, but nevertheless 3 of these are much improved. Relapses of pain took place respectively five weeks, six weeks, four months, nine months, a year, and two years after operation. In the last case the kidney slipped during a sudden strain, but the symptoms have almost entirely passed off again. Cases associated with hydronephrosis did not do well. Although the number of cases is small, some evidence is forthcoming as to the best method of operating. Four procedures are represented : — 1. Transcortical Suturing, catgut or silk sutures being passed through the kidney substance and the muscles, or over the last rib. The failures are 5 out of 14, which is a large proportion ; 2 kidneys became loose again. In 18 cases the kidney was sutured to the muscles with catgut, but it is not clear whether the cortex or the capsule was pierced. Of these 11 were cured, 4 reheved, and 3 no better. 2. Suture of Capsule. — In 8 cases the capsule was sutured to the muscles with catgut. Here again the results were poor, and 2 worked loose. 3. Phenol and Sling. — The kidney was painted with pure carbolic acid, and an iodoform gauze sling put in beneath the lower pole and left ten to fourteen 346 INDEX OF PROGNOSIS days. The end-results are quite good, only 3 out of 19 failing. One case (not examined) is said to have relapsed. The writer has seen laceration of the kidney, with hsemorrhage and escape of urine, follow removal of the gauze. 4. Goelet's Method. — The capsule is secured by two mattress sutures of silk- worm gut passing through the muscles and skin at a higher level. Only ten cases appear, but the results are not so good as the last-named. End-results after Various Operations. Method Cases Cured EeUeved No better Suture to muscles Transcortical suture - Suture of capsule Phenol and sling Goelet's . . - . 40 u s 19 10 22 8 3 12 6 7 1 v> 4 " 2 11 5 S 3 2 We may conclude, therefore, that by nephropexy probably 50 per cent will be cured, but one in three or four will not be relieved at all. Better selection of cases will doubtless improve on these results in the future, and, in particular, operation is not advisable unless the pain is relieved by recumbency. The third and fourth methods just mentioned give a higher proportion of cures, namely, about 60 per cent, and only 15 per cent of failures. References. — Billington, Movable Kidney, Cassell, 1910 ; Wilson and Howell, Movable Kidney, London, 1908 ; Rovsing, Archiv. /. Min Chir. 1914, p. 183 ; Mills and others, Proc. Roy. Soc. Med. Surg. Section, 1914, Feb. p. 137. A. Rendle Short. MUMPS. — Mumps is only exceptionally fatal. Amongst 58,331 cases occur- ring in Denmark during the years 1870 to 1894 and reported by Ringberg, there were only 7 deaths, of which 3 were in children. Comby states that there was I fataht}'- amongst 496 cases in the French army during the years 1862 to 1865; but Denime, at Berne, reported 2 deaths in 117 cases. It is rarely fatal except from complications. Complications. — Orchitis is the most serious comphcation : not because it is at all frequently associated with a fatal result, for that is not the case, but because it often terminates in atrophy of the testis. Orchitis usually sets in about the seventh or eighth day of the illness, but may occur at any time within six weeks ; it may follow a mild attack of mumps. It is most frequently met with in young men, and is rare in little boys and old men. Its frequency appears to vary considerably in different epidemics. Catrin states that it occurs in 16 per cent of males of all ages ; but Laveran and Comby put the incidence much higher, from 30 to 33 per cent. Comby, however, refers only to epidemics in the French army. Catrin's estimate is probably nearest the truth. A large proportion of the cases of orchitis end in atrophy ; 60 per cent according to Catrin, 70 per cent according to Laveran. Very severe cerebral symptoms occasionally arise during an attack of mumps, either during the parotitis or after the testis has become affected. But as a rule such symptoms do not last long, and the patient recovers without any cerebral or mental after-effects. Pancreatitis is another complication which is accompanied by alarming symptoms. It usually arises within a week of the onset of the attack of mumps. It has been known to occur in as many as 5 out of 33 cases (in an outbreak reported by Edgecombe). There may be severe abdominal pain. MUSCULAR ATROPHIES 347 vomiting, and collapse. But in spite of the apparent severity, the prognosis is nearly always favourable. Permanent deafness is, in rare cases, the result of an attack of mumps. The cause is usually inflammation of the internal ear. e. W. Goodall. MUSCULAR ATROPHIES. Arthritic Muscular Atrophy. — In this form, which accompanies any acute or chronic joint affection, and which is limited to the muscles around the affected joint or joints — being usually more marked in the extensors than in the flexors, — the prognosis depends upon the recovery of normal mobility in the affected joint. The absence of fibrillary movements, and the presence of electrical reactions which are normal or, at the most, merely quantitatively diminished, are here of corroborative value. Suitable massage and movements of the affected muscles and joints rapidly produce improvement, the ultimate result being proportional to the degree of mobility attained at the particular joint. Ischaemic Muscular Atrophy (v. Volkmann's paralysis), the result of muscular compression by splints or bandages which have been too tightly apphed, is met with only in the forearm, and is confined to the muscles on the flexor aspect of the hand. Within a few hours, the forearm muscles become tender, and the fingers and hand swollen ; and unless the splints are removed and properly adjusted forthwith, the affected muscles are gradually infiltrated by fibrous tissue, causing them to become hard and leathery in consistence, with impossi- bility both of active contraction and of passive stretching. In this variety of muscular atrophy, due to interstitial myositis, the contracture of the wrist and fingers, once established, is obstinately resistant to the most energetic massage and electrical treatment ; and the best prospect of regaining a useful limb is offered by the excision of a portion of the radius and ulna, thereby shortening the forearm to correspond with the shortened flexor muscles. Neuritic Muscular Atrophy follows lesions of motor or mixed nerves, whether in isolated affections of individual nerve-trunks (such as the facial, ulnar, or musculo- spiral), or in multiple neuritis from any cause (alcohol, lead, arsenic, diabetes, beri-beri, malaria, diphtheria and other infective diseases, etc.). The prognosis varies according to the underlying cause, and according to the degree of degenera- tion which has occurred in the affected motor nerve. Sometimes the cause cannot be removed, as in diabetic neuritis. In other cases, as in alcoholic neuritis, it is removable with considerable difficulty. In others again, as in diphtheritic and malarial neuritis, and in ordinary ' rheumatic ' facial palsy, there is a tendency to spontaneous recovery. Accurate diagnosis of the cause is therefore of supreme importance. The degree of degeneration that has occurred in the nerve and muscle fibres, in any particular case, is determined by the examination of their electrical reactions. Myopathic Muscular Atrophy. — In this form — whether of the pseudo-hyper- trophic type, or of the primary atrophic type (where the disease, congenital in origin, consists in a primary decay of the muscle-fibres, with a reversion, first, to an embryonic structure, and ultimately ending in disappearance of the contractile sarcoplasm), — the prognosis is unfavourable as regards recovery. The rate of progress of the disease, however, varies within wide limits. Some patients become bedridden and helpless within a few years, and die (from some inter- current disease) before attaining adult age. In others, the disease advances with extraordinary slowness, and the patient may be able to get about for thirty or forty years after the onset of his symptoms. Other cases, again, seem to come to a standstill, and remain at the same stage of muscular atrophy for an apparently indefinite period. Patients with myopathy, however, rarely live to 348 INDEX OF PROGNOSIS an advanced age. The pseudo-hypertrophic form has a relatively worse prognosis as regards life than the primary atrophic type. Progressive Muscular Atrophy (peroneal or Charcot-Marie-Tooth type), which usually begins in childhood and adolescence, and is characterized by wasting of the peripheral muscles of the Umbs which leads to early claw-hand and to tahpes, bilaterally symmetrical, has a prognosis very similar to that of the myopathies : i.e., it progresses with extreme slowness, and may even come to a standstill. Here the prognosis as to Ufe depends upon preventing the patient from becoming bedridden. The orthopedic surgeon can often prolong hfe, either by providing suitable supports for the feet and knees, or by various operations upon the contractured feet, enabUng the patient to get about, even when all the muscles below the knees are completely paralyzed. Progressive Muscular Atrophy (chronic anterior poliomyelitis), from degenera- tion of the anterior cornual cells, may affect the spinal cord alone, or it may also attack the medullary motor nuclei, producing bulbar paralysis {see Bulbar Palsy). In nine tenths of the cases the. muscles of the upper limbs are attacked earliest, especially the intrinsic muscles of the hand. Sclerosis of the pyramidal tracts, which frequently accompanies the anterior cornual lesions, is evidenced by increase of the deep reflexes, especially in the lower limbs, and by the develop- ment of an extensor type of plantar reflex. The malady is usually progressive, but sometimes it becomes arrested. The chief dangers to hfe arise when the respiratory muscles are affected, or when, from bulbar palsy, deglutition is ren- dered difficult ; in such cases, not only does malnutrition result, but there is a risk of inhalation-pneumonia. In cases which become arrested as a result of treatment, the atrophied muscles do not recover ; there is simply a halt in the advance of the symptoms. The prospects of such arrest are improved by systematic hypodermic administration of strychnine, beginning with Jg- gr. daily, and quickly increasing to Jg- gr. and -^j gr. according to the regime laid down by Gowers, which should be persevered with for raany months. Electrical treatment does not appear to affect the progress of the disease materially, but sometimes ;ir-ray treatment over the medulla, in cases of bulbar palsy, has apparently brought the degenerative process to a standstill. The muscular atrophy of acute anterior poUomyelitis is referred to in the article on Infantile Paralysis. Purves Stewart. MYASTHENIA GRAVIS. — There are few diseases in which it is more difficult to form an accurate prognosis in an individual case than in myasthenia gravis. Once the disease has been recognized by the presence of the characteristic and transient fatigue of certain groups of muscles, especially the ocular, facial, masticatory, palatal, laryngeal, pharyngeal, and tongue muscles, the large proximal muscles of the limbs and, most dangerous of all, the respiratory muscles, — once these phenomena have become established, the outlook is grave. Some cases have been known to end fatally within a few weeks ; others again, with symptoms apparently no less severe, have survived for five or ten years, or even longer. Spontaneous remissions not infrequently occur if the patient leads a quiet life, free from physical exertion. Hard manual labour, or physical effort of any sort, aggravates the symptoms. The im.mediate cause of death is generally an attack of fatigue of the respiratory rauscles. Sometimes individual attacks of this sort may, for the time, be tided over by means of artificial respiration, combined with oxygen inhalations. Every myasthenic patient ought to have a cyUnder of oxygen at hand, with the necessary tubing attached, ready for such an emergency. Fatigue of the muscles of deglutition may cause attacks of choking, and is another sign of serious significance. Purves Stewart. MYOCARDIUM, PRIMARY DISEASE OF 349 ^ MYCOSIS FUNGOIDES. — This rare, but dangerous, skin disease shows two stages : there is first an itching erythematous rash, which may last for years ; then f ungating tumours form in the skin and become numerous and widespread. There is always great pruritus. The tumours have been compared to a tomato in appearance. After a long course the disease ends fatally, the patient being carried off at last by sepsis and exhaustion. Occasionally metastases appear internally. A few cases have been reported as having been cured by x-ray treatment. Reference. — Sequeira and others, Proc. Roy. Soc. Med., Dermatol. Sect., 1914. A. Rendle Short. MYELOID SARCOMA.— (See Bone Tumours.) MYOCARDIUM, PRIMARY DISEASE OF.— To say that the outlook in any case of valvular disease depends ultimately on the state of the cardiac muscle is to utter an obvious platitude. Yet there are degrees in the paramount importance of the myocardium. In the kind of case that is usually described as one of chronic valvular disease, the two factors to be assessed are the amount of extra work imposed on the myocardium by the valvular lesions, and the fitness or unfitness of the myocardium to meet that extra demand. On the other hand, there is a group of cardiac lesions that attack the musculature of the heart directly and immediately, either with or without a simultaneous injury to the valves and other accessories of the cardiac mechanism. In such cases the prognosis will have to be calculated in respect of two factors : (i) The course usually followed by the morbid process at work in that particular case ; and (2) The nature and extent of the injury to function discernible at the time of examination. I. — Prognosis according to the Particular Morbid Process Present. The primary diseases of the cardiac muscle maybe (i) Acute, or (2) Chronic. Those which constitute the former group are for the most part infective. I. Acute Infections of the Cardiac Muscle. — There are four acute infections in which myocardial lesions play a predominant part : diphtheria, rheumatic infection, typhoid fever, and influenza. Of these the rheumatic infection is the only one in which the valves and pericardium are also attacked ; and even here, these lesions do not attain to such a pitch of intensity during the active phase of the rheumatic process as to share prognostic importance equally with the damage which has been inflicted directly upon the myocardium by the infection. In diphtheria, it would appear that about 25 per cent of all the deaths are due chiefly or solely to cardiac failure. In other words, if the average mortality of this disease be reckoned at 10 per cent, there is a chance that one person out of every 25 attacked by diphtheria will die of cardiac failure. Sudden syncope is fairly frequent in cases carelessly treated. It is quite impossible to assess in figures the effect of antitoxin treatment in reducing these risks, but it is tolerably certain that the risk of cardiac failure is directly proportional to the intensity of the infection itself ; and since nothing is so potent as antitoxin in combating the virulence of the infective process, it follows that one of the chief benefits of the treatment lies in the fact that it interposes a kind of barrier be- tween the infected mucosa and the susceptible tissues of the cardiac wall. This is borne out by the fact that serious and fatal cardiac phenomena are much more often encountered in cases of diphtheria where antitoxin treatment has been 350 INDEX OF PROGNOSIS delayed than in those treated early. One other point that is of the highest import in the prevention of cardiac failure is the absolute necessity for care in regard to convalescence. A very large fraction of the fatal attacks of syncope occur during convalescence, after the severity of the infective process has died down. The patient is allowed to sit up too soon, and falls back dead. This calamity — one of the most distressing of experiences for the medical attendant as well as for the relations — can be averted by ordinary precautions : convales- cence must be prolonged, and the patient should be allowed to sit up by degrees only, one pillow at a time. It is especially important to realize that the condition of the patient immediately before such catastrophes have occurred has failed to give any forewarning of approaching danger, so that these precautions must be observed even in cases that are following a relatively favourable course. Acute rheumatic carditis is dealt with under a separate heading {see p. 447). In typhoid fever, the cardiac factor is probably of more importance than appears on the surface. It is, however, obscured by the nervous and other evidences of toxaemia ; and it is so unusual to encounter cases in which the chief clinical features are cardiac that these may be dismissed with the remark that sudden death occurs in a few cases of typhoid fever, but that the cardiac origin of such calamities is not definitely proved. Persistent cardiac disabiUty following typhoid fever is a neghgible quantity. True influenza is a rare disease in this country at the present time. Cardiac complications are very important, both in relation to the possibilities of a fatal termination, and also to the duration of the period of disability which is so apt to follow this disease. Sudden death has been known to occur, but it is excessively rare. On the other hand, persons whose cardiac musculature was damaged by arteriosclerotic or other lesions before the attack, are apt to find that influenza leaves them more conscious of cardiac disability than they were before the illness. Even those whose hearts were sound before the attack are often left with minor evidences of cardiac enfeeblement ; these symptoms usually pass off in the course of a few weeks, provided ordinary care as to work and rest is exercised. In other infections, such as lobar pneumonia, scarlet fever, and so on, symptoms and signs of myocarditis are often manifest ; but it is only as part of the general picture, the phenomena are mild as a rule, and death is never or almost never due to cardiac complications alone. 2. Progressive Degenerations of the Myocardium. — Here there is often an overlapping of etiological factors. For instance, you are consulted by a man with thick, contorted arteries, with a history of syphilis and signs of alcohoUsm. His cardiac enfeeblement is probably due in some measure to aU three factors ; but in what measure to any particular one ? So far as prognosis is concerned, the difficulty is to some extent mitigated by the fact that, whatever the cause may be, it is always possible to discover the state of the cardiac functions, and this is after aU more important than precise knowledge as to the nature of the morbid processes which are playing havoc with those functions. Yet in making a forecast in disease, it is necessary to know not only where we stand at the time of examination, but also what further progress along the downward path is to be expected. It is therefore imperative to make full inquiry into the causes in any given case of chronic myocardial degeneration. Of all the various factors, none is more serious than chronic alcoholism. The writer has found that it is always wise to treat with the utmost respect any case of chronic myocardial disease in which there is reason to suppose that the tissues have been long subjected to the deleterious effects of alcoholism. In many of these cases the serious nature of the myocardial disorder is plain to see, for the MYOCARDIUM, PRIMARY DISEASE OF 351 symptoms afford the clearest possible indications of failing contractility ; but even where this is not so, and the functions are not badly deranged, the fact that the patient has been in the habit of alcoholic excess bodes ill for his heart's chance of surmounting the tasks that lie ahead of it. Not only so, but there is this further disadvantage about the effect of long-continued alcoholic intemper- ance on the heart, that it persists after the cause has been removed. Or perhaps one can express it better in this way, that a man who has been alcoholic up to forty and abstemious since, will tend to run a quicker downward course if at the age of fifty he begins to manifest evidences of cardiosclerosis. It is nevertheless true that withdrawal of alcohol in any such case will affect the outlook favourably, the more definitely so if the cardiac symptoms are as yet trivial. Another fact of ominous significance in a case of progressive myocardial degeneration is a history or other evidence of syphilitic infection. This matter is more fully discussed under a separate heading {see Cardiac Syphilis) ; here it is enough to say that in any case of myofibrosis cordis it is the practitioner's duty to seek by every possible means for evidences of a luetic factor. This is particularly to be suspected in cases where the symptoms are severe and the physical signs disproportionately slight. Whenever there is reason to believe that the myocardial disease is in part due to syphilis, the prognosis is much graver than in an ordinary straightforward case of senile heart. This is true even of those cases in which there are none of the aortic lesions that constitute so characteristic a feature of cardiac syphilis. About 50 per cent of cardiac syphilitics die suddenly. The other factors which should be looked for in a case of the kind are those which injure the myocardium through the arterial lesions that they imitate. Of these, mere senility is the least grave. Many an elderly man shows signs of cardiac decay which have developed so slowly that the corresponding symptoms are scarcely perceived by the patient himself. He has to take his hills a little more deUberately than he used to do, but this gives no anxiety, since he regards it as one of the penalties of advancing years. Such a man should be told no more than this, that his heart is not so young as it was, and that he must be content to accept his breathlessness as an automatic index of the line separating what he may from what he maj'^ not undertake. That same growing old which is responsible for the signs at the time of examination is not likely to accelerate unless there be some definite force, over and above that of mere senescence, at work upon his arteries. Of the various types of overstress to which the heart is exposed, continuous emotional strain appears to be the most universally deleterious. The exact manner of its action is not understood, but no one who has seen many cases of cardiosclerosis wiU fail to recall examples of business or family worry accelera- ting the final debacle. The importance of physical strain as a factor in the causation of myocardial degeneration is a debatable point. One thing at least is clear, that overstress of a senile heart is hable to dire consequences much more often than an even greater burdening of the adolescent or j^outhful heart. Mitchell Bruce's Lumleian Lectures, delivered in 1911, contain a great deal of very useful infor- mation as to prognosis in cardiovascular degeneration. In the cases which supply the fundamentals of his discourse, he found that cardiac overstrain in the young and healthy did not shorten life much, if at all, for the average duration of life after the strain was 34 years, and the average age at death 66 years. Of other factors, high arterial tension is one of the most serious. A majority of such cases end in cardiac failure. There are three points to bear in mind in constructing a prognosis here, (i) If the hyperpiesis be attributable to some 352 INDEX OF PROGNOSIS provocative factor that can be checked, so much the better for the patient ; where it is due to something , such as manifest renal disease, that we can do Uttle to mitigate, the outlook is bad. (2) The actual height of the pressure matters less than its course. Other things being equal, a rising tension is bad ; it means an increase of the cardiac burden. Fall in the pressure is also a bad sign if it be accompanied by evidences of increasing cardiac inadequacy ; it proves that the heart is faihng in its prime duty, that of maintaining a steady supply of blood to the peripheral organs and tissues. (3) And this is merely another way of sajdng that a high pressure is not necessarily a sign of evil omen — the fact that treatment fails to bring down a raised tension is not in itself to be deprecated in every case. AU the organs, including the myocardium itself, depend on the maintenance of a steady blood-pressure for their nutrition ; and it is probable that in many cases a high pressure is essential to the sustenance of the cardiac muscle and its functions. Bruce, in the lectures already referred to, separates a ' metabolic ' group of cardiosclerotic subjects — obese, self-indulgent persons, with sugar and usually albumin in the urine. The cardiac phenomena of such patients tend to run a benign course, particularly if the bad ways of Uving be not incorrigible. The average period elapsing between the onset of cardiac symptoms and the patient's death was I2|^ years in Bruce's cases ; one patient lived for 32 years after the onset of symptoms. Of course it is necessary to recollect in this, as in renal cases, the possibihties of death from some non-cardiac cause such as uraemia or acid intoxication. A gouty element in the case is not in the patient's disfavour. On the other hand, a strong family history of cardio-arterial degeneration must be reckoned as an unhappy feature of the case. In the very obese it is common to encounter symptoms and signs indicative of myocardial inadequacy, and these are not to be under-rated. They point to an overloading of the subpericardial interstices with fat, which often infiltrates the muscle itself along its connective-tissue planes, crushing and starving the muscular fibres. Patients in this state are therefore iU prepared to cope with the emergencies of hfe ; they fail with undue ease in the presence of acute disease, particularly bronchitis and pneumonia. Two other factors remain for consideration — the patient's temperament and his circumstances. The worrying, splenetic individual makes a bad cardiac patient, and so does the man whose affairs are hard to escape from ; and the combination of the two, sometimes encountered in successful, pushing business or professional men, is particularly deadly. To such persons the inevitable advice — " Eat, drink, and smoke sparingly, work moderately, and worry not at all " — too often appears so impossible of accomplishment that it is disregarded, and downfall ensues. So much for the place of etiology in the prognosis of myocardial disease. II. — Influence of the Nature and Amount of Functional Injury SHOWN at Examination. We must next consider the relative importance of symptoms and physical signs, and in order to arrive at a proper understanding of their significance it is essential to reahze they are merely means to an end — the assessment of the capacity of the cardiac muscle to do its work. Now, the chief end of the myocardial tissues lies in the ventricular contractions ; it is to perform this task that the heart exists. Therefore the gravest features of myocardial disease are those which point to impairment of the contractility of the ventricles. Whatever the cause of the trouble, this holds good. MYOCARDIUM, PRIMARY DISEASE OF 353 Impairment of Contractility of Ventricles. — We come here to a fact that has not yet received all the attention which it deserves, despite all the teachings of the past twenty years : the fact that symptoms afford a more reliable basis for the estimation of ventricular contractility than physical signs. First among these symptoms is breathlessness. Often it is the first to be noticed, and the ease with which it is evoked constitutes an excellent gauge of the state of the ventricular wall. At first it is only noticed when the patient puts himself to some unusual exertion, such as climbing a hill or hurrying to catch a train. By degrees his field of cardiac response, to borrow Mackenzie's phrase, becomes more and more limited, till walking on the flat becomes a difficult task. Other things being equal, the more readily the patient's breath fails, the worse the prognosis. There are also various forms and degrees of paroxysmal dyspnoea, the signifi- cance of which is important in respect of prognosis. When a person with myocardial disease develops Cheyne-Stokes breathing, it does not of necessity forebode evil. For example, an elderly man with elderly arteries and some cardiac enlargement is found to exhibit Cheyne-Stokes breathing during sleep : here it is of little significance unless other signs of contractile failure begin to be manifest or the respiratory periodicity itself become rapidly more and more definite. Grouping of the respiratory movements is of importance only when it is one of a group of symptoms suggesting gradual shrinkage of ventricular contractility. When we come to an aggravated degree of the same kind of phenomenon, however — to the various forms of periodic dyspnoea with subjective distress which are grouped together within the term ' cardiac asthma ' — a graver condition is encountered. If a patient with chronic myocardial disease begins to be afflicted with attacks of respiratory distress, coming on chiefly at night, this is in and by itself a sign of impairment of the contractile power of the ventricle. It appears from recent work by Lewis and others that the actual cause of this type of dyspnoea is an acidosis dependent on deficient oxygenation of the blood. To accept this explanation affords a basis for the indubitable fact that the more extreme the dyspnoea the worse the prognosis. The writer has observed cases of chronic myocardial disease in which the approach of the end has been foreshadowed by the development of a periodic dyspnoea more or less continuous, and amounting in its intensity to a veritable air-hunger, in association with other evidences of acidosis — ethereal smell in the breath, vomiting and diarrhoea, delirium, and other nervous symptoms. As part of such a syndrome as this, the periodic breathlessness is as grave a feature as can be. Where heart- block is present, various degrees of grouped disturbance of the respiratory rhythm may occur ; these are usually proportional to the degree of block present, and do not therefore furnish any index of the amount of impairment of contractility. The significance of cardiac pain as a sign of defective contractile power has beeA fully considered under the heading of Angina Pectoris, so that httle time need be devoted to it here. Suffice it to say that the appearance of cardiac pain in any case of myocardial disease, whether the lesion be acute or chronic, is always a serious matter, because it portends inadequacy of the ventricles' power to contract. The actual importance of pain as a quantitative index of contractile failure is conditional on several considerations. First, how easily is it provoked ? Second, how easily is it relieved, particularly by vasodilators ? Third, what other evidence is there of myocardial disease ? Fourth, how severe is the pain ? The order of these questions is roughly that of their relativd importance. Angina must always be regarded as a symptom and not a disease, significant from the prognostic standpoint not for its own sake but by virtue of that which it reveals. 354 INDEX OF PROGNOSIS A symptom which is held in great awe by the pubhc as evidence of cardiac danger is the liability to faint. Now this view is certainly not supported by clinical experience, which shows that this particular symptom, so far from being an important sign of myocardial decadence, is rarely associated with cardiac disease at all. It is true that a man seized with an anginal attack will often faint as a result of the pain which he endures, and that the myocardial patient may die suddenly : but apart from these two catastrophic types of faint, which are seldom foreshadowed by less minatory degrees of syncope, the cardiac patient is little if at all more prone to faint than the ordinary individual. The fainting attacks of children, which have so often led to an unfortunate statement about a weak heart, are nearly always attacks of minor epilepsy, and have nothing whatever to do with heart disease. Dropsy is an accurate index of impairment of contractihty in disease of the myocardium, but it takes a little time to develop, so that it is seldom in evidence in acute myocarditis. But in the chronic degenerations of the cardiac muscle it is an almost constant feature, in the later stages if not before. Its value as an indicator of failing contractile force is to be found by a consideration of the extent and depth of the oedema, its rate of development, and its behaviour under the influence of rest and other therapeutic measures. In this connection it is well to remember two things. First, nothing but actual personal examination of the patient's ankles should suffice to convince one as to the presence or absence of oedema ; and second, the word ' dropsy ' is very alarming to many patients, and should therefore be avoided as far as possible. There are also two fairly obvious precautions to observe before attributing cEdema of the legs to cardiac disease. First, every means must be used to assure oneself that it is not a renal dropsy, and this should comprehend thorough examination of the urine, including microscopic examination of the centrifuged deposit. Second, the possibihty of some associated cause of oedema, such as varicose veins or fibroids of the uterus, should not be forgotten. Even after all precaution has been exercised, however, it is sometimes impossible to determine whether oedema is partly, mainly, or wholly cardiac ; or whether it does perhaps owe its origin to coincident renal or other disease. When such difficulties arise, the importance of oedema as a quantitative index of loss of contractihty is to some extent discounted, and we must be content to assess our patient's future fortune by such other means as are at our disposal. The daily output of urine shrinks with failure of contractility, and increases again under successful treatment. Whenever possible this must be accurately measured and charted. There are few symptoms of more definite prognostic value than this in cases of myocardial disease that have reached the stage at which rest in bed and continuous observation are necessar5^ A symptom which may appear near the end, especially in cases of acute myocardial damage, is vomiting ; it is not uncommon in the severe forms of cardiac rheumatism and diphtheria. In such cases it is nearly always associated with other evidences of approaching cardiac failure, and is a sign of the very gravest significance. In diphtheria, the children who vomit usually suffer from epigastric pain, and display a bruit de galop, the majority dying within two or three weeks of the onset. The pulse furnishes two useful indications of contractile failure. The alternating pulse and its prognostic import are discussed in the article on Pulse, Irregu- larities OF, but here its paramount importance as a sign of failing contractility must be insisted on. Although it is true that people maj'^ live for years after this type of variation has been first noticed, yet it is always a mark of grave myocardial degeneration. The other pulse change which argues the same thing MYOCARDIUM, PRIMARY DISEASE OF 355 in a person whose heart muscle is diseased is progressive quickening. If there is no extrinsic factor, such as pyrexia, to explain this away, it is an ominous proof of increasing incompetence of the ventricular wall to perform those vital duties that are expected of it. In an adult with myocardial disease, a pulse running persistently at over 120 per minute is a signal of immediate danger. Among the physical signs indicative of contractile failure, there are two that are of some prognostic value. The first of these is perhaps seldom appreciated at its true value — weakening of the cardiac sounds. In acute rheumatic heart disease, for example, it is almost possible to measure the unhappy progress of the myocardial enfeeblement by the softening of the first sound at the apex ; in the great majority of the cases of this description where a pericardial rub is or has been heard, weakening of the first sound at the apex is a sign of severe myocarditis, and not of pericardial effusion. In the other acute infections, such as typhoid fever, it may be almost the only indication of approaching ventricular failure. Of course, the intensity of the first sound varies widely according to the thickness of the chest-wall and other factors, in which difierent individuals difier widely from each other ; so that it is not safe merely to compare the heart sounds of any one person with an imaginary general standard. The comparison should rather be between the first sound at the apex and the second sound at the base ; or between the sounds as heard on one day as compared with their intensity a day or two later. At the same time it is legitimate, and indeed highly necessary, to recognize the prime importance of feeble heart-sounds in a person with average thoracic walls, in a case of myocardial disease. The appearance of the gallop rhythm points in the same direction. In saying this one does not of course include the cases, common in childhood, in which a close imitation of the true bruit de galop is produced by a combination of reduplication of the second sound with rapid action of the heart. True gallop rhythm is always a sign of ventricular inadequacy, one of those valuable hints which must be interpreted as serious even when there is little collateral evidence to support such an interpretation. To exemplify this point : a short time ago a woman came into the writer's out-patient room complaining only that she felt run down. Examination of the chest disclosed the presence of a bruit de galop, and the urine was found to be that of subacute nephritis. Chiefly on the strength of the gallop rhythm, the woman was strongly urged to come into the hospital, but she postponed her decision ; within a week she died suddenly. And this sign is ominous when it appears in cases of acute infective disease. One does, it is true, come across cases in which recovery ensues even though there has been a gallop rhythm ; but such are the exceptions. Finally, certain changes in the lungs portend a speedy dissolution, because they are also evidence of waning contractility. Of these, two stand pre-eminent — acute pulmonary oedema and infarction of the lung. The former is an almost constant feature of the last phase in cases of acute rheumatic carditis doomed to early death. Infarction is more often recovered from than acute oedema. Hydrothorax is also a bad feature of a case of chronic myocardial disease, partly because it proves a weak muscle, and partly because it adds a new embar- rassment to the act of respiration. A sign of approaching cardiac failure to which Mackenzie has drawn attention is the development of fine crepitations at the bases. This, if looked for, is a valuable forewarning of difficulties, which may be averted by timely insistence on a period of rest. As Morison points out, these crepitations appear and disappear according to the patient's changes of posture, always appearing in the most dependent part of the lung. All these phenomena owe their serious import to the fact that they arise from impairment of the contractile force of the ventricles, the very thing for which 356 INDEX OF PROGNOSIS the heart has been evolved and on which hfe depends. The gravest generalization that can be made about any case of primary myocardial disease is that there is evidence of failing of the contractile force of the ventricles. Impairment of Tonus. — As to the other myocardial functions, it may seem a splitting of straws to differentiate between contractility and tonus, but so far as prognosis is concerned there is certainly a difference, if we regard as signs of lost tone the appearance of a systolic murmur of mitral incompetence, and ventricular dilatation. Many a case of cardiosclerosis in which there are most definite and threatening signs of exhausted contractility goes on to the end with little or no dilatation. Indeed, in such cases the appearance of a mitral systolic murmur, denoting failure of tone in the muscular tissue of the auriculo- ventricular ring, may be attended by actual relief of the symptoms, possibly because the overtaxed ventricle is thus freed of some of the mass of blood to be lifted by each systole. Each of these phenomena, ventricular dilatation and mitral incompetence, demands separate and detailed consideration. The important aspect of dilatation, so far as prognosis is concerned, is its course rather than its extent. Rapid stretching of the ventricle in acute disease is an untoward feature, because it proves that the muscle is thoroughly saturated with poison ; but it carries no immediate threat of dissolution, unless there are simultaneous signs of impaired contractility. In acute rheumatic carditis, for instance, it is remarkable how large the heart may become without remaining so permanently or killing the patient. Even in so insidious a disease as cardio- sclerosis, acute dilatation may prove temporary, though of course this is exceptional. Generally speaking, the more rapid the enlargement of the heart, the worse the prognosis. Again, it will go worse with the patient if dilatation persists in spite of treatment, for two reasons : because it argues profound injury to the cells of the cardiac wall, and because a permanent increase in the cubic content of the ventricle imposes a correspondingly increased burden of blood for the ventricle to lift at each systole. As to the mitral systolic murmur that so often makes itself heard in primarily muscular cases of heart disease, there can be no question that in such it owes its origin to a fall in the tonicity of the muscle which forms part of the mitral ring. What, then, is its prognostic significance ? It is remarkable to find how close an agreement there is as to its unimportance — whether in the chronic or in the infective lesions of the myocardium — among those who have made a systematic study of the point. The only weight it can be said to carry is that it sometimes serves to confirm a diagnosis of heart disease that would otherwise rest on .•suspicion only. In diphtheria. White and Smith, of Boston, U.S.A., who made A statistical study of nearly a thousand cases, found that the presence of a systolic ibruit at the apex added nothing to the gravity of the prognosis, even when the iniurmur persisted long into convalescence. Over and over again Mackenzie ;and other systematic writers on myocardial decay have of recent years insisted on the same fact, that a mitral systolic murmur adds nothing to the gravity of the case. Indeed, the sense of many of these writings is to the effect that patients with syphilitic, atheromatous, and other chronic diseases of the cardiac muscle do better if to the evidences of diminishing contractile power there be added signs of ventricular dilatation, or a mitral systolic murmur, or both, than if the case be marked only by evidences of lessened contractility. It follows from this, that the loudness of an apical bruit is no criterion of the seriousness of the case : except, perhaps, in the direction opposite to that which might at first seem obvious, for it is certainly reassuring to discover in what looks otherwise like a very severe case, say, of cardiac diphtheria, a loud murmur at the apex. In such a case we accept it as welcome proof that the heart still MYOCARDIUM, PRIMARY DISEASE OF 357 possesses some contractile force. Finally, it is a mistake in treatment to keep patients in bed after acute illness until the murmur which it has caused has disappeared. It may persist for weeks or months, and such long confinement to bed does the patient far more harm than good. Disturbances of the Other Functions of the Cardiac Muscle. — The rhythmic production of stimuli, the capacity for excitation by those stimuli, and the function of conductivity are all considered fully in the article on Pulse, Irregularity of. There are two types of irregularity that do not matter — sinus irregularity and extrasystoles — the latter being so common in cardiosclerosis as to be almost the rule. It is well worth while to realize the absolute insignificance of the extrasystolic type of arrhythmia : many an elderly man is needlessly and indeed hurtfully " cabined, cribbed, confined " in his activities by a medical attendant who is frightened by discovering that the pulse is irregular, without perceiving that the irregularity is of the unimportant kind. Paroxysmal tachycardia has rather more significance, for on the one hand it proves the existence of an abnormally irritable focus in the diseased heart wall, while on the other it adds the burden of excessively rapid work to that which the imperfect ventricular muscle can barely undertake. This extra stress reveals itself during the attacks in several ways ; the heart becomes rapidly dilated, the legs may swell, the patient is cyanosed and distressed, and the pulse may even become alternating. The gravity of the outlook is obviously enhanced in any given case of myocardial disease when there occur paroxysms of tachy- cardia with such dire effects ; and their serious import is to be measured in terms of the readiness with which each attack exhausts the heart. Information as to this is yielded by observation of the behaviour of the heart during the paroxysm, and also by its condition after the attack is over. The condition of auricular flutter is transitional, both in nature and importance, between that of paroxysmal tachycardia and that of auricular fibrillation ; probably its worst possibility is that it may pass over into the latter. Fortunately it seems often to yield to digitalis. The totally irregular pulse of auricular fibrillation is always an unwelcome feature of myocardial disease, whether acute or chronic. It means that the cardiac muscle has reached a certain point in its downward career, from which it can never recover permanently. Patients with primary muscle disease of the heart who develop this type of arrhythmia fare worse than those in whom it constitutes a late phase of chronic mitral disease ; in the former, the ventricle is less able to cope with the rapid irregular stimuli handed down to it by the auricle than in the latter, for the cells of its wall are already barely fit to carry on their systolic task. Much depends in this, as in auricular flutter, on the response of the heart to digitalis treatment, which should receive a proper trial before a bad prognosis is arrived at ; if a course of full doses of this drug, given under suitable conditions, fails to relieve the dyspnoea and slow the pulse, then the prognosis is indeed gloomy. Hay points out that the reaction of the heart to the new rhythm (or want of it) should be observed ; by this means some gauge of the ventricle's capacity to stand the strain will be forthcoming. He also remarks that those cases in which the irregularity and its attendant disabilities come on suddenly and without premonition do worse than those in which the onset is more gradual. The majority of myocardial decadents do not survive the onset of this irregularity for more than three years. The presence of signs of interference with the conduction of impulses from auricle to ventricle (lengthening of the a-c interval, heart-block of various grades) adds to the severity of the prognosis ; and the greater the degree of interference 358 INDEX OF PROGNOSIS the more is this the case. The presence of heart-block in any case of cardiac disease proves that there is a gross lesion of the deep myocardium. In acute infective disease this block nearly always turns out to be transient, so that it does not -warrant a gloomy view of the case on its own account ; but in the chronic myocardial degenerations it is otherwise, for here the lesion of conduc- tivity is nearly always progressive or at least permanent, and except in some syphilitic cases, it is not influenced by treatment. Even so, however, an absolutely bad prognosis is not warranted ; for on the one hand the heart-block may interfere but little with the efficient emptying of the ventricles in systole, while on the other there is always just a chance that it may pass off after an undeterminable interval and reappear no more. It is always important not to allow the heart-block to make one forget the other features of the case ; for the prognosis depends on a reasonable consideration of the state of all the cardiac functions, and the influence of all the disturbances encountered on the power of the heart to carry on the circulation in an efficient manner. The Likelihood of Sudden Death in primary disease of the myocardium depends on two things. It may occur as a result of rupture of the cardiac wall or gross interference with a part of the myocardium due to thrombosis or embolism ; or it may much more commonly result from an exhaustion of the contractile power of the ventricular muscle. We are forewarned of the former type of possibility by pericardial friction or rapid enfeeblement of the heart's action, especially if it follow close on the heels of an anginal attack. Attacks of this kind — anginal pain, rapid weakening of the cardiac sounds, with pericardial friction — occurring in cases of chronic myocardial disease, warrant the gravest prognosis. The majority of such cases terminate fatally within a few days ; and even if he survive, the patient's future career must be guarded with the utmost care. The evidences of failing contractile power have been fully described above, and it need only be repeated that the chief end of the heart is to contract efficiently, so that anything which suggests an encroachment on this function is a grave feature of the case. The whole art of prognosis in heart disease lies in the ability of the physician to discover whether this power is threatened or not. The Influence of Treatment on prognosis is unhappily small, apart from those points that have already been mentioned by the way. It is no use flogging a tired horse, and not much good can be derived from the saturation of a diseased myocardium with tonic and stimulant drugs. The lines along which most preservation of life is to be effected in these cases are (i) Grappling with the cause ; and (2) Saving the heart from overstress, especially of the sudden type. Carey F- Coombs. MYOPATHIES. — [See Muscular Atrophies.) MYOSITIS OSSIFICANS. — Two conditions pass under this title, the one a generalized slow ossification of muscles all over the body, producing a so- called ' brittle man,' and the other a newly described disease in which, after a fracture, a mass of bone forms in the neighbouring muscles owing to dissemination of osteoblasts. Generalized Myositis Ossificans is rare, lasts many years, and shows alternate periods of advance and arrest. It always ends fatally, lasting about ten or twelve years. The termination is usually due to pulmonary troubles from fixation of the chest. Traumatic Myositis Ossificans has only come into prominence since the intro- duction of massage and movements in the treatment of fractures, and the use of skiagraphy for diagnosis. The commonest site for the mass of bone is in NASAL ACCESSORY SINUSITIS 359 the substance of the brachiahs anticus after an injury of the lower end of the humerus or dislocation of the elbow. The writer has seen it in the gastro- cnemius in association with fracture of the condyle of the femur. The hard mass in the muscle can be moved upon the underlying bone. It usually appears some weeks or months after the original injury, and may cause severe limitation of movement. The prognosis depends to a considerable degree on the treatment. Early removal by operation usually leads to recurrence, and no benefit is obtained. During the first few weeks or months, absolute fixation with a plaster case or splint appears to give the best results. After the ossification is complete and the bony mass has settled down, it may be removed, but not until several months have elapsed. Schulz gives the German Army figures for the years 1897-1907. Ninety- nine were operated on, of whom 26 per cent were invahded out of the army ; 313 were treated by sphnts, etc., of whom i6-6 per cent were invaUded out. It must be remembered, of course, in comparing these figures, that naturally the worst cases were treated by operation. When the original injury affects the joint, the outlook is much graver than when the bone was broken. Thus, of cases operated on for this form of myositis ossificans by Chabrol, there were 95 bone injury cases, of which 77 were cured, 15 better, 3 no better ; and 25 following dislocation, of which 8 were cured, 8 better, and 9 no better. It will be wise, therefore, to trust to rigid fixation in the dislocation cases. The time occupied by the treatment varies, but is seldom less than three months, and may be much longer. Reference. — Lapointe, Rev. de Chirurg. 