HX00048178 VolJL Cataract To EndometkiTis ■recap f OR. JOSllUa RGSETT RC"^/ SiX^ i960 u.d Columbia (Mnitiewiitp CoUege of ^fjpsiciang anl) ^uraeons Hibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/sajoussanalytic02sajo SAJOUS'S Analytical Cyclop/Edia OF Practical Medicine BT CHARLES E. de M. SAJOUS M.D. ONE HUNDRED ASSOCIATE EDITORS ASSISTED BY CORRESPONDING EDITORS COLLABORATORS AND CORRESPONDENTS Illustrated witb CbromO'Cithograpbs engriivings ana maps Third Revised. Edition VOLUlxrEl II PHILAnELPHIA F. A. DAVIS COMPANY PUBLISHERS 1905 COPYRIGHT, 1905, BY F. A. DAVIS COMPANY. I Registered at Stationers' Hall, London, Eng.| Philadelphia, Pa., U.S. A.: The Medical Bulletin Prlntlng-houM, I'JlUfl Cherry Street. Sou 2. PREFACE. The majority of the sections included in the first volume, as stated in the preface of the latter, were prepared under the immediate supervision of the editor and submitted to the various members of the associate staff for revision and cor- rection. Each associate enjoying the privilege of erasing, changing, and adding anything he chose, the correctness of the views advanced was insured, while the innovations as to form introduced by the editor could satisfactorily be carried into effect. The second volume inaugurates the regular plan of the work as regards elaboration: all the articles have been prepared by their respective editors, and the result shows the kind interest taken in the work by all the members of the staff, to whom the editor extends expressions of sincere gratitude. The aim of the editor is not only to facilitate the labor of the practicing physician and to assist investigators and authors in their researches, but he also seeks to elucidate, through contributions from men possessing special knowledge or unusual experience in a particular line, diseases which, owing to their com- plexity, arc not generally understood. This plan has borne fruit, and the readers will have before them, in this volume, exceptionally-valuable articles on a num- ber of exacting subjects, namely: "Cerebral Hremorrhage," by Dr. William Browning, of Brooklyn; "Cirrhosis of the Liver," by Professor Adami, of Montreal; "Cholera," by Professor Eubino, of Naples; "Cholelithiasis." by Pro- fessor Graham, of Toronto; "Diabetes," by Professor Lepine, of Lyons, etc. The better-known affections have also been edited by writers of special ability. Among the articles of this kind is that on "Diphtheria," by Drs. Northrup and Bovaird, of New York, who contribute a masterly review of our present knowledge of this affection from every stand-point. The papers by Professor Bondurant, of Mobile, on "Chorea"; Dr. Norman Kerr, of London, on "Cocaiuo- mania"; Dr. Oliver, of Philadelphia, on "Cataract"; Prof. Nathan S. Davis, of Chicago, on "Constipation"; Dr. Vickerj-, of Boston, on "Dilatation of the Heart," are, among others, particularly entitled to the readers' special attention. An infirmity but little studied by the general practitioner is "Deaf-mutism." A section giving an exhaustive review of the subject has been contributed by Dr. Holger Mygind, of Copenhagen, one of the greatest living authorities upon the pathogenesis of this condition. (iii) JT PREFACE. Eepeated inquiries having reached the central department as regards the authorship of the fifty-page article on "Animal Extracts" which appeared in the first volume, the editor wishes to state that he wrote it himself, and that he fully appreciates the kind expressions relating thereto, and also the many encouraging reviews which the medical press has accorded the first volume. The Editok. 2043 Walnut Street. STAFF OF ASSOCIATE EDITORS. J. GEORGE ADAMI, M.D., MONTREAL, P. Q. ANDREW F. CURRIER, M.D., NEW YORK CITY. LEWIS H. ABLER, M.D., PHILADELPHIA, PA. ERNEST W. GUSHING, M.D., BOSTON, MASS. JAMES M. ANDERS, M.D., LL.D., PHILADELPHIA, PA. GWILYil G. DA\aS, II.D., PHILADELPHIA, PA. THOMAS G. ASHTON, M.D., PHILADELPHIA, PA. N. S. DAVIS, M.D., CHICAGO, ILL. A. D. BLACIvADER, M.D., MONTRE.\L, P. Q. E. D. BONDURANT, M.D., MOBILE, ALA. AUGUSTUS A. ESHNER, JI.D., PHILADELPHIA, PA. SIMON FLEXNER, M.D., PHIL.iDELPHIA, PA. DAVID BOVAIRD, M.D., NEW YORK CITY. LEONARD FREE.\L\N, M.D., DENVER, COL. WILLIAM BROAVNING, M.D., BROOKLYN, N. Y. S. G. GANT, M.D., NEW YORK CITY. WILLIAM T. BULL, M.D., NEW YORK CITY. J. :McFADDEN GASTON, M.JJ., ATLANTA, GA. CHARLES W. BURR, M.U., PHILADELPHIA, PA. HENRY T. BYFORD, M.D., CHICAGO, ILL. HENRY W. CATTELL, M.D., PHILADELPHIA, PA. J. McFADDEN GASTON, Jr., M.D., ATLANTA, GA. E. B. GLEASON, M.D., PHILADELPHIA, PA. EGBERT H. GRANDIN. .M.D.. NEW YORK CITY. WILLIAM B. COLEY, M.D., NEW YORK CITY. J. P. CROZER GRIFFITH, .M.D.. PHILADELPHIA, PA. FLOYD ;m. crandall, M.n., NEW YORK CITY. C. M. HAY, M.D.. nULADELPniA, P.V. (V) STAFF OF ASSOCIATE EDITORS. FREDERICK P. HEXRY, M.D., PHIT.AnELPHIA, PA. L. EM3JETT HOLT, il.D., JvEW TOKK CITY. EDWARD JACKSOX, M.D., DEXVEK, COL. W. W. IvEEN, M.D., PHILADELPHIA, PA. EDWARD L. KEYES, Jk., M.D., NEW YORK CITY. ELWOOD R. laRBY, M.D., PHILADELPHIA, PA. L. E. LA FETRA, M.D., XEW YORK CITY. ERNEST LAPLACE, M.D., LL.D., PHILADELPHIA, PA. E. LEPINE, M.D., LYONS, FRANCE. F. LEVISON, M.U., COPENHAGEN, DENMARK. A. LUTAUD, M.D., PARIS, FRANCE. G. FRANK LYDSTON, M.D., CHICAGO, ILL. F. W. JL^RLOW, M.D., SYRACUSE, N. Y. SIMON MARX, M.D., NEW YORK CITY. ALEXANDER McPHEDRAN, M.D., TORONTO, ONT. E. E. MONTGOMERY, M.D., I'lIILADEI.PHIA, PA. IIOLOER MYGIND, M.L., COPENHAGEN, DENMARK. W. p. NORTHRUP, M.D., NEW YORK CITY. RUPERT NORTON, M.D., WASHINGTON, D. C. H. OBERSTEINER, M.D., VIENNA, AUSTRIA. CHARLES A. OLIVER, M.D., PHILADELnnA, PA. WILLIAM OSLER, M.D., BALTIMORE, MD. LEWIS S. PILCHER, M.D., BROOKLYN, N. Y. WILLIAJI CAMPBELL POSEY, M.D., PHILADELPHIA, PA. W. B. PRITCHARD, M.D., NEW YORK CITY'. •JAMES J. PUTNAM, M.D., BOSTON, MASS. B. ALEXANDER RANDALL, M.D., PHILADELPHIA, PA. CLARENCE C. RICE, M.D., NEW YORK CITY. ALFRED RUBINO, M.D., NAPLES, ITALY. REGINALD H. SAYRE, M.D., NEW YORK CITY^. JACOB E. SCHADLE, M.D., ST. PAUL, MINN. .JOHN B. SHOBER, M.D., I'JIILADELPIIIA, PA. J. SOLIS-COHEN, M.D., I'HILADF.T.PHIA, PA. SOLO.MON SOLIS-COIIEN, M.D., I'HILADKI.I'IIIA, PA. STAFF OF ASSOCIATE EDITORS. H. W. STELWAGOK, M.U., PHILADELPHIA, PA. HERMAN F. ^'ICKERV, M.D., BOSTOX, MA§S. D. D. STE\VART, M.D., rniLADELPHLA, PA. LEWIS A. STIMSON, M.D., NEW TOKK CITY. J. EDWARD STUBBERT, M.D., LIBERTY, N. Y. A. E. TAYLOR, M.D., SAN FBANCISCO, CAL. J. MADISON TAYLOR, Ji.U., PHILADELPHIA, PA. M. B. TINKER, M.D., PHILADELPHIA. PA. F. E. WAXHAM, il.D., DEXTER, COL. J. WILLIAM WHITE, M.D., PHILADELPHIA, PA. .JAMES C. WILSON, M.D , PHILADELPHIA, PA. C. SUMNER WITHERSTINE, M.D., PHILADELPHIA, PA. ALFRED C. \\00D, M.U., PHILADELPHIA, PA. CHARLES S. TURNBULL, M.D., PHILADELPHIA. PA. WALTER WYi\L\N, M.D., WASHINGTON, D. C. TABLE OF CONTENTS. (Volum II.) PAGE A. C. E. Mixture 88 Amoebic Dysentery 590, 595 Ankle, Dislocation of 587 Antitoxin in Diphtheria 551 Anus, Stricture of 310 Arterial Cirrhosis 236 Asiatic Cholera 134 Astragalus, Dislocation of 587 Biliary Cirrhosis 228 Blood-vessels, Injuries of, due to Disloca- tions 577 Brain, Hernia of 691 Burns of Conjunctiva 308 Burns of Cornea 331 Caffeine 266 Caffeine Poisoning 267 Carpal Bones, Dislocation of 580 Carpo-metacarpal, Dislocation of 580 Cataract 1 Catarrhal Conjunctivitis 279 Catarrhal Croup 352 Catarrhal Dysentery 588, 601 Centrilobar Cinhosis 237 Cerebral Abscess 20 Cerebral Hemorrhage 31 Cerebral Hernia 691 Cerebral Paralysis, Infantile 675 Cerium 52 Cervical Vertebra, Dislocation of 569 Chaulmugra-oil 53 Chloral Derivatives and Compounds 54 Chloral Poisoning 62 Chloralamid 59 Chloralose 59 Chlorctone 61 Chloroform 65 Chloroform Poisoning 76 Chlorosis 89 Cholecystenterostomy 127 Cholccystotoniy 128 Choledochotomy 131 PAGB Cholelithiasis 104 Cholera Asiatica 134 Cholera Infantum 155 Cholera Morbus 162 Cholera Nostras 162 Choluria 167 Chorea ITO Chromic Acid 185 Chrysarobin 186 Chyluria 187 Cimicifuga 191 Cimicifuga Poisoning 192 Cinchona, Derivatives and Compounds. . . 193 Cinchona Poisoning 199 Cinnamon and Derivatives 202 Cirrhosis, Gliasonian 237 Cirrhosis of Liver 204 Clavicle, Dislocation of 570 Clitoritis 241 Coca 243 Cocaine 243 Cocaine Poisoning 244 Cocainoniania, or Cocaine Habit 256 Coccyx, Dislocation of 5S2 Cochin China DiaiThcea 600 Coffee and Caffeine 264 Coffee Poisoning 265 Colchicum 269 Colocynth 275 Colocynth Poisoning 276 Conjunctiva, Diseases of 277 Conjunctivitis 279 Constipation 309 Convallaria Majalis 318 Copaiba 319 Copaiba Poisoning 321 Copper 322 Copper Salts, Poisoning 325 Cornea, Disorders of 330 Corn-ergot and Corn-silk 339 Costal Cartilages, Dislocation of 570 Cotton-plant 339 Creasote and Preparations 341 Creasote Poisoning 344 TABLE OF CONTENTS. PAQB Croup 352 Croupous Conjunctivitis 300 Cubeb 359 Curara 360 Curara Poisoning 362 Cystitis ■. 363 Deaf-mutism 373 Dermatitis 404 Diabetes Insipidus 423 Diabetes Mellitus 427 Diarrhoea Alba (see Cholera Infantum). Diarrhoea, Cochin China 600 Diarrhoea, Infantile (see Infantile Diar- rhoea and Cholera Infantum). Digitalis 466 Digitalis Poisoning 475 Dilatation of Heart 483 Diphtheria 497 Diphtheritic Conjunctivitis 303 Diphtheritic Dysentery 589, 604 Dislocations 562 Dysentery 587 Dysmenorrhoea Oil Eclampsia 622 Eczema 635 ElTusions, Pulsating Pleural 673 Egyptian Ophthalmia 291 Elaterium and Elaterin 651 Elaterium Poisoning 652 Elbow, Dislocation of 577, 580 Elephantiasis 652 Empyema, Thoracic 659 Empyema, Tubercular 673 Encephalitis 674 Encephalocele 691 Endometritis 696 Ensifomi Process, Dislocation of 570 Fibula, Dislocation of 586 Fingers, Dislocation of 581 Follicular Conjunctivitis 282 Foreign Bodies in Conjunctiva 308 Foreign Bodies in Cornea 331 Olissonian Cirrhosis 237 GlosBO-labio-laryngeal Paralysis 077 Oonorrbf/'al Ophthalmia 285 OoHsypiuni Horbaceuni 339 Granular Conjunctivitis 291 Heart, Dilatation of 483 Hernia Cerebri 091 PAOB Hip, Dislocation of 5S2 Huntingdon's Chorea 185 Hydrencephalocele 691 Hypnal 61 Injuries of Conjunctiva 308 Interlobar Pleurisy 671 Jaw, Dislocation of 569 Knee, Dislocation of 585 Laryngeal Diphtheria 507 Lordosis 070 Lupus of Conjunctiva 304 Lymphatic Conjunctivitis 299 Membranous Croup 356 Meningocele 691 Meningo-encephalitis, Chronic 687 Metatarsus, Dislocation of 587 Miliary Ophthalmia 291 Nasal Diphtheria 500 Nerves, Injuries due to Dislocations 577 Occiput, Dislocation of 569 Oculomotor Palsy GS5 Opacities of Cornea 333 Ophthalmia, Egyptian 291 Ophthalmia, Gonorrhoea! 235 Ophthalmia, Miliary 291 Ophthalmia Neonatorum 288 Paget's Disease 417 Paracentesis Thoracis 066 Paralysis, Bulbar 675 Paralysis, Crossed 37 Paralysis, General, of Insane 088 Paralysis, Infantile, Cerebral 075 Paralysis of Uculomotor Nerve 085 Patella, Dislocation of 580 Pediculosis 642 Pelvis, Dislocation of 582 Pemphigus of Conjunctiva 305 Pericellular Cirrhosis 234 Pharyngeal Diphtheria 501 Phlyctenular Conjunctivitis 299 Pleural Effusions, Pulsating 673 Pleurisy, Intei'lobar 071 Poisoning, Caffeine 207 I'oisoniiig, Chloral 62 Poisoning, Chloroform 70 Poisoning, Cimicifuga 192 TABLE OF CONTEXTS. Poisoning, Cinchona 199 Poisoning, Cocaine 244 Poisoning, Coffee 205 Poisoning, Colocynth 276 Poisoning, Copaiba 321 Poisoning, Copper Salts 325 Poisoning, Creasote 344 Poisoning, Curara 362 Poisoning, Digitalis 475 Poisoning, Elaterium 652 Polioencephalitis, Inferior 677 Polyuria 423 Portal Cirrhosis 207 Pterygium 307 Purpura 199 Purulent Conjunctivitis 284 Pyothorax 663 Quinetura 197 Quinic Acid 198 Quinidine 197 Quinoidine 198 Quinoline 198 Quinolinic Acid 198 Quinopicrie Acid 198 Quinovic Acid 198 Radio-ulnar Joint, Dislocations of 5S0 Radius, Dislocation of 579 Ribs, Dislocation of 570 Septic Diphtheria 505 Shoulder, Dislocation of 572 Skyphosis 670 Spine, Dislocation of 509 Sporadic Cirrhosis 239 Sternum, Dislocation of 570 Stigmata Maydis 339 Stricture, Anal 310 Strumous Conjunctivitis 299 Subacromial Dislocations 572 Subastragaloid Dislocation 587 Sydenham's Chorea 170 Syphilitic Diseases of Conjunctiva 305 Tarsus, Dislocation of 587 Thoracic Empyema 659 Thumb, Dislocation of 581 Tic Co-ordin6 184 Tonsillar Diphtheria 501 Trachoma 291 Tubercular Diseases ot Conjunctiva 304 Tubercular Empyema 073 Tumors of Conjunctiva 305 Tumors of Cornea 333 Ulna, Dislocation of 579 Urine, Bloody, in Cystitis 303 Ustilago Maydis 339 Vernal Conjunctivil.s 283 Vertebrce, Dislocation of Lower Cervical. . 509 Secondary Cirrhosis 237 . Semilunar Cartilages, Dislocation of 585 | Zuckerguss Leber 237 SAJOUS'S Analytical Cyclopedia of Practical Medicine. CATARACT.— Gr.,xaTapaxT>;s; from xarapdaaaiv, to fall down. Definition. — By the term "cataract" is meant an opacity, partial or complete, of the crystalline lens. Varieties. — The opacity of the crystal- line lens may be (a) primary or idio- pathic, (b) secondary to diseases of other ocular structures, and (c) symptomatic of other disorders. Symptoms. — The objective symptoms vary according to the variety of the cataract, being mainly dependent upon the extent, the character, and the density of the lenticular opacity. In the immature forms the anterior chambers may be shallower than normal, this being due to a forward protrusion of the iris, produced by a swelling of the lens. In hypermature cataract the ante- rior chamber may become deep, while in tlie mature condition it is practically of normal size. The mere inspection of the pupil with- out the aid of oblique illumination does not always give conclusive evidence in regard to the presence of cataract; yet, generally, especially in fairly-advanced eases, the pupillary area appears dull gray or glistening white, according to the character, the condition, and the age of the lenticular opacity; a condition, 2- however, that needs careful clinical con- firmation before any certainty as to diag- nosis can be vouchsafed. At times the pupil may appear almost entirely black or brown in tint. In some, particularly indeterminate cases of this type, the catoptric test is of value. Very rarely, glistening polychromous, crystalline masses may stud the pupillary area. Study of the eye-ground in the in- cipient stages will frequently, especially in comparatively young and ametropic subjects, reveal coarse local changes con- nected with the uveal tract. In all cases, except when contra-indicated, and in all stages, mydriatics should be resorted to, to make as thorough a study of the in- tra-ocular conditions as possible. Vision is always disturbed to a greater or less degree, according to the situation, the extent, and the nature of the opacity. Exniiiination, with Dr. Rogers, of records of Inst 250 cases of cataract of nil forms seen jointly in tlie Inst three years, nnd, excluding juvenile, lamellar, nnd traumatic cataract. Forty-six found nnionsr patients still young enough to have active ciliary muscles. Thirty- seven of these had prnotically normal vision, ranging from 5-6 to 5-5. when their refraction errors were corrected, nnd almost all came complnining of as- thenopia rnther than of dimness of vision. A minute exnmination bv means of ob- CATAEACT. SYMPTOMS. lique illumination revealed small clouded areas in the peripheral layers,, sometimes few in number and sometimes numerous, or minute points of opacity scattered throughout the lens-substance in such a manner as to make it seem incredible that in spite of this obstruction the pa- tient had vision of 5-5 — or average nor- mal acuity. C. F. Clark (Columbus Med. Jour., July 19, '98). Attention called to error frequently made in hasty diagnosis of senile cataract by general practitioners, who misinter- pret the reflection of light by transparent lenses in elderly persons, and particularly in those belonging to the African races. The gray color of the pupil is often mis- leading, and may influence the physician to express his opinion that cataract is present, when further examination with oblique light and with the ophthal- moscope will convince him that his diag- nosis is erroneous. Hansell (Phila. Poly- clinic; Georgia Jour, of Med. and Surg., Sept., '98). The subjective signs are fairly con- stant in all forms of cataract. Large, circumscribed, peripherally-seated opaci- ties are much less destructive to sight than small ones, or even faint nuclear haze situated opposite the pupillary area. Nearly always during the formative period, motes, "veils," and "cobwebs" are spoken of, while at times multiple and distorted vision is the chief com- plaint. As the lens becomes more opaque, however, the sight becomes more and more reduced, until, eventually, any large objects can no longer be discerned, although if the condition be uncom- plicated, the distinction between light and darkness remains. During the incipient stages of cataract it frequently happens in the aged that they are able to dispense with lenses or- dinarily used for near-work, and at times require concave ones for distant vision. This, which is due to an increase in the refractive power of the eye, consequent upon swelling of the lens, before any opacity makes its appearance, is known as '"second sight." Pain and photo- phobia, which are best relieved by smoked glasses, are rather infrequent symptoms in the early stages, and are referable to the pressure of the swelled lens on the ciliary body and iris. As already stated, there are three varieties of cataract: (a) primary or idiopathic, (&) secondary to diseases of other ocular structures, and (c) sympto- matic of some systemic disturbance. In two of three eases which had been struck by lightning cataract developed in both eyes two days later. Both pa- tients, one a boy of 13 and his brother 11 years old, had been unconscious, the former for a short time, tlie younger for two days. Linear extraction was per- formed in both, with success. In the third case, a man of 24, unconsciousness had lasted ten minutes only. Some time later a cataract developed in the right eye. Extraction with iridectomy proved successful. Comparatively few cases of cataract due to lightning-stroke have been described in literature. Joseph Preindlsberger {Wiener klin. Woch.. Mar. 28, 1901). A cataract may remain permanently limited to some particular portion of the lens, or it may gradually involve the en- tire lens-substance and lead to complete opacification. The former variety, which is divided into several types, dependent upon the locality of the lens involved, may be either congenital or acquired. When the opacity is situated in the anterior pole of the lens, the condition is known as anterior polar cataract or anterior py- ramidal cataract. The cause of the con- genital form is supposed to be due to some foetal disturbance operating dur- ing the development of the lens. In the polar variety, which, in reality, is one of the true cataractous forms, the opacity assumes the figure of a star or rosette, with its radii extending toward the pe- CATARACT. SYMPTOMS. riphery. It has been seen to follow con- tusions of the globe, to appear as a part of pigmentary retinitis, and exliibit it- self as a consequence of uveitis. The post-natal form, as a rule, is the per- manent result of rupture of a corneal ulcer, by which the anterior capsule of the lens is brought into contact with the inflamed cornea, leading to prolifera- Capaular cataract. {Becker.) tion of the epithelial cells of the lens occupying the position of the pupillary area, with the formation of a subcapsular opacity after tlie reformation of the anterior chamber; this being in addi- tion to the nebule, which, as a rule, but faintly marks the site of the previous corneal ulceration. When, in addition, there is a deposition upon the anterior face of the capsule which in itself is irregular, opaque, and thickened di- rectly beneath, the condition is known as anterior pyramidal cataract: in real- ity an opacity in both the lens and its anterior capsule. The disturbance in vision depends upon the extent of the capacity. Treatment, as a rule, is un- availing, except the possibility of an optical iridectomy should the opacity be large and the pupil small. When the opacity is situated at the opposite pole of the lens, the condition is designated as posterior polar cataract, or posterior pyramidal cataract. In most instances the latter form, which is not a true cataract, is congenital in type, and is due to some interference with the in- complete disappearance of the hyaloid artery. It is recognized as a small dot or point on the posterior capsule at the posterior pole of the lens, projecting backward into the vitreous humor. True posterior polar cataract is, at times, found as the initial point of election of the senile form, and is not infrequently seen associated with uveal disorder as- sociated with lymph-stream disturbance and liquefaction of the vitreous body. Generally it appears in the stellar form of opacity. In this variety interference with vision depends not only upon the size of the opacity, but also upon con- comitant and relevant changes. Treat- ment, to be of any avail, must be di- rected, if possible, toward any existing cause. A third form, although separated into quite a series of groupings, consists of localizations in various parts of the lens. Opaque stripes extending from pole to pole, and often combined with the cen- tral and the zonular forms, are known under the name of "spindle-shaped" or "fusiform" cataract. Minute dots, usu- ally mostly situated in the central por- tion of the lens, and frequently grouped in the anterior cortex, are known as punctate cataract. Small spheroidal Posterior cortical cataract. (Sic/iei.) opacities in the nucleus, of congenital type, have, by some, been described as central cataract. As a rule, tliey are all mere concomitants of gross intra-ocular pathological change. Zonular opacities situated between the nucleus and the cortex of the lens, both of these portions being transparent, are CATARACT. SYMPTOMS. not uncommon. At times they may progress as a series of minute opaque processes, or '"riders," as they are termed, rendering the entire, lens opaque. This variety of cataract, also known as peri- nuclear or lamellar, is either congenital Congenital cataract with riders. (Sichel.) or forms during infancy in rachitic sub- jects or those who have been afEected with convulsions. Usually it is binocu- lar, but it may occur in but one eye, and almost without exception is but very slowly progressive, though cases in which the opacity has become total have been reported. Upon account of the situa- tion of the main opacity or opacities, vision is usually markedly disturbed, necessitating either artificial mydriasis, iridectomy, or lens-removal. If the appearance of the lens shows that the opacity is probably stationary, and if the zone of the opacity be not so broad that, after the pupil has been dilated with a mydriatic, vision is bet- tered, it is advisable to expose a portion of the transparent periphery of the lens by an iridectomy, thus obtaining an eccentric clearer pupil through which the subject can look. If, on the other hand the peripheral zone of transparent lens-matter be narrow, and if there be evidences of increase in the cataract, it is preferable to remove the lens, either by extraction, when the nucleus is well hardened, or by discission, when the lens-matter appears soft. Traumatic Cataract. — As a rule, this form of lenticular opacity is the re- sult of a rupture or disturbance of the capsule of the lens from an injury which permits the aqueous or vitreous humor to come into contact with the lens-fibres. The laceration in the capsule may be caused by either direct injury by means of the penetration of a foreign body or indirectly by contusion. Shortly after the capsular laceration the lens-fibres near the rent begin to cloud and swell. Later, if it be the ante- rior capsule that is injured, they ooze out into the anterior chamber, appearing as gray, fluffy-looking masses. The aque- ous humor, however, soon dissolves the lens-masses that have passed into the anterior chamber, and, gaining freer access to the interior of the lens by the removal of the primary plugs of lens- matter, causes more or less of the lens- substance to become opaque, swelled, and absorbed. In this way, after the ''"r, „,,;„: r- Congenital, nuclear, and perinuclear cataract. (Sichel.) lapse of some time, the major portion of the lens-substance may be dissolved and the pupil again become almost black. In most cases, however, the capsular wound cicatrizes and becomes closed, stopping the process of absorption before the removal of the lens-material by the CATAHACT. SYilPTOMS. spontaneous-liquefying method is fully attained. Many cases of traumatic cataract pur- sue their course with but few signs of inflammation, but a successful termina- tion is often prevented by the develop- ment of iritis caused either by direct in- jury or by pressure of loose or swelled lens-matter. Septic matter may be also introduced into the eye either at the time of the traumatism or later, giving rise to iridocyclitis, panophthalmitis, and even periophthalmitis. If not pre- vented it not infrequently happens that secondary glaucoma supervenes. This condition is generally due to either a blocking of the angle of the anterior chamber by pressure or the presence of a mass of lens-matter obstructing the passage of the aqueous humor through the spaces of Fontana. The increasing forms of cataract are roughly divided into four stages. As a rule, they begin in isolated areas, but increase and multiply until all of the lens-substance is aifected. The most frequent form is that known as senile cataract. In the first, or incipient, stage the opacities usually begin in the periphery of the lens. They appear either in the form of spots or of stria, which radiate from the lenticular equator toward the centre of the lens. This condition is known as cortical cataract. In other cases the nucleus of the lens may become quite hazy and opaque, while the periph- ery may remain comparatively clear. This variety is ordinarily designated as nuclear cataract. In most instances, however, the two forms, in which both the cortical and the nuclear portions of the lens are affected, are associated. Clinically, in the stage of development of the cataract the anterior chamber will be found but slightly shallowed or of normal depth, and the opacities will, by oblique illumination, appear as white or gray streaks and sectors with dots. In the second stage, or that of ripen- ing, the lens is swelled, this being due to the fact that it contains an increased quantity of fluid. The opacities are more pronounced, while numerous clear spaces are scattered throughout the lens- substance. As a rule, the anterior sur- face of the lens has an iridescent, bluish- white appearance. The anterior cham- ber is shallow. Clear spaces situated in the lens between the iris and the opaque portions of the lens-substance can be recognized by oblique illumination, allowing a shadow of the iris to be cast Well-advanced cortical cataract. {Sichel.) upon the lens at the side from which the light is thrown. In the third, or mature, stage the lens has returned to its normal size, this being, in great measure, due to the loss of the lenticular fluids by resorption. The clear spaces in the lens-substance are replaced by opacities, and the ante- rior chamber has regained its normal depth. The iris fails to cast a shadow. The lens presents a dull-gray or waxy appearance, and its anterior face is seen to be situated on a level with the pupil- lary margin of the iris. Should the pupil be artificially dilated, it will be found that the red reflex from the fundus, which can be dimly obtained CATAKACT. SYMPTOMS. while the cataract is in its immature stage, is lost. In the fourth, or hypermatnre, stage, as a rule, one of two changes occurs: either the cortical substance disinte- grates and becomes fluid, while the nucleus remains hard, — so-called "Mor- ganian cataract," — or the broken-down cortical substance becomes more greatly inspissated and dries into a hard and somewhat flattened mass. In hypermature cataract the anterior chamber is of normal depth, the iris fails Section through Morganian cataract. {Becker.) to cast any shadow, and the surface of the lens appears either homogeneous or exhibits irregular dots in the situation of the ordinary physiological sectors. If, however, the overripening process be more advanced, fatty and calcareous de- generation occurs in the lens and its cap- sule, the anterior chamber becomes deeper than normal, and tremulousness of the iris can be seen. In Morganian cataract the nucleus may sink to the bottom of the liquid contents contained within the lens-cap- sule, the walls of the capsule may come in contact with one another, and the volume of the lens-mass become increas- ingly smaller until nothing but a thin, transparent membrane remains: so- called "membranous cataract." Practically, according as the dimen- sions of the nucleus of the lens vary, a cataract is spoken of as hard or soft. When there is no hard nucleus the cat- aract is said to be soft; so that, as a rule, all cataracts occurring in persons under 35 years of age fall under this category. In older subjects, however, the lenticular nucleus is larger and more or less sclerosed; so that opacities occur- ring in such persons are designated as hard cataracts, although the cortices of such lenses may be quite soft. In some senile cataracts the general sclerosis becomes so pronounced that the entire lens is involved in it. In such a condition the cataract, as a rule, ap- pears a dense, reddish brown and mark- edly translucent. This variety is usu- ally termed 'Tjlack cataract." Secondary Cataract. — This condi- tion refers to the changes that are, at times, observed in the capsule of the lens following, for example, extraction of cataract. It is frequently seen after the attempted removal of an immature cat- aract in which a portion of the lens- substance remains. This occurs when the capsular membranes become agglu- tinated together and the escape of any remaining lens-material is prevented. In many instances it happens that the entire pupillary area is not covered by the opacity, and fairly-satisfactory vision may be obtained. When the condition does not develop until some months after the primary op- eration for extraction, it is generally de- CATARACT. ETIOLOGY. pendent upon a fresh proliferation of the epithelial layer, with reduplication of the capsule. Etiology. — Congenital conditions op- erating upon the causation of cataract, which, at times based upon well-founded clinical observation, have been deter- mined to be hereditary in type, prac- tically resolve themselves either into developmental disturbances in the eye or antenatal inflammatory reaction of the organ. Tlie influence of heredity in the pro- duction of cataract traced through sbc generations. In no instance was there any evidence of consanguinity. The transmission was effected by females alone. Fromaget (Gaz. Hebd. des Sci- ences M6d. de Bordeau.x, July 30, '93). Senile change does not produce cata- ract, but predisposes to it; the efficient determining causes are both ocular and general, while the general causes are not particular diseases, but the condi- tions arising in the course' of disease. Jackson (Universal ^led. .Journal, Dec, '93). General disease, independent of senil- ity, particularly if of vascular or lym- phatic type, becomes, at times, a causa- tive factor. Thus, diabetes mellitus is responsible for about 1 per cent, of cases, this variety being bilateral and develop- ing rapidly. Rachitis, nephritis, and some affections of the skin are credited with the production of the condition. Cataract atl'ecting primarily the pos- terior pole and cortex is not uncommon in association with retinitis pigmentosa and other diseases of the pigmentary coat of the eye; but, apart from these conditions, the presence of this variety of opacity of the lens is strongly indic- ative of the presence of some serious interference with proper tissue metab- olism, and, of all such alterations, by far most frequently of diabetes. The special form which the variety takes is that of a rounded central posterior polar opacity, along with the formation of striie in the posterior layers of the cortex, these strise being broad at the equator of the lens, with their apices pointed to the posterior polar region. These strise become broader and broader at the expense of the intervening clear portions, and then the opacity spreads to the anterior cortical layers, and last the central portions become non-trans- parent. The author thinks that there Formative changes in a dcgenenUing lens. {Becker.) is quite a sharp line of distinction into two classes of cataract in regard to this matter. In one, the anterior cortex la affected before the posterior; this is the ordinary senile cataract. In the other the posterior cortex and pole are af- fected first, as described above; this is the form associated with choroidal dis- ease and metabolic anomalies. Klein (Wiener klin.Wochen.,4,5, 1901; Ophthal- mic Keview, April, 1902). Certain tonics, such as ergot and naph- thalin introduced into the system, are eminently causal in character. Local diseases and traumatism fre- quently produce all forms and varieties, CATARACT. PATHOLOGY. PROGNOSIS. especially in changes affecting the Ijmph-stream formation and circulation, and where the solvent power of the lymph-fluids can be made to exert their influence directly upon th,e unprotected and exposed fibres themselves. Influence of astigmatism in the genesis of cataract: in 33 cases of bilateral cata- ract, 20 were found in which the more astigmatic eye first became cataractous, 5 were seen in which the less astigmatic eye was first afl^ected, and 8 in which astigmatism was either absent or equal in the two eyes. Astigmatism should not be considered a cause of cataract, but rather as simply a condition which favors its development. Roure (Recueil d'Ophtal., Jan., '95). Attention called to the frequency of hard cataract in bottle-finishers, who are exposed to the brilliant light and intense heat of a furnace during their working hours. Both eyes are practi- cally always afl'eeted. The disease be- gins early in life and progresses slowly. It usually starts as a posterior polar cortical cataract. The disease can be prevented by wearing dark-blue specta- cles. Six cases are reported. Robinson (Brit. Med. Joui-., Jan. 24, 1903). Pathology. — By most recent author- ity, cataract is said to be, as a rule, caused by a too-rapid sclerosis and shrinkage of the nucleus. As one of the results, a cessation in the growth of the surrounding lens-fibres takes place. These separate from one another at cer- tain places, especially in the area be- tween the nucleus and the cortex, and particularly in the equatorial region of the former, producing fissures or cavities that gradually become filled with an albuminous liquid, which coagulates and produces spheroidal bodies known as the spheres of Morgagni. Later, the lens- fibres which constitute the walls of the fissures become translucent and un- equally swelled, giving rise to large and mostly nucleated vesicles of varying sizes and shapes. After total disintegra- tion of these fibres and cells with their remains has fairly well taken place, the epithelium of the lens becomes abnor- mally thickened, the most peripheral lens-fibres become vacuolated, and the capsule of the organ becomes abnormally separated by the pathological process at work. In contrast to this breaking-down of the cortex, the shninken and hard- ened nucleus, as a rule, remains prac- tically unchanged. In tlie various forms of congenital cataract the course of events may prob- ably be traced in this manner: An in- flammatory process has attacked the difl'erent eyes in varying intensity; the ribbon-like opacity which each cornea bears as an evidence of this is most marked in the eyes with most posterior synechiiE and capsular cataract. Fol- lowing the disturbance in nutrition pro- duced by the inflammatory attack, the capsular epithelium and lens degenerate, and, in consequence of shrinking proc- esses, rupture of the posterior capsule ensues. The gap is filled up by a capsu- lar cataract, and thence arises an ad- hesion of capsule to lens-substance. In one case witnessed occlusion did not take place and the lens-fibres grew out- ward. After the inflammatory process had run its course (and it lasted a vari- able time in the different cases) lens- fibres were developed, the plentifulncsa and quality of which depended on the condition of the epithelium. E. V. Hip- pel (Von Grade's Archiv f. Ophthal., liv, 1, 1902). Prognosis. — The diagnosis of cataract being once established, it frequently be- comes necessary to be able to decide how long it will take for the cataract to be- come mature, or what is known aa "ripe." Tliis is very dilTicult, as the rate of progress is extremely variable. Senile cataracts may require years to be- come sudiciently opaque and hardened for operative interference, while, on the contrary, in a few rare instances, they CATAKACT. PROGNOSIS. have ripened over night. It is gener- ally wise, therefore, if the signs of cat- aract be discovered in elderly persons not to alarm them by telling them of its existence, as vision may not be seriously disturbed for a long time. Particularly is this so in nervous females in frail health. Under all circumstances, how- ever, it is better that the diagnosis be communicated to some responsible friend or relative of the patient. At times, among men especially, those who are harassing themselves with monetary and business affairs, it is best to acquaint them with the nature of the disturbance in order that better hygienic living may be obtained. As a general rule, cataracts in the young, those due to general dyscrasia, and the secondary forms, all develop rapidly. On the contrary, all forms of opacity which commence in the periphery as narrow radii are slower in extension than those in which there are dot-like and broader opacities. In reference to the prognosis of the result of operative interference for the removal of cataract, numerous factors must be taken into consideration. In many cases it is essential to determine the probable condition of the interior of the eye by means of the so-called candle- test. No matter how dense a cataract may be, a patient with a healthy fundus should be able to recognize the position of a candle-liglit placed in all parts of the visual field while the organ is con- stantly directed toward a second candle situated at a central fixation-point. If the moving light be lost at any point in the field, a disturbance of one or more of the ocular tunics may be diagnosed with almost certain precision and the prognosis rendered relatively unfavor- able. If all light-perception be lost, op- erative procedure would be useless. The condition of the appendages of the eye must be noted, and any disease of them should be carefully treated. The state of health of the patient should be good as possible. General dyscrasia and old age do not contra- indicate operative interference, although they render the chances of a successful termination somewhat less. Profound anaemia, depressed mental conditions, and pulmonary complica- tions, on the other hand, are all ex- tremely apt to militate greatly against any operative success. The surroundings of the patient, the cliaracter of the place of operation, the time of year, and the hour of the day must all be taken into consideration. The more aseptic the conditions under which the operation is to be performed, the greater are the chances of a success- ful termination; in fact, this is the greatest of all the prognostic factors. Operations performed in hospitals are much more certain to be successful than those which are performed in private houses. In regard to the effects of the char- acter and the condition of the cataract itself upon the prognosis, the general rule is that the more nearly mature the cataract is, the more certain are the chances of resultant good vision. In some very old subjects, where the nu- cleus of the lens is large and well scle- rosed, extraction may be made with every chance of eventual success. Op- erations upon overripe cataracts are not apt to be very successful. The frequency of fluid vitreous, the degenerate condi- tion of the zonule, and the density of the capsule, all are serious complicating conditions. Reports of 400 extractions of senile cataract by Prof, von Rothmund, of which 25 were complicated: The visual 10 CATARACT. TREATMENT. acuity ■was satisfactory (at least Vw) ^ 63.5 per cent.; 1.7 per cent, ^vere total faOures. Prognosis: while positive re- sponse to the usual tests is in general favorable, it does not absolutely exclude disappointments. Thus, in 1 ease with normal function to ante-operative tests, an old detachment of the retina was found after extraction. On the other hand, 5 cases with complete lack of power to recognize colors resulted in good vision and presented no complica- tions whatever. Of 39 eases of hyper- mature cataract the vision was satisfac- tory in but 18; in 10 eases of adherent cataract the result was satisfactory in 5. Ebner (Miinch. med. Woch., vol. xliv, Jahrg. No. 16, '97). As long as a person has the capacity to read with the fellow-eye, it should be let alone. The moment he is not able to read with the other eye, an extraction should be performed, with the under- standing that almost certainly a subse- quent needling operation of the opaque capsule might be safely undertaken. Dudley S. Reynolds (Ophthalmic Rec, June, '98). Treatment. — The removal of cataract can be secured only by operation. Re- ported instances of its cure by absorp- tion, by means of drngs, or by massage are misleading, and usually emanate from persons or institutions devoted to the purpose of mere monetary gain. It it probable that the temporai7 visual improvement which is, at times, obtained by such patients is due to the instillation of a mydriatic, for, if the opacity be cen- tral, dilatation of the pupil may be ren- dered sufTiciently large to remove the iris from before the clear periphery of the lens, thus permitting vision through the unobstructed portion of the lens. Un- fortunately, however, the improvement, which, at best, is but temporary, lasts only during the time of the effect of the drug. Cataract apparently chocked for eight- een monthB and for two years by twice a day instilling a couple of drops, or applying, ^rith an eyecup for from one to two minutes to the open eyes, 2.5- per-cent. solution of ether iodide, which is readily absorbed. Badal (La Semaine Medicale, Nov. 31, 1901). Three cases of cataract treated by iodide of potassium and sodium wash. These are applied in a cup for a few minutes, with the eyelids wide open, twice a day. By this treatment a cata- ract fails to progress further and re- mains stationary. Badal (Jour, de M6d. de Bordeaux, July 21, 1901). Potassium iodide has a marked effect upon opacities of the crystalline lens, in that it stays their progress. It also promotes retrogression of traumatic len- ticular cataract. Its influence is very slight in traumatic opacities of the cap- sule. L. Verderau (Revista de Ciencias Medicas de Barcelona, Jan., 1903). The development of cataract may be retarded by careful and repeated cor- rection of any existing anomaly of re- fraction and by constant care of the patient's general health. Operations. — There are two opera- tive methods of treating cataract: one by absorption and the other by extrac- tion. The first is applicable to soft cat- aracts only, and is consequently limited to those found in young subjects. It has for its object the bringing of the aque- ous humor into contact with the lens- fibres by means of an artificial opening made in the anterior capsule of the lens. This is accomplished by entering a needle, especially prepared for the pur- pose, through the lower and outer or upper and inner quadrant of the cornea, and incising those portions of the ante- rior capsule of the lens which arc situ- ated opposite the pupillary area. The pupil should have been primarily dilated as much as possible with some eiTicient mydriatic. Care should always be taken, particularly in very young sub- jects, that the capsular incisions are not made too extensively and that they do CATAEACT. TREATMENT. 