1912, 657. A. Rendle Short. NASAL ACCESSORY SINUSITIS.— The risk to life in suppuration of the accessory sinuses, whether acute or chronic, is only slight. In more than 25,000 post-mortems, such suppuration was the cause of 18 deaths, while in the same series, aural suppuration was responsible for ten times that number.^ Acute cases usually resolve, either without any treatment, or with minor operative measures. Such resolution may be delayed for weeks or months, and then take place without operation. Measures apphcable to all sinuses, both with and without operation, are the injection of vaccines and the local injection of bismuth paste. Vaccine Treatment. — In acute cases, vaccines are usually contra-indicated. The following results were obtained in chronic cases ; in the majority, however, some operative measure was also employed. Results of Vaccine Treatment in Chronic Nasal Accessory Sinusitis. Reporter Harmer^ Logan Turner^ Allen^ - Birkett* Levy* - Patterson* - Brawley* Cases treated 41 5 30 4 15 11 10 Total 116 14 2 20 6 1 4 47 (or 40 per cent) 13 (or U per cent) 36o INDEX OF PROGNOSIS All of the cases reported as cured had been recently operated upon, so that it is impossible to say how much credit should be given to the vaccine. Vaccines are useless as a substitute for operation. They may be of some slight help afterwards, but even this is not certain. Bismuth Paste. — Injections of this paste into the diseased sinus, as advocated by Beck,* may hasten cure after operation, but, hke vaccines, they are not a substitute for it. We shall now proceed to consider the results of the operative treatment of each sinus in detail. Maxillary Sinus. — The majority of acute cases resolve, even without treatment. Complications are rare, and fatalities almost unknown. Treatment consists in the washing out of the cavity through the inferior meatus with trocar and cannula, combined with the application of vasoconstrictors to the nasal mucosa to promote drainage. Cure, in a really acute case, is almost certain under treat- ment. Chronic cases seldom, if ever, recover spontaneously. The treatment is operative, and alternative methods are : (i) Nasal puncture and lavage through trocar and cannula ; (2) Alveolar drainage ; (3) Intranasal operation (Claone) ; (4) Radical operation through the canine fossa (Caldwell- Luc). 1. Nasal puncture and lavage through trocar and cannula is an unsatisfactory method in chronic cases. A cure can sometimes be obtained, but only if the puncture is repeated a large number of times. Thus, Koenig and Mahu® record cases cured by twenty-seven and fifty-four punctures respectively. The majority of patients, however, would object to so many repetitions of any operation, even if very slight. 2. Alveolar drainage, by the insertion of a tube through a perforated tooth- socket, with subsequent washing out, was formerly the accepted method. A fair proportion of cases can be cured by this means. Tilley,' out of 27 cases, obtained a cure in only 5, whilst Logan Turner* records cure in 62 out of 113 cases, a total percentage of 47. 3. The intranasal operation consists in making a large opening into the antrum through the inferior meatus of the nose. The results are better than those of the alveolar operation. Logan Turner* records 44 cures in 55 cases treated, Goning' 21 in 23, Rethi^" 90 in 100, and Parker^^ 12 in 15, a total percentage of cures of 81. Claone*, the originator of this operation, claims that it vdW cure 80 per cent of cases. 4. The radical canine operation consists in making a free opening into the cavity through the canine fossa, curetting the lining membrane if necessary, and then making a free opening from the antrum into the nose. This operation is the most certain in its results. Tilley gives 34 cures out of 37 cases, and Logan Turner* 12 out of 12. Cure will be obtained from this operation in something over 90 per cent of cases. Objections to it are, the fact of its being a more severe operation than any of the others, the occasional post-operative neuralgia or anaesthesia from injury to the infra-orbital nerve, and the anaesthesia of teeth froni the division of the nerves supplying them. To sum up : Repeated nasal puncture and alveolar drainage are unsuitable, the former because of its uncertainty and necessity' for repetition, the latter because a cure is not obtained in more than half the cases. In favour of the intranasal operation is the fact that it is a slight one, and can, if desired, be performed under local anaesthesia. The canine operation gives a better chance of cure (over 90 instead of 80 per cent), but it is more severe, and more likely to give rise to troublesome sequelae. Logan Turner''^ has shown that cases with an excess of lymphocytes in the NASAL ACCESSORY SINUSITIS 361 discharge are more resistant to treatment, and should therefore have the more radical operation. Frontal Sinus.- — Although fatalities are rare, they occur more often in affec- tions of this sinus than of any other. The risks are either an intracranial infection (abscess or meningitis), or infective osteomyelitis of the cranial bones. Acute cases, in the absence of complications, are readily cured by intranasal treatment. Coagleyi^, in a total of 58 cases, obtained a cure by intranasal methods in 54, or 93 per cent ; 2 cases died, or 3-4 per cent. This is probably a higher rate of mortality than the normal, only the more severe cases getting to the specialist for treatment. Chronic cases are very much more difficult to cure ; but the mortality, apart from operation, is very slight. Treatment is operative, and the alternatives are : either (i) Intranasal methods to improve drainage and allow of washing out ; or (2) One of the many varieties of external radical operation. 1. The intranasal method consists in a partial or complete removal of the middle turbinal bone, and opening of the portion of the ethmoidal labyrinth which is in relation to the nasal opening of the sinus. The operation has only recently been used to any large extent. Coagley,^* from an experience of 79 cases, records 14 per cent cured, and 51 per cent improved. Gruner^^ gives 16 cures out of 18 cases. Ingals,^^ from an experience of 39 cases, concludes that a cure can be obtained in 95 per cent. Watson Williams^' has operated on 48 cases, with cures in about 50 per cent, and i death. Tilley,^' in an experience of 30 cases, has obtained cure or relief in " a majority of them." Thus, the operative mortality in these 216 cases is only 0-46 per cent. If by cure is meant freedom from all discharge, as well as relief from symptoms, it is only obtained in a minority of cases. Probably from 50 to 75 per cent are reheved from all troublesome symptoms. 2. The external radical operation, as exemplified by the Killian method, aims at obliteration of the sinus. It was performed much more frequently a few years ago than at present. Results of External Radical Operation for Frontal Sinusitis. Reporter Cases treated Cured Improved Died Lindtis .... Hornis Hosca!" .... Watson Williams" - Marshik^^ .... Von Eicken^ 21 28 34 28 100 11 22 32 11 8 15 1 2 3 3 Total 265 — — 9 (or S'4 per cent) Thus, out of 265 cases, the mortality from the operation was 3-4 per cent. In III of them in which the result is recorded, a cure was obtained in 67 per cent, and improvement in 26 per cent. In addition to the risk to life, the external operation always gives rise to more or less deformity, and may be followed by complications. Skillern,- in a review of his 20 cases, has found some unpleasant after-results in nearly all, ranging from paralysis of the upper lid and anaesthesia of the forehead, to blindness on the operated side from injury to the optic nerve. To sum up : In the presence of such complications as orbital abscess, the external operation is essential. In other cases, the intranasal operation, with 362 INDEX OF PROGNOSIS a mortality of about 0-5 per cent, will relieve symptoms in some 50 to 75 per cent, and has no unpleasant sequelae. The radical external operation has a mortality six times as great, gives rise to deformity and other complications, but will ensure relief or cure in 80 to 90 per cent of cases. Ethmoidal and Sphenoidal Sinuses. — Suppuration of either sinus may cause death by meningeal involvement ; or, in the case of the sphenoidal sinus, by a septic thrombosis of the cavernous sinus. Either event is rare, but StClair Thomson^* has collected 40 deaths as a result of sphenoidal sinusitis. Both conditions usually occur together and associated with suppuration in the frontal sinus and antrum. A cure will usually result when the cavities are freely opened intranasally ; but, in the case of the ethmoidal cells, anatomical conditions sometimes prevent this being satisfactorily performed without undue risk. References. — ^Treital, Berlin klin. Woch. li, 1139 ; Wertheim, Arch. f. Laryngol. Bd. II ; Pitt, Brit. Med. Jour. 1890, i, 643 ; *i7th Int. Cong. Med. 191 3 ; ^Bacterial Diseases of Respiration ; '^Laryngoscope, igio ; ^Ibid. ; ''Rev. Hebd. de Laryngol. 1906, April ; ''Jour, of Laryngol. xix, 74 ; ^Edin. Med. Jour. 1908, Oct. ; ^Gaz. Hebd. des Sci. Med. 1912, April 21 ; ^°Arch. Internat. de Laryngol. 1910, Sept. ; ^^Brit. Med. Jour. 1908, Oct. 10 ; ^^Edin. Med. Jour. 1910, April ; ^^Trans. Am. Laryngol. Assoc. 1905 ; ^^Ibid. ; ^^Arch. f. Laryngol. Bd. 24 ; ^^Laryngoscope, 1910 ; ^Troc. Roy. Soc. Med . 1914, May ; ^^Deut. Zeit. f. Chir, Bd. 116 ; ^^Calif. State Med. Jour. 1912, Feb ; ^Zeit. f. Ohren. Bd. 61 ; ^^Proc. Roy. Soc. Med. iqii, May ; ^^Rev. Hebd. de Laryngol. 1910, i ; ^'■'V erhandl. Deutsch. Natur. u. Artze, 1908 ; ^^Trans. Med. Soc. Lond. 1906, xxix, 14. A. J. Wright. NEPHRITIS, Acute Nephritis is always a serious disease which demands a guarded prognosis ; yet there is a natural tendency to recovery, and in many cases recovery does take place, with apparent return to normal kidney function. Some authorities hold, however, that complete recovery is more apparent than real, and that a kidney, once attacked with acute inflammation, is left permanently weak and Hable to recurrence of inflammatory disease : this is particularly well illustrated in the case of scarlatinal nephritis. In considering prognosis in a given case, the first essential is to establish the diagnosis of acute nephritis, and to eliminate the existence of an acute exacerbation in the course of a subacute or chronic nephritis. Diagnosis may be easy in private practice, if the physician is familiar with the patient before the onset of his illness ; but, when seen for the first time during the attack, diagnosis may present difficulties. An acute onset, with possibly some fever ; a urine small in amount, of high specific gro-vity, containing copious albumin, blood, and numerous tube-casts ; an absence of definite cardio- vascular changes : these point to an acute nephritis. If cardiovascular changes are recognizable, the physician is bound to suspect the existence of an acute exacerbation in the course of a chronic nephritis. An estimation of the quantity and specific gravity of the twenty-four hours urine will, at times, give assistance. If the amount be about the normal, and the specific gravity a little low, an under- lying chronic condition should be suspected, and a guarded prognosis given. Unfortunately for diagnosis, acute nephritis does not always show the frank onset as given in the text-books, but may begin insidiously, and be only discovered when its existence for some time has led to feelings of ill-health, and on examin- ation of the urine the presence of albumin and blood is discovered. In such cases, the diagnosis is often difficult, and the ultimate prognosis does not seem to be so favourable as when the onset is sudden and frank. The patient's history may aid by putting the physician on his guard ; previous headache, polyuria, frequency of micturition at night, point to a chronic lesion. In health, as is well recognized, the amount of urine secreted during the twelve hours of day is three to four times the amount of that secreted during the twelve hours of night. In NEPHRITIS 363 certain diseased conditions, and especially in chronic nephritis, this ratio is altered, and the quantity of night urine may equal, or even exceed, the quantity secreted during the day. This leads to a complaint of frequency of micturition at night, a complaint which may be one of the first symptoms for which advice is sought in chronic interstitial nephritis. If the diagnosis of acute nephritis be established, what are the patient's chances of complete recovery, and what of the duration of the disease ? The statistics of the Royal Infirmary, Edinburgh, show that, during the years 1904 to 19x2, 400 cases of nephritis, diagnosed as acute, came under treatment. Of these, 1 85 were discharged as cured, giving a percentage of cure as 46 ; while 140 were discharged as ' relieved,' i.e., had passed into a subacute or chronic condi- tion, with relief of symptoms, but liable at any time to a relapse, with an acute exacerbation of their chronic disease. The mortality in the 400 cases was 51, or 12 per cent. Such statistics, though they cannot be strictly applicable to nephritis in private practice, are, tnevertheless, far from reassuring, and show how guarded the prognosis must be. In giving a prognosis, the practitioner is guided by the severity of the attack and the cause of the affection. Thus, the acute nephritis of scarlet fever, and the true acute nephritis of diphtheria, may be, and often are, very rapidly fatal. On the other hand, in a considerable number of cases of nephritis not consequent upon a specific infection, the acute symptoms subside, the albuminuria may disappear, and the patient may be discharged as cured after an average stay in hospital of six weeks. Even then prognosis must be guarded ; for subsequent attacks are common, and the inflammatory affection does not clear up with the same facility on the second occasion. The principal factors which influence prognosis during the acute stage are : the amount of urine which the kidneys are capable of secreting ; the condition of the cardiovascular system ; the presence or absence of uraemic symptoms and secondary inflammatory conditions. When the quantity of urine is reduced to a few ounces of a highly albuminous, blood-stained fluid, or when there is complete anuria, prognosis is very grave. Complete anuria is said by some to be necessarily fatal ; but, while this is commonly true, it is not universally so, as cases are recorded, and it is the writer's experience, that recovery may take place after from twelve to fourteen hours, or even more, of complete suppression. The condition of the cardiovascular system merits careful consideration. A frequent, irregular pulse, with evidence of loss of myocardial tonicity, is always of grave import. The gravity of the condition will be accentuated if haematuria, or possibly haemorrhage from the alimentary canal, has led to any considerable anaemia ; in fact the presence of marked anaemia may turn the scale against recovery. Pericarditis is usually a terminal phenomenon, and is commonly of streptococcal origin. Urcsmia is a common cause of death, especially, according to Dickenson, in patients over sixteen years of age ; in younger patients, inflammations of the respiratory tract are even more fatal than uraemia. CEdema of the lungs and of the glottis are very grave phenomena, which may appear with great sudden- ness, and prove fatal in a few hours. The question of prognosis in acute nephritis is always difficult and uncertain. Most surprising recoveries may take place. Equally surprising and disappointing fatalities may occur, say, from a uraemic convulsion in a patient who, casually examined, does not appear to be in a critical condition. As with treatment, so with prognosis ; every case must be carefully studied, considered on its own merits, and due weight given to the more important factors. Amongst other factors, consideration must be given to response to treatment. Favourable signs 364 INDEX OF PROGNOSIS in the early stages are an increase in the quantity of urine and a diminution in the oedema; in the later periods, diminution in the albumin, blood, and formed elements in the urine, and a definite diuresis. When improvement is taking place, not only is there an increase in the quantity of urine and a diminution in the amount of albumin, but a change takes place in the character of the deposit : epithelial cells and free blood-corpuscles become less numerous, and epithelial and blood-casts are gradually replaced by the hyaline and granular varieties. It has been suggested that some prognostic value can be attached to the size, and especially to the breadth, of the tube-casts found in the deposit — large broad epithelial casts showing a profound desquamation of the tubules, — but it seems very doubtful if reliance can be placed on this factor. At times, in the course of an acute nephritis, improvement seems to take place — albumin diminishes, the urinary quantity returns to about the normal — but the patient remains somewhat anaemic, a little oedema may be found about the eyes and ankles, the centrifuge shows the presence of granular and fatty casts, and, after a time, the radial artery becomes faintly palpable. Such a patient is passing into a condition of subacute diffused nephritis, and ultimate recovery seems doubtful. Particu- larly disappointing are cases where improvement is, at first, apparently rapid, the urinary amount returns to the normal, with only a trace of albumin, and casts are difficult to find, even with the centrifuge : yet, whenever the diet is altered from the minimum of protein and the maximum of carbohydrate and fat, a fresh exacerbation takes place, accompanied by haematuria. In such cases, the kidneys have been so damaged that they cannot undertake a reasonable amount of work, and the chance of ultimate recovery is not good. Yet, in acute nephritis, even when apparently of a hopeless character, there is always a chance of recovery, which encourages the physician to persevere in therapeutic measures. The writer well remembers the case of a young man who had been ill for two months. The urine was greatly reduced in quantity, and contained copious albumin, blood, and tube-casts of all varieties. There was universal anasarca, so marked as to require draining : Southey's tubes were introduced into the legs, and a trocar into the abdomen. For five days the patient lived on a nitrogen- and chloride-poor diet, and passed most of his time seated on the edge of his bed with the feet dependent, draining continuously, the tubes being changed from time to time. With the disappearance of the oedema there was rehef of the circulation, the rested kidneys regained their functional activity, and within a few months the patient passed an Army Board for a commission in India. One may sum up experience, then, by saying that, in acute nephritis, prognosis must always be guarded ; recovery may take place, even in apparently hopeless cases ; but a considerable proportion of the suffers pass into a subacute or chronic condition, with interstitial and cardiovascular changes, from which complete recovery never takes place. {See also Scarlet Fever.) Chronic Diffused Nephritis is very justly looked upon as a grave condition, the prognosis in which is bad. Cases are recorded where recovery has taken place ; but there always remains the doubt if the line had been sufficiently drawn between a somewhat persistent form of acute nephritis and a true chronic diffused nephritis. The fatal issue may occur in from six months to two years, and may result from general exhaustion, with pronounced anaemia. These patients frequently exhibit profound alimentary disturbance, and can neither take nor assimilate sufficient nourishment. Frequently there is failure of the myocardial tonicity, with dilatation and pronounced anasarca. Uraemia, in its protean manifestations, or pneumonia, may prove the terminal feature ; or an infective process, resulting in an inflammation of a serous membrane. Prognosis will always be grave, but certain features will help in assessing the NEPHRITIS 365 gravity. When there is marked diminution in the quantity of urine, and anasarca is universal and extreme, and the phenol-sulphone-phthalein and other tests show a marked loss of functional activity, the patient will seldom survive more than a few months. When the urinary quantity is not much reduced below the normal, and the urine, though containing a large amount of albumin, shows only a limited number of tube-casts and leucocytes, and the functional activity is not pronouncedly reduced, the condition may run a much more chronic course, and pass ultimately into the ' small white kidney.' The patient may have periods of fair health ; but a small upset, such as a mild tonsillitis, may precipitate grave symptoms, with a recurrence of oedema ; and during one of these exacerbations the patient dies. Help in prognosis may be obtained by considering the functional activity of the kidneys, the condition of the circulatory system, and the results of treatment. When there is marked delay in the excretion of iodide of potash, or of phenol-sulphone-phthalein, the prognosis is grave. Yet at times the excretion of the phthalein may be as low as 16 per cent in two hours, months before the fatal issue. Cardiac dilatation and arterial degeneration are of grave import. CEdema may be due to salt retention ; but salt retention may be combined with degenerative changes in the smaller vessels, and with cardiac failure. When oedema is due to salt retention, there will be diminished chloride excretion in the urine, and a salt-free diet will usually give considerable amelioration of symptoms. When salt-free diet is instrumental in producing a diuresis with diminished oedema, prognosis is less grave than when vascular degeneration and cardiac failure are causal factors which are uninfluenced by a salt-free diet. In those cases, the mere mechanical presence of the fluid in the cavities and tissues has a deleterious influence on the functional activity of the organs, and increases malnutrition. Neither the alimentary canal nor the heart can carry on its work efficiently ; anaemia and malnutrition increase ; and defective coronary circulation adds to the difficulties of the already embarrassed heart. Again, it may be found that, at times, a period of protein- free diet will give considerable relief of symptoms. Speaking generally, then, it may be concluded that response to treatment makes the immediate prognosis less serious, while want of proper response renders it very grave. Chronic Interstitial Nephritis. — Pathologists are gradually returning to the view that the underlying and primary factor in chronic interstitial nephritis is a disease of the smaller blood-vessels, a widely diffused disease of the arterioles of the internal organs, in which the vessels of the kidney participate. The disease, in its fully developed form, involves the kidney, producing the primary contracted or small red granular kidney. This being so, it may at once be granted that the condition is incurable. True it is that Senator has stated that recovery is possible if the disease is taken early ; but this, if correct, is exceptional, and is outside the field of practical politics. Yet cases as seen in private practice must not be assessed at the same degree of gravity as the fully developed picture obtaining in the hospital ward. The established diagnosis of chronic interstitial nephritis does not by any means condemn the sufferer to a life of invalidism. In the writer's experience, the existence of chronic interstitial nephritis has been compatible with an active business career for fifteen years after the diagnosis was definitely established. Other observers have recorded cases where the condition has lasted twenty, and even thirty, years. Prognosis depends, not so much on anatomical changes, as upon the functional activity of the kidney and of the heart. This being granted, it is obvious that the patient has a right to a full knowledge of his condition and the factors which should regulate his life, — for much of the outlook will depend upon his ability to lead a simple life. It is fortunate when tlie disease is discovered early, and when the physician can 366 INDEX OF PROGNOSIS obtain the hearty co-operation of the patient in regulating diet and working hours, with a view to maintaining reasonable health and prolonging life. As Janewary points out, cases of chronic interstitial nephritis fall into two groups. In one group the clinical picture is that of some degree of cardiac insufficiency, and death is a cardiac death. In the second the predominant symptoms are cerebral — headache, vertigo, and apoplectic attacks — and there is evidence of severe renal insufficiency. In forming an estimate of the gravity of the prog- nosis, consideration must be given to the condition of the circulation, to the kidney function, and to the occurrence of complications of a ursemic type. Every case will require individual study, and too much importance must not be given to a single factor. Cardiac hypertrophy of the concentric type, with high blood-pressure, will be present ; yet if the functional activity of the organ be maintained, immediate prognosis may be favourable. Unfavourable phenomena are those suggestive of loss of compensation — palpitation, dyspnoea on mild exertion, and marked increase in the area of cardiac dullness, with some oedema about the ankles. These factors show a loss of tonicity. No doubt they may disappear under therapeutic measures, but they show that the heart has been working beyond its reserve, and that a breakdown is imminent. In this respect, consideration of the blood-pressure is important. It may be accepted that, within reasonable limits, high blood-pressure is necessary in these cases to maintain the functional activity of the kidney ; but excessive blood-pressure throws extra work on the heart, and it may break down under the strain. A blood-pressure of i8o to 200 mm. Hg, or over, must tax the powers of the heart considerably, and must lead in the end either to cardiac insufficiency or to a cerebral hcemorrhage. A systematic estimation of the blood-pressure will greatly help the practitioner in forming a prognosis. Given that it is moderately high, constant from month to month, with no signs of failing tonicity, and with fair general health, prognosis may be regarded as comparatively favourable. If, however, notwithstanding treatment, the blood-pressure is persistently rising, prognosis becomes grave ; either the heart will fail, or a cerebral haemorrhage will close the scene. [See Arterial Tension, High.) A factor which must be taken into consideration in prognosis is the patient's ability and willingness to carry out treatment. The patient who can spend the winter months in an equable and mild climate, pay an annual visit to a spa, and carefully carry out directions as regards the avoidance of chulls, over-work, and dietetic errors, has obviously a far better chance of prolonged life than the working man exposed to all weathers, or the harassed professional or business man living a life of strain. The manner of death in chronic interstitial nephritis must always be uncertain ; most commonly, however, it is a cardiac death, a death from failing compensa- tion, at times combined with distressing ursemic symptoms. Sudden death from cerebral haemorrhage is not uncommon. Albuminuric Retinitis. — The practitioner will find the systematic use of the ophthalmoscope a most valuable aid to prognosis in chronic nephritis. The retinal changes which may be present have been enumerated by Gowers as : Diffused opacity from oedema, white patches, hjemorrhages, optic papilUtis, diffused retinitis, and optic changes consecutive to inflammation. Of these changes, the first three are comparatively common, the second three are of less frequent occurrence. The most characteristic and striking are the white or yellowish glistening spots about the macula and optic disc and, in more advanced cases, scattered through the retina. At first small and scattered, they may coalesce and form larger spots which, situated in the proximity of the disc, may NEPHRITIS 367 be as large as the disc itself. At the macula, they occur as numerous small glistening points ; or they may radiate as interrupted lines, or fan-like streaks, in all directions. These changes are degenerative in character, and may be accompanied by hasmorrhagic extravasations ; or extravasations may occur alone, and may vary, according to age, from the bright red of the recent, to the dark red and finally atrophic patch marking the site of absorption of a former extravasation. The vessels of the retina will often show sclerosis, and as Gunn pointed out, they have an exceptionally bright reflex ; the central light streak is very distinct and sharp, while the whole surface of the vessel is of a somewhat lighter shade than usual. These changes in the retina are degenerative in character, and are collectively described as albuminuric retinitis. They occur most frequently in chronic interstitial nephritis, and are of very grave import. A patient with definite albuminuric retinitis seldom survives more than two years ; a few cases are recorded where the patient has lived for longer, but these are the exception, not the rule. The gravity of albuminuric retinitis in its bearing on prognosis cannot be over-estimated. (Such a statement does not, of course, apply to the retinal changes which may occur in the kidney of pregnancy ; there, complete recovery of kidney health may occur, but the patient may be left with permanently damaged vision). Estimation of Renal Function. — To the physician, anatomical changes are only important in so far as they interfere with the functional activity of an organ. By investigation of the activity of the kidney, valuable data will be obtained for the estimation of prognosis in nephritis. Of the different functional tests, the most valuable is the phenol-sulphone-phthalein test described by Kowntree and Geraghty ; the simplest for the practitioner is the iodide of potash test. The phenol-sulphone-phthalein test depends upon the capacity of the kidney for the excretion of the pigment. The apparatus required consists of a one-litre flask and a colorimeter. Before making the observation, the patient is given a drink of water. The injection, which can be obtained in an ampoule, i c.c. of which contains 6 mgrams of the phthalein, is injected into the muscles of the lumbar region. The patient empties the bladder at the end of one hour after the injection, and again at the end of the second hour. The urine voided at the end of one hour is poured into a litre flask, and rendered strongly alkaline with caustic soda solution to give the maximum red colour ; water is now added to the litre mark, and the mixture shaken and, if necessary, filtered to remove phosphates. The standard colour for comparison is obtained by the dilution of I c.c. of phthalein solution in a litre of water. This is placed in the standard tube of the instrument, while the urinary mixture is placed in the observation tube ; the colours are adjusted, the scale is read off, and the percentage of excreted pigment obtained. Unless the excretion of phthalein is very much retarded, the ordinary urinary pigment does not interfere with accurate estimation. In health, 43 to 70 per cent (usually about 50 per cent) of the pigment is excreted during the first hour, 70 to 90 per cent during the first two hours ; excretion is practically complete after two hours. A diseased kidney shows a very marked decrease in excretion during the first two hours. No pigment may appear by the end of the second hour in very grave cases of renal inadequacy. Excretion is noticeably decreased in acute nephritis, but it is especially in subacute and chronic conditions that the test is of value in estimating prognosis. Phthalein is excreted mainly, if not entirely, by the tubules, and deficient excretion points to a deficient functional activity of the tubules. No absolute figures can be given as a guide to prognosis from the functional test ; but, speaking generally, an excretion of 50 per cent and under shows serious renal inadequacy. In many cases of parenchymatous nephritis, excretion falls to 30 per cent or lower ; 368 INDEX OF PROGNOSIS the lower the percentage, the graver the prognosis. In chronic interstitial nephritis, when the kidney function is being fairly well maintained, excretion will be from 50 to 60 per cent. When ursemic phenomena are present, the percentage will fall very low, in some cases even to zero. In these cases there is pronounced inadequacy, with nitrogen retention. In chronic nephritis, a pronouncedly low excretion points to an unfavourable prognosis, even though no apparent uraemic phenomena are present. The iodide of potash test is simple, but not of the same value as the phthalein test. If ji gr. of iodide of potash be given to a healthy individual, it will be recognizable in the urine in a very few minutes ; and the total quantity will be excreted within about sixty hours, when the urine will no longer give the tests for iodine. Iodide of potash is eliminated by the tubules, and when there is disease of the tubules, the elimination of iodide is greatly delayed, the time being doubled or even trebled in some cases. {See also Uraemia.) Francis D. Boyd. NERVE INJURIES. — These differ from those of other structures by reason of their function. Not only does the nerve itself suSer, but the parts supplied by it are affected, and it is with regard to these as well as, and more often than, to the nerve itself, that the treatment is directed and the prognosis depends. Injury may affect a nerve in its course (in continuity) or at its termination, one of its branches of distribution being involved. Injury in Continuity. Two groups are recognized : — 1. Those in which the naked-eye continuity of the nerve is interrupted partially or completely, which I am accustomed to term anatomical division. 2. Those in which the injury produces partial or complete interruption of conduction without naked-eye solution of continuity. To this I give the name physiological division. Prognosis in General. — -Prognosis depends not only upon prompt treatment at the time of the accident, but to a large extent on efficient supervision for many months. The treatment of injury to a nerve in its continuity consists in keeping up the nutrition of the parts supplied by it and preventing the occur- rence of contractures in muscles opposed to those affected, until conduction is restored by natural means alone or aided by operation. In comparatively few cases, apart from accidental wounds in which it is essential, is operation necessary ; it should always be avoided if possible, and sufficient time given to be certain that recovery will not ensue unaided. Relaxation of paralyzed muscles must be maintained until voluntary power is restored ; unless this is done, recovery may be indefinitely delayed. This muscular relaxation is the most important point in treatment, but it is the one most often neglected. It is quite useless to undertake the treatment of a case of nerve injury unless this can be carried out. In cases needing operation it is too often assumed that when once the ends of the nerve have been united the surgeon's work has ceased ; it has only just begun. The careful supervision of the patient and the direction of the treat- ment, it may be for two or three years, is most important. Complete Anatomical Division. In complete anatomical division, immediate primary suture is the correct procedure, the nerve being united by absorbable suture and wrapped to prevent the formation of adhesions. NERVE INJURIES 369 Prognosis after Primary Suture. — Primary union, by which was understood union of the divided ends of a nerve without the occurrence of complete degener- ation in its peripheral end, is not possible. This subject excited considerable controversy between the years 1 860-1 880. To Letievant^ is due the principal credit of explaining by his clinical observations the fallacies upon which the assumption was based. Before recovery can take place, degeneration must occur in the peripheral end of the nerve, followed by regeneration and reunion with the central nervous system. Many papers have been written concerning the time of recovery after primary suture, but in the majority of instances they consist of collections of isolated cases recorded by others. The fallacies are so numerous, the question of the exact details of the operation and after-treatment is so impossible to define in collections of this type, that the conclusions are of little value. One of the earliest tables of collected cases occurs in Howell and Ruber's'-^ masterly paper on the regeneration of nerves. They concluded that 66 to 80 per cent of the cases recovered. Sir Anthony Bowlby^ appears to have been the first to attempt to settle the question by personal observation of a series of cases. He observed the results of 28 cases of primary suture, in many of which, however, the first note was made several years after suture. He considered 16 were successful and 4 failures. Dr. Henry Head and the writer* published a series of cases investigated at short periods from suture to recovery. The question was fully considered by the latter in his Erasmus Wilson Lectures in the following year." Perfect recovery is possible after primary suture ; perfect function may be restored to the affected muscles, and no difference noticed by the patient in the sensation of the part as compared with the corresponding sound one. Although possible— and I have seen it follow primary suture even of the ulnar nerve — it is unusual. For it to occur, the operation of suture must have been carried out with great care, the wound must heal by first intention, and the after-treatment be efficient. The prognosis will depend to a certain extent upon the nerve injured ; for example, the musculospiral nerve in the lower third of the arm carries no exclusive supply to any portion of skin, and the muscles it innervates are not so intimately associated with delicate movements of the fingers as are those supplied by the ulnar. Complete recovery is reached more frequently and more rapidly than in other nerves. The further the seat of injury from the periphery, the longer the time neces- sary to full recovery, and the less likely is it to occur. I have personally observed over 60 cases of primary suture. In all, motor power was regained and the second stage of sensory recovery completed. It is unusual, however, for complete recovery to ensue. In a recent paper, Spisharny^ states, from investigation of 18 cases of suture, that perfect recovery did not occur in a single case, but 66 per cent of the patients were able to resume work. If the nerve injured is the median or ulnar, it is improbable that recovery, either motor or sensory, will be sufficient to enable delicate movements to be skilfully performed. Thus, wliile the hand might be perfectly useful to an unskilled labourer, it would be a useless member to an artist or executive musician. The time after suture at which recovery occurs varies with the distance of the point of suture from the periphery and the method of healing of the wound ; 24 370 INDEX OF PROGNOSIS suppuration prolongs it very considerably. In division of one of the nerves of the forearm, muscular recovery commences about nine months after suture, but perfect sensory recovery cannot be expected under three years. Secondary Suture. — Recovery is much slower and prognosis less hopeful than after primary suture. In none of my 37 personal cases, or in many others which have been seen at varying times after suture, did perfect recovery ensue. While this is possible after primary suture, it is improbable after secondary. The first question to be considered is the relation of the interval between division and suture to recovery. Howell and Huber,' and Kennedy,* among others, considered that the prognosis was better and the time of recovery shorter, the sooner after injury the nerve was sutured. I stated in my Erasmus Wilson Lectures that there was no direct relation between the length of time which has elapsed since the injury in cases in which operation was performed before the lapse of two to three years. This is in agreement with Bowlby's^ experience. Although I believe that the time after injury at which suture is performed has no direct relationship to the length of time necessary for recovery, it has an important indirect one, in that most of the factors hindering complete recovery develop as time advances. Although instances of ' successful ' operation have been recorded nine (Jessop^**) and fourteen (Chaput^^) years after division, muscular recovery is unlikely after about three years. There are many factors to take into consideration in estimating the chances of recovery : If the nerve was divided in an open wound, its method of healing ; nothing hinders recovery to so great an extent as suppuration : the condition of the muscles as regards wasting and the retention of irritability to the constant current ; the presence of contractures in opposing muscles, and the condition of ligamentous structure surrounding joints. The condition of the hand of a patient, for example, who has suffered division of the ulnar nerve below its dorsal branch, in whom a marked claw-hand has developed, is little likely to be improved by suture, although the muscles may regain their irritability to the interrupted current. It is extremely important to attempt to estimate the probable extent of recovery. From the motor standpoint, if great wasting with contracture has occurred, as is so common after ulnar injuries, operation is not worth under- taking ; if there is no contraction on stimulation with the constant current on several examinations, suture is useless. The length of time irritability persists varies, but I have obtained response twenty years after division. But if trophic ulceration is present, operation will cure it and prevent recurrence, for protopathic recovery is almost certain, and ulceration, as Head and the writer have shown, ceases on the restoration of protopathic sensibility. Considerable interest attaches to the commencement of the first stage of restoration of sensibility. From time to time instances of ' rapid ' return of sensibility after secondary suture have been recorded by many observers, among the more recent being Ballance^^ ^nd Kennedy." I have carefully examined for it after operation in 37 personal cases, but have not yet observed it. My attention has more than once been drawn by hospital residents to the ' rapid return of sensibility to prick,' after secondary suture, which, on careful testing in the usual manner, proved to be deep sensibility. In one patient upon whonr I had performed secondary suture of the median nerve, it was said that sensi- bility to prick had returned on the day following operation. On testing, I found that he complained of pain on pressure, but could not distinguish the sharpness of the point of a pin ; it was equally painful, and produced the same sensation, as pressure with the blunt end of a pencil ; moreover, he was entirely NERVE INJURIES 371 insensitive to the painful interrupted current, and all temperature appreciation was absent. There was no doubt that the pain was that caused by deep pressure, which could be readily evoked before operation. The time of commencement of the first stage of sensory recovery may be shorter than after primary suture, the changes of the peripheral end necessary to regeneration of the nerve being advanced at the time of suture. I have seen it as early as the thirtieth day, but much variability obtains, and, speaking generally, the time necessary for the completion of the first stage is always long, and the interval between the second and third nearly double as long. I have never yet seen perfect sensory recovery after secondary suture, although I have watched patients for over seven years, and examined them up to fifteen years after suture. In all, some difference could be appreciated between the two limbs, an area of changed sensibility remaining, with imperfect appreciation of the compass test. Much less variation occurs with regard to motor recovery, but the time required is invariably longer. Prognosis after Nerve Bridging. — Under the term ' nerve bridging ' are included all those procedures undertaken to restore anatomical continuity when the ends of a divided nerve cannot be brought into apposition. We have a choice of methods that have been used more or less successfully from time to time. Those of proved value may be put into four groups. 1. Transference of a portion of nerve from another source (nerve transplant- ation) . 2. Provision of a path along which the nerve may regenerate (tubular suture, flap operations, etc.). 3. Utilization of neighbouring nerve (anastomosis or crossing). 4. Shortening the limb by resection of bone. Nerve transplantation is the operation of choice. In 1906'* I investigated the recorded cases of nerve transplantation, added fresh cases, and brought others up to date. Among the 30 cases, 8 were examples of transplantation of human nerve (homo-transplantation) ; of these only 3 were reported at a sufficient interval after operation to admit of recovery. This was complete in 2. Out of 22 instances of transplantation of nerve taken from one of the lower animals (hetero-transplantation), 16 were reported at a period after operation that would have admitted of some recovery ; of these only i, or at the most 2, recovered completely. Tubular suture aims at providing a path for the new axis-cylinders, free from fibrous tissue. Many substances have been used for this purpose, among them decalcified bone, collodion, preserved animal's artery. I prefer a tube composed of a portion of one of the patient's superficial veins. In performing this operation the nerve is prepared and both ends freshened ; a portion of superficial vein of appropriate size is then excised and slipped over one end of the nerve. The ends are loosely united with catgut, the vein is drawn over the junction, and the whole surrounded with Cargile membrane. The results given by this operation are superior to those obtained from hetero-transplantation. The results of flap operations have been uniformly unfavourable. The possibility of utilizing neighbouring nerves attracted the attention of investigators at an early date. Two distinct operations are included — nerve crossing and nerve anastomosis. In nerve anastomosis, an attempt is made to bring the axis-cylinders of the affected nerve into end-to-end contact with some of those of the sound nerve ; in nerve crossing, the peripheral end of the affected nerve is united end-to-end with the central portion of a divided sound nerve. Excluding the cases in which the operation was performed on the facial nerve, I collected 25 examples; of these 12 were reported at a suflicicnt time after 372 INDEX OF PROGNOSIS operation to enable an opinion to be given as to the result. Two were un- doubtedly perfectly successful. Four were certainly improved by the operation, and were probably successes, but the records are too scanty to enable a definite opinion to be given. Thus, out of the 12 cases reported sufficiently long after the operation, only 2 were failures ; some improvement took place in all the others. This is a better result than that given by Powers, ^^ who considered that 50 per cent were successful. The prognosis in cases of bone-shortening is that of secondary suture. Incomplete Anatomical Division. In order to understand the prognosis of these injuries, their nature must first be considered. In wounds of nerves which do not completely destroy their continuity, it is found that at least a third of their diameter may be destroyed without producing any change, or one of a transient nature only, unless the injury is near the point at which a branch is given off, when the symptoms resemble those of division of that branch. This is confirmed by the experiments of Bruandet and Humbert,^® who found that the fibres in a peripheral nerve which go to make up any branch do not become grouped until just before it leaves the parent trunk. In certain situa- tions also — for example, in the anterior primary division of the fifth cervical nerve — the nerve fibres are arranged in a well-defined order, and incomplete division of this nerve may entail complete division of those motor fibres which supply the spinati and deltoid muscles. Again, in the trunk of the great sciatic nerve the external and internal popliteal nerves remain separate ; hence incomplete division of the great sciatic may cause complete division of the external or internal popliteal nerve. In accidental wounds of nerves, in addition to the incomplete anatomical division, there is usually physiological division, the result of the transient compression of the intact nerve fibres by the cutting instrument or effused blood. Absence of symptoms in many cases is due to the fact that more nerve fibres are present in the trunk of a nerve than are necessary to the supply of the part. When symptoms are present, the recovery of function is due to restoration of conduction in the fibres which have suffered an incomplete physiological division. Those fibres which are separated from their nerve centres must of course degenerate and regenerate before they can again carry on their functions. It must, however, be remembered that the injury to the anatomically intact nerve fibres may be so great that complete physiological division is produced ; , this may also arise at a later period as the result of compression by fibrous tissue. If efficient treatment at the time of the accident, or later, is carried out, recovery is usually perfect, both motor and sensory. In some cases, however, in which the treatment at the time of the injury was not operative, complica- tions ensue. After a period of improvement, deterioration of function sets in. due to involvement in fibrous tissue. Recovery in these cases does not usually occur apai't from operation. In other instances, pain arises in the full distiibution of the injured nerves, sometimes accompanied by hyperalgesia, in rare instances by glossy skin. In these cases the damaged portion of the nerve must be removed and continuity re-established ; the prognosis is then that of secondary suture. Subcutaneous Injuries. — Taken generally, prognosis is much more favourable than after nerve section, except in the case of traction injuries of the brachial plexus. NERVE INJURIES 373 As the result of pressure — long-continued or sudden— all the immediate symptoms of complete division may develop. When the injury is incomplete and physiological, recovery rapidly ensues. All forms of sensibility recover together, and localization, so seldom restored after suture, is rapidly regained. With regard to motor symptoms, unless the reaction of degeneration develop, ]50wer is quickly regained by the affected muscles. Restoration of sensibility to all forms of stimulation is perfect usually within six to twelve months. At the end of a fortnight, if the affected muscles are still paralyzed, their electrical reactions should be taken. If at this date the muscles react to the interrupted current, or give the reactions of incomplete division, non-operative treatment should be continued. Recovery can be confidently expected in the former case in a few weeks, in the latter in a few months. If true reaction of degeneration develop, the prognosis is unfavourable ; operation becomes necessary, with all the drawbacks of secondary suture. After neurolysis has been carried out, recovery is usually rapid. Injury to Terminal Branches. The principal symptom of the involvement of the terminal branches of a nerve in scar tissue or callus, is pain referred to the distribution of the roots from which the affected nerve arises, with in some cases paresis or paralysis. These symptoms are seen most often after finger amputations. The prognosis is good if the condition causing the symptom is removed by operation, when the pain and tenderness are still confined to the scar or stump ; when they have spread to other nerves, or are associated with hysteria or muscular affections, it is by no means favourable. If the pain is not relieved, or recurs, no further local operation should be done if the first was thorough. Before proceeding to the only remaining operative treatment in these cases — division of posterior roots — Weir-Mitchell treatment must be tried after removal of all cause for worry. It is useless treating advanced cases while compensation proceedings are pending. Weir-Mitchell treatment must also be adopted after operation in the cases complicated by hysteria. When muscular symptoms are present, the affected muscles must be kept relaxed by suitable apparatus, and daily massage given until voluntary power returns. It is often twelve months before muscular recovery is complete. Special Nerves. Facial. — The nerve may be injured as the result of fracture of the base of the skull primarily or from involvement in callus, and during the course of mastoid operations, during operations in the parotid or submaxillary regions, or from forceps pressure during childbirth. When injured as the result of fracture, whether involved primarily or secondarily, the division is usually incomplete, and perfect recovery ensues in about three months. Facial paralysis following operation on the middle car is, as a rule, due to incomplete division. Spontaneous recovery is usual in the majority of cases, but may take twelve months. The incomplete facial paralysis, which may occur as the result of operations in the submaxillary region, is rarely permanent if the wound heals by first intention. Careful electrical testing is necessary in order to enable an opinion to be given with regard to the necessity of operative treatment. If true reaction of degeneration develops, no time should be lost, but operation carried out. In but few cases is it possible directly to unite the divided ends of the nerve, .and nerve anastomosis is neccssarv. 374 INDEX OF PROGNOSIS The best results are given when, as first suggested by Korte/' the hypo- glossal is used and the anastomosis is of the partial peripheral type. The prognosis varies with the cause of the paralysis, being better when the division results from injury than when it is the result of neuritis. Suppuration of the operation wound renders success doubtful. The first sign of recovery usually appears about the third or fourth month, the face while at rest becoming more symmetrical, although there is no return of voluntary power. A few weeks later it is noticed that the angle of the mouth can be moved, at first only with movements of the tongue ; then the muscles of the upper lip, and finally those of the forehead. With exercise, the move- ments become dissociated, and finally emotional movement may return. For a few weeks after operation, the side of the tongue is paralyzed, causing difficulty in speech and deglutition ; this passes off, but the affected side of the tongue may remain smaller for a considerable time. In 40 cases collected by the writer, improvement occurred in all reported at a sufficiently late date ; but in comparatively few did emotional movement return, the face on the side of the injury remaining immobile in smiling. It is safe to say that in the majority of cases the appearance of the face at rest will become normal. Recurrent Laryngeal Nerve. — This nerve is not infrequently injured in operations upon the thyroid gland. The paralysis is usually temporary, and disappears within three months. If at the end of that time recovery has not taken place, operation offers a good chance for recovery. In the first case of secondary suture recorded (Shelton Horsley^^), recovery was almost perfect fifteen months later. Brachial Plexus. — It is now well established that the prognosis of injuries to the brachial plexus, taken as a whole, is worse than those elsewhere, although, as noted by Bardenheuer,*^ and more recently by Winnen,'" the seriousness has been exaggerated. Von Bruns^^ found that while spontaneous recovery ensued in 66 per cent of subcutaneous injuries of peripheral nerves, only 26 per cent of similar plexus injuries got well spontaneously. Warrington and Jones,-'- from the examination of cases under their care, found spontaneous recovery in 30 to 40 per cent. Winnen 30 per cent, with 70 per cent improvement. These unfavourable figures are due in part to the nature of the injury. In a large proportion of cases the nerves are overstretched, and this results in haemorrhage into the sheath and consequent fibrosis ; in addition, if it leads to rupture, the fibres give way at different levels ; hence spontaneous recovery is unusual when the signs of complete division are present, and is apt to be imperfect in cases of incomplete division. Again, it is possible that the injury in some cases tears the roots away from the cord. Even after operation, the prognosis is not so good as, for example, after secondary suture of the median at the wrist or the musculospiral. This has to do to a great extent with the length of time neces- sary to complete recovery ; in many cases the patient ceases to attend for efficient after-treatment, and when recovery of the nerve has finally become complete, the muscles are atrophic, and contractures of the opponent muscle render the regeneration of the nerve futile. Brachial Birth Paralysis. — The prognosis is favourable if efficient treatment is adopted from the time of birth. Nerve recovery has taken place in 70 per cent of the cases under my care ; but in these lesions particular care is necessary in order to prevent over-stretching of the paralyzed muscles and over-action of their opponents. Unless this is carefully attended to, although the nerve recovers completely, the child is Jeft with a damaged limb. This point has NERVE INJURIES 375 recently been emphasized by Fairbank,-^ who has devised an eificient splint for the purpose. With regard to operation : this is necessary in a minority of cases. If at the end of three months from birth the reaction of degeneration is present, operation should be carried out as soon as convenient. If it is possible to excise the damaged portion of nerve and perform end-to-end suture, the outlook is favourable ; but when this is impossible and nerve anastomosis becomes necessary, perfect recovery is unlikely to take place. Post-ancesthetic Brachial Paralysis. — These injuries of the plexus are by no means uncommon, although published cases are few. Cotton and Allen,-** in 1903, were only able to collect 30 from the literature. It occurs in patients in whom, during the course of operation, the arms are abducted and externally rotated or raised above the head. The right arm is usually affected. Stretching over the head of the humerus with the arms elevated above the head is the probable cause of the infraclavicular injuries. In all cases the lesion is incom- plete, corresponding to the slight violence which produced it. The prognosis is good ; all the cases that I have had under observation have recovered completely without surgical intervention, and all except one of those collected by Cotton and Allen. Injury due to Presence of a Cervical Rib. — A cervical rib is by no means an unusual cause of injury to the brachial plexus as the result of long-standing pressure. In cases in which the nervous symptoms are marked, removal of the rib is the only treatment. The result of this is on the whole good. As in other cases in which muscles are affected as the result of prolonged nerve-pressure, the question of perfect recovery will depend upon the extent of the wasting and deformity produced. When this is well marked, some atrophy and deformity of fingers always remain. The nervous symptoms fall into two groups, paralytic and neuralgic. As a rule these co-exist. The subject has been fully discussed at the Royal Society of Medicine.-* Thorburn reported 20 cases (14 personal), and came to the conclusion that pain was relieved in four-fifths ; paralysis cured in certainly one-half. Sargent, as the result of operation on 29 cases, speaks of " the most gratifying immediate results obtained in those cases in which pain had been the prominent feature." Hinds Howell collected the after-results in 25 cases, and came to the conclusion that " in the majority of cases pain will be reheved or cured. With regard to muscular weakness and atrophy, the expectation is that the operation, if it is not too long delayed, will greatly improve the condition." (See Cervical Rib.) It was pointed out that a paralysis of the brachial plexus may occasionally occur as the result of operation, but if performed by those skilled in the procedure is unusual and transient. Operative treatment undoubtedly removes the most distressing symptom of this condition. Circumflex Nerve. — Injury to this nerve is unusual, and is usually subcutaneous the result of pressure of the dislocated head of the humerus or a crutch, and results in an incomplete physiological division. Treated on the usual lines, recovery ensues as a rule, but is generally slow. Even if the paralysis persists, operation is not often necessary, for the supinators and clavicular fibres of the pectoralis major acting with the trapezius may compensate for its loss. Ulnar Nerve. — The prognosis in cases of injury to the ulnar nerve depends upon the care taken to prevent the development of claw-hand. If in cases of incomplete division or after primary suture a suitable splint is worn, perfect recovery may take place, although it is unusual in the latter. 376 INDEX OF PROGNOSIS Perfect recovery never ensues after secondary suture, or releasing the nerve from pressure in case of injury the result of old deformity of the elbow or long- standing dislocation. Some weakness of the intrinsic muscles of the hand always remains. Musculospiral Nerve. — The prognosis is more favourable than after injury of any other nerve. It supplies no important area with sensibility, its muscles are none of them intrinsic. Most of its injuries are subcutaneous, resulting in incomplete physiological division. If treated by relaxation of the paralyzed muscles, recovery is rapid, and usually perfect within three months. ■V\Tien operative treatment is necessary to free the nerve from injurious pressure, restoration of function usually commences in a few weeks. After secondary suture, motor power usually returns in nine to twelve months, and perfect use is regained within eighteen. References. ^Traite des Sections Nerveuses, Paris, 1873; -Jour. Physiology, xiv. ; ^Injuries and Diseases of Nerves, London, 1889 ; *Brain, Summer No. 1905, ex ; ^Lancet, 1906, Mar. 17, 24, 31 ; ^Zentr. f. Chir. 1913, No. 3r, s. 1222 ; ''Loc. cit. ; ^Brit. Med. Jour. 1904, ii, 1065 ; ^Lancet, 1902, ii, 198 ; ^'^Brit. Med. Jour. 1871, ii, 640 ; ^^Bull. et Mem. de la Soc. de Chir. 1905, xvu, 471 ; ^-Trans. Roy. Med. and Chir. Sac. 1902, 290 ; ^^Phil. Trans. Roy. Soc. 1897, 188 B. 257 ; ^^Edin. Med. Jour. Oct. 1906 ; ^^Ann. Surg. 1904, xl, 632 ; ^^Archiv. gen. de Med 1905, No. 11 ; ^''Deut. med. Woch. 1903, No. 17 ; ^^Ann. Surg. 1910, i, 524 ; ^^Archiv. f. Chir. 1909, Bd. 89 ; ^°Deut. Zeits. f. Chir. Bd. 118, 1912, s. 416 ; ^^Neurol. Centr. 1902, s. 1042 ; ^^Lancet, 1906, ii, 1644 ; ^^Ihid, 1913, i, 1219 ; ^^Boston Med. and Surg. Jour. 1903, cxlviii, 499; ^'Proc. Roy. Soc. Med. 1913, vi. No. 5, Clin. Sect. 113-127- James Sherren. NEURALGIA, TRIGEMINAL. — We shall only consider here the prognosis of the severest form of neuralgia, tic douloureux, and shall assume that ordinary medical treatment, and the examination of the teeth, nasal accessory sinuses, etc., has proved abortive. The neuralgia is severe in character, comes on in occasional paroxysms, and shows no tendency to spontaneous cure. The methods of treatment, then, with which we have to do, are (i) The peripheral neurectomies ; (2) Alcohol injection ; and (3) The removal of the Gasserian ganglion by the Hartley- Krause method. 1. The Peripheral Neurectomies, such as removal of a piece of the lingual and inferior dental nerves, excision of the infra-orbital nerve, or the Braun-Lossen operation on the second division of the trigeminal nerve, are all comparatively safe, so far as the immediate risk to life is concerned ; they have the very serious drawback that permanent cure by their means is most exceptional ; and when it does occur, it is always open to suspicion that some peripheral dental or other cause, capable of simple treatment, has been overlooked. Out of 43 cases treated by neurectomy, the average duration of relief from pain was ten months (Putnam and Waterman). 2. Alcohol Injection into the Gasserian ganglion is somewhat difficult of technique, and it may not be possible to reach the desired spot ; but it appears to be perfectly safe, so far as risk to life is concerned. Even if the injection is made by mistake into the subdural space, nothing worse than a headache results. The relief given, if the alcohol can be correctly placed, is very marked, and lasts for a long time, even if it is not permanent ; there is usually complete freedom from pain for many months or years. Harris was able to give this relief in 80 out of 86 cases. The test of success is the production of immediate anaesthesia in the whole distribution of the fifth nerve. The injection can be repeated, if recurrence takes place, with equally good results. Hartel followed up 25 cases, 15 for more than six months ; of these 15, 9 were free from pain and 6 relapsed. A serious trouble is that keratitis may result ; this took place in 6 out of the 25 patients, and one eye had to be enucleated. Possibly covering the eye may give better success. NEURITIS 377 Removal of the Gasserian Ganglion is, no doubt, a serious operation, but the mortality, in skilful hands, is not as high as is commonly supposed. Horsley, Hutchinson, and Krause together report a death-rate of 4 per cent. Some years ago, Horsley had operated on 120 patients with 6 deaths. Rawling puts the mortality at 5 per cent. Very possibly it may be higher in the practice of those who have seldom or never performed the operation. The rehef appears to be certain, complete, and permanent. Here again there may be trouble with the eye. Hartel shows that keratitis has followed in 30 out of 207 successful removals of the ganglion, that is, about 15 per cent. References. — Harris, Lancet, 1912, i, 21S ; Hartel, Deul. Zeits. f. Chir. 1914, xxvi, 429. ^. Renile Short. NEURITIS. — There are two great groups into which cases of neuritis are classified : — (i) Multiple or peripheral neuritis, where many or all of the peri- pheral nerves are involved ; (2) Local neuritis, where only a single nerve, or portion of a nerve, is affected. I. Multiple Neuritis or Polyneuritis. — In most cases this is due to some poison. This poison may be introduced from without, as in the cases of alcohol, arsenic, lead or, less commonly, mercury, phosphorus, or copper ; or it may be the result of micro-organisms producing specific diseases, or of their toxins, as in diphtheria, influenza, malaria, septicasmia, gonorrhoea, beri-beri, leprosy, syphilis. Multiple neuritis may also be produced by poisons arising within the bod3% as in diabetes, pregnancy, etc. Of these varieties, the commonest of all is alcoholic polyneuritis. It is unnecessary to describe the clinical features of this disease. Its onset is insidious, and the symptoms may take weeks or months to attain their maximum intensity. If the alcoholic habit continues, the neuritis persists indefinitely, until the patient becomes bedridden ; contractures of the limbs develop, especially in the feet ; and the patient dies, sooner or later, from some intercurrent malady, usually of pulmonary origin. If however, the poison be withdrawn, and if massage and electrical treatment are then assiduously carried out, the symptoms may even continue to increase for two or three weeks, before coming to a standstill. There is then usually a stationary period of one or two months before signs of improve- ment begin to appear. Then the pains and the hypersesthesia gradually diminish, the cutaneous anaesthesia clears up, and the motor paralysis recovers in from four to six months from the time of onset of improvement ; the proximal muscles recover before the distal. Last of all, the deep reflexes return ; a patient may have complete sensory and motor recovery for weeks or months before the deep reflexes reappear. The prognosis as to life, in a case of multiple neuritis from any cause, depends on various factors. The motor, rather than the sensory, symptoms are of signifi- cance in this respect: The more rapid the onset of paralytic symptoms, the more dangerous is the case. When the symptoms have attained a considerable severity within a few days, there is a grave risk of extension to the respiratory muscles. Implication of the diaphragm and intercostals greatly increases the seriousness of the case, more especially if the cardiac muscle be enfeebled, as is so often the case. Patients with multiple neuritis have a particularly feeble power of resistance to pulmonary infections, whether by the tubercle bacillus, the pneumococcus, or other organisms ; and the presence of lung complications, even a simple bronchitis, is always a serious matter in such patients. A characteristic form of mental affection, known as Korsakow's psychosis, occurs in some cases nf polyneuritis. Its symptoms arc those of mild mental 378 INDEX OF PROGNOSIS confusio-i, especially with regard to times and places, together with impairment of memory for recent events ; so that a patient who is bedridden from polyneur- itis may give descriptions of recent long walks which she has taken (the patient is iisually a woman), and of the various people and places whom she has thus visited. The nature of the poison which produces the multiple neuritis has little or no influence per se upon the prognosis as to recovery. The different forms of polyneuritis run a similar course. A great deal, however, depends on whether the source of the underlying poison, once it is recognized, has already been removed, as in diphtheria or septicaemia ; whether it can be cut off with ease, as in lead or arsenic ; whether there is a tendency to relapse, as in alcohol ; or finally, whether it cannot be removed, as in diabetes, cancer, lepros}^, etc. 2. Local Neuritis. — Recognition of the underlying cause, and its removal, if possible, are the first essentials in every case of local neuritis. Thus, in a neuritis due to local pressure (e.g., by crutches, callus from an old fracture, cervical ribs, tumours, etc.) the underlying cause can sometimes be removed. In other cases, the exciting cause has already produced its effect on the nerve-trunk, and we have to deal with the result (e.g., in local neuritis due to bruising or inflammation of the nerve, or to exposure to cold). In other cases still, we have to do with a disease which produces a primary degeneration of the nerve-fibres (e.g., in diabetes, malaria, enteric fever). In a still further class, the fibrous tissues of the nerve-trunk, its sheath or perineurium, are primarily attacked, and the degenera- tive changes are secondary (e.g., in gouty, syphilitic and leprous neuritis). The prognosis, therefore, of any individual case of localized neuritis is that of its underlying cause. Electrical Reactions. — In cases of local neuritis of a mixed nerve, where both sensory and motor phenomena are present, sensory functions generally recover before motor, although this rule is not without its exceptions. With regard to motor paralysis, the prospects of recovery are best estimated by a careful study of the electrical reactions. To niake an accurate prognosis, however, the motor paralysis must have lasted at least ten days, to allow time for degenerative changes, if any, to have developed. If, after ten da3^s or a fortnight of motor paralysis, we find the typical ' reactions of degeneration ' — i.e., total loss of faradic excitability, with reversed polar reactions and a slow sluggish response to galvanism, — the degeneration of the nerve-fibres is complete, and recovery will not commence for three months at least, possibly not for a year; and even then, if recovery ultimately sets in, it will probably be imperfect and associated with a certain amount of contracture. If, on the other hand, the electrical reactions are normal to faradism and galvanism, or if there be merely a quantitative diminution, without polar changes, recovery may be expected to begin in from three to six weeks from the onset of the paralysis. Sometimes we meet with partial or incomplete reactions of degeneration, consisting in a sluggish contrac- tion to galvanism, with reversed polar reactions, but with preservation of a certain amount of faradic response. In such cases, we may expect improvement in from six to eight weeks from the onset of the paralysis. Examination of the reaction of the muscles to condenser discharges is a valuable addition to faradic and galvanic stimulation as a means of electro-diagnosis and prognosis. A healthy striated muscle-fibre reacts to condenser shocks of the smallest condensers (e.g., ooi to OI2 microfarad), with the shortest and fastest wave-lengths ; whereas a degenerated muscle requires larger condensers (e.g., 0-50, i-oo, 2-00, or even S'oo microfarads), with longer and slower wave-lengths. Purees Stewart. (ESOPHAGUS, STRICTURE OF 379 (EDEMA, MALIGNANT. — This disease, one form of the old-fashicned Hospital Gangrene, used to exact a frightful toll in the pre-antiseptic era. The term should be reserved for cases of spreading gangrene following on a wound, with gas-bubbles in the tissues, due to Welch's Bacillus aerogenes capsulatns, or the Bacillus oedematis nialigni. According to Welch, the prognosis is not as absolutely hopeless as might be imagined. If an early high amputation is performed, about 40 per cent of the patients may be saved. In 1898 the mortality was given as 95 per cent. When the gangrene is extensive and the patient looks poisoned, the outlook is very grave indeed, and death will probably ensue in a day or two. The surgical experiences of the Great War have thrown new light upon our conceptions of this disease, which has unfortunately been common amongst wounded lying out long without treatment, and especially if earth infection took place. When the condition is still localized, and there is a blackened, emphysematous area close to the wound but not far up the limb, it can be checked in many cases by injections of oxj'gen bubbles through a needle, and the application of hydrogen peroxide. When, however, a larger area than the palm of the hand is affected, amputation is usually required, and the best results are obtained if the flaps are left open. It is too soon yet to present the relative value of methods in statistical form. Haycraft reports that of 21 wounded soldiers treated by amputation, only 5 died, and in 4 cases incision and drainage was sufficient to save life. Reference. — Haycraft, Lancet, 19 15, i, 592. A. Rendle Short. (ESOPHAGUS, STRICTURE OF. — Stricture of the oesophagus may be — (i) Functional {cardiospasm) ; (2) Simple, usually due to scar-contraction after swallowing a corrosive ; (3) Malignant. 1. Cardiospasm, a condition in which the entrance into the stomach is tightly contracted, whilst the oesophagus above may be hugely distended, is rare. It may be recognized by the oesophagoscope, and by a skiagram after a bismuth meal. It persists for years, apart from treatment, and shows no tendency to spontaneous cure. Dilatation, by various complicated means, usually gives a good result. 2. Simple Stricture, due to scarring, may be recognized by the history, by skiagram, by the failure to admit a bougie, and by the glistening white appear- ance without ulceration seen with the oesophagoscope. At least 9 out of 10 of the cases can be dilated up by bougies, passed, if necessary, by the aid of the oesophagoscope. If this fails, a temporary gastrostomy will often allow of successful retrograde catheterism ; or, in a week or two, the rest to the oesophagus allows of a bougie being passed. Dilatation of the stricture has to be kept up for many years at regular intervals. Oser reports on the cases treated at Vienna during the past ten years. Out of 47 patients, 27 were treated by dilatation, with 21 cures and i death ; 14 by gastrostomj^ and retrograde catheterism, with 10 cures and i death ; 6 by gastrojejunostomy, etc. (for burns of stomach), with 5 cures and no deaths ; the other patients were improved, or lost sight of. 3. Malignant Stricture, of course, has a hopeless outlook. Apart from gastro- stomy, the duration of life is usually not more than six months from the onset of dysphagia ; that operation prolongs life a few months. A good many deaths, and one success, have followed excision of the growth. Reference. — Surg. Gyn. and Obst., Abstract, 1913, xvi, 17. A. Rendle Short. ORCHITIS, TUBERCULOUS.— (See Epididymitis, Tuberculous.) 38o INDEX OF PROGNOSIS OSTEITIS DEFORMANS (PAGET'S DISEASE).— Of this rare disease there are not many more than a hundred cases recorded, but most surgeons of experi- ence can recollect one or two others which have not found their waj' into print. It is a chronic incurable affection which may not shorten life. The strange feature of the prognosis is the considerable probability that a malignant bony growth will eventually appear. Of 34 cases followed to their termination, this was the cause of death in 12. Reference. — Elmslie, St. Barfs. Hosp. Rep. igo8, 121. A..Rendle Short. OSTEOMALACIA. — This disease appears to be more commonly met with on the Continent than in England or America. It affects young women for the most part, though a few cases are recorded in males and in children. The outlook is very grave. According to the older authorities, it goes on in most cases to a fatal termination in from two to ten years, the patient being bedridden most of the time. Durham records 22 out of 145 cases in which natural recovery, more or less complete, was observed. It is most unfavourably influenced by pregnancy, and is often first recognized at that time. As is well known, the pelvis becomes very contracted, and Caesarean section will probably be required. The child is normal. Many of the mothers have died in childbirth. In a small number of cases, double oophorectomy has been performed, and there is some evidence that this improves the outlook. Fehling reports 14 cases : 6 of these were cured for three years or more ; 2 were better for a time and then relapsed ; the rest died or were lost sight of. Other observers have recorded temporary benefit with relapse following. There are a few cases known in which great benefit followed adrenalin injections. References. — Durham, Guy's Hosp. Rep. x. 1064 ; Kaipe, Amer. Jour, of Obstet. 1912, Ixv. 582. ^, Rendle Short. OSTEOMYELITIS. — It is not easy to estimate the prognosis of such a disease as this in formal terms, for any bone may be affected, and with every degree of severity. Prognosis as to Life. — In man}' cases there is very considerable danger to life. The rare infections of the skull and vertebral column are very fatal, and the majority of young children with perforation into the joint (Sir T. Smith's Acute Arthritis of I^ifants) also die. Even with the commoner affections of the long bones there is grave risk. During the years igot to 1910, at the London Hospital, 34 per cent of the patients died ; the usual causes of death were endo- or pericarditis, empyema, or abscess of the lung. Others die of cachexia at a later date. Signs of danger are — extension of the infection over the whole length of a large bone such as the femur or tibia, multiple bone involvement, rigors, and signs of trouble in the chest. In chronic cases, great wasting and cachexia, apart from efficient treatment, point to a probably fatal termination. The 3-ounger the patient the graver the outlook. Early and thorough surgical intervention is of the utmost importance in the acuter types of the disease. Prognosis as to Limb. — Very early operation, laying open the whole infected area, will avert the long illness which necrosis necessarily involves. Unfortunately the surgeon is generally too late, and part of the bone will die. In the worst cases, the periosteum is rapidly stripped up and the osteoblasts are killed, so that no regeneration of bone will take place. This is the rule in necrosis of the lower jaw. Usually, however, an efficient new bone is formed in time ; but it takes months for the sequestrum to separate, and again, after that is removed. OVARIAN TUMOURS 381 for the sinuses to close. It is likely to be from six months to a year or more before the patient is well. Necrosis of the popliteal plate of the femur is a very trying condition for all concerned, as the separation of the sequestrum may take an interminable time. Many of the cases are cut short, at last, by an amputation, on account of failure of the general health. Reference. — Kennedy, Brit. Med. Jour. 1912, ii, 114. A. Rendle Short. OVARIAN TUMOURS. — The prognosis in ovarian tumours is very largely dependent upon the nature of the growth. With the exception of certain adventitious accidental phenomena which we shall consider later, the outlook is good, doubtful, or bad according to the histological characters. At the outset, it cannot be too definitely asserted that naked-eye characters alone are an insufficient guide ; and in no region of pathology are the services of ah expert histologist, experienced in the study of ovarian tumours, more valuable than in expressing an opinion upon such a growth ; even under the microscope, there are certain cystic-solid tumours on which it is difficult to express a decided opinion. The relative proportion of benign to malignant tumours varies considerably ; thus Macnaughton-Jones^ collected the figures from German clinics, and in a series of 2893 cases only 11 per cent were reported as malignant; while Mrs. Scharlieb^ found i6-6 per cent malignant out of 150 cases, and Glendining* found 17 per cent carcinomatous out of 106 cases occurring in the Chelsea Hospital for Women in the years 1908 and 1909. From the point of view of prognosis, we have always been in the habit of dividing ovarian tumours into three groups : (i) The simple (forming the largest) ; (2) The semi-malignant ; and (3) The malignant. 1. The Simple. — In the simple unilocular ovarian cysts, the results of operation are good : probably there is no more uniformly successful operation in surgerj^-. A small proportion of cases have to be opened up again owing to slipping of the ligature round the pedicle, and occasionally such a case is lost. This accident usually results from ligaturing a large pedicle together with a piece of the broad ligament, so that when the uterus is pulled on or displaced, a portion of the ligated tissues tends to be withdrawn. A more remote accident occasionally follows failure to bury the stump of the pedicle ; in such a case the sequence of events is the formation of a band, the passing of gut under the band as in hernia, and eventual strangulation. 2. The Serai-malignant. — This variety comprises those ovarian tumours known as proligerous cystadenomata and papuliferous ovarian cysts. In these cases, the chief difficulty arises in excluding malignancy, as many of thenx simulate columnar-cell carcinoma very closely. They are here distinguished from the properly malignant cysts because they do not show true metastases : secondary masses are the result of contact implantation ; they are practically never found outside the abdominal cavity unless they occur in the scar of an abdominal incision ; and they do not invade the lymphatic glands. The presence of secondary nodules on the peritoneum, omentum, or intestine is not to be taken as indicating hopeless malignancy. Thomlin'' has recorded cases in one of which there were vegetations all over the peritoneum, and yet at the end of four years the patient was apparently well and cured ; while in another case, having to leave a tumour the size of a hazel nut in the pouch of Douglas, he was able to assert three and a half years later that this mass had not increased in size. Pozzi'' says that he has himself observed that vegetations present on the intestines at the first operation were absent at a second operation. 382 " INDEX OF PROGNOSIS The presence of ascites, although obviously a grave complication, is not to be regarded as hopeless, as numerous observations have been made in which the ascites was not necessarily fatal. The gelatinous fluid often encountered in some cases in this group must be taken as grave, but is indicative of the semi- malignant character. The ordinary rules as to recurrence in malignant growths scarcely apply to the cases belonging to this group. Thus, Pozzi^ operated on a young girl with enormous ascites, and removed double papillomatous ovarian cysts ; after twenty years the growth took on malignant characters, and the patient did not survive the second operation more than eighteen months. Such an observation, although extreme, is typical of many cases, and leads to the conclusion that in some instances the growths take on a more malignant nature. The clinical characters of the more malignant tumours in this group are — rapid and sudden enlargement, rapid loss of weight with cachexia, extensive fixation to neighbouring viscera and structures, considerable oedema of the limbs and abdominal wall when the volume of the tumour and the amount of ascites is taken into consideration, and, finally, the presence of pleurisy. The operative results in these cases are not good. In Mrs. Scharlieb's^ series, the immediate mortality — that is, within a month of operation — was about 15 per cent, and at least 50 per cent were known to have died within three years. There seems to be no doubt that many cases in this group, if caught early before dissemination has occurred, are comparatively successful : when ascites and secondary vegetations are observed, it is still advisable to remove both ovaries if possible, as although the condition is ultimately almost certainly fatal, yet in some cases life is prolonged for years. Many cases will require tapping from time to time, in order to relieve the intra-abdominal tension. This simple operation has been performed a considerable number of times — over a period of years in some cases. 3. The Malignant. — The third group includes malignant tumours, whether cystic or solid. In these cases the outlook is not promising. If at the time of operation there is no evidence of secondary spread — as shown by vegetations on the peritoneum, and the presence of free fluid — the prognosis is generally regarded as better ; but it is surprising how frequently such cases return with metastases within the year ; the original diagnosis was that of an endothelioma or cystadenoma, but in the light of subsequent history it has often to be changed to one of adenocarcinoma. Kachel® reports that, of all malignant ovarian tumours upon which operation is performed, only 20 per cent are alive after two years, and that a considerable proportion of these cases have extensive recurrences of growth. Secondary Changes. — -Axial rotation occurs in about 2 per cent of cases of ovarian cysts, but generally is much more common in dermoid tumours and in cysts of medium size and ovoid form. The operative results are uniformly good, provided infection and necrosis have not occurred. Infection most commonly occurs following an axial rotation. Provided the case is seen before extensive peritonitis has occurred, the results are good, if drainage is employed for a few days in all cases showing any rise of temperature. Later results following mild infection of the ovarian tumour are seen in dense peritoneal adhesions, rendering operation tedious and difficult, and greatly increasing the risk. Rupture was found by Spencer Wells, in a series of 1000 cases, to take place in 2-4 per cent, but this figure appears abnormally high. In the majority of cases, rupture is caused by rough examination, occurs in broad-ligament cysts, and is attended by no ill effects. In a few cases, however, papillary cysts and dermoids rupture, causing dissemination of vegetations or dermoid structures. PANCREATIC CYSTS 383 Ovarian Tumours and Irradiation. — Ovarian tumours have been treated by X rays on the assumption that iibroids were under treatment, with the result that shrinkage has been described in one or two instances, but no record of complete disappearance exists. Kelly and Burnam'' record a case of an ovarian cyst which, one year after 60 mgrams of radium had been applied for forty- seven hours, showed a reduction in volume from 8 to li inches in diameter. Ovarian Tumours and Pregnancy. — The questions of operative interference and the result to be expected therefrom have special importance when pregnancy is complicated by the presence of an ovarian swelling. The inclination both of the medical attendant and of the patient is to postpone any operative inter- ference; but the following figures taken from a statistical article by Barrett, ^ point unmistakably to the conclusion that the operative line of treatment is much the better course. He gives the results in 114 cases. Of these, 76 were operated upon before term : the maternal mortality is given as 1-3 per cent, and abortion or premature delivery occurred in 12 per cent; in 8 cases double ovariotomy was performed, and in six of these cases, pregnancy con- tinued to term. The other 38 cases were treated expectantly and were not operated upon before term : the maternal mortality was 18-4 per cent ; of the total 38 cases, 7 escaped operation, but 4 of these died, and the remaining 3 still have their cysts. Prognosis of Ovarian Cysts apart from Operation. — In the absence of operative treatment, the question of the prognosis is more difficult. It is necessary to refer to older writers, such as Spencer Wells*, who had occasion to see numerous patients who refused operation. He asserted that when the C3'^st had attained such a volume that the general health was affected, the duration of life would not exceed two years, and that these two years were full of misery, pain, and despondency. On the other hand, T. P. Franck records a case of a cyst known to exist at the age of 13, and still present at 88 years of age. Also cysts have been known to exist for twenty -five and even fifty years, but were generally of dermoid nature. References. — ^Proc. Roy. Soc. Med. (Obst. and Gyn. Sect.), 1910, i, 97 ; ^Ibid. 85 et seq. ; ^Ibid. 96 ; *Med. Times, 1881, i, 213 and 275 ; '"Traite de Gyn. ii, 933 ; ^Centr. f. Gyn. 1907, li, 1603 ; ''Jour. Amer. Med. Assoc. 1914, ii, 622 ; ^Surg. Gyn. and Obst. 1913, Jan.; ^Ovarian and Uterine Tumours, 1882. Bryden Glendining. FACET'S DISEASE. — [See Osteitis Deformans.) PANCREATIC CYSTS. — Cysts of the pancreas, excluding hydatids and blood cj^sts, are usually due to pressure upon the pancreatic duct, either by chronic inflammation of the head of the gland, or scarring after an injury. This being so, they almost invariably show a steady increase in size which necessitates inter- ference, though they may not at the time be causing any great inconvenience. The usual procedure is to open the cyst, perhaps apply carbolic acid to its interior, plug it with gauze, and drain. To attempt to dissect it out is ordinarily too dangerous to be worth the trouble. The simple operation for drainage is not very serious. Of 160 cases in the literature collected by Mayo Robson, 20 died and 140 i^ecovered, though i died later of diabetes. Of 138 cases treated by incision and drainage, 16 died of 22 treated by partial or complete excision, 4 died. Mayo Robson himsel had II patients, of whom 10 recovered. There is, however, a good deal of trouble occasionally from persistence of the sinus, and the discharge may contain active trypsin which leads to self-digestion and a raw painful condition of the skin about the orifice of the drain. On the other hand, if the sinus closes, in a few cases the cyst has reformed. a. Rendle Short. 384 INDEX OF PROGNOSIS PANCREATITIS. — We shall have to consider, (1) the prognosis of Acute pancreatitis, including the suppurative, haemorrhagic, and gangrenous varieties ; (2) Abscess of the pancreas; and (3) Chronic pancreatitis. I. Acute Pancreatitis. — B}- this we mean an acute attack of \'iolent pain in the upper abdomen, \\ith some fever and vomiting and it may be diarrhoea, which is of such severity that an explorator\- operation is performed and reveals extensive areas of fat necrosis, and a swollen, inflamed, suppurating, haemorrhagic, or gangrenous pancreas. It is almost impossible to make a diagnosis during life with any certainty- apart from the operation-findings. It is therefore not feasible to give any account of the prognosis in non-operated cases. Although very grave, the condition is by no means hopeless. Thus Moynihan records 7 recoveries out of 11 operations. At St. Thomas's Hospital, 1907-1911, there were 16 cases \^'ith 7 recoveries and 9 deaths ; at the ^Middlesex Hospital 8 cases -with 2 recoveries and 6 deaths. On the other hand, at three Bristol hospitals, of 7 cases all died, and Blaxland and Claridge have reported a series of 7 cases, all fatal, at Norwich. Korte finds in the hterature 103 cases oper- ated on by fifteen surgeons ; 41 recovered and 62 died. In his own clnic, 34 patients were treated by drainage of the pancreas ; of these, 18 were cured and 16 died. The death-rate is therefore probably about 60 per cent. Death-rate after Operation for Acute Pancreatitis. Movrdhan 11 j 4 St. Thomas's Hospital - 16 1 'J Middlesex Hospital 8 6 Bristol - - - - 7 7 Norwich - - - - 7 1 Korte (literature) - 103 41 1 62 Korte (personal) 34 18 1 16 The prognosis varies with the following conditions : — a. The Time of Operation. — Thus Korte relates : Operation in first week, 12 cases, 8 cured, 4 died ; in second week, 4 cases, 3 cured, i died ; operation in 3rd and 4th weeks, 14 cases, 7 cured, 7 died ; operation later, all died. It would appear, however, that Korte's series must include a number of mild cases, because in Enghsh practice the patient is frequently dead in a week,' whether operated on or not. b. The Nature of the Operative Interference. — Mikulicz quotes from a series of cases in the literature, where on 36 occasions the pancreas was actively attacked (by blunt puncture, etc.) and drained, 25 recovering and 11 dj-ing ; in 41 in- stances it was left alone, and only 4 recovered. Too much importance must not be attached to these figures, because it is probable that the first group contains less acute cases where a definite abscess was found, and that the latter group would include the gangrenous and haemorrhagic cases where there is little to be done except put a drain down to the pancreas. In Korte's series, 7 cases were drained posteriorly ; of these, 5 died. c. The Operation Findings. — The gangrenous and hjemorrhagic cases are very grave indeed, and seldom recover (2 out of 13 in Korte's clinic). When there was acute pancreatitis without necrosis or pus, Korte saved 11 out of 14. It is difficult to mention a time of average survival, because the patients differ so. In many cases, they are ill for less than a week before death terminates their PARALYSIS AGITANS 385 sufferings. Others drag on for a month or more ; they are very liable to suffer from self-digestion of the wound, subphrenic abscess, or pneumonia. Korte had 7 cases of severe post-operative haemorrhage, all but i proving fatal. The writer has published a case of acute pancreatitis of the accessory pancreas in the wall of the jejunum, which proved fatal in spite of operation. 2. Abscess of the Pancreas. — Although grave, the outlook in this group is by no means so serious as in the acute class just discussed. Abscess of the pancreas is generally the late result of a relatively mild attack of acute suppurative pancreatitis. Korte had 7 cases with 5 recoveries. Villar has abstracted from the literature 53 cases of abscess of the pancreas, whereof 33 recovered and 20 died. Some of those who recovered from their immediate trouble were b^' no means perfectly cured, but eventually developed symptoms of diabetes, phthisis, or extreme wasting. 3. Chronic Pancreatitis. — We include here those cases in which there is chronic jaundice and perhaps also pain, the diagnosis from gall-stones on the one hand and cancer of pancreas on the other being difficult if not impossible. We do not, in this section, include those cases in which the classical symptoms of diabetes supervene, but there is always the possibility to be borne in mind, in giving a prognosis, that this disease may eventually declare its presence when there is known to be cirrhosis of the pancreas already present. It is not probable that chronic pancreatitis will get well, apart from operation, when it has advanced so far as to produce persistent jaundice. Two methods of treatment are possible, cholecystenterostomy and drainage of the gall-bladder. The operation mortality is given by Mayo Robson as 8 deaths in 113 cases from the literature, so that the true mortality may be about 10 per cent — higher, no doubt, after cholecystenterostomy than after simple drainage. Neither operation can be relied upon to give first-class results ; the fistula may fail to close, and if the gall-bladder and duodenum have been short-circuited, sepsis may invade the bile-passages from the bowel. Accurate figures are lacking, but probably the majority of the patients are cured by a cholecystenterostomy. References. — Mikulicz, Ann. Surg. 1903, ii, i ; Sampson Handley, Archiv. Middlesex Hosp. 1912, Feb. 20 ; Korte, Ann. Surg. 1912, Iv, 23. ^. Rendle Short. PAPILLOMA OF THE LARYNX.— (See Larynx. Papilloma of.) PARALYSIS AGITANS. — This is a progressive, but not a fatal, malady. Be- ginning unilaterally in most cases, it may remain confined to the face and limbs, of one side for years ; but sooner or later the other side also becomes affected with the characteristic rigidity and tremor. Worry, excitement, business anxiety, and strenuous mental exertion all aggravate its symptoms. The rigid, mask- like face, with its expression of unutterable sadness, not infrequently disguises a cheerful, and even a humorous, frame of mind ; although, in other cases, the patient becomes depressed by the consciousness of the inveterate nature of his malady. The intellectual faculties, however, are usually preserved unimpaired, even in the most advanced stages of the disease. By the judicious administration of hyoscine, we can usually mitigate not only the rigidity and tremor, but the characteristic restlessness which is so trying to the patient. Purves Stewart. PARALYSIS, BULBAR.