11 not penetrate too deeply into the lens- structure, in order that the lens-mass may not be disturbed too greatly. General anjesthesia is not necessary. The instillation of a few drops of a 2- per-cent. solution of hydrochlorate of cocaine is sufficient to render the opera- tion painless. The patient should be placed in a recumbent position and the eyelids should be separated either by a speculum or by an elevator and the fin- gers of an assistant. After the proced- ure a few drops of sulphate of atropine should be instilled into the conjunctival cul-de-sac and ice-compresses applied until the eye becomes free from any signs of operative irritation. If no complications arise and there be sufficient reason, the operation can be repeated as soon as the absorption of the loosened cataractous masses seem to have been sufficiently accomplished and the mass itself has become stationary. The incisions in the second and any subse- quent operations may be made more freely, as the danger of swelling of the lens-fibres is lessened, this being due to the diminished volume of the lens-ma- terial. In uncomplicated cases the ab- sorption of the cataractous masses is generally accomplished in eight or ten week's time. It is concluded that: 1. Certain len- ticular opacities, most often situated in the naso-inferior quadrant of the lens, occasionally are practically stationary and may be designated "non-progress- ive." They do not handicap the patient's ocular abilities, and may with propriety be separated from the class to which the name incipient eatjiraet is ordinarily given. 2. Certain lenticular opacities undoubtedly depend on what may be designated "disturbances of the choroid," as apart from active and actual choroi- ditis; and their progress is sometimes apparently checked by measures — optical, local, and general medicinal — which re- store the choroid coat to normality. Such measures do not, however, remove from the lens the opacities which have already formed when the patient comes under treatment. 3. Certain lenticular opacities which appear in association with diabetes mellitus, nephritis, lith- femia, and arteriosclerosis, particularly the last two diseases, are sometimes ap- parently retarded, like those in No. 2, by measures which are suited to the pa- tient's general condition in connection with local and optical therapeutics, but these measures never dissipate the lens lesions already present. 4. The extrac- tion of unripe cataracts is preferable to any of the ordinary operations for ripen- ing cataract. 5. Tliere is no evidence that electricity has the slightest influ- ence in checking the rate of progress of incipient cataracts, or in dissipating the opacities which have formed. 6. There is very insufficient evidence, if any, that massage of the eyeball favorably modi- fies the rate of development of cataract. 7. There are no "specific remedies" for the treatment of cataract, and there is no reliable evidence that drugs exist which cause the absorption of partially or fully formed cataracts. 8. All lenticu- lar opacities, unless the "non-progressive" group, should indicate a thorough in- vestigation of the patient from the gen- eral as well as the ocular stand-point, and the employment of remedies accord- ing to the findings. G. E. de Schwcinitz (Jour. Amer. Med. Assoc, Dec. 8, 1900). The principal complications of the pro- cedure are iritis and secondary glaucoma. The first is supposed to be caused either by pressure or "chemical irritation" ex- erted by the lens-matter on the iris. As a rule, it may be prevented by keeping the pupil well dilated with some power- ful mydriatic or combination of mydri- atics. If the second form of complica- tion appears, the lens-matter should be immediately removed by extraction through a linear incision. In traumatic cataract the patient should be placed in bed as early as pos- sible. Ice-compresses should be applied either constantly or intermittently to CATAKACT. TREATMENT. the eye in order to reduce inflammatory reaction, and atropine slrould be in- stilled at regular intervals to prevent the occurrence of iridic inflammation. Or- dinarily under such plan of treatment, the lens-substance will gradually absorb without any complicating disturbances. The danger of secondary glaucoma with its accompanying symptoms should never be lost sight of, and intra-ocular tension should be repeatedly tested. If such sjTnptoms should intervene, as much of the lens-matter as proper at the time should be removed without delay. This may be readily accomplished by a sim- ple incision through the cornea into the anterior chamber and the soft- ened lens-masses carefully and gently coased out along the groove of a Daviel Bpoon. In operating upon shrunken or mem- branous cataracts, it is not so essential to provoke absorption of the remaining cataractous material as it is to obtain a clear space in the toughened and opaque capsule through which vision can be gotten. The operation is ordinarily performed by means of two needles which are passed rather obliquely through the cornea, one near to the nasal and the other close to the temporal border of the membrane. This done, both are pushed backward into the chosen portion of the opacity, and the points of the instruments separated from one another in such a manner that no traction is exerted upon the iris and ciliary body, thus producing a clear hole in the membranous mass. Complete atropinization of the eye be- fore extraction of cataract is extremely favorable to the successful issue of the operation. Confirmed by a trial of the method in 170 cases. Out of these, pro- lapsus of the iris occurred only in 7 cases, — i. e., 4 per cent., wliile before the use of atropine the percentage of pro- lapsus was 15. Muttermilch (Gazeta Lekarska, No. 9, '96). Simple linear extraction is applicable to the removal of both the soft and the membranous varieties of opacity. It is preferred by many operators to discis- sion, and may be employed in any case where the lens-substance is sufficiently soft to flow through a small corneal wound. The operation is performed as fol- lows: After a speculum has been in- serted, or the eyelids separated by an assistant, the globe is grasped by a fi.xa- tion-forceps, and the point of a kera- tome or the tip of a von Graefe knife is entered into the anterior chamber through the cornea, usually about three or four millimetres from the limbus. If the former instrument is used, it is passed directly through the corneal membrane, but, as soon as its tip enters the anterior chamber, the cutting-blade is laid upon a plane that is parallel to that of the iris. It is then pushed forward until the corneal wound has obtained a length of several millimetres. It is then slowly withdrawn, in order to prevent the aqueous humor from coming away too quickly, with the possibility of a prolapse of the iris. If a von Graefe knife is used, the movements given to the instrument must be very carefully performed, in order to avoid wounding the iris-tissue. A cystotome is passed into the anterior chamber through the same corneal wound, care also being taken to avoid wounding the iris. Free incision in the anterior capsule of the lens is then made with it. After the incisions have been accomplished, the cyslotome is withdrawn, and the loosened lens-matter is evacuated, as previously explained, by means of a Daviel spoon. If necessary, the operation may be done with the addition of an iridectomy. In CATAKACT. TREATMENT. 13 this event, the corneal incision is made nearer the limbus and should be slightly longer. After the withdrawal of the knife, the tips of an iris-forceps are to be introduced into the anterior chamber and a fold of iris directly over the sphincter of the pupil grasped and gently drawn through the wound and cleanly snipped off with a pair of fine scis- sors. Cystotomy and extraction of the lens-massings then follow, a just de- tailed. As it frequently happens that lens- matter is left behind, a number of opera- tors practice its removal by suction- syringes of special construction. The procedure, however, has never obtained general favor. The operation for the removal of a hard cataract consists essentially of three steps: the corneal incision of sufficient size to permit of the passage of the lens; an incision, or a series of them, into the anterior capsule of the lens (cystotomy) in order to allow the egress of the lens- matter through it; and the delivery of the lens-substance from the eyeball it- self. Before the actual operation is made, certain preliminary details should be carefully attended to. A general warm bath should be given to the pa- tient the night before the operation. Care should be exercised to make his head clean with Castile soap and water. The bowels should be relieved by a gen- tle laxative, in order that they may not be disturbed for the first few days after the operative procedure. The instruments, with the exception of the knives, which should be immersed in alcohol for at least twenty minutes prior to their use, should be boiled. After the cleansing has been completed, they should be kept in a tray of alcohol during the entire operation, being dipped for a few moments in a tray of sterile water just as they are being picked up for use. The patient having been carefully prepared and the field of operation having been excluded from external con- tamination for a couple of hours previ- ously by a few turns of a roller bandage, his eyelids, eyebrows, eyelashes, and adjacent parts should be thoroughly washed with a saturated solution of boric acid. The lids should be gently everted and the upper and lower cul-de-sacs flushed with the same character of solu- tion. Several drops of a 2-per-cent. solution of hydrochlorate of cocaine are then introduced into the eyes at five- minute intervals, for about fifteen min- utes before the operation, care being taken that the eyelids are kept closed and that a clean towel is thrown over the field of operation. If possible, the patient should lie flat on his back in the bed that he is to occupy. If circum- stances do not permit this he should be placed upon some form of operating- chair or table. The source of light should be situated so that there shall be a field of uniform illumination upon the exact points to be operated upon. If the surgeon be ambidextrous, he may place himself in front of the patient or behind him in accordance with comfort and existing circumstances. A trained assistant should be present and assume such a position that he may be able to hand the instruments to the surgeon or receive them from him with such skill and rapidity that the operator may be able to keep his vision fixed upon the field of operation during the successive stages. Prior to any procedure it is well for the surgeon to speak kindly and quietly to the patient for a few moments to gain his confidence and at the same time inform him of certain movements of the eyes that may be necessary during 14 CATAKACT. TREATMENT. the operation. He should be cautioned against holding his breath and strain- ing and told to resist all desire to close his eyes forcibly. By these few injunc- tions quietly and authoritatively given, the most intractable patients may be rendered obedient, the soothing words thus given often bearing fruit to the surgeon a hundredfold. All these minor, but most essential, preliminaries being satisfied, the eyelids are to be separated by an elevator held in the hands of a skilled assistant, who is capable, if necessary, to momentarily re- move the instrument without any dam- age to the organ. The patient is asked to look down. The globe is firmly held in any desired position by gently taking a fold of bulbar conjunctiva about two or three millimetres' distance from the corneal limbus within the grasp of a fixation-forceps held with one hand, while with the other the corneal section is to be made. The knife most generally employed is one introduced by von Graefe, which consists of a long, straight, narrow blade converging at its far ex- tremity into a sharp point. Unless contra-indicated, the primary puncture should he made just within the margin of the clear cornea at the outer ex- tremity of a horizontal line, which, as a rule, would pass three millimetres be- low the summit of the membrane. The cutting-edge of the knife should be situated upward and its point directed toward the centre of the cornea. After the tip of the knife has been made to enter the anterior chamber, it should be carried directly across and re-entered into the corneal tissue at the point de- sired. The section should then be com- pleted by an upward movement so regu- lated that the corneal section is kept true and smooth throughout its entire extent. At this stage the elevator, in uncomplicated cases, is removed and not used again. The first stage of the opera- tion being completed, the surgeon next addresses himself to the performance of the second stage, or that of capsulotomy, or so-called cystotomy. Directing the patient to look down and without any fixation-instrument in position, if pos- sible, he introduces a cystotome, with the heel of the cutting-point first, between the lips of the corneal wound, and inserts the point of the instrument into the anterior capsule, without dislocating the lens, in such a manner as to be able to make a series of as free incisions as he may believe desirable and in such po- sitions as he may deem the best. These having been obtained, the cystotome is withdrawn in such a way that the iris is not wounded during the procedure. The avenue of escape for the lens having been made, it remains to practically com- plete the operation by the performance of the third stage, or that of the deliv- ery of the lens. The surgeon should, with the ball of the finger-tip of one hand upon the sclera just below the lower edge of the cornea, and a spatula held in the other hand and placed upon the sclera just above the corneal sec- tion, make a series of delicate, yet steady, upward and forward pressures and coun- ter-pressures until just one-half of the lens has engaged in the corneal wound, when, by a dextrous and slightly tilting and upward motion from side to side, the lens will emerge without any com- plication whatever, and the corneal flap will fall smoothly into place. Should the pupil not be round and should any lens debris be seen, the eyelids are to be closed and a slight gentle rotary motion be made upon the globe through the upper lid by the fingers. If there be any cortex remnants, the stump of the flay) is to be slightly depressed and the CATAJaACT. TREATMENT. 15 masses gently, though as completely as possible, washed out of the anterior and posterior chambers by free irrigation from varying positions with warm sterile water or boric-acid solution without the introduction of any instrument whatso- ever into the chambers. After the lens has been delivered and anything, such as blood-clots and lens debris, which might prevent the proper union of the lips of the corneal wound have been removed, the conjunctival cul- de-sac is to be flushed with a warmed solution of boric acid and the pupil and corneal flap seen to be in proper posi- tions. The eyelids of both eyes are then gently closed and held together, if neces- sary, by one or two narrow strips of isinglass plaster, A few carefully-adjusted and smoothly- applied turns of gauze bandage over squares of sterilized gauze properly cov- ered by pledgets of absorbent cotton should be made without disturbing the patient. Strict injunction to remain quiet for at least twenty-four hours' time should be given, any necessary desires being properly cared for by competent attendants. Case in which destruction of the eye by htemorrhage followed the extrac- tion of a cataractous lens, which had been dislocated downward, and which was safely removed by simple extraction without the use of a wire loop or of fixa- tion of the lona. A few minutes after the operative procedure tlie patient com- plained of severe pain in the temple and back of the head. An examination re- vealed the presence of a copious hsemor- rhage from the corneal wound, which was at once controlled by placing the patient in an upright position. There was a deep glaucomatous excavation in the other eye, but at no time coidd any hfemorrhages be observed in the fundus. Jackson (Annals of Ophthal. and Otol., Jan., '94). The chief factor in the causation of ocular hemorrhage after extraction is an increase in the blood-tension. Mi- croscopical examination of an eye, which was lost as a result of such an accident, showed that the choroidal and retinal vessels had very much thickened walls and that there had been a classical total retrochoroidal htemorrhage. The hism- orrhagic extravasation seemed to have originated at the entrance of the pos- terior ciliary vessels in the posterior and external regions of the choroid, and did not occur untU three days after the extraction of the lens. Terson (Archives d'Ophtal., Feb., '94). An instance of destructive hoemorrhage during extraction of a cataract: The patient was a female 82 years of age. The liquefied state of the cortical sub- stance, tlie presence of cholesterin crys- tals in the lens, the sagging downward of the lenticular mass, the tremulous irides, and finally the very fluid vitreous, all gave indications of degenerative proc- esses which had occurred in the eyes be- fore opacity of the lens had taken place. In this case the prolapse of vitreous fol- lowed immediately on the section, and a hiEmorrhage appeared instantly after the delivery of the lens. Eisley (Annals of Ophthal. and Otol., Jan., '94). Case of double cataract extraction fol- lowed by haemorrhage, with subsequent restoration of vision : The subject was 71 years old, and in a very poorly nourished condition. He was a sufferer from vari- cose veins over the whole body and ex- hibited other evidences of vascular dis- ease. Gasparrini (Annali di Ottal., Oct., Nov., '94). Intra-ocular hiemorrhage. with subse- quent shrinking of the globe, following cataract extraction in a woman, 78 years of age, with degenerative heart disease: The patient died about eight months later from angina pectoris. Lee (Prac- titioner, June, '95). Five cases in which no cause could be assigned for the htemorrhage: There was no want of smoothness in the course of the operations except in one case, and this was so slight as to be ordinarily of no significance. Suggestion was made that a preliminary iridectomy is prob- ably a valimble measure in these cases, 16 CATARACT. TREATMENT. and when done such have been reported as successful. Wadsworth (Boston Med. and Surg. Jour., Sept. 3, '97). Choroidal hemorrhage after cataract extraction is by no means so rare as has been thought. Over 50 cases have been reported, and many remain unpublished. It is due solely to the diathesis of the patient, the principal cause being an atheromatous condition of the vessels, or an abnormal tension of the eyeball, suddenly reduced by the incision in the cornea and the outflow of aqueous. When such a haemorrhage occurs the best treatment is to raise the patient's head, to relieve the pain, and to watch the eye carefully, at the same time being prepared to perform enucleation as early as possible. J. A. Spalding (Archives of Ophthal., vol. XV, No. 1, '97). Local changes in the choroidal veins predispose to post-operate hemorrhage within the eye. Bloom (Graef's Ar- chives, July 19, '98). If no pain be complained of, the dress- ings should be allowed to remain for twenty-four hours, at the end of which time they should be removed, the eye inspected, and the conjunctival cul-de- sac gently flushed with a solution of boric acid. If all has gone well it will be found that the anterior chamber has re- established itself and that the eye is quiet. If there be any injection, if the pupil is small, or if any sign of inflam- matory reaction be present, a drop or two of sulphate of atropine or, better, hydrochlorate of scopolamine should be instilled. At the end of forty-eight hours' time the dressing over the sound eye may be removed, but that on the operated eye, which can be made lighter, should be allowed to remain for another day, when plain smoked glasses or, if unobtainable, a suitable shade can be worn. To prevent tendency to prolapse of the iris and to favor smooth healing of the corneal incision, it is essential that the patient should rest absolutely quiet in bed for the first forty-eight hours. If he be old and feeble, more latitude can be given to his movements, which must be accomplished by the aid of careful attendants. At the end of the second day, a bed-rest may be em- ployed, and on the third day, if the healing has been uncomplicated (which under the circumstances will be so almost without exception), the patient may be allowed to sit up. For the first twenty- four to forty-eight hours the diet, which is to be regularly given, should be liquid and semisolid. On the third day the bowels can be opened by a gentle laxa- tive. After this, liberal nourishment may be ordered. Although reelination of the lens in the very aged at one time was largely employed, and is still to some extent, personal observations at Hirschberg's clinic has shown that e.xtraction is, after all, the most feasible procedure, even very late in life. The author's observa- tions embrace 1645 cases of nuclear cataract, among which there were 36 patients over 80 j'ears of age. Only in 2 cases were the results not entirely satisfactory. Advanced age does not, therefore, offer an unfavorable progno- sis for cataract extraction. In very restless patients general anajstliesia may be employed. Delirium will occasionally occur, but the most serious complica- tions are those related to the heart, lungs, and bladder. In one case heart disease gave rise to piilmonary oedema, which, however, was controlled by mor- phine. Mendel (Berliner klin. Woch., Aug. 12, 1901). The operation which has just been de- scribed is what is known as simple ex- traction, or extraction without iridec- tomy and is the one that is ordinarily in use to-day and should be the one chosen in all suitable cases in which there are no contra-indications. One hundred consecutive extractions; extraction without iridectomy preferred ; Knapp's method of making the cap- CATARACT. TREATMENT. 17 sulotomy followed. Discission resorted to in 88 per cent, of private eases and CO per cent, of liospital cases, tlie operation being performed about three weeks after extraction. No cause to regret the ex- traction of an immature cataract. Weeks (N. Y. Med. Jour., Aug. 3, '95). Study and comparison of 1032 cases of combined extractions and 1123 cases of simple extractions: Conclusion that the simple method extraction is far superior to all others in the very great majority of eases, and that, while it is a somewhat more dilBcuIt operation than the com- bined method, any experienced surgeon will find the results proportionately greater. King (Med. Rec, Feb. 23, '95). Details of 1519 cases in which the operation of extraction was performed during the five years,— 1889 to 1893 in- elusive,- — in the practice of eleven dif- ferent surgeons: Extractions with iri- dectomy, 1091, as against 276 in which simple extraction was performed; while 161 had an iridectomy done some weeks at least before the cataract was removed. The percentage of successful cases only amounted to 83.78, and 13.51 had no useful vision. Of all the 1519 cases the percentage of enucleation after extrac- tion amounted to 1.90. Although nee- dling is, as a rule, such a simple proced- ure, yet many cases subsequently do badly. Glaucoma occurred in 2.08 per cent, of the cases after secondary opera- tions on the capsule, while it occurred in only 0.42 per cent, of cases after extrac- tion, r. Devcroux Marshall (Royal Lon- don Oplithalmic Hospital Reports; Uni- versal Med. Journal, Mar., '96). In looking over notes of between 500 and GOO personal cases, the most success- ful cataract operations have been those in which it was possible to extract the lens in its capsule and without an iri- dectomy. In 118 of s\ich cases only 3 eyes were lost. The next best lot of cases are those in which the lens was extracted in its capsule after an iridec- tomy; out of 91 of tlicse cases only 3 eyes were lost. B. H. Gimlctte (Indian Lancet, Apr. 16. '98). Case of a woman, aged 35 years, who was nearly blind. The right eye was undeveloped and there was a capsulo- cretaceous cataract in the left eye. A very large flap was made and a large iridectomy was performed as a first operation. Thirty-seven days after the first operation the cataract, which was found to be more capsular than creta- ceous, was removed. Five years after the operation the patient reads the newspapers without glasses; the vision Vo> and she wears a 4 or 5 '/j D. for dis- tance. E. L. Parks (Boston Med. and Surg. Jour., Jan. 10, 1901). Depression of the lens in cataract is indicated in some instances notwith- standing the brilliant results obtained from extraction by modern methods. The classes of eases to which this ap- plies are those in which conditions are present which render it doubtful whether any operation should be undertaken. For example: 1. Those who are greatly enfeebled by age and other infirmities. 2. Where physical obstacles to extrac- tion are present: e.g., small palpebral fissures, small eye, and deeply set in the orbit. 3. Chronic conjunctivitis and dac- rj-oc^'stitis. 4. Considerable degree of deafness. 5. In the insane. 6. Chronic bronchitis. 7. Fluid vitreous, with tremu- lous iris. 8. Where extraction has been unsuccessfully performed in one eye. 9. In the htemorrhagic diathesis. Power (Brit. Med. Jour., Oct. 26, 1901). In 1000 consecutive cataract ex- tractions performed on 864 patients, of whom 130 had both eyes oper- ated, obtained good results (vision from V« to %«) in 89 per cent.; in- different (vision poor, but sufficient to enable the patients to go about alone) in 5.7 per cent.; failures in 4.5 per cent. Of the failures, 3.6 per cent, were diie to sepsis, the others to intraocular liiemorrhage. iritis in 2 cases, iridocyclitis in 1, and delachetl retina in 1. Of these 45 failures. 20 had been done with iridectomy and 19 with- out. The indifferent results (5.7 per cent.) were due to various causes, such as sepsis, opaque cortex, iritis, glau- coma, overripencss, mercurial cloudiness, vitreous prolapse, and so on. Of 351 pa- tients from whom family histories were obtained, in S4, or nearly 24 per cent., parents and other relatives had had eat- 18 CATARACT. TREATMENT. aract. ilaynard (India Medical Gazette, Feb., 1903)". Many operators, however, still make use of an iridectomy before tliey expel the lens, justly claiming for this method that it enables them to get rid of any remaining cortical matter much more readily. They also state that it prevents prolapse of the iris and that the lens may be extruded through a small^^ wound. Those who prefer extraction without iridectomy urge that the advantages of a round, mobile pupil make it the opera- tion of choice. The contra-indications are: an unripe cataract, increased intra- ocular tension, a small rigid pupil, and an intractable patient. Despite the most careful precautions, prolapse of the iris does occur in a few case of simple extraction, usually ap- pearing during the first twenty-four or forty-eight hours. If it be small, it may be let alone. If it be considerable, and the lips of the wound remain ununited, the line of corneal incision may be opened and the prolapsed portion of the iris excised with an iridectomy-scissors. Should the prolapse occur after the wound has united, it is best either to wait until about the tenth day, when a formal iridectomy can be made, or, if not productive of any irritation and the pupil is not much distorted, it can re- main undisturbed, cicatrization and flat- tening subsequently taking place. Conclusions readied from study of last 70 cases operated for secondary cataract are that in 9.5 per cent, of all cases dis- cission is to be preferred to all other methods of handlinfj secondary cataracts. In the 70 eases improvement of vision was observed in (54, in 5 it remained the game, and in 1 it was somewliat reduced. Discission is justifiable, but there should not be the slightest pulling or tearin,;? with the discission-needle. The knife- needle to cut with, and an ordinary dia- cission-needle to fix with, are the safest precautions against secondary glaucoma after such procedures. Knapp (Trans. Amer. Ophth. Soc., '98). In certain cases in which complica- tions are feared, or when it is advisable to hasten the maturity of the cataract, an iridectomy known as preliminary iridectomj', can be performed some time before the extraction of the lens is made. If it is desired to ripen the lens after the iridectomy has been performed, the lens may be triturated with a spatula either directly applied to the anterior capsule or indirectly through the cornea. Rapid swelling and opacification of the lens is said to follow these procedures, and the extraction in many cases is made pos- sible in several weeks' time after the operation. The lens-substance, how- ever, in these cases seem to have obtained an undue degree of friability, which may be detrimental to the complete re- moval of the lens-substance. Some operators have adopted the method of syringing the anterior cham- ber after the removal of the main body of the lens, in order to remove any re- maining cortical matter. As this plan, however, entails the bringing of another instrument, which may be an additional source of infection, into the eyeball, and is always attended by more or less local reaction, its disadvantages seem to be so many that its employment has never be- come general. Details of last 400 personal operations: Incision entirely in the margin of the transparent cornea, in a plane parallel to that of the iris, and with a small con- junctival flap. Corneal incisions tend to be complicated by adlierenee of the iris and by keratitis; more peripheral in- cisions are disturbed by prolapse of iris and cyclitis. The conjunctival flap pro- tects against infection of the wound: a matter of great importance in countries CATARACT. TREATMENT. 19 where conjunctival and lacrymal affec- tions are common. The opening in the capsule is made with a cystotome, be- hind the upper part of the iris near the equator of lens, and is six or seven milli- metres in extent. Tlie lens is expressed without introducing a spatula; no in- strument of traction is employed even in complicated cases. Reposition of the iris is made bj' means of a sound or stylet that is slightly curved. Binocular bandage is used. The patient need not be kept in bed. The dressing is changed after twenty-four hours, sooner if neces- sary; minute inspection of the ej-e and of the wound; immediate ablation of any prolapse of iris. Knapp (Annales d'Oculist., Oct., '97). Entire absorption of cloudy lens or capsule-remains may often be accom- plished by the use of from 5 to 15 grains of potassium iodide three times daily for several weeks after extraction. Wicherkiewicz (Woch. f. Therap. u. Hyg. d'Auges, Sept. 8, '98). In order to prevent secondary cataract, the lens is, at times, removed in its cap- sule. This is accomplished by deliver- ing it by a spoon or a loop, after an iridectomy has been performed, without the performance of a capsulotomy. As the operation is, at times, attended by loss of vitreous humor, it is not fre- quently employed. Many of the accidents occurring dur- ing cataract extraction are the results of want of skill. In some instances, how- €ver, it happens that the patient's con- dition is such that a successful result can scarcely be expected. Deafness, loss of self-control, and great stupidity ■are all harmful and even injurious at times. Although planned with the utmost ■exactness, it sometimes happens that the size of the lens is misjudged and the normal corneal section is made too small. If tliis occurs, the incision should be en- larged by one or two clean snips with a scissors. Should prolapse of the vitre- ous humor take place during the deliv- ery of the lens, an iridectomy had better be carefully done and the lens removed with a loop or a spoon. Prolapse of the vitreous humor occurring after the ex- traction of the lens is much less serious for the time being. It interferes, how- ever, with tire proper coaptation of the lips of the wound and renders inflam- matory action more liable, while in many cases it becomes a most harmful com- plication for the future welfare of the organ. Usually there is some discomfort for several hours after the operation. Should this continue and be at all marked, the bandage should be removed and the eye inspected. At times great relief will be given by gently pulling down the lower eyelid and giving exit to an accumula- tion of tears or by allowing a faultily placed eyelash to escape into proper position. If the eyeball appears the least injected and the slightest signs of iritis be present, atropine should be im- mediately instilled into the conjunctival cul-de-sac. Suppuration may appear, usually taking place before the third or fourth day, and is traceable to infection, generally from lacrymal disease. In a few instances it is dependent upon a lack of nutrition to the eye. If it is due to the former, it is best combated by cau- terization of the edges of the incision, the instillation of sulphate of atropine, the use of hot compresses, and attention paid to the general health. An eye whose lens has been removed is termed aphakic, and, in order that its vision may be useful, it must be pro- vided witli an artificial lens correspond- ing in relative strength to the crystalline lens that has been removed, plus a cylin- drical one to correct any astigmatism resulting from cicatrization of the cor- 20 CEREBRAL ABSCESS. neal incision. To this artificial lens must be added a convex spherical one of two or three dioptres' strength for use during near work. As cicatrization is usually not completed until four to six weeks after the operation, it is better to postpone ordering glasses until at least that time. Corneal measurements after extraction of cataracts: Conclusions from an ex- amination of 59 cases: — 1. Two weeks after the flap-extraction of cataract there is corneal astigmatism varying from 1.75 D. with rule to 22.0 D. against rule. 2. The greatest amount of this astig- matism disappears in the following four to six weeks. 