— (.See Bulbar Palsy.) PARALYSIS, INFANTILE.— (5ee Infantile Paralysis.) PARANOIA. — (See Mental Diseases.) 25 386 INDEX OF PROGNOSIS PARATYPHOID FEVER.— There are two varieties of this disease, the one due to the Bacillus paratyphosus {A), and the other to the Bacillus paratyphosus (B). The former is met with in Asia, and especially India, and not in Europe ; the latter, on the other hand, occurs in Europe and is rare in Asia. The fatality of paratyphoid (A) is about 2 per cent ; of paratyphoid {B) about 3 per cent. The fatahty is therefore much lower than that of typhoid fever. But paratyphoid cannot be distinguished from typhoid fever except by bacterio- logical examination of the blood and stools, or by careful agglutination tests. Death in paratyphoid fever is usually due to some complication ; and the complications are much the same as are met with in typhoid, though their incidence in the one disease is much lower than in the other. If, therefore, any complication arises, the prognosis should be based on the same considerations as apply in the case of typhoid fever. £. J4/. Goodall. PELIOSIS RHEUMATICA.— (5ee Purpura.) PEMPHIGUS AND PEMPHIGOID AFFECTIONS. — It is important to define exactly what diseases are included under the term pemphigus before endeavouring to estimate the prognosis. The description ' pemphigus ' has been applied to many eruptions characterized by the formation of bullae or blisters, but the use of the word is now more limited. Recently the convenient term ' pemphigoid ' has been coined to cover a number of allied conditions which will be considered here. Pemphigus Neonatorum is a bullous variety of impetigo occurring in newly -born infants. The eruption is chiefly on the trunk, and is often associated with a septic condition of the umbilicus. The mortality is about 30 per cent. The cause of death is generally septicaemia or pyaemia, the infection becoming generahzed through the umbilical stunip. Provided the lesions are confined to the skin, and that they are properly dressed by antiseptic ointments, the outlook is not unfavourable. Pemphigus Contagiosus is the name given to a bullous impetigo which is most commonly seen in the tropics, but is occasionally met with in this country. The eruption consists of large blebs filled with a serous fluid at first, but subsequently the contents may become purulent. To this eruption the name pemphigus is often given, and many of the so-called mild cases of the disease are of this type. The eruption usually yields rapidly to antiseptic treatment. Epidermolysis Bullosa (so-called Hereditary Traumatic Pemphigus) is a rare affection, characterized by the formation of blebs containing serum or blood, caused by slight friction or pressure which, in the normal subject, would be unattended with any reaction whatever. It varies very much in its severity, and various degrees are often seen in several members of the same family and through several generations. If severe, it may incapacitate the sufferer from doing ordinary labour throughout life. In the less severe cases, it is a constant source of annoyance and a hindrance to work. Moreover, the abraded surfaces are Uable to infection. Though the disease must be looked upon as incurable, there are cases in which the development of the blebs becomes less marked with the approach of puberty. Dermatitis Herpetiformis. — This affection is one of the most troublesome m the domain of dermatology. It is characterized by the development of a poly- morphic eruption, consisting of erythematous areas Avith groups of herpetiform vesicles or bullae of variable size. The eruption is attended with great irritation, and sometimes with pain. It tends to develop in earl}^ life, and may persist for many years. The attacks occur at intervals, and vary greatly in their severity. PENIS, CARCINOMA OF 387 In some cases the periods of intermission are very short, so that the sufferer is rarely free from the eruption ; in others, there are long intervals between the attacks. An attack can usually be controlled by arsenic, pushed to the capacity of the patient, and by ointments containing sulphur. In some instances the patient is able to carry on his avocations owing to the limited area affected ; in others an almost complete incapacity is produced. We are ignorant of the cause of the affection, and are, therefore, unable to do more than temporarily relieve the condition. Hydroa Gravidarum or Hydroa Gestationis is dermatitis herpetiformis occurring in pregnant women. It commonly appears between the third and sixth month, and often recurs with successive pregnancies ; as a rule, the severity of the disease increases with each succeeding attack. In many cases the eruption clears up soon after the delivery of the child ; but in some instances the disease may start after parturition. It is rare to find the condition so severe as to determine the pregnancy, and recovery is the rule. Pemphigus Acutus. — This is a rare affection occurring in butchers and others who handle dead carcases. It is believed to be due to a diplococcus, which has been isolated by Bulloch and others. The prognosis is extremely grave. The symptoms are those of a grave septicaemia, and death occurs in 75 per cent of the cases, in from one to three weeks after the onset of the disease. In the minority of the cases, convalescence begins in from three to four weeks. Pemphigus Chronicus. — This disease, which is somewhat rare, is of grave prognosis. Of 30 cases admitted with this diagnosis into the wards of the London Hospital, 19 died, but this does not represent the entire mortality, because several cases running a very chronic course were removed to the infirmary and died there. It is exceedingly difficult to state at the onset what course the affection is likely to run, for many cases begin with a limited eruption which gradually extends in spite of treatment. As a rule, the younger subjects are most likely to recover. The fatal issue usually occurs in from three to eighteen months, but in some cases a longer course is seen, the disease passing on to pemphigus foliaceus. Pemphigus Foliaceus. — This variety of pemphigus is characterized by the formation of flaccid bullae, followed by a condition of general exfoliation of the skin. It may be primary, or the sequel of the chronic form of pemphigus, or rarely of dermatitis herpetiformis. The course is chronic, and the affection may persist, with exacerbations and remissions, for two or three years or longer. A fatal issue is brought about by gradual asthenia, diarrhoea, or some intercurrent disease. Pemphigus Vegetans. — This is an exceedingly rare disease, characterized by the formation of bullae in the base of which vegetations rapidly develop. The fatal issue usually occurs in from two to six months. Though nearly always fatal, a few cases occur in which the eruption is limited to the limbs and trunk, and runs a benign course. j. //. Sequeira. PENIS, CARCINOMA OF. — Prognosis always depends upon accurate diagnosi.', and therefore it will be necessary, before giving an opinion as to the outlool, to make certain that the condition is not a tertiary syphilitic ulcer, primary chancre, or mass of hard warts, all of which are, of course, curable conditions. Epithelioma of the penis is not a particularly malignant variety of cancer. Apart from operation, it always leads to a fatal termination in the course of one to three years. Various methods of operative treatment are in use, such as : Amputation of the penis ; extirpation of the penis (Pearce Gould's method) ; one of the above INDEX OF PROGNOSIS with bilateral removal of inguinal glands, either at the same time or subse- quently. The disease is uncommon, and reliable statistics are not easy to obtain. Mere amputation of the penis, except in a broken-down subject, is a trifling operation. At St. Bartholomew's Hospital, prior to 1900, there was i death in 53 cases. The mortality of Gould's operation at that time was said to be 6 per cent. Clearance of the groin glands would, no doubt, add to the risk to some extent, but the immediate danger to life depends far more on the general health of the individual than on the exact nature of the operation. The end-results were worked out by Butlin^ in a series of 65 cases treated, prior to 1900, by simple amputation of the penis, usually without clearance of the inguinal glands. Of 65 cases followed three years, 23 were still free from recurrence, or 35 per cent. There were no difficulties with micturition, and coitus was still possible for some of them. The principal factors in prognosis are the rate of growth up to the time seen and, especially, whether the groin glands are palpably enlarged ; if they are, the outlook is much more serious than in cases where they cannot be felt. Of 9 recurrent cases, in 3 the growth returned in the penis, and in 6 in the groin glands only. This is, of course, a strong argument for clearance of the inguinal region. It also demonstrates that total extirpation of the penis by Gould's method need only be adopted for extensive growths, because there is no great tendency to spread back in the corpora cavernosa. It would no doubt be wise, and it is quite possible, to remove the lymphatics of the deep fascial plane in a continuous sheet, from the growth to the inguinal glands, by a dorsal incision along the penis. Even if the patient is not permanently cured, amputation of the penis is nearly always a great relief to liim. Reference. — ^Butlin, Operative Surgery of Malignant Disease, 2nd ed. A. Rendle Short. PERICARDITIS. — {See also Rheumatic Peri-, Myo- and Endocarditis.) Nowhere is a knowledge of etiology and pathology more essential to clinical accuracy than in pericarditis. It is quite futile to attempt a forecast of the probabilities in a case of pericarditis without knowing how it began. There are two reasons for this. First, the lesions underlying or associated with peri- cardial inflammation may have far more bearing on the course of the case than the pericarditis itself. Second, inflammation of the pericardium runs a very different course according to the cause. The commonest of all the forms of pericardial inflammation is that which is associated Avith rheumatic carditis. As this is discussed under a separate heading (see Heart, Chronic Valvular Disease of), no more need be said here than will serve to bring it into line with the other types. First, it is scarcely accurate to speak of rheumatic pericarditis as if it were of itself a disease. It is never more than one feature of that which includes it — namely, rheumatic pancarditis. When the rheumatic infection attacks the heart, the muscle and the mitral valve are always injured, the pericardium nearly always, and the other valves sometimes. When the pericardial inflam- mation is sufficiently intense, it gives rise to an audible rub. This is so striking a feature of the case that it is labelled ' pericarditis,' and the fundamental fact that the whole heart, and not the pericardium only, is damaged, is lost sight of. Second, the fact that there are signs of pericarditis is nevertheless of considerable prognostic importance, for it is a proof that the dose of infective agent that has been cast into the heart by its coronary blood-supply is a large one. The mortality of cases in which a rub is heard is much higher than in cases of PERICARDITIS 389 rheumatic carditis without friction (20 per cent, as compared with a mortality certainly under 10 per cent even if only severe cases be included). Third, the permanent disabling of the heart is greater in cases of rheumatic carditis with implication of the pericardium than it is in those that show no signs of pericarditis, for a certain amount of adhesion is an inevitable result of rheumatic pericarditis. The extent to which these adhesions inflict real disability on the heart is doubtful ; some allusion to this matter will be made below. Finally (and this also will be discussed below), effusion into the pericardial sac is a very rare complication of rheumatic carditis. Most of the cases in which this used to be diagnosed were in reality cases of acute dilatation due to myocarditis. The whole import of rheumatic pericarditis, therefore, is that it is a sign that the attack of carditis of which it is one feature is a severe one. In general, the more definite and intense the signs of pericarditis, the worse is the outlook ; but the state of the myocardium is far more important than that of the pericardium, and it is in this direction that one should look for guidance in prognosis. A second type of pericarditis is that provoked by the pneumococcus . This may occur as a complication of lobar pneumonia in adults, or in small children in connection with empyema. In the latter group it is difficult to detect and equally difficult to treat ; the results are therefore very bad. The examples of accurate diagnosis and early operation are very few ; whereas suppura- tive pericarditis is a fairly common complication of pneumococcal empyema in infants and young children. Of the 102 cases complicating lobar pneumonia collected by various writers, 70, or 68 per cent, ended fatally. This of course excludes cases in which the diagnosis was only made post mortem. In both types of case it is possible that operation facilitated by early diagnosis might not have saved raany lives ; for when pericarditis occurs in small children, the patient is nearly always very ill as a result of an empyema, of which the pericardial lesion is only a complication : and the adults who show signs of pericarditis with their pneumonia are often of the type that resists the original disease badly. Moreover, the pneumococcal effusions are seldom large, so that even if operation were more often possible it might not add a great deal to the patient's chance of recovery. Still, the fact remains that if there is an effusion of any bulk, nothing but operation can save the patient's life. The choice of operation will be considered below. Cases of tuberculous pericarditis do better so far as the immediate results of operative procedure are concerned. It is true that of 42 cases so treated, only II are regarded by those who report them as being cured ; but this is because in many instances temporary amelioration was followed by aggravation of the lesions in other organs. Tuberculosis of the pericardium is nearly always part of a more general infection, and it is on this fact that the prognosis largely turns. There are two kinds of cases, the chronic adhesive and the acute exudative ; the former complicates the more chronic form of pulmonary tuberculosis, the latter arises as the result of generalized infection. The patient's chances of survival turn in part only on the course of his pericardial infection, if there be tuberculosis of other tissues. If it be merely one event in a generalized miliary tuberculosis, it is obvious that the only prognostic importance of signs of tubercu- losis of the pericardium is that they reveal something of the intensity of the infection, and by that much add to the gravity of the prospect. Much the same is true of the pericarditis which may complicate the various forms of septiccBmia and pycemia. In many cases, no doubt, it is only at the post-mortem that these lesions are found. This fact was borne in upon the writer some years ago, in the course of an investigation into the cardiac lesions of pyaemia. The number of cases of pyaemia recorded in the autopsy books of 390 INDEX OF PROGNOSIS the old pre-antiseptic days of surgery was in itself a revelation ; and in a very large percentage of these the pericardium, contained pus. Nowadays this type of pericarditis is happily less familiar, but we encounter it sometimes as a feature of puerperal septicaemia, acute osteomyelitis, and the hke. When it occurs under these circumstances, pericarditis is of necessity a grave factor in an already unpromising situation, since it furnishes evidence that the circulating blood is saturated with micro-organisms. But this does not carry with it an immediate sentence of death, for the literature contains several instances of recovery after surgical treatment of pyopericardium due to this type of infection. It is true that in most of these cases death has not been long delayed. Some other lesion of a vital organ, arising from the same infective process, kills the patient, even though the pericardiuni has been successfully drained. Pericarditis is an occasional complication of typhoid fever. It is not invariably fatal ; two of the three cases observed by Thayer. recovered. The same is true of pericardial lesions provoked by gonococcal infection ; in the case recorded by Robin and Fiessinger recovery followed paracentesis. In the pericarditis of scarlet fever the prognosis depends on the nature of the organism provoking it. If the pericardial inflammation be but one incident in the course of a severe septic scarlatina, its importance is that it adds to the gravity of the prognosis. If it arise during or after convalescence, it is most probably rheumatic, and the prognosis is that of acute rheumatic carditis. Four other forms of pericarditis remain to be considered. The so-called terminal cases, due to streptococcal and staphylococcal infection, and compli- cating chronic diseases, especially renal disease, are not always fatal. It is impossible to set this statement on a statistical basis, because there are two facts which vitiate any calculations — the difficulty of discerning between true peri- carditis and mere hydropericardium, and the very small percentage of pericardial lesions of this type which are diagnosed during life In general it may be said that the appearance of pericarditis in any chronic disease such as diabetes, Bright's disease, or cancer, adds substantially to the immediate risks, the chance of survival depending almost entirely on the general condition of the patient at the onset of the pericarditis. In traumatic pericarditis the outlook naturally depends on a variety of factors, apart from the state of the pericardium itself. Limiting our consideration to the pericardial lesions as far as possible, we find that, if all cases be included, the mortality is about 40 per cent. If only those cases be counted in which the injury has failed to penetrate the chest wall, it seems that about three-quarters get well. In the open cases the occurrence of air in the pericardium is not necessarily fatal. When the pericardium becomes implicated in malignant disease arising within the thorax, signs of pericarditis may become manifest. In such, a promise of immediacy is added to an already fatal prognosis. This is particularly true of perforation of the cancerous oesophagus into the pericardial. cavity. Last of all, there is the pericardial rub which, appearing suddenly in a case of chronic myocardial disease, furnishes proof of some gross lesion of the cardiac wall — thrombosis, embolism, or rupture. This is always a sign of the utmost gravity, for even if the patient be not immediately destroyed, his survival cannot be more than brief. But it is not only as a revelation of sinister forces that pericarditis carries a threat of death. The rapid collection of fluid within the pericardial sac may kill the patient. There is also the formation of adhesions, and their influence on the cardiac efficiency, to be thought of. Acute sero-fibrinous pericarditis cannot of itself kill the patient ; but it does on the one hand prove the existence PERICARDITIS 39i of certain collateral dangers, such as rheumatic myocarditis ; while on the other hand it threatens more or less directly to hamper and possibly overcome the heart by leading to pericardial effusion or adhesion. Effusion into the pericardium, in amounts sufficient to endanger the life of the patient, is a very rare result of rheumatic infection. Some eminent observers declare that it never amounts to enough to call for paracentesis. There are, however, a number of cases of the kind in which it has been thought necessary to puncture the sac. In these the results were roughly as follows : the course of the case was not materially altered in about 50 per cent ; in 25 per cent there was some transient improvement ; while in the remaining 25 per cent paracentesis appeared to give material and lasting relief from a condition of urgent peril. The writer has never seen a case of rheumatic pericarditis in which the operation would have been justified, either by the signs during life or by the post-mortem findings. In the series of cases of effusion into the pericardium brought forward at the Royal Society of Medicine discussion in 1910, there were only 9 rheumatic cases in which it had been thought advisable to empty the sac, and in only 3 of these was life prolonged by the proceeding. Clear effusions are perhaps more characteristic of tuberculosis than of any other infective process, but they are often semi-purulent in this disease. As has been already remarked, the immediate outlook in those cases of tuberculous effusion that are diagnosed during life (about 6 per cent of all cases) is fairly good ; the choice between paracentesis and pericardiotomy seems to depend on the character of the fluid, the former procedure sufficing for the clear cases, while the more elaborate operation is called for if the exudate be puriform. At any rate, the results in the published cases, in which this rule seems to have been roughly followed, work out about equal. It should be added that if the exudate be hsemorrhagic, this is no contra-indication to paracentesis, as cure has followed the operation is several such cases. This is true of pericarditis due to other infections beside tuberculosis. The dangers of simple hydropericardium are as a rule overshadowed by the more direct risks implied by the underlying lesions, and the outlook is therefore that of the cause. Pyopericardium is a desperately dangerous disease, whatever the infection that is responsible for it. The risks are, first, those due to such other lesions as the causal infection may have provoked ; second, those that arise from the fact that purulent pericarditis is very difficult to detect (in only 6 of Poynton's 100 cases in children was it diagnosed during life) ; third, those that are due to the risks of surgical treatment, the only form of treatment that can hold out any hope of cure ; and finally, those that are included within the possibility of increase of the effusion to the point at which the cardiac movements become fatally hampered. Suppose the condition has been detected in a patient who is fit to be operated on ; what plan of treatment promises the best results ? The figures published by various writers, and tabulated in Blechmann's excellent monograph, show that mere paracentesis has never saved life ; that the percentage of survivals after incision of the pericardial sac is about 46 in a total of nearly 100 recorded cases ; that the recovery-rate following simple incision is 28 per cent ; after pericardiotomy with costal resection, 55 percent; after operation through the epigastric incision recommended by Ogle, 66 per cent. These figures demonstrate clearly the superiority of the methods in which free drainage is secured. Such figures as are available are not very convincing as to the advisability or otherwise of drainage in pericardial tuberculosis ; but the general opinion of surgeons and physicians, expressed at recent discussions, is to the effect that if incision be practised at all, it should be sewn up and not left to drain. 392 INDEX OF PROGNOSIS In pneumopericardium the outlook is of necessity dependent to a large extent on the antecedent conditions ; and as it often forms a late incident in a morbid process that would be sufficiently desperate even if there were no irruption into the pericardium, it is not to be wondered at that the death-rate is high — 28 out of 43 cases (Cowan, Harrington, and Riddell). The more abrupt the invasion of the pericardial sac, the worse the prognosis. There remains to be considered the vexed question of chronic adhesive peri- carditis. This is met with under several sets of circumstances. In the cardiac rheumatism of childhood, some adhesion is very common (in three-quarters of Poynton's autopsy cases, and nearly half of the writer's). In the various forms of chronic indurative mediastinopericarditis the sac is more or less obhterated. A third rare group of cases is that embraced within the term ' polyserositis.' These may be due to tuberculosis or to no obvious cause. It would at first sight appear to be a simple matter to accept the position that adherent pericardium is always a serious condition ; but there are two considera- tions that complicate the issue. In the first place, all the diseases named inflict other disabihties on the heart or other vital organs, and it is difhcult to separate these from the direct effects of pericardial adhesion. In the second place, the fact that the pericardium is adherent is by no means always discoverable clinically. The rheumatic type of case is by far the commonest, and here there is, in the writer's opinion, no reliable sign of pericardial adhesion. Of all the phenomena that have been described as pointing in this direction, there is not one that may not be present in the absence of adhesion ; and it would seem that all of them are due rather to the great cardiac enlargement that is so constant a feature of just those cases in which post-rheumatic adhesion of the pericardial sac is likely to occur — in the adolescent or young adult who has just managed to survive repeated attacks of acute rheumatic carditis, though with a heart much enlarged and otherwise crippled. Be this as it may, the fact no doubt remains that in those cases of post-rheumatic disease in which there are adhesions not only obliterating the pericardial sac but also binding the epicardium to the neighbouring tissues, the heart carries on its work far less efficiently than in cases where there are only valvular disabilities to be overcome. If, therefore, the clinician feels himself in a position to diagnose this condition in a case of post- rheumatic heart-disease, the prognosis he must form will be much graver ; patients in this class of case rarely attain the age of thirty. In the non-rheumatic type of case the prognosis is to be reached along the same lines ; if there be signs of adhesion uniting both pericardial layers into one membrane, and that again into inseparable fusion with the surrounding tissues (and nobody claims to be able to diagnose mere intrapericardial adhesions), then the prospect of cardiac failure, within a few years at the outside, is added to such other portents as the disease in its attack on other organs may furnish. The main interest of the question as to the influence of treatment on prognosis centres around the effect on the patient's outlook of the operation described by some as cardiolysis, but more accurately by others as thoracostomy. Of 30 cases of which the writer has been able to collect the reports, only i died as the immediate result of the operation ; of the remainder, 7 are described as receiving little or no benefit, while in the remaining 22, various degrees of improvement were observed. In reading these records, one is struck by the fact that the disappointments occurred principally in the rheumatic cases, and operations of this kind are not likely to be practised in the future for such cases, except perhaps as giving space to an enlarged heart. The cases most likely to benefit from this operation belong to the polyserositis group. Carev F. Coomb's. PERITONITIS, PNEUMOCOCCIC. — {See Pneumococcic Peritonitis.) PERITONITIS, TUBERCULOUS 393 PERITONITIS, TUBERCULOUS. — It is very difficult to appraise correctly the relative value of medical and surgical treatment in this disease. Results of Medical Treatment. — We \\all first collect the evidence as to the outlook when cases are treated by medical means only. There is no lack of statistics of a sort, but many of them are vitiated by ill-arrangement, inadequate details, or too early reporting. Thus Faludi, by adding up a mass of German reports, quotes 156 cases treated without operation, of which about a third got well ; but we do not know for how long a time they were watched. The writer has obtained details of 14 cases treated in various institutions in Bristol by fresh air, iodoform, mercurial ointment, cod-liver oil, etc. All of these were followed for at least two years, and most of them for four years or more. Of the 14, 10 were cured, i relapsed, and 3 died ; one of these last three had an immediate operation just at the end, when death was already imminent. Ochsner, by the analysis of a mass of figures, concludes that half of the cases treated medically get well ; but that half of these relapse later, so that only a quarter are finally cured. Borchgrevink followed up 17 cases treated medically ; 3 of these died, and 14 were well for two years or more. It is quite useless to set these figures up as an alternative to those obtained by surgical intervention ; for the great majority of the patients treated medically are handed over to a surgeon as soon as it becomes evident that they are not doing well ; and it is quite certain, therefore, that the Bristol cases and Borchgrevink's, for instance, are much too favourable, representing, as they do, only those patients who are not bad enough to be operated on. In an orphan asylum in Bristol, where the physician preferred to treat all cases medically, 6 were cured and 3 died ; they were all well cared for from the first, and obtained plenty of fresh air, good food, and skilled nursing ; so that these results are probably too favourable. In dealing with this disease, the worst statistical reports are more likely to be correct than the best. It is probably fair to accept Faludi's view, that about one-third will recover, and two-thirds will eventually die, apart from surgical intervention. Results of Operation. — These Eire much easier to obtain with some degree of reliability, though here also there is a tendency to report too soon. Most of the figures are taken from hospital records, and may therefore be trusted. In Caird's and Borchgrevink's and in the Bristol series, the patients were followed for more than two years ; in Czerny 's, the majority were followed over three years, but others for a lesser period ; Ochsner's and Bottomley's were traced for one year only. Results of Operation for Tuberculous Peritonitis. Eeporter Cases operated on Died within a month Cases followed Cured Relapsed or not cured Died later Bottomley - Borchgrevink Czerny - Ochsner Matteson Caird - Bristol hospitals - 41 32 53 31 33 3 1 3 7* 24 22 38 20 37 17 20 11 13 18 15 17 8 11 2 9 I 11 9 11 5 20 9 7 Total - 190 14 178 ! 93 1 13 I 72 '°'c?nfr i-6 2'7 per cent 71-3 2-0 25-7 1-0 per cent 16-8 7-9 72-2 3-0 per cent 24-7 5-3 67 -3 1-2 424 INDEX OF PROGNOSIS Particulars of After-history of Patients who were ADMITTED TO SANATORIUM WITH FeVER. Stage I STAGE II STAGE HI After -history- Turban's sanatorium (alter 1-7 years) Vejleljord sanatorium (after 2-105 years) Turban's sanatorium (after 4-7 years) Vejlefjord sanatorium (after 2-10| years) Turban's sanatorium (after 1-7 years) Vejlefjord sanatorium (after 210S years) Able to work Unable to work on ac- count of tuberculosis Died from tuberculosis Unknown per cent 90 5 5 per cent 100 per cent 44-4 14-4 37-8 3-3 per cent 77-1 22-9 per cent 12-3 7-4 77-7 2-5 per cent 20-5 3-9 7R-6 0-5 Climate, naturally, cannot be ignored. Much better results are obtained in cold or temperate climates than in hot or tropical ones. Again, results are not so good in situations which are damp, or wind-swept and exposed, as in dry or more protected situations. A change of climate is as beneficial to the consumptive as to others, but not essential. In suitable cases, an after-cure at an altitude is of service in expanding the lungs. In the later stages, life is probably prolonged if the patient is able to avoid marked climatic changes, and to reside at some place where the conditions are suitable for the particular indications of the case. Results of Sanatorium Treatment.- — The results obtained by treatment in a sanatorium vary, as might be anticipated, according to the condition of the patient and the character of the lesion at the time treatment is commenced. The results obtained when treatment is commenced in what is known as Turban's Stage I* are far better and more lasting than those obtained when treatment is commenced in Stage III. Further, the results are more lasting according to the class from which the patient is drawn and according to the character of his work and surroundings. In the case of the working classes, about 50 to 60 per cent of those treated in Stage I may be expected to be capable of work five years after their discharge from the institution ; whilst in those belonging to the upper classes, the percentage given by some authorities is as much as 80 to 90. It is unwise to rely too rauch on statistical proof under present conditions, for it is difficult to compare data from different institutions, owing to the different methods adopted in classification and treatment. For example, in some institutions a proportion of patients receive tuberculin ; in others, this remedy is not used. Certain broad conclusions, however, may be drawn, and the statistics of the results of sanatorium treatment given below are useful for that purpose. These are largely taken from the excellent chapter on this subject in Sir R. Douglas Powell and Dr. Hartley's book on Diseases of the Litngs and PleurcB. * Turban's classification may be described as follows: — Stage I. — A slight lesion which does not exceed one lobe or two half lobes. Stage II. — A slight lesion which extends further than in Stage I, but at most to two lobes ; or a severe lesion which extends, at most, to the volume of one lobe. Stage III. — All lesions which are not included in Stage I or II. N.B. — A slight lesion is equivalent to infiltration: a severe lesion is equivalent to consolidation and excavation. PULMONARY TUBERCULOSIS 425 I. — Showing Results of Treatment in 267 Cases of Early Pulmonary Tuberculosis (Stage I, Turban) admitted to the Stanhope Sanatorium during the Years 1900-1908. Year of admission Cases discharged Condition to April so, 1908 Percentafie known to be Total Returned to work At work At home Dead Lost sight of Re- admitted^ at work on April 80th, 1908 1900-1901 1901-1902 1902-1903 1903-1904 1904-1905 1905-1906 1906-1907 1907-1908 14 26 20 .. 33 35 37 51 51 14 23 21 28 30 35 45 43 7 8 7 18 16 17 29 34 1 1 1 4 5 6 15 2 10 5 6 11 7 4 1 5 7 7 8 4 7 12 1 1 1 2 1 1 50 30-8 35-0 54-5 45-7 46-0 56-9 66-7 Totals 267 239 136 33 46 50 7 50-0 * Not included in the total cases discharged during the year. II.. — Showing Results of Sanatorium Treatment in 317 Cases of Advanced Pulmonary Tuberculosis (Stage III, Turban) admitted to the Stanhope Sanatorium during the Years 1900-1908. Cases discharged Condition on April ,io, 1908 Year of admission known to be Total Returned to work At work At home Dead 12 Lost sight of Re- admitted* at work on AprQ 30th, 1908 1900-1901 12 3 0-0 1901-1902 20 8 2 — 17 1 — 10-0 1902-1903 31 17 <> 26 3 1 6'5 1903-1904 29 11 3 — . 26 — 10-3 1904-1905 37 19 6 1 27 3 16-2 1905-1906 68 25 7 8 46 7 1 10-3 , 1906-1907 62 23 10 9 41 2 3 161 1907-1908 58 24 14 32 12 — — 24-1 Totals 317 130 44 50 207 16 7 13-9 * Not included in the total cases discharged for the year. These statistics of Dr. John Gray, which are confirmed and improved upon by other Enghsh observers such as Dr. Burton Fanning, show the capacity for work at varying intervals. They also show that of the 267 patients treated in an early stage, 46 were known to be dead and 50 were lost sight of in 190S ; whereas of the 317 patients treated in an advanced stage, 207 were known to be dead. The statistics of the German State Sanatoria, although not strictly comparable, as they refer to all classes of cases, show that 44 per cent of the male and 51 per cent of the female patients were capable of working four to five years after their discharge from the institution. 426 INDEX OF PROGNOSIS III. — Showing the Immediate and After-results in Male Patients Treated in German Sanatoria under the Provisions of the Invalidity Insurance Law during the Years 1904 to 1908. Year of treatment Number of patients Immediate results, showing per- centage capable of woik after leaving the sanatorium After-results, showing the percentage of patients capable of work at the end of various years after leaving the institution. 1904 1905 1906 1907 1908 1904 1905 1906 1907 1908 16,957 19,085 21,959 22,258 26,437 79 81 82 81 81 73 61 76 53 63 77 48 54 fio 77 44 49 55 65 77 III^.. — Showing the Immediate and After-results in Female Patients Treated in German Sanatoria under the Provisions of the Invalidity Insurance Law during the Years 1904 to 1908. Year of Number of patients Immediate results, showing per- centage capable of ■work after leaving the sanatorium After-results, showing the percentage of patients capable of work at the end of various years after leaving the institution. 1904 1905 1906 1907 1908 1904 1905 1906 1907 1908 6,520 7,536 9.063 9,816 12,288 81 83 85 84 86 76 66 78 59 67 81 55 60 70 80 51 55 63 6<) 82 Slightly better results have been obtained in other German sanatoria. Thus, in the case of the Prussian and Hessian Railway Company employes, 60 per cent were capable of full work five years after leaving the sanatorium, although a considerable proportion of the cases (26 per cent in 1908) were in Turban's Stage III. IV.- -Showing the Immediate and After-results of Sanatorium Treatment AMONG THE EMPLOYES OF THE PRUSSIAN AND HeSSIAN RAILWAY Companies during the Years 1904 to 1908. Figures showing the percentage of patients capable of full ■work at the end of various years after leaving the institution Year of Number of patients treatment 1904 1905 1906 1907 1908 1904 716 81-7 74-6 66-6 63-0 59-8 1!)05 810 85 "3 76-7 71-8 68-1 1906 1,180 — — 85-8 70-0 73-0 1907 955 — — — 81-0 73-0 1908 1,152 — 82-5 PULMONARY TUBERCULOSIS 427 In patients belonging to the upper classes, the results of sanatorium treatment show that in the early cases a larger percentage are capable of work than is shown by the statistics for the working classes, and confirm the observation that treatment in the later stages is seldom accompanied by satisfactory results for any length of time. Dr. Noel Bardswell has given the results obtained in the case of patients treated by him at the Mundesley Sanatorium from 1901 to 1905, as observed to the year 1909. V. — Showing Results obtained in 241 Male and Female Patients BELONGING TO THE UPPER CLASSES AT THE MUNDESLEY SaNATOPvIUM, Norfolk, during the Five Years 1901 to 1905. All Cases considered toi ^ether Tear ot dis- charge Number dis- charged Number known to be well or alive on January 1st of each year since discharge Condition ol patients on January 1902 1903 1904 1905 1906 1907 1908 1909 1901 1902 1903 1904 1905 58 (5) 53 55 (2) 34 15 215* 49 39 48 33 39 52 27 35 43 33 26 32 36 31 13 24 31 35 29 12 22 30 34 29 9 20 26 32 28 8 Well - 99(41-0)1-7.^ Alive - 15 ( 6-2) (*' " Died - 101 (41-9) ^ Died in U9-9 sanatorium 19 ( 8-0) J Lost sight of 7 (3-0) Total 241 * In addition to these 215 cases, 7 patients (.ig ares in brackets^ were discharged, but have since been lost sight of, and 19 died in the sanatorium, making the total treated 241. Incipient Cases. 1901 10 (2) 10 10 10 9 9 8 7 6 Well - 46 (74-0) I ^... Alive - 1 ( 1-6)) '^^ 1902 15 — 15 14 14 14 13 13 12 1903 18 (2) — — 18 16 16 15 15 15 Died (none in sanatorium) 11 (17'C) 1904 11 — — — 11 11 11 11 11 1905 4 58t 4 3 3 3 Lost sight of 4 ( 6-4) Total 62 + In addition to these 58 cases, 4 patien^^s (figures in brackets) were discharged, but have been lost sight of, making the total treated 62. - Moderately Advanced Cases. 1901 24 (3) 23 17 15 12 11 11 11 11 Well -47(49-4U„.„ Alive - 10(10-5/^-'"' 1902 19 — 19 16 15 14 14 13 12 1903 25 — 24 21 16 16 16 15 Died (one in sanatorium) 35 (36-8) 1904 16 — — — J 6 16 lij 15 14 1905 7 7 7 5 5 Lost sight of 3 ( 31) Total 95 X In addition to these 91 cases, 3 patients (figures in brackets) were discharged, but have since been lost sight of, and one died in the sanatorum, making the total treated 95. 428 INDEX OF PROGNOSIS Far-advanced Cases. Year Number dis- charged Number known to be well or alive on January 1st of each year since discharge charge 1902 1903 1904 1905 1906 1907 1908 1909 1, 1909 (percentage in brackets)- 1901 1902 1903 1901 1905 24 19 12 7 4 66§ 16 12 12 8 9 10 6 6 6 6 6 4 4 4 2 5 4 4 3 2 4 4 3 3 1 3 2 2 3 WeU - 6 (7-1)1 -(..Q Alive - 4(4-7)i'^^^ Dieci(i8 in sanatorium) 74 (88 '0) Lost sight of - Total 84 § In addition to these 66 cases, i8 patients died in the sanatorium, making the total treated 84. Careful observations in the same direction have been made by Dr. Lawrason Brown and the late Mr. E. G. Pope on the results obtained in 2,222 patients admitted in all stages of the disease, who were treated at the Adirondack Cottage Sanatorium in New York State. The immediate results gave a per- centage of 56 apparently cured, and 32 arrested, out of 620 early cases. VI. — Showing the CoNnixioN on Discharge of 2,222 Patients admitted to THE Adirondack Cottage Sanatorium, New York State, U.S.A. Number of patients Condition on Discharge Condition on admission .Apparently cured (per cent) Disease arrested (per cent) Disease active (per centl Died in the sanatorium (per cent) Incipient Cases Moderately Advanced Far Advanced 620 1,329 273 56 12 32 46 16 11 40 78 003 200 6 00 The after-results of these cases, calculated in terms of 1000, showed : — 1. That 750 patients out of 1000 discharged as apparently cured survived at the end of 15 years, as against 850 out of 1000 of the general population. 2. That the expectancy of life in those discharged with arrested disease (which includes 32 per cent of the incipient cases, 46 per cent of the moderately advanced, and 16 per cent of far advanced) was between seven and eight years. Results of Tuberculin Treatment.— It is difficult to prove by any method other than the personal supervision of a large series of cases, that tuberculin is of the value in pulmonary tuberculosis that most authorities on this disease consider it. Statistics are open to many fallacies when used for such a purpose ; but it is recognized — much more strongly by physicians in Germany, Switzerland, and America than by most physicians in England, it is fair to add— that tuberculin is of considerable value both as regards the immediate and ultimate results of treatment. If this were not so, the great extension in the use of this remedy seen both in Germany and England would be unaccountable : for example, in 1905 tuberculin was employed in 36 out of 123 private and public sanatoria in Germany ; in 1906, in 57 out of 132 ; and in 1907, in 77 out of 135. In three years, then, the figures rose from 29 to 57 per cent. To my mind, the best summing up on PULMONARY TUBERCULOSIS 429 this subject is that of Dr. Lawrason Brown, who says, " Tuberculin when properly given does no harm, may produce no apparent result, and ^may markedly benefit an individual patient who can follow at the same time the hygienic-dietetic treatment while in a health resort, at home, at rest, or at work. Some patients, even in advanced stages, reap great benefit. The immediate and ultimate results are improved, fewer relapses occur, and more patients lose the tubercle bacilli in their sputum." ^My own experience is to the effect that patients suffering from consumption, and in whom there are no contra- indications against the use of tuberculin, not orily lose their bacilli in greater numbers when tuberculin is effectively administered than patients who do not have this remedy, but suffer from relapses less frequently. Statistics on such a subject tend to be fallacious, but a few may be given to support the above generalizations. The problem may be discussed from, amongst others, three points of view : (i) The disappearance of tubercle bacilli from the expectoration ; (2) The immediate results of treatment from a clinical standpoint ; (3) The ultimate results. 1. The Disappearance of Tubercle Bacilli. — Dr. Radcliff, of the King Edward VII Sanatorium, found that in patients treated by sanatorium methods and no tuber- culin, the percentage of cases in which the bacilli disappeared was as follows : — - Stage I, 45-6 per cent ; Stage II, 19 per cent ; Stage III, 8-9 per cent ; or taking all cases together, 2 3' 3 per cent. Loewenstein, on the other hand, using a more searching technique, found that in patients treated by sanatorium methods and tubercuhn, the percentage of cases in which the bacilli disappeared was as high as 5"29 per cent. Bandeher, in a similar series, found the percentage to be : Stage I, 100 per cent ; Stage II, 87'3 per cent ; Stage III, 44^2 per cent ; and Curschmann gives Stage I, 80 per cent ; Stage II, 477 per cent ; Stage III, 33-7 per cent. We may say, then, that so far as statistics go, there is evidence of the value of tubercuhn in causing the disappearance of tubercle bacilli in all stages ; and that when we take all cases in one group, we find that with sanatorium methods alone less than 25 per cent of the patients lose the bacilli from their expectoration, but that when tuberculin is added to the treatment, the percentage is over 50. 2. The Immediate Results of Treatment from a Clinical Standpoint. — Trudeau found that in the incipient cases the results were very satisfactory with sana- torium methods alone, and that they were but slightly enhanced by the use of tuberculin. In the moderately advanced cases 27 per cent of those in whose treatment tuberculin was given were cured, as against 6 per cent where tuberculin was not given ; 55 per cent were arrested when tuberculin was given, as against 51 per cent when it was not ; whilst iS per cent remained active when tuberculin was given, as against 43 per cent when it was not. 3. The Ultimate Results.- — Turban found that of 86 patients whose sputum contained bacilli and who were treated with tuberculin, 52 -3 per cent are capable of work from one to seven years after their discharge from the sanatorium ; whereas, of 241 patients whose sputum also contained bacilli and to whom no tuberculin was given, only 39-4 per cent gave a similar result. Ritter found that the following percentage of his patients were capable of work one to four j'ears after their discharge from his sanatorium (50 being examined only about one year after their discharge) : — Patients Capable of Work One to Four Years after Discharge FROM Sanatorium (Ritter). Stage I. — Treated with tuberculin, 9.) per cent; without tuberculin, 72 per cpnt „ n.-- ,, „ „ 82 „ ; ,, „ 57 „ in.— „ ,, „ 50 „ ; „ „ 22 430 INDEX OF PROGNOSIS Lawrason Brown's statistics show an advantage in favour of tuberculin, but to a slighter extent. Of his moderately advanced cases discharged with active disease, however, 41 per cent were alive of those treated with tuberculin one to fifteen years afterwards, as against 22 per cent of those not so treated. Arthur Latham. PULSE, IRREGULARITIES OF THE,— The fundamental principle under- lying accuracy of prognosis in cardiac arrhj^thmia is the same as that which has been enunciated in regard to cardiac pain ; the outlook in each case depends chiefly on the cause, for arrhythmia, like angina, is only a symptom, and not in itself a disease. There is, however, a difference between the two, for the type of irregularity that is encountered gives valuable intelligence of itself as to the state of the myocardium ; and in any case of heart disease it is the myocardium, and especially that of the ventricles, that counts. Each kind of irregularity must therefore be considered on its own merits, as well as in connec- tion with the associated lesions. Sinus Irregularity. — This comes first in order of frequency, as well as of unimportance. This aberration, in which the whole heart, ventricle as well as auricle, participates, is always due to extracardiac causes, and is therefore never indicative of a cardiac lesion. Practically, therefore, it has no prognostic significance ; though perhaps, when it develops in a case of meningitis or intra- cranial tumour, it may be regarded as evidence of increasing pressure within the skull, and assessed accordingly. From the cardiac point of view it is of the highest importance that we should recognize the lack of significance of this type of arrhythmia ; for it is extremely common in childhood and youth : so common indeed, that a child under ten with a perfectly regular pulse is a clinical curiosity. Nervous subjects are in like manner very prone to exhibit this alteration of rhythm. When the pulse, under the stress of supracardiac influences, shows an extreme degree of sinus irregularity, it is apt to alarm both patient and medical attendant, unless the latter has assured himself of its harmless origin. The mere fact that a pulse is very irregular has no prognostic meaning ; yet there are many people crawling miserably through an invalid existence to-day because, being possessed of an exaggerated sinus irregularity in early life, they were labelled as having weak hearts, and were restricted as to exercise. Any medical of&cer to a public school can tell a tale of boys sent to school with certificates of unfitness for games, certificates which have no other basis than a sinus arrhythmia. A certificate of this type is tantamount to malpraxis ; for in these days of graphic methods of analyzing the heart's rhythm, there is no excuse at all for such a mistake. Even when these methods are not available, much needless misery might be avoided if it could be realized that irregularity of the pulse, no matter how extreme, is of no significance in a child or adolescent who shows no other evidence of cardiac disease. The Extrasystolic Type of Arrhythma. — Of this condition almost the same may be said. Premature contractions, whether arising in auricle, ventricle, or junctional tissues, are due in some cases to the development of hypersensitive foci in the myocardium, in others to extracardiac influences ; not even in the first kind of case, however, does the extrasystole count for much. As James Mackenzie puts it, even in elderly people the extrasystole is of no more importance than the presence of tortuous temporal arteries. The writer has often seen extrasystoles develop in persons at or past nfiddle life, without other signs of cardiac disease, and continue intermittently or persistently for years, without introducing any hurtful condition other than the mild panic which is often experienced by patients who have become aware of their own extrasystoles. Even in cases where the pulse is confused by a whole medley of these premature PULSE, IRREGULARITIES OF THE 431 ectopic beats, the outlook is no worse than in cases where the extrasystole is occasional. When this type of irregular pulse makes its appearance for the first time in a case of organic heart disease, it is rarely of any significance. There are two exceptions to this rule. The first of these is the case of the patient with advanced post-rheumatic disease of the mitral valve — cases which usually fall within the category of mitral stenosis. Here the appearance of auricular extrasystoles may sometimes foreshadow the descent of the heart into that condition of total irregularity which may be regarded as the beginning of the end [vide infra, 'Total Arrhythmia'). But this sequence is by no means inevitable, and it w^ould be very bad practice to frighten the patient by any mention of its possibility. The other exception is sometimes encountered in persons whose ventricular contractility is becoming impaired by cardiosclerosis or other progressive myocardial disease. An extremely significant proof of this impair- ment is furnished by the supervention of the alternating pulse {vide infra). In a few cases this alternating pulse is first, and for short periods, set in motion by an extrasystole ; first comes an extrasystole, and then follows a bout of alternating beats. Even here, however, it is not so much the extrasystole as that which it ' unmasks ' (to borrow Lewis's word) that is of grave import. As a general rule, therefore, it is true to say that the extrasystole may be ignored so far as the prognosis is concerned. There is no form of irregularity of which the patient himself is more painfully aware than this ; and his restoration to a sense of well-being is often largely dependent on the confidence with which his medical adviser is able to say that there is nothing the matter with him. The assurance that must necessarily underlie the delivery of such a statement is scarcely possible of attainment, in many cases, except by means of graphic analysis of the pulse irregularity, or apart from that familiarity with the meaning of the various kinds of arrhythmia which it is hard to acquire without the practice of graphic methods. There is no area in the whole range of medicine where accurate prognosis is more absolutely dependent on accurate diagnosis than that of cardiac arrhythmia. Tachycardia. — This is the next kind of irregularity to be considered. Here it is first necessary to discriminate between quickening of the pulse by cardiac causes and that due to extracardiac influences. Tachycardias of the former class, such as those of hyperthyroidism and the fevers, are of course outside the purpose of this paragraph. Persistent rapidity of the pulse, other things being equal, is not a good sign in heart disease, but it scarcely comes under the heading of ' irregularity.' This practically limits the subject to a consideration of paroxysmal tachycardia, of a disorder, that is to say, that is characterized by attacks of rapid, regular pulse. Such attacks begin and end abruptty, without any gradual transition from or into the normal rate. Here the prognosis turns not so much on the nature of the attack itself as on the condition of the heart between and during the paroxysms. The best kind of case is that which occurs in an otherwise healthy 5'oung adult with no evi- dences of organic disease of the heart. The worst kind is that in which the patient is afflicted with advanced heart disease of the post-rheumatic or of the cardiosclerotic type, and in which each bout of tachycardia aggravates the signs of cardiac insufficiency (oedema, dyspnoea, alternating pulse, and the hke). The import of paroxysm.al tachycardia is graver, the older the patient ; in persons at or past middle life these attacks are apt to reveal myocardial inadequacy, even where it was not otherwise suspected, in the following manner : when the heart has been beating at its heightened speed for a little time, the excessive call for ventricular work begins to induce fatigue of the myocardium. 432 INDEX OF PROGNOSIS which is evidenced by shortness of breath, precordial distress, cyanosis, alter- nating pulse, and even dropsy. Such phenomena are specially liable to occur in elderly persons, and they have a doubly ominous significance : in the first place, they discover mj^ocardial shortcomings that were not previously known to exist ; and, further, each attack throws a fresh overstrain on a ventricular wall which is already taxed to its utmost by the ordinary calls of life, and thus aggravates its inadequacy. Other things being equal, a fast tachycardia is more exhausting to the ventricular contractility than a relatively slow one ; Wenckebach considers that there is a ' critical speed ' of i8o per minute, at which the ventricular systole of one cardiac cycle coincides with the auricular systole of the next cycle, producing what he calls ' obstipatio sanguinis.' It should be added that patients do not die during attacks, though the foregoing remarks will suffice to impress the gravity of the overstrain thrown by a prolonged bout of tachycardia on a heart that is already seriously diseased. To sum up what has been said as to the general outlook in paroxysmal tachy- cardia : it is of grave import in proportion to the amount of ventricular weakness which it reveals or induces. This answers the first question put by patients suffering from this trouble, as to its significance in regard to life prospects. But they are also, and not unnaturally, concerned to know how far they are to expect relief from the acute discomfort of mind and body occasioned by each attack. To this question it is extremely difficult to give a satisfactory reply. Each case appears to have its own remedies, and it is impossible to prophesy success from the use of any single one of them. On the other hand, no case ought to be regarded as incurable : even where it is an accompaniment of grave organic lesions, this type of irregularity may disappear completely. Neither is prolonged duration to be accepted as evidence of incurability ; cases of years' duration have been known to clear up entirely. Other types of tachycardial paroxysm — those which constitute varieties of auricular flutter and fibrillation respectively — will be considered under those headings. Auricular Flutter. — The next form of arrhythmia which calls for notice is this newly-defined condition. This is a tachycardia, usually paroxysmal, or at least periodic, arising in the auricle, which beats regularly but at a great rate. Some- times all these fast beats come through to the ventricle, but more often they — or rather a proportion of them — are blocked in transit, so that the ventricular rate is one-half, one-third, or one-quarter of the auricular. The writer recently had occasion to review the published reports of this condition, and summarized the prognosis by saying that " auricular flutter has no grave significance so far as is known, except where it occurs in cases of organic heart disease. Here it betrays a fairly advanced degeneration of the auricular musculature, and it adds to the burden of the heart by excessive speeding up of the ventricle." To this may be added the fact that flutter seems to pass over into fibrillation of the auricle in some cases — a possibility which is of course evidence of the fact that flutter is a sign of auricular degeneration when it is associated with organic disease of the heart. Totally Irregular Pulse — Auricular Fibrillation. — We come next to the consideration of the totally irregular pulse — the most consistently organic of the recognized types of arrhythmia. It is now recognized universally that this disturbance of the heart's action arises in a phenomenon known as auricular fibrillation (Lewis), consisting of replacement of the orderly auricular systole by a disordered tremulous movement of the whole auricular musculature. This latter appears to originate from many irritable foci in the auricular myocardium taking over the function of stimulus production, and the result is that an PULSE, IRREGULARITIES OF THE 433 absolutely irregular stream of stimuli is rained down by the fibrillating auricle into the ventricle. Clinically this makes itself apparent in an irregular pulse — not merely an occasional disturbance of an otherwise normal rhythm, but a total absence of rhythm of any kind. Added to this, the usual evidences of auricular contraction disappear from the graphic records and from the other physical signs. When this rhythm first makes its appearance in a case of heart disease (nearly always either post-rheumatic or cardiosclerotic) it means that the wall of the auricle has reached a certain stage in its downward career. The forces that are tampering with its food-supply have carried their nefarious designs to a definite point of success. The first prognostic fact in relation to the totally irregular pulse is therefore this, that it is an unmistakable mark of auricular degeneration. Even where this disorder first makes its appearance in transitory attacks, between which the rhythm returns to the normal, it is sure to become permanent sooner or later. Ninety-nine times out of a hundred, then (for it seems that there are rare exceptions), total arrhythmia spells grave organic disease. The next question to be answered is the expectation of life after this dis- turbance has appeared. As to this, there is a difficulty which may be best illustrated by contrasting two cases recently under the writer's observation. At one end of the scale was the case of an elderly man with cardio- sclerotic and alcoholic degeneration of the myocardium, who died only twelve days after the pulse had become totally irregular. At the other end comes a man with mitral stenosis whose pulse was found to be quite irregular over four years ago ; yet this has not prevented him from keeping on at his rather laborious work in a tan-yard, practically without intermission, since that time. The explanation of this discrepancy is to be found in the fact that the ventricle, and not the auricle, is the vital part of the heart. The danger of the totally irregular pulse is probably twofold : in the first place, the rapid, irregular stream of stimuh pouring down on the ventricle from the auricle imposes a great strain on the former ; and secondly, if the auricle is out of action, this adds somewhat to that venous stasis which does so profound an injury to the nutrition of the myocardium (among other tissues), and thus assists materially in precipitating cardiac downfall. It is the first of these factors that is the more immediately dangerous ; and in any case it is the condition of the ventricular wall on which depends the ultimate fate of the heart, as to whether it shall continue to work effectively or not. The two cases mentioned above bring out this point very strongly ; in the first, alcohol and senility had already reduced the ventricular myocardium to the verge of bank- ruptcy, so that the onset of an irregular pulse proved to be the last straw. In the other, the active phase of the rheumatic infection was long past, and, as is often the case under such circumstances, the ventricle was almost well again, so that it was able to carry on the circulation, though exposed to the additional worry of a rapid and disorderly series of stimuli descending on it from above. It is the paramount importance of the ventricle that explains the contrast between the behaviour of the cardiosclerotic and the post-rheumatic heart respectively, after the supervention of total arrhythmia. In the first of these, the arterial degeneration that has undermined the efficiency of the auricular wall has been equally active in its attack on the ventricular myo- cardium ; so that when the stage is reached at which the auricular rhythm goes wrong and thus imposes an extra strain on the ventricle, that structure is already barely able to cope with the demands made upon it by the ordinary rate and rhythm of stimulation. In the post-rheumatic type of heart disease, 28 434 INDEX OF PROGNOSIS on the other hand, the degenerative changes induced in the cardiac wall by overwork and chronic stasis proceed more quickly in the auricles than in the ventricles, because in every such case there is mitral obstruction, which throws the burden of overstress upon the auricular wall. As a result, the auricle breaks down and fibrillates, while the ventricle still has plenty of work left in it. Consequently the new burden thrown upon it by the disorderly behaviour of the auricle fails to overwhelm it. The dominant importance of ventricular integrity explains the different way in which some cases of mitral stenosis respond to the onset of auricular fibrillation and the total arrhythmia dependent thereon. In some, the rheumatic process that estabhshed the valvular deformity, at the same time injured the ventricular myocardium and induced dilatation ; for various reasons this is more persistent in some cases than in others, and it is in such that the supervention of the totally irregular rhythm produces its most deiinite effects so far as this type of cardiac disease is concerned. So far, then, our conclusion is that in any given case exhibiting the total arrhythmia of auricular fibrillation, the outlook turns on the condition of the ventricle. It remains to translate this into chnical terminology. First, the prognosis is generally better if the underlying disease be post-rheumatic than if it be cardiosclerotic, alcoholic, or syphiUtic in origin. Second, bad signs are oedema, anginal pain, and grouped respirations. The more pronounced and easily provoked the dyspnoea, the worse the prognosis. And finally, the extent to which the symptoms improve under the influence of rest and digitalis, measures which meet with quite a remarkable response in some cases and none at all in others, is an important index of probabilities. The pulse should become slower, the output of urine should increase, and the subjective symptoms should be definitely mitigated, within a few days — a week at the outside — of the institution of such treatment. If this improvement is not manifest, it means that the patient is incapable of receiving benefit from any form of help ; and the gravity of the prognosis is directly proportional to this insensibility to appropriate therapeutics. To sum up : the appearance of total arrhythmia in any case of heart disease adds to the gravity of the prognosis. In any given case the future depends upon the efficiency or otherwise of the ventricle, and on the response to treatment. Heart-block. — Here the prognosis is necessarily grave. This is not to say that it is an irrecoverable phase of heart disease. In many cases of extreme heart- block the unexpected has happened ; the normal rhythm has been restored : but the general rule is that heart-block depends on gross organic disease involving central and vital portions of the myocardium. The risk of sudden asystole is considerable where there are the syncopal or epileptiform attacks which, when they coincide with the long pulse pauses of heart-block, constitute the Stokes-Adams syndrome. Patients who suffer in this way may go out quite abruptly, being found dead in bed or the hke ; or they may be quickly exhausted by a rapid series of such attacks occurring at brief intervals. In milder cases, where only every fourth, third, or even second beat drops out, the prospect of sudden death from block and syncope is remote, provided the patient is willing and able to restrict his activities within the hmits allowed him by his cardiac lesion. In any individual case of heart-block, there are four considerations upon which the prognosis rests. The nature of the lesion causing the block is the first of these. Acute heart-block — i.e., injury to conductivity by an infective lesion of the myocardium — is usually slight and transitory ; it does not appear greatly to pervert the course of the disease from that which it would have followed if no heart-block had occurred. In ulcerative endocarditis, however, the super- PULSE, IRREGULARITIES OF THE 435 vention of heart-block may be a serious feature ; it may indicate direct extension of a burro\ving ulceration into the auriculo-ventricular connections. Chronic heart-block is much more often encountered than that due to acute lesions. Its commonest causes are arteriosclerosis and syphilis. Of these two, the latter gives the best chance of recovery, since it is amenable to specific treatment. Even so, however, cure is only effected in a few cases. The arteriosclerotic cases tend to get worse, slowly as a rule, sometimes rapidly. This introduces the two other points of importance — the degree of block present, and the course which it follows under observation. It is pretty obvious that the advanced degrees of block are more to be feared than comparatively mild phases ; but in estimating the bearing which the point has on the prognosis, it is essential to take into consideration the progress or otherwise of the inter- ruption of conductivity. This is best illustrated by comparing two cases recently under the writer's care. The first patient was an old lady with pronounced arterial degeneration. Her illness began with occasional attacks of block ; but within a week it was practically continuous, and in ten days from the onset she was dead. The other patient, an elderly man of placid temperament, gives a history of ten years' bradycardia and fainting attacks. He hves quietly, and though he has, for several years at least, been the subject of complete heart-block, he seems little the worse for it so long as he refrains from physical or mental stress. His cardiac symptoms have made no perceptible progress for years. This comparison affords a vivid illustration of the fact that a severe but stationary degree of block is less minatory than a mild but progressive case. One more point will arise for consideration in any given case — the other signs of cardiac disease. So far as the likelihood of a fatal issue is concerned, a bad prognosis is of course inevitable when there are signs of impaired contractility in addition to the evidences of interrupted conduction ; in such a case it is obvious that the block may be of minor importance, the outlook depending more directly on the state of the other myocardial functions. If, however, we are essaying a forecast of the course that the block itself wiU follow, then the general condition of the heart makes rather less difference, except that gross enfeeble- ment of contractile power tends to accelerate the destruction of the conducting function. As for the possibiUty of lessening block by treatment, apart from the syphilitic type of case spoken of above, nothing has any direct effect as a rule. Alternating Pulse. — One other aberration of the pulse is generally included in descriptions of arrhythmia, the alternating pulse. This term should include nothing except the alternation of weak and strong beats of the same length. When this is encountered, it is always a sign of advanced or advancing exhaustion of contractility — par excellence the vital function of the myocardium. It is therefore an ominous feature of any case of heart disease. It is true that in some cases its first appearances are transitory ; it may be detected during a bout of paroxysmal tachycardia, or for a few beats following an extrasystole ; even so, it is to be received as a forewarning of further troubles to come, and even where it is unsupported by other evidence of myocardial deterioration, it forms sufficient reason, of itself, for warning the patient that his activities must be restricted in future. Summary. — The aim of this article has been to show that in any case marked by irregularity of the pulse, this symptom should always be analyzed so that its exact mode of origin may be determined ; and further, that it should always be considered in conjunction with the other means of examining the heart. Nothing is more wildly inaccurate than prognosis founded on the degree of arrhythmia withont scientific exploration of its origin. Carey F. Coombs. 436 INDEX OF PROGNOSIS PURPURA. — Purpura is to be regarded as a symptom rather than a disease. It appears to depend upon a defect in the small vessels, probably the veins. In many instances it is a mere incident in the course of a disease, and such cases need not be discussed here. The following special varieties are recognized : (i) Purpura simplex ; (2) Purpura hcemorrhagica ; (3) Schonlein's purpura (Peliosis rheumatica) ; (4) Henoch's purpura. Statistics regarding cases of purpura give little help in regard to prognosis, since the severity of the different types varies greatly. It may be noted, however, that Mackenzie found the mortality in a series of 200 consecutive cases to be 14 per cent. As a general statement, it may be said that the severity of purpura increases with advancing j'ears. In purpuric subjects, attacks are liable to become more frequent and the resulting anaemia is more severe. 1. Purpura Simplex. — -This is a mild form usually seen in children. The haemorrhages are seldom larger than petechiae, and in most cases are confined to the limbs. Prognosis is favourable. Successive crops of spots may appear for three or four days, but as a rule the patient is well within a fortnight, although the pigmented spots may be seen for some weeks. The associated symptoms, such as fever or diarrhoea, never give rise to serious trouble. In a few instances an attack of purpura simplex has been followed by symptonis of purpura hasmorrhagica. Cases have been reported in w-hich the purpuric spots were followed by gangrene. Some of these are to be explained by the administration of salicylates or iodides. Apart from such causes they are extremely rare. 2. Purpura Hsemorrhagica. — This is the most formidable type of purpura. Prognosis may be the more serious from the fact that it usually affects children already in delicate health, although it also attacks adults. The purpuric spots appear and soon increase in number and in size. Epistaxis, bleeding from the gums, haematemesis, haematuria, and, less comm^only, haemoptysis may occur. The patient becomes profoundly anaemic with great rapidity. In a week the corpuscles may have fallen to 50 per cent. Cases of purpura fulminans, occurring especially in children, may be fatal within twenty-four hours ; in some of these the end comes before there has been any obvious bleeding from the mucous membranes. Cerebral haemorrhage, kidney disease, haemorrhage into the suprarenals, and heart-failure or exhaustion from repeated bleedings, may also lead to a fatal result. In favourable cases, symptoms cease or lessen in from one to two weeks. There is always a prolonged period of convalescence. Patients are weak and emaciated, and several months may elapse before the blood regains its normal condition. While we must regard prognosis in purpura hasmorrhagica as somewhat grave, perha.ps the most striking thing about it is the large proportion of very severe cases which recover. The chief points on which we can base a prognosis are as follows : The more severe and frequent the cutaneous haemorrhages, the more serious is the case. Haemorrhages from the mucous membranes, if at all severe, add to the gravity of the condition ; of these, epistaxis has probably the least serious significance. Haemorrhage from many mucous membranes is more serious than from one. Marked pyrexia, albuminuria, constitutional disturbance, and mental depression are unfavourable signs. Accurate information regarding the effect and progress of the hemorrhages is to be obtained by a frequent use of the haemocytometer and haemoglobinometer. PYELOCYSTITIS 437 An intermediate group of cases is that in which special symptoms associated with the haemorrhages arise. These include the occurrence of blebs, ulcers, or necrosis as the result of the cutaneous haemorrhages ; haemorrhages into the tongue may give rise to great swelling and tension, and may even call for relief by incision ; recurring epistaxis may persist after other symptoms have been arrested. 3. Schonlein's Purpura (Peliosis Rheumatica). — This variety is associated with pain and swelling in the joints, urticarial and inflammatory lesions of the skin, and a variable degree of fever. The outcome is usually quite favourable. Fatal cases have occurred, but with great rarity. It is, however, associated with a very large number of possible complications, and recurrence of the disease is exceedingly common. The symptoms of an attack may be very persistent ; recurring crops of petechiae and attacks of fever and arthritis may persist for over a year. A very potent factor in determining relapses is exertion, and it may be stated here that rest in bed is the one therapeutic measure of outstanding importance in all forms of purpura. Pharyngitis, sometimes so severe as to lead to gangrene of the tonsils and uvula, may occur. The other complications are those usually associated with rheumatism ; endocarditis, pericarditis, pleurisy, albuminuria, chorea, and hyperpyrexia may supervene. It should be remembered, however, that in spite of the somewhat formidable list of possible contingencies, their actual occurrence is so rare that peliosis rheumatica in the average case may be regarded as a benign affection. 4. Henoch's Purpura. — This variety is associated with vomiting, colic, and diarrhoea. A considerable number of cases associated with intussusception are on record. There are joint swellings, and cutaneous affections such as erythema may accompany the purpura. Actual haemorrhages from mucous membranes may occur. Prognosis is fairly good, but a fatal outcome may take place. Osier recorded 3 deaths in a series of 11 cases. In one the fatal outcome was the result of an intense hemorrhagic nephritis. Haemorrhage from mucous membranes, nephritis, and exhaustion are the chief dangers, in the absence of any association with a grave abdominal condition. When intussusception is present, it dominates the position as regards prognosis, but it is, of course, more dangerous because of the purpura. Relapses are a common feature, and attacks of Henoch's purpura may recur for years. g. L. Gulland. A. Goodall. PYELOCYSTITIS. — Pyelocystitis includes a number of conditions differing in gravity, and therefore varying in prognosis. The infection is most commonly due to the B. coli communis, which is usually present in pure culture. B. coli pyelocystitis is acute or chronic ; and it may be uncomplicated or complicated. In acute uncomplicated B. coli pyelocystitis the infection has occurred in a previously healthy urinary tract. The origin may be traced to haemorrhoids, acute or chronic colitis, appendicitis, chronic constipation, dysentery, or some other intestinal trouble, or there may be no apparent cause. The attack may be moderate or severe. It is usually possible during the first two days to form an estimate of its probable severity. In a moderate attack, the temperature may rise to 101° or 102°, and is ushered in by a slight shivering or a feeling of chilliness. The bladder symptoms may be severe and distressing. Kidney symptoms are less prominent, amounting to slight pain and tenderness, but no enlargement of the organ ; they may be entirely absent. 438 INDEX OF PROGNOSIS In a severe attack the initial rigor is also severe, and may be repeated ; the temperature rises to 102° or 104°, or even to 105° F., and the patient shows evidence of profound toxaemia. There is severe pain in the kidney, the abdo- minal muscles are rigid, the kidney region is tender, and the kidney, if it can be felt, is enlarged. A mild attack such as has been sketched above may be expected to last for ten or fourteen days. There is no danger to life, and the principal points in the prognosis are : that relapses are very frequent if the patient is allowed to get up or to go out too soon ; and that it is impossible to say, even in a mild attack of pyelocystitis, whether a bacilluria may not persist and give rise to future trouble. In a severe attack there is danger to life. If the patient is old, or very stout, or bronchitic, or otherwise incapable of withstanding a severe toxaemia, he will probably succumb after a week or ten days. On the other hand, when the patient suffers from no such complication, the immediate prognosis is more favourable. The temperature remains high for about a week, but after that time should commence to fall, and at the end of ten or fourteen days from the onset of the illness will have reached normal. If the temperature remains high and the symptoms show no sign of abating at the end of a week, the out- look is less favourable, and will, if no improvement occurs in the next three or four days, become grave. After one or more of such relapses, the patient usually succumbs. Operation in such cases should not be too long delayed. If at the end of a week the acute symptoms persist, and the patient is beginning to lose ground, operation should be performed. The results of nephrotomy are not very satisfactory. In 20 cases of nephrotomy for acute pyelonephritis, there were 7 deaths (35 per cent). In surviving cases, the late results are also unsatisfactory : the acute symptoms subside, but chronic pyelonephritis persists, and nephrectomy may be required at a later date. The best results in acute cases have been obtained by nephrectomy, after ascertaining that the second kidney is healthy. In 17 cases of nephrectomy there were no deaths. Where the acute symptoms subside without operation, the infection in some cases disappears. In a large number of cases, however, it persists in a mild form, the principal symptoms being those of slight chronic cystitis. In such cases there is a constant danger of recurrence — which takes place sometimes after short intervals, and sonietimes after some years. Secondary stone- formation in the renal pelvis or in the bladder is not uncommon in such cases, and there is a danger of ascending pyelonephritis of the healthy kidney, leading to suppression of urine and death. Some cases go on for many years without any change, but the patient suffers chronic ill health, and is unfit for great or prolonged efforts, either physical or mental. In some of these cases the original focus of infection, such as chronic intestinal stasis, produces a chronic toxaemia, to which that from the kidney is added. In other cases the kidney is the principal or only source of the toxaemia. Nephrectomy is the only effective treatment in the latter class, and is frequently a difficult and dangerous operation. In some cases of chronic pyelocystitis the principal focus of infection lies in the prostate. In such cases the symptoms are principally those of cystitis ; the pyelitis passes off after a slight preliminary attack, or persists in a mild form. Recovery depends upon successful treatment of the chronic prostatitis. The prognosis for ultimate recovery is somewhat better in these cases, but in some the condition persists in spite of vigorous and prolonged treatment. PYLORUS. CONGENITAL STENOSIS OF 439 Chronic pyelocystitis may be complicated by stone in the kidney or bladder, by movable kidney, diverticulum of the bladder, stricture, or enlarged prostate, or by bladder growths. The prognosis in such cases depends upon the possi- bility of removal of the stone or other complicating disease. Until this is done the pyelocystitis cannot be cured. Two special forms of B. coli pyelocystitis may be mentioned. The pyelitis of infancy and childhood is a frequent form. It occurs in infants a few months old and in young children, and takes an acute course. The condition occasion- ally ends fatally, but recovery takes place in the great majority of cases, even when a very high temperature is recorded, and profound toxaemia, even coma, is present. The cases improve rapidly under treatment ; the temperature falls, and the symptoms subside in a week or ten days. The pus may remain for several weeks, and the bacteria for longer, but eventually these also disappear. Pyelonephritis is a not infrequent complication of the early months of pregnancy, arising usually in a previously healthy urinary tract, but occasion- ally as an exacerbation of a chronic pyelocystitis. Premature labour occurs in 25 per cent of severe cases. When the acute attack occurs early in pregnancy, and there is an interval of normal temperature before parturition takes place, the puerperium is usually apyretic. If, however, the acute attack occurs late in pregnancy, there is usually fever during the puerperium ; but puerperal infection does not occur. If the pregnancy be interrupted, the child is usually ill-nourished, and dies in one-third of the cases. If the attack occur late, and the pregnancy go on to full term, the child is usually healthy and well-nourished. The production of abortion, or the induction of premature labour, is seldom necessary, but it may be called for in a severe case. After parturition, the pyelonephritis may subside, and the urine may clear and become sterile ; but more frequently bacilluria and some degree of pyelonephritis persist, and exacerbation occurs during succeeding pregnancies. /. W. Thomson Walker. PYELONEPHRITIS {See Pyelocystitis. ) PYLORUS, CONGENITAL STENOSIS OF {see also Stomach, Surgical Affecions OFj.^ — Though rather new to the profession, this disease is by no means a rarity. The large proportion of cases recognized in the first-born infants of medical men makes it probable that a number of deaths occur in other children without a diagnosis. The hall-mark of the condition is the association of vomiting with constipation, palpable pyloric tumour, and visible gastric peristalsis. The symptoms usually come on at the age of about four weeks, and apart from treatment are fatal in a few weeks. It is still hotly debated whether the treatment ought to be purely medical or purely surgical. Scudder, for instance, denies that any cures have ever been effected by medical means, and urges operation in every case. Results of Medical Treatment. — Medical treatment includes lavage, careful feeding by the best modern methods (including citrated milk, peptonized milk, albumin water, or breast milk, all in small quantities), and perhaps a little tincture of opium. There is no doubt that many cases have recovered under such treat- ment. The proportion varies in different statistics from 10 to 60 per cent ; it is probably less than half the total number. Monier's figures give 80 to 90 per cent of fatalities under medical treatment. In any individual case, the prognosis depends upon the following factors. Children of 8 lb. do better than those of 6 lb. Diarrhoea is very ominous. 44° INDEX OF PROGNOSIS Head-retraction and fever may be seen just before death. Large vomits are apt to induce fatal collapse. If the weight continues to fall and the vomiting persists after two to three weeks of careful medical treatment, it is not Ukely that the child will hve, apart from operation. It must be remembered that the small intestine is thin and atrophic, and any attempt to ' feed up ' the child, before or after operation, wiU probably induce fatal diarrhoea. In favourable cases treatment takes six to twelve weeks. The tumour is probably permanent : in cases described by Batten and many others, the persis- tence of the hjrpertrophy was verified by autopsy long after more or less perfect cure of the symptoms. There is some tendency to relapse in later life ; Scudder quotes a number of authorities to this effect. Results of Surgical Treatment. — From 1898 to 1905 the results of surgical treatment were not very good, but probably better than those obtained by medical means. According to Scudder, the mortahty of operation was 46-5 per cent. Paterson in 1906 collected the records of 25 cases treated by gastro- jejunostomy, of which 13 died of the operation, 3 died \^dthin two months, and 9 were cured. Pyloroplasty was more successful : of 9 recorded cases, 3 died of the operation, i died two months later of diarrhoea, and 5 were cured. Since 1905, three short series have been pubUshed by Scudder showdng much better results. These include, first, 10 cases operated on by several surgeons on the Pacific coast, and recorded by Stillman ; second, a group of 9 in the practice of Richter, of Chicago ; and third, Scudder's own series of 17 operations. These combined give a record of 36 cases, with only 5 deaths — that is, a mortahty of i3'8 per cent. These American cases were treated by gastrojejunostomy. Scudder's patients have been followed for periods varying from one to eight years (all over two years, -with a single exception) . All but three were under eight weeks old at the time of the operation. The difference in the mortahty before and since 1905 is due partly to improved technique, but no doubt principally to the fact that in the older series the surgeon was called in when the infant was already greatly reduced after the failure of medical means, whereas the American surgeons quoted above would operate as soon as the diagnosis was made, wdthout waiting to see the results of dieting, lavage, and so forth. We consider, personally, that a fortnight is a suitable period during which to try medical means. Results of Operation for Congenital Pyloric Stenosis. Keporter Cases Died ol Died operation later i Cured ^ft^f.l°'i J Gastrojejunostomy - Scudder's three series since 1905 25 9 36 13 3 3 1 1 5 1 1 9 5 31 Apparently the operation does not lead to any reduction in the mass of the pyloric muscle. A baby operated on by Murphy recovered well from the operation, but died six and a half months later from causes unconnected ■with the gastric trouble : the tumour of the pylorus persisted unchanged. Scudder states that in nine cases after a gastrojejunostomy in these infants, bismuth skiagraphy showed that the food passed through the stoma and not through PYONEPHROSIS 44 1 the pylorus : it is well known that the food passes only through the normal passage and not by the stoma after a short-circuiting operation in patients or animals with no pyloric obstruction ; evidently, therefore, the mechanical obstruction of the circular muscle persists. After successful operation, the children grow up into normal individuals. A very sturdy boy, aged four, on whom gastrojejunostomy was performed in his second month, is known to the writer. To summarize, we may conclude on the evidence before us that medical treatment will save certainly less than half the patients, perhaps so few as 10 per cent, and that the survivors may suffer from persistent symptoms of pyloric obstruction ; that the operation-mortality in early cases is less than 20 per cent, but may be 50 per cent if medical treatment has been persisted in before the surgeon is called ; and that neither medical nor surgical treatment leads to any improvement in the pyloric hypertrophy. References. — Miller, Medical Diseases of Children, igii, 260 ; Paterson, Lancet, 1906, i, 577 ; Scudder, Ann. Surg. 1914, lix, 239. a. Rendle Shnrt. PYONEPHROSIS, — There are two types of pyonephrosis, and the prognosis is different in each. The first type is pyonephrosis secondary to uronephrosis (hydronephrosis), or uropyonephrosis ; the second is pyonephrosis developing from acute pyelonephritis. In uropyonephrosis the condition is unilateral, and the actual obstruction is situated high up in the ureter, being due to a stricture, stone, or duplication of the ureter. The superadded infection is usually haematogenous. Pyonephrosis developing in pyelonephritis occurs especially in cases of old- standing disease of the lower urinary organs, such as stricture, chronic prostatitis, enlarged prostate, growths of the bladder, etc. There is frequently bilateral disease, but the second kidney is not necessarily pyonephrotic. The general S5^mptoms of uropyonephrosis are often moderate, although in some cases the character of the illness resembles that of the other form of pyonephrosis. In pyonephrosis due to pyelonephritis, the patient is seriously ill, with a high swinging temperature and other symptoms of toxaemia. Unrelieved pj'onephrosis may lead to a fatal result in ten or fourteen days ; or the course may be more prolonged, and the pus find its way through the wall of the sac and form a perinephritic abscess, death taking place from exhaustion after some weeks. The prognosis depends upon the patient obtaining prompt relief by opera- tion, and upon the presence or absence of infection of the bladder and of the second kidney. In a few cases where a mild infection of a hydronephrotic sac has occurred, it is possible to do a plastic operation for removal of the obstruction, and what remains of the kidney is saved. In the majority of cases, however, the choice lies between nephrotomy and nephrectomy. Nephrotomy can be performed in the very worst cases when the patient is weak from prolonged suppuration, and in cases where it is impossible to esti- mate the value of the remaining kidney, or when this organ is known to be the seat of advanced disease. The mortality of this operation is from 17 (Kiister) to 23 per cent (Tuffier). After the operation an improvement in the work of the second kidney is usually observed, and the general health greatly improves. In 27 per cent of cases the sac shrinks and the patient is cured. In a certain number of cases septicaemia persists, and the work of the second kidney is still poorly performed. This is due to continued suppuration in the thick fibrous-walled cavity, to undrained pouches, to abscesses in the walls 442 INDEX OF PROGNOSIS and partitions, to stones being left in the sac (i6 per cent of cases), or to the persistence of the ureteric block. A fistula remains in from 45-6 per cent (calculous pyonephrosis 34-2 per cent, non-calculous pyonephrosis 57-1 per cent) to 56 per cent (Kiister). Secondary nephrectomy is indicated when septicaemia persists ; when it is believed, from the inadequate secretion of the diseased kidney and the ab- sence of disease in the second kidney, that a depressed renal function in the latter will improve after nephrectomy ; and when the patient is gradually losing ground from prolonged suppuration. The mortaUty of secondar};- nephrectom.y is only 5-9 per cent. If this be added to the mortalit^^ of nephrotomy (23-3 per cent), the total mortality of nephrotomy followed by nephrectomy at a later date is 29-2 per cent. Primary nephrectomy should be performed when it is certain, from examina- tion of the urine of the second kidney, that the function of this organ is adequate. The mortality of this operation is 17 per cent. The prognosis after nephrectomy, in cases where the second kidney and the bladder are healthy, is very good, and there is no reason to expect that the duration of life \vill be shortened. On the other hand, in cases where there is chronic cystitis which does not clear up after nephrectomy, and especially where the second kidney is already infected, the danger of acute pyelonephritis of the remaining kidney, with suppression of urine, is very considerable. Even if this take place, however, the outlook is not hopeless. The writer has per- formed nephrotomy on the solitary kidney in such a case, and the patient is known to be alive and in fair health several years after. /. W. Thomson Walker. PYOSALPINX.— (See Salpingitis.) RECTAL PROLAPSE.— In young children, the great majority of cases of prolapse of the bowel get well in the course of a few months with simple treatment (replacement, purgatives, astringent lotions, etc.). It is not possible to quote exact statistics. It is only in a few instances that any operation is required. In adults, on the other hand, there is little tendency to amendment, and operation will be necessary. Paraffin injection is going out of fashion ; although it may be immediately successful, cases of ischiorectal abscess have been recorded at a long interval afterwards. When only the mucous coat prolapses, searing it to the muscle with the cautery is very successful. Severe cases require excision, and this is usually satisfactory, though temporary incontinence may follow ; this nearly always gets well at last. In a few rare cases colopexy is necessary ; this is well spoken of ; no doubt failure is very rare, but the writer has seen a case. A. Rendle Short. RECTUM, CANCER OF. — Prognosis in carcinoma of the rectum largely depends on the stage at which the disease is detected. In this connection it is impossible to insist too strongly upon the importance of a digital examination of the rectum in every patient, whatever his age, presenting rectal symptoms. It must be borne in mind that rectal cancer may occasionally occur as early as the second decade of hfe. A cylindrical-celled carcinoma of the rectum has been recorded in a girl of eleven, the youngest case of carcinoma on record. Cancer of the rectum begins upon one aspect of the bowel wall as a small ulcer, which spreads circularly both along and across the bowel. As it spreads it puckers up and contracts the affected area of the mucosa, and thus strictures the bowel. Accordingly intestinal obstruction or perforation is the usual cause RECTUM, CANCER OF 443 of death in untreated cancer of the rectum. Even when a well-defined stricture has formed, a bridge of normal mucosa can still be detected forming part of the circumference of the stricture, and the breadth of this bridge gives some idea of the stage which the cancerous ulcer has reached. Even more important is it to determine whether the growth has passed outside the walls of the rectum. If the growth is fixed to its surroundings, this is probably the case. The vertical extent of the growth in the axis of the rectum is a less important point. It used to be considered that a rectal growth was only operable if the examining finger could pass through the stricture and feel normal mucosa above. With modern methods, extension of the growth along the bowel for a considerable distance is not in itself a bar to operation. It must be remembered that methods of estimating the operabilitj^ of a growth from local examination only are open to fallacy. In certain cases, while the primary growth is still small and mobile, metastases may form in the hver, probably owing to cells carried there by the blood-stream. On the other hand, fixation of the growth may result from merely inflammatory changes. A final estimate as to the operabiUty of a rectal carcinoma can only be given when the abdomen has been opened and its interior examined manually. This is one of the advantages which the combined abdomino-perineal operation possesses over other methods. Since most cases of cancer of the rectum occur in advanced hfe, the general condition of the patient's health — and more especially the condition of the heart and kidneys — is an important element in the prognosis. Unless their vital organs are fairly sound, patients cannot be expected to tolerate an operation for the extirpation of the growth. On the other hand, apparently delicate patients, if free from organic disease, often withstand severe operations well. The worst subjects apart from organic disease are, in my experience, of the stout florid type with soft tissues, especially if alcohol has been habitually indulged in. Prognosis as regards Recovery from Radical Operation. — The follo\\'ing table by Tuttle, quoted by Swinford Edwards, gives the mortality of the different methods of operation up to the date of its pubhcation : — Mortality of the Various Operations FOR Rectal Cancer. — {Tuttle.) Method Xumber of Cases Deaths Jlortality Sacral Perineal Abdominal Combined 913 569 49 22 211 76 18 9 per cent 23-1 13-5 3(;7 40-9 These figures show a high mortality for all methods except the perineal. At the present time they do not afford a correct view of the risk involved in the abdomino-perineal method, a risk which by improved technique is reducible, as I shall be able to show, to a fraction over 15 per cent. In my opinion, with rare exceptions, and possibly excluding squamous-celled growths beginning in the anal region, the only two operative procedures worth considering in cancer of the rectum are : first, abdomino-perineal excision of the rectum with the formation of a colostomy ; second, simple colostomy. This view excludes the possibility of retaining the natural faecal outlet at the anus, an end very desirable in itself. But attempts to bring down the upper 444 INDEX OF PROGNOSIS colon and attach it to the sphincters are very dangerous to hfe. The mortality of an abdomino-perineal excision terminated by bringing down the bowel is at least double that of the same operation terminated by a colostomy. Even if the patient survives the operation, the anal sphincters may subsequently be- come fibrotic and useless. The danger of recurrence of the growth in the anal structures left behind is also a very real one. In most cases, too, the final result is a sacral anus, owing to the breaking down of part of the hne of union of the bowel. But what of excisions of the rectum performed from below ? While some surgeons, notably Mr. Harrison Cripps, have recorded satisfactory results in a considerable number of cases, others, especially Mr. W. Ernest Miles, have experienced recurrence in almost every case. My own experience of these operations accords with that of Mr. Miles. But it has not been my good fortune to meet with early cases, where the growth is a small one and well localized to one portion of the bowel wall. In such cases some competent authorities, e.g., Mr. Lockhart Mummery, would advocate perineal excision. I agree with Mr. Mummery that very stout patients, those with impaired constitutions, and those over seventy years of age, are unsuitable subjects for the abdomino- perineal operation. In such cases I should perform a simple colostomy. But even in small early growths, if the patient is a suitable subject, I should advocate the complete operation ; for it is known that glandular involvement may occur when the local growth is still in an early stage, and the abdomino-perineal operation is the only procedure by which reasonable security can be attained. As regards immediate risk, the perineal operation is undoubtedly the safer procedure at present. But as the combined operation is being rapidly improved, I anticipate that its mortality will soon fall to lo per cent. Mr. Cripps's mortality for perineal excision is 8 per cent (3 deaths in 38 cases). Mr. Miles, among 26 cases of the abdomino-perineal operation, lost 10, a mortality of 38 per cent. The same operation, perhaps however on rather more restricted lines, shows in my own hands a mortality of 2 among 13 cases, excluding a fatal case in which a large fibroid uterus was removed at the same time. Only one death occurred in the first ten cases, a result mainly due, I believe, to the method of post-operative saline infusion which I advocate. My present mortahty thus works out at only 15 per cent, a figure which is not unsatisfactory. My experience shows that the abdomino-perineal operation, though neces- sarily a severe one, is fairly safe when performed under favourable conditions. Age is not a bar to it, for my series of successful cases includes two patients over sixty years of age. It must be preceded by a careful preparation of the patient, with the object of rendering the lower bowel as aseptic as possible and of increasing his resisting power to micro-organisms. For this latter purpose the prophylactic use of vaccines is advisable. The operation should never be done except in a fully equipped operating theatre and in the operator's familiar surroundings. If this rule is broken, minor contretemps will sooner or later occur, which in such an operation may have serious consequences. Prognosis as regards Recurrence after Operation. — The published results of Mr. Ernest Miles show the prognosis of different methods of operation in the hands of the same surgeon. They are a convincing testimony to the superiority of abdonrino-perineal over perineal operations. In his search for the ideal method, Mr. Miles has passed through various stages. He describes how, between 1889 and 1900, he did operations from the perineum, with section of the bowel one inch above the margin of the growth. These operations were followed by recurrence in an average period of twelve months. During 1902 to 1904 he performed fourteen operations with a wider removal of RECTUM, CANCER OF 445 the perineal skin and the ischiorectal fat, the operation otherwise remaining the same. Recurrence took place in every case, and was most common in the levator ani. In a third series of eleven cases, 1904-5, Kraske's method was adopted ; the mesorectum and the levatores ani were extirpated, and the bowel was divided three inches above the uppermost limit of the growth. Recurrence took place in every instance, and seven of the recurring growths involved the lower margin of the bowel and the adjacent mesocolon. As Miles remarks, these recurrences probably arose either from pre-existing permeation of the apparently healthy rectal wall, or from metastases in the paracolic lymph nodes — that is to say, the disease returned in tissues situated above the field of operation. He accordingly decided to excise as much of the pelvic colon and its mesocolon as he could reach. After this operation recurrence followed in every case, and in fourteen cases it took place in the pelvic peritoneum and the pelvic mesocolon — tissues which could not be removed by an operation performed entirely from below. Miles accordingly abandoned the perineal method ; he had performed it successfully in 58 patients, of whom 55 were known to have suffered from recurrence, a percentage of return of 94-82 per cent. Since abandoning the perineal operation Miles has developed an abdomino-perineal method, which in many details is his own. He has done this operation 42 times, with a mortality of 40 per cent. The operation would appear from his statistics to be unjustifiable after the age of sixty, since no patients who submitted to it beyond that age recovered from it. Among the 25 patients who have survived the operation, only 4 have had recurrence of their disease. At the present time 19 patients are living, and 10 of them have survived the operation more than two years without, up to now, showing any sign of recurrence. These results are a brilliant advance on any that have been hitherto pubhshed. Among my own 1 1 cases who survived the operation, i is living live years later but has recently developed signs of recurrence, and i died of her disease about a year after the operation. The other 9 are alive and well, so far as I know ; one is doing full work as foreman at a lead works, another as a policeman ; four of them have been seen or heard from recently. Most of my cases are too recent to claim as successes, but the results to date are satisfactory. A final judgement on the abdomino-perineal operation will not be possible for some years, but its superiority over the older methods is already established. Mr. Lockhart Mummery, in his recent work, quotes the following percentages of three-year cures following the perineal methods of operation : Harrison Cripps 25 per cent, Hochenegg 17-2 per cent, Tuttle 14-8 per cent. These figures were no doubt obtained by a selection of cases far more rigid than is now applied, a fact which must be borne in mind as increasing the advantage shown by the combined method. Influence of Radium Treatment on Prognosis. — The value of radium in cancer of the rectum is not yet determined, but Wickham and Degrais (1913) state that inoperable cases of cancer of the rectum have certainly found in radium a palliative and useful treatment, that radiation may clear the passage by dissolving the nodules, that the haemorrhage, discharge, and pain diminish, and that the general condition of the patient consequently improves. In two cases they were able to avert a colostomy, and to prolong a tolerable existence for periods of twelve and fifteen months respectively. It is obvious that the subject has not yet reached a stage in which general statements are possible, and in any particular case the results of treatment are uncertain. A case of my own shows that radium may convert an inoperable into an operable case. The patient, a man of sixty, was pronounced beyond the range of operation by a well-known surgeon, and was brought to me for a 446 INDEX OF PROGNOSIS second opinion. I agreed that the case was inoperable, and advised a trial of radium. The treatment was carried out by Dr. N. Finzi. Within a few weeks the edges of the growth became flat and fibrotic, so that it might have been mistaken for a simple stricture ; shght mobility could now be detected in it. I then advised and carried out an abdomino-perineal radical operation. Two tubes of radium were inserted at the operation into the pelvic cavity, one from below aiid one from above. The peritoneum forming the floor of the recto- vesical pouch was intected, and the operation was here necessarily an incomplete one. Whether as a radium effect or not, suppuration occurred in the pelvis, and during convalescence a troublesome attack of pyehtis occurred ; but at present, a year later, the patient remains well and free from recurrence. Cases suitable for Colostomy. — In a very large proportion of the cases unsuit- able for radical operation, an immediate colostomy is the proper line of treat- ment. The operation should not be deferred until obstruction is imminent. As Mr. Swinford Edwards says : " That I would perform a colostomy on every patient upon whom I had decided that a radical operation was inadmissible I will not say, but rather that I would strongly advise the operation as soon as any of the symptoms of the disease became so marked as to interfere -with the comfort of the patient." This statement, in my opinion, rather underestimates the importance of colostomy. The operation is not merely a means of increasing the patient's comfort ; it appears to exercise a definite influence in retarding the progress of the disease. Prognosis after Colostomy. — The prognosis in cases of cancer of the rectum treated by a simple colostomy is much more hopeful than is generally believed. First, in regard to the question — Is life worth living with a colostom}^ wound ? Upon this point most patients, and some medical men, are apt to take quite unjustifiably gloomy views. Numbers of people with a colostomy opening go about their daily work, and are to all appearance normal individuals. Thus, a well-known police magistrate with this disabihty sat on the bench for some years ; among patients of my own, one is foreman at a factory, another a police constable doing full duty, another a dressmaker who makes frequent Continental journeys in the course of her business. There are two conditions essential to a successful colostomy, one that the opening shall be well situated (preferably in the midst of the rectus muscle) and properly made, the other that it shall be properly managed by the patient. An injection of soap and water, followed by the use of the bed-pan before rising in the morning, will usually ensure freedom from trouble during the day. Care must also be exercised by the patient in regard to diet, and laxative foods must be taken in strictly regulated quantities. Having considered prognosis with regard to comfort, we may turn to the outlook in regard to the symptoms of the growth and its rate of advance. The diversion of the septic stream of faeces from the surface of the ulcer is followed in practically all cases by a diminution or cessation of niucopurulent discharge from its surface. Accordingly, the teasing diarrhoea or rectal tenesmus produced by the irritant discharge diminishes or ceases, especially if the lower bowel is periodically washed out through the colostomy wound with a mild antiseptic such as boracic lotion. There is a corresponding improvement in the bleeding, and, except in very advanced cases, in the sacral pain, for both of these signs are mainly of septic origin. For some years the patient may be able to forget that the growth, though quiescent, is still present. Sooner or later, however, sciatic pains will indicate infiltration around the sacral plexus, and frequency of micturition, with albuminuria and hsematuria, will indicate invasion of the bladder. Compression of the ureters will be followed by ascending pyelo- RHEUMATIC FEVER 447 nephritis, which is likely to end the case if in the meantime hepatic metastases do not manifest themselves. The period of relief from symptoms which follows a colostomy varies widely. It may be estimated at from one to five, or even seven, years. In one case within my knowledge a simple colostomy was followed after some years by complete cicatrization of the growth, spontaneous closure of the colostomy, and re-establishment of the natural anal evacuations — an instance of the natural cure of cancer : it is probable, however, that in this case the disease will ultimately re-assert itself. While a properly made and managed colostomy wound need give little more trouble than a set of artificial teeth, an ill-made prolapsed one, with colitis of the bowel above and sepsis about the opening, is undoubtedly a misery to which some patients will consider death preferable. w. Sampson Handley. RELAPSING FEVER. — There are now known to be at least three, or probably more, species of spirochaetes causing fever of the relapsing type — Indian, European, and African (African tick fever). Where the treatment is purely symptomatic, the mortality is mainly due to complications, particularly pulmonary ones, though the septicaemic nature of the disease may cause death. The various epidemics have differed in the mortality. In Bombay, Vandyke Carter gave the mortality as iS per cent, and Choksy in the same city from 1898 to 1907 gives an average mortality in 9,275 cases of 30-6 per cent. A much lower mortality has been recorded in Northern India ; and with the other forms of relapsing fever found in Egypt, Russia, Ireland (famine fever), and Africa (African tick fever), it is only 4 per cent. The previous condition of the patient is important, as those who are badly fed and in overcrowded cities have a higher mortality ; nevertheless well-fed and well-cared-for Europeans may die from the disease. Salvarsan has a marked effect on relapsing fever, but the number of cases treated by it has not been large enough for the effect on the mortality to have been adequately tested. c. W. Daniels. RENAL CALCULUS. — [See Kidney and Ureter, Calculus of.) RHEUMATIC FEVER. — The prognosis here must depend upon the particular organs that are most affected in the attack. If they are vital ones, such as the heart and brain, and are severely injured, the risk to life is great ; but where the articulations chiefly suffer, though there may be great distress, the actual danger to life is small. It is a very difficult undertaking in this disease to single out a particular manifestation and lay down rules that apply to it alone, for in the course of the illness we continually find one lesion obscuring the prognosis of another. There still remains, however, a demand for the prognosis of the individual lesions, and the writer will accordingly first consider, under the general term ' rheumatic fever,' the prognosis of the articular manifestations. There is another difficulty in the prognosis of rheumatic fever which is caused by the inadequacy of the name. If we use the term rheumatic fever, we discover that the disease may occur without fever in childhood, and that such a lesion as rheumatic pericarditis may be present with a subnormal temperature ; yet in childhood also the term acute rheumatism is often inapplicable, for the onset may be most stealthy. The condition most comparable to rheumatism in its general course is tuberculosis, for in both there occur febrile and afebrile attacks, gradual and acute onsets, and all degrees of duration. 448 INDEX OF PROGNOSIS Fulminating cases of acute rheumatic arthritis are apparently not so frequent as they used to be. In rheumatism, as in gout, we do not meet with so many of those cases from which have been drawn the pictures of the disease we read in our text-books of twenty-five years ago. As Litten observed, the type of the disease has apparently become more septic in character. The prognosis in these acute attacks, provided the heart is not damaged, is good, and acute rheumatic arthritis tends to complete recovery. Since the introduction of salicylates, such cases have been much easier to handle ; but when we search for accurate facts upon the exact improvement they have produced in the prognosis, we are baffled. There are several im- portant reasons for this. On the one hand, the frequency of some degree of heart affection is more generally realized, and the knowledge of the behaviour of the disease in childhood is much more definite. On the other hand, with our increasing knowledge, we are getting milder cases under supervision more readily. We have one element, that of cardiac infection, leading us to think that the disease lasts quite as long as heretofore, and the other, the treatment of the milder cases, leading us to think that the duration of the disease is shortened. It is almost exactly forty years since these drugs were first used in this country by Dr. T. J. Maclagan, and in the early eighties careful statistics were made to elucidate the value of such treatment as compared with the alkaline method, or the natural course of the disease. These investigators showed conclusively that pain was rapidly relieved and fever lowered. Dr. Pye Smith found that in 1 80 out of 355 patients these symptoms were arrested in five days, but in only 3 out of 24 cases treated expectantly was there the same good result. The influence upon relapses was much disputed ; Dr. Pye Smith had 93 relapses in his 355 cases; Dr. Donald Hood found 34 relapses in 850 cases treated without these drugs (4 per cent), and 182 in 1250 cases treated -with them (14-6 per cent). To the writer, it seems that our conception of rheumatism has so changed that it is not possible at the present time to express in statistics the influence of the salicylates. This is clear, that these drugs have no lasting effect upon rheumatic processes, for fresh infections or recrudescences are very frequent in childhood ; but acute articular rheumatism is greatly relieved and the pain and distress are much diminished. For these reasons the prognosis is improved. There are, however, some cases in which the articular symptoms, though less violent, are more intractable, requiring large doses of the salicylates to keep the symptoms under control. It is a matter of opinion as to whether there are cases in which these drugs are ineffectual, but it has been the writer's experience to see some in which, while several of the joints recover completely, others drift into a rheumatoid condition, and believing as he does that there is a rheumatic form of rheumatoid arthritis, he is not prepared to accept the dictum that an arthritis which does not yield to the salicylate treatment is necessarily non- rheumatic. We are here face to face with the great problem of the present time in the treatment and prognosis of rheumatic fever — are the salicylates specific antidotes ? This much we can assert with regard to the arthritis, that when it does not react to this method of treatment, and yet is of what we call the rheu- matic type, the prognosis as to the future is uncertain. Hyperpyrexia, although less fatal since the introduction of the cold-bath treatment, is still, in spite of the salicylates, of very uncertain prognosis. In late years it has been a very rare occurrence; the diminution in frequency did not occur at the time of the introduction of salicylate of soda, however, but some years later, and this may mean an alteration in the character of the disease of RHE UMA TIC FE VER 449 temporary duration, rather than the possession of any real control of Jthe symptoms. Mental symptoms may, in adult life, though rarely, add considerably to the gravity of the prognosis of acute rheumatism. Great depression and even mental derangement, may occur. Unless there is a previous history of mental instability, a gradual recovery may be expected. Another troublesome group of symptoms in the adult are abdominal. These may take the form of dilatation of the stomach or troublesome vomiting and gastralgia, or again of pain located apparently in the large bowel and leading to troublesome distention or obstinate hiccough. Recovery may be much delayed by these complications. Whether rheumatism is a cause of acute appendicitis has not been certainly established, but should this prove to be the case it is clear that the prognosis in such a complication is to be judged by the general indications that govern the prognosis of appendicitis. Where rheumatic fever attacks a patient living in an insanitary house, the character may become almost typhoidal. There is great prostration, and the tongue becomes dry and cracked, the course is long, and troublesome vomiting may prevent the use of the salicylates. Although the eventual recovery may be good, it is slow, and the illness may last for months. There is little to guide us as to the prognosis of future attacks. Our common sense tells us that if the original attack in an adult is dependent upon some gross exposure to chill and to general carelessness, there is good hope that with proper care in the future the first attack will also be the last. The writer believes that if there is recurrent tonsillitis with obviously diseased tonsils, their enucleation will improve the outlook. In general terms, then, the outlook in acute articular rheumatism is good as to life and to complete recovery ; but such a general statement is of little value, seeing that in a large number of cases the heart is more or less affected, and that upon the degree of this affection the prognosis in acute rheumatism mainly depends. In children the articular symptoms are of little prognostic importance. There seems no serious difference in the prognosis dependent upon the variety of salicylate compounds used in the treatment. Those who push these drugs usually combine the sodium salt with sodium bicarbonate, but others claim that the acid aspirin is even more effectual. In the severe articular forms the writer prefers the salicylate of sodium, finding it less likely to upset the digestion; but it must be premised that only the purest drugs are used. It is important to remember that in childhood, if these drugs are pushed too heavily and without reference to the particular patient, bad and even fatal results may follow in a case of moderate severity. As a general guide, it is useful to recognize three classes of arthritic lesions in rheumatic fever : — 1. The acute severe type, recovering rapidly and completely. 2. The relapsing subacute type, also recovering, but more slowly. Such attacks may leave some weakness in the larger joints. 3. The more pernicious type, drifting into the rheumatoid group. This latter, many authorities regard as non-existent. There may be great muscular wasting in some of these cases of severe rheumatic arthritis ; and in children in whom the hands are badly affected, the result may resemble precisely the rheumatoid arthritis of young adults. Very good recovery m.ay, however, result, though the improvement is generally slow and such cases are not frequent. The prognosis in the cardiac affections is discussed elsewhere {see Rheumatic Peri-, Myo-, a.nd Endocarditis). f. J . Poynlon. 29 450 INDEX OF PROGNOSIS RHEUMATIC PERI-, MYO-, AND ENDOCARDITIS (ACUTE).— It is most essential that we realize that these three lesions are not as a rule independent entities in rheumatisna, but that the cardinal lesion of severe types is a carditis aiiecting to a greater or lesser extent all parts of the heart. Both in the child and adult these cardiac lesions are the ones that chiefly influence the prognosis of rheumatic fever, and because of their greater frequency in the child it is generally admitted that the prognosis is the more serious at this early age. The outlook is very grave when severe carditis occurs in a child with a family history of rheumatism on both sides, in the very young (five years and under), and in those who are surrounded by poverty and neglect. The most virulent cases are liable to commence abruptly with somewhat unusual symptoms, such as vomiting and diarrhoea, severe shivering or sudden acute thoracic pains, and considerable fever. On the other hand, we must be prepared to find that a general carditis may gradually appear in some delicate children with remarkably few alarming signs, and though the course is more protracted than in the first group, the ultimate result may be most unfavourable. I. Pericarditis. — This is the commonest cause of a fatal event in acute rheu- matism. The cause of death is the general carditis, but the pericardial lesion is the most evident warning of this occurrence. Some of the most dangerous cases show remarkably little fever, and in the last days of the illness the chart may even give a subnormal record. This is a point that should not be lost sight of b}^ those who regard a fall of temperature at the time of the administration of salicylates as necessarily a good omen. Livid pallor, a rapid small pulse, great dilatation, and feeble cardiac sounds are signs of a deadly infection, whether nodules develop or not. Delirium is a bad sign, but it is not at all frequent in childhood. The fatal issue may be unexpectedly abrupt from syncope. Those who are acquainted with this virulent form of rheumatism will recognize at once from the general appearance and rapid development of the heart disease that the prognosis is very bad, for should the patient rally for the time, the heart is usually irretrievably damaged, and the more speedy death is really the happier event. Fortunately, these cases are comparatively rare, and we know that pericarditis is more often an event in a recurrent attack of cardiac rheumatism. This fact is one of considerable interest, for it reminds us that with recurrent infection the resistance seems to lessen, a principle which may be also applied to the endocardial lesions. The occurrence of nodules is much more frequent in the child than in the adult, and the lesion is one which leads us to consider with particular care the prognosis of the case. Dr. Cheadle made the general statement that these lesions were as a rule associated with grave heart disease, and that the prognosis was accordingly grave. This general rule holds good. Thus, of 39 of the writer's cases that came to hospital showing nodules among other manifestations, 15 died. Although, then, this lesion is a very important one in prognosis, we must not fall into the error of looking upon its occurrence as a sentence of death. The writer has seen rare cases in which the heart has been scarcely damaged, and in which excellent recovery has followed. There are other cases in which the nodules disappear, and the heart, though damaged, makes a good recovery and becomes well compensated, and the child does not suffer from another attack of rheumatism while under observation. We must guard against the error of mechanical precision in judging of these cases, and not permit ourselves, on detecting nodules, to state dogmatically that the condition is hopeless ; on the contrary, though justified in fully admitting their prognostic importance, we must judge each case by the broad lines of clinical inquiry, and above all must RHEUjMATIC peri-, MYO-: AND ENDOCARDITIS 451 estimate the degree of cardiac damage. This is the more necessary because it may not have occurred to some physicians that these nodules are only the visible evidence of a process which occurs elsewhere in the subcutaneous tissues without forming visible projections, as post-mortem and histological investigation has shown. This being the case, it is quite possible, though clearly difficult of proof, that in many more cases than we think, some degree of local subcutaneous infection occurs short of obvious nodule formation, and the actual appearance of the prominences will then only represent a somewhat greater severity of this same process. In adolescents the occurrence of nodules is also as a rule associated with grave, but by no means necessarily fatal, heart disease. Among the less virulent cases, we can recognize a group in childhood in which there is obstinate and recurrent carditis, with a subacute and recurrent peri- carditis. In these there are numerous manifestations, such as nodules and erythemata, endocarditis is invariable, and more than one valve may be attacked. The outlook is bad, for though these children may pass through one or more attacks, even in convalescence they never seem to be quite free from rheumatism, and the heart is irretrievably damaged. In London we see a number of these cases, of all degrees of severity, and they include some of our most favourite and our most familiar hospital in-patients. There is a third group in which only a single acute attack of pericarditis may occur, and among them occur examples of remarkable recovery, the heart apparently throwing off the infection with very little, if any, permanent injury. In a few of these the cardiac valves seem to escape entirely, although such an event always rouses the suspicion that the illness is not rheumatic. These are not difficult cases to recognize ; the child is usually a strong one, the pericarditis is evanescent, the symptoms are mild, and the cardiac dilatation is fleeting. Unfortunately, in the hospital class we do not meet with many of them, but in the well-to-do they are more frequent. In the adult, pericarditis is much less frequent, but when it occurs the prognosis must always be cautious, for here again it is an indication of a grave infection, and the damage to the myocardium is at this age a very serious event. Never- theless, there are all grades of severity in the adult as in the child, and good recovery may occur even when the patient is over fifty years of age. The guiding principles lie in the estimation of the virulence of the attack and the degree of cardiac failure that results. The prognosis of carditis and pericarditis must also be influenced by the degree of care in convalescence. At all ages this is of the greatest importance, and it is very advisable to picture the pathological changes that occur in this carditis, for thus alone can we realize the time that is needed for the inflammation to subside, the exudation to be absorbed or organized, and the heart to compen- sate for the necessary impairment of functions. Attention must be paid not only to the physical signs in the heart, but also to the general condition of the patient, for the heart may show good evidence of recovery, but the delicacy of the patient may warn us not to commence to apply the test of increasing calls upon its powers until this recovery has become assured for some while. We have to be continually reminding the parents that, for the child, the problem is not one of the immediate future but of his whole career. It is useful in considering the prognosis of rheumatic pericarditis to recognize three main types : — 1. The acute and transient. 2. The subacute and relapsing. 3. The virulent form proving rapidly fatal, or, if less severe, leading irresistibly into the second variet3^ 452 INDEX OF PROGNOSIS The influence of adherent pericardium upon the prognosis takes us beyond the scope of acute rheumatism. [See Pericarditis.) Pericarditis is always a long illness, although in the most favourable cases all activity of the lesion may be over in three weeks. The quieting down of active symptoms marks, however, only the commencement of that very gradual and cautious convalescence upon which the real progress so greatly depends. The guiding principle in this stage is not to take an abstract period of time, but to study the behaviour of the heart in each cautious forward step. Some patients get forward much faster than others, and these lose rather than gain by prolonged and complete rest. Others need more rest than would have been expected. In both instances, if progress is cautious, we can alter the details without doing any real harm, even if the advance has been a little too rapid. It is the abrupt transi- tion from invalidism to ordinary life that may alter the prognosis of this condition from good to bad. The temperature, the pulse-rate, the character and position of the cardiac impulse, and the nutrition of the patient are guiding points. Three weeks of normal temperature after a rheumatic pericarditis is, in general terms, a useful time to allow before attempting to make any forward step at all. 2. Acute Myocarditis. — The importance of this is well recognized, but the accurate estimation of its severity is not yet within our powers, and for this reason we must temper dogmatism with caution. The more modern methods of cardiac examination are helping us with the study of arrhythmias that may result from rheumatic myocarditis, but we must not take the occurrence of arrhythmia as necessarily an index of the power or weakness of the cardiac muscle, and we must remember also that the unit of arrhythmia — the extra- systole or premature contraction — is one which requires much more study before its true meaning is understood. Acute dilatation from myocardial poisoning may prove fatal even in childhood, but it is a very rare occurrence. When it occurs, there are such clear signs of cardiac failure and intense illness that the danger is apparent. A much more frequent occurrence is cardiac dilatation, followed by the failure of the heart to compensate for a mitral lesion which clinically appears to be one of ordinary severity. These are the mitral cases that run such a disastrous course at all ages. The action of the heart remains feeble and rapid, and the dilatation only recovers in part. The child is short of breath, and cardiac tonics do not produce the effect that is wished. An adult, if forced by circumstances to return to work, soon breaks down, with evident signs of mitral insufficiency. In such cases, the factor of an adherent pericardium always comes in for considera- tion, but there is no doubt that in many of them no such complication has occurred. There can be little doubt that the most important element in the prognosis is the early recognition of this myocardial weakness, and a determined attempt to cope with it by prolonged rest and care at its first appearance. When once such a heart as this has been overstrained, the outlook is bad. It need hardly be added that, if this be true of mitral cases, it is even more so of aortic or combined mitral and aortic lesions. There is a third group of cases in which the myocardium appears to suffer almost alone, and the valves to escape ; these are not the virulent acute cases mentioned above, but those in which, after an attack of rheumatism, the heart remains dilated, the action rapid and often irregular, pallor, and symptoms of breathlessness, nervousness, and palpitation, with or without syncopal attacks, are prominent, and there is a real danger, owing to the absence of a definite valvular murmur, of considering the condition as neurasthenic. Such a condition is very obstinate, but in childhood good recovery may be made after many months. In adult life much will depend upon the occupation. The mildest RHEUMATIC PERI-, MYO-, AND ENDOCARDITIS 453 examples of this condition are the transient dilatations which occur so frequently in first attacks of rheumatic heart disease, and from which recovery may be rapid and complete, if their true meaning is appreciated. It will be apparent that in dealing with the prognosis of myocarditis in rheuma- tism we are continually driven to realize its existence, not by a clinical sign, but by evidence that we have put too great a strain upon a heart which we believed was stronger than proved to be the case. This difficulty must always be remem- bered as one of the most important facts in the study of rheumatic heart disease. Once more we may usefully recognize three classes : — 1 . The acute simple dilatation which with care recovers completely. 2. The subacute obstinate cases that require much time and caution before a good result is obtained. 3. The virulent cases which may actually prove fatal, but more frequently much increase the danger of concomitant pericardial and endocardial lesions. 3. Acute Endocarditis. — Simple rheumatic endocarditis is never fatal, for the lesions are small, and would be negUgible if it were not for the functions of the structure attacked ; but the bearing of these lesions upon the ultimate prognosis is of immense importance. We can lay down some useful guiding lines upon this point from clinical experi- ence. We recognize that the combined aortic and mitral lesion, particularly if the aortic is predominant, is a grave event. In childhood these cases, if severe, usually point to a great tendency to develop future attacks, and to a fatal termin- ation before adult life is reached. The writer believes that if they survive to early adult life they are prone to develop malignant rheumatic endocarditis, and sometimes they develop frequent attacks of angina pectoris. The solitary aortic lesion is rare in childhood, but if severe the prognosis is bad. Simple mitral endocarditis, if associated with grave myocardial weakness, runs a very disastrous course in the young ; but when, as is more usual, it is compensated, the outlook is good. If there is no further rheumatism, many of these cases recover in a way which can hardly be realized until they have been followed for some five or six years. The murmur, which was loud, and heard over a wide area, may disappear, or only be audible when the child is lying down, and even then perhaps only be recognized b}^ the physician who has followed the case closely. The writer believes that slight aortic lesions may also sometimes disappear. Mitral stenosis does not, as a rule, give rise to symptoms in childhood, although its origin is frequent at this age, but if it does the outlook is bad. If before puberty, recurrent bronchitis, embolism, or attacks of tachycardia, and cyano.sis with dyspnoea, have occurred, or if there has been an attack of heart failure with dropsy as the result of this lesion, we must be prepared for invalidism and early death. On the other hand, slight mitral stenosis, though always more serious than slight regurgitation, may, after childhood, never make headway, and a useful life may follow. When, however, we take a broad survey of this lesion and couple with it the greater frequency of rheumatism in the poorer classes, we are forced to the conclusion that it represents a form of rheumatism which is very prone to dog the footsteps of its victim through life, and we find that death is very usual under forty-five years from chronic heart disease, or some accident associated with the lesion. The following statistical points may be of service in helping the reader to focus some of the facts that bear upon the prognosis of rheumatic heart disease. Taking 150 fatal cases in children under twelve years of age, we find the mortality somewhat greater in females : 59 per cent, as against 41 per cent in males. Up to 3I years 3i to 4i .. 4i to 5i „ 5i to 64 „ 6| to 74 .. 74 to 84 „ 8^ to 94 .. 9i to loi- loi to 114 454 INDEX OF PROGNOSIS Allowing for the great difficult}^ there is in establishing without doubt that any particular attack is a first one, about 30 per cent of fatal cases occur in the first attack. The age incidence of fatal cases rises to about the tenth 3'ear, thus : — 0-6 per cent. - 3-9 7-4 9-4 - 12-7 - 12-7 - 15-3 20 ,, 12 At least 86 per cent of fatal cases of rheumatic heart disease show active rheumatism in the last illness, and death from chronic heart disease alone is very unusual. The cardiac lesions found after death are very definite and often very extensive. In at least 90 per cent the pericardium is more or less damaged. The mitral valve was damaged in 149 out of 150 cases, the aortic valve in 34 per cent, the tricuspid in 24 per cent, and the pulmonary in 3 per cent. The multiple valvular lesions in the severe rheumatism of childhood are well exemplified by these numbers. When confronted with a case of acute rheumatism in a child of five years or under, the following figures will give an idea of the conditions that may be expected. Eight out of 52 such cases proved fatal, that is, about 16 per cent. Definite heart disease occurred in about - 85 per cent. Arthritis or arthritic pains - - - -70 Chorea -------35.. Sore throat - - - - - - - 20 Nodules - - - - - - -15 When we turn to adolescents and adults, and look into the after-histories of a considerable number, we come upon a very suggestive and interesting fact. Putting aside as beyond the scope of this article the numerous cases of death from chronic heart disease, we find the great danger is not carditis, but malignant endocarditis. This point has such close bearing upon the prognosis in acute rheumatism, that the writer feels that he is not trespassing upon the ground of another contri- butor when he gives the examples shown in the table on the opposite page. Closely allied, and probably of the same nature, were 7 further cases in adults, the victims of repeated rheumatism in childhood, who showed many of the signs of malignant endocarditis, and eventually recovered for the time, after long and dangerous illnesses. It is evident, then, that the physician who deals with acute rheumatism in the adolescent and adult must take into account the possibility of malignant endo- carditis, and this particularly in the cases in which the aortic and mitral valves have been both damaged by previous rheumatism. Whatever interpretation he may choose to put upon the occurrence of these malignant lesions, the fact of their intimate, and in the writer's opinion direct, association with the nature of the early illnesses cannot be put aside in the prognosis of acute rheumatism. RHEUMATOID ARTHRITIS 455 A study of 2O0O post-mortem examinations upon adults brought home this fact to the writer, that more rheumatic patients die from malignant endocarditis than from an acute rheumatic carditis such as occurs in children, or indeed from any form of acute rheumatism that is generally recognized. Table Showing the Sequence of Malignant Endocarditis UPON Attacks of Acute Rheumatism. Onset of Sex Onset of Acute Rheumatism Malignant Endocarditis M 10 years ----- 13 years M 6, 8, and 10 years - 10 ',, F 23 years 37 „ F 12 and 13 years 14 „ F 7 and 20 years - - - - 21 „ F As a child - . . . 37 „ M 11, 14, 17, and 18 years - 19 „ M 42 years ----- 50 „ F 12 years ----- 16 „ M As a boy and at 16 years - 27 „ F 12 years ----- 16 „ M 7 years _ - - - - 13 ., F 12 years ----- 17 „ F 8, 13, and 15 years - 24 „ F 38 years . - - . . 48 „ M 18 3'ears . - . - - 28 ,. F 13 and 17 years 27 „ F As a child 32 „ The influence of treatment by special drugs or by special methods upon the prognosis of rheumatic endocarditis is most difficult to estimate. The most important claim in recent years has been that the salicyl group, if used effectively, is a specific to the rheumatic process. The writer is not himself at all convinced upon this point, and would express his own view by the statement that in a case of severe rheumatic carditis he would not feel confident that pushing these drugs would not do harm rather than good. He has seen this method of treatment used on many occasions, and yet at the time of writing has still this feeling of lack of conviction. There seem to him no convincing papers, and the recent one by Dr. R. Miller in the Quarterly Journal of Medicine appears to him to be more of the nature of a defence of the administration of large doses than a proof of their value. Doubtless, the truth will be ascertained in the future. Such a method as Dr. Caton's has much improved the prognosis of early endocarditis by demanding a complete rest for the patient, while a definite procedure, which in itself would appear to be devoid of any danger, is being carefully carried out by the physician. f, j, Poynton. RHEUMATOID ARTHRITIS. — The prognosis of rheumatoid arthritis must be made at present on broad and general lines, for we have to realize that a considerable change in the attitude toward the nature of the condition has taken place in recent years. There is a general feeling that some infective process is the exciting cause of the condition, or, what is probably more correct, that a variety of infective processes are concerned. The tendency now is to lay much emphasis upon the infection, and, from the point of view of investigation, this attitude seems to offer the best chance of making advance. Nevertheless, when we come to consider prognosis, we must admit that in many cases no causal 456 INDEX OF PROGNOSIS infection has been demonstrated, and must further bear in mind that the indi- vidual constitution — whatever the nature of rheumatoid arthritis may be — has probably an important bearing upon the course of the illness. It would be, then, a mistake to lose sight of possible fallacies in the present state of our knowledge. Thus, for example, a patient may be suffering from some degree of pyorrhoea alveolaris, but it does not necessarily follow that this is the determining cause of an associated rheumatoid arthritis. The writer's experience must be that of many others in finding that a patient has had clear evidence of rheumatoid arthritis at a time when the teeth and gums were in excellent order, and j'et some years later, with failure of health, both teeth and gums have become diseased, and the rheumatoid arthritis is still in evidence. In other cases, unhealthy conditions have been corrected, but no obvious change in the course of the disease has followed. He would be the first to aUow that the primary step in the study of such a case is a search for some local focus of infection, but is not prepared yet to admit that its discovery has necessarily solved the problem of the origin of the disease. Although encouraged by such a discovery to hope that a means of diminishing the severity, or even of arresting the course, of the disease had been found, he could not confidently assure his patient, on the evidence at present available, that such a happy event would follow. Then, again, we must admit that in a considerable number of cases we can find no focus. This is certainly no proof that the condition is not infective, for, when all is said, the demonstration of an obvious local focus, though of the greatest importance, is an example of a somewhat crude method of infection. We do not always find gross local foci in cases of tuberculosis, or of pneumococcal infection, or of the rheumatic, for these infections may gain access to the system without a great parade at their site of entrance. Dr. James Lindsay's statistics upon this question of infective foci are of interest. In 138 cases in females : — No focus was found in - "65 Vaginal discharge in - - - 36 Pyorrhoea alveolaris in - - 19 Otorrhoea ----- 7 Gastric ulceration - - - 5 After childbirth - - - - 4 Rhinorrhoea - - - - i * Chronic tonsillitis - - - i Thus, in almost 50 per cent of these cases, no infective focus was forthcoming. The prognosis then must clearly be based on broad lines, to some of which consideration will now be given. Predisposing Causes. — i. The family history is doubtless of some importance, for we cannot but believe that the occurrence of the disease in several generations and members of the same famil}^ points to a weakened resistance to the infection, if there be one, or to some mysterious metabolic perversion if the fault should lie there. 2. The question of age incidence introduces the usual difficulty of deciding what is to be called rheumatoid arthritis, and upon which there is no agreement at present possible ; but we find that the disease in early life is likely to be more virulent, whereas in more advanced life, the natural tendency'' to degenerative lesions in the joints favours chronicity and crippling. 3. Sex. — The liability to rheumatoid arthritis in females is undoubtedly greater than in males ; but when it occurs in the male it may be equally severe. RHEUMATOID ARTHRITIS 457 4. The mode of onset is of some importance. There is a group of cases in which rheumatoid arthritis begins acutely and affects many joints, producing rapid destruction. Among these cases, often called acute rheumatoid arthritis, are some of the worst examples of the disease. These are easily recognized by the fever, general toxsemia, and extensive and severe lesions. On the other hand, when they are less severe, although there may be much damage, the eventual recovery may be fair, and no second attack need necessarily occur. In any case, the illness will certainly be long and recovery slow. 5. Another very important group begins with acute symptoms affecting a few joints, or possibly only one. The onset is to this extent acute, but the general illness slight. In this group the cause is often obscure and the tendency to further attacks very decided. The most experienced may make grievous mis- takes in prognosis here, because there is at present nothing certain to guide the opinion. The first attack was mysterious, and the cause equally so. Accord- ingly, we find such patients coming to us a year or two later much crippled, and complaining that they were told at the time of their first attack that if they did so and so, and underwent such and such a course of treatment, they would be cured in six months. The essential point to remember is that when an arthritis of mysterious origin occurs and shows a tendency to be recurrent, the prognosis must always be tinged with caution. In another group, the onset is even more gradual, with mysterious pains and vasomotor changes, and these may prove to be most intractable, and end in complete disablement. Once again, the unknown factors in the disease baffle accurate prognosis. 6. Occupation. — It is probable that occupation is of very considerable import- ance in prognosis. The writer has been struck by the great severity of the disease in school teachers. The nerve-wearing life of the board schools, the effort to be of rather more importance than one can afford to be, and the struggle to get the necessary qualifications to reach this position, seem to combine in undermining the resistance to this disease in the most deadly fashion. Again, there can be no doubt that long and anxious nursing of a near relative, or any other continual nerve-strain, may antedate a most serious rheumatoid arthritis, or greatly aggravate the course of the disease if it has already com- raenced. 7. Surroundings are also important. There seems no doubt that cold damp houses, a low-lying swampy country, and a heavy clay soil, foster the chronicity of this disease. A favourite garden may do much harin to a delicate patient who is threatened with rheumatoid arthritis. Damp, changeable climates, such as our own, are generally agreed upon as favouring the disease. It is clear, therefore, that in making a prognosis we must take a broad survey of the general position, as well as pay close attention to the special points in the particular case. Bearing in mind, then, these general indications, we come next to the prognosis in the particular case, and find that this is a complicated problem. The danger to life in general terms, and with rare exceptions, is indirect rather than direct ; the joy of living is destroyed far more often than life itself. There are, nevertheless, two important points in the prognosis : one concerned with the general constitutional disturbance, the other with the local arthritic lesions. Cases in which profound toxaemia is evident in the sallow pallor, general depres- sion, bouts of fever, loss of strength, tachycardia, and vasomotor changes, are among the most serious. In such, multiple arthritic lesions, sometimes of great extent, are coupled with profound muscular wasting. In such, too, grave signs of organic lesions of the spinal cord occasionally develop. In every direction treatment is embarrassed by the loss of strength and hope, by the distress on 458 INDEX OF PROGNOSIS movement, and by the spontaneous neuritic pains. Among them are some of the most terrible examples of human suffering that are known in the field of medicine. On the other hand, if the cachexia yields to treatment, and the arthritic lesions are not too far advanced, we know that in young subjects after a prolonged illness sometimes remarkable recovery may occur. Joints which only show active peri- articular lesions are not beyond hope, but it is when the atrophic shrivelling of the tissues supervenes that we realize that recovery of the affected parts is not possible. The less virulent but mysteriously relapsing cases are of most uncertain prog- nosis, and number among them many courageous but hopelessly crippled patients, who live for years fighting against increasing disability. Yet we see in this group many cases in which the relapses cease as mysteriously as they appeared, and then there may be fair recovery, with a greater or less degree of infirmity, when hope has been almost abandoned. When the condition occurs in the elderly, there is much more likelihood of degenerative lesions occurring ; the synovial membranes become greatly hyper- trophied, loose bodies embarrass the joint and cartilage, and bone may be greatly damaged. In these cases only a few joints — but unfortunately often the knees — may be involved. Such patients may be stout and heavy, and their muscles weak ; accordingly, though the disease may be very limited, the crippling is great. The factor of injury has also to be reckoned with, for these insecure joints are very likely to be wrenched by a sudden false movement, and injury produces a very serious change for the worse in such diseased tissues. Injury, indeed, is sometimes credited with being the determining factor ; but though it may be the means of drawing attention to the condition, the writer believes that if, as is often the case, other articulations become involved, the injury is only a secondary factor, and he would judge of the prognosis in such cases as in those of the same type without any traumatic history. The condition of the digestion and the bowels influences prognosis. Constipation depraves the general health, and dyspepsia interferes with the generous diet that is so needful in the asthenic cases. The correction of these difficulties may do more good than any local treatment for the arthritis. A short space may be devoted to a condition in childhood looked upon by many as a form of rheumatoid arthritis, but first clearly defined by Dr. G. F. Still. It is a multiple peri-articular arthritis with enlargement of the spleen and lymphatic glands. The condition is a very striking one, and the recurrent attacks of fever are most suggestive of the presence of an infection. The writer more than once has seen such a case improve in the most remarkable way while under careful supervision, and then, without any discoverable reason, drift back to the last stage of emaciation and illness while in precisely similar surroundings. The prognosis of the characteristic cases is very serious ; great crippling results, and death may occur. In some of the fatal cases, general pericardial adhesion has been found, the result of a pericarditis unsuspected during life. No treatment appears certainly to influence their course, although liquid paraffin and other intestinal disinfectants seemed to do good in a few cases for a while. There appear to be transitional cases of less severity, some of them approaching closely the character of subacute rheumatism, and these may improve after several years, and eventually make a good recovery. Some of them seem to the writer to be associated with damp, low-lying districts, and this danger, if RHEUMATOID ARTHRITIS 459 corrected, favours the outlook. The first step that he would insist upon in any case of this kind would be removal from damp surroundings. The Influence of Treatment upon Rheumatoid Arthritis. — This is a question of much importance, and there can be little doubt that the great emphasis that at the present time is laid upon the infective element in the condition must eventually lead to much clearer views upon the value of numerous methods now in use. If the condition is infective, there are two main indications for treatment : one to attack the infection, the other to promote the constitutional resistance. The first aims at destroying the focus of infection and counteracting the morbid effects already at work. It is clear from the pathology of the disease that many of the changes are inflammatory in nature, and run through the usual phases of such changes. There is the period of activity and the period of retro- gression, and that of more or less perfect healing. Unfortunately, in many cases we do not know the nature of the infection, and the prognosis is the more serious on this account. It is rational to remove possible foci and to give proper rest to the tissues while the infection is active. It is also rational to treat cases with vaccines if the nature of the infection is known, and this method is really one of undoubted efficacy ; but seeing that vaccines are often used without a con viction of the nature of the infection, and only on the hypothesis that some focus which has been singled out contained the real agent, the prognosis in many cases is not certainly improved, and more accurate details are still needed before we can estimate the improvement in the outlook resulting from such methods. The evidence of reliable data is urgently required. If the infection is thought to be located in the large bowel, then high douches are rational ; but here again there seems good reason to think that the intestinal symptoms are frequently not the primary focus, but are a part of the general disorder, and so again the prognosis from this point of view remains uncertain until we can get more reliable data. There are numerous methods of treatment directed to the damaged joints. It cannot be too much insisted that if the disorder is infective these methods do not deal with the cause of the disease. When Nature is conquering the local infec- tions, then these measures, properly applied, favour the rapidity and completeness of recovery ; but it is difficult to see how radiant heat, or massage, or Aix or Vichy douches, or peat or fango baths, can do more than assist a process of recovery — and to this extent improve the prognosis. Whether kataphoresis has real power in directly attacking local foci of infection must still be regarded as uncertain. When we turn to internal remedies, we see once more that some are used to attack the supposed site of infection, as, for example, guaiacol carbonate and other intestinal disinfectanis, while others are used to strengthen or alter the patient's general condition. Among these latter remedies we find alteratives, including mineral waters, and tonics, such as iron and arsenic, quinine, etc. In such diverse conditions as those we are considering, it is eminently possible that in some cases of the so-called ' rheumatic gout ' class internal treatment by drugs or by waters may be helpful, for in these metabolism seems certainly at fault ; on the other hand, where the infection seems predominant, it is difficult to see how water-drinking will help, unless the minute traces of radium are to be looked upon as antibacterial. Radium water has come into prominence in the last few years, and the latest accounts give a bright vision of its future. The writer cannot yet be in a position to make a statement as to the influence of this treatment upon the prognosis. When we realize how our spas have clung to the minute traces that are found in their natural waters, we may well wonder whether 46o • INDEX OF PROGNOSIS ' Ichabod ' is now ringing in their ears. Doubtless, the value of this treatment will soon be appraised ; but at the time of writing there seems to be no justifica- tion — in what is striving to be a balanced opinion upon prognosis — for the assertion that a great advance has been made in the management of the disease . We can understand how much the prognosis may be improved if, with clear evidence of damp and cold surroundings, we are able to substitute warmth, dryness, and cheerful company, for then we are certainly assisting the best of all healers — Nature . There is another group of remedies which aim at altering the nervous influences, and success must largely depend upon how much of truth there is in the view that rheumatoid arthritis is largely the result of disordered innervation. Such methods as blistering the spine come into this category. We cannot escape from the fact that some have had great successes, and thus bettered the prog- nosis ; yet we have met with patients who have fled from the stringent blister none the better, but rather the worse. Here, again, we need more definite details and indications before we can appraise the value of such methods in the question of prognosis. One point stands out clearly with regard to treatment, and this is that the prognosis is not infrequently made decidedly worse by over-zeal. If we are to accept as a working basis that the condition is an infection, the patient must be studied as an individual, and the stage of the infective process must be recognized, and this, too, with the humbling knowledge of our ignorance of the exact nature of the infection. Forgetfulness of these points leads to our seeing a weakly patient reduced to the last stage of debility by an avalanche of therapeutic methods, some of them not apparently rational, and then the outlook is definitely rendered more gloomy. There can, ho\ Bacillus aerogenes capsulatus, 155 ation . . 351 Arteries, peripheral, aneurysm of . . 43 gangrene due to 379 ARTERIOSCLEROSIS 80 — coli pyelocystitis 437 — dangers of anesthetics in 33 — oedematis maligni, gangrene due — distribution of changes in 85 to 379 — etiological factors 80 — paralyticans in causation of — with mental disturbances of old general paralysis . . ' . . 324 age 336 — paratyphosus A and B . . 386 — pneumonia with . . 404 Bacteriology of acute appendicitis 66 — relation to aphasia 53 — empyema . . 163 — stage of development 83 — pleuritis 401 — and valvular disease 218 — puerperal sepsis . . 416 Arteriovenous aneurysm 47 — ulcerative endocarditis . . 164 Arthritic muscular atrophy . . 347 Bands, intestinal, and chronic Arthritis, acute, of infants . . 380 appendicitis . . 76 — following sprains.. 250 complicating appendicitis . . 61 — gummatous 506 obstruction due to . . 241 — gonorrhceal . . . . 201, 204 Banti's disease (see Anaemia, Splenic) 16 — rheumatic (see Rheumatic Fever) 447 ascites due to. . 89 ARTHRITIS, TUBERCULOUS . . 85 Bardenheuer's method in fractures 174 Arthropathies, tabetic 508 Bassini method in inguinal hernia . . 214 ASCITES 88 Bath treatment of typhoid fever . . 521 — in biliary cirrhosis 280 Bedsores in hemiplegia 502 — complicating ovarian tumours . . 382 Bence- Jones's proteinuria . . 13 — operative treatment 90 Bennett's fracture . . 186 — in portal cirrhosis 278 BERI-BERI 95 paracentesis and surgical Beta-oxybutyric acid in test for treatment 278 acidosis 5 — prognosis from cytological data 92 Bile-ducts, cancer of, after gall-stones 194 — and the question of splenectomy 18 Bilharziosis complicating vesical Ascitic fluid, physical characters of 91 calculus 96 Asphyxia in papilloma of larynx . . 267 Biliary cirrhosis of liver 280 Aspiration of hydatid cyst . . 233 — complications of apj)^endicitis . . 62 Aspirin in rheumatic fever . . 449 Birth paralysis of brachial plexus . . 374 ASTHMA, BRONCHIAL 92 Bismuth paste injections in nasal — ' cardiac,' with angina pectoris. . 49 accessory sinusitis . . 360 from impaired ventricular BLACKWATER FEVER 95 contractibility 353 Bladder, atony of, prostatectomy Astragalus, fracture of 181 and 410 Asylums (see Mental Hospitals) 298 302 BLADDER, CALCULUS OF 95 Ataxia, mistaken diagnosis in dis- recurrence after operation . . 98 seminated sclerosis . . 153 results of operation . . 97 — plumbic 271 vesical and renal complications 96 ATAXIAS (see also Tabes Dorsalis, 506) 93 — complications in pyonephrosis . . 441 Atheroma with malaria, cerebral BLADDER, EXSTROPHY OF . . 98 haemorrhage due to . . 288 — — results of various operations 99 — mental disturbances of old age . . 336 BLADDER, GROWTHS OF 100 — mistaken for abdominal aneurysm 37 — gunshot wounds of 5 Athletics, influence on albuminuria 12 — malignant growths 102 Atrophies, muscular (see Muscular results of operation 104 Atrophies) 347 suitability for operation. . 103 Atrophy of liver, acute yellow 276 — papilloma of 100 Atropine with general anaesthesia . . 24 pre-cancerous nature of 103 — influence on post-operative vomit- — rupture of 3 ing 35 — total extirpation of, results 105 surgical shock 34 — troubles in tabes dorsalis 507 Aura in epilepsy 169 BLADDER, TUBERCULOSIS OF 105 Auricles, conditions of, in mitral relation to epididymitis 166 stenosis 222 Blindness from measles 290 548 INDEX OF PROGNOSIS PAGE 294 395 207 14 Blindness from meningitis . . — in tabes dorsalis . . Blood alkalinitjr reduction, valuable indications — changes in pernicious anaemia . . — coagulation, iafluence in haemo- philia . . — count in aplastic ansmia — — leukaemia secondary anaemia — — splenic anaemia — — of iafancy — dissemination of melanotic sar- coma . . — examination in puerperal sepsis — pressure in chronic interstitial nephritis hemiplegia — — high (see Arterial Tension) . . — — — and myocardial degeneration 352 — — — pre-eclamptic . . . . 13 — — relation of anaesthetics to . . 33 — serum in excessive vomiting of pregnancy . . . . 540, 541 — transfusion in pernicious anaemia 399 Blood-stained ascites Boils with diabetes . . Bone affections in tabes — changes of congenital talipes . . — excision in Volkmann's parah'sis Bone-marrow administration in per- nicious anaemia BONE TUMOURS Bothriocephalus latus, pernicious anaemia due to ' Botryoid ' liver due to sj^philitic cicatrices Bottini's operation in enlarged prostate Brachial artery, hematoma of — plexus injuries Brain, actinomycosis of — changes in, in chron.ic alcoholism relation to mental diseases . . — diseases, orgamic, mental sym- ptoms of — injuries of (see Head Injuries) . . functional defects following — lesions due to anteriosclerosis — syphilitic disease of — tumours of (see Cerebral Tumoirr) 124, 125 — — ataxia due to BREAST, CANCER OF — — apart from operation — — influence of pleural adhesions operation and recurrence after — — prognosis after recurrence . . simple diseases preceding . . BREAST, SIMPLE DISEASES OF Breathlessness (see Dyspnoea) Bright's disease (see Nephritis) with mental sj^mptoms British Medical Association Com- mittee on Fractures . . Bromide treatment of epileptic insanity . . . . . . 330 272, 273 15 17 291 416 366 501 78 92 148 508 509 347 398 106 395 2S1 412 206 374 9 327 296 328 210 212 84,85 325 94 no no 115 III 112 116 n6 362 338 175 PAGE Bronchial asthma (see Asthma, Bronchial) . . . . . . 92 — disease, dangers of anaesthetics in 33 BRONCHIECTASIS 1 16 BRONCHITIS 118 — with measles . . . . . . 289 — recrudescence after inhalation anesthesia . . . . . . 35 BRONCHOPNEUMONIA . . . . 1 18 — complicating appendicitis . . 60 measles . . . . . . 289 whooping-cough . . . . 543 Bronzed diabetes . . . . . . 148 Brophy's operation for cleft palate 137 Brouardel's tables of work capacity after fractures . . 188, 189 Bruit de galop in contractile failure 355 Buboes of neck in tj-phus fever . . 524 BULBAR PALSY . . . . . . II9 muscular atrophy due to . . 348 Bullous diseases (see Pemphigus) . . 386 BURNS AND SCALDS . . . . I20 r^^CUM, actinomycosis of . . 8 ^-^ — gastric symptoms associated with aft'ections of . . 494 — tulaerciilous . . . . . . 121 Calcaneum, fracture of . . . . 181 Calcined magnesia in papilloma of lar^Tix . . . . . . . . 267 Calculi after prostatectomy . . 410 — prostatic (see Prostatic Calculi) 412 — renal (see Kidney, Calculi of) . . 258 — — complicating vesical calculus 97 — — with gastric s^'mptoms . . 495 — vesical (see Bladder, Calculus of) 95 Calculous anuria . . . . . . 261 Cancer of breast (see Breast) . . no — colon (see Colon) . . . . . . 140 — following *'-ray treatment . . 283 — intestinal obstruction due to . . 243 — of jaw . . . . . . . . 247 — kidney . . . . . . . . 251 — lai-ynx (see Lar}.Tix) . . . . 265 — lip (see Lip, Cancer of) . . . . 274 — ovaries . . . . . . . . 381 — penis (see Penis, Carcinoma of) 387 — pericarditis with . . . . 390 — of prostate (see Prostate, Cancer of) 408 — pulmonary tuberculosis with . . 420 — of rectum (see Rectum, Cancer of) 442 — relation of gastric ulcer to . . 489 — of scrotum . . . . . . 469 — as sequel to gall-stones . . . . 194 — of spine . . . . . . . . 484 — stomach . . . . . . 486, 496 — — - pernicious anaemia due to . . 395 — testis . . . . . . . . 510 — ■ ' th}-roid ' . . . . . . . . 109 — of tongue (see Tongue, Cancer of) 513 — uterus (see Uterus, Cancer of) . . 526 — — fibroids as predisposing causes 532 — vesicular mole as origin of . . 343 — vulva (see Vulva, Carcinoma of) 541 Cancerous stricture of oesophagus . . 379 Cancrum oris . . . . ■ . • • 122 — - complicating measles . . 290 SUPPLEMENTARY INDEX 549 PAGE Carbohydrate deficiency, acidosis due to. . . . . . . . 5 Carbolic acid and sling method in movable kidney . . . . 345 in tetanus .. .. 512, 513 Carbon-dioxide snow in rodent ulcer 463 Carbuncle with diabetes Carcinoma (see Cancer) ' Cardiac asthma ' with angina pectoris from impaired ventricular contractility CAEDIAC SYPHILIS myocardial degeneration in Cardiolj'sis in chronic adhesive peri carditis Cardiosclerosis (see Myocardium, Pri mary Disease of) Cardiospasm . . Cardiovascular signs of hemiplegia . — system in acute nephritis Carditis, acute, rheumatic (see Rheu matic Pericarditis, etc.) Caries of spine (see Spinal Caries) abscess from . . Carotid aneurysm — arter}^ hfematoma of Carpal scaphoid, fracture of Caesarean section in eclampsia — — placenta prsevia Castration in hypertrophy of prostat — tuberculous orchitis Catalepsy in adolescent insanity Cataract in diabetes. . Catarrh with asthma Catarrhal stomatitis.. Catheterism, retrograde, in stricture of oesophagus — ureteral, importance in renal growths . . . . . . 252 Cauda equina, injury of . . . . 482 Cauterization in cancer of uterus . . 529 vulva . . . . . . . . 542 — treatment of asthma . . . . 93 CELLULITIS 123 — cervical, with scarlet fever . . 466 Cerebellar abscess following ear disease 244 — lesions, ataxia due to . . . . 94 Cerebral abscess . . . . . . 244 — complications of whooping-cough 543 — haemorrhage (see Strokes) . . 500 — — with mitral stenosis.. .. 223 — irritation after head injuries . . 212 — lesions due to arteriosclerosis 84, 85 causing aphasia . . . . 53 mental symptoms with . . 328 — symptoms of lead poisoning . . 271 — — with mumps . . . . . . 346 — — in typhus fever . . . . 524 — — ataxia due to. . . . . . 94 — — disseminated sclerosis i taken for . . . . . . 153 CEREBRAL TUMOUR, MEDICAL . . 124 — — results of operation . . . . 127 CEREBRAL TUMOUR, SURGICAL . . 124 Cerebrospinal fluid, escape of, in head injuries — meningitis (see Meningitis) . . 294 148 49 353 122 351 392 349 379 501 363 450 477 412 47 206 186 158 399 409 167 334 149 93 499 379 Cervical cellulitis with scarlet fever — dilatation in eclampsia . . CERVICAL RIB — — nerve injury due to . . — spine, fracture and dislocation of Cervicitis, gonorrhoeal Cervix uteri, cancer of Charcot's Joints — — in tabes Charcot-Marie-Tooth type of muscu- lar atrophy Cheyne-Stokes breathing in hemi- plegia - — — myocardial disease . . CHICKEN-POX dilldbirtli, mental diseases associ- ated with Children, acidosis in cyclic vomiting — bronchitis and bronchopneu- • monia in — delirium of — development of mental inhibition — frequencv of arrhythmia in — mental disturbances of . . — new growths of kidney in — pyelitis of — in relation to anaesthetics — rheumatoid arthritis of . . Chimney-sweep's cancer Chloral habit . . — poisoning . . Chlorbutyl, influence on post- operative vomiting . . — pre-anaesthetic administraton of Chloroform anaesthesia, methods of • — — relative safety of — contra-indication in jaimdice . . — poisoning, delayed — — — following appendicectomy — relation to status lymphaticus . . — — surgical shock — in spinal analgesia Chloroma CHLOROSIS Cholecystectomy and cholecyst- otomy for gall-stones Cholecystenterostomy in chronic pancreatitis CHOLECYSTITIS — with chronic appendicitis — from gall-stones . . Cholelithiasis (see Gall-stones) Cholera — infantum Chondroma — of testis CHOREA — benefits and dangers of drug treatment — mental symptoms in CHORION-EPITHELIOMA — following vesicular mole Chrysarobin treatment of psoriasis Circulatory disturbances, albuminuria due to . . — lesions, dangers of anaesthetics in Circumflex nerve, injuries to Cirrhosis, ascites with PAGE 466 159 128 375 481 203 526 129 508 348 501 353 129 331 118 339 320 430 333 253 439 29 458 469 328 155 35 25 27 22 276 30 63 30 34 26 274 129 195 385 132 75 194 193 133 150 107 510 133 134 339 135 343 414 13 33 375 55° INDEX OF PROGNOSIS PAGE Cirrhosis, cj'tology of ascitic fluid in 92 — of liver (see Liver, Cirrhosis of) 277 — stomach .... Clavicle, dislocation of — fracture of CLEFT PALATE Climacteric, mental disturbances of — suicidal impulses at CLunate, effects on pulmonary tuber- culosis — in rheumatoid arthritis Climatic treatment of renal tuber- culosis . . Club-foot (see Talipes) Cocaine habit, hopeless prognosis of — in local analgesia. . Cocainism, chronic . . Coley's fluid in sarcoma of bone Colic, gall-stone — lead (see Lead Poisoning) — renal, with appendicitis . . COLITIS — resulting from chronic appendiciti CoUes's fracture COLON, CARCINOMA OF — gunshot wounds of Colonic etherization . . Colopexy in gastroptosis Colostomy, prognosis after — for rectal cancer (see Rectum) — results in carcinoma Coma in diabetes — with eclampsia . . — in exophthalmic goitre — head injuries — hemiplegia Compensation, fractures and the question of . . Compression in abdominal aneur5-sm — aneurj'sm of peripheral arteries Concussion of brain without signs of injury . . — the spine . . Condylomata, gonorrhceal Confusion, mental (see Mental Diseases) Confusional symptoms in adolescent insanity CONGENITAL DISLOCATION OF HIP — hj-dronephrosis — hypertrophy of pylorus . . — and instinctive criminals — mental weakness . . — stenosis of pylorus — syphilis hepatic cirrhosis of . . Congestive dysmenorrhcea . . Conjunctivitis with measles. . Constipation with chlorosis.. — chronic, with asthma — in melancholia — and rheumatoid arthritis Contraction after bums CONTUSIONS, ABDOMINAL . . . . I Convulsions in bronchopneumonia 119 — hemiplegia . . . . . . 501 — syphilitic brain disease . . . . 325 — uraemic . . . . . . . . 524 250 187, 192 135 335 336 422 457 256 509 328 25 155 109 193 270 65 137 77 185 140 4 28 496 446 443 141 148 159 174 211 38 44 211 3o, 481 203 321 334 142 • • 233 .. 487 ■ • 320 322 439, 496 •■ 505 . . 281 .. 158 290 .. 131 93 ■ - 308 •- 458 121 Convulsions in whooping-cough . . Copper salts in actinomj^cosis Corneal aiJections with measles — ulceration in exophthalmic goitre Corriadi's method of wiring in abdo- minal aneurvsm COXA VARA ' Cretinism Criminals, congenital and instinctive Crises of tabes dorsalis Cuboid, fracture of . . Cuneiform bones, fracture of Cyanosis with measles Cyclical albuminuria — vomiting of children, acidosis in Cyst, hj'datid Cystectomy, mortality results of . . Cystic goitre . . — growths of brain (see Cerebral Tumour) Cystitis (see Br adder, Tuberculosis of, 105 ; Pyelocystitis, 437) — with cancer of bladder . . — complicating gonorrhoea 201 — and prostatectomy — tuberculous (see Bladder, Tuber- culosis of) — with vesical calculus Cystoscopy, importance in renal growths Cysts of bone — • ovarian (see Ovarian Tumours) — pancreatic (see Pancreatic Cysts) Cytology of ascitic fluid PAGE 543 9 290 173 38 143 324 320 508 182 182 290 12 5 232 105 199 124 104 203 410 105 96 252 109 381 383 "DACTYLITIS, tuberculous .. 88 ^^ Davos, statistics of treatment at 423 Deafness from meningitis — after mumps Death-rate variations of anesthesia Decadence, mental disturbances of Deciduoma malignum (see Chorion- epithelioma) . . Decompression operation for cerebral tumour Defective control of will Defectives, epileptic. Defects, bodily, with congenital amentia Degeneracy, delusional insanity a part of Degeneration, alcoholic — stigmata of . . . . 304, 323 Delhi boil (see Tropical Diseases) 517 Delirious mania (see Mental Diseases) Delirium, epochal, of childhood . . • — ' muttering,' in acute mania . . — • tremens (see Mental Diseases) . . — • of young children Delusional mania . . . . 315, 318 — melancholia . . . . . . 310 Delusions in epilepsy . . . . 329 Dementia (see Mental Diseases) . . 322 — following typhoid fever.. .. 521 — precox (see Mental Diseases) . . 335 — primary . . . . . . . . 321 — puberty and adolescent disturb- ances preceding . . 333, 334 294 347 19 335 135 126 319 329 323 319 327 314 333 315 326 339 SUPPLEMENTARY INDEX 551 PAGE Dementia, secondary . . . . 322 Dengue fever.. .. .. .. 517 Dental abnormalities with migraine 141 Depression in adolescent insanity . . 334 — influenza . . . . . . . . 338 — mental disturbances of childhood 333 — states of, seen in private practice 311 De Ribes' bag in placenta prsevia . . 400 Dermatitis herpetiformis . . - . 386 — various causes of . . . . . . 161 Dermoid cysts (see Ovarian Tumours) 381 Diabetes, the acidosis of . . . . 5 — bronzed . . . . . . . . 148 — with cirrhosis of liver . . . . 279 — influenza with . . . . . . 240 DIABKTES, INSIPIDUS . . • ■ 143 DIABETES, MELLITUS . . . . 144 albuminuria in . . . . 12 — — association with arteriosclerosis 82 pregnancy in relation to . . 149 surgical operations in . . 149 — pericarditis with . . . . 390 — pneumonia with . . . . . . 404 — pulmonary tuberculosis with . . 420 Diabetic gangrene . . . . . . 197 — mental symptoms . . . . 338 — neuritis, muscular atrophy due to 347 Diaceturia (see Acidosis) . . . . 5 — with cirrhosis of liver . . . . 279 — post-auffisthetic . . . . . . 30 Diarrhoea in exophthalmic goitre . . 174 DIARRHCEA, INFANTILE 1 50 — in measles. . . . . . . . 290 Diazo-reaction in pulmonary tuber- culosis . . . . . . . . 422 Diet in chlorosis . . . . . . 131 — influence on eclampsia . . . .13, 14 — salt-free, influence on ascites . . 90 Dietl's crises in movable kidney . . 343 Digestion and rheumatoid arthritis 458 Digitalis in mitral stenosis . . . . 224 Dilatation of cervix in eclampsia . . 159 — stomach . . . . . . . . 488 DIPHTHERIA 1 50 — bronchopneumonia following . . 119 — cardiac failure in . . . . . . 349 — with measles . . . . . . 290 Diphtheritic myocarditis, significance of mitral systolic murmur in 356 — neuritis, muscular atrophy from 347 Dipsomania (see Mental Diseases) . . 320 Dislocations . . . . . . . . 250 — of hip, congenital . . . . 142 — knee . . . . . . . . 263 — myositis ossificans following . . 359 — of spine . . . . . . . . 480 DISSEMINATED SCLEROSIS . . . . 153 Dissemination of melanotic sarcoma 291 Distention of bladder in tabes dorsalis . . . . . . 507 Diuretics, influence in ascites . . 89 Dropsy in myocardial disease . . 354 DRUG HABITS 154 Drugs, morbid cravings for . . . . 328 Drimkenness (see Mental Diseases) 320, 326 Duct carcinoma . . . . . . no Dum-dum fever . . . . . . 517 PAGE DUODENAL ULCER . . 1 5 6, 492 — — after burns . . . . . . 121 — — with chronic appendicitis . . 75 — — perforation . . . . . . 492 subphrenic abscess following 502 Duodenum, ruptures of . . . . 2 Dupuytren's fracture, rareness of good results . . . . . . 175 Dwarfishness with congenital amentia 324 DYSENTERY (see also Colitis, 138) 156 — amoebic . . . . . . 139, 156 — tropical bacillary. . .. 138, 156 DYSMENORRHCEA 157 Dyspepsia, appendix . . 74, 495 — with chlorosis . . . . . . 131 Dysphagia in laryngeal tuberculosis 268 — after laryngectomy . . . . 266 Dyspnoea in impaired ventricular contractility . . . . . , 353 — after laryngectomy . . . . 267 — in papilloma of larynx . . . . 267 "pAR disease, intracranial complica- -'-^ tions of . . . . . . 243 Echinococcal cyst, cerebral . . 125 ECLAMPSIA 158 — ■ albuminuria pireceding . . . . 13 — foetal prognosis . . . . . . 160 — maternal prognosis . . . . 158 ECTOPIC PREGNANCY . . . . 1 60 ECZEMA AND ECZEMATOUS ERUP- TIONS 161 — marginatum . . . . . . 461 — of nipple, preceding cancer . . 116 Educability with epilepsy of early childhood . . . . . . 329 ■ — of the feeble-minded . . . . 323 Effusion into pericardium in rheu- matic infection . . . . 391 — pleuritic . . . . . . . . 401 Egyptian splenomegaly, hepatic cirrhosis with.. .. .. 279 Elbow, dislocation of . . . . 250 — fracture of . . . . 184, 191 — - tuberculosis of . . . . . . 88 Electrical reactions in infantile paralysis . . . . . . 238 local neuritis . . . . . . 378 muscular atrophies . . . . 347 Electro-therapy in sciatica . . . . 468 Embolic gangrene . . . . . . 197 Embolism, cerebral (see Strokes) . . 500 — pulmonary, complicating appen- dicitis . . . . . . 59 following operation for vari- cose veins . . . . . . 539 Embryoma of testis . . . . . . 510 Emetine treatment of amoebic dysen- tery 139, 156 Emotion as a factor in myocardial disease . . . . . . 351 Emotional influences in chlorosis . . 130 Emphysema with asthma . . . . 93 — influence in bronchitis .. .. 118 — pneumothorax and . . . . 406 EMPYEMA 162 — of the gall-bladder . . . . 132 552 INDEX OF PROGNOSIS PAGE PAGE Empyema, pneumococcal, in children, Excitement, morbid, with organic relation to pericarditis 389 brain disease 328 — pneumothorax due to . . 406 EXOPHTHALMIC GOITRE . . 170 Encephalitis, influenzal 239 anaesthesia in operation for . . 32 Endocarditis, acute rieumatlc 453 complicating chlorosis 132 ENDOCARDITIS, ULCERATIVE 164 danger signals 174 with malformed heart 231 mental symptoms in 339 mitral disease 221 prospects of relapse . . 173 as sequel to acute rheumatism 454 sequelae 173 Endometritis, gonorrhoeal . . 204 surgical treatment . . 171 — sloughing, and abscess (puerperal) 415 Exophthalmos, pulsating, after head Endothelioma of testis 510 injury . . 212 Ensiform cartilage, fracture of 187 192 Exstrophy of bladder 98 Enteric fever (see Typhoid Fever) 518 Extension method in fractures. ENTERITIS, TUBERCULOUS 165 Bardenheuer's 174 Enterocolitis in children 150 Extirpation of peripheral aneu- Enucleation of hydatid cyst 233 rj'sms . . 44 Epidermolysis bullosa 386 Extradural abscess . . 244 Epididymis, new growths of (see Extrasystolic type of arrhj'thmia . . 430 Testis) 510 Extra-uterine gestation (see Ectopic Epididvmitis, gonorrhoeal . . 200 Pregnancy) 160 EPIDIDYMITIS, TUBERCULOUS 166 Eye affections with arteriosclerosis 84 with renal tuberculosis 255 measles 290 Epigastric pain, pre-eclamptic 13 migraine 141 Epiglottis, amputation in tuberculosis 269 — complications of small-pox 473 Epilepsie larvee 330 tabes dorsalis 507 EPILEPSY 168 — symptoms in lead poisoning . . 271 — beer- and cider-drinking and . . 330 pre-eclamptic 13 — infantile convulsions simulating 236 — mental unsoundness with 329 "p^CAL fistula following appendix operations — minor, fainting of children due to 354 58 — traumatic 212 with psoas abscess . . 413 Epileptic convulsions in syphilitic tuberculous peritonitis 394 brain disease . . 325 — impaction . . 240 Epileptics, recurrent dislocation of obstruction due to . . 240 shoulder in . . 251 Face, actinomycosis of 8 Epiphysitis, syphilitic 506 Facial expression in chronic alcohol- Epithelioma (see also Cancer, Carci- ism . . 327 noma) of bladder 103 melancholia . . 308 — after burns 121 mental diseases 300 — chlorion- (see Chorion-epithelioma 135 stuporose insanity . . 321 — following ;!;-ray treatment 283 — nerve, injuries to . . 373 — of jaw 248 — palsy (see Nerve Injuries) 373 -^ lip (see Lip, Cancer of) . . 274 muscular atrophy from 347 — tongue (see Tongue, Cancer of) 513 Fainting, rareness in myocardial — vulva (see Vulva, Carcinoma of) 541 disease . . 354 Epulis (see J aws. Tumours of) 247 Fallopian tube, chorion-epithelioma Equinovarus (see Talipes) . . 509 of 135 Eruptions, eczematous 161 gonorrhoeal infection of 204 ERYSIPELAS 170 inflammation of (see Salpin- Erythremia (see Polycythemia) . . 407 gitis) 463 Estlander's operation for empyema 164 Famfly history in acute rheumatic Ether anesthesia, relative safety of 23 carditis 450 — pneumonia 36 cardio-arterial degeneration 352 — in relation to status lymphaticus 30 mental disease 303 surgical shock 34 phthisis 421 ■ — in spinal analgesia 26 rheumatoid arthritis 456 Etherization, various methods of . . 28 — susceptibility to lead poisoning. . 270 Ethmoidal sinusitis . . 362 Faucial inflammation with measles 290 Ethyl chloride anaesthesia, methods oJ 29 Favus of the scalp . . 461 and ethyl bromide, relative Febrile albuminuria.. 12 safety of . . 22 — diseases, acidosis in 5 Exaltation, mental (see Mental Dis- Feeble-minded 323 eases) . . 312 — Royal Commission on Care and — as prelude to dementia . . 322 Control of 320 Excited and resistive melancholia . . 310 Femoral aneurj'sm . . 45 Excitement of mania 312 — artery, haematoma of . . 206 — maniacal, in senility 336 Femur, fracture of . . . . 178, 189 SUPPLEMENTARY INDEX 553 PAGE - PAGE Femur, sarcoma of . . . . 107, 108 Fractures of spine . . 480 Fever, influence on lymphadenoma 287 — spontaneous, in tabes . . 508 Fibrillation, auricular 432 — of sternum . . . . 187, 192 in myocardial disease 357 — tarsal scaphoid . . 182 Fibro-adenoma of breast . . 116 — tibia and fibula .. .. 180, 190 Fibroids (see Uterus, Fibroids of) . . 530 — wrist bones . . . . 186, 191 — bleeding, complicating pernicious Friedreich's ataxia . . 94 anaemia 397 Frohlich's type of hypopituitarism. . 7 — with cancer 530 Frontal sinusitis (see Nasal Accessory Fibromatosis of stomach 498 Sinusitis) 361 Fibromyoma, ascites with . . . .89, 90 Frost-bite, gangrene from . . 197 Fibrosarcoma of jaw. . 247 Fungating endocarditis (see Endo- Fibrosis of liver, syphilitic . . 281 carditis, Ulcerative) . . 164 Fibula, fracture of . . . . 180, 190 Furunculosis with diabetes . . 148 — sarcoma of . . . . 107, 108 Fingers, fracture of . . . . 186, 192 riALL-BLADDER complications of appendicitis . . — tuberculosis of . . 88 62 Finsen light in lupus vulgaris 283 — drainage in biliary cirrhosis 280 Fistula, fsecal, with psoas abscess . . 413 — inflammation of (see Chole- following appendix operations 58 cystitis) 132 — from gall-stones . . 193 GALL-STONES 193 — after prostatectomy . . 410, 412 — and biliary cirrhosis 280 Flutter, auricular 432 — with chronic appendicitis 75 Folie circulaire (see Mental Diseases) 317 — chronic pancreatitis simulating 385 Food, excessive, in etiology of — frequent absence of symptoms . . 193 arteriosclerosis 82 — with gastric symptoms . . 495 Foot, fracture of bones of . . 182, 191 — intestinal obstruction due to . . 242 — tuberculosis of . . 88 — operation mortality 194 Foramen ovale, patency of 230 Gallop rhythm in contractile failure 355 Foreign bodies, intestinal obstruc- Galvano-cautery in laryngeal tuber- tion due to . . 241 culosis . . 269 Foetal prognosis in eclampsia 160 GANGRENE 197 Foetus, relation of albuminuria of — in diabetes 148 pregnancy to 14 — following purpura 436 FRACTURES 174 — hospital (see CEdema, Malignant) 379 — of astragalus 181 — in strangulated hernia 215, 217 — Bennett's . . i85 Gasserian ganglion, removal, in — of bones of wrist and hand 186 trigeminal neuralgia.. 376 — calcaneum 181 Gastralgia, ' appendix ' 74 — carpal bones, with sprain 249 Gastrectomy in carcinoma . . 496 — carpal scaphoid . . 186 — chronic ulcer 491 — clavicle . . . . . . 187, 192 — plastic linitis 498 — CoUes's 185 Gastric carcinoma 486 — of cuboid . . 182 surgical treatment . . 496 — cuneiform bones . . 182 — crises of tabes . . 508 — elbow . . . . . . 184, 191 — and duodenal ulcer with chronic — estimation of work capacity after 188 appendicitis . . 75 — of femur . . . . . . 178, 189 — lavage in congenital pyloric — humerus . . . . . . 182, 191 stenosis . . . . 439, 496 — influence of age in non-operative — symptoms associated with dis- treatment 176 eases elsewhere 494 — Jones's (5th metatarsal) . . 182 of gall-stones I 3 — of metatarsals 182 with movable kidney 344 — myositis ossificans following . . 359 — • — of rheumatic fever . . 449 — in neighbourhood of joints 176 — ulcer (see Stomach, Diseases of) 487 — operative and non-operative chronic, operative treatment 491 methods considered . . 174 connection with chlorosis . . 132 — of patella . . . . . . 179, 190 hffimatemesis . . 490 — pelvis . . . . . . 188, 192 operative treatment . . 488 urethral stricture in 525 perforation 489 — Pott's 180 — ■ — subphrenic abscess following 502 — — rareness of good results 175, 191 Gastritis (see Stomach, Medical Affec- — of radius and ulna . . 185 191 tions of) 486 — report of B.M.A. Committee on 175 Gastro-enterostomy in chronic dila- — of ribs 188, 192 tation of stomach 488 — scapula . . . . . . 187, 192 Gastro-intestinal hjemorrhage with — simple 174 acute appendicitis 64 — of skull 210 Gastrojejunostomy in carcinoma . . 497 554 INDEX OF PROGNOSIS Gastrojejunostomy, complications after — in gastric ulcer — injurious in gastroptosis — in plastic linitis . . — pyloric stenosis . . — stricture of oesophagus . . Gastropexy in gastroptosis . . Gastroptosis Gelatin injection in abdominal aneurysm . . intrathoracic aneurysm General paralysis (see Mental Diseases) Genu valgum — varum and rickets German measles (see Rubella) — State sanatoria for consumption, statistics of treatment at . . Gestation, extra-uterine (see Ectopic Pregnancy) Gigantism (see Acromegaly) Gland clearance in cancer of lip . . — enlargement, disappearance in lymphadenoma Glanders, acute and ctronic . . Glands, tuberculous (see Lj-mphade- nitis) . . Glaucher's disease (see Anaemia, Splenic) Glioma, cerebral . . . . 124, Glucose treatment before anaestheti- zation, influence of . . Gluteal aneurysm Glycosuria, alimentary — association with arteriosclerosis ascites . . — chronic — in exophthalmic goitre . . — hemiplegia — hepatic cirrhosis . . — pregnancy — tuberculous meningitis . . Goelet's operation in movable kidney GOITRE — exophthalmic (see Exophthalmic Goitre) Gonococcal peritonitis GONORRHCEA GONORRHCEA IN THE FEMALE — meningitis as a sequel . . — and sterility — systemic manifestations GOUT . . — with asthma — in etiology of arteriosclerosis . . — and myocardial disease . . — rheumatic . . Gouty diathesis with migraine Graves's disease (see Exophthalmic Goitre) . . Gumma, cerebral Gums, tumours of . . Gunshot wounds of abdomen head heart . . spine . . 210, 493 490 495 498 440 379 496 495 39 43 324 461 463 425 160 7 275 287 16 128 7 46 145 82 91 145 173 501 279 149 295 346 170 390 200 202 295 202 201 205 93 82 352 459 142 170 125 247 4 212 231 483 H^MARTHROSIS of knee joint Haematemesis with acute appen- dicitis — chronic appendicitis — gastric ulcer — movable kidney . . — portal cirrhosis . . . . 277, Haematocele, pelvic (see Ectopic Pregnancy) HEMATOMA, ARTERIAL Hcematoporph\T:inuria from drug poisoning Hematuria in acute nephritis — complicating appendicitis — in malignant growths of kidney Hsemochromatosis . . . . 91, — cirrhosis of HEMOPHILIA. Haemoptysis with mitral stenosis . . Haemo-retinitis in lead poisoning . . Haemorrhage, the anaemia following — in biliary cirrhosis . . — in cancer uteri, ligation of arteries in — cerebral (see Strokes) — — • with mitral stenosis . . — concealed, with abdominal aneu- rysm . . — dangers with vesicular mole — in ectopic gestation — gastro-intestinal, with acute appendicitis . . — intracranial (see Head Injuries) — in lymphadenoma — lymphatic leukaemia — pernicious anaemia — portal cirrhosis . . . . 277, — pre-eclamptic — in ruptmre of uterus — into spinal cord . . — in syphilitic cirrhosis of liver . . — typhoid fever — unsuspected, after abdominal contusions Haemorrhagic purpura (see Purpura) HEMORRHOIDS Hallucinations of hearing at the climacteric — in melancholia Hand, fracture of bones of 186, Hanot's cirrhosis Hartley-Krause operation in tri- geminal neuralgia Hart's (Stuart) method of estimating acidosis index HEAD INJURIES — — • functional defects following Headaches, paroxysmal (see Migraine) — pre-eclamptic Heart, arrhythmia not a sign of weakness of . . — block myocardial disease . . 353, HEART, CHRONIC VALVULAR DISEASES — — relation of primary disease of myocar- dium to — complications in bronchitis — condition in asthma 263 64 75 490 344 279 160 206 155 363 65 252 148 279 207 223 271 15 280 529 500 223 37 342 160 64 210 287 272 397 279 13 535 520 I 43& 209 336 308 192 280 377 5 210 212 341 13 430 434 357 217 349 118 93 SUPPLEMENTARY INDEX 555 HEART, CONGENITAL MALFORMA- TIONS OF — defects of position — dilatation of — — -in exophthalmic goitre — ■ — ■ rheumatic myocarditis — disease, albuminuria in . . anjEsthesia in operations with ascites of gravity of failing contractile force . . — — muscular (see Myocardium) — — in relation to arteriosclerosis — — - — chorea — — - — • pulse (see Pulse) spinal analgesia in operation with — efiect of influenza on . . — failure in diphtheria treatment in convalescence. — irregular (see Pulse, Irregularities of) — lesions in angina pectoris with pleuijitis . . — — pneumonia . . . - 404, — muscle, assessment of working capacity of . . — rheumatism of (see Rheumatic Pericarditis, etc). — sounds, weakening of, in contrac- tile failure — state of, after anginal attack . . — symptoms in acute nephritis . . chronic diffused nephritis . . interstitial nephritis secondary ansemia . . HEART, SYPHILIS OF — valvular disease of, relation to pericarditis — with ulcerative endocarditis HEART, WOUNDS OF Hebephrenic dementia Hedonal, dangers of anesthesia with Hemiplegia (see Strokes) — following infantile convulsions — in head injuries . . — mental symptoms with . . — relation to aphasia — pseudo-bulbar palsy due to Henoch's purpura Hepatic artery, aneurysm of — cirrhosis (see Liver, Cirrhosis of) Hereditary ataxia — traumatic pemphigus Heredity in adolescent insanity 333, — and arteriosclerosis — epilepsy — haemophilia — influence of chlorosis — in mental disease. . — mental and neurotic, without symptoms — in migraine — senile mental disturbances HERNIA — danger of strangulation . . — intestinal obstruction due to . . 230 230 356 173 452 13 33 356 349 80 133 430 27 239 152 350 430 48 401 406 352 450 355 49 363 364 366 15 122 164 231 335 28 500 236 211 328 53 119 437 38 277 94 386 334 80 169 207 130 303 340 142 336 213 213 243 PAGE Hernia, results of operation . . 213 HERNIA, STRANGULATED . . . . 215 Herniotomy, results of . . . . 216 Heroin habit . . . . . . . . 155 Herpetiform dermatitis . . . . 386 Hiccough with post-haemorrhagic anaemia . . . . . . 15 Hip, congenital dislocation of . . 142 — dislocation of . . . . . . 250 — tuberculosis of - . ■ • • • 86 Hodgkin's disease (see Lymphade- noma) . . . . . . . . 286 Homicide, uncontrollable impulse to 320 Homicidal impulse in melancholia 310 Hospital gangrene (see CEdema, Malignant) . . . . . . 379 Hospitals, risks of infection in . . iii Hour-glass stomach . . . . . . 491 Humerus, fracture of . . . . 182 — sarcoma of . ■ . ■ 107, 108 Hydatid cysts of pancreas . . . . 383 HYDATID DISEASE 232 of spine .. .. no, 484 — mole (see Mole) . . . . _ . . 342 Hydroa gravidarum or gestationis. . 387 Hydrocephalus after meningitis . . 294 Hydrogen peroxide in malignant CEdema. . . . . . • ■ 379 HYDRONEPHROSIS 233 — following impacted calculus . . 258 — intermittent, in movable kidney 344 — pyonephrosis secondary to . . 441 — results of operations . . . ■ 235 Hydropericardium . . . . 390, 391 Hydropneumothorax . . .. •• 407 Hydrosalpinx . . . . . • ■ . 464 Hydrothorax in chronic myocardial disease . . . . . • 355 — after ether inhalation . . . . 36 Hydruria . . • • • • . • I44 Hyperchlorhydria with movable kidney . . . . • • • • 344 Hypernephroma of kidney . . . . 251 Hyperpyrexia in children, mental disturbance with . . . . 333 — rheumatic fever . . . - • . 448 Hypertrophic biliary cirrhosis . . 280 Hypnotics in senile dementia . . 337 Hypochondria at the climacteric . . 336 Hypochondriacal melancholia . . 310 Hypopituitarism . . . . . • 7 Hysterectomy in cancer of body of uterus . . . . . . . . 530 — — cervix . . . . . . . ■ 528 — excessive vomiting of pregnancy 541 — fibroids of uterus . . . . 533 — rupture of uterus. . .. .. 537 Hysteria, delusional insanity a part of 319 — disseminated sclerosis diagnosed as . . . - ■ • • • 153 — from spinal injuries . . • • 480 TDIOCY 322 — after meningitis . . . . 294 — similarity of epilepsy of early childhood to . . . • • ■ 329 Ileus complicating appendicitis . . 60 Iliac artery, external, aneurysm of 46 556 INDEX OF PROGNOSIS PAGE Imbecility — analogy to adolescent insanity — moral — ' postponed ' — similarity of epilepsy of early childhood to . . Imperforate anus (see Anus, Imper- forate) . . Impetigo, bxillous Incontinence after prostatectomy 410, 411, 412 India, form of endemic cirrhosis of liver in INFANTILE CONVULSIONS — diarrhoea . . — mortality increased by malaria INFANTILE PARALYSIS — splenomegaly Infantilism with congenital amentia Infants, acute arthritis of — eczema of . . — pyelitis of . . — splenic ansmia of Infarction of lung in impaired ventri- cular contractility . . Infection and rheumatoid arthritis 455, — from unoperated renal calculi . . Infections, neuritis due to . . Infective endocarditis (see Endo- carditis, Ulcerative) . . Inferior vena cava, wounds of INFLUENZA — cardiac complications in — mental symptoms from . . Influenzal meningitis Inguinal hernia Injection treatment of intussuscep- tion . . sciatica Injuries (see Wounds) Innominate aneurysm Inoculation, antityphoid Insomnia in mental diseases disturbances at climacteric. . — senile dementia . . Intellect in paralysis agitans Interventricular septiun, patency of Intestine, gangrenous, in strangu- lated hernia . . . . 215, 217 — gunshot wounds of . . . . 4 — rupture of . . . . . . 2 Intestinal crises of tabes — disinfectants in rheumatoid arthritis — lavage in pernicious anaemia INTESTINAL OBSTRUCTION . . and chronic appendicitis complicating appendicitis . . — — dangers of post-operative vomiting from gall-stones spinal analgesia in . . — resection for intussusception Intermittent limp with arteriosclerosis Intoxication, acid (see Acidosis) . . 5 — ' hydatique ' after operation for cyst 233 323 334 320 322 329 52 386 280 236 150 288 237 517 324 380 162 439 355 459 259 377 164 238 238 350 337 295 214 245 468 46 523 302 336 337 385 230 508 459 398 240 76 60 35 194 27 246 INTRACRANIAL COMPLICATIONS OF EAR DISEASE — haemorrhage (see Head Injuries) Intratracheal insufflation . . Intrathoracic aneurysm (see Aneu rysm. Intrathoracic) Intubation or tracheotomy in diph theria . . INTUSSUSCEPTION . . — chronic — Henoch's purpura with . . — injection of water in — results of operation Iodide of potassium, influence in actinomycosis test in nephritis, technique Iodides in chronic alcoholism — spinal tumours . . — syphilis Iodine, nascent, in laryngeal tuber culosis — — in lupus vulgaris Iron in chlorosis — pernicious anemia Irritability, a favourable sign in melancholia . . Ischemic contracture (see Muscular Atrophies) TACKSONIAN epflepsy in syphfl ^ itic brain disease Jaundice, association with ascites — complicating appendicitis — in congenital syphilitic cirrhosis of liver — eclampsia . . — liver atrophy • — pernicious anaemia — portal cirrhosis . . — puerperal sepsis . . Jaw, actinomycosis of — dislocation of . . JAWS, TUMOURS OF Jejunal ulceration after gastrojeju nostomy Jejunostomy in gastric carcinoma — plastic linitis Joint affections, muscular atrophy from . . — — of tabes Joints, fractures in neighbourhood of JOINTS, INJURIES OF — • involvement in osteomyelitis ■ — syphilitic . . — tuberculosis of (see Arthritis) Jones's fracture (5th metatarsal) XAHLER'S disease Kala-azar — endemic cirrhosis of Calcutta allied to Katatonic dementia . . Keloid after bums . . Kidney, calculus of, with gastric symptoms complicating vesical calculus — — — carcinoma 109 517 280 335 121 495 96 104 SUPPLEMENTARY INDEX 557 Kidney complications, anaesthesia in operations with . . . . 33 ascites of . . . . . . 89 — function, methods of estimation of 367 — gunshot wounds of . . . . 5 — hydronephrotic (see Hydrone- phrosis) . . . . . . 233 — lesions with appendicitis . . 65 in etiolog>' of arteriosclerosis 82 — • - — high arterial tension with . . 79 KIDNEY, MOVABLE (see Movable Kidney) 343 Dietl's crises in . . . . 343 gastric and mental symptoms in 344 intermittent hj^dronephrosis in 344 — — results of operation . . . . 344 KIDNEY, NEW GROWTHS OF . . 251 age factor in . . . . 253 duration and operative results . . . . . . 252 — operations on (see Hydronephrosis Pyelocj-stitis, Pyonephrosis) KIDNEY, POLYCYSTIC . . . . 254 — rupture of . . . . . . 3 KIDNEY, TUBERCULOSIS OF . . 254 — — results of medical, etc., treat- ment . . . . . . 256 results of operation . . . . 257 spontameous cure of . . . . 255 with vesical tuberculosis . . 105 relation to epididymitis . . 166 KIDNEY AND URETER, CALCULUS OF 258 — — — anuria from . . . . 261 — asepsis and infection . . 259 — • results of operation . . 260 recurrence. . . . . . 261 size and number . . . . 258 unilateral and bUateral . . 259 Kinks, intestinal, and chronic appen- dicitis . . . . . . . . 76 complicating appendicitis . . 61 obstruction due to . . . . 241 Knee, internal derangement of . . 263 — results of operation . . 264 — joint, fracture involving 179, 190 KNEE-JOINT, INJURIES OF . . . . 262 — perforating wounds of . . . . 264 — ruptured ligaments of . . . . 263 — tulDerciilosis of . . . . . . 87 Kocher's operation in cancer of tongue hernia . . . . . . 213 Korsakow's psychosis in pohmeuritis Kraepelin's classification of dementia praecox manic-depressive insanity . . Krokiewicz's sheep-brain emulsion in tetanus T ABOUR, effect of fibroids on . . — premature, induction it mental disease of preg nancy — rupture of uterus in Lactation, cancer of breast during Lactational insanity . . Laennec's cirrhosis . . 514 214 377 335 316 513 533 332 535 no 332 277 Laminectomy for paraplegia in spinal caries . . . . . . 478 — spinal injuries . . . . . . 482 tumours . . . . . . 484 Lancereaux's gelatin injection in abdominal anemrysm . . 39 — — — intrathoracic aneurysm . . 43 Lane's operation for cleft palate . . 136 Langenbeck's operation for cleft palate . . . . . . . . 136 Lardaceous disease, ascites of . . 89 Laryngeal complications of measles 290 — — scarlet fever . . . . . . 467 — crises of tabes . . . . . . 508 Laryngectomy and laryngostomy in tuberculosis . . . . 269 — results of, in cancer . . . . 266 LARYNX, CARCINOMA OF . . . . 265 th\TO-fissure in . . . . 265 — chicken-pox invading . . . . 129 LARYNX, PAPILLOMA OF . . 267 — scald of . . . . . . . . 121 LARYNX, TUBERCULOSIS OF . . 268 — ulceration of, in typhoid fever . . 520 Lateral sinus thrombosis . . . . 244 Lavage in congenital pyloric stenosis 439, 496 LEAD POISONING 270 and arteriosclerosis . . . . 81 — — mental symptoms of . . . . 340 Leishmaniasis . . . . . . 517 LEPROSY '271 Lethargic symptoms in adolescent insanity 334 Leucoplakia vulvae, precancerous . . 541 LEUCOCYTH^MLA 271 — chloroma . . . . . . . . 274 — lymphatic . . . . . . 272 — medullary . . . . . . 273 — mixed forms . . . . . . 274 LICHEN PLANUS 274 Ligament of knee, rupture of . . 260 Ligature in abdominal aneurysm . . 38 — aneurysm of peripheral arteries 44 — operation in exophthalmic goitre 172 Lightning pains of tabes . . . . 506 Linitis, plastic . . . . . . 498 LIP, CANCER OF 274 prospects of cure and reciur- rence . . . . . . 275 results of operation . . . . 274 Litholapaxy in presence of bladder complications . . . . . . 96 Lithotomy and litholapaxy, results of 97 Liver abscess, amoebic . . 140, 156 LIVER, ACUTE YELLOW ATROPHY OF 276 • special danger signals . . 277 LIVER, CIRRHOSIS OF . . . . 277 — — biliary . . . . . . . . 280 — — Indian form of . . . . 280 — — parasj'philitic. . .. .. 281 portal . . . . . . . . 277 jaundice and ascites of . . 278 syphilitic . . . . . . 280 — diseases, ascites of . . . . 89 glycosuria associated with . . 145 — hydatid disease of . . . . 232 558 INDEX OF PROGNOSIS Liver rupture of — stab and gunshot wounds of . . Local analgesics, relative safety of. . Locomotor ataxy (see Ataxias, 93, and Tabes Dorsalis, 506) Lorenz's operation in congenital dislocation of hip Ludwig's angina Lumbar puncture in meningitis Lunacy (see Mental Diseases) Limatics, tuberculosis in . . Lung, actinomycosis of — affections with measles . . — changes in impaired ventricular contractility . . — collapse of, bronchiectasis due to — diseases, relation of influenza to LUPUS, ERYTHEMATOSUS . . LUPUS VULGARIS — — dangers of x rays in . . — — excision and Finsen light in LYMPHADENITIS, TUBERCULOUS . . — medical and general treatment . . results of operation . . LYMPHADENOMA — medical treatment — necessity for microscopical ex- amination — surgical treatment Lymphatic dissemination of melan- otic sarcoma . . — fistula (see Thoracic Duct, Wounds of) . . Lymphatic leuksemia Lymphatism, relation of anaesthetics to lyrACEWEN'S acupuncture abdominal aneurysm Madura foot (mycetoma) Magnesia, calcined, in papilloma of larjmx . . Magnesium sulphate injections puerperal sepsis in tetanus MALARIA — chronic, ascites due to . . Malarial neuritis, muscular atrophy from Malignant disease, ascites with after duodenal ulcer . . vesicular mole hydronephrosis with. . of hip . . larynx pericarditis with of stomach tongue . . — endocarditis (see Endocarditis, Ulcerative) — — as sequel to acute rheumatism — goitre — growths of bladder (see Bladder) jaw kidney . . originating in a mole of prostate — melanoma PAGE 2 4 25 142 124 295 296 420 9 289 355 117 239 281 282 283 283 284 284 285 286 287 291 513 271 29 38 288 267 418 513 347 89 493 343 233 274 265 390 496, 498 513. 517 164 454 199 100 247 251 342 408 291 Malignant oedema (see (Edema, Malignant) . . . . . . 379 — ovarian tumours.. .. .. 381 — pustule (see Anthrax) . . . . 51 — scarlet fever . . . . . . 465 — stricture of oesophagus . . . . 379 Malta or Mediterranean fever . . 517 Mania (see Mental Diseases) . . 312 — a potu . . . . . . . . 326 — following typhoid fever . . . . 521 — and melancholia, relation between 316 Manic-depressive Insanity (see Mental Diseases) . . . . 305, 316 Marie's cerebellar type of ataxia . . 94 Mark, the pugilist's, shock from blow on . . . . . . I Marriage of epileptics . . . . 168 — haemophilics . . . . . . 209 — influence in chlorosis . . . . 131 — mental heredity and . . . . 340 — after syphUis . . . . . . 506 Mastitic form of carcinoma. . . . no Mastitis, chronic . . . . . . 116 Masturbation in mental disease . . 339 Matas' operation in aneurysm . . 44 Maxilla, removal for malignant growth . . . . . . . . 248 Maxillary sinusitis, various opera- tions for . . . . . . 360 Maydl's operation in exstrophy of bladder . . . . . . 99 MEASLES 288 — age influence on mortality in . . 288 — bronchiectasis as a sequel . . 116 — complications . . . . . . 289 — influence of social status . . 290 Meckel's diverticulum, obstruction due to . . . . . . . . 242 Mediterranean fever.. .. .. 517 Medullary leukaemia ... .. .. 273 Melaena with acute appendicitis . . 64 Melancholia (see Mental Diseases) . . 305 — with adolescent insanity . . 334 — agitated, at the climacteric . . 336 — following typhoid fever . . . . 521 influenza . . . . . . 338 — and mania, relation between . . 316 — in senile mental disturbances . . 336 MELANOTIC SARCOMA . . . . 29 1 principles and prospects of operation . . . . . . 292 Melanuria . . . . . . . . 91 Membranous colitis . . . . . . 137 — dysmenorrhoea . . . . . . 158 — gastritis . . . . . . . . 486 Memory, affection of in chronic alco holism . . . . — affected in epilepsy after influenza 327 330 338 — prodigious, with congenital amentia 324 Mendez's serum in anthrax. Meningism MENINGITIS — complicating typhoid fever — following ear disease — meningococcal mental after-effects . . — pneumococcal 51 295 294 520 245 294 294 294 SUPPLEMENTARY INDEX 559 PAGE - PAGE Meningitis, relation to aphasia 53 Mental diseases, mania, simple — syphilitic . . 326 exaltation . . 312 — tuberculous 295 statistics of all forms . . 315 movements in, simulating manic-depressive insanity 305 316 chorea 134 manner of onset 299 Meningococcal meningitis . . 294 — • — masturbation in 339 Menopause, fibroids and the 535 melancholia 305 — influence on epilepsy 168 delusional and homicidal 310 — mental symptoms at 336 duration of 307 Menorrhagia with uterine fibroids . . 531 excited and resistive 310 Mental change in epilepsy . . 169 favourable prognosis of . . 306 from lead poisoning . . 271 indications of improve- — • condition in chorea 134 ment 307 — deficiency following meningitis. . 294 hypochondriacal . . 310 MENTAL DISEASES . . 296 from influenza 338 adolescent insanity, facial ex- periodicity and recurrence 309 pression in . . 300 premonitory symptoms . . 311 tendency to periodicity in 318 recoveries in private prac- recurrence 334 tice 311 age and temperament in . . 305 suicidal impulse in 309 312 alcoholic dementia and de- unfavourable indications 308 generation . . 327 morbid cravings for drugs . . 328 alcoholism and alcoliolic disease 326 paranoia, facial expressions in 301 — acute 326 phthisical insanity . . 338 — chronic 327 of puberty and adolescence 333 dipsomania 320 puerperal insanity 331 epilepsy and 331 intercurrent diseases ' respectable excess ' 327 with . . 331 • amentia 322 rarer etiological and clinical — — anatomical and physiological forms 337 relations of brain to 296 response to treatment 302 associated with childbirth 331 Scottish Board's statistics of causation and prognosis 301 recoveries, etc. 298 of childhood . . 333 states of depression seen in Clouston's law of heredity in 305 private practice 311 • conditions of confusion and marked and regular alter- stupor 321 nation and periodicity 317 — congenital weakness 322 mental enfeeblement 322 conditions of mental exaltation 312 stigmata of degeneration 304, 322 simple depression and syphilitic 325 elevation 305 — disturbance with movable kidney 344 — — danger of recurrence . . 303 — hospital, response to treatment in 302 — — defective control, insane impulse 319 numbers and age of patients ' delirious mania ' 314 now sent to 298 delirium tremens 326 — inhibition in chronic alcoholism 327 the disturbances of decadence . . 335 medico-legal aspect of 321 dementia 322 non-development of . . 320 dementia prascox 335 — and neurotic heredity, without — — epileptic 329 symptoms 340 epochal disturbances 332 — stigmata with congenital amentia 324 facial expression in . . 300 — stress in etiology of arteriosclerosis 82 factors influencing prognosis 296 — symptoms in acute rheumatism ' foUe circulaire ' 317 and chorea 339 general paralysis 324 Bright's disease 338 syphilis as cause 324 diabetes 338 heredity in . . 303 from influenza 337 idiocy . . 322 of lead and arsenical poisoning 340 importance of time element in 300 with mumps . . 346 insomnia in . . 302 in myxoedema 339 lactational insanity . . 332 neuritis 377 mania . . 312 organic brain diseases 328 acute 313 rheumatic fever 449 as prelude to dementia 322 syphilitic 325 from syphilis . . 326 Mercurial stomatitis . . 499 a potu 326 MERCURTAT.TSM 341 — chronic 315 Mercury treatment of cardiac syphilis 123 — delusional . . . . 315 318 syphilis 503 good and bad indications 314 syphilitic jaundice . . 276 56o INDEX OF PROGNOSIS PAGE Mesothorium in cancer of uterus . . 529 Metabolic S5'stemic lesions, anaes- thesia with . . . . . . 33 Metacarpals, fracture of . . 186, 192 Metatarsals, fracture of . . 182, 191 Mexico, endemic form of hepatic cirrhosis in . . . . . . 280 MIGRAINE 341 Milk diet, influence on eclampsia . . 13 jMitral and aortic disease, combined 228 • — regTirgltation • • • • • . 218 — stenosis . . ■ . • ■ ■ . 220 — • — effect of treatment . . . . 223 — — rheumatic . . . . . . 453 — systolic murmur, significance in myocardial disease . . . . 356 MOLE, SIMPLE 342 MOLE VESICULAR 342 — — chorion-epithelioma following 135, 343 complications and mortality of 343 effect on fertility . . . . 343 Monomania .. .. .. .. 318 Moore's method of wiring in abdo- minal anemrysm . . . . 38 Moral deterioration in chronic alcoholism . . . . . . 327 — imbecility . . . . . . . . 320 Morphia a cause of post-operative vomiting 35 — with general anaesthesia . . 24 — habit . . . . . . . . 154 — influence on surgical shock . . 34 Morton's fluid in spina bifida . . 476 MOVABLE KIDNEY 343 Dietl's crises in . . . . 343 intermittent hydronephrosis in 344 results of operation . . . . 344 Mucinoid ascites . . . . . . 92 Multilobular cirrhosis of liver . . 277 MUMPS 346 Mundesley Sanatorium for consump- tion, statistics of treatment at 427 Murray's proximal compression in abdominal aneurysm . . 38 MUSCULAR ATROPHIES . . . . 347 — atrophy, arthritic . . . . 347 in infantile paralysis. . . . 237 ischaemic . . . . . . 347 myopathic .. .. ... 347 neuritic . . . . . . 347 progressive . . . . . . 348 pathological identity of bulbar palsy with .. 119 Musculospiral nerve, injuries to . . 376 — paral3'sis in fracture of humerus 183 MYASTHENIA GRAVIS . . • • 348 Mycetoma . . . . . . . . 288 MYCOSIS FUNGOIDES . . • • 349 Myelitis following spinal injuries . . 480 Myelocythaemia . . . . . - 273 Myeloid sarcoma . . . . . . 107 — tumour of jaw . . . . . . 247 Myeloma, multiple . . . . . . 109 — Bence-Jones's proteinuria in . . 13 Myocardial disease with aortic regur- gitation . . . . . . 226 Myocardial disease, pulse irregularity in . . . . . . . . 430. in angina pectoris . . . . 48- — syphilis . . . . . . . . 122 — and valvular disease, relation of 218 Myocarditis, acute rheumatic . . 452 — pericarditis with . . . . 388, 39a Myocardium, assessment of working capacity of . . . . . . 352 MYOCARDIUM, PRIMARY DISEASE OF 349 — — — acute infections . . . . 349 in chronic alcoholism . . 350 diphtheria . . . . 349 — — — functional injury shown at examination . . . . 352 — — — impairment of contractility of ventricles . . . . 353 — — — impairment of tonus . . 356 influence of treatment . . 358 likelihood of sudden death 358 — — — the morbid process present 349 — — — significance of mitral sys- tolic murmru: in . . 356 S3'philitic 351 — progressive degenerations of . . 350 Myomectomy for uterine fibroids . . 534 Myopathic muscular atrophy . . 347 Myopathies (see Muscular Atrophy) 347 Myositis, interstitial, atrophy due to 347 MYOSITIS OSSIFICANS . . • ■ 358 Myxoedema, mental symptoms in . . 339 "NJ AIL-EXTENSION method in fractures, Steinmann's .. 174 Narath's operation for ascites . . 279 Nasal abnormalities with migraine 141 NASAL ACCESSORY SINUSITIS . . 359 — — — ethmoidal and sphenoidal 362 — — — frontal sinus . . . . 361 — — — maxillary sinus . . . . 360 — vaccine treatment in . . 359 — treatment in asthma . . . . 93 Nascent iodine in laryngeal tubercu- losis . . . . . . . . 268 lupus vulgaris . . . . 282 Nausea, with post-haemorxhagic anaemia . . . . . . 15 Neck, fracture and dislocation of . . 481 Necrosis in osteomyelitis . . . . 380 — typhoid fever . . . . . . 520 Negroes, fatality of small-pox in . . 472 Neosalvarsan treatment of syphilis 503 Nephrectomy for calculus . . . . 261 — malignant growths . . . . 252 — renal tuberculosis . . . . 257 — tuberculosis of bladder . . . . 106 NEPHRITIS 362 — acute . . . . . . . . 362 — albuminuria apart from . . 11 — after burns . . . . . . 120 — chronic diffused . . . . . . 364 — — interstitial . . . . . . 365 methods of estimation of renal function . . . . 367 — — pulmonary tuberculosis with 420 — complicating typhoid fever . . 520 — with diabetes mellitus . . . . 12 — mental symptoms with . . . . 338 SUPPLEMENTARY INDEX 561 Nephritis, pericarditis with . . I'AGE /^BESITY, with diabetes or glyco ^ suria PAGE — pleuritis with to I 146 — pneumonia with . . 404 — and myocardial disease . . 352 — with scarlet fever 466 Obstruction, intestinal 240 — uraemia of . . 524 Obstructive biliary cirrhosis 280 Nephrolithotomy, results of 260 Obturator method in cleft palate . 137 Nephropexy in movable kidney, Occupational influences in chlorosis 130 end-results of . . 344 CF-dema of acute nephritis . . 363 et seq. Nephrotomy and nephrectomy in — feet, association with ascites . 91 pyelocystitis 438 — legs with ascites of cirrhosis 278 pyonephrosis . . 441 biliary cirrhosis 280 — nephropexy, etc., in hydro- (EDEMA, MALIGNANT 379 nephrosis 235 — in myocardial disease 3.54 NERVE INJURIES 368 — pre-eclamptic 13 brachial plexus 374 — pulmonary, after ether inhalation 36 — — ' bridging ' operations 371 in impaired ventricular con — circumflex and ulnar 375 tractility 355 facial . . 373 GEsophagoscope, use in stricture . 379 with fractured skull . . 212 (ESOPHAGUS, STRICTURE OF 379 injury in continuity . . 368 Old age, mental disturbances of . 335 — — terminal branches 373 Olecranon, fracture of 185 musculospiral . . 376 Omnopon with general anassthesia . 25 primary suture 369 Oophorectomy, double, in osteo - recurrent laryngeal . . 374 malacia . . . . 380 secondary suture 370 Oophoritis and salpingitis . . 463 — operations in sciatica . . 468 Open-air treatment of phthisis 419 — superior laryngeal, operations — — recurrent cancer 114 on in tuberculosis . . 269 Operation, limits of anaemia justify - — syphilis 505 ing 16 — tonics in melancholia 308 Ophthalmia, gonorrhoeal 201 Nervous influences in rheumatoid Ophthalmoscopic tests in chronic arthritis . . . - 457, 460 nephritis 366 — lesions, dangers of anaesthetics in 33 Opium alkaloids with general anaes - — symptoms of exophthalmic goitre 173 thesia . . 25 movable kidney 344 — habit 328 — system, affection in rickets 46r — poisoning . . 154 in diabetes 148 Opsonic index of ascitic fluid 92 — tone, lowering by influenza 338 Optic complications of tabes dorsalis 507 Neuralgia, sciatic (see Sciatica) 467 Orchitis, atrophy of testicle after . • 346 NEURALGIA, TRIGEMINAL . . 376 — from mumps 346 Neurasthenia, from spinal injuries. . 480 — tuberculous (see Epididymitis) . . 166 Neurectomy for trigeminal neuralgia 376 Organo-therapy in Addison's disease 9 Neuritic Muscular Atrophy . . 347 Orthopa3dics in peroneal atrophy . • 348 NEURITIS 377 Os magnum, fracture of . . . 186 — peripheral, in chronic alcoholism 327 Ossification, muscular (see Myositis — sciatic (see Sciatica) 467 Ossificans) • 358 Neurological conditions in relation OSTEITIS DEFORMANS • 380 to mental disease 304 Osteoma 106 Neuroses of childhood, mental dis- OSTEOMALACIA ■ 380 turbance with 333 OSTEOMYELITIS • 380 — liability to be transformed into — pericarditis complicating 390 mental attacks 341 Osteotomy in coxa vara 143 Neurosis underlying dysmenorrhoea 157 Otitis media complicating scarlet fev er 467 Neurotic and mental heredity, with- whooping-cough . . 543 out symptoms 340 intracranial complications f 243 New-born, ophthalmia of . . 201 with measles . . 290 — pemphigus of 386 — after mumps, deafness due to . 347 Nipple, Paget's disease of . . 116 OVARIAN TUMOURS 381 Nitrites in high arterial tension 80 ascites due to 89, 90 — significance of effect in angina — — malignant 382 pectoris 40 — — and pregnancy 382 Nitrogen excretion, indications 6 rupture of 382 Nitrous oxide anaesthesia, relative Oxygen in myasthenia gravis 348 safety of . . 23 — treatment of malignant cedem< 1 379 in spinal analgesia 26 Nodules, significance in acute rheu- pAGET'S disease fsee Osteitis matic pericarditis 450 Deformans) 380 Novocain in local analgesia . . 25 of the nipple . . 116 36 562 INDEX OF PROGNOSIS PAGE Pain, cardiac, in myocardial disease 353 Palate, cleft (see Cleft Palate) . . 135 Pallor in abdominal contusions . . 2 Pancreas, abscess of . . . . . . 385 — rupture of . . . . . . 3 PANCREATIC CYSTS 383 PANCREATITIS 384 — with mumps . . . . . . 346 Papilliferous goitre . . . . . . 199 Papilloma of bladder 100 — kidney . . . . . . . . 251 — larynx (see LarjTix) . . . . 267 — ovarian, ascites with . . . . 89, 90 — of tongue . . . . . . . . 517 Paracentesis in ascites . . 90, 278 — - pericarditis . . . . . . 389 Paralyses, muscular atrophy due to 347 PARALYSIS AGITANS . . 385 — birth, of brachial plexus. . . . 374 — bulbar (see Bulbar Palsy) . . 119 — diphtheritic . . . . . . 151 — general (see Mental Diseases) . . 324 — infantile (see Infantile Paralysis) 237 — from lead poisoning . . . . 271 — musculospiral, in fracture of humerus . . . . . . 183 — from nerve injuries (see Nerve Injuries) . . . . . . 368 — senile insanity preceding . . 337 — following spinal injuries (see Spine, Injiuries of) . . . . 48 r — V. Volkmann's . . . . . . 347 Paralytic obstruction complicating appendicitis . . . . . . 60 — phenomena of arteriosclerosis . . 84 — talipes . . . . . . . . 509 Paranoia . . . . . . . . 318 — facial expression in . . . . 301 Paranoid dementia . . . . . . 335 Paraplegia with spinal caries . . 478 Parasitic eczema . . . . . . 162 Parasyphilitic portal cirrhosis . . 281 PARATYPHOID FEVER . . . . 386 Parenchymatous goitre . . . . 199 Parotitis (see Mumps) . . . . 346 Paroxysmal dyspnoea in impaired contractility of ventricles . . 353 — tachycardia in myocardial disease 357 Patella, dislocation of . . 250, 263 — fracture of . . . . 179, 190 Patellar ligament, rupture of . . 260 Patent foramen ovale . . . . 230 — interventricular septum. . . . 230 Paterson's operation for ascites . . 279 Peliosis rheumatica (see Purpvura) . . 437 Pelvic inflammation, gonorrhoeal . . 204 Pelvis, fracture of . . . . 188, 192 urethral stricture in. . . . 525 Pemphigus acutus and chronicus . . 387 — contagiosus . . . . . . 386 — ■ foliaceus . . . . . . . . 3S7 — neonatorum . . . . . . 386 PEMPHIGUS AND PEMPHIGOID AFFEC- TIONS 386 — vegetans . . . . . . . . 387 PENIS, CARCINOMA OF . . • ■ 387 Perforated duodenal ulcer . . . . 492 — ■ gastric ulcer . . . . . . 489 PAGE 508 4 522 342 401 388 120 133 392 450 389 391 107 521 54 204, (see Pneiunococcic 278 390 402 415 390 393 394 92 165 Perforating ulcer of foot in tabes . . — wounds of abdomen Perforation in typhoid fever 519, — of uterus from vesicular mole . . Pericardial effusion with pleurisv . . PERICARDITIS — after burns — chorea associated with . . — chronic adhesive . . — rheumatic, acute . . — tuberculous Pericardium, infusion into in rheu- matic infection Periosteal sarcoma . . Periostitis in typhoid fever. . Peritonitis from appendicitis (see Appendicitis) . . — ascites with — cirrhosis with — gonococcal — pneumococcic Peritonitis) — puerperal . . — traumatic . . PERITONITIS, TUBERCULOUS ascitic, ulcerous, and fibrous types cytology of ascitic fluid in . . — — with enteritis . . — in typhoid fever . . . . 519, 522 PERNICIOUS ANEMIA . . . . 395 — — effect of treatment . . . . 398 — — history and blood changes . . 395 — — operations in . . 395, 397, 399 symptoms . . . . . . 397 Peroneal muscular atrophy . . 348 Pertussis (see Whooping-cough) . . 542 Perversions in puberty and adoles- cence . . . . . . . . 334 Peters' operation in exstrophy of bladder . . . . . . 99 Petit mal (see Epilepsy) . . . . 168 Pfannenstill's nascent -iodine method in larjTigeal tuberculosis . . 268 lupus vulgaris . . . . 282 Phalanges, fractures of . . 187, 192 Phenol and sling method in movable kidney Phenol-sulphone-phthalein test in nephritis — technique Phlebitis in typhoid fever . . Phlebotomus fever . . Phlegmonous gastritis, diffuse Phosphaturia . . Phthalein test for renal function Phthisical insanity . . Phthisis (see Pulmonarj' Tubercu losis) . . Phj'siological albuminuria Pigmentation in Addison's disease — diabetes . . Piles (see Haemorrhoids) Pisiform, fracture of Pituitary gland feeding, influence on acromegaly, etc. . . . operation in acromegaly . . 7 treatment in diabetes insipidus 144 PLACENTA PR.2;VIA . . • • 399 345 367 520 517 486 144 367 338 418 209 186 S UPPLEMENTA R Y INDEX 563 Plastic linitis Pleural adhesions, influence in breast cancer . . — effusion, bronchiectasis due to. . complicating appendicitis . . — — — ovarian tumour, operation curative . . Pleuritic disease, dangers of anaes- thetics in PLEURITIS — high tuberculosis mortality due to — importance of sanatorium treat- ment . . Plumbic pseudo-tabes Plumbism (see Lead Poisoning) — and arteriosclerosis — mental symptoms of Pneumococcal empyema — meningitis — pericarditis — pleuritis . . PNEUMOCOCCIC PERITONITIS PNEUMONIA — after burns — complicating appendicitis diphtheria typhoid fever . . — danger of, in progressive muscu- lar atrophy . . — in diabetics — influenzal . . — after laryngectomy — myocarditis with . . — peritonitis as sequel — post-operative — unresolved, bronchiectasis due to Pneumonic tuberculosis Pneumopericardium . . PNEUMOTHORAX — artificial, in pulmonary tubercu- losis Podalic version in placenta praevia Poisoning, acid (see Acidosis) — arsenic mental symptoms of — delayed chloroform following appendicectomy — by drug habits — lead — - — and arteriosclerosis . . mental symptoms of — mercurial . . — neuritis due to . . — post-anaesthetic . . Poliomyelitis, chronic anterior — and polio-encephalitis Polycystic kidney (see Kidney, Polycystic) POLYCYTHEMIA Polyneuritis . . Polyorrhymenitis, ascites with Polypus, effect on asthma of removal Polyserositis, pericardial Polyuria — in acute nephritis Popliteal aneurysm . . — artery, haematoma of Portal cirrhosis (see Liver, Cirrhosis of) PAGE 498 Post-ana3sthetic brachial paralysis. . PAGE 375 — toxaemia . . 30 115 after appendicectomy 63 117 Potassium iodide, influence in actino- 60 mycosis 9 test in nephritis — technique 368 90 Pott's disease (see Spinal Caries) . . 477 — fracture . . 180 33 rareness of good results 175 , 191 401 Pregnancy, acidosis in toxaemic 402 vomiting of . . 5 — albuminuria of . . 13 402 — with appendicitis . . 67 271 — dermatitis herpetiformis in 387 270 — during typhoid fever 521 81 — ectopic 160 340 — and epilepsy 168 163 — influence in chlorosis 131 294 osteomalacia . . 380 389 — influenza during . . 240 401 — jaundice in 276 402 — malaria and 288 403 — mental diseases of 332 120 — with mitral stenosis 224 60 — molar, effect on fertility. . 343 152 — ovarian tumours and 383 520 — pernicious anaemia due to 395 — pyelitis of . . 439 348 — in relation to diabetes . . 149 149 — scarlet fever and . . 466 239 — - and small -pox 473 266 — spinal caries 478 350 — typhus fever 524- 402 — uterine fibroids and 532 36 — vomiting of (see Vomiting of 117 Pregnancy) 540 420 Pressure baths in emphysema with 392 bronchitis 118 406 effect on asthma . . 93 Progressive muscular atrophy 348 421 pathological identity of 400 bulbar palsy with 119 5 Prolapsus recti (see Rectal Prolapse) 442 77 PROSTATE, CANCER OF 408 340 PROSTATE, HYPERTROPHY OF 408 30 complicating vesical calculus 96 63 with gastric symptoms 495 154 Prostatectomy for cancer . . 408 270 — end-results of suprapubic and 81 perineal . . . . 410, 411 340 — for hypertrophy . . 409 341 Prostatic calciUi 412 377 — tuberculosis, relation to epididy- 5, 7 mitis.. 166 348 with vesical tuberculosis 106 237 Prostatitis complicating gonorrhoea 200 Proteinuria 13 254 Pseudo-angina 51 407 Pseudo-bulbar paralysis 119 377 PSOAS ABSCESS 412 89 in spinal caries 479 93 PSORIASIS 414 392 Puberty, influence on epilepsy 168 144 — mental disturbances of . . 333 362 Puerperal infection, gonorrhoeal . . 215 45 — insanity 331 207 intercurrent diseases with . . 331 277 PUERPERAL SEPSIS 415 36A 564 INDEX OF PROGNOSIS Puerperal sepsis, pericarditis compli- cating . . Puerperium, dangers of fibroids during . . — pernicious anemia beginning at Pugilist's ' mark,' shock from blow on Pulmonary actinomycosis . . — changes in impaired ventricular contractility . . — complications of appendicitis . . measles . . . . 289, — embolism following operation for varicose veins — lesions, dangers of anaesthetics in — oedema after ether inhalation — stenosis, congenital and regurgitation PULMONARY TUBERCULOSIS artificial pneumothorax in effects of climate factors influencing prognosis importance of after-conditions mental symptoms of . . — — occurrence with laryngeal . . — — pericarditis complicating peritonitis with pleuritis a cause of high mor- tality . . . . 401, pneumonic form pneumothorax curative in relation of influenza to with renal results of tuberculin treat- ment sanatorium treatment Turban's classification Pulse in abdominal contusions — bronchopneumonia — excessive vomiting of pregnancy — head injuries — importance as indication in aortic regurgitation . . — indications in contractile failure PULSE, IRREGULARITIES OF THE absolute dependence of pro- gnosis on diagnosis alternating pulse — — auricular flutter the extrasystolic type frequency in childhood and youth heart-block sinus irregularity tachycardia . . total arrhythmia in myocardial disease PURPURA — haemorrhagica — Henoch's . . — Schonlein's — simplex Pustule, malignant (see Anthrax) Pyaemia complicating scarlet fever — pericarditis complicating — puerperal . . PYELOCYSTITIS Pyelolithotomy, results of - . 390 533 395 355 59 290 539 33 36 230 229 418 421 422 420 421 338 268 389 394 402 420 406 239 255 428 423 424 I 119 540 211 225 354 430 431 435 432 430 430 434 430 431 432 357 436 436 437 437 436 51 467 389 415 437 261 PAGE Pyelonephritis (see Pyelocystitis) . . 438 — complicating vesical carcinoma 104 — pyonephrosis secondary to . . 441 Pylephlebitis complicating appendi- citis . . . . . . . . 62, 64 Pyloroplasty in congenital stenosis, results of . . . . 440, 496 Pylorus, congenital hypertrophy of 487 PYLORUS, CONGENITAL STENOSIS OF 439 medical treatment 439, 496 — — — surgical treatment 440, 496 PYONEPHROSIS • 441 — with hydronephrosis • 233 Pyopericardium • 391 Pyorrhoea alveolaris, relation to rheumatoid arthritis. . • 456 Pyosalpinx • 464 Pyrexia of lymphadenoma . . . 287 — measles . 290 QUININE, abortion due to . . 288 "D ADIUM in cancer of rectum . . 445 tongue 514 — — uterus . . . . . . . . 529 vulva . . . . . . . . 542 — fibroids of uterus . . . . . . 534 — lichen planus . . . . . . 274 — ovarian tumours . . . . . . 383 — papilloma of larynx . . . . 267 — recurrent cancer of breast 113, 115 — rodent ulcer . . . . . . 462 — sarcoma of bone . . . - . . 109 — water in rheumatoid arthritis . . 459 Radius, myeloid sarcoma of . . 107 — fracture of . . . . 185, 191 Railway spine . . . . ■ . 480 Reactions, electrical, in local neuritis 378 RECTAL PROLAPSE 442 RECTUM, CANCER OF . . . ■ 442 mortality of various operations 443 radium in . . . . . . 445 recurrence after operation . . 444 Reciirrent laryngeal nerve, injuries to 374 Reflexes in tabes dorsalis . . . . 506 Refraction, errors of, with migraine 141 Refracture of patella . . . . 180 Regurgitation, aortic . . . . 224 — mitral . . . . ■ . • • 218 — pulmonary . . . . • • 229 RELAPSING FEVER 447 influence on lymphadenoma 287 Renal artery, aneurysm of . . . . 38 — colic with appendicitis . . . . 65 — contusions, etc. (see Kidney) Rest treatment in Addison's disease 9 Retinitis of chronic nephritis . . 366 Retinitis in lead poisoning . . . . 271 — prognostic value in gout . . 206 Rheumatic carditis, dilatation in . . 356 relation to pericarditis . . 388 — facial palsy, muscular atrophy from . . . . • . • • 347 RHEUMATIC FEVER 447 Are the salicylates specific ? 448 — gout 459 SUPPLEMENTARY INDEX 565 Rheumatic infection, effusion into pericardium in . . . . 391 — origin of valvular disease . . 218 RHEUMATIC PERI-, MYO-, AND ENDO- CARDITIS (acute) . . . . 450 Rheumatism, acute, mental sym- ptoms in . . . . . . 339 — all cases of chorea to be looked upon as due to .. ._. 133 — chronic pericardial adhesions in 392 — the liability to recurrence in . . 133 — post -scarlatinal . . . . . . 467 EHEUMATOID ARTHRITIS . . . . 455 influence of treatment . . 459 predisposing causes . . . . 456 — — rheumatic form of . . . . 448 Still's disease.. .. .. 458 Rib, cervical (see Cervical Rib) . . 128 nerve injury due to . . . . 375 Ribs, fracture of .. .. 188, 192 Richter's hernia . . . . . . 217 RICKETS 461 — genu valgum with . . . . 198 — influence on bronchopneumonia 118 — and splenic anaemia of infancy 18 — whooping-cough with . . . . 543 Rigors in typhoid fever . . . . 519 RINGWORM 461 — fungi causing ' eczema ' . . . . 162 Robertson (Ford) or causation of general paralysis . . . . 324 RODENT ULCER . . • . • • 462 Rogers's hypertonic solution in bacillary dysentery . . . . 138 Routte's operation for ascites . . 279 RUBELLA 463 Rupture of bladder . . . . . . 3 — intestine . . . . • . ■ • 2 — kidney . . . . - . • • 3 — liver . . . . . . . . 2 — ovarian cyst . . . . . . 382 — pancreas . . . . . . _. . 3 — spleen, from abdominal contusion i, 3 — urethra . . . . . . • • 525 — uterus (see Uterus, Rupture of) 535 from vesicular mole . . . . 342 CACRO-ILIAC disease, tuberculous 88 ^ Sacrum, fracture of . . . . 192 Salicylate treatment in mental symptoms of rheumatism and chorea . . . . . . . . 339 Salicylates in rheumatic carditis . . 455 — in rheumatic fever . . . . 448 Salicylic acid in prophylaxis of tetanus . . . . . . 512 Salpingectomy, results of . . . . 464 SALPINGITIS 463 — gonorrhoeal . . . . . . 204 — tuberculous . . . . ■ . 465 Salpingo-oophoritis .\ . . . . 463 Salt-free diet to avert eclampsia . . 14 in diabetes insipidus. . . . 144 influence on ascites . . . . 90 Salvarsan treatment of cardiac syphilis . . . . . . 123 lymphadenoma . . . . 286 pernicious anaemia . . . . 398 PAGE Salvarsan treatment of relapsing fever . . . . . . . . 447 — — syphilis . '. . . . . 503 — — syphilitic mental disease . . 325 Sanatorium treatment, importance in pleuritis . . . . . . 402 in laryngeal tuberculosis . . 268 recurrent cancer . . . . 114 — — - results in phthisis . . ■ . 423 Sanitation and rheumatic fever . . 449 Sarcoma, cerebral . . . . . . 128 — of jaw . . . . . . . . 247 — kidney . . . . . . . . 251 SARCOMA, MELANOTIC . . . • 291 — — principles and prospects of operation . . . . . . 292 supervening on a mole . . 342 — of spine . . . . . . . . 484 — stomach . . . . . . . . 498 — testis . . . . . . . . 510 — tongue . . . . . . . . 517 — transformation of lymphadenoma into . . . . . . . . 286 Sarcomata, myeloid and periosteal . . 107 Sarcomatous degeneration of uterine fibroids . . . . . . 531 Scalds (see Burns and Scalds) . . 120 Scalp, cellulitis of . . . . . . 124 Scaphoid, carpal, fracture of . . 186 — tarsal, fracture of .. .. 182 Scapula, fracture of . . . . . . 187 — sarcoma of . . . . . . 108 SCARLET FEVER 465 acute nephritis of . . . . 363 — — ■ complications . . . . 466 myocarditis with . . . . 350 pericarditis of . . . . 390 symptoms of special serious- ness . . . . . . . . 466 Schauta's operation in cancer of uterus . . . . _ . . _. . 528 Schede's operation for varicose veins 539 Schonlein's purpura . . . . . . 437 School certificates, pulse irregularity and . . . . . . . . 430 — teachers, severity of rheumatoid arthritis in . . . . . . 457 SCLATICA 467 Scirrhus of breast (see Breast) . . no Sclavo's serum in anthrax . . . . 51 Sclerosis, disseminated . . . . 153 SCOLIOSIS 468 Scopolamine with general anaesthesia 24 Scopolamine-morphia, influence on surgical shock . . . • 34 Scottish Board of Lunacy, Reports of 298 SCROTUM, CARCINOMA OF . . • • 469 SCURVY 469 Seborrhoeic eczema . . . . . . 162 Secondary anaemia (see Anaemia, Secondary) . . . . . - 15 Semilunar bone, fracture of . . . . 186 — cartilage, injuries to . . . . 263 Seminal vesicles, tuberculosis of, with vesical tuberculosis . . 106 — vesiculitis complicating gonorrhoea 201 Senile gangrene . . . . . . 197 566 INDEX OF PROGNOSIS Senility, eczema of . . — and melancholia . . - — mental disturbances of . . — myocardial degeneration in — premature, from alcoholism Sepsis in burns and scalds . . — cancer of bladder — vesical calculus . . Septic complications in head injuries — conditions, anaesthetics in SEPTICEMIA . . ■ • — pericarditis complicating — puerperal (see Puerperal Sepsis) Serum therapy in bacillary dysentery bronchopneumonia . . and diphtheritic heart failure in exophthalmic goitre gonococcal meningitis meningococcal meningitis pernicious anaemia . . — — puerperal sepsis septicaemia — — tetanus typhoid fever . . ulcerative endocarditis Sesamoid bones of thumb, fracture of Sexual power after epididymectomy prostatectomy 410, 411 Sheep's brain emulsion in tetanus . . Shock in abdominal contusions — from fear in anaesthesia . . — relation of anaesthetics to — in ruptured kidney, significance of Shoulder, adhesions following sprain — dislocation of — tuberculosis of . . Silver salts, influence in gonorrhoe Sinus arrhythmia — thrombosis, lateral Sinusitis, nasal accessory (see Nasal Accessory Sinusitis) . . Skin, actinomycosis of - — affections in diabetes — antecedent conditions predispos ing to eczema — symptoms in melancholia Skull, injuries of (see Head Injuries — sarcoma of Sleep in relation to mental disease Sleeping sickness (see Trypanoso miasis) . . Sleeplessness (see Insomnia) SMALL-POX — age incidence — complications — influence of race in — sex incidence — special symptoms — vaccination and . . Sodium bicarbonate, influence on acidosis Solar plexus, death from blow over Soubottine's' operation in exstrophy of bladder Spa treatment of rheumatoid arthritis Speech, effects of chronic alcoholism PAGE 162 309 335 351 327 120 104 96 211 33 469 389 415 139 119 349 171 295 294 398 417 470 512 522 165 187 167 412 513 I 21 33 3 250 250 88 200 430 244 361 9 162 308 210 108 302 517 470 470 473 472 471 472 474 100 459 327 PAGE Speech, effects of laryngectomy on . . 266 — results in cleft-palate operations 136, 137 Sphenoidal sinusitis . . . . . . 362 SPINA BIFIDA 475 Morton's fluid and operation in . . . . . . . . 476 Spinal analgesia, after-effects . . 36 contra-indications . . . . 27 death-rate under . . . . 26 — — methods of . . . . . . 29 relative safety of . . . . 25 SPINAL CARIES 477 — — abscess from . . . . . . 412 — cord, haemorrhage into . . . . 481 — curvature (see Scoliosis) . . 468 Spine, fractures of . . . . . . 480 — hydatid cysts of . . . . . . no SPINE, INJURIES OF 479 gun-shot wounds of cord . . 483 value of laminectomy . . 482 SPINE, TUMOURS OF . . . . 484 results of operation . . . . 485 — typhoid . . . . . . ■ . 521 Spirochaetosis . . . . . . . . 447 Spleen enlargement in leukaemia 272, 273 — gunshot wounds of . . . . 4 — ruptured, from abdominal contu- sion . . . . . . . . I, 3 Splenectomy in cirrhosis of liver . . 279 — contra-indicated in leukaemia . . 274 — in splenic anaemia . . . . 17 of infancy contra-indicated 19 SPLENIC ANEMIA 16 ascites due to . . . . 89 Splenomedullary leukaemia . . . . 271 Splenomegalic polycythaemia (see Polycythaemia) . . . . 407 Splenomegaly, Egyptian, hepatic cirrhosis with.. .. .. 279 — infantile . . . . . ■ . . 517 — primary (see Anaemia, Splenic) 16 Splint compression, Volkmann's paralysis from . . . • 347 Sprain-fracture . . . • . . 249 Sprains . . . • . • • • 249 — arthritis and adhesions following 250 Sprue . . . . . . • • . • 138 Stanhope Sanatorium, statistics of treatment at . . . . • . 425 Staphylococcal infections, pericar- ditis with . . . . . . 390 — meningitis . . • . . • 295 Starvation, the acidosis of . . . . 5, 6 Stasis, pitch of, in mitral stenosis . . 222 Status lymphaticus, relation of anesthetics to and spinal analgesia . . Steinmann's method in fractures Stenosis, aortic — mitral — pulmonary, acquired congenital — of pylorus, congenital — tricuspid . . Sternum, fracture of Sterility, gonorrhoea and — vesicular mole and 29 27 174 227 220 229 230 496 . . 229 187, 192 202 •• 343 439, SUPPLEMENTARY INDEX 567 of 486, Stigmata of degeneration in mental disease — — with mental heredity in secondary dementia Still's disease Stimulants in pneumonia, need pushing Stokes-Adams syndrome Stomach, carcinoma of relation to ulcer — cirrhosis of — dilatation of — gunshot wounds of — hour-glass . . STOMACH, MEDICAL AFFECTIONS OF — sarcoma of STOMACH, SURGICAL AFFECTIONS OP — syphilis of STOMATITIS (simple, aphthous, mer- curial, ulcerative) Stovaine in local analgesia . . Strain, emotional and physical, in causation of myocardial degeneration . . Streptococcal empyema — infections, pericarditis as ter- minal phase of — meningitis . . — pleuritis Streptothricosis, relation to actino- mycosis Stricture of oesophagus — urethral . . . . . . 525, STROKES — mental symptoms with . . Strychnine in chronic anterior polio- myelitis — doubtful benefit with general ansesthesia — in retarding bulbar palsy Stupor in dementia prsecox . . — mental (see Mental Diseases) . . Stuporose symptoms in adolescent insanity Subclavian aneurysm SUBPHRENIC ABSCESS complicating appendicitis . . Suicidal impulse at the climacteric in lactational insanity melancholia . . . . 309, puerperal insanity Suicide, uncontrollable impulse to . . Sulphate of magnesium in tetanus. . Sulphonal poisoning. . Summer diarrhcea of infancy Suprarenal extract in excessive vomiting of pregnancy 540, Suture of nerves — operations in movable kidney . . Syme's operation in cancer of tongue Sympathectomy in exophthalmic goitre . . Syncope, rareness in myocardial disease Synovial fringes, hypertrophied Synovitis of knee-joint — syphilitic . . PAGE 304 340 322 406 434 496 489 498 484 491, 496 487 499 25 351 163 390 295 401 379 526 500 500 348 25 119 335 321 334 46 502 58 336 332 312 331 320 513 155 150 541 369 345 514 171 354 263 262 506 PAGE SYPHILIS 503 — acute yellow atrophy of liver due to. . . . . . . . 276 — and aortic regurgitation. . . . 224 SYPHILIS, CARDLA.C 122 — cerebrospinal, disseminated scler- osis simulating . . . . 153 — congenital. . . . . . . . 505 — cure in primary stage . . . . 503 — early cure of, to prevent general paralysis . . . . . . 325 — of liver, ascites of . . . . 89 — myocardial degeneration in . . 351 — as predisposing cause of general paralysis . . . . . . 324 — relation to Addison's disease . . 9 angina pectoris . . 47, 50 aphasia of thrombotic origin 53 — — arteriosclerosis . . . . 81 dilatation of aorta . . . . 53 — of the stomach . . . . . . 487 — tertiary symptoms . . . . 505 — tuberculosis with. . . . . . 420 — value of salvarsan, mercmry, and iodides compared . . . . 503 — and valvular disease . . . . 218 Syphilitic bulbar palsy . . . . 119 — cirrhosis of liver . . . . . . 280 SYPHILITIC JOINTS . . . . 506 — mental ssrmptoms . . . . . . 325 Syphiloma, cerebral . . . . . . 125 'TTABES, disseminated sclerosis -•■ mistaken for . . . . . . 153 TABES DORSALIS (see also Ataxias, 93) 506 Tabetic arthropathies — ataxia Tachycardia (see Pulse, Irregularities of) — paroxysmal, in myocardial disease 357 — progressive, in contractile failure 355 TALIPES Talma-Morison operation for ascites Tarsal scaphoid, fracture of . . Tarsus, fractures involving 182, Tar -workers' cancer . . Taxis in strangulated hernia Teeth, carious, removal with opera- tion for tuberculous glands — relation to rheumatoid arthritis ' Teething convulsions ' Temperament, effect on arterio- sclerosis — in myocardial disease Temperature in head injuries — hemiplegia — high, in children, mental disturb- ance with . . . . . . 333 — importance in puerperal insanity 331 — in measles. . . . . . . . 290 — relation of anaesthetics to . . 33 — in typhus fever . . . . . . 524 Temporosphenoidal abscess . . 244 TENOSYNOVITIS 509 Testes, results of mumps on . . 346 TESTIS, NEW GROWTHS OF .. 510 — tuberculous (see Epididymitis) 166 Tests for acidosis . . . . . . 5 508 93. 506 431 509 278 182 191 469 215 285 456 236 83 352 211 501 568 INDEX OF PROGNOSIS PAGE PAGa TETANUS 511 Transport, influence on abdominal — after burns 121 wounds 4 Tetronal poisoning . . 155 Trapezium and trapezoid, fracture of 186 Thoracentesis, pneumothorax due to 406 Traumatic epilepsy . . 212 Thoracic aneurysm (see Aneurysm, Trendelenburg's operation for vari- Intrathoracic) 39 cose veins 539 — duct, wounds of . . 513 Tricuspid valve, congenital atresia of 230 Thoracostomy in chronic adhesive — valve, lesions of 228 pericarditis 392 Trigeminal neuralgia (see Neuralgia, Throat affections with measles 290 Trigeminal) . . 37& Thrombophlebitis, puerperal 415, 417 ,418 Trional poisoning 155 Thrombosis, cerebral (see Strokes) 500 Tropacocaine in local analgesia 25 — — relation to aphasia . . 53 TROPICAL FEVERS 517 — complicating appendicitis 59 TRYPANOSOMIASIS 517 — lateral sinus 244 Tubal disease (see Salpingitis) 463 — venous, complicating chlorosis . . 132 — gestation (see Ectopic Pregnancy) 160 in typhoid fever 520 Tubercle bacilli, influence on brain Thrush 499 disease 338 Thymus, enlarged, with exophthal- Tuberculin in renal tuberculosis . . 256 mic goitre 172 — Addison's disease 10 Thyro-fissure in papilloma of larynx 267 — epididymitis 167 — results in laryngeal carcinoma . . 265 — lupus vulgaris 284 Thyroid, ansesthesia in operations on 32 — lymphadenitis 284 — cancer 109 — pulmonary tuberculosis 428 — extract in excessive vomiting of — vesical tuberculosis io5 pregnancy . . . . 540, 541 Tuberculoma, cerebral 125 — gland administration in cretinism 324 Tuberculosis, acute, complicating affections with congenital measles 290 amentia 324 — of bladder (see Bladder, Tuber- — operations in exophthalmic goitre 172 culosis of) 105 — treatment and mental symptoms — breast 116 of myxoedema 339 — cfficum 121 Th5T:oidectomy for goitre . . 199 — with diabetes 149 Tibia, fracture of . . . . 180, 190 — effusion into pericardium in . . 391 — sarcoma of . . . . 107, 108 — of kidney . . 254 Tic douloureux (see Neuralgia, — larynx (see Larynx) 268 Trigeminal) 376 — miliary, caseous, and pneumonic 420 Tick fever (see Relapsing Fever) . . 447 — pulmonary (see Pulmonary Tuber- Tobacco in etiology of arteriosclerosis 81 culosis) 418 Tongue, actinomycosis of . . 8 after lymphadenitis 284, 285 TONGUE, CANCER OF 513 relation of influenza to 239 mortality of operation 514 — and scarlet fever. . 467 prognosis apart from operation 513 — following spinal injuries 479 prospects of cure 515 — syphilis with 505 time and situation of recurrence 516 Tuberculous abscess from spinal — papilloma of 517 caries . . 412 — sarcoma of 517 — arthritis (see Arthritis) . . 85 Tonsillectomy with operation for — empyema . . 163 tuberculous glands . . 285 — enteritis 165 Tonsillitis with rheumatic fever 449 — epididymitis (see Epidymitis) . . 166 Tooth's peroneal muscular atrophy 348 — glands mistaken for lympha- — report on cerebral tumour 125 denoma 286 Toxaemia, post-operative . . 30 — lymphadenitis (see Lymphadenitis 284 after appendicectomy 63 — meningitis . . 295 Toxaemias of pregnancy 332 movements in, simulating — and rheumatoid arthritis 455 chorea 134 Toxaemic jaundice complicating — peritonitis (see Peritonitis, Tuber- appendicitis . . 62 culous) 393 — vomiting of pregnancy . . 540 Asiatic form of 89 Toxic angina . . 51 cytology of ascitic fluid in 92 Toxins causing arteriosclerosis 81 — pleuritis . . 401 Tracheotomy or intubation in — salpingitis 465 diphtheria 152 — tenosynovitis 510 — in laryngeal tuberculosis 269 Tufnell's treatment in abdominal — papilloma of larynx 267 aneurysm . . 39 Trance in adolescent insanity 334 intrathoracic aneurysm 42 Transfusion of blood in pernicious Tumours of bladder (see Bladder, anaemia 399 Growths of) . . 100 S UPPLEMENTA R Y INDEX 569 PAGE Tumours of bone . . . . . . 106 — brain, ataxia due to . . . . 94 — — disseminated sclerosis mis- taken for . . . . . . 153 — — mental symptoms with . . 328 — cerebral . . . . . . 124, 125 — — relation to aphasia . . . . 53 — complicating vesical calculus . . 96 — of jaw, lower . . . . . . 249 upper . . . . . . . . 247 — kidney . . . . . . . . 251 — larynx, malignant . . . . 265 papillomatous . . . . 267 — malignant, hydronephrosis due to 233 — ovarian (see Ovarian Tumours) 381 — of spine (see Spine, Tumours of) 484 Turban's classification of pulmonary tuberculosis . . . . . . 424 Tympanites with ascites of cirrhosis 278 TYPHOID FEVER 518 age, sex, and character of the attack . . . . . . 518 — — cardiac complications in . . 350 -in etiology of arteriosclerosis 81 haemorrhage in . . . . 520 perforation . . . . 519, 522 ■ pericarditis complicating . . 390 peritonitis in . . . . . . 519 pregnancy during . . . . 521 prophylactic inoculation . . 523 — — surgical treatment . . . . 522 symptoms and complications 519 treatment . . . . . . 521 — form of scarlet fever . . . . 466 — spine . . . . . . . . 521 Typhoidal meningitis . . . . 295 TjTJho-mania (see Mental Diseases) 314 TYPHUS FEVER 523 age incidence.. .. .. 523 — — sex, complications, and special symptoms . . . . . . 524 156, 492 .. 487 75 502 493 508 173 138 T T LCER, duodenal . . ^ — gastric with chronic appendicitis . . operative treatment and duodenal, subphrenic abscess due to — jejunal, after gastrojejunostomy — perforating, of foot, in tabes . . Ulceration of cornea in exophthal- mic goitre Ulcerative colitis — endocarditis (see Endocarditis, Ulcerative) . . . . . . 164 — stomatitis . . . . . . . . 499 Ulna, fracture of . . . . 185, 191 — myeloid sarcoma of . . . . 107 Ulnar nerve, injury to . . . . 375 Umbilical hernia . . . . . . 214 Unciform bone, fracture of . . . . 186 Unconsciousness (see Coma) UR.21MIA . . . . . . . . 524 — of acute nephritis . . . . 363 — from renal calculus . . 258, 261 Urea excretion, defective, pre- eclamptic . . . . . . 14 relation to acidosis . . . . 6 Ureter, calculus of (see Kidney) . . — operations on in hydronephrosis URETHRA, RUPTURED URETHRAL STRICTURE Urethritis, gonorrhceal . . 200, Urethrotomy in stricture Urinary complications of tabes dor- salis — obstruction with gastric sym- ptoms . . — system function in eclampsia . . Urine, albumin in (see Albuminuria, Nephritis) — daily output of, in impaired ventricular contractility — deviation of course in exstrophy of bladder — diazo-reaction of, in pulmonary tuberculosis . . — examination in diabetes. . — — excessive vomiting of preg- nancy — — nephritis . . . . 362, post-operative toxaemia pregnancy — extravasation of . . . . 525, — iodide of potash test, technique — normal, albumin in — phthalein test, technique — tests for acidosis . . Uropyonephrosis (see Pyonephrosis) Uterine tumours, ascites due to 8g Uterus, affections connected with salpingitis UTERUS, CANCER OF of the body . . of the cervix iibryoma as predisposing cause of — — results of treatment — chorion-epithelioma of . . UTERUS, FIBROIDS OF with cancer . . degenerative changes in — — operative treatment palliative and expectant treatment . . risks in presence of . . — gonorrhceal infection of . . — perforation or rupture of, with vesicular mole — results of operative treatment . . UTERUS, RUPTURE OF PAGE 258 235 525 203 526 507 495 159 354 99 422 147 540 367 31 14 526 368 II 367 5 441 - 90 464 526 529 526 532 528 135 530 530 531 533 535 531 204 342 537 535 Y'ACCINATION, antityphoid .. 523 — and small-pox . . . . 470 Vaccine therapy, in bronchitis . . 118 effect on asthma . . . . 93 gonorrhoea . . . . 201, 202-5 — — nasal accessory sinusitis . . 359 puerperal sepsis . . . . 417 rheumatoid arthritis . . 459 typhoid fever.. .. .. 522 — — ulcerative endocarditis . . 165 vesical tuberculosis . . . . 106 Vaginitis, gonorrhceal . . . . 202 Valvular disease (see Heart) . . 217 with angina pectoris . . 48 570 INDEX OF PROGNOSIS Valvular disease, relation to primary- disease of myocardium Varicella (see Chicken-pox 349 129 — bullosa, gangrenosa, and hamor rhagica (see Chicken-pox) VARICOCELE . . — with renal growths VARICOSE VEINS eczema with . . Variola (see Small-pox) Varix, aneurysmal . . Vasectomy in hypertrophy of prostate 409 Vasodilators in high arterial tension 80 — significance of effect in angina pectoris Veins, varicose (see Varicose Veins) Vejlefjord Sanatorium, statistics of treatment at . . Vena cava inferior, wounds of Venesection in aortic regurgitation Venous thrombosis, complicating chlorosis gouty . . Ventricles, condition of, in mitral stenosis — impaired contractilit}^ of importance of symptoms in 353 Version, podalic, in. placenta praevia 400 Vesical rupture, etc. (see Bladder) — moles (see INIoles) chorion-epithelioma following 135 Venous thrombosis in typhoid fever Visceral crises of tabes Visual phenomena of migraine Vitry-Sezary operation for ascites . . Volkmarm's paralysis . . Volvulus, obstruction due to — results of operation for . . Vomiting in abdominal contusions . . — in exophthalmic goitre . . — intestinal obstruction — measles — with movable kidney — in myocardial disease — with post-haemorrhagic anaemia — post -operative VOMITING OF PREGNANCY . . toxaemic, acidosis in . . Von Eiselsberg's report on cerebral tumour VULVA, CARCINOMA OF Vulvovaginitis, gonorrhoeal. . 129 538 254 539 162 470 47 49 539 423 238 224 132 206 223 353 342 342 520 508 141 279 347 241 242 I .. 174 240, 243 290 • • 344 354 15 34 540 5 125 541 202 W7ASSERMANN reaction (see * ^ Syphilis) of ascitic iluid in general paralysis . . syphilitic mental disease tuberculosis . . Wasting in exophthalmic goitre 504 92 324 325 420 174 Water injection in intussusception 245 Wertheim's hysterectomy in cancer of cervix . . . . . . 52S Whitehead's operation in cancer of tongue.. .. .. .. 514 Whitman's operation in coxa vara. . 143 WHOOPING-COUGH 542 — bronchiectasis as a sequel . . 116 — bronchopneumonia with . . 118 Widal reaction . . . . . . 519 Wiring of sac in abdominal aneurysm 3S intrathoracic aneurysm . . 43 Woolsorters' disease.. .. .. 51 Workmen's compensation, fractures in relation to . . . . . . 188 Wounds of abdomen, non -perforating i perforating . . . . . . 4 — head . . . . . . . . 210 — heart . . . . . . . . 231 — inferior vena cava . . . . 238 — joints . . . . . . . . 251 — knee . . . . . . . . 264 — mahgnant cedema due to . . 379 — pericarditis from . . . . 390 — of spine . . . . . . . . 479 — thoracic duct .. .. .. 513 — treatment to prevent tetanus . . 512 Wrist, fracture of bones of 186, 191 — sprained . . . . . . . . 249 — tuberculosis of . . . . . . 88 Wjmter-Handley operation for ascites 279 "V-RAY burns .. .. .. 121 ■^ X rays in cancer of uterus . . 529 vulva . . . . . . . . 542 — chronic anterior poliomyelitis . . 348 — fibroids of uterus. . . . . . 534 — harmful in splenic anaemia of infancy . . . . • • 19 — influence in prognosis of breast cancer . . . . . . . . 114 — in injuries of knee-joint . . . . 262 — leukaemia . . . . . . 272, 273 — lichen planus . . . . . . 274 — lupus erythematosus, epitheli- oma following . . . . 282 vulgaris, dangers of . . . . 283 — lymphadenoma . . . . 286, 287 — mycosis fungoides . . - . 349 — ovarian tumours . . . . ■ . 383 — psoriasis . . . . . • - • 4^4 — recurrent cancer of breast . . 113 — renal calculi ■ ■ ■ ■ ■ • 258 — and ringworm . . ■ • • ■ 461 — in rodent ulcer . . . . . . 462 — splenic anaemia . . • . • • i7 — value of secondarj' . . 113, 114 YELLOW FEVER .. -.544 -'■ Young's bar-punch operation in enlarged prostate - . 412 JOHN WRIGHT AND SONS LTD., PRINTERS, BRISTOL. 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