3. It is slowly reduced for six months, after which it seems there are no further changes. Bearing these facts in mind, it is evi- dent that an accurate estimation of the ultimate glasses cannot be made at the end of two weeks. A. 0. Pfingst (Ar- chives of Ophthal., July, '96). Case of extraction of cataract in which union was delayed for twenty days. It finally took place, however, with good vision. G. C. Harlan (Trans. Amer. Ophth. Soc, '98). Analysis of a series of 500 consecutive operations for primary cataract, per- formed between June 22 and November 2, 1901, a period of nineteen weeks, in the Government Ophthalmic Hospital, at Madras. All but 30 of these operations were done on the Saturdays of this period, making an average of 27 opera- tions for each operating day. On an average of from 12 to 10 patients were operated upon in an hour. In making a section in the sclero-corncal margin, the author endeavors to graduate the section according to the size of the lens. Each patient was inspected and dressed daily after the operation. As little in- terference with the parts as possible is made after operation. Atropine is used as a routine measure on the third morn- ing after operation, provided there is no centra-indication; the sound eye is un- bound on the fifth morning, the eye operated upon is released on the seventh day if all is going well, and the patient is discharged at this time to report as an out-patient. Stress is laid on the importance of treating any complication that may be present prior to operation. This applies even to slight congestion of the conjunctiva. The author presents an interesting analysis of the complica- tions and of the results obtained in these cases, and closes with the warm commendation of McKeown's irrigating apparatus, Which, he states, reduced the vitreous losses in this series to 2 per cent.; by emptying the capsule and chamber of debris it has minimized the need for subsequent eapsulotomy and has enabled the author to dispense with the introduction of instruments into the eye after the escape of the nucleus; it is of great value in clearing the cham- ber of fluid; by gently and evenly re- placing the iris, it has been most valu- able and it has expedited recovery, inas- much as it has left behind so little cortex to be absorbed; another advan- tage which it possesses is that of ren- dering operation possible in very imma- ture cataracts. Elliot (Lancet, Nov. 8, 1902). Chaeles a. Oliver, Philadelphia. CATAREH, NASAL. See Nasal Cavities. CATAREHAL BRONCHITIS. See BnoNCiirris. CATARRHAL LARYNGITIS. See Laryngitis. CATARRHAL Pneumonia. PNEUMONIA. See CEREBELLITIS. See Encephalitis. CEREBRAL ABSCESS. Definition. — Ccrcljrii] abscess is a focal siipjiuralive enceplialitis affecting either the gray or white matter or both. The abscess may be single or there may be several separate foci of suppiirafion. (See, also. Encephalitis.) CEREBRAL ABSCESS. SYMPTOMS. 21 Symptoms. — The symptoms may be of acute rapid onset or they may develop slowly and insidiously during several weeks or even months. Clinically the symptoms are divisible into those which are general and those which are local or focal, the former being those of general diffused cerebral compression or irrita- tion, the latter representing perversion or interruption of motor, sensory, or special function, varying according to the anatomical site of the abscess. Among the general symptoms which are most common are headache and lassi- tude, perversion of the intelligence and the emotions, disturbances of sleep and of consciousness, vertigo, vomiting, con- vulsions, and sometimes optic neuritis. These general symptoms will vary some- what in degree and character, according to the mode of onset. When the abscess produces symptoms rapidly the headache is more intense; as a rule, there is a more active or decided involvement of intelligence and consciousness, some- times manifesting itself in acute delir- ium or in profound somnolence or semi- coma; there may be rigors, with an abrupt and decided rise of temperature, and the whole picture suggests an active meningitis from which, indeed, it may be, and often is, difficult to distinguish it. General convulsions are not uncom- mon in cases with acute onset. When the symptoms are of slow gradual devel- opment they are usually much less in- tense in degree. The headache is rela- tively mild; the vertigo may be slight; vomiting may be absent or occur only rarely; instead of somnolence or coma there may be simple apathy, and a state of simple mental confusion with irrita- bility may appear instead of delirium. The temperature in such cases is usually normal or subnormal; occasionally those patients will exhibit periods of remis- sion attended with a very dangerous semblance of well-being and comfort. Sooner or later the disease becomes ag- gressive, and evidences of focal disturb- ance may be observed by which the site of the abscess may be determined. These focal symptoms will vary, as has been stated, in accordance with the function of the brain-area affected by the abscess. There are several methods of approach — short-cuts, so to speak — to a considera- tion of the focal symptoms. Brain-ab- scess is apt to develop in certain areas according to the cause with a constancy which is of decided value in localization. When due to an extension from ear dis- ease, for example, the abscess is nearly always found in one of three localities: the temporo-sphenoidal lobes, the cere- bellum, or the pons-medulla region. More than half of all cases are located in the temporo-sphenoidal lobes or the cerebellum. If the pus enters through the medium of a secondary phlebitis of the lateral sinus the abscess will quite probably be found in the cerebellum. If the pus enters the superior petrosal sinus it will be found in the cerebrum and probably in the temporal lobe. When caused by trauma the abscess usually bears some relation in its location to the site of the trauma, though sometimes the pus-formation is at a remote part of the brain from the seat of injury, as, for ex- ample, in the occipital lobe, the blow having been received over the frontal region. Cerebral abscess, when due to necrosis or disease of the bones of the face, is frequently located in the frontal lobes or at the base; when from syphilis or tuberculosis, its site is, as a rule, the motor convexity, the base, or the cere- bellum. Pya?mia and other constitu- tional infections are apt to induce multi- ple abscesses, which seem rather prone 22 CEREBRAL ABSCESS. SYMPTOMS. to develop in the distribution of the middle cerebral artery of the left hemi- sphere. The data of cerebral localiza- tion should be applied in determining the site of the abscess in .each instance. The principles of localization in cases of uncomplicated brain-abscess located in actiye regions apply with unusual con- stancy, the diffusion of symptoms being less than in tumor, hemorrhage, or any other focal disease. It should not be forgotten, however, that brain-abscess occurs occasionally without any apparent focal symptoms at all, and sometimes, indeed, with very few general sjinptoms, the diagnosis being a post-mortem revelation. Analysis of 1G9 cases, including 6 per- sonal. Of this number, 98 were cases of abscess proper, and of these 40 were located in the temporal lobe and 31 in the cerebellum. Localizing sjTnptoms were found, in a large proportion of cases, conspicuous by their absence. As to subnormal temperature, in only 2 cases of these 98 was the temperature below normal. The most constant altera- tion of temperature was a moderate ele- vation. Aphasia was present in only 6 of 40 cases, involving the temporal lobe, many of them on the left side. Frank Allport (Jour. Amer. Med. Assoc, Oct. 22 to Dee. 24, '92). While in many cases an acute abscess of the brain may be diagnosed with some certainty, a chronic cerebral abscess may exist and yet give no positive indication of its presence. Too often the condition is only discovered by postmortem exami- nation. The diagnostic indications of a chronic abscess of the brain are few and untrustworthy. Of first importance among such indications is the presence of a sufTieicnt cause, such as middle-ear disease, local injury, or caries of the cranial bones. Not that the exciting cause need be so grave as these; the absccHH may follow any of the specific fevers, and, as these occur so very frcfiuenlly without leaving any such gequcloe, the connection may not be rec- ognized. The signs of a chronic cerebral abscess are few in number, — pyrexia, lieadache, and optic neuritis, — but none of these can be depended on; pyrexia is often completely absent, and, as Murri points out, in many cases a subnormal temperature is present; the headache, if localized and persistent, and occurring after one of the usual exciting causes, is suggestive, but nothing more; and optic neuritis may equally be a sign of a, tumor or meningitis. Other symptoms such as paralyses, though often of use in determining the situation of a lesion, are of no value in deciding as to its nature. If we have in any case a suf- ficient cause, and the signs already men- tioned are well marked, we may be fairly confident that an abscess is present, but we cannot be at all certain. Augusto Murri (Lancet, Jan. 5, 12, 26; Feb. 2, '95). Study of 32 cases, 13 of which were in children under one year of age, 9 of these being under six months and 5 under three months; 3 occurred during the second year, and 5 each in the third, fourth, and sixth years, no case being included in which the patient was five years old or over. Conclusions: In a large proportion of the cases only general symptoms are present, and these in very great variety. Focal symptoms may be misleading un- less they are constant; and even then they may depend upon associated lesions, s\ich as meningitis. Motor symptoms only can be trusted, since the sensory symptoms are difficult or impossible to determine in infants or young children. L. E. Holt (Archives of Pediatrics, Mar., '98). Report of 2 cases of abscess of the brain due to the pneumococcus, and 7 cases from literature. The first per- sonal case occurred some weeks after recovery from an attack of bronclio- pneumonia. Vertigo, transitory loss of consciousness, cramps and pain in the right arm, followed by contractures and involuntary movements were first noted. Within a few days tliere was complete right hemiplegia and rapid death from coma. At the autopsy slight hepatiza- tion of the lungs was found, but no CEREBRAL ABSCESS. DIAGNOSIS. 23 bronchiectasis, suppuration, or gan- grene. An abscess was found in the left parietal lobe, destroying part of the corona radiata, and extending immedi- ately under the meninges, which were inflamed and suppurating. The pus from the abscess contained a large num- ber of Fraenkel's diplococci, together with chains of streptococci. The second patient complained of joint pains, suf- fered from delirium, and died within a few days of the onset of illness. Hepa- tization was found also at the bases of both lungs. A small abscess was found in the corona radiata of the left hemi- sphere under the lower part of the as- cending parietal convolution, the pus of which, as well as the meningeal e.xudate, contained Fraenkel's diplococcus, to- gether with staphylococci and strepto- cocci. In only one of the 9 cases recorded was the pneumococcus the only organism found. Boinet (Rev. de M6d., Feb. 10, 1901). Diagnosis. — Ordinarily it is quite ap- parent in patients suffering from cere- bral abscess that some affection of the brain exists. It is by no means so easy always to decide that the symptoms are due to abscess. The diseases which most often confuse the diagnosis are menin- gitis, tumor, and sinus-phlebitis. The difficulty encountered in differentiating brain-abscess from sinus-phlebitis and meningitis is increased by the fact that the same causes may operate to produce either of them. This is especially true of trauma and the various infectious dis- eases and also of disease of the internal ear, though the latter points to abscess rather than meningitis or phlebitis. In all three the temperature is affected, but it is usually above normal and sometimes quite high in meningitis and phlebitis, while it is either below normal or quite irregular in abscess. Although almost all observers agree that subnormal temperature is the rule in brain-abscess, it must not be depended upon. Case in which the temperature reached to 105° or lOG" F., and was so irregular as to suggest pyaemia and thrombosis of the lateral sinus. Again, much stress is laid upon the presence of a cerebellar gait, yet this was often the result of irritation of the auditory nen-e or of irritation of the semicircular canals. Optic neuritis is sometimes present, but not often, probably because there was no time for it to develop. JI. Allen Starr (Med. Rec, Dec. 11, '97). Cerebellar abscess may be distinguished from labyrinthine disease by its more violent headache, its persistence, and its location; and by the somnolence which increases from day to day. In abscess of the temporo-sphenoidal or occipital lobes of the cerebrum there are motor affections, paresis, contractures, spasms, but always on the side opposite to that of the lesion or the otitis; and aphasia and hemianopsia are important signs. In glioma, gliosarcoma, tuberculoma, and parasitic tumors of the cerebellum there is a tendency to produce other than local symptoms. Syphilis must always be carefully sought for in the history. Dieulafoy (Le Progres Mfd., .June 30, 1900). Abscess may be present for a consid- erable time without giving rise to any symptoms; there may be no car compli- cation ; twitchings, drowsiness, mental inactivity, which are often present, are apt to be attributed to renal disease. Another symptom, which was prominent in personal cases, was extreme emacia- tion, which, to the ordinary practitioner, is only too liable to suggest only tuber- culosis or malignant disease. Burnet (Practitioner, June, 1903). In meningitis the onset is usually more acute, the symptoms more diffused, the delirium is more conspicuous, the tendency to rigidity and generalized spasm is more marked; there is photo- phobia and a state of wide-spread cuta- neous hypera?sthesia with accelerated respirations and irregular, high pulse. Focal symptoms are less -common in meningitis e.xcept in cases affecting the base, when the number and degree of involvement of craninl nerves is more marked than in cerebral abscess. If the 24 CEREBRAL ABSCESS. DIAGNOSIS. meningitis is localized and circum- scribed, I do not believe it is possible to make the difYerentiation positively. Tenderness of the skull over the site of the disease points to abscess rather than meningitis in such cases. Traumatic brain-abscesses may be con- founded with traumatic meningitis, apo- plexy, encephalitis, tumor, epilepsy, and traumatic neuroses. A one-sided trau- matic apoplexy or a hsemorrhagic non- purulent encephalitis may, from symp- toms alone, easily be taken for abscess. Suppurative meningitis occurring with an abscess is likely to be overlooked. An abscess of the brain is marked by normal or subnormal temperatures; fever is by no means a necessary symptom. If an attack begins with a rise of tempera- ture, it is probably not due to an ab- scess of the brain, certainly not to an uncomplicated one. A slow pulse is, per- haps, the most reliable single symptom. Patients suffering from ear troubles often become hysterical, and a hasty diagnosis of hysteria, even if the typical symptoms are present, may falsely be made in cerebral abscess of the otitic origin. Oppenheim (Fortschritte der Med., Nov. 15, '90). Symptoms of brain-abscess due to middle-ear suppuration based on 195 cases. It occurs most frequently in early middle life. Out of 175 cases in which the sex was stated, 122 were males and only 53 were females. In 181 cases of temporo-sphenoidal abscess 85 occurred in the right hemisphere and 90 in the left. Tlie variations in the temperature show no characteristic feature, normal or subnormal, a slight or even a considerable rise being vari- ously observed, the complications, such as meningitis or sinus-phlebitis, account- ing for these. The uncomplicated must be separated from the complicated be- fore positive deductions can be drawn. The temperature variations noted in 170 cases were: Normal, 40; elevated, 100; subnormal, 18. In cases of uncompli- cated brain-absccHH tlie temperature is raJBcd in about one-half. Chills are not frequently noted. The most frequent of the cerebral symptoms is headache, which was present in 103 cases. Stiff- ness of the neck was noted 12 times, and general convulsions 10 times. Gen- eral headache is valueless as a sign, but localized headache and tenderness are of some diagnostic importance. It seldom declares itself, however; in 28 cases it was on the same side as the abscess, while in 14 other cases tenderness in tue temporal region of the same side was complained of. Disturbance in cerebra- tion occurred in more than one-half of the cases. Mental symptoms were rare, and the sensory disturbances ranged from a slight form of slow cerebration to loss of consciousness and coma, which occurred in 74 cases. Even heavy stupor did not adversely influence operative procedure. The pulse was slowed in 73 instances. In GO cases changes in the fundus were noted. As to localized cerebral symptoms, aphasia occurred 53 times in a total of 90 abscesses of the left temporo-sphe- noidal lobe. Hemianopsia was met mth times. Motor disturbances on the op- posite side, whether of the nature of paralyses or as unilateral convulsions, were noted in 70 cases. Hammerachlag (Monats. f. Ohrenh., Jan., 1901). The principle employed in the urethro- scope and other instruments for illumi- nating cavities applied to an instrument devised by tlie writer, i.e., the "encepha- loscopc," by means of which one is able to readily diflerentiate between an acute and chronic brain abscess. The clinical value of the instrument is threefold. One can determine accurately: (1) wlictlicr an abscess-cavity is completely cviicuatcd, (2) tlie presence of bands of adhesions which obstruct drainage, and (3) whether the abscess-cavity is acute or chronic. The differentiation is made on tlie difference in tlie appearance of tlic walls of the cavities, which the author describes at length. Wliiting (In- tcrnat. Jour. Surg., 8ci)t., 1003). In sinus-phlebitis the swelling back of the ear with tenderness on pressure and a cord-like hardness of the jugular at times will determine the nature of the CEREBRAL ABSCESS. ETIOLOGY. 25 condition with little difficulty. Within the past year lumbar puncture has found some favor as a means of differentiating abscess from meningitis and sinus- thrombosis. If the fluid withdrawn is clear and does not contain micro-organ- isms the disease is probably meningitis. Excess of leucocytes also indicates men- ingitis. The diagnostic value of lumbar puncture is, however, exceedingly prob- lematical as yet, and promises to remain 60, in the opinion of the writer, so far as brain-abscess is concerned, for a very in- definite future. Most of the cerebral complieationa ob- served occur in connection with chronic cases of suppurative otitis media. One should be chary, however, about making a diagnosis of brain-abscess in these cases on the first appearance of cerebral symp- toms; it is better to watch the case for two or three days before deciding, as not infrequently apparently serious cerebral symptoms gradually disappear as a free discharge from the ear is established. Above and back of the car is the region of the brain concerned in the storage of the memories of the sounds of words. If this part of the brain is injured, the person becomes unable to understand what is said to him. Again, everything that we call to mind by our visual sense employs the function of the occipital lobe of the brain: the visual centres. The connection between the hearing-centres in the temporal lobe and the visual centres in the occipital lobe is made by a long tract lying under the cortex of the brain: a distinct associa- tion-tract. When this tract is destroyed, as it often is in abscess of the temporal lobe, if one ask such a person what some object is that is held up before him, he recognizes the object, but cannot call it to mind and name it, because of the destruction of this jissociation-tract. This peculiar lack of association is an important symptom to elicit in cases of suspected abscess of the temporal lobe, yet it is not commonly mentioned in te.\t-books. M. Allen Starr (Jlcd. Rec, Dec. 11, '97). Conclusions that in children the rapid progress, fever, and a history of injury or otitis generally make a diagnosis from tumor easy. In the slower cases, in which there is little or no fever, valuable assistance may be obtained from lumbar puncture. From acute meningitis the diagnosis is more difficult, and in the cases in which there are only terminal symptoms tlie diagnosis is impossible. In the more protracted eases the distinctive points with reference to abscess are the slower and more irregular course and, as a rule, a lower temperature. L. E. Holt (Archives of Pediatries, Mar., '98). In a case of pycemia of the sinuses accessory to the brain, or with a history of trauma with rapid loss of flesh and strength, the presence of a high tempera- ture for a period of seventy-two hours, followed by a decline in temperature and an increase in the rapidity of the pulse, with pronounced flexure of the ex- tremities, progressive increase in the dilation of the pupils, a half-unconscious condition with uncontrollable restless- ness, peculiar indisposition of the pa- tient to obey requests, the presence of sugar in the urine, slow respirations, tendency when standing to go toward one side, or swinging of the hands always toward one side, and the entire absence of paralysis, comprises a set of symptoms indicative only of abscess within the cerebellum. L. J. Hammond (Archives of Pediatrics, June, '99). The symptoms of brain abscess divided into three groups: 1. Symptoms due to deep-seated suppuration. 2. SjTuptoms due to increased intracranial pressure. 3. Focal symptoms. The surgeon sees only those cases in which the diagnosis is easy and the results are good, while the neurologist sees all, the doubtful and the fatal cases, and is not quite so sanguine as to results. Hoppe (.Jour. Amer. Med. .\ssoc.. Mar. 14. 1903). Etiology. — Abscess of the brain is always a secondary condition dependent upon the intracranial invasion of micro- organisms from adjacent or remote sources of infection. Anv one of the 26 CEREBRAL ABSCESS. ETIOLOGY. pus-producing micro-organisms may act as an exciting cause. The atTection may occur at any age, but is most frequently observed in adolescence and middle adult life. It is rare in very young children (Holt) and in old age. Males are more often affected than females in propor- tions varying from 3 to 1 to 5 to 1 ac- cording to the observer. By far the most frequent source of infection is purulent disease of the middle or internal ear. More than a third of all cases originate from this source (Pitt). Cerebral ab- scess is far more common from chronic than from acute suppurative disease of the ear. This fact has been established beyond question by an analytical study of several thousand cases (Jansen). It was formerly admitted that the development of an otitic abscess neces- sarily implied a pre-existing chronic suppuration of the ear. To-day, how- ever, it is known, from cases observed during the recent epidemics of influenza, that cerebral abscess may develop after an acute suppuration of the ear. Mon- nier (La Presse M6d., Nov. 6, '95). More than one-half of all cases orig- inate from aural disease. The statistics of .Jansen, who found, in an aural clinic in Berlin, abscess only in the proportion of 1 case to 20.50 cases of acute otitis, and 1 to 400 of chronic suppurative otitis, are misleading. Abscess is twice as frequent in adults as in children. As to Hessler's statement that three-fourths of all fatal cases of otitis present puru- lent pachymeningitis, it is found that in less than one-fourth of these cases is there any direct communication apparent between the tympanum and the extra- dural abscess, mierobic migration having taken place through microscopic avenues. Taking 119 cases of true encephalic ab- Bcess, analysis shows, with reference to localization, 82 in the middle lobe, 24 in the cerebellum, 4 in both cerebrum and cerebellum, 3 in the pons, 2 in the occipital lobe, and 1 each in the frontal lobe and cerebelbir peduncle. Cerebellar abscesH is more frequent in adults than in children, in whom the location is almost exclusively in the temporo-sphenoidal lobe. Picque and Ferrier (Annales des Mai. de I'Oreille du Larynx, du Nez, etc., Dec, '92). Statistics upon cerebral abscess follow- ing disease of the ear based on 100 cases personally observed, 91 being examined after death; in 9 the abscess was opened during life. The frequency of such ab- scesses in the cerebrum is nearly twice as great as in the cerebellum; in chil- dren below ten years of age their fre- quency is three times that of adults, this difference being, perhaps, the greater distance of the tympanum from the cere- bellum in children. The liability of males is twice that of females, and the generally admitted fact of the disease being more common on the right than on the left side is borne out by statistics. As regards the extension to the brain from the diseased teinporal bone, (1) the cerebral abscess most often occurs where the dura is implicated, in cases of dis- ease of the petrous, or mastoid; (2) the dura and brain-substance between the diseased bone and the abscess are gener- ally diseased ; in only 6 out of 90 cases was tlie intermediate brain-substance normal. More careful observation may show more cases of direct extension of the suppuration from the diseased bone than is now thought to be the case. Otto Korner (Archiv f. Ohrenheilkunde, vol. xxix, '90). Next most common cause of brain- abscess is trauma of the face or skull. Practically all cases occurring in very young children are due to one of these two causes. Rt\idy of 32 cases, 13 of which were in diildrcn under one year of age, 9 of tlieae being under six months and 5 un- der three months; 3 occurred during the second year, and 5 each in the third, fourth, and sixth years, no case being included in which the patient was five years old or over. Conclusions: 1. Abscess of the brain in children under five years is rare. 2. The principal causes are otitis and traumatism. 3. It rarely follows acute otitis, but CEREBRAL ABSCESS. ETIOLOGY. 27 most often neglected eases, and is usually secondary to disease of the petrous bone. 4. In tlie cases occurring in infancy without evident cause, the source of in- fection is probably the ears, even though there is no discharge. 5. The development of abscess after in- jury to the head without fracture of the skull is extremely rare. In nearly all the traumatic cases definite cerebral symptoms shows themselves within the first two weeks after the injury. In cases with falls as remote as several months, there is probably some other cause, such as a latent otitis. L. E. Holt (Archives of Pediatrics, Mar., '98). Among adults surgical diseases of the ethmoid bone, the orbit, the antrum, necrosis of the maxillary bones and sometimes caries of the teeth, disease of the frontal sinus, and pyogenic affec- tions of the nose and throat are occa- sional sources of intracranial pus-infec- tion. Several cases have occurred as complications in erysipelas of the face or scalp. Suppurative adenitis of the cervical glands is another well-known source of infection. Pus-accumulations anywhere in the system — even in remote localities, as the liver, the lungs, the Fallopian tubes, etc. — may, by circula- tory metastasis, be attended with a com- plicating cerebral abscess. Sudden death of a soldier who wag considered to be in perfect health, the autopsy showing a multiple abscess of the left frontal lobe. The man, at the time of his death, was reclining on a bench, reading a newspaper. A few weeks previously he had received a gun- shot flesh-wound of the arm, in an en- gagement with robbers, which had healed readily, the bone not having been in- jured. The abscess was evidently sec- ondary to the injury of the arm, though not a single symptom — mental or phys- ical — suggested its presence. Surgeon Turner, U. S. A. (N. Y. Med. Jour., Mar. 14, '91). The brain may be, and often is, at- tacked in general pysemia and septi- ca:;mia, and tuberculosis and syphilis affecting the encephalon may present the local conditions of abscess. Various con- stitutional diseases of infectious origin, among which may be mentioned small- pox, typhus and typhoid fevers, grippe, and cerebrospinal meningitis are occa- sionally complicated with brain-abscess. Three eases of abscess in the right cerebral hemisphere, all occupying nearly the same position in the centrum ovale, all attended with left lateral homony- mous hemianopsia, with great weakness of the left arm and leg, the loss of power being greater in the leg than in the arm, the face escaping almost en- tirely, and with sensory impairment on the left side. The infective material in two was probably derived from distant suppuration, and in one from an injury of the scalp although the incomplete post-mortem examination renders this uncertain. J. T. Eskridge (Med. News, July 27, '95). Two cases of metastatic abscess of the brain from primary actinomycosis of the lungs. Both cases were considered clin- ically to be of tuberculous origin. C. H. Martin (Jour, of Path, and Bact., Nov., '94). Aphasia during convalescence after evacuation of brain-abscess. Dr. Jack's case corroborates the view of Broca and Trousseau, who first maintained that there is no writing-centre in the sense of a centre in which are stored up the kinesthetic memories of written words and capable of stimulation independ- ently of Broca's convolution. The in- ability to write in this case was abso- lutely coincident with the inability to talk. When the auditory centre either failed to recall the memory of the sound of the word, or, if rememliered, failed to convey the stimulus properly to the kinesthetic speech-centre, it failed also to communicate it to the centre for the movements of the hand. That the centres and fibres affected were not destroyed is shown by the complete recovery. G. L. Walton (Boston Med. and Surg. Jour., Dec. 26, 1901). 28 CEKEBRAL ABSCESS. PATHOLOGY AND JIORBID ANATOMY. PROGNOSIS. Pathology and Morbid Anatomy. — Brain-abscess is always secondary to the intracranial invasion of pyogenic micro- organisms. The growth of such abscess is steadily progressive except when, as occurs occasionallj', a membranous wall of tissue develops, inclosing the pus and preventing its encroachments upon surrounding structures; when so sur- rounded, the abscess is said to be of the incapsulated variety. 'WTien incapsula- tion occurs the further progress of the disease is temporarily and sometimes for long periods of time arrested. The dan- ger of rupture is always present, how- ever, such rupture resulting in sudden apoplectiform symptoms with death, the picture simulating a sudden vascular lesion. In its incipiency brain-abscess presents the local appearance of what has been termed "acute, red softening." Later the pus changes from a reddish- yellow to a greenish or greenish-yellow color, and is at times quite offensive in odor when exposed. The complications usually found are sinus- phlebitis and thrombosis (lateral and superior petro- sal), leptomeningitis, extensive meningo- encephalitis, and purulent pachymenin- gitis. Leptomeningitis and sinus-throm- bosis are especially common in cases due to aural disease. Charcot and Leyden crystals found in pus from cerebral abscess. These crys- tals have been found in the expectora- tion of asthmatics, the foeces of antcraics, from the AncJiiilostnmum duodenale, in the semen, in bone-marrow, and in other conditions. So far, they seem to have no constant Bip:nificance. Campbell (Med. Chronicle, Feb., '94). The streptothrix found in a case of abseesB of the brain characterized dur- ing life by epileptiform attacks. This streptothrix developed well in different culture-media, though only completely on potato. In the primary pus and in the potato culture it presented the form of ramifying filaments with knob-like terminations. It stained well by Gram's method. Inoculated into the guinea-pig it did not prove pathogenic. Inoculation into a rabbit caused diffusion of the parasite in the organism without phe- nomena of reaction or of pseudotubercu- losis. Ch. F6r6 and Faguet (Le Bull. M6d., Aug. 25, '95). Infection may spread from the tym- panic cavity in four directions: (1) upward through the vault, (2) outward through the external table of the proc- ess, (3) downward mainly through the lower wall of the mastoid cells, and (4) backward along the groove of the mas- toid sinus. Infection spreads, not only through necrotic perforations, but also along the lymph- and blood-vessels of the osseous canaliculi. An unusual mode is through the groove of the trans- verse sinus and the foramen lacerum posterius. Quervain (Sem. M6d., Aug. 20, '97). Case of neglected middle-ear disease in which a large necrotic focus was found immediately beneath the groove for the attachment of the tentorium, midway between the hiatus Fallopii and the aqueductus vestibuli, communicating with a focus in the left side of the cere- bellum. Bacteriological and histological examination revealed the staphylococcus pyogenes albus, staphj'lococcus cereus flavus, and the bacterium vulgare (pro- teus vulgaris). A. P. Ohlmacher (Cin- cinnati Lancet-Clinic, Sept. 4, '97). Prognosis. — Brain-abscess is almost always, if not always, inevitably fatal if treated otherwise than surgically. The duration is variable. The acute cases generally terminate within a week or ten days in death. The slow incapsulated variety may extend over months and even years, the patient dying finally from exhaustion or perhaps siiddonly from rupture of the abscess-sac. Analysis of 109 cases in which pus in some form was present in the brain; only 11 recoveries occurred, all of which were operative cases. In 10 other cases the pus was evacuated, cither by opera- CEREBRAL ABSCESS. TREATMEXT. 29 tion or spontaneously. Every case not operated upon died, while more than 50 per cent, of those in which the skull was trephined recovered. This emphasizes forcibly the imperative necessity for operative interference in all cases of cerebral abscess. Frank Allport (.Jour. Amer. Med. Assoc, Oct. 22 to Dec. 24, '92). The prognosis of cerebral abscess due to ear disease after operation is not as good as might be expected, because these abscesses are not infrequently multiple (20 per cent.) and on account of the difficulty in making a correct diagnosis. A number of these abscesses run a latent course. Occasionally the sj-mptoms are few and of a passing character. Again, the patient is sometimes seen in the last stages of the disease, when the abscess has burst through to the surface of the brain or into the ventricles. Even when the patient has been under observation in hospitals diagnostic mistakes are pos- sible. ^Mien the abscess is accompanied by other intracranial complications a correct diagnosis may be out of the question. Grunert (Berl. klin. Woch., Dec, '96). The course of an otitic cerebral ab- scess is regularly acute or subacute. In many cases pus opens into the ventricles or on the meninges after some days or weeks, and proves fatal. It is not rare, however, that the course is slow and that the purulent formation ceases, and the virulence of the infection may then be so light that a limiting wall will form. If the cerebral tissue surrounding the abscess is in nearly a normal condition, absorption can occur. The membrane limiting the purulent focus may undergo calcareous degeneration. Roepke (La Trat. MCd., .June 15, 1900). Prognosis based on statistics of 195 cases of brain-abscess due to middle-ear disease, 180 of which warrant the fol- lowing conclusions: Out of 106 cases in which the brain was explored through the squamous temporal, 40, or 37.7 per cent., recovered. Of 64 that were ex- plored through the mastoid region, 31, or 48.4 per cent., recovered. Of 10 cases in which the brain was exposed, both through the tegmen nntri and through the squamous temporal, 8, or 80 per cent., recovered. Hammerschlag (Monats. f. Ohrenh., Jan., 1901). E.xamination of the fundus shows that in intracranial suppuration following ear disease neuritis or choked disk is rare, unless a combination of suppurative foci exist. From a prognostic point of view, changes in the papilla are of no value. As a rule, there is a distinct retro- gression of the inflammation several days after the pus has been evacuated. But even if it should persist or increase, the outlook is no less favorable. 0. Kerner (Deutsche Arch. f. klin. Med., vol. Ixxiii, 1902). Every brain case should be explored where the symptoms are focal regard- less of the supposed pathological lesion. H. C. Gordinier (Amer. Jour, of Insan- ity, Jan., 1903). Treatment. — Every case of brain-ab- scess should be operated upon and the pus evacuated just as soon as the diag- nosis can be made. In no department of brain-surgery have results been so brilliantly successful. In a great major- ity of cases the abscess is easily accessible and can be readily reached. The sur- geon should not wait for coma or grave symptoms of irritation or pressure, but should enter the cranial cavitj', at least in an exploratory way, as soon as it seems probable that cerebral symptoms in a given case point to abscess-formation. In trephining after traumatic brain affection it is advisable to distinguish late and early cerebral abscess. The late abscess apparently does not arise in tlie contused part itself, but in a healthy one, just like non-traumatic abscesses after traumatic suppuration in the bones and soft parts. These late abscesses gen- erally lie deep, and are covered by nor- mal cerebral cortex. The early abscesses usually arise in the injured area, into which infective material penetrates from without. Fatal meningitis is often asso- ciated with immediate suppuration. If 30 CEREBRAL ABSCESS. TREATJVIENT. the suppurative process is slower, how- ever, and the wound in the brain small, adhesions of the cerebral membranes take place in the region of the injury, and abscesses may result. These ab- scesses are, to a certain extent, the re- sult of retention of pus in the nests and sacs of a deep wound, and are generally superficial and cortical. They do not develop before two weeks. Very early onset of paralysis or s3'mptoms of irrita- tion are rather signs of meningitis, while the late appearance of symptoms points rather to abscess. (Nasse.) Details of sixty-seven mastoid opera- tions. Most of them were done in the usual method of Sehwartze, but the later cases, to the number of about a dozen, were done by Stacke's method of dis- secting off the auricle and soft tissues of the canal and laying them forward, chiseling away the posterior bony wall and anterior wall of the attic, so as to throw meatus, attic, antrum, and tym- panum proper into one open and visible cavity, then replacing the soft parts and transplanting a flap of canal-lining into the antrum. In these methods radical removal of all diseased structures is at- tempted, yet in such an open manner as to rob the operation of many of its gravest dangers; important structures can be more surely avoided, healing is likely to be greatly expedited, and the recovery should be secured with a condi- tion far less likely to relapse into cho- lesteatoma or other renewed troubles. Panse (Therap. Gaz., Apr. 15, '92). In opening the skull for cerebral ab- scess the surgeon need not be always anxious about replanting the bone re- moved, considering that in three cases the gaps, without replantation, were soundly filled up, — more so than in some cases in which the replantation had been practiced. In order to drain the septic abscesHes replantation had been imprac- ticable, hut the result was, nevertheless, a sound restoration of the bony case. Kushton Parker (Liverpool MedieoChir. Jour., Jan., '9.5). At the present time it is possible to reach, and to deal successfully with, the following conditions: 1. Abscess in the cerebrum, especially in the temporo- sphenoidal lobe. 2. Abscess in the cere- bellum. 3. Purulent formations at the base of the skull: (a J extradural ab- scess; (bj subdural abscess. 4. Infective thrombosis of the sigmoid sinus, even when secondary foci may exist. In all these conditions it is essential to explore the cavities of the middle ear by removing the outer wall of the an- trum. The partitions of the roof and sigmoid groove separating the middle ear from the temporo-sphenoidal lobe above and from the sigmoid sinus be- hind are the two great pathways by which infective matter effects its en- trance into the interior of the cranium. In operating, the path of invasion should be systematically followed up, and this may be done with safety and with efficiency by means of the rotary burr propelled by a dental engine. Thomas Barr (Archives of Otology, vol. xxiv, Nos. 3 and 4). Case of abscess of the temporo-sphe- noidal lobe opened and drained through the osseous auditory meatus. The advantages of this method of oper- ating are obvious: In the first place, we get good and efficient drainage from below. The drainage-tube can, if neces- sary, be kept in position for months without any discomfort. It can easily be removed and replaced, and there is no danger of not again finding the ab- scess-cavity. We can also at the same time cffieiently treat and cure the attic and mastoid cells, which in these cases are nearly always affected, and thus pre- vent any recurrence of the disease. Only one incision and only one operation are necessary. The operation and after- treatment are more difficult and tedious than in the ordinary metliod of trephin- ing, but the results are certainly more satisfactory. Adolph lironner (Brit. Med. Jour., Aug. 21, '97). In children a study of thirty-two cases, no case being included in which the pa- tient was five years old or over, led to the conclusion: that on account of the great amount of shock attending brain- surgery in very young children, an oper- CEREBRAL ABSCESS. CEREBRAL H/EMORRHAGE. 31 ation should not be urged unless definite localizing symptoms are present, the principal one being hemiplegia. L. E. Holt (Archives of Pediatrics, Mar., '98). In cerebral operations a large area of the skull should be removed. It both enables us to examine the brain better when exposed, and also, if benefit is to be obtained from relief of cerebral pres- sure, it surely increases that chance ; and also it scarcely increases the danger of the operation. E. D. Fisher (N. Y. Med. Jour., Apr. 16, '98). Delay in operating until the appear- ance of unequivocal localizing symptoms, or recourse merely to opening of the mastoid when it may be reasonably as- sumed that cerebral abscess exists, is a far greater injustice to the patient than his subjection to an exploratory trephin- ing of the cranium. Collins (Amer. Jour, of Med. Sci., Apr. '99). It is important to determine the na- ture of the micro-organism producing the abscess at as early a period as pos- sible. A large opening in the skull recommended after first turning down a large scalp-flap. For the drainage of an abscess in the temporo-sphenoidal lobe the trephine opening should be made Vs inch above the suprameatal spine. In operating for a cerebellar abscess the trephine should be placed with its upper edge just below Reid's base-line and its anterior edge touching the posterior border of the mastoid process. In incising the dura mater the opening should be made by a flap rather than by a crucial incision. The use of a long, narrow, straight bistoury recom- mended for the exploration rather than the use of the exploring needle or can- nula, as the incised wound of the brain heals better than the punctured wound. The finger is also to be used for ex- ploration. Irrigation of an abscess of the brain should only be resorted to when tliere is free exit for the fluid, such as is accomplished by the use of a tube. Tamponing these cavities with gauze is not approved. Recurrence of symptoms, especially in cerebellar ab- scess, is not an uncommon thing a few days after the opening of a brain- abscess, and it is duo either to a reac- cumulation of the fluid or el.se to an entirely new formation of pus in an- other part of the same lobe. C. A. Bal- lance (Lancet, May 25, '1901). Wm. Broaddus Phitchard, New York CEREBRAL HEMORRHAGE. Definition. — Under this head are classed all cases where there is an ell'usion of blood due to the rupture of some vessel within the substance of the brain proper or in the pia. This htemorrhage usually starts in the brain, but may force its way out and become subarachnoidal or ventricular. Except in case of accidents, it rarely makes its way into the subdural space. The dural system of arteries is quite distinct, and bleeding from this source should be considered separately. Simple tingeing of fluids about the brain, not coming from any blood-focus, does not constitute a cerebral hjemor- rhage in the strict sense. Varieties. — It is customary to classify these cases according to the part of the brain that is the seat of the hagmorrhage as cortical, subcortical, or of the central ganglia; frontal, or of either lobe, pon- tile, cerebellar, etc. Besides the above, however, there are several subforms, as: — Ingravescent. — This is a term ap- plied to large effusions developing slowly, — i.e., for a period of several hours or for a day or two. Tliis form is largely observed in haemorrhage at the externa] capsule; the peculiarity is owed, first, to rupture of a large per- forating artery that passes up at tliis point, and, secondly, to the parallel course of tlie nerve-fibres in this tract whereby they continue to separate as the pressure increases. Symmetrical. — Here there is a double hfrmorrhage, starting from corre- 32 CEREBRAL ILEMORKHAGE. SYIMPTOMS. spending points of the two hemi- spheres. Meningeal and Ventricular. — These forms may either start as such — though rarely — or they may start from vessels in the brain-substance and then rupture through into one or the other of these spaces. Traumatic. — Due to violence or in- jury, in contradistinction to the general run of spontaneous cases. Punctate and Capillary. — These are sufficiently explained by the terms. Of themselves they are rarely of suffi- cient moment to be of other than patho- logical interest. Symptoms. — Prodeomata.- — The so- called premonitory symptoms include headache, dizziness, pallor or flushing of the face, fullness in the head, flicker- ing before the eyes, visual obscuration, poor sleep, tinnitus aurium, thickness of the tongue, numbness or peculiar tinglings of one side of the body, heavi- ness of extremities, slight mental changes, — as lapses of memory, drowsi- ness, and irritability, — changed, slowed, or intermittent pulse, etc. These, when occurring in an elderly person, are thought by many pliysicians to point to an impending haemorrhage. There is no doubt that such symptoms fre- quently precede thrombosis. This fact, together with the lack of adequate pathological proof and inability to ac- count for premonitions in htemorrhage, has caused a disinclination among con- servative observers to recognize any con- nection of the kind. In some cases, however, there may be a preliminary oozing sufTicient to produce slight symp- toms. Further the evidence of a vaso- motor influence suggests that a local paralysis of vessels with sufTicient dila- tation to irritate the adjacent tracts may precede the actual rupture. This, how- ever, in a few days ends in a frank at- tack of apoplexy. In the aged most of these symptoms point rather to throm- bosis; but in earlier years they may give warning of incipient haemorrhage. Constipation is common in the pro- dromal stage, but is too usual a matter to have any diagnostic significance. Turgidity of the vessels of the head, severe pain in the head, convulsive twitehings of an extremity (Jacksonian), unilateral chorea, etc., are rare, and be- long to the initial stage of apoplexy — or, of course, more often its later stages. Onset. — The symptoms that may mark the onset of the attack include the vari- ous prodromata just mentioned; also faintness or general prostration, convul- sive movements, aphasia, paralysis, stu- por and even unconsciousness, free per- spiration; slow, tense pulse, etc. The regularity and the sequence with which these appear are very variable. In fulminant attacks the severest symp- toms may promptly develop, and even death itself be not long delayed. Sud- den death may occur if the trouble is in the pons. Oftener there is a gradual in- crease, both in the number and the se- severity of the manifestations, for some little time: one, two, three, or more hours. Headache. — Very often there is no special complaint of pain in the head, and again headache has been such an habitual thing with the patient that lit- tle importance can be attached to it. Nephritic complications, when present, tend also to rob this symptom of value. In many cases, however, there is head- ache, severe, deep, and general in char- acter, less often localized. It becomes more pronounced as the effusion in- creases in volume, and, even when the consciousness has become more or less oliscured, the sufTcrcr may persist in put- CEREBRAL HiEMORRHAGE. SYMPTOMS. 33 ting a hand to the head, evidently be- cause some degree of pain or distress is still perceived. When, therefore, we meet a headache unusual to the patient, excruciating in character, not otherwise explicable, and associated with suggestive phenomena, it acquires some value as a symptom. A low, occipital pain is common in cases of cerebellar apoplexy; but as it may be due to other causes its only sig- nificance comes from association. Vomiting. — This is a common symp- tom and one of much clinical impor- tance, its value, however, depending much on the certainty with which urffimia can be excluded. Nausea may, of course, attend dizziness, faintness, or thrombosis; but actual vomiting, aside from urtemia (especially if the person is reclining), argues, in a suspicious case, for haemorrhage. This applies to the increasing period of the effusion. [It has been claimed to be especially frequent in cerebellar htemorrhage, but, as stated, it is common in all forms. W. Browning.] Where the latter is at all voluminous, in almost any part of the brain we see vomiting, often severe and even some- what prolonged. Its occurrence depends upon the volume of the effusion, the speed with which it is poured out, and to some extent upon its location. In the slower, or ingravescent, forms, even though they finally reach a large size, there is less tendency to emesis. It is where we find other evidence of an apoplectic seizure that this symptom ac- quires value; then it also assists mate- rially in differentiating the nature of the brain-process. Nearly always some other plausible explanation is proffered: the person has just eaten overheartily, been lying in a cramped position, had an hypodermic. taken medicine that upset the stomach, or been suffering from gastric catarrh. The diagnostician must, of course, be able to discount such suggestions. Yawning and Sighing. — These are very frequent and striking symptoms in haemorrhage, and are often more marked if the patient is in a sitting position. There is a slight parallelism between them and the vomiting. But as they are also common in cases of thrombosis and may occur in embolism while there is a badly damaged heart, they have only a limited diagnostic value. In cases of haemorrhage these manifestations sug- gest that the focus has already reached a sufficient size to produce some degree of brain-anasmia. Coma and Other Disturbances of Con- sciousness. — These are of great impor- tance for both the positive and the dif- ferential diagnosis. But at the same time they are matters most difficult to describe or define with exactness and in accordance with the facts. Coma is a state of profound uncon- sciousness not due to sleep, syncope, or drugs. But in practice we meet all kinds and degrees of disturbance of conscious- ness. The eyes may be open and staring, yet the person fail to make any responses to our interrogations and evidently fail to have any understanding of language or surroundings. More often there is a condition of stupor that admits of but partial and temporarj' recognition. "We can then conveniently distinguish coma, stupor (a partial coma: "semicoma- tose"), and dazed conditions. The duration of these states is next in importance. They may be of such tran- sitory nature as to pass unnoticed, or they may last several hours or days, the lighter degrees being, of course, as a rule, of shorter duration. The time in the attack when coma supervenes is also 34 CEREBRAL H.EMOREHAGE. SYMPTOMS. to be notedj if at the start it may be partly a direct shock-effect; if later and more gradual it indicates that the ef- fusion has reached a large volume. The size of the output requisite to produce this symptom varies much with its location. A small clot in the pons, for instance, will produce a much deeper impression on consciousness than one of far-greater size in the pallium. Wer- nicke and others have sought to explain this by the smaller size of the vessels, their indirect course, and hence slower leakage in the hemispheres. But this view is negated by several facts, how- ever well it may explain the favorite sites of hasmorrhage. [A competent medical friend offers the following more scholarly definition; "Coma is a condition of profound un- consciousness, the result of injury, dis- ease, or some form of intoxication." But the sleep of chloral or morphine is not termed coma, while, on the other hand, that of alcoholism often is. Neither is true coma always so profound. In fact, there seems to be a considerable latitude in the use of this term. Perhaps the above definition might be modified as follows: Coma is a state of unconsciousness due to some other cause than sleep or syncope. The cfTects of in- toxications, soporifics, or anjEsthetics should only be called coma when the person can no longer be roused to con- sciousness. W. Browning.] The comparison of a large number of these cases shows that involvement of the sensory tracts has little or no influ- ence on consciousness, while other cases with equal-sized foci involving certain parts of the motor path show, as a rule, very marked impairment of conscious- ness. From a psychological stand-point this seemingly anomalous fact agrees with conclusions based on other evi- dence. But it is cited here to prove that much depends on the part involved as to the effect on consciousness. A close analogy can also be drawn with cases of embolism. The writer has shown that embolism involving only parts above the basal ganglia does not cause coma. Inasmuch as in many of these eases a large patch of brain-tissue is involved, and as, further, the sudden- ness of the attack must be equal, what- ever the part involved, it follows that here again much must depend on the particular structures included, for smaller infarctions, if only they involve the ganglia, often do bring on coma. It can consequently be stated that, whatever accessory influences there may be, there are but two important govern- ing factors in the development of coma: the size of the hfemorrhage and the particular part of the brain implicated. These deserve a little further considera- tion. As to the amount of hemorrhage that will of itself cause coma, experiments on animals by Pagenstecher, von Schulten. and others have led to the conclusion that in the human being one and a half to two ounces is about the extent of limitation of the brain-space that can be borne without interruption of psy- chical functions. (More can be tolerated in a diffuse effusion like a meningeal hcemorrhage than in a confined focus.) The exact amount thrown out in a case of apoplexy is rarely, if ever, known, since some of the fluid is promptly ab- sorbed or scattered, and, independent of that, it is impossible to more than esti- mate the volume of these irregular foci. So far as such rough estimation goes, it corresponds fairly with the experimental results. This applies to cases in the hemispheres (pallium). Wlien the size of an effusion is stated to be that of a hen's egg, it may be considered to equal two ounces of fluid. Uence, haemor- rhage of that bulk should be, and in CEREBRAL HEMORRHAGE. SYMPTOMS. 35 practice is found to be, on the border- line. It may be expected to at least produce stupor and frequently some coma. When of greater volume, coma very generally results. In the basal ganglia, however, a much smaller amount may suffice. The principle here is that the effusion, by its volume, exerts such a general press- ure on the whole cortex as to obtund consciousness. Of the sufficiency of this factor there is no question. It may act by producing an anaemia or by more direct mechanical effect. Further, a compression, before ineffective, may be- come sufficient if the arterial pressure sinks. As to the susceptibility of different parts, injury below the oblongata {i.e., in the cord) does not cause coma. The syncope of shock or even sudden death may result, but not real coma. And it is uncertain whether hsmorrhage of the oblongata has much tendency to pro- duce coma; most such cases are small and any stupor is masked by respiratory and other phenomena. In the old case of Fabre (quoted by Gintrac and others) some loss of consciousness attended a small htemorrhage of the left p)Tamidal body. But in several other cases of small effusion in other parts of the oblongata no distinctly comatose condition has de- veloped. At the other brain-pole — i.e., corticad of the central ganglia — we have already seen that coma is essentially a conse- quence of general brain-compression. In this major portion of the encephalon there is little difference between the vari- ous parts. Apparently the occipital lobe tolerates infringement better than the frontal and parietal lobes; but there is no decisive difference. Regarding the cerebellum, the general opinion agrees with the evidence that uncomplicated hasmorrhage when mod- erate in amount does not invoke coma. But in these rather rare cases either rupture occurs or, if much size is at- tained, there is so much pressure on sub- jacent structures as to obscure the bear- ing of the case. There still remains the region of the central ganglia, the cerebral crura, and the pons. Hasmorrhage of the caudate nucleus is prone to bring on coma. That in the lenticular nuclei and in the thai- ami is somewhat less apt to do so. When in a cerebral crus, there is commonly some coma or, at least, stupor, though these hfemorrhages are rarely volumi- nous. Those of the pons are most in- clined to cause coma, though usually small unless they have already ruptured. A comparison of this last group of cases (involving the brain-stem) brings out forcibly one fact already referred to, — viz.: that haemorrhages in the sensory path show but little tendency to cause coma, while those in the motor path have a marked tendency in that direc- tion. This fact stands out quite as clearly when they are compared by vol- ume. It is, of course, not certain whether this applies specially to the mo- tor tract or to other and less under- stood tracts closely associated with them; it may be fibres to the so-called somoes- thetic area. So far as this coma-zone has been noticed in the past, it has been thought to depend upon the fact that here were grouped fibres passing to, and thus influencing all parts of, the brain. Secondary Factors in the Causation of Coma. — There are, of course, various other influences that affect this result. The person's susceptibility is one; car- bonic-acid poisoning due to superficial respiration is another. But most im- portant of these is the rapidity with which the effusion occurs. On the ex- 36 CEREBRAL HEMORRHAGE. SYjVH'TOMS. perimental side it is well known that the effect on consciousness depends somewhat on the rapidity with which the compression is produced. But it is rare in clinical work to meet cases where a hasmorrhage has taken place with any such rapidity as in the average experi- ment. As Liddel long ago pointed out, considerable time is taken up before the bleeding stops. We also know that in the slow, ingravescent form, though a day or two elapse in the process, coma just as certainly supervenes when the volume of the focus becomes adequate. The disappearance of coma is attrib- uted to a re-establishment of the cir- culatory balance, to reduction of press- ure from lessened cerebrospinal fluid, and perhaps a gradual tolerance to the focus. The shock-efllect passes off, and some of the fluid of the focus is ab- sorbed. Aphasia. — This symptom, of itself and without corroborative manifestation, is rarely indicative of cerebral htemor- rhage. A considerable majority of all cases of aphasia are due to other causes (see article on Aphasia, vol. i). These are mostly transient forms lasting from a few hours to a few days and embracing all degrees of speech-impairment up to its complete loss. They are occasioned by gout, urffimia, and less frequently other toxic conditions. Possibly the standard writers do not take sufficient notice of these transient forms. Even of the more lasting cases a certain num- ber will be due to thrombosis, embolism, etc. Only in a part of the cases of cerebral haemorrhage do aphasic symptoms ap- pear. To produce these the speech- tract must either be directly injured by the effusion or indirectly implicated by pressure. This, of course, only occurs when, in right-handed persons, the lesion is on the left hemisphere, and in left- handed in the right hemisphere. Ap- parent exceptions to this rule occur as in a recent case (of embolism) where an originallj'-left-handed youth had so trained himself that he passed for a right-handed person. All degrees and forms of aphasia oc- cur in association with hemorrhagic apoplexy. AVhere it is due to implica- tion and not to direct involvement of the speech-centre or tract, then recovery from this symptom may occur, the time required and the extent of recovery be- ing dependent on the circumstances of the case. By speech-centre we, of course, mean not only the motor centre in Broca's convolution, but also the hear- ing-centre and other associated parts. Inasmuch as all forms of aphasia and paraphasia are involved, it is not prac- ticable to enter on a discussion of them here. Convulsions, Tivitcliings, etc. — Earely a few spasmodic twitches occur during the onset-period in the territory where paralysis is developing. These may not be noticed unless in the face. It is not certain that they point to a cortical focus. Quite distinct from these are the uni- lateral clonic convulsions (Jacksonian type) that occur in the rare cases of efi'usion about the cortical motor area. Such cases are far oftener of traumatic than of spontaneous origin. Of course, urasmic convulsions may bring on or accompany an apoplectic sei7Aire, though this is unusual. Other- wise general convulsions in this condi- tion point strongly to ventricular hoem- orrhage or to rupture into the lateral ventricles. [Tlipy filfio are not rare in thrombosis, and in both moninpoal and frontal lioomonhagcs. W. Buowninc] CEREBRAL H.EMOREHAGE. SYMPTOMS. 37 Even in case of such rupture, how- ever, convulsions do not always follow; nor does slight oozing, as in many cases of impending rupture, have this effect. When such convulsions do occur, they may be of the severest character that we ever witness. In any case, such com- plications give a very bad outlook, for ventricular rupture is only more cer- tainly and rapidly fatal than uraemia. Rigidity of the paralyzed or even both sides is also frequent in ventricular rupture. Paralysis ; Respiratory Paresis. — This is one of the commonest as well as most striking and characteristic symptoms, although not a necessary accompani- ment. It may affect either motion or sensation or both. The time of the attack at which it develops depends on the location and the rapidity of development of the efEusion. Usually it appears with the onset of the seizure, though at first frequently but a mild degree of paresis; in such a case we can conclude that, as yet, the motor path is only suffering from pressure. In occasional cases the paralysis is not man- ifest until later or becomes pronounced only in the reaction-stage; but it is then difficult to distinguish from an increas- ing effusion. Motor involvement constitutes the most marked and important manifesta- tion of average cases, and when present may range all the way from the slightest degree of weakness up to complete flac- cidity. ^^^lile any of tlie voluntary mus- cles may suffer, certain prevalent types can be made out. Monoplegias and more limited paralyses, running as such from the start, occur in some of the rare cases of ha3morrhage corticad of the internal capsule. When this is in the occipital, frontal, or temporal lobes, there may be no definite paralysis unless the focus becomes so large that the transmitted pressure affects the motor neurons. But, as the great majority occur in the basal ganglia or pons, the hemiplegic type is by far the most common. Of this there are two distinct forms: the one of sim- ple hemiplegia, where all the affected parts are on one side (arm, leg, and face, all or in part), and the other of crossed hemiplegia, where an arm-and-leg pa- ralysis on one side is associated with some involvement of the cranial motor tracts on the other side. This latter form is typical of localization in the pons, be- cause of the fact that the cranial tracts have already decussated, while the first form is that due to the common site in the basal ganglia. In the very rare cases of bleeding in a cerebral crus, there may be a special form of crossed paralysis: involvement of the arm and leg on the side opposite the lesion and oculomotor paralysis on the same side, due to the intimate relationship of this nerve with the cms. There is some basis for the view that lesions of the thalamus may present a special characteristic. This consists of loss of emotional or pantomimic move- ments, while the volitional motions are still preserved. This applies specially to the cranial distribution. If, on the con- trary, the cranial paralysis is due to lesions more anterior at the same level or higher up there may be a preserva- tion of the so-called mimic, with a loss of voluntary, movement. In practice, haemorrhages of this region are usually so massive that both grades of motion are equally lost. It is possible that something of the kind also holds for the extremities, since we sometimes see cases of hemiplegia where, in sleep, the patient is able to lift a hand to the head. Here may also be classed the so-called methemiplegic 38 CEREBRAL H-^MOREHAGE. SYMPTOMS. movements; these are such as occur in a paralj'zed part in association with vol- untary movements in the corresponding well part. In ordinary hemiplegia ,we find the arm and leg motionless or nearly so, a little motion possibly remaining in the fingers or toes. The arm lies helpless by the side or across the chest. The pa- tient, if requested to move it, reaches over with the other hand. The leg stays in almost any position in which it is placed. In the complete form it is im- possible for the patient to turn in bed or to rise at all from the recumbent position. In coma the paralysis may be presumed from the drawn face, expi- ratory puffing of one cheek, and the heavier, passive drop of the affected arm when lifted and let go. As a rule, the leg improves faster than the arm, perhaps, as claimed, because the arm-tract is apt to be more involved than the leg, or, perhaps, because the leg-movements (as in walking) are more automatic in character. It is consid- ered an unfavorable omen when, on the contrary, the arm improves faster than the leg. The hypoglossal and facial tracts are more apt to escape direct im- plication, and the upper facial quite reg- ularly escapes (a point of distinction from like hysterical paralysis). Sensory loss is also a common though less frequent and lasting accompaniment than motor. In many cases it is so transient that in a few days little trace of it remains. Its occurrence depends on interference with the sensory neu- rons. Their most exposed point is at the carrefour smsitif (posterior border of the internal capsule), where the sensory tracts are more closely grouped than elsewhere in their course. This point )B also about opposite the commoner sites of haBmorrhage, though a little to one side, which harmonizes with the fact that permanent loss of sensation is the exception. The most-marked feat- ures of this type are loss of common sensation in the opposite half of the body and homonymous hemianopsia (blind- ness of opposite half of visual field of each eye). Hearing may also be inter- fered with and sometimes taste and smell, the latter two only on the opposite side. In hemorrhages involving either the hearing-centre in the first temporal gyre, the visual centre in the cuneus, the other sensory centres, or the paths connecting these with paxts below, there will be a correspondingly-limited loss of sensation. In pons lesions the special senses escape, unless occasionally those of hearing or equilibrium. At the same time the tracts for general sensation to the other side of the body may sufEer. In cases where there is more lasting anaesthesia it involves deep parts and mucous membranes as well as the sur- face. Eye-symptoms. — Pupillary changes have but little value here for purposes of localization. They do, however, serve one important and usually overlooked purpose: the presence of anisocoria (in- equality of the pupils) is valuable ob- jective evidence of the existence of some real lesion, and has a bearing on differ- ential diagnosis. Of course, this pre- supposes the existence of corroborative symptoms and the recent acquisition of the inequality. The possibility of latent anisocoria should be excluded by deter- mining whether the condition persists on full illumination of the two eyes; if, on so testing, the pupils become equal, the inequality can be put down as proli- ably an affair of long-standing or spinal in origin. Tnn(|ua]ity of the pupils may occur in large effusions that by pressure weaken CEREBRAL HEMORRHAGE. SYMPTOMS. 39 the oculomotor on that side and thus allow that pupil to dilate. It is conse- quently not rare in cases involving the frontal lobe or basal portions of the cere- brum. In pons troubles anisocoria is common, though both pupils may be large or small according to the degree of third-nerve involvement. In menin- geal forms the pupils are often affected, though there is no rule here for our guidance. Conjugate deviation of the eyes very often points to a lesion on the same side, but this is not an invariable rule. Diplopia or more distinct evidence of paralysis of external ocular muscles is unusual except in comatose conditions. Its interpretation depends on the indi- vidual case. Ophthalmoscopical changes are not sufficiently marked in the early stages to be of any value, nor are they often much more so in the later. After development of the full apoplectic state there may be some choking of the retinal veins, espe- cially on the side of the lesion. Miliary aneurisms have been observed in the retina, but are quite unusual. Ha°mor- rhages of the retina may indicate ne- phritis; but only to that extent suggest the cause of any cerebral condition. Bowels. — Constipation frequently pre- cedes or accompanies the attack. Or, on the contrary, where there is deep uncon- sciousness or prolonged stupor, and espe- cially if drastic purgatives are given, in- voluntary discharges may occur. Their chief importance lies in the necessity, then, of scrupulous care lest eczema and bed-sores develop, and in the commen- tary they offer on the state of con- sciousness or the possibility of dementia. Urine. — At the onset the urine is usu- ally acid. Transient glycosuria is a pos- sible accompaniment of luTmorrhage in any part of the brain. The sugar usu- ally disappears from the urine in from a few hours to a couple of days. Pre- sumably it originates from shock to the so-called sugar-centre. When this spot in the floor of the fourth ventricle is directly involved, the sugar may persist longer, though it usually subsides, even then, in a week or two. As a part of the same manifestation there may be a polyuria simply, that is then even more fleeting in character. Albuminuria is a frequent and more serious accompaniment. Like the pre- ceding symptoms, it may be but tran- sient in character; but its presence is always a cause for anxiety. Many cases of apoplexy are due to Bright's disease, and an examination of the urine, there- fore, should be a routine procedure in all cases. Hemicliorea. — This is of rare occur- rence. It may either precede the attack (prehemiplegic chorea), though this is unusual where hoBmorrhage is the cause, or it may develop during the recovery stage (posthemiplegic). It is thought to be due to irritation either of the motor tracts or else of some band of fibres closely associated with these. It is a symptom of irritation rather than of de- struction, and hence is never present where the paralysis is complete. If an inaugural symptom, then it disappears as the paralysis deepens; otherwise it comes on as the paralysis begins to mend, and in turn also disappears as the paralysis wears away. Hence its appearance in convalescence is a good omen, however annoying to the patient. It is not a symptom of the attack itself. This affection involves strictly one side of the body only. It may take in principally an arm or the lower extrem- ity, but usually involves both more or less. In degree it varies much according to the stage; but is often severe and con- 40 CEREBRAL HEMORRHAGE. SYMPTOMS. tinuous in character. The type of move- ments is hardly different from that of ordinary chorea of childhood. Tendon-reflexes. — At the onset and during the period of development no great changes in the reflexes can be made out, unless diminution. But so soon as the effusion seriously interferes with the motor path and even more after the sub- sidence of shock the tendon-reflexes of the paralyzed parts show a decided in- crease; this may apply both to the force of the reflex and to the extent of area from which it is elicitable. In gross lesions the pathological jerks like ankle- clonus and wrist-clonus may also be demonstrable, either immediately and temporarily, or later on after descend- ing degeneration. It is necessary to compare the two sides to settle the relevancy of the symptom. Even then there are cases in which both knee-jerks are increased from unilateral lesion, in proportion, perhaps, to an incomplete decussation of the pyramidal tracts, as is further shown by the somewhat bi- lateral paralysis of the lower extremi- ties. As a rule, however, we find a purely-unilateral exaggeration of the tendon-reflexes. OxnEU Symptoms. — Those pertaining to the period of the seizure are almost described by their enumeration. A slightly-subnormal temperature (one to two degrees) may frequently be found for an hour or two after the onset. Later an increase of temperature is not unusual. It amounts to but a few de- grees at most and is transient in char- acter, lasting only a few hours, as a rule. These variations in temperature are somewhat commensurate with the sever- ity of tlie seizure. From the experi- ments of Ott and otliers it is known that there are so-called heat-centres as far corticad as the caudate nucleus, and it is to disturbance of these that the hyper- thermia is doubtless due. It is claimed for pons hffimorrhage that the tempera- ture may rise from the start. Trouble in swalloM'ing (dysphagia) may be simply an expression of the gen- eral weakness, though at times it seems to partake of the nature of a central paralysis. It necessitates extra care lest food slip down the trachea. The respiration is often affected. Stertorous breathing is an attendant on the deeply-comatose state. In the sub- sequent weak condition of the severe cases Cheyne-Stokes respiration may ap- pear at any time and is especially prone to do so in the hours of deep sleep. It may also occur in the primary coma. The subsequent mental condition often shows impairment of intelligence, psychical functions, memory, and mental grasp. These incline to be the greater, the severer the attack. Laughing or crying on inadequate provocation, an anxious haste in carrying out anything planned, and many other aberrations might be cited. PERrPHERAL TROUBLES. — • Contract- ures. — These may develop some weeks after the attack, and are usually spastic and functional rather than organic. They are associated with great increase of the tendon-reilexes. By a slow, steady counter-pressure complete ex- tension can be effected, but the part quickly becomes flexed again on relaxa- tion. This condition means little else than that the corresponding fibres of the pyramidal tract are involved. Sep- arate from this is the early rigidity due to stimulation of the motor tracts by the irritative lesion. OSdema. — Tliis condition of the par- alyzed part is not of very frequent oc- currence. It has been thought to be due to degeneration of the pyramidal CEREBRAL HjEMOERHAGE. DIFFERENTIAL DIAGNOSIS. 41 tract, but it sometimes develops so early after the apoplectic seizure that the neural change could hardly have taken place. The amount of swelling may be little or much, and changes readily with the position of the patient. It collects at the most dependent part of the ex- tremity. Neuritis. — Occasionally a degenera- tive neuritis develops in the affected area. Considerable pain may be asso- ciated with it, though this must not be confused with the muscular tenderness that often follows directly on the paral- ysis. The reason for the occurrence of this form of neuritis is not well under- stood. Possibly it is an outside process grafted on such nerve-fibres as have least resistance. Decubitus. — This is not, as a rule, as liable to occur or as resistant as in dis- orders directly involving the peripheral neurons. Still, from the inability of the . paralyzed patient to relieve pressure on prominent parts, from the maceration by the discharges when not scrupulously cared for, and from the frequently im- paired sensation, it is very easy for bed- sores to develop. Trophic changes are supposed to be due to trouble with the innervation from the peripheral neurons; but Nothnagel and others have adduced some facts in- dicative of trophic influence from certain parts of the brain. Vasomotor disturb- ances, lowered arterial tension, etc., are observed on the paralysed side. Differential Diagnosis. — This has to be made between liaGinorrhage and the following conditions: Embolism, throm- bosis (including its precedent conditions, such as syphilitic arteritis), pseudoseiz- ures, certain toxaemias (as urremia, gout, alcoholism, etc.), simple fainting, hys- teria, and sudden death from various causes. The practice of uniting nearly all of these under the one head of apoplexy is, unfortunately, too common. While our diagnostic methods are not sufficient for all cases, the following principles will usually suffice to differentiate. Good medical judgment is here a strict neces- sity. To know our patients, their past histories, and any chronic disorders from which they may be suffering is of great advantage. Embolism. — Against embolism speak: the absence of any distinct mitral or aortic lesion, the presence of headache or other prodromal manifestation; deep coma, especially late development; vom- iting, pronounced anisocoria, and ad- vanced age. Thrombosis. — Against thrombosis speak: youth unless the patient be a syphilitic, coincident or early rise of bodily temperature, early and deep coma, vomiting, great inequality of the pupils, high barometric pressure at time of onset, beginning of attack when the per- son is under effort or excitement, a pulse of high tension, the absence of prodro- mata, and the existence of vigorous gen- eral health. PsEUDOSEiZDEES. — The question of a pseudo-attack can only arise where the subject is also suffering from either pro- gressive dementia, tabes, disseminated sclerosis, or possibly the results of alco- holism. The other possibilities can be ex- cluded more readily and on general lines. Following conclusions reached from study of eight cases of cerebral htcmor- rhage, embolism, and thrombosis: 1. In cases of hemiplegia from cerebral hccra- orrhage which terminate fatally, large hoemorrhages arc not frequently found in the retina on the same side as the brain- lesion, while no hnemorrhages are pres- ent in the opposite retiLO. 2. In cerebral 42 CEREBRAL HAEMORRHAGE. ETIOLOGY. embolism the same retinal condition is occasionally met with; also in cerebral embolism occasionally the retinal vessels are slightly dilated on the side of the brain-lesion. 3. In thrombosis of the middle cerebral artery, when the throm- bosis extends down into the internal caro- tid, the vessels of the retina on the side of the brain-lesion may be markedly di- lated and tortuous, while the retinal ves- sels of the other eye are normal. R. T. Williamson (Brit Med. Jour. June 11, '98). The term apoplexy is still loosely used even by the best writers. Cerebral arterial disease is almost never due to vascular involvement of the brain, ex- cepting when the cardiac or respiratory centers are involved. Sudden death is almost always due to heart disease. A diagnosis between cerebral haemorrhage and thrombosis is desirable, but impos- sible. In haemorrhage the treatment should be directed to lower vascular pressure, while in thrombosis exactly the opposite line of procedure should be employed. H. N. Moyer (Amer. Medicine, May 25, 1901). Differential symptoms of pons haemor- rhage as compared with cerebral haemor- rhage: (o) Headache, malaise, vomiting. (6) Sudden and profound coma, (c) Twitching of the face and limbs or both, (d) Miosis and convergent strabismus or conjugate deviation (away from the side of the lesion), (e) Slow, irregular breathing. (/) Irregular pulse, {g) Dys- phagia, (h) Paralysis of limbs or crossed paralysis and exaggerated reflexes, (i) Gradual rise of temperature, sometimes to high points. (/) Death inside of twenty-four hours. Acute softening of the pons-medulla is probably more frequent than haemor- rhage. It may be divided into three gen- eral groups: 1. The syndrome of medul- lary softening. 2. The syndrome of pons softening. 3. A general syndrome, in- cluding symptoms seen in lesions of both pons and medulla, or in lesions in which the focus, while lying in one part, ex- tends into the other. This latter symp- tom group is as follows: (1) hemiplegia; (2) pain-temperature; (3) ancesthesia on the same side as hemiplegia; (4) loss of deep (muscular) sensibility, with ataxia, often on opposite side to hemi- plegia; (5) lateropulsion to side of le- sion; (6) paralysis of various cranial nerves, especially seventh to twelfth, on the side opposite to the hemiplegia; (7) dysphagia and dysarthria; (8) paralysis of sympathetic on same side as lesion, with miosis and refraction of globe; (9) subjective sensations of vertigo, roaring in ears, parathria, and pain; (10) disturbances in rhythm of pulse and respiration. C. L. Dana (Medical Rec- ord, Sept. 5, 1903). Etiology. — The immediate cause of the hsemorrhage is, of course, the rupt- ure of some vessel, usually an artery, but occasionally a vein. Back of these vascular changes we come to the real causes that interest the practitioner. And here there is a broad distinction between senile conditions and those other factors that may be active at any period of life. In the young a considerable propor- tion of the rare cases is due to the rupt- ure of some single large aneurism in the vessels of the pia; as to their etiology, little is known. Except for these and be- fore the advent of senility we find either nephritis, syphilis, local softening, trau- matism, abnormal blood-conditions, or possibly certain nervous influences as the predominant causes. Miliary aneurisms have much less to do with its causation than has previ- ously been held, and, apart from mechan- ical causes, such as trauma, etc., haemor- rhage of the brain is most frequently due to disease of the vessels that causes a loss of elasticity in their walls. Typical miliary aneurisms are rare, but ather- omatous and syphilitic changes of the vascular walls play a very extensive rOle. Mechanical causes are more common than is commonly held to be the case in producing hicmorrhagc, without any real arterial disease suHicicnt of itself to produce it. L. Stein (Deut. Zeit. f. Nervenh., vol. vii, p. 313, 'OB). Case in an infant 5 days old. Not- withstanding absence of marked cerebral CEREBRAL HAEMORRHAGE. ETIOLOGY. 43 symptoms, extensive hoemorrhage into the brain, no convulsions or even un- consciousness were present. T. M. Rotoh and A. H. Wentworth (Boston Med. and Surg. Jour., Aug. 15, '95). Case of mixed haemorrhage and throm bosis secondary to mitral disease in a child 7 years old. Fox (London Lancet Jan. 27, '94). While cerebral hoemorrhages often fol low the development of small aneurisms, and embolic lodging in arteries may cause the development of aneurisms aneurism with subsequent cerebral hoemorrhage as the result of verrucose endocarditis may also occur. In 3 cases — the patients being 32, 45, and 50 years of age, respectivelj' — fatal cerebral htem- orrhage could be ascribed to the lodg- ment of a septic embolus, a fresh endo- carditis ingrafted on old disease being found, the arteries and the kidneys be- ing healthy. Four other illustrative cases mentioned. M. Simmonds (Deut. med. Woch., May 30, 1901). In traumatic cases the violence is a sufficient explanation. As a rule, the hfemorrhage results promptly. But there are now several cases on record showing that several hours or days, even a week or more, may intervene. These are mostly meningeal forms, yet it is cer- tain that some are intracerebral. It is these cases of delayed apoplexy that serve to associate the traumatic with the other varieties. Nephritis is one of the most certain causes. The arteriosclerosis that de- velops may later degenerate, allowing the vascular tunics to give way. In'any case the heightened blood-pressure and perhaps the circulating toxins so weaken the arterial wall that under some sudden stress it breaks. Syphilitic alterations of the vascular parietes seem at times to be the imme- diate cause of their rupture; though this claim needs a better basis than the fact that the patient is a specific or that antisyphilitic remedies produce a good effect. Much more certain are the cases where the break results indirectly. In them a former specific arteritis, that may long since have run its course, has left behind it a cicatricial and hence weak- ened spot which ever after remains. Like §11 sear-tissue, this has less resist- ance and too often in time yields. This point bas been strongly urged by Gow- ers. There are also evidently other cases in which softening of this origin makes the intermediary link to vascular rupt- ure. In neither of these latter forms can specific treatment well have any value; they differ only etiologically from the general run. Of 100 non-fatal personal cases 36 were due to syphilis; they occurred in early life and were often multiple in character. Cerebral htemorrhages were rarely repeated. Many cases showed changed vital conditions and personal habits. C. L. Dana (N. Y. Med. Jour., Jan. 5, '95). Local softening. This may be due to traumatism, embolism, septic infection, syphilis, or whatever other cause. The focus is usually not a large one, and not the cause of any definite sjTuptoms. Even if its presence were known, it is hard to see how anything could be done to remedy it or ward off this particular sequel. The prevention of the softening must depend on the general management of those affections that lead to it. Abnormal constitutional blood-condi- tions, such as scorbutus, purpura, per- nicious anjemia, leucocythaDmia, and severe infections with hai^morrhagic di- athesis may act as efficient weakeners of the vessel-parietes. IlEcmophilia is not known as a cause, however much it might darken a case. Nervous influences. The probability of these as a factor was suggested by the writer to explain certain occasional peculiarities, as the onset during sleep, 44 CEREBRAL HEMORRHAGE. PATHOLOGY. when the blood-pressure is lowest, the absence of aneurisms as a source of haemorrhage in many cases, the asserted occurrence of prodromata at times, and especially the occurrence of symmetrical haemorrhages. It is to the vasomotor control of these parts that such action must be assigned. This principle rests on the close bilateral association of the brain-hemispheres, and presumes that any general influence — as from the abdominal or thoracic viscera, reach- ing some centre or part of one hemi- sphere — affects at the same time or in immediate sequence its opposite in like manner. Possibly by allowing a dilata- tion of the arteries to the respective parts a strain is exerted on the vessels sec- ondary thereto, and thus weak points give way. Whether this cause can of itself be sufficient or whether it at most is only an immediate cause cannot be stated. Two cases of apoplexy which were considered as hysterical. Trophic lesions, such as oedema and hfemorrhage, as ob- served elsewhere in the body, may exist in the brain, according to his view. Hys- terical hiEmatemesis, hjemoptysis, and ecchymosis are well known ; there is no reason why similar lesions should not be found within the cranial cavity. There was no autopsy in either of the cases; if there had been, the hysterical nature of a haemorrhage could not have been dem- onstrated in this way. Gilles de la Tourette (Bull, et Mfimoires de la Soc. des H-Op. de Paris, June 4, '96). The changes that old age brings are universally recognized as predisposing to apoplexy. This has, in times past, lead to the assumption that cerebral haemor- rhage was only a matter of years. Be- cause senility is added to the other fac- tors this trouble is more frequent in the aged, though it has been found that in the very old cerebral thrombosis is a more frequent result. But, as the pre- vious causes are quite as common in the younger or stress years of life, there is no immunity at any period. Distinct from the above are the im- mediate provoking causes, of which there are many: straining at stool, lift- ing of heavy weights; plethoric states, as after excessive eating; rage, fright, the sexual act or other great excitement, severe coughing, meteorological condi- tions (rise in barometer, fall in atmos- pheric temperature), etc., come under this head. These all act by increasing the blood-pressure. Presumably they are, of themselves, insufficient without previous vascular change. Hereditary influence. Case of a man of 25, who had a bilateral cerebral h£em- orrhage, whose father and one brother died of left hemiplegia at 58 and 28 years, respectively, and whose sister died of apoplexy at 25 years. No history of syphilis. Bernard (BiJl. de la Soc. Anat., No. 26, '93). Case of cerebral haemorrhage in a woman of 52, with tumors of the parotid and frontal regions, who received 28 cubic centimetres of chloroform, the anassthesia lasting one hour and Ave minutes. Coma followed at once, last- ing eight hours; then she gradually recovered, showing left-sided complete paralysis of the arm, less complete of the leg and right side of the face, with complete insensibility in the left arm, less marked on the entire left side of the body. She slowly recovered. Boureau (Revue de Chirurgie, July, 1902). Pathology. — This resolves itself into three questions: (1) as to the vascular changes preceding or attending the rupt- ure, (2) as to the blood thrown out, and (3) as to the changes of nerve-tissue re- sulting therefrom. 1. In the usual spontaneous cases we find some alteration of the vessel-wallt that weakens their resistance. Fatty and atheromatous degeneration is com- mon in the aged, and appears earlier in CEREBRAL H.-EMORRHAGE. PATHOLOGY. 45 those who have done heavy lifting, over- indulgence in alcoholics, or for any cause developed premature senility. Nephri- tis and the uric-acid diathesis lead to arteriofibrosis, which later breaks down. Specific arteritis leaves an atrophic con- dition of the vascular wall, and this may, in time, yield. Aneurisms (miliary) sometimes develop, as found by Bou- chard and Charcot, doubtless on the basis of some of the conditions just men- tioned, and presently one or the other of these may give way. Later studies have shown that far from all spontaneous cases are due to the rupture of such aneurisms. We must conclude that weakened spots sometimes give way directly; i.e., without the intervention of such dilatation. Three cases of multiple lesions of the brain. These are very uncommon, hav- ing been the only ones found out of a total of 4000 post-mortem examinations. Clinically they are interesting because the symptoms during life did not lead to suspicion of the presence of the ex- tensive lesions found post-mortem. In the first case there was headache, un- consciousness lasting two hours, and muscular twitchings, but no paralysis after a htemorrhage consisting of more than an ounce of blood. After the sec- ond hiemorrhage there were headache, spasm, but no motor paralysis, hemia- nopia, and dementia, and yet the second clot was larger than the first, and it was only after the third attack, when more than five ounces of blood was ef- fused, that hemiplegic symptoms and coma supervened. This case is an ex- ample of the adaptability of the brain to rapid increases of intracranial press- ure. Freybergcr (Edinburgh Med. Jour., Nov., 1901). In numerous other cases purely local troubles so undermine the vessel's strength that it ruptures. The writer has shown this for foci of softening; these erode and weaken the wall of some vessel in the involved area; then, of course, rupture easily results. Em- bolism also, and in like manner, some- times occasions an early break at the point of plugging. Then tumors not rarely so weaken and drag on the local vessels that small and large haemor- rhages result. There is no conclusive evidence that either increased blood-pressure or nerv- ous influences are ever of themselves suf- ficient to rupture a brain-artery, without pre-existing degenerative changes in the vessel-wall. Though any part of the brain may be the site, there are certain favorite start- ing-points. These correspond to the territory of the terminal arteries, viz.: the pre- and post- perforating and the branches from the basilar entering the pons. Statistics regarding site have been collected in this country by Dana. Seventy-seven personal cases appar- ently confirming Dana's views. Longest duration since attack had been twenty- two years. E. D. Fisher (N. Y. Jled. Jour., Jan. 5, '95). Four cases of traumatic cerebral hemorrhage, in all of which the vessel ruptured was the middle meningeal. In one case, a man aged 75, operation re- sulted in perfect recovery. Rasing (Hospitalstidende, No. 3, '93) ; Little- wood {London Lancet, Feb. 17, '94). 2. As to the blood thrown out. There is less resistance to the outflow in the gray than in the white matter. It may vary in quantity from minute capillary extravasations up to those of several ounces. Some coagulation soon takes place in the extra vasated blood; but be- fore this has occurred the blood — if, e.g., it has found a way into the cavities or meninges — may have scattered ■widely in these spaces and have even passed over in part to the other side. Where, how- ever, it has not broken through, but been retained in one focus, it remains long enough and sufficiently fluid to 46 CEREBRAL HJEMORRHAGE. PATHOLOGY. work its way into all accessible inter- stices. This is assisted, so long as the flow continues, by the pressure of the blood in the ruptured vessel. As a con- sequence, the focus is always irregular and ragged in shape. Much also de- pends on the surrounding structures; if these are stratified tracts the blood naturally makes a long pocket; if, how- ever, these are soft tissues or matted fibres, then a more globular focus re- sults. The free fluid and granular material is gradually absorbed, leaving the char- acteristic brownish pigment and some- times pultaceous material that long re- mains like a cyst. Experimental studies to determine the age of haemorrhagie extravasations. Haemorrhage artificially induced in rab- bits through a trephine-opening. Ani- mals lived from one to seventy-two days. Certain changes in cellular metamor- phosis and in chemical character found to occur with marked constancy. Most marked changes corresponded with the first, second, fifth, sixth, eighteenth, twentieth, and forty-fifth days. Hsemo- siderin is the chemical medium through which the age of the haemorrhagie extrav- asation may be approximated. Herman Durck (Review of Insanity and Nerv. Dis., June, 94). 3. Changes of nerve-tissue, caused or provoked by the haemorrhage. The pri- mary effects consist of tearing and com- pression of the surrounding substance. The fibres and gray matter may be forced apart, but often they are ground up, disintegrated, and mixed with the blood, making a pulp into which pro- ject abundant fragments of severed tracts. Where fibres are simply forced apart, there may be scarcely any of this chowdering, the compression of adjacent tissues being then all the greater. In limited efFusions the compression is ex- erted ehieflv on the immediate neigh- borhood; but, where the volume is considerable, it may aft'ect the whole brain, as is shown by the vomiting, coma, etc. Nerve-fibres once severed do not, so far as we know, ever reunite; conse- quently loss of function due to this cause must be permanent. On the other hand, fibres whose function is disturbed by compression or oedema inay yet regain their usefulness, and to this is due the degree of recovery that we often see. For on this acute stage there follows one of reaction. It is largely due to the ac- companying infiltration and inflamma- tory cedema of adjacent parts that so many cases end fatally in from two to ten days. Even where life is retained this reaction still further Jeopards neigh- boring structures and diminishes the ex- tent of eventful recovery. There are finally certain secondary changes of nerve-tissue that may de- velop. These affect only such nerve- fibres as have either been directly sev- ered by the effusion or so much involved as to be unable to recover even their trophic function. Then the portions of these neurons that have been cut off from their respective cells undergo de- generation the same as do severed fibres in peripheral nerves. In the case of the pyramidal or spinal motor tracts this degeneration may extend do^vn the cord to the anterior horns; but the terminal, or spinal, motor neurons, being inde- pendent structures, are not generally involved in this process. Of course, fibres going to other parts of the brain will degenerate in like manner if sev- ered from their parent-cells. While in the peripheral nervous system there may be a regeneration of severed or degen- erated fibers, nothing of the kind is known to occur in the central nervous system. CEREBRAL HAEMORRHAGE. PROGNOSIS. 47 Prognosis. — This must be based on the following factors and on the accuracy with which we can determine them. There are, however, two separate ques- tions in the matter of prognosis: one has regard to the continuation of life and the other to the extent of recovery from the attack. The age of the patient. In childhood the rare cases that do occur are usually severe; but, if the attack itself is out- lived, the natural recuperative power is so great that the person will live on indefinitely. Improvement may be ex- pected for some years, but entire recov- ery is unusual. In middle life the outcome depends on the causal trouble and the severity of the apoplectic attack. Where the motor involvement is not great or is due to indirect pressure, practically complete restitution of all functions is occasion- ally observed. More often some impair- ment of the involved area remains. If the primary cause still obtains, this also interferes with recovery and the general outlook. In senile conditions (tortuous or cal- cified arteries, dry and wrinkled skin, areus senilis, etc.) but limited recovery is to be expected. Life may be pro- longed, but most depends on the promptness with which the attack is checked. The subsequent length of life depends much on the kindness and care with which the chronic invalid is sur- rounded. Nephritis. Here we must distinguish between unimportant secondary or cas- ual albuminuria and real kidney disease. The latter, when present, limits recov- ery and determines the eventual dura- tion of life. Even with this complica- tion, however, if the site and extent of the effusion be favorable, the paralytic condition may be fully recovered from. Syphilis. The existence of this sys- temic infection is principally of etio- logical importance. It may constitute an indication for treatment, but other- wise has little significance. Severity and nature of the attack. This is the great guide to prognosis. Coma, stertor, vomiting, prolonged semiconsciousness, extensive and com- plete paralysis, etc., indicate a large effusion with much damage to the brain, both in local destruction and general shock. Consequently there is immediate danger to life and much less chance of functional recovery when life is pro- longed. In proportion as these features are less prominent the chances for pres- ervation of life and for recovery are increased. Prolonged high temperature, or a rise to 104° or 106° F., makes a fatal prog- nosis probable. General convulsions, as indicative of ventricular rupture (barring ura2mia), are a particularly-bad omen, death usu- ally resulting in from a few hours to a few days. Location and size of the lesion. These two features are complementary. For, though much depends on the site, still a large outpour by its mere volume may include temporarily all the effects of the smaller, and certain general effects in addition. Pontile hasmorrhages are more often promptly fatal, doubtless from the im- portance of the local centres and passing tracts. The outpour is also more rapid because from relatively large vessels and close to the parent-trunk. On the con- trarj', hemorrhages of the pallium (that part of the cerebral hemisphere above the central ganglia) commonly become vast in size before inducing as serious symptoms. Inequality of the pupils developing as 48 CEREBRAL ILEMORRHAGE. TREATMENT. a part of the attack, especially where the larger is on the side of the supposed haemorrhage, siiggests a large focus, and hence points to a more serious condition. This is, however, by itself quite inde- cisire. After the acute stage has been tided over the extent of presumable recovery is the main matter for prognosis. Here, besides the points already presented, other manifestations have to be consid- ered. The state of the tendon-reflexes in the involved area must be determined; if there is any increase compared with the other side, we can pretty safely con- clude that some permanent injury of nerve-tracts will remain, though a slight local increase is not incompatible with apparent functional recovery. Any marked increase of these reflexes — as ankle-clonus or wrist-clonus or a knee- jerk of ten inches, say — means lasting paralysis. The occurrence of oedema or contractures in the paralyzed part signi- fies so grave a lesion of the motor path as to preclude hope of recovery. The anaesthesias that are so frequently present in the early or acute stage rarely prove lasting. The occasional develop- ment of chorea in the affected extremi- ties is in so far a good sign as it indi- cates returning conductivity of the mo- tor tracts. Three important prognostic indica- tions: 1. Renal disease the most im- portant. 2. Cheyne-Stokes respiration. 3. Hyperpyrexia. If one, two, or all three be present, patient will, in all prob- ability, not recover. Diabetes, chronic alcoholism, typhoid fever, idiopathic anffimia will also exert fatal influence. A. G. Barrs (Brit. Med. Jour., May 18, ■9.-,). Treatment. — It cannot be too strongly urged that the first desideratum is a cor- rect diagnosis. Upon this must our treatment primarily depend to be efTi- caciouB, since the adections that most closely simulate cerebral haemorrhage demand directly opposite treatment. As the therapeutic indications in cere- bral hemorrhage vary considerably ac- cording to the stage of the trouble, they can best be considered under four heads: — Prevention. — In general the prophy- lactic management is indicated by the etiological factors. If there are any sus- picions of prodromata, the patient must be warned against all lifting and strain- ing, the bowels be kept free (calomel or salines), any overtension of the pulse be eased by mild depressants, and the patient kept in a wann atmosphere well protected from all chilling. Digitalis and cardiac stimulants of every sort should be carefully avoided. Any nerv- ous overtension can advantageously be remedied with bromides, and their use here is regularly in order. During the AttacJc. — Some cases are promptly fatal, meningeal, and ventric- ular forms being usually of this kind. Nearly always, however, the effusion progresses for some time. It is here that the physician can be of great serv- ice, and as there is rarely time to call for consultants it is important that every practitioner understand the methods fully. The first and main object is to stop further haemorrhage. Our efforts should he directed to a lowering of the arterial pressure, and to a derivation of the Mood- current to other parts; i.e., in general to a reduction of the supply to the brain. For this purpose a variety of means are available and when promptly applied are successful. Management of cerebral hDemorrhage and its abortive treatment: 1. Do not Rive stimulants. Their use in such cases is most reprehensible. The patient is prostrated, and the lay mind naturally turns to tonics and bracers: about the CEREBRAL HEMORRHAGE. TREATMENT. 49 worst thing that can be done. 2. Do not resort to saline injections. During the acute stage a limitation of fluids is in order. 3. Do not use the depressant diaphoretics, such as ipecac, pilocarpine, or apomorphine. They t«nd to nauseate : an inclination otherwise too common, and, in the degree of attempts at vomit- ing, most undesirable. 4. Do not pre- scribe digitalis. It is a dangerous drug in any individual with a liability to apoplexy, and for this, if for no other reason, of unquestionable utility in nephritis. If anything of this sort must be used, strophanthus, in the author's experience, is by far the safest. 5. Do not resort to opiates. 6. Do not try nitrites. 7. Do not permit any muscular exertion on the patient's part; and mov- ing by others should be limited as much as possible. In the subacute stage the important question is; when should the patient be encouraged to sit up? He should be kept as quiet as possible for the first few days, lest further effusion occur from the same vascular rupture. In about a week sitting up should be en- couraged. Give vascular depressants in lesser dose at this time. Care should be taken that the patients should not be allowed to remain listless abed and thus a secondary dementia be favored. In the chronic stage, which is often hopeless enough, the use of nux vomica, massage, electricity, etc., is to be tried. The chief benefit will be derived from cultivating in the patient whatever power remains. William Browning (New York Med. Jour., Feb. 15, 1902). Position of the Patient. — The main essential is a sufficiently prone attitude to insure complete relaxation of all the muscles, since we know that muscular effort tends to increase arterial tension. On the other hand, dropping the head too low favors the flow of the blood to the brain: a principle that we apply in cases of fainting, ansmic exhaustion, chloroform syncope, etc. The best posi- tion, then, for a patient with progressing cerebral haemorrhage, is to have the body sufficiently reclining to be fully relaxed and the head considerably elevated. When a patient has sunk into a state of unconsciousness from brain compres- sion from intracranial hsemorrhage, a re- covery from this state will not occur unless the compression is relieved. War- basse (Brooklyn Med. Jour., Jan., '99). Sometimes the vomiting in such a case appears to be eased by turning the person on the right side; it is further claimed that turning the person on the paralyzed side eases the stertor. Vaso-drugs. — The proper use of these remedies is our most valuable single re- source. Ergot can well be discarded. The cardiovascular depressants — gelse- mium, veratrium, or aconite — are suffi- ciently powerful and yet ordinarily safe means. Either of these can be admin- istered hypodermically, though they also act promptly by the mouth. Where the pulse warrants its use, it is well to begin with gelsemium. In adults the fluid extract can be started with an initial dose of 2 to 5 drops and fol- lowed by drop-doses at intervals de- pendent on the closeness with which the case can be . watched. It should be pushed until its physiological action is manifest, whether little or much is re- quired. The full benefit of the drug is not obtained unless its paralyzing effect is secured. When medication on tliis line has to be continued for any length of time, it may be necessary to change, especially from full doses of gelsemium. Then the others become useful. Veratrium is next in order; and both because of the more general familiarity of the profession with this drug, and of our knowledge of its safety from the ample experience with its use in puerperal eclampsia, it will, with most practitioners, prove the most acceptable remedy from the start. 2—4 50 CEREBRAL HAEMORRHAGE. TREATMENT. With the use of aconite for this purpose I have no experience; but, relying on its physiological action, there is no doubt that in the absence of either of the other drugs this might be a fair substitute. It is usually advisable to keep up some influence of this kind for from a couple of days to a week. The use of nitroglycerin in this stage of brain hemorrhage almost certainly does harm, and should be abandoned. All stimulants, vascular tonics, mor- phine, or opiates, and, for the time, strychnine should be carefully avoided. The possibility of increasing the co- agulability of the blood by internal agencies does not yet seem to have been realized. AutodepMion. — This can be prac- ticed by constriction of the extremities near the trunk. This is a very promptly- acting, but temporary, expedient with many limitations. A coarse binder should be used. Brittle vessel-walls are a distinct contra-indication. Only suf- ficient force should be used to more or less shut off the veins without affecting the arteries (if too much we but strangle the extremity; if too little we fail of our purpose). Care must be had lest the extremity become too cold. Finally the constriction must be eased up gradually, lest the sudden influx into the general circulation again start up haemorrhage. Warm bottles to the extremities, mus- tard to the soles, and gentle frictions are, of themselves, useful in drawing blood to the parts, and are doubly so when constriction is resorted to. Compression of the carotids is a doubt- ful measure, as the vessels in older pa- tients are easily injured and a steady control of the current for any length of time is rarely possible. Ligature of a carotid is literally adding injury to in- sult. Ice to the head is a popular plan, but also of very uncertain value. If used at all for this purpose, it might far better be applied over the carotids in the neck. Depletion of Body-fluids. — Formerly this was the main treatment, and prac- ticed in the form of venesection. Many still think highly of this procedure for vigorous patients with a tense pulse. "The indications for venesection are a regular, strongly-acting heart, and an incompressible pulse." The most common and still accepted method is by purgatives, as a drop of croton-oil on the tongue, a good dose of calomel, or a glycerin-and-sulphate-of- soda enema. Pilocarpine might be admirable, since it acts both as a depressant and a fiuid- depleter, but for certain risks, as of pul- monary cedema. There may be other matters that re- quire attention. Convulsions should be promptly stopped, and for this purpose a few whiffs of chloroform may suffice. The efforts of vomiting are injurious, but it is seldom possible to arrest them. If the bladder is full, catheterization may be necessary. Treatment of the Eeaction {or the Sub- acute Stage). — Here there is still some shock, an actual destruction of brain- tissue, a compression of adjacent tracts by the extravasation, and an inflamma- tory reaction of immediately-surround- ing parts. We have little to offset this. Counter-irritation can hardly act that deeply. Iodides, to favor quick absorp- tion of clot, are the routine treatment. Trephining, with evulsion of clots, would be in order in this condition, although, owing to difficulty in exact localization and the usual depth of the focus below the surface, such operative relief is rarely feasible. During this period we may have to continue de- CEREBRAL HEMORRHAGE. TREATMENT. 51 pressants, and wait with nux vomica or its alkaloids. "Negatively the use of digitalis in a patient who has once suf- fered from brain-haamorrhage is ever after a risky matter." Case of traumatic htemorrhage into the white brain-substance followed by aphasia, hemiparesis, and Jaeksonian epilepsy. Recovery after surgical inter- ference. Conclusions: 1. Extravasations of blood of traumatic origin can be removed from the brain-substance by surgical methods, as well as contused and destroyed brain- substance, and in the same manner pathological and circumscribed portions of brain-matter. 2. It is possible that extravasations of blood other than those of traumatic origin may be removed by surgical interference. 3. The brain does not resent surgical procedures more than any other part of the body. Borsuk and Wizel (Archiv f. klin. Chir., B. 54, H. 1, '97). Two cases of cerebral haemorrhage treated by trephining with a view to evacuation of the clot. In the first case a htemorrhagic cavity was exposed in the right parietal lobe, and several clots mixed with detritis of cerebral sub- stance were removed, the operation re- eulting in a rapid and complete cure. In the second case a clot could not be found, but the patient gained consider- able benefit from the relief of intra- cranial pressure due to the exploratory trephining. The author, in discussing the question of surgical intervention in cases of cerebral htemorrhage, puts on one side the proposal to ligate the com- mon carotid. The benefit to be derived from this operation he holds to be il- lusory, as it cannot influence existing lesions, and that it can do good in pre- venting renewed htemorrliage has not been proved. Moreover, it is undoubtedly a grave procedure and may by itself cause death. In the author's opinion, the surgeon should endeavor to expose by trephining the seat of htemorrhage, to suppress cerebral compression by re- moving the clots, and also to prevent or overcome infection of the attacked por- tion of brain by drainage. The cranium. it is suggested, should be trephined over the fissure of Sylvius. The dura mater, having been exposed by an orifice from 3 to 4 centimetres in diameter, should be incised, and the brain punctured by an exploratory needle in the direction of the internal capsule. If a htemorrhagic focus be dis- covered, it should be exposed by incision of the cerebral substance and the cavity be freely laid open and drained by gau2e. This operation will, it is stated, often remain simplj- an exploratory one, and in many ctises — as, for instance, those of abundant effusion and ventricular and bulbar haemorrhages — such treatment, the author acknowledges, will be quite useless. In certain eases, however, life may be saved by exposure of the region of haemorrhage, and the mode of inter- vention proposed by the author is held to be free from risk. Lambotte (Ann. et Bull, de la Soc. de Jl6d. d'Anvers, July-August, 1902). For the hemiplegic after the condi- tion has settled down into the chronic stage our resources are sadly limited. Str}-chnine or its congeners internally, sometimes electricity locally to the mus- cles, and care of the general health com- prise all that is rational in customary procedure. Eecently a German writer has done good service by calling attention to the importance, in these cases, of doing everything to bring activity again into the patient's impaired nerve-tracts. He shows that by rousing these persons, lift- ing them — when not too feeble — into a sitting position, getting them once more interested in life; further, by ex- ercising actively and semipassively the paretic muscles, we can save the patient from the further degeneration that so often ensues and may even effect great gain. To the value of this principle I can heartily subscribe. Ere beginning this plan, however, we must wait until the danger of immediate relapse is past, 52 CERIUM. THERAPEailCS. — say, usually until the end of the first week or ten days. William Browning, Brooklyn. CEEEBKO-SPINAI MENINGITIS. See Meningitis. CERIUM. — This is an exceedingly rare metal, found in nature only in the form of a hydratecl silicate. Its chief source is a Swedish mineral known as cerite, though it also occurs in brown apatite, and is always found in con- nection with lanthanum and didymium. Unfortunately the salts that are em- ployed medicinally are often found dis- appointing in therapeutic efficacy, owing to the presence of these two latter min- erals. Cerium is white, very brittle, almost infusible, and insoluble in water. Its salts appear as white granular pow- ders that for the most part are only slightly soluble in water and alcohol, and one, the oxalate, is wholly insoluble therein; with the exception of the valerianate, all are practically odorless and tasteless. Preparations and Doses. — Cerium bromide, 5 to 20 grains. Cerium nitrate, 1 to 10 grains. Cerium oxalate, 2 to 15 grains. Cerium valerianate, 1 to 10 grains. Physiological Action. — Practically nothing is known as to the physiological action of the cerium salts; not even their elimination is understood. They are, however, tonic, sedative, and ant- acid, and the bromide and valerianate are also to some degree antispasmodic. Therapeutics. — The bromide salt is a comparatively recent introduction, but it is the least valuable of the bromides, and as a tonic and sedative inferior to other preparations. The nitrate was in- troduced by Sir James Y. Simpson as substitute for bismuth salts, nitrate of silver, and hydrocyanic acid. "In chronic intestinal eruption, a peculiar and intractable form of disease for which arsenic and silver nitrate are generally prescribed, Simpson employed the salts of cerium with marked advantage" (Waring). Gastric Disorders. — In irritable dyspepsia attended with gastrodynia, pyrosis, and chronic vomiting there is no remedy so prompt and satisfactory as cerium oxalate or valerianate; both, too, often afford ready relief in the vomiting of pregnancy; but, as before remarked, it is desirable that the salt be pure. In seasickness French authorities praise the valerianate; but here it is admittedly greatly inferior to "amyl- nitrite given by the mouth. Oxalate of cerium tried in seasickness in doses of 10 to 25 grains every two to three hours. It is superior to any other means personally tried. Also found serviceable in hundreds of cases of sick headache and in the morning sickness of pregnancy, but it must be in doses of at least 10 grains to do any good. W. H. Gardner (Med. Record, June 2, '88). Cerium given in seasickness in doses of Vi ounce every two hours in a num- ber of cases. Opinion expressed that it will relieve moro patients than any other remedy yet suggested. M. C. Wal- dron (Med. Record, June 23, '88). In diarrhoeal conditions, or any form of irritation of the intestinal tract, either the oxalate or valerianate prove far superior to any of the bismuth salts; so also in any form of vomiting that is reflex from intestinal or cerebral irrita- tion, spasmodic in character. Nervous Disoiiders. — W hooping- cough, too, is sometimes relieved in a most striking way by salts of cerium. In epilepsy, chorea, and other con- vulsive diseases in which nitrate of silver CHAULMUGRA-OIL. PHYSIOLOGICAL ACTION. 53 is frequently employed, cerium salts deserve trial, for, as Simpson remarks, they are certainly attended with the ad- vantages that, at the same time, they act as tonics and sedatives. Their use may be persevered in without endanger- ing appetite or digestion and without fear of discoloring the skin. In some cases of migraine the cerium salts afford speedy relief; but it is prob- able that here the chief value of the remedy lies in its antacid effect. In the gastric crisis of locomotor ataxia cerium oxalate may be employed with decided success. The duration of the attack is lessened, the vomiting greatly reduced, and the pain and na jsea relieved, sleep returns, and alimentation is, to a certain extent, possible. Ostan- koff (La M6d. Mod., Aug., '96). Case of a woman, 40 years old, hys- terical, who was accustomed to take oxalate of cerium, and who finally de- veloped a cerium habit. She once took Vj ounce in six hours and during two months ingested 5 ounces. No apparent effect was noticeable, though she de- clared it made her "feel more comfort- able." Craigen (Med. Standard, Sept., '9G; Med. Age, Oct. 26, '9G). CESTODES. See Parasites, Intes- tinal. CHALAZION. See Blepharitis. CHANCRE. See Syphilis. CHANCROID. See Syphilis. CHAPPED LIPS. See Mouth. CHAULMUGRA-OIL.— This is a pale- brown or yellowish-brown oil obtained by expression from the seeds of the Gynocardia odorata, which is a native of farther India, more particularly of the Malay Peninsula, and is most abundant in the forests between Sikkim and Han- goon. It is always solid and unctuous in the temperate zone; has a disagree- able taste and smell; and is a compound of palmitic, hypogasic, cocinic, and gyno- cardic acids, of which latter a fair prod- uct will usually yield from 10 to 12 per cent. The oil generally found in market is rarely pure; and doubtless its vari- able characteristics are responsible for the fact it no longer enjoys in Europe and America the reputation that obtains thereto in India and the Orient. Gynocardic acid is the active con- stituent. It is a yellow, unctuous solid with acrid, burning taste, the odor of the oil, and melts at 85° F. "With sul- phuric acid it strikes a green color, which has been cited as a test for character and purity; but, unfortunately, palmitic acid gives the same precise reaction. Preparations and Dose. — Chaulmugra liniment. Chaulmugra-oil, 5 to 30 minims. Chaulmugra ointment (1 to 3). Gynocardic acid, 1 to 5 grains. Physiological Action. — Chaulmugra- oil (or chaulmoogra-oil) and gynocardic acid alike appear to be highly alterative and tonic in action. Both, in medium doses, leave an unpleasant taste in the mouth, and likewise some irritation of throat and pharynx; later a feeling of nausea supervenes, with oppression in the epigastrium, followed, perhaps, by vomiting, usually by slight purging, after which all symptoms quickly subside. The gynocardic acid is less likely to produce nausea; hence is more readily tolerated. Under continued administra- tion nutrition seems to be improved, and a gain in weight is likely to be observed. Applied locally, both are demulcent and lubricant; but, like all fatty sub- stances, they act more benignly when the acute stages of inflammation have passed. This fact should always be borne in mind when prescribing as an ointment or liniment or when applying 54 CHAULITUGKA-OIL. CHLORAL. pure in skin affections, to inflamed joints, etc. Therapeutics. — The inhabitants of southeastern Asia have long employed chaulmugra-oil, both externally and in- ternally, in the management of leprosy, skin diseases of a chronic scaly variety, in scrofula, rheumatism, etc. Its most prominent effects have been observed in the tubercular and anaesthetic forms of leprosy. Case of macular leprosy in boy of 14. Patient first manifested signs of the dis- ease at the age of 10, when erythematous and pigmented raised patches, mostly ansesthetic, appeared on various parts of the body. Chaulmugra-oil was given in doses of 12 drops daily with persistent increase, so that by the end of a year the daily quantity had become 400 minims. The anaesthesia, swelling, and erythema entirely disappeared from the patches, and the pigmentation was rapidly fading. T. D. Savill (Lancet, 1, p. 1283, 1900). In psoriasis, lupus, and allied skin affections; in old eczemas with thick- ening of the skin; in scabies and ring- worm; in the form of liniment as an application in rheumatic arthritis, rheu- matic gout, stiff joints, and strains. Mixed with chloroform and menthol it appears to have been very beneficial in some cases of neuralgia, sciatica, etc. In giving the oil internally it is best to begin with 3 or 4 grains, administer- ing after meals, and gradually increasing to the limits of toleration, which will usually be found somewhere between 30 and 60 grains. If the acid is employed, it is best administered in the same way, viz.: */2 grain after meals and gradu- ally increased to 3 or 5 grains. It must be admitted, however, that these prep- arations do not seem as active in the temperate zone as in the tropics, and that the white races are not so appre- ciably affected thereby as the dark. CHEST, INJURIES OF. See Wounds AND Injuries of Thoeax. CHICKEN-POX. See Varicella. CHILBLAIN. See Pernio. CHILLS AND FEVER. See Malarial Fevers. CHLORAL: ITS DERIVATIVES AND COMPOUNDS.— Chloral, or anhydrous chloral, is by no means chloral-hydrate, as is generally imagined and so very erroneously taught. Chloral, per se, is a trichloracetic aldehyde, and can be obtained only in the form of a color- less liquid, which, when shaken with water, absorbs one molecule of the latter and forms a solid, constituting chloral- hydrate. It also possesses an aldehyde odor; it boils at 201.2° F., while chloral- hydrate only boils at 207° F. By ox- idation it forms trichloracetic acid, and the action of nascent hydrogen reduces it to aldehyde; by the alkalies it is at once decomposed into chloroform and a formate of the alkali employed. True chloral is difficult to keep, and always requires to be tightly corked in a dark- hued container and carefully set away in a dark, cool place. It possesses little interest for the physician, except as be- ing a source of chloral-hydrate, and the fact that sulphuric acid added to the latter causes it to decompose into meta- chloral and chloral. Preparations and Doses. — Chloralamid (chloralamide; chloral-formamide), 10 to 45 grains. Chloral-ammonium, 15 to 30 grains. Chloral-antipyrine (hypnal), 15 to 30 grains. Chloral-caffeine, 3 to 10 grains. Chloral-camphor (camphorated chlo- ral), topical chiefly; internally, 10 to SO CHLORAL. PREPARATIONS AND DOSES. 55 Chloral, croton- (see Butyl-chloral). Chloral-formamide (see Chloral- amid). Chloral-hydrate, 10 to 50 grains. Chloral-imide (chloralamid; trichlo- rethylidenimide), 10 to 30 grains. Chloral-menthol (menthol-chloral; mentholated chloral), for topical use. Chloral-ose, or chloralose, 1 to 3 grains. Chloral-quinine, 3 to 10 minims. Chloral-thymol, topical application only. Chloral-iirethane (iiral; iiraline; ura- lium; urethane-chloral), 10 to 45 grains. Chloral suppository, 15 grains of mixt- ure. Chloral syrup, 30 to 120 minims. Chlorobrom, or chloro-brom: a mixt- ure of potassium bromide and chloral- amid. Bromochloral, compound liquid of, 30 to 120 minims. Butyl-chloral-hydrate, 15 to 30 grains. Butyl-chloral mixture, 4 to 8 drachms. Butyl-chloral pills, 1 every one or two hours. Butyl-chloral pills with gelsemium, 1 every one or two hours. Chloral-ammonium is a white, crys- talline powder with a chloral odor and taste, soluble in alcohol and ether, in- soluble in cold and decomposed by hot water, melting at about 147° F. It is employed as an hypnotic and analgesic, is claimed never to disturb the stomach, and to be devoid of all the unpleasant factors peculiar to chloral-hydrate: claims by no means substantiated. It is employed chiefly in nervous insomnia of all kinds and also in mental troubles. Chloral-antipi/riiie is, perhaps, better known by its trade name: "hypnal." It is scarcely so much a chemical as a mechanical compound, and is had in colorless crystals that are soluble in six parts of water. It is hypnotic, analgesic, antipyretic, and antiseptic, and chiefly employed in insomnia, headache, spasm, cough, etc. Chloral-hydrate is the drug in most frequent use, and, as already remarked, is obtained by the addition of one mole- cule of water to anhydrous chloral, whereby are formed crystals (monoclinic prisms) melting at 135° F., and at 207.5° separating into chloral and water; the vapor is not combustible. It has a some- what pleasant, penetrating, pungent, aromatic odor, in which, also, is speedily recognized more than a mere suggestion of acridity. Bitter to taste, it is also, in some degree, caustic; is more or less volatile according to the atmospheric conditions to which it is exposed; solu- ble in almost anything and everything, including fixed and volatile oils; and, when triturated with equal proportions of stereopteus or camphoraceous bodies, combines to produce a liquid. A great deal of the chloral-hydrate marketed is of impure quality, being in combination with chloral-alcoholate (to the presence of which untoward accidents are fre- quently laid), hydrochlcric acid, chlo- rides, etc. The test authorized by the British Pharmacopoeia is that of sul- phuric acid acting on a strong solution of the drug in chloroform, whereby, if absolutely pure, no brown color is devel- oped; the U. S. P. directs the acid to be employed withoiit chloroform and the mixture also to be warmed, and re- quires it shall not blacken. JIanifestly the last test is not as reliable or delicate as that of the B. P. A fair idea of purity can be had, however, by pressing be- tween two leaves of blotting-paper, when, if impure, oily spots will be formed. It should make a neutral solution with water without forming oily drops; should not be decomposed readily by the 56 CHLORAL. PREPARATIONS AND DOSES. action of the atmosphere; the aqueous solution acidulated with nitric acid affords no evidence of chlorine when treated with silver nitrate. Chloral-caffeine appears as colorless, glittering, small rods or leaflets, solu- ble in water. It is said to be a molec- ular combination of the drugs repre- sented, but this has never been defi- nitely proved; certain it is that alkalies decompose it into chloroform and caf- feine. Being hypnotic, sedative, and analgesic, it has been employed, both by the mouth and hypodermically, and in nervous insomnia, neuralgia, sciatica, rheumatism, headache, etc. Chloral-camphor or camphorated chlo- ral, thymolated chloral, carbolated chlo- ral, quinine-chloral, and mentholated chlo- ral, with the exception of the first named, are employed only in a topical way; all are made by melting the re- spective constituents with chloral. Thus the camphorated — which appears as a transparent, almost colorless, syrupy liquid — is prepared by triturating equal parts of gum camphor and chloral-hy- drate in a warm mortar; it is soluble in all proportions in alcohol, ether, oils, and fats, but not at all in pure water; is antiseptic, analgesic, and slightly epi- spastic applied externally, and internally administered powerfully hypnotic and narcotic. Chloral-phenol is an oily liquid com- posed of 3 parts of carbolic acid and 1 part of chloral-hydrate; is analgesic and antiseptic, and employed by inhala- tion, or is topically applied. Chloral-quinine is another fluid devel- oped by mechanical mixture of two drugs, but is more of a curiosity than a medicament. Chloral-menthol and chloral-thymol dif- fer little from chloral-camphor, and are put to much the same uses. Chloral-formamide, or chloralamid, is unfortunate in having a rival called chloralimide or chloral-imide, the latter being a trichlorethylidenimide. Thera- peutically, they are practically identical, save that the latter is about one-third more active and is not decomposed by water. Both are obtained as bitter, lustrous, colorless crystals, decomposed by heat, soluble in alcohol, 1 to 2, and in water about 1 to 20. They are hyp- notic, but not analgesic. The claim is advanced that vmdesirable effects are less frequent and less marked than from chloral-hydrate, but this is probably true only as regards the measure of activity. Neither are, in any degree, uni- form as to action. Chloralose is obtained from anhydrous chloral and glucose by means of heat, whereby are formed small, colorless crystals of bitter, disagreeable taste, slowly soluble in water, readily so in alcohol. It is deemed an hypnotic, and claimed to act by reducing the excit- ability of the gray matter of the brain, and also that it is free from the disa- greeable after-effects manifested by the heart, and the cumulative tendency that sometimes follow the exhibition of chlo- ral-hydrate. Properly this compound is an anhydroglucochloral, and in large doses is intensely toxic. Chloral-urethane (known also as chlo- ral-carbamide, urethane-chloral, ural, uralium, and uraline) is obtained by heating chloral-hydrate with urethane, then successively adding concentrated hydrochloric and sulphuric acids. It appears both as colorless, shining, lam- inated crystals and as a white powder, soluble in alcoliol and ether. It is rec- ommended as an hypnotic, especially in epileptic dementia, but is uncertain in effects and disagreeable to take, and CHLORAL. PREPARATIONS AND DOSES. 57 not infrequently nausea and disorders of digestion follow its exhibition. Chloral-hydrocyanate conies in white rhombic prisms, or as a white crystal powder, soluble in alcohol, ether, and water. It contains 15.33 per cent, of hydrocyanic acid, and is superior to the latter in that it is more permanent, and the dose more exact. One part dissolved in one hundred and sixty-six parts of water makes bitter-almond water. The "liquor iromo-chloral compositus" of the British Pharmacopoeia is made by dissolving 1600 grains of chloral-hydrate in 400 minims each of tincture of can- nabis Indica, and tincture of fresh orange-peel, 1600 minims of henbane- juice, 30 drachms of syrup, and 4 drachms of fluid extract of licorice; then is added 1600 grains of bromide of potas- sium, previously dissolved in 7 ounces of distilled water, and the whole filtered; finally sufficient distilled water is added to bring the amount up to 20 imperial ounces. Chloral suppositories, each containing 5 grains of chloral-hydrate and 10 grains of cacao-butter (oleum theobroma3), can- not be made with heat, for even if it should not wholly decompose the chlo- ral, the mixture will not set firm; in- stead, the combination, which, by the way, is apt to be very irritating, must be obtained by compression in molds. The suppositories are very useful in in- fantile convulsions where nothing can be administered by the mouth, and each one should be forcibly retained within the sphincter for a few moments, by the finger if necessary. Syrup of chloral is obtained by dis- solving 80 grains of chloral-hydrate in 90 minims of water, and then adding simple syrup enough to make 1 ounce. Bvtyl-chloral-hydrate — or croton-chlo- ral-hydrate as it is sometimes, but wrong- fully, termed — appears in pearly-white crystalline scales possessed of a pungent odor resembling that of chloral-hydrate, and an acrid nauseous taste; it is solu- ble, 1 to 43, in cold water, freely solu- ble in rectified spirit, and 4 to 1 of glyc- erin. It is available in the same way as chloral-hydrate, and is claimed to be more efficacious as an analgesic, espe- cially in neuralgias. Buiyl-cMoral-aniipyrine or butyl-hyp- nal, appears as colorless, transparent needles of butyl-chloral odor and bitter taste, which are soluble in alcohol, ether, chloroform, benzin, and (1 to 30) water. Perchloride of iron gives a red solution; alkalies decompose into antipyrine, alka- line formate, and propyl-chloroform. Its properties resemble those of hypnal. Butyl-chloral mixture, which is a very useful anodyne, is made by dissolving 4 grains of butyl-chloral in 15 minims of glycerin and water to make 1 ounce. Butyl-chloral pills are made of a strength of 3 grains each of the drug added to sufficient glycerin of traga- canth or mucilage of gum arable to make a mass; when the same are desired with gelsemium, hydrochlorate of gelse- mine, in the proportions of V200 of ^ grain, is added to each pill. Butyl-chloral syrup is merely 16 grains of the drug dissolved in 1 ounce of hot syrup. Glycerile of chloral is merely 1 part of chloral-hydrate in 4 parts of glycerin, and is employed chiefly as a solvent for certain alkaloids. Glycerole of camphor and chloral, which is a very effective anodyne em- brocation, is made as follows: — ^ Camphor, powdered, 75 grains. Chloral-hydrate, 60 grains. Glycerin, 4 drachms. Alcohol, 3 drachms. Juniper-oil, 30 minims. 58 CHLORAIi PREPARATIONS. PHYSIOLOGICAL ACTION. Mix in a glass container and expose to gentle heat (not over 10-1° F.) until solution is effected. Let cool, bottle, and keep well stoppered. Carmine-chloral — which is so useful to microscopists as a stain, and invaluable in examining pollen nuclei — is made as follows: Carmine, 2; absolute alcohol, 20; hydrochloric acid, 2 parts; heated on a water-bath for thirty minutes; then, adding 25 parts of chloral-hydrate, cool and filter. Hypodermic Use. — Chloral-hydrate has been administered hypodermically, but is generally to be condemned on account of its caustic action, the necessity of multiplying punctures, and of employing very dilute solutions. Vulpian declares that it tends to induce hsematuria, though not to the same degree as when employed by intravenous injection. Croton-chloral is a trifle more suitable from a remedial stand-point, but not from a physical one; it is also highly irritant. Leoni recommends the follow- ing solution, 16 minims of which con- tain '/i grain of the drug: Croton- chloral, 16 grains; warm glycerin and cherry-laurel water, of each, equal parts up to 352 minims. Physiological Action. — Externally ap- plied, all cliloral preparations are more or less irritant, but likewise antiseptic and sometimes analgesic. Internally they are generally sedative to the nervous system, and secondarily to the heart: a feeling of lassitude, of irresistible drowsiness, or even sleep may be produced (though sometimes preceded by a stage of excitement, particularly in alcoholics), slowing of pulse and respira- tion, and pupillary contraction. Sensi- bility and reflex excitability are not dis- turbed by ordinary medicinal doses, but disappear when large amounts of the drug are exhibited. There is also lower- ing of temperature. Probably brain- ansemia is induced, whereby sleep fol- lows, the act being more nearly normal, physiologicallj', than that produced by any other drug, there being no malaise on awakening. Liebreieh, who first introduced chloral, believed that it exerted its effect through the circulation by liberating therein free chloroform and formic acid; but this seems improbable, because the alkali of the blood is too feeble to effect the trans- formation, and its albumin is considered antagonistic to such a process. Again, no smell of chloroform can be observed in the breath, and no anaesthetic effect is produced on the sleeper by moderate doses. Farquharson ("Therap. and Mat. Med.," '89). Chloral has antiseptic properties, de- stroying low organisms and preventing the decomposition they induce. Small doses are without obvious effect upon the stomach; large doses may be fol- lowed by nausea and vomiting. Biddle ("Mat. Med. and Therap.," '96). Chloral-hydrate acts upon the cere- brum as a powerful and certain hyp- notic; acts as a depressant to the centres at the base of the brain; depresses the functions of the spinal cord; produces slowness and weakness of the heart's action, vasomotor paralysis, and muscu- lar weakness with anajsthesia. Murrell, Lond. {"Man. of Mat. Med. and Therap.," '96). Resemblance of the psychosis of chronic chloral poisoning to natural sleep em- phasized. The reason of this will be found in the fact that, like natural sleep, chloralism is the result of a congestion of the brain or of the action of a poison upon the brain-cclls. A. F. Akopenko (Vratch, Apr. 29, 1900). Various drugs have been employed, gome of them dangerous, to render people 8tu])id and unconscious as an accessory to robbery. The criminal classes, how- ever, have largely settled down to the use of chloral-hydrate, and it is from 30 to 00 grains of this substance, usually administered with beer, that furnishes the famous "knock-out" drops. Editorial CHLORAL PREPARATIONS. CHLORALAinD. CHLORALOSE. 59 (Boston Med. and Surg. Jour., Oct. 5, '99). Butyl-cliloral-hydraie acts very much like chloral-hydrate, but is less powerful as an hypnotic, induces somewhat less cardiac depression, is not so irritating to mucous membranes, and appears to have a specific action upon the branches of the fifth pair of nerves. Liebreich believes that its action upon the heart in even fairly large doses is not danger- ous, and that life can be saved by means of artificial respiration after the respira- tion-muscles have ceased action, but the erroneousness of these conclusions has been demonstrated in the physiological laboratory. It is evident that its admin- istration cannot be conducted with much less caution than that of chloral-hydrate. It is largely eliminated by the kidneys as vtrobutylchloralic acid. Butyl-chloral-hydrate has hypnotic powers, but it is so rarely used for this purpose that on practical grounds it should be dissociated from the group of hypnotics in spite of many structural and other affinities. It produces anaes- thesia of the head without loss of sensi- bility to the rest of the body, which in man is confined to the area of the fifth nerve. In large doses it produces sleep, and in fatal doses destroys by paralyz- ing the medulla oblongata. Ringer and Sainsbury ("Manual of Therap.," '97). Cliloralamid. — A marked effect of this drug is its tendency to produce mucous diarrhoea. It acts more powerfully upon the cerebral cortex than any other por- tion of the nervous system, causing sleep and muscular relaxation; is claimed to be only feebly depressant to the cord, and in medicinal doses to have little effect upon the circulation. It was in- troduced as a substitute for chloral-hy- drate, backed by the assertions that it was less unpleasant to take, absolutely without objectionable effect on the heart, and that its hypnotic effect is two-thirds that of chloral. Although it acts with tolerable certainty in simple insomnia, it generally fails, if administered in medicinal doses, when pain and excite- ment are present. On the whole, it can- not be said to have met the expectations raised in its behalf. In moderate doses it seems to sometimes stimulate respira- tion, rendering it deeper and fuller, but unless its administration is carefully watched an opposite effect is soon pro- duced. The physiological action of chloralamid is similar to that of chloral upon the cerebrum, but upon the circulation is ordinarily so slight as to offer a marked contrast to the depression produced by the latter drug; only in large or poison- ous doses does it depress the heart and cause a fall in blood-pressure. A moder- ate degree of respiratory depression may follow the administration of large amounts, and death results from paral- ysis of respiration. It has been thought to have a soothing effect upon the spinal centres and thus to diminish reflex ex- citability, but its action upon the nerv- ous system other than the cerebrum is hardly appreciable. It is excreted as urochloralic acid. Griffin (Foster's 'Trac. Therap.," '9G). Upon the action of this drug a large amount of experience has been accumu- lated by a number of observers, the world over, and the general verdict is that it does not depress the heart or circulation, does not lowerteraperature,that it exerts a decided action in many cases of in- somnia from pain, and that after-effects and by-effects are rarely witnessed. At the same time it must be admitted that collapse symptoms have been observed in a few cases and likewise erythematous eruptions. It certainly is a very valu- able hypnotic. Ringer and Sainsbury ("Handbook of Therap.," '97). Chloralose. — This drug was introduced as a substitute for chloral-hydrate, with the claim that it is hypnotic, — causing sleep in birds and mammals as well as in man, — analgesic, exerts its effect 60 CHLORAL PREPARATIONS. CHLORALOSE. chiefly upon the gray matter of the brain, and unlike chloral does not de- press the spinal cord; also that it is with- out any irritant effect on either stom- ach or intestines; indeed, that it is entirely devoid of unpleasant after-ef- fects — all of which has by no means been definitely substantiated. It should be administered with caution. The introducers assert that 75 grains will, in a dog of 2 '/i pounds' weight, pro- duce symptoms of intoxication followed by a most profound sleep in which all sensibility is lost, although the reflex activities are greater than normal. Upon the circulation the drug has but little power, the arterial pressure — even when there is profound unconsciousness — being scarcely affected. During unconscious- ness not only is the motor side of the spinal cord more active than normal, but the cerebral cortex was also found to be extremely excitable. H. C. Wood ("Princ. and Prac. of Therap.," '94). The toxic dose is about Vioooo of the body-weight. When injected into a frog in this proportion produces a condition similar to that observed after removal of the cerebral hemispheres. Spontaneous movements are abolished, but reflex and automatic actions remain intact. Soon afterward, however, respiration is par- alyzed, followed by the disappearance of all reflex activity, and the animal lies apparently dead; but on opening the thorax the heart is found beating quite vigorously, this cardiac action continuing for two or more hours after the abolition of the respiratory movement. The sleep produced in man is sometimes preceded by muscular tremors or simple twitch- ings, dizziness, and difficulty of speech; the sleep i.s more profound than normal, the patient becomes insensible to pinch- ing or pricking of the skin, and the corneal reflexes seem to be absolutely abolished. Chambard (Revue de Mfide- cine, Apr. 10, '94). The respiration is slowed, and by large doBcs its rhythm is somewhat altered. Cappelletti (Uniao MM., Sept., '94). Chloraloflc is a prompt and safe hyp- notic; it acts more rapidly than any drug except morphine. It is also more prompt and etBcient in smaller doses than chloral. Five grains, the maxi- mum dose, may be repeated in an hour. Nine cases of insomnia referred to, some of them exceedingly severe, in which sulphonal, trional, and other hypnotics prove ineffective. Chloralose produced excellent results. James Tyson (Jour. Amer. Med. Assoc, Apr. 6, 1901). The action of chloralose is chiefly upon the brain and the spinal cord. On the brain it causes two effects, one of depression and one of excitability, the former intense and lasting, the lat- ter slight and fugacious. The depres- sant action presents itself as sleep and sedation; the sleep comes rapidly, is exceptionally preceded by intoxication; heaviness of the head, stupor, or mod- erate cephalalgia, this being often quite marked, but not exaggerated; at other times lassitude, feebleness of the lower extremities, and various other troubles on different days, the narcosis being fol- lowed by a feeling of well-being. The drug also has the peculiar property of causing physical blindness; it is capable of producing dilatation of the pupil and diminution of visual -acuteness, some- times accompanied with diplopia. It in- creases the appetite markedly, and ex- ceptionally may cause gastric disturb- ances, eructations, thirst, and vomiting. It does not produce an increase in the amount of urine secreted, but causes a relative polyuria immediately after its administration. (Montyel.) Toxic symptoms observed in two pa- tients: one sufl'ering from diabetes, the other from uterine flbroid, the symptoms being trembling, starting, nausea, vomit- ing, a species of dull restlessness accom- panied by incoherence, and involuntary evacuation of urine and ficces. Touve- naint (Le Prog. MOd., No. 19, '94). Three gi'ains of the drug produced poisonous symptoms in a child of years: there was trembling, convulsions, CHLORAL PREPARATIONS. CHLOllETONE. 61 and later a cataleptiform condition which lasted two hours. Bardet (Le Bull. M6d., Feb. 18, '94). Nocturnal paralysis followed a dose of 3 grains administered to an adult. FCrfi (Rev. Neurolog., No. 6, '94). Trembling and intellectual stupor ob- served in adults. Morel-Lavalliie (Le Bull. M6d., Feb. 7, '94); Villeprand (ihid.); Talamon (La M6d. Mod., Jan. 27, '94). Complete loss of memory in one in- stance after the ingestion of 4 grains; intense prurigo as the result of a like dose in another; symptoms of paresis with threatened asphyxia in a third. Lombroso (Riforma Med., No. 131, '93). The ingestion of 4 grains of chloralose in two hours induced complete insensi- bility and coma; the pulse was 180, the heart-beats imperceptible, face and ex- tremities cyanosed, epileptoid movements of limbs, and cold perspiration. Death seemed imminent. Rendu (Le Bull. Med., Mar. 10, '95). Five or six similar cases were published in La Mfidecine Moderne during 1894. Several were reported to the SociC't6 de Th6rapeutique. Russian physicians, not- ably Chemelewski, added to the category. Herzen (Kevue MCd. de la Suisse Rom., June 20, '95) ; Delabrosse (La Nor- mandie MiSd., No. 15, '95) ; and Dufour (Marscille-m6d., Dec. 15, '95) corroborate as the result of personal experiences. The drug has one very important defect in that it occasionally provokes toxic symptoms, which manifest themselves by an exaggeration of the reflex excita- bility of the medulla oblongata, amount- ing almost to convulsions; in addition to this, it is very difficult to decide upon the proper dose, as its action varies not only in different persons, but even in the same person. Foster ("Prac. Tlierap.," vol. i, '9G). Chloral-hydrocyanaie has the action of the cyanides; it is about one-seventh as strong as prussic acid. It is an excellent preservative of solutions intended for hypodermic use. Chloral-caffeine has been introduced for the treatment, hypodermically, of sciatica and other rheumatic affections, and all cases of irritation of the periph- eral nervous system. It has been em- ployed subcutaneously in doses of from 2 to 5 grains, and is said to be painless. Its physiological action has not, as yet, been definitely worked out. Chloral-carbamide, or chloral-urethane, is hypnotic, partakes of the action of chloral-hydrate, but is uncertain in ef- fects, disagreeable to take, and is often followed by nausea and disorder of di- gestion. Hypnal, or chloral-antipyrine, has all the properties of chloral-hydrate, in- cluding all the objectionable features of the latter, and depresses the heart more seriously. It is claimed that the anti- pyrine renders it analgesic, and there- fore will induce sleep in the presence of pain; but such action is uncertain and ephemeral. Butyl-hypnal apparently differs in no way from the preceding. Chloretone, a new preparation, is solu- ble to the extent of 1 per cent, in cold water. It is an hypnotic and an anal- gesic, a l-per-cent. solution being equal to a 4-per-cent. solution of cocaine. The customary dose is from 6 to 18 grains, but there is a case on record in which 108 grains were taken at one time, which had no other effect than to cause the patient to sleep for about three days. Chloretone passes unmodified from the digestive tract to the blood. (R. TV. Wilcox.) Chloretone has little or no effect upon tlie pulse, respiration, and blood-pressure for hours, but eventually, if the dose be large enough, these become depressed and the animal dies, the heart stopping be- fore respiration. Chloretone has a pro- foundly depressing effect upon the body- temperature, lowering this more than any otlier drug, with the possible excep- tion of alcohol. This depressing effect is evident before the nnimnl is even drowsy, and is in ratio to the dose given. 62 CHLORAL PKEPARATIONS. UNTOWARD EFFECTS. It may be partially prevented by keep- ing the animal very warm. Any drug which can exert such an effect upon the total heat of the body is one which re- quires to be used with great caution in medical practice. This is doubly impor- tant, as the drug is verj' slowly got rid of; no antidote, with the exception, per- haps, of external warmth, is known. Rudolph (Can. Pract. and Review, June, 1900). Chloretone is one of the best of the hypnotics. Usual dose is from 3 to 5 grains at bed-time. It is best given dis- solved in alcohol or whisky and followed by a glass of milk. F. F. Ward (Med- icine, vi, p. 642, 1900). There is no other efficacious, practical antiseptic that is so conspicuously anaes- thetic as chloretone, when applied locally, and at the same time so utterly devoid of any harmful effects, either local or constitutional. T. A. Dewar (Therap. Gaz., Feb. 15, 1900). Chloretone is especially recommended as an hypnotic and local ansesthetic. There are no depressing after-effects, and it is safe to administer large doses. Ten to 15 grains, repeated in two hours if necessary, is the usual dose. W. M. Donald (Ther. Gaz., vol. xvi. No. 1, p. 18, 1900). Chloretone is the safest of all hyp- notics. It should be given in from 15- to 20grain doses in severe cases, and repeated often enough to produce the desired effect. For hypodermic use, a saturated solution of chloretone in a mixture containing 15 per cent, of alco- hol and 85 per cent, of water is suffi- ciently strong to produce local anajsthesia for minor operations. A still more powerful local anajsthetic may be pro- duced by mixing equal parts of chlore- tone and ctlier. This is particularly use- ful to dentists as an application to the ncrve-pulpg when it is advisable to re- move them. W. B. Hill (N. Y. Med. Jour., Aug., 1900). Toxic and Untoward Effects. — The toxic and untoward cfTocts, except as has heretofore been stated, are practically identical to those of all chloral deriva- tivcB. It is believed that most of the untoward results arising during the ad- ministration of medicinal doses are due to impurities, — chlorinated substances, — and, fortunately, such are rai-e. These are, for the most part, disturbances of respiration, including dyspncea and par- tial asphyxia; irregular action of the heart; irritation of the conjunctiva; swelling of the epiglottis and false vocal cords; icterus, increased jaundice; bed- sores (rarely); dimness of vision, per- haps even temporary blindness; ery- thematous, urticarious, and eczematous rashes, etc. What constitutes a poisonous dose is not known, since so small an amount as 20 grains has induced fatality, while, on the other hand, I have known of the ingestion (by accident) of 480 grains without any ill effects succeeding. Death may arise from cardiac syncope, from paralysis of the respiratory centre with coma and gradual suffocation, or from excessive depression of bodily tem- perature; a series of cases are recorded in which were evinced symptoms akin to blood-poisoning with purpuric and scorbutic eruptions, ulceration of gums, and great prostration, leading to death. Treatment of Poisoning. — First, stimu- lants to the heart and respiration, and, second, attempts directed toward in- creasing temperature. Strychnine has been heralded as a physiological anti- dote, because it is antidoted by chloral, but this premise is, unfortunately, not a safe guide; atropine and amyl-nitrite (by inhalation) are more reliable agents; yet strychnine may be valuable as a means of sustaining the action of the heart. (Jase of a middle-aged man who was in a mental state bordering on melancholia, due to worry and the use of alcohol. Choral-hydrate, 40 grains, ami poLaRsiuin bromide, 15 grains, were directed every three hours, with a double dose at bed- CHLORAL PREPARATIONS. THERAPEUTICS. 63 time. Prescription was written on Thursday, and the patient was not seen again until the following Monday. He was then found in bed with his knees and chin approximated; tlie extremities cold, and he was jerking and rolling about. Breathing was slow and sterto- rous; pulse was slow and soft; face was ashen gray, with parched lips and swollen tongue; there was marked stupor. Since the prescription had been given he had had the prescription filled four times, and had been drinking half a small glassful at a dose. During the time he had eaten heartily and had taken little or no alcohol. It is estimated that during the three days he had taken no less than 8 ounces of the mixture, or 640 grains of chloral and 9G0 grains of potas- sium bromide. Recovery was rapid under strychnine. P. F. Rogers (Med. Record, Mar. 10, 1000). Chloralism is a form of drug addiction which appears to be more common among women. As in all other forms of drug addiction, some previous neu- rosis will be found to precede the first use of chloral. The sleep which it pro- duces is so profound and followed by no unpleasant sensations that it is repeated as often as occasion calls for it. Chloral can be taken secretly for a long time without any suspicion of its use. After a time the efTect of its use appears in disordered digestion, the ir- regular heart-action, and the increased nervousness and muscular unsteadiness. In persons past middle life a form of cardial asthma with a tendency to de- lirium appears. These and many other obscure symptoms finally merge into de- lirium and death. Some observers have noticed that chloral-takers have pecul- iar blueness of the extremities, with venous congestion; also marked list- lessness and lack of energy as promi- nent symptoms of this addiction. Chlo- ralism is confined largely to the more prosperous classes of society. This drug can be disguised in many ways and used as a fascinating sleep-producer. The amount varies from 20 to 2000 grains a day. Often considerable time will elapse before toxic symptoms appear; then, suddenly extreme prostration with delirium comes on, ending fatally. Sud- den palsies, with vasomotor disturb- ances, hcart-faUure, and low stages of delirium, should suggest chloralism, par- ticularly if alcohol, opium, cocaine, and chloroform be excluded. The statement of the patient concerning his condition is of no value. AVhere the history indi- cated extreme neuralgia and insomnia and a sudden passing away of these con- ditions, the assumption that chloral is used is possible. When it is established that chloral addiction is present, the patient should be isolated at once and placed under positive restraint and the drug withdrawn. Alcohol, opium, chlo- roform, ether, and cocaine are all con- tra-indicated as substitutes. Vegetable narcotics, such as hyoscyamus, valerian, lupulin, bull-nettle, and others of this class, may be given as substitutes and withdrawn at the earliest moment. Then comes the usual tonic treatment of nux vomica, strychnine, and arsenic. Cin- chona and iron are also excellent drugs. The insomnia and neuralgia with de- ranged nutrition which follow the with- drawal should be treated with baths, foods, and careful hygienic management of all the functional activities of the body. Many secret remedies for neu- rotic troubles contain chloral, and de- cided symptoms of chloralism often ap- pear. Chloralism has been mistaken for general paralysis, neurasthenia, and hy- peroemia, as well as several affections of the cord. Many opium and alcohol cases are found to be complicated ^vith chloral addiction, and their recovery is more difficult. T. D. Crothers (Med. Standard, Aug., 1901). Therapeutics. — In convulsive and spas- modic disorders chloral is undoubtedly one of the best remedies in the materia medica. It has been found useful in asthma (see Eespiratory Diseases); puerperal, infantile, and general convul- sions; chorea and epilepsy; tetanus, trismus, whooping-cough, etc. Eespiratory and Cardiac Diseases. — The value of chloral and its derivatives in respiratory maladies is not so appar- 64 CHLORAL PREPARATIONS. THERAPEUTICS. ent as in many other classes of diseases, but they nevertheless appear to possess a certain degree of utility, especially in certain forms of asthma, laryngitis, bron- chitis, etc. In the sleeplessness of cardiac and bronchial catarrh ehloralamid is particu- larly serviceable. Its influence upon the circulation is feeble, and not at all in- jurious; hence it may be employed in cardiac maladies. Biddle ("Mat. Med. and Therap.," '96). Chloral-cafleine in doses of 3 to 4Vj grains may be used hypodermically in asthmatic attacks. Foster ("Prac. Therap." vol. i, '96). A full dose of chloral is often useful in a paroxysm of asthma ; the shortness of breath, which affects the emphysematous on catching cold, also often yields to its influence. When dyspnoea occurs at night 25 to 30 grains at bed-time calms the breathing and gives sound, refreshing sleep; but when the dLfiiculty is con- tinuous, 2 to 6 grains should be given several times daily. It is necessary to give the drug with caution to patients with emphysema and bronchitis accom- panied by obstructed circulation mani- festing itself in lividity and dropsy. Ringer and Sainsbury ("Hand-book of Therap.," '97). Mental Diseases. — Chloral deriva- tives undoubtedly have a special value in this class of maladies by reason of their hypnotic action. Chloral-hydrate espe- cially causes sound, refreshing, natural sleep; but no chloral preparation is to be depended upon, save in special instances or when topically applied, as an obtund- ent of pain. In physical derangements, running all the way from ncrvoUH excitability up to delirium tremens, puerperal eclampsia, acute mania and tetanus, in nervous asthma and hiccough, chloral-hydrate is an excellent remedy. Roth ("Mod. Mat. Med.," '9.5). In eighty-two cases of insanity a sed- ative cfTcct was noticed in from fifteen to twenty minutes after taking chloral- ose; the most satisfactory results were obtained in maniacs, epileptics, and al- coholics. Haskovec (Kevue Neurolog., Oct., '95). Diseases of Kidneys and Genito- urinary Organs. — Few seem to be aware of the value of the chloral deriva- tives in disease belonging to the above classes, and, perhaps, the most startling claim advanced is the one that accredits chloral-hydrate with being a most valued agent in the treatment of ailments char- acterized by albumin in the urine. The evidence of its value in urEcmia, etc., is to be found under the classification of Spasmodic and Convulsive Diseases, which are sometimes benefited by this remedy. Skin Diseases and Neoplasms. — Here the chloral preparations have been greatly employed, and not without reason. Chloral-hydrate, it is claimed, if a strong solution is painted on warts and corns, will insure their gradual dis- appearance. Chloral-hydrate, chloral- ammonium, chloral-camphor, and chlo- ral-phenol have exhibited some measure of value in the management of stubborn skin eruptions, including pruritus and eczema, and are, at least, useful as topi- cal applications in relieving burning and itching. Chloral-hydrate, in 2- to 5- per-cent. aqueous solution is frequently effectual in relieving bromidrosis and hyperidrosis. Cholera and cholera morbus are maladies in which chloral compounds have been employed, but not with such measure of success as to warrant the practitioner's depending upon them solely. Scarlatina and Dii'irTiiUHiA. — In scarlet fever hydrate of chloral is highly recommended in frequently-repeated small doses, — say, 1 to 5 grains, accord- CHLORAL PREPARATIONS. CHLOROFORM. 65 ing to age; it has a marked sedative effect, controls inflammation both in throat and kidneys, and even tends to prevent such sequelte as otitis media and glandular swelling and suppuration. In diphtheria chloral-hydrate or chloral- camphor in suitable solution may be em- ployed as a topical application to the throat and larynx, and the internal ad- ministration of the former is often a valuable adjunct to other treatment. Seasickness. — Chloral preparations are widely advised as a remedy. Though sometimes efficacious, they often prove as futile as others of the host of remedies that purport to be effective. Febrile Maladies. — It will be read- ily surmised that chloral preparations, chloral-hydrate especially, may find a place in the treatment of pyrexias, not alone because of its sedative, antiseptic, and hypnotic properties, but also be- cause of its distinct influence upon tem- perature. Chloral-hydrate is often emploj-ed, and very valuably, in fevers, particularly ty- phoid and tj'phus, especially where want of sleep, together with delirium, rapidly wears out the strength of the patient. Ringer and Sainsbury ("Hand-book of Therap.," '97). Other morbid conditions in which chloral-hydrate, and some other of the chloral compounds have been employed with varying measures of success are: rheumatism and sciatica; as a dressing for bed-sores and other ulcers, including suppurating malignant and non-malig- nant growths, cracked nipples, anal fis- sure, etc.; as an application to abort, fel- ons and boils; for the vomiting of preg- nancy; for a purgative action pure and simple; and as a tfenifuge in conjunc- tion with male fern and croton-oil. The following is claimed by Bonatti to be a prompt, certain, easily administered drastic purgative, active when even jalap and croton-oil fail: — J^ Infusion of senna, 10 ounces. Chloral-hydrate, 24 to 45 grains. Syrup, 1 ounce. — M. After the removal of polypi, the appli- cation of chloral-hydrate will often de- stroy the base of the growth. Its inter- nal administration frequently relieves the pain of acute catarrh of the middle ear, and moreover tends to be remedial by checking and reducing inflammation. A 5-per-cent. solution is sometimes useful to remove granulations in the middle ear, especially if the discharge is markedly purulent. The application of chloral-camphor has sometimes proved effectual in assuaging the pain of mas- toid disease. Vesicant Action. — Powdered chlo- ral, sprinkled over adhesive plaster, gently wanned and laid on the skin, makes a speedy, painless, and effective blister, at least equal if not superior to cantharides and more safe as regards children. When a marked effect is rapidly re- quired, chloral hydrate is better than cantharides and has none of its disad- vantages. With children, next to iodine it is the counterirritant of choice. The blister will produce erythema, vesica- tion, or ulceration, as desired. M. T. Brennan (Montreal Med. Jour., May, 1902). CHLORIDE OF ETHYI. See Ethyl Chlohide. CHLOEINE. See derivatives: Potas- sium Chlorate, Sodium Chloride, etc. CHXOROFORM. — This well-known ana-sthetic was simultaneously discov- ered, in 1831. by Guthrie, of the United 66 CHLOKOFOEil. PHYSIOLOGICAL EFFECTS. States; Soubeiran, of France; and Lie- big, of Germany. Dumas later on gave it its present name, and Sir James Y. Simpson, of Edinburgh, first used it as an anaesthetic. Chloroform (ChClj; specific gravity, 1.497 at 62.5° F.) is a tercliloride of formyl, obtained by the action of chlo- rine upon alcohol, the methods usually employed being either the addition of chloral-hydrate to an alkaline solution or of chlorinated lime to ethyl-oxide. This is distilled and subsequently puri- fied by the addition of sulphuric acid, sodium carbonate, and lime, and redis- tillation is then resorted to. Chloroform appears as a neutral, color- less fluid, possessing a sweetish and hot taste, and giving off a fragrant and char- acteristic odor. It possesses marked solvent powers, rapidly dissolving alka- loids, iodine, bromine, volatile oils, etc.; but is itself only sparingly soluble in water. It is distinctly so, however, in alcohol and ether. Chloroform is not inflammable under ordinary circumstances, except when mixed with alcohol. When used, how- ever, in the presence of a gas-flame, it is likely to become decomposed, and the product may prove noxious to the per- sons inhaling it. Chloroform-vapors are broken up into chlorine and carbonic oxide by gaslight, causing bronchial irritation in those present, asphyxia in the patient, and even death. Herson-Leidon (Deutsche med. Woch., Apr. 3, '90). Hydrochloric acid and carbon dioxide, and not monoxide, are the toxic agents. Kunkel (MUnch. med. Woch., Apr. 4, '90). A coal-gas flame in an ill-ventilated room and a somewhat prolonged exhibi- tion of chloroform may, by forming a compound with the latter, induce serious symptoms in patient, surgeon, and assist- ants. Illustrative instances. Charles G. Lee (Liverpool Medico-Chir. Jour., July, '95). Identical efl'ects observed. Irritating agent, a carbon-oxychloride, or phosgene, discovered by Sir Humphry Davy. Pat- erson (Practitioner, vol. xlii). Warning against use of chloroform near a gaslight, ethylene-chloride being thereby formed. In tabetic patients fatal coma may be induced. Eehn (Le Bull. Med., May 12, '95). Case of a man shot in the abdomen, who was brought to the hospital at night and immediately operated upon by gas- light. As a result of the chloroform narcosis, which had to be kept up for four hours, powerful chlorinated vapors were produced. Two of the surgeons and several of the Sisters of Mercy were overcome and one of the latter has since died. (Inter. Med. Mag., Apr., '98.) The administration of chloroform while artificial lights are burning is likely to produce broncho-pneumonia and cedema of the lungs, with marked passive con- gestion of the liver and kidneys. This variety of poisoning also occurs with some frequency in druggists and chemists wlio use chloroform in the presence of gas-flames. Kenelm Winslow (Boston Med. and Surg. Jour., May 11, '99). Even under ordinary conditions the chloroform usually employed for anaes- thetic purposes tends to decompose and to form hydrochloric acid and carbonyl- chloride. According to Newman and Ramsay, this latter substance is the cause of the majority of cases of after-sickness. This can be overcome by keeping a little slack lime in the bottles and filtering in the supernatant liquid as required. The deleterious effects of chloroform become especially manifest when kept in a bottle containing air and exposed to light. Physiological Effects and Centra-in- dications. — The conclusions of Lawrie and of the Hyderabad Commission, the principal of which is that failure of respiration is the only possible way by which death is produced by chloroform, CHLOROFORM. PHYSIOLOGICAL EFFECTS. 67 has now run the gauntlet of several years' criticism and may be said to no longer be accepted by the profession, and espe- cially by experienced anaesthetists. In- deed, many competent observers have reported cases in which the heart ceased before the respiration, and Mr. Leonard Hill has recently expressed the view that the cause of chloroform collapse was in all cases a primary failure on the circulatory mechanism, the respiration failing secondarily on account of the auEEmia of the bulbar centres. He had examined all the tracings taken by the Hyderabad Commission, and found that in them (although it was not so inter- preted by the experimenters) the same typical fall of arterial pressure actually occurring before the cessation of respira- tion observed by him elsewhere. Thus their own experimental evidence contra- dicts the conclusions arrived at by the workers on the said commission. A correct view would probably include both factors: a conclusion which Horatio C. Wood reached eight years ago, when he said: "If any evidence is to be at- tached to the statements of competent witnesses it is certain that in some cases, under the influence of chloroform, the pulse and respiration have ceased simultaneously, while in other instances the respiration has ceased before the pulse, and in still other cases the pulse has ceased its beat before the respiratory movements were arrested." Lauder Brunton has since given precision to our knowledge by an exhaustive study of the question, which led him, in the main, to believe that cases of simple danger without death were due to failure of respiration, while death was brought about through arrest of the heart or arrest of the heart and respiration to- gether (neuroparalysis); furthermore, that the most common cause of neuro- paralysis, as found by Casper, was strang- ling (as in drowning), which kills by neuroparalysis as often as by asphyxia. [Variations in circulation due not only to the above various factors, but also to alterations effected by chloroform in the central nervous system and local nervous mechanisms. As shown by Waller, elec- trical reaction is profoundly altered by anaesthetics; hence distinct danger in con- ditions of nerve-prostration and post-in- fluenzal neurasthenia. The whole ques- tion of reflex inhibition of the heart under chloroform bristles with diflScul- ties. If fear were simply the cause, such cases would occur often under ether, as that substance, when badly given, pro- duces more terror, breath-holding, and struggling than chloroform; and yet ether seldom, if ever, kills in this way. Unquestionably, chloroform — whether through poisonous effects on protoplasm or in some other way — exerts some dele- terious influence upon tissues of patients, which renders them less able to with- stand any unusual strain imposed upon them. Dudley Buxton^, Assoc. Ed., An- nual, '9G.] Arrest of the heart is one of the most important causes of collapse during chloroform anaesthesia. The paralysis of the vasomotor centre which is provoked by the latter brings about the rapid fall of tlie blood-pressure, and this fall, by depriving the cardiac muscle of its ex- citant, is one of the causes of the arrest of the heart. Evenhoff (Vratch; Union MC'd., July 11, '97). The principal danger from chloroform antesthesia is the sudden syncope from cardiac paralysis, which is as likely to occur in strong as in weak subjects; it happens more frequently at the begin- ning than at the end of antesthetization, presents conditions of the greatest diffi- culty for treatment, and frequently re- sults in death. In view of these condi- tions, although the superiority and greater convenience of chloroform in cer- tain cases of cerebral surgery, operations on the respiratory passages, etc., may give it preference, its adoption as a rou- tine antesthetic ought to be condemned. 68 CHLOKOFOKM. CONTRA-INDICATIONS. Editorial (Boston Med. and Surg. Jour., Aug. 26, '97). Out of some 2400 patients ■who were etherized, 10 developed temperatures with some respiratory complications, and aU had gas before ether. Six of these had bronchitis, 1 pleurisy, and 3 broncho- pneumonia, 1 of these last being a fatal case. Seven of these cases occurred in summer. In none of these 10 cases was there previous history of bronchitis; all were in good condition and took the an- aesthetic well. The operations were pro- longed ones, and with 1 exception on the trunk, necessitating bandaging, which would prevent free expectoration. A number of patients in had condition from alcohol or sepsis, and subjected to short operations under ether without gas, did not develop any lung complica- tion. These last patients, however, did not have to traverse corridors. Not one out of 600 chloroform cases, of which many were for mouth operations, de- veloped any respiratory trouble. Chloroform is recommended for all long operations on the trunk, or, if ether be given at first, it should be changed after a time for chloroform. Crouch and Corner (Lancet, May 24, 1902). Effect produced on the isolated mam- malian heart by perfusion of chloroform when the chloroform is exhibited not in saline solution, but in the blood itself. Administered in physiological saline so- lution, it depresses the heart's beat much more powerfull3' than when admini.stercd in blood in the same percentage strength. The effect of chloroform from 0.05 per cent, up to 0.1 per cent, in blood is to depress the heart-beat only equivalcnlly to chloroform solutions aliont twelve times less concentrated in physiological saline solution. Byles, Harcourt, an 1 Horsley describe their method of esti- mating the amount of chloroform dis- solved in blood. From their results tlicy infer that the retaining power of the blood for chloroform is also associated In some degree with the integiity of the corpuscles at the time of entry of the chloroform into the blood. Sherrington and Sowton M'.rit. Med. .Jour., .Tuly 23, 1004). The heart also shares the brunt of responsibility with the respiratory tract as far as contra-indications are con- cerned; bnt if the operator bears in mind the fact that, the nearer muscular integrity of the organ is discerned, the greater the safety, he will at once have a key to the lesion which may prove tlie basis of complications. Fatty degenera- tion and dilatation are the main condi- tions to fear, because the cardiac walls are the most compromised and may not be able to resist the engorgement result- ing from increased arterial pressure. Valvular lesions only increase the dan- ger if they are obstructive. In that case, even, compensative hypertrophy may also compensate for the extra resistance in- duced. In aortic insufficienc)', as emphasized by Giffen, it is necessary to study heart- rhythm and arterial pressure. So long as the rapidity of the heart's action does not disturb the rhythm — viz.: first sound, second sound, pause — within reasonable physiological limits, or, in other words, the arterial pressure (composed of the time [rapidity] and intensity [muscular impulse]) does not overcome rhythm, the anassthetic can be given without in- creased danger. Phj'sicians and surgeons are agreed that accidents in chloroform anresthesia are not more frequent in patients with aortic or heart disease than in patients with other illness. Nor does cardiac or aortic disease contra-indicate chloroform as an anaesthetic, if the disease is not acute and infectious, if the patient is not too feeble, or if dyspnoea, asystole, or symptoms of pericardial symphysis have not appeared. In some eases of atheroma and cardiac disease the heart condition even improved after chloroformization. The main conlra-indication to chloro- form in patients with heart disease is the presence of dyspnoea. This is, how- ever, but temporary. Accidents may be CHLOROFORM. CONTRA-INDICATIONS. 69 due to impure chloroform, or may oc- cur under chloroform, yet may not be due to the chloroform. The question whether etlier or chloroform is to be preferred as the anoesthetic has not yet been definitely settled. Ether is to be preferred in nervous patients, with kid- ney disease, low arterial tension, pro- found anjemia, and depression. It is contra-indicated in pulmonary disease, dyspnoea, etc. Ethyl bromide has been given first by Richelot with success, fol- lowing with chloroform after anaesthesia has begun. Laborde advises atropine, morphine, and sparteine, hypodermically, before chloroformization. Pure chloro- form, well given, to a patient prepared for it, almost never kills. Henri Hu- chard (Jour, des Praticiens, May 31; Phila. Med. Jour., Sept. 13, 1902). Disorders of the respiratory tract are as liable to compromise the issue as any grave cardiac disease. Great caution should be observed in the administration of chloroform in all asphyxial condi- tions, — i.e., when the respiratory area is to any degree restricted through the pres- ence of growths, pysemic accumulations, emphysema, etc. In scrofulous children the presence of enlarged bronchial glands is to be surmised, and the anaes- thetic should be administered with un- usual care. In affections complicated by liquid effusions, however, the danger may be thwarted when it presents itself. Case showing what timely evacuation of contents of pleura will do in such cases. As soon as evidences of asphyxia showed themselves the skin was divided with one cut of bistoury and the pleura was instantly opened and pus evacuated, the almost moribund patient quickly re- turning to life. Guermonprcz (Jour, des Sciences MC-d. de Lille, May 4, '95). Fatal accidents during administration of chloroform are especially liable to oc- cur in persons with the lymphatic con- dition, enlarged thymus, etc. F. Strass- mann (Berliner Klinik, Feb., '98). Langlois and Eicliet have shown by experiments on animals that in surgical anaesthesia extreme care should be taken that the movements of expiration be not interfered with. This might be extended to expiration, likewise, and the necessity of protecting the via vilcB against the ingress of mucus, saliva, blood, etc., thus emphasized. Following remarks founded on 0657 ad- ministrations of anaesthetics at London Hospital. Other things being equal, the stronger the patient, the more trouble with the anaesthetic. Deaths from chloro- form are more common in the middle period of life, and more men than women die from this agent. Chloroform is more dangerous during the early stages of ad- ministration; respiration should be care- fully watched, and every breath should be both heard and felt. Watching the chest or abdomen is a fallacious guide. Obstructed breathing is best relieved by unlocking the teeth and pushing the jaw forward. There were 13 cases in the 6657 administrations in which the threatening symptoms occurred. When dangerous symptoms arise during or after the use of an anaesthetic, one or more of four factors may be responsible: first, the anaesthetic itself; second, the condition of the patient; third, the posture of the patient; and, fourth, the surgical opera- tion. W. Hewitt (Lancet, Feb. 19, '98). Attention has been called to the im- portance of examining the urine, espe- cially for albumin, before subjecting a patient to a general ansesthetic, and par- ticularly in subjects of middle or ad- vanced age, whose appearance suggests the presence of renal disease. Whether the presence of albumin in the urine should prohibit any surgical operation is a mooted point. Snow laid it down as an axiom that, if an operation must be per- formed, however serious it might be, the administration of an anaesthetic was justifiable, on the whole, and that rule has been pretty generally adopted with- out any manifest bad results. Benjamin Ward Richardson, referring to the above, stated that he had administered ether, 70 CHLOROFORM. CONTRA-INDICATIONS. chloroform, and methylene to great num- bers of persons suffering from albuminu- ria, without any untoward results. The marked increase of albumin noted in albuminuric cases and the presence of it in cases which had not shown any be- fore the administration of the anaes- thetic shown in the following abstracts, nevertheless counsel prudence. It seems obvious that renal lesions can but cause increased blood-pressure, and thus tend to enhance the likelihood of cardiac syncope, and that, when kidney lesions are known to exist, chloroform should be administered with unusual pre- caution. The urine of one hundred male pa- tients studied before and after chloro- form narcosis. Tlie alteration of the kid- ney is a tissue-lesion which removes the power of inhibiting the loss of serum- albumin, the causes of which lie in the poverty of 0X3-gen in the blood, the de- struction of blood-corpuscles by the chlo- roform, the injury to the tissues by the liberated chlorine, and, lastly, the lower- ing of blood-pressure. As evidence for the occurrence of a tissue-lesion, the fact was adduced that in 44 out of 56 cases investigated upon this point, after nar- cosis, the urine contained nucleo-albu- min. V. Friedliinder (Viertel. f. ger. Med., Dritte Folge, B. 8, Supplement, H., p. 94). After prolonged chloroform narcosis in healthy persons there is prolonged dis- turbance in metabolism of albuminous substances. Kast and Hester (Zeit. f. klin. Med., vol. xviii, '95). Result of a study of two hundred and fourteen cases of chloroform aniestliesia in which the urine was carefully exam- ined. Albuminuria occurred in 80 per cent, of the eases, lasting from two to six days. Sugar and acetone were never found. In 60 per cent, casts were pres- ent, mostly hyaline, but also a few cpitlieliul and granular. All degrees of changes were found in the kidneys, from single hypcricmia and capillary hicmor- rhagcB to extensive coagulation necrosis of the renal epithelium. K. Ajello (Mon- ograph, Milan, '96). Examination of the urine in 130 cases of anfesthesia, — 60 from ether and 70 from chloroform. In 8 cases out of 13 in which there was albumin in the urine before the anfesthesia there was an in- crease of the albuminuria : 4 times after ether and 4 times after chloroform. Eisendrath (Deut. Zeit. f. Chir., B. 40, '96). Effects of ether and chloroform nar- cosis on the kidneys. In 29 per cent, of the cases after etherization albumin was found in the urine, and in 18.89 per cent, after chloroform narcosis. In each ease the urine before the operation was free from any trace of albumin. The ether- ized animals showed renal alterations consisting of diffuse hfemorrhagie nephri- tis, with preponderating glomerulitis and multiple renal haemorrhages. The su- periority of ether over cliloroform from the point of view of safety is shown. Babacci and Bebi (II Policlin., May 1, '96). Examination of the urine of 54 people after chloroform anajsthesia, and of 41 cases after ether anassthetization. Nar- cosis in chloroform cases lasted, on an average, 57 minutes, and in the ether cases one and a half hours. There were 10 cases of albuminuria and cylindruria after chloroform; 15 cases after ether. In 3 of this last series there was pre- existing kidney disease. Autopsy in 2 ether cases showed ha;morrhagic nephri- tis affecting especially the glomeruli. Al- bumin is more frequently observed in the urine after ether than after chloro- form, but the nephritis caused by ether is transitory, while that due to chloro- form is likely to become chronic. Le- grain (Ann. des Mai. dcs Org. Genito- Urin., No. 2, p. 191, '97). Permeability of the kidneys after chloroform narcosis tested with solution of rose aniline. As a rule, it took twenty-four hours to get rid of all traces of the pigment, the patient hav- ing, as far as was known, healthy kid- neys. In every case elimination was de- layed by chloroform anresthesia; while it took thirty-five hoTirs to eliminate the pigment before chloroform, in one case it required foi'tyone hours after- CHLOROFORJI. CONTRA-I^^)ICATIONS. 71 ward. No constant relation between the quantity of chloroform and dura- tion of the anaesthesia and the altera- tion in renal function could be detected, as the personal equation of the kidney varies so much. The quantity of urine after chloroform narcosis was, for the most part, reduced. Benassi (Gazz. degli Osped., Mar. 3, 1901). If pieces of kidneys taken from an animal that died from chloroform are hardened and fi.xed b}' proper reagents, the border of the epithelial cells in the convoluted tubes is destroj'cd. This is of extreme importance, as the border of the epithelial cells is to the kidney what the rods and cones are to the eye, which being destroyed will render the eye blind. The kidney therefore losing that border can no more serve as a filter. The in- tegrity of the epithelial cells is abso- lutely indispensable for a good function of the kidneys. Twenty-five years ago Heidenhain attributed to those cells the property of eliminating urea. We know now that the function of the cells with their intact border is secretion. They extract from the blood certain products. The renal secretion will therefore de- pend upon the integrity of the cells of the tubules. This important function is impaired by chloroform, when adminis- tered as an anresthetic, but the cell is capable of recuperating. Renaut (Jour, des Praticiens, No. 15, 1902). The inhibiting influence of cliloroform narcosis upon general metabolism has been considered as a prominent factor in the etiology of untoward phenomena, and Guthrie and Kiefer have ascribed some deaths occurring some days after the administration of the anaesthetic to defective elimination of excretory prod- ucts. Casper, Behrend, Langenbeck, and other authorities have shown that chronic chloroform poisoning does act- ually occur; and Guthrie ascribed to autointoxication: either a fatty condi- tion of the liver (and, therefore, func- tional disturbance of the organ) exist- ing before the anaesthetic was given, or to chloroform and operation-shock com- bined, which aggravated the condition already present. It is supposed that lessened oxidation, such as some believe ether and chloroform can cause, leads to deposition of fat in the liver and else- where, and so would prevent fat being oxidized on its way from the liver into the general circulation. Chloroform decomposes blood in pres- ence of an alkali and liberates carbonic monoxide; also in the bodj' in alkaline blood. This may account for some deaths from chloroform. Desgrfs and Nicloux (Jour, of Amer. Med. Assoc, Jan. 29, '98). Chloroform may cause death several days after administration, from causes which are at present unknown. The changes found in such cases after death chiefly consist in fatty degeneration of the heart-muscle, of the liver, and of the kidneys. The degeneration, although usually present in several of these organs, is more often specially localized in one or other; the resulting clinical features vary accordingly. The degeneration in question is analogous to that observed in animals dying from long-continued chloroform ansesthesia. Salen and Wallis (Centralb. f. Chir., Aug. 19, '99). Ungar, Strassmann, and other observ- ers have also found that fatty changes could be induced in the liver through the influence of chloroform upon the blood-vessels and tissue-cells. As a re- sult, the urine becomes loaded with alkaloidal bodies which the kidneys can- not eliminate with suflicient rapidity. Hence the autointoxication. As a result of chloroform narcosis there are present fatty degeneration of organs, especially fatty infiltration of the liver and fatty changes in the cardiac and skeletal muscles, kidneys, and stomach; these fatty changes arise from the action of chloroform upon the blood-corpuscles and tissue-cells. Some subjects show a greater susceptibility to these effects of chloroform than others. Chloroform is contra-indicated in all cases of fatty liver; whenever this condition is not discoverable by clinical evidence, the fact that the liver-function is hampered 72 CHLOROFOKM. METHOD OF ADinXISTKATION. POSITIONS — as shown, for example, by alkaloidal bodies in the urine — should be taken as eontra-indicative to ehloroform. Ungar and Strassmann, Thiem, and Fischer (Deutsche med. Zeitung, p. 4, '89) ; Os- tertag (Virchow's Archiv, vol. cxviii, p. 2). After death from chloroform there is a decided acid reaction of the fluids and tissues, and the lessening in alkalinity actually occurs during chloroform in- halation. Taken in connection with the researches of East and Hester, showing that fatty degeneration follows pro- longed inhalation, this possibly explains the lethal effects that chloroform exerts on the cells. The urine, further, has its acidity increased after chloroform. It would appear as if the acid excretions of the working-muscles, etc., usually readily neutralized by the cells (Langendorfif ), are left unaltered, or are imperfectly neu- tralized during chloroform inhalation. Slansfelde (Omaha Clinic, Sept., '92). Method of Administration. — Position. — The position of the patient bears an important influence upon the results. When the splanchnic vasoconstrictors are paralyzed by injuries or poisons, such as chloroform, the influence of gravity becomes manifest, as shown by Leonard Hill, owing to dilatation of the abdomi- nal veins with corresponding emptying of the heart and cessation of cerebral circulation; hence the numerous acci- dents reported witnessed in the dental position; that is to say, that employed by dentists for the removal of teeth. Death in sitting posture occurs from Budden cessation of the heart's action, through abdominal engorgement and de- pletion of cerebral vessels. Two cases in which, through extensive injuries of cranium, large areas of brain proper were exposed. Under prolonged anffHthesia, chloroform reduced cerebral circulation. Tn one case in which the local hffimorrhage was severe the latter HubHidcd as soon as patient was fully under anjesthctic. Bedford Brown (Ther. Gaz., Dec. 15, '94). The use of chloroform and ether is always dangerous in ordinary dental sur- gery, and is unjustifiable. Nitrous-oxide gas is, by far, the best dental anaesthetic. H. Sewill (Archives of Otology, Dee. S, '94). For operations about the mouth or throat full extension of the head upon the trunk, while the patient is lying down, answers admirably, but, as shown by Buxton, it produces some congestion of the head and neck vessels, which in certain subjects induces a very undesir- able amount of bleeding. If the exten- sion is not exaggerated, however, and if the head is supported beyond the edge of the table so that the traction upon the anterior portion of the neck through an excessive extension is not too great, the abnormal bleeding can be avoided. For the removal of adenoid vegetations this position is of value. In the illustration shown herewith, while the general posi- tion of the patient is, on the whole, the proper one, the head is unduly forced downward. A small pillow or three or four towels adjusted to the edge of tlie table to support the head somewhat higher would place the patient within easy reach of the surgeon and at tlie same time avoid the danger of excessive bleeding. For operations in the vault of the pharynx, as in the case of adenoid growths, the blood is thereby prevented from flowing in the direction of the larynx: an element of danger, in many cases, when the position of the body is on a line to that of the region operated upon. Dudley Buxton calls attention to the fact that the lateral position, recom- mended by many, is by no means pos- sible in stout persons, while short-necked subjects also bear this position badly. He prefers to place a pillow well under CHLOROFOKM. ADMINISTRATION. ATMOSPHERIC CONDITIONS. 73 the shoulders, giving just sufficient ex- tension of the head upon the trunk for practical purposes. This position I have found a most advantageous one in opera- tions about the posterior nasal space. A certain amount of care must be taken when the head is not fully ex- tended, however, that the tongue, dur- ing the deep stage, be not allowed to fall back against the pharynx and thus tend to occlude the respiratory area. the surrounding air as a cause of danger. When the air is surcharged with moist- ure the chloroform condensation in the pulmonary air-cells and its subsequent entrance into the blood are impeded; the stages of narcotism will, by this, be prolonged. Recovery is also slower. Syncopal attacks in a moist atmosphere are more likely to terminate fatally. Again, the moisture which should escape from the air-passages cannot do so when Position for tlie removal of post-nasal growths. {Kcinhil Franks.) (UuMln Jourual of Medical Scionco. March. ■«.) Howard, in 1888, showed that the most effectual way of opening the air-passages was by forced extension of the head upon the trunk, tliereby raising the epiglottis and tongue; but this does not prove true unless excessive extension be resorted to; and, as this is inadvisable, the benefit of Howard's method is not obtained. Influence of Aiwoxpheric Conditions. — Benjamin Ward Eichardson attached much importance to the condition of the atmosphere is too saturated, and the tendency to waterlogging of the lungs under chloroform is increased. The temperature also bears a marked influence when it is high, the volatiliza- tion is more rapid, its diffusion and con- densation are increased, and both the onset and the recovery are more rapid. The safest temperature is 60° to 70° F.; a higher rather than a low range is best. 74 CHLOROFORM. ADMINISTRATION. PREPARATION OF THE PATIENT. Chloroform anaesthetization under varying atmospheric pressures: The ac- tion of chloroform is more rapid but less lasting if the atmospheric pressure is re- duced. The elimination of chloroform by the lungs is much more rapidly ef- fected in animals subjected to very low pressures. Benedicenti (Archives Ital. de Biol., vol. xxiv, No. 3, '9S). In India the mortality from chloro- form does not exceed 1 in 8000 cases, and in some of the largest institutions it is less than 1 in 20,000 eases. Safety does not appear to be related to any special constitutional condition of Indian races and but little to their habits. It is prob- ably due entirely to the warm atmos- phere, which favors the rapid action of the drug and its rapid elimination. To obtain simUar safety in England, it would be advisable to operate in well-ventilated rooms, with a temperature not below 70° F. Anffisthesia should be produced gradually, with the chloroform diluted with plenty of air. Arthur Neve (Brit. Med. Jour., Nov. 5, '98). Preparation of the Patient. — The pa- tient should be in an entirely-loose gar- ment and in the recumbent position. A quiet, well-ventilated, and well-lighted room should be selected. Any foreign body, such as false teeth, tobacco, or any accumulation of mucus, should be removed from the mouth, naso-pharynx, and nasal passages. All solid food should have been with- held for at least four hours and no liquid food for at least two hours before the administration of the ana3sthetic, al- though a small quantity of brandy or whisky may be given a few minutes be- fore if the patient be at all debilitated. [This recommendation is of the great- est importance J for the regurgitation of food when the patient is under the antes- thetie may, by entering the larynx, cause asphyxia. Sajous.] The patient's fear should, as much as possible, be allayed Ijy kindly and en- couraging words, death being sometimes caused by heart-syncope, resulting from fright. A show of surgical instruments should be avoided. Mental factors may be influential causes in the production of chloroform- death. Fear and anxiety may cause pro- found circulatory distm-bance, and this condition may predispose to danger when an anesthetic is given. In such cases an hypodermic injection of morphine should be administered, and ether should be employed instead of chloroform if there is no contra-indication. Robert Ballard (Lancet, May 7, '98). If the operation is at all to be pro- longed or be of such a nature as to cause severe pain in the waking state, an hypodermic injection of morphine, V4 grain, should be administered twenty minutes before the chloroform is given. Administration and Dose. — As in the case of other agents, it is obvious that the purest chloroform obtainable should be employed. Many instruments were devised for the purpose of administering auEEsthetics in general (the principal ones will be described under Ether), but these are seldom employed outside of hospitals. Except under certain condi- tions, when the anaesthetic is admin- istered in the presence of gaslight, the simplest way to apply chloroform is on a towel or handkerchief; or a cone or funnel may be made with a folded towel into which the anaesthetic may conven- iently be dropped. On account of its irritant action, chlo- roform should not be allowed to come into contact with the eyes or face. In the case of a fair-skinned female patient, it is advisable to apply vasclin or cold cream where the chloroform-vapor is likely to touch the skin. A drop-bottle should be employed for tlie ana'sthc'tic, tlie pouring-out method usually employed licing a dangeroii.-i procedure. CHLOROFOKM. ADIIINISTRATIOX AND DOSE. 75 The patient lying upon his back, his chest is bared, a compress placed over his mouth, and 2, 3, or 4 drops of chlo- roform poured upon it. The compress or cone is held so as not to close com- pletely the nostrils and mouth, thus en- abling the patient to inhale well-diluted vapor at first. In fifteen seconds the chloroform will have evaporated, when 4 or 5 drops more are then allowed to fall on the centre of the compress, this being turned rapidly so as to avoid an .excessive intake of fresh air. This ma- noeuvre is repeated about every half- minute. When narcosis is complete, 2 or 3 drops of the anaesthetic are used every minute. Coughing indicates that the air inhaled is too heavily charged with chlo- roform, while struggling in the first stage tends to show that the patient is feeling the want of air — a terror-inspir- ing sensation. The extreme danger of rapid chlo- roformization was repeatedly emphasized by Richardson, who argued that fatal re- sults follow upon the sudden impact of chloroform — an irritant vapor — upon the nervous periphery of the breathing- surfaces. (See influences upon the nasal mucous membrane, infra.) Tliis sudden impact causes, in his opinion, a contrac- tion of the pulmonary arterial vessels; thence results ischjemia of the lungs and overfilling of the right heart, leading to cardiac stand-still. A few minims of chloroform injected into a vein kills the heart-muscle outright and beyond recov- ery. If the animal is healthy the lungs prevent such a catastrophe when the chloroform is inhaled; but the author contends that when the heart is not healthy the lethal dose may be so small that it may pass through the lungs and reach the heart, causing fatal syncope. Wliile gradual, rather than rapid, chlo- roformization (two minutes for infants, three for children, and four or five for adults — Snow) is recommended, the dan- ger is urged of overcaution, as the blood grows highly saturated with chloroform before anaesthesia is obtained, and the organs and tissues are so saturated with chloroform that, should any causal acci- dent arise, it is fatal in spite of all efforts to withdraw the chloroform from the blood, since reabsorption into the blood takes place from the tissues. To settle this question Kionka con- ducted a series of researches to deter- mine quantity of ether or chloroform necessary to produce narcosis. He found the dose required to be relatively small. Narcosis was obtained when the air con- tained from 0.15 to 1.3 per cent, of chlo- roform, or 2.1 to 7.9 per cent, of ether. The minimum quantity of ether neces- sary to produce anaesthesia could be greatly exceeded without endangering life, and narcosis could be prolonged by using the same dose, while, under similar conditions, chloroform invariably caused death of the animal. Sleep under ether, when once established, could be main- tained with a smaller dose than that re- quired to produce it. From the begin- ning chloroform caused early arrest of heart and respiration. Eobert Bell has noted that the symp- toms of approaching danger under chlo- roform always appear in the following order: (a) coughing, (6) gasping, (c) choking, and (d) struggling. If, at the first appearance of coughing, the vapor is given more diluted, no further diffi- culty will arise. On the other hand, W. A. Parker ascribed the small number of deaths observed in Scotland to tlie fact that the anaisthetists are not afraid of chloroform; they use it fearlessly in un- stinted doses, pushing the patient rap- idly under. Buxton states that there seems every 76 CXBCLOEOFORM. UNTOWAKD EFFECTS. reason to believe that an overdose of chloroform may be arrived at in one of two ways: (1) a sudden intake of a lethal dose, which, according to Sansom, who followed Snow's emphatic teaching, may be taken when even a small quantity of the anaesthetic is thrown on lint or a towel, or (2) through accumulation of the drug in the body. This commonly shows itself by paralyzing the medullary centres and so producing cessation of respiration. Impairment of expiration is the most usual cause of this, due in many cases to some mechanical cause, such as emphysema, falling back of the tongue, sucking in of the lips, or block- ing of the air-ways by mucus or blood. As regards the lower mortality re- ported from Scotland, Buxton argues that many deaths under chloroform have occurred in that country; even as early as in the days of Simpson. As no public investigation is held correspond- ing with coroners' inquests, as is the case in England, no report gets into the pub- lic press. He reaches a conclusion sus- tained by experience, and verified by a wide-spread review of the literature, to the effect that every individual requires a specific dose : the drunkard and athlete require much ; the pale, frail, ancemic woman very little. The stages of chloroform narcotism as given by Snow and Buxton are divided into four: — The first stage, from the commence- ment of inhalation to the loss of con- scious control of the limbs. The second, to the stage of lo.S8 of con- junctival reflex and rigidity of the mus- cles. The third, or surgical stage, when the muscles are relaxed (in the main), the corneal reflex is lost, and the pupil is contracted. The fourth stage, when the medullary centjes are affected, the pupils dilate, the respiration gradually fails, the muscles are absolutely relaxed, the sphincters cease to act, while the circulation fails. Beyond this stage convulsions occur, the breathing ceases, and the heart and circulation come to a stand-still. The complete relaxation of the muscles can, in some cases, be arrived at only by the patient's entering the fourth stage, and, in the case of chloroform, such pushing of the anaesthetic can only be accom- plished by seriously jeoparding the pa- tient's life. In the case of ether, how- ever, a patient can, with ordinary care, be allowed to pass into this stage with- out danger. At all times during the administration of the anaesthetic the respiration and the circulation should he simultaneously watched. Xlntoward Effects. — The chances that no trouble will be met with stand as 1500 does to 1, provided average care has been taken in determining whether the case be not one offering unusual chances against a successful administration. But in all cases certain allowances must be made not only for previously-undiscov- ered elements which may suddenly bear their influence upon the issue, but also for known conditions which also modify the form of issue. Owen states that there is always risk in giving chloroform or any other anaes- thetic to a child; but this risk is dimin- ished in proportion as the vapor is ad- ministered in a careful manner and by a well-instructed person. It is impor- tant to bear in mind, in this connection, that the general impression that children very rarely succumb to the influence of chloroform is erroneous. The many deaths in children ranging from early in- fancy to 15 years of age have served to emphasize this fact. CHLOROFORM. UXTOWARD EFFECTS. SHOCK. 77 On the other hand, the fear that un- toward results will follow the use of an anaesthetic in patients of advanced age is equally exaggerated, as shown by a large series of cases reported in which no unusual effect was witnessed. Heath, for instance, administered chloroform to a woman 94 years old, to reduce a dis- location. The patient bore the anaes- thetic calmly and easily. Indeed, acute suffering is a prolific source of fatal shock in old people, and antesthesia thus becomes a life-saving agent in them. As regards the increased liability to untoward effects through disease, Key- nier recently showed that, according to the more or less great resisting power of the various cells affected during the anaesthetization, are fatal accidents lia- ble to occur. While in alcoholics, whose cerebral cells are in a continual state of hyperesthesia, delirium is observed, which may reach the stage of delirium tremens; but in these, also, heart-wall degeneration is probable, and early syn- cope is likely in proportion. In hyster- ical subjects all varieties of hysterical at- tacks may occur, even paralysis and syn- cope. The same is the case in epileptics. In morphinomaniacs only slightly in- toxicated chloroformization is easily and rapidly accomplished; in others, on the contrary, it is more dangerous. In ataxic subjects the period of medullary excitement nearly always gives rise to reflexes which may arrest the respiration and heart-movements. To these morbid conditions must be added those enumerated and involving the circulatory, respiratory, and urinarj' systems, and prolonged abdominal op- erations, strangulated hernia in old and exhausted subjects, colotomy and colec- tomy, etc. Extra watchfulness should be observed in all such cases, and shock anticipated by preliminary measures: stimulants, strychnine, etc. Shock. — Murray- Aynsley emphasized the fact that many deaths under chloro- form occurred within a very short time after the commencement of inhalation, or when comparatively trifling, although painful, operations were to be performed (extraction of teeth, etc.) were due to slioclc during imperfect ancesthesia. He denies that the experiments performed by the second Hyderabad Commission prove that shock under chloroform was not competent to produce syncope, as in them painful operations were per- formed on animals coming out of chlo- roform, and in a condition where, as he contends, analgesia persisted, although anaesthesia was imperfect. Closely connected with the production of shock is fear, which tends greatly to increase the chances of cardiac syncope, through the exaggerated functional ten- sion induced. White has shown that even a small amount of chloroform is capable of inducing a fatal issue under these circumstances. There is a marked difference in this particular between Europeans and Hindoos: a fact which has served to markedly decrease the mor- tality of anaesthesia in India. The letters which are constantly ap- pearing in current medical journals in- aicate very plainly the views which are held in this country on the vexed sub- ject of chloroform versus ether as an antcsthetic, but less is generally known of the opinions of the profession in America on this matter. It might per- haps be hastily assumed that in the United St-ates, the home of antesthesia by ether, no other drug, and least of all chloroform, would be habitually used. To those who are of this opinion the statements made by Dr. J. A. Bodine, Adjunct Professor of Surgery at the New York Polyclinic, will come as :» 78 CHLOROFORM. UNTOWARD EFFECTS. SHOCK. surprise. In a recent lecture he admits freelv that chloroform possesses many advantages over ether, but points out that the administration of the former has been follo^Yed by a considerably larger proportion of deaths from the anaesthetic than when the latter was employed. He thinks, however, that this unfortunate fatality might be offset to some extent by the deaths which take place some time afterward, from kidney irritation and lung involvement after ether. He contends that most chloroform deaths are due to vasomotor paralysis, and that deaths from fright occur just in the same way. Two instructive and suggestive cases are cited. In the first, the patient, a very nervous individual, became so frightened before the opera- tion that the rhythm of his breathing was seriously disturbed; the anaesthetist, in consequence of this, gave him some preliminary training in deep breathing before the administration of the chloro- form; the cone was placed over his face, and he was told to breathe deeply; after a few gasps he ceased to breathe and could not be resuscitated. Not a single drop of chloroform had been adminis- tered. In the second case, the patient, who was also a very nervous man and very fearful of the result of the opera- tion (for hsemorrhoids), was given an enema before any anaesthetic was ad- ministered; he thought this was the first step of the operation, ceased breathing, and died. In both these cases the necropsy revealed no morbid state except the tense abdominal veins, in wliich nearly all the blood of the body had collected as a result of the vaso- motor paralysis consequent upon the fright. Dr. Bodine, therefore, concludes that fright may be an element in the pro- duction of death in cases in which chloroform is used. He states that seven out of every ten deaths reported from chloroform anajsthesia occur during the preliminary stage, when only a few drops up to a. drachm have been given. There is nc;;ativc evidence also in the fact that in obstetrical practice chloroform is the ana'sthctic of choice; this is due to al- most complete absence of a chloroform mortality during labor. As an explana- tion of this freedom from danger we have the circumstance that women are not fearful about the anaesthetic in their confinements, but ask freely for it. Children, also, are not frightened as adults are, and consequently sufl'er little from chloroform as an anresthetic. Dr. Bodine refers, in addition, to the inter- esting fact that the negro of the South- ern States stands chloroform very well; he has a child-like faith in lus physician and does not fear anj' of the measures that he may adopt. Yet the negro may die from fright, as a graphic story of a student trick told by the writer proves. The conclusion is, therefore, reached that we must, for the safe administra- tion of chloroform, eliminate fright. Dr. Bodine tells his patient to put his hands tightly together, the fingers interlacing, and to grip them firmly; he asks him to fix his mind upon that action, to listen to the voice of the anaesthetist and to do what he tells him, and to breathe deeply and quietly and not to mind the sensations which come over him. General conversation in the neigh- borhood of the patient should not be allowed. The writer, in conclusion, thinks that if deaths from fright could be elimi- nated, chloroform would be a much safer anaesthetic than ether, and says: "If I had to choose an anaesthetic for myself to-morrow, I should take chloroform, but I should want it administered by a careful expert anaesthetist." These views, although jjcrliaps opti- mistic, are well worthy of being kept in mind by the profession on this side of the Atlantic. Editorial (Brit. Med. Jour., Feb. 21, 1903). Too prolonged a fast prior to taking; chloroform is considered dangerous by Murray-Aynsley. Christopher Heath, when an operation is likely to be very prolonged, administers an enema of hot beef-tea, half an hour before the admin- istration. Silk hafl recommended the "hospital regimen" for some days before the operation. CIlLOKOl-'OKll. UNTOWARD EFFECTS. STRUGGLING. 79 Stimulants were advocated even by B. VV. Eichardson, who gave alcohol in definite doses, twenty minutes before the inhalation. Formula: — IJ Tinct. chloroformi, 1 drachm. Spir. tenuior, 1 ounce. This was given in water and sweetened if preferred. Foxwell also gave alcohol when the heart was not orderly and calm five min- utes before beginning the administra- tion of the anassthetic, but opium, given two or three hours before, he considered even better. Too little importance is usually at- tached to struggling, which, according to Lawrie, is produced (1) by fright, leading to purposeful resistance; (2) by choking or asphyxia from overconcen- tration of the vapor, owing, generally, to the cap being held too close to the face at first or afterward when the chloro- form is being renewed; and (3) by in- toxication, — i.e., the so-called "strug- gling stage." Dudley Buxton considers the struggling of intoxication as ex- tremely dangerous. The breathing is then irregular and the amount of chloro- form in the circulation is considerable, anaesthesia being nearly complete: fac- tors markedly increasing the chances of cardiac syncope and general toxjemia. The inhaler should be removed from the face for a few respirations, which does not necessarily cause a break in the narcosis, as chloroform still remains in the air-cells; and, as soon as respiration has resumed its normal character, the chloroform is reapplied. Certain regions are especially prone to encourage cardiac syncope when sub- mitted to rough handling in surgical pro- cedures. Traction upon the omentum and undue manipulation of the intestines and other viscera are probably the most active factors of this kind. Operations upon the anus have also shown a tend- ency in this direction. Operations that would be attended by great pain without an anesthetic seem to show the greatest tendency to produce cardiac failure. The part played by reflex action in the production of syncope has not as yet re- ceived much attention. Laborde, some years ago (1890), observed that the heart of the monkey was immediately arrested by the irritative action of chloroform- vapor on the nasal distribution of the trigeminus, and observed that the ap- plication of a solution of cocaine to the nasal mucous surfaces prevented the untoward result. Recently Eosenberg, Guttmann, and others have utilized this prophylactic measure during surgical anffisthesia, and have lauded its merits. The vapors of this drug are able, by their irritating action upon the nervous elements within the naso-pharyngeal mucous membrane, to determine a brusque arrest of the heart and respira- tion. This paralysis occurs, moreover, very easily if the subject be put under chloroform during a state of very great excitement. In order to prevent as far as possible this cause of death, which is always imminent, as soon as one ap- proaches the nose of a sick person with a compress soaked with chloroform it is necessary to decrease the unnecessary excitement of the patient and the sus- ceptibility of the terminal expansion of the fifth cranial nerves. The best means, according to the author, of accomplish- ing this purpose consists in giving a pre- ventive injection consisting of hydrate of morphine. 0.10 gramme; sulphate of atropine. 0.01 gramme; sulphate of sparteine. 1.00 gramme; distilled water, 10 grammes, to every individual to be chloroformed. Irrigation of the nasal mucous membrane and of the pharynx and glottis with a concentrated solution of cocaine is also of great benefit in sup- pressing the susceptibility of these re- 80 CHLOROFOKM. SYMPTOMS OF COLLAPSE. gions. It is also necessary to have care to keep the tongue forwara in the mouth •with special forceps during the entire duration of the chloroformization, thus avoiding a sliding of this organ back- ward over the orifice of the glottis, thereby provoking asphyxia, and being ready to carry out rhythmical traction on this organ in case unfavorable symp- toms arise. Laborde (Medical News, July 5, 1902). One hundred and twenty experiments to ascertain the part played by vagus inhibition in chloroform poisoning. In 54 cases vagus inhibition embarrassed the circulation to a more or less dan- gerous extent, and in 33 experiments was the immediate cause of death. To sum up: 1. A heart which has been poisoned by inhalations of chloroform of a strength of 2 per cent, and upward can always be permanently inhibited by stimulation of the vagi with the faradic current when the blood-pressure has fallen to about 40 to 50 millimetres of mercury pressure. 2. Chloroform raises the excitability of the vagus mechanism, particularly in the early part of the ad- ministration. 3. The increased excita- bility of the vagus mechanism is due to the action of chloroform on the vagus- centres, and the inhibitory action is more intense from being exercised upon a heart whose spontaneous excitability is diminished by the action of the chloro- form upon it. 4. Chloroform adminis- tered to morphinized dogs in air contain- ing not more than 1.5 per cent, of the vapor, after a period of mild excitation slowly depresses vagus excitability. The excitability may again be raised with more or less readiness according to the duration of the administration and tlie endurance of the vagi by increasing the pcrccntiige strength of the chloroform or by asphyxia. 5. Vagus inliibition is, in dogs, the great factor in the causa- tion of sudden death from chloroform. 0. DangcroiiH inhibition is liable to occur whenever the strength of chloroform in the air inhaled rises above 2 per cent. E. H. Embley (Hrit. Med. .Tour., April 12, 1902). Raul has tracer] chloroform deaths to reflex paralysis of the tongue and neigh- boring parts, while Yallas considers pri- mary syncope, due to laryngeal reflex, as one of the usual modes of death when chloroform is employed. We have, in the production of asthma through intranasal pressure, distinct col- lateral evidence of the nervous relation- ship existing between the upper and lower respiratory tract, and, in the re- current branch of the pneumogastric, an evident indirect association between the larynx and {he heart, to say nothing of the sympathetic system, which plays the most important role in all reflex mani- festations. Symptoms of Collapse, — According to Guthrie, the symptoms are alike in all cases, and are as follow: Sudden and complete blanching of the face takes place, leaving it of a ghastly-gray hue. The term "pallor" conveys no idea of the actual appearance. The eyelids fall open, the eyeballs are fixed in the up- ward position, with pupils fully dilated as under extreme atropinism. At the same time the cornea becomes glazed and sticky, giving an appearance which, once seen, is never forgotten. It can only be described in a somewhat fanciful manner by saying that the light seems to fade from the eye as does the color from the cheek and lips. Probably it is due to flaccidity of the cornea from de- crease of intra-ocular tension, noticed by Dubois (See. de Biologic, '84). It is the undoubted look of death. The appearance of a person in a dead faint, or just after a severe accident, is no more than the shade of that which obtains in cases of chloroform collapse. The pulse and cardiac impulse are at these times no lonfjer to he felt. Respira- tion commonly ceases at the moment when the llanching and stoppage of the pulse occur, but at times a few feeble and irregular inspiratory gasps are subse- CHLOROFORM. SYMPTOMS OF COLLAPSE. 81 quently drawn. The patient is, to all appearances, dead. Whether the heart actually ceases to beat at such times will probably never be ascertained, for the moments are too valuable to be spent in delicate investigations on this point. Neither is it possible to affirm from clin- ical observation that the heart becomes dilated, as in the experiments of Mac- AVilliam and Johnson on animals. Time cannot be wasted in mapping out the area of the heart's dullness in a patient who is in imminent danger of death. In some cases lividity, accompanied by turgescence of the veins of neck and face, immediately precedes the blanch- ing and look of death, and is coincident with the stoppage of respiration. Pos- sibly dilatation of the heart has actually taken place, and the condition is that of the true cardiac syncope described by Snow. It might be objected that, were dilata- tion present, the cyanosis should con- tinue, and not give place to pallor; but, possibly, as the heart fails regurgitation takes place into the inferior cava, and allows the blood from the distended veins of neck and head to enter the right heart. In children, cyanosis, except where actual mechanical asphyxia has been pro- duced, is less apparent than pallor. Un- der treatment, children almost invariably recover from these alarming conditions, whereas in adults the reverse is unfort- unately the case. Athetosis of the fingers is a premoni- tory sign of impending asphyxia in chloroform narcosis. Koblank (Centralb. f. Gynilk., No. 1, 1900). As a rule, the preliminary signs of collapse are sufficiently well marked, and if observed in time many a catastrophe may be averted. These signs are circulatory and respi- ratory. The circulatory sign is the presence of increasing pallor, not amounting to absolute blanching. Failure of respiration is marked by a peculiar type of breathing, in which ex- piration is extremely short and inefficient, while inspiration is sudden, forcible, and gasping, often accompanied by falling of the lower jaw, and spasmodic clonic con- traction of the chin-depressers and mus- cles of the neck. The inspiratory gasps are irregular and broken, and occur with increasing slowness until the condition of sudden collapse ensues. This type of breathing is precisely similar to that which is often seen in a patient dying of respiratory failure from other causes. Under the influence of chloroform the pupil first dilates and then contracts. The dilatation of the pupil of incomplete chloroform narcosis is due, according to Arthur Ward, to mental, sensory, or sympathetic impulses aflecting the semi- narcotized cerebrum, and so giving rise to reflex inhibition of the centre of the third nerve. The activity is, therefore, due to the fact that the centre itself is not narcotized. In complete narcosis the contracted pupil is due to the com- plete subjection of the cerebrum, while the unopposed third-nerve centre re- mains active, all cerebral reflexes being now barred. I7i dangerous narcosis the third-nerve centre itself becoming poisoned, its action no longer controls the pupil, which dilates and grows less and less sensitive to light, while the globe becomes fixed. This fixation of the eyeball, to- gether with the stertor of breathing and the sluggish pupils, forms the contrast between the danger-stage of chloroform sleep and the second stage, when dilata- 82 CHLOROFORM. METHODS OF RESUSCITATION. tion of the pupil is associated with shallow breathing, etl'orts at vomiting, pupils reacting to light, and return of conjunctival and other reflexes. The period of going under is, Ward thinks, the one of most danger. The patient then, by holding his breath, debilitates the respiratory centre by cutting off its oxygen-supply, and so predisposes it to injur}' by any access of strength of the chloroform-vapor. Any material dilatation of the pupils means either that the patient is coming around — pupil active and other reflexes will follow — or that the patient is getting too far under, — stertorous breathing, sluggish pupil, fixed eyeballs. In first case more chloroform; in second, drug to be withheld till contraction recurs. A. H. \Yard (Cleveland Med. Gaz., Sept., '95). The degree of narcotism present may, to a great degree, be determined by pu- pils. Breathing, pupil, and pulse must be watched. White (Brit. Med. Jour., Apr. 20, '95). When breathing assumes automatic character, indicating that patient is un- conscious, the amount of chloroform should be regulated by the size of the pupil; pin-point pupil is the safest sign; large pupil may mean narcosis. R. Gill (Jour. Amer. Med. Assoc, June 8, '95). The pupil becomes smaller as the pa- tient goes under the influence of the drug, and just enough chloroform should be given to keep the pupil a moderate size. Although the moderately con- tracted pupil reacts when one eye is opened, yet, when both eyes are opened, the pupils suddenly become contracted. This is tlic limit of the pupillary reac- tion to liglit in chloroform narcosis. A few more drops may then be added slowly; but, if he is almost awake, they must be dropped on rapidly. Adolf Flockemann (Ct-nlralb. f. C'liir., May 25, 1901). Methods of Resuscitation. — When there are indications of syncope, no time should be lost in ascertaining the degree of danger present and the most active means, artificial respiration by Syl- vester's method or inversion, while an assistant is giving hypodermic injection oi" '/so grain of strychnine, should at once be resorted to. Whether artificial respiration will or will not succeed depends, according to B. W. Eichardson, upon several circum- stances: (1) the time which has elapsed since apparent cessation of vital action in the lower animals, even after seven minutes' restoration has occurred; (3) a high temperature, which favors clot- ting in the pulmonary circulation; (3) extreme cold; (4) rough movement; (5) inexpert artificial respiration may give the coup de grace to the enfeebled heart. The defects usually witnessed consist in too-rapid motions, and incomplete emptying of the kings, so as to induce rapid elimination of the chloroform. Murray-Aynsley lays stress upon the fact that artificial respiration should not be begun by an act of inspiration; that is, by dragging the arms above the head, for such a proceeding sei-ves to promote further absorption into the blood of the chloroform from the saturated air in the lungs. They should first be brought down close to the body; the thorax is then compressed and the arms are only elevated when the chloroform-laden air is as much as possible forced out. Care should be taken to clear thoroughly the mouth and throat of saliva, mucus, vom- ited matter, blood, etc., that may be present. Wood considers "forced respiration" the most valuable plan. He employs a pair of bellows which are connected with a tracheal tube by India-rubber tubing; a face-mask is also required. Cases in which, all the usual resusei- tative mciisures having failed, complete inversion and suspension by the bent knees over the operator's shoulders re- CHLOROFORM. METHODS OF RESUSCITATION. 83 suited in recovery. Prince (Ther. Gaz., Jan., '93). Rapid and violent artificial respiration and overvigorous efforts in the direction of inversion, etc., may, if the heart is already deeply clilorofornied, lead to a fatal distension of that organ. Leonard Hill and Barnard (Brit. Med. Jour., Nov. 20, '97). Complete inversion — i.e., suspending the patient by the feet or bent knees — is sometimes rapidly effective. Dudley Buxton regards Nekton's inversion method as the best procedure in cardiac failure when no pulmonary or venous engorgement. In his opinion, artificial respiration stands facile princeps for cases of failure of respiration when due to narcotism of medullar)' centres. Kelly recommends the following plan, which combines inversion and artificial respiration in an especially-effective manner: "On the first indication of failing respiration the administration of the anesthetic should be instantly suspended and the wound protected by a fold of gauze. An assistant steps upon the table and takes one of the patient's knees under each arm and thus raises the body from the table until it rests upon the shoulders. The anaes- thetizer in the meanwhile has brought the head to the edge of the table, where it hangs extended and slightly inclined forward. The patient's clothing is pulled down under the armpits, completely baring the abdomen and chest. The op- erator, standing at the head, institutes respiratory movements as follows: In- spiration, by placing the open hands on each side of the chest posteriorly over the lower ribs, and drawing the chest well forward and outward, holding it thus for about two seconds; expiration, reversing the movement by replacing the hands on the front of the chest over the lower ribs and pushing backward and in- ward, at the same time compressing the chest. The success of the manuiuvre should be demonstrated by the audible rush of the air in and out of the chest." The following plan of resuscitation was pursued by Maas, and, after over an hour, in each case successfully: The mouth was opened, the tongue drawn forward, and the epiglottis raised. The precordial region was then compressed thirty or forty times a minute (the fre- quency of respiration). A^Tienever this was stopped, syncopal symptoms again appeared. Subsequently tracheotomy was performed, as it was difficult to keep the air-passages free; but this did not assist the circulation. The respirations becoming almost imperceptible, Sylves- ter's method of artificial respiration was adopted, and more vigorous pressure made over the breast. A similar course was adopted in the second case. The manoeuvre is thus performed: The op- erator stands upon the left side of the patient, and presses, with quick, strong movements, deep down in the region of the heart with the fingers of the right hand, while the ball of the thumb is placed above the left clavicle. The num- ber of compressions is one hundred and twenty or more per minute. The left hand should seize the patient upon the right side of the thorax. Case in a child, apparently dead, in which the Konig-Maas method — rapid compression (about 120 per minute) of the priEcordium — followed by ultimate recovery. Seven minutes had elapsed during which neither heart-bent nor respiratory effort could be detected. Leedham Green (Birmingham Med. Rev., Feb., '95). A method recommended by Prus is warranted when other means of resusci- tation have failed. This consists in ex- j)osing tlie pericardium by making an I opening through the chest-walls — a 84 CHLOROFORM. METHODS OF EESUSCITATION. trap-door flap of skin, muscles, and ex- eected ribs — and grasping the heart and pericardium. The firmness of the grasp is then increased every second — simu- lating its own normal action. Cases re- cently reported have shown that the heart, even in doomed subjects, may be brought to react, at least for a time. For eases of eardiac failure the heart- muscle should be grasped and compressed intermittently by pushing the hand backward beneath the xiphoid cartilage. Hiffe (Brit. Med. Jour., Feb. 6, '92). Case in a boy aged 15 years. After tracheotomy and prolonged attempts to establish artificial respiration, an open- ing was made in the anterior wall of the thorax on the left side and the peri- cardium exposed. Rhythmical compres- sion of the heart excited slight move- ments of this organ, and pulsation was observed in the large blood-vessels of the thoracic cavity, but the respiration, in spite of strenuous and prolonged efforts to restore the action of the lungs, was not renewed, and after an interval of half an hour, during which cardiac massage was energetically and persistently practiced, the movements of the heart ceased. Aglinzeff (Centralb. f. Chir., No. 21, 1901). Case of chloroform narcosis in a man 24 years old. Ten minutes later the trachea was opened and air was blo-wn into the lungs, but without result. Prus's cardiac massage was then decided upon. An incision was made in the skin and muscles parallel to the third and fifth ribs and left sternal edge. The third and fourth ribs were cut close to the sternum, and two and a half inches were resected in the flap. In doing this the left pleural cavity was accidentally opened. The hand was then introduced, and the heart, with the pericardium still intact, was grasped. No movements were felt, but rhythmical coinpressionH were syHtematically practiced, partly by grasping the organ and partly by pressing it against the back of the ster- num. After a short time slight contrac- tions were felt, wliifh gradually in- creased, and at the end of one-half hour ' spontaneous respirations were initiated. At the end of three hours breathing was deep and without effort. Four hours from the commencement of in- halation respiration became ditHcult, and after a few minutes ceased. The heart continued to beat from midday until 8 P.M. The temperature of the body was fairly maintained, falling slightly; after eight hours it was 98° F. Freyberger (Hospitalstidende, B. viii, No. 47; Treatment, Jan. 4, 1901). Massage of the heart as a means of resuscitation tried in dogs. The pro- cedure of massage of the heart shown to be both sound therapeutics and per- fectly justifiable in all cases of death from cliloroform or any other ansBS- thetic, as well as from drowning and allied conditions, when all other means of resuscitation have failed. E. C. Kemp and A. W. Gardner (Boston Med. and Surg. Jour., May 21, 1903). Strychnine. — The value of strychnine as an antidote to chloroform, when given hypodermically, is insisted upon by many, and the experience of the past few years seems to corroborate this opin- ion. Its main object is to sustain vitality until sufficient elimination of the ansES- thetic has taken place. It must be used energetically and administered hypo- dermically. The use of the electrical current in act- ing upon the respiratory centres at once, and by increasing the current rapidly, keeps the respiratory mechanism during tlie dormant stage of strychnine after injection. S. T. Reid (Brit. Med. Jour., Nov. 20, '97). Hydrocyanic Acid. — This agent has been suggested by Hobday recently, but its use is not to be recommended until its merits will have been demonstrated. Electricily. — According to II. C. Wood, attempts to excite contraction of the diaphragm by electric stimulation of the phrenic nerve are fraught with danger, the overflow of the current being likely to lead to cardiac inhibition. Rockwell, however, has reached the con- CHLOROFORM. METHODS OF RESUSCITATION. 85 elusion that the inhibiting fibres going to the heart are less affected by electric- ity than the accelerator nerves. The beneficial efl:ects of the faradic current are due, not to any action it has on the heart's rhythm, but to its stimulating influence over respiration. The strength of the current employed to produce this efl:ect on respiration is much less than need be if a cardiac stimulation is aimed at, and the appli- cation of one pole over the pit of the stomach and the other under the angle of the lower maxillary near the anterior border of the stemo-mastoid is often fraught with excellent results. Cold. — The failure of respiration un- der an anaesthetic may sometimes be overcome and spontaneous respirations initiated by pouring a quantity of ether upon the bared abdomen. The cold thus produced will, says Hare, often prove successful in restarting breathing. The well-known measure of slapping the surface with wet towels is generally utilized, but does not represent an ef- fective procedure in serious cases. Nitrite of Amyl. — Great reliance is placed, by W. M. Killen, on immediate use of nitrite of amyl, combined with artificial respiration. Marsh states that it is at the initial stage of heart-failure that it is invaluable. Dudley Buxton argues that whatever value nitrite of amyl may possess, it does not, he thinks, act as an antidote to chloroform. He has found it most serviceable in failure of the circulation from prolonged severe operations, in collapse, and fear-syncope. Injections of Salt Solution. — The in- jection, either intravenous or hypoder- mically, of the physiological solution (6 per cent.) of sodium chloride has been advocated in chloroform toxaemia. The quantity to be injected depends upon the amount of blood lost during the op- eration. For chloroform toxaemia the injection either intravenous or hypodermically of the physiological solution of sodium chlo- ride is very highly recommended. Bob- rofT (Lancet, Jan. 9, '92). Infusion of salt solution in heart- failure advocated. Reim (Centralb. f. Chir., Nos. 17, 19, '95). Suprarenal Capsules. — The extract of these organs has recently been recom- mended owing to the powerful action of this agent upon the vasomotor system. Conclusions reached after a series of observations made upon dogs for the pur- pose of testing the action of the supra- renal extract upon these animals when they have been narcotized by chloroform almost to the point of arrest of the heart and respiration: 1. The intravenous in- jection of the suprarenal extract is ca- pable of saving the lives of dogs suffer- ing from extreme chloroform narcosis. 2. Compared with the procedures of other investigators, notably those of Schiiller, Laborde, and of Konig-Maas, intravenous injections of the extract are preferable on account of its more rapid action. 3. Ex- tract of suprarenals exercises a marked influence upon the respiration, the blood- pressure, and the tone of the heart- muscles even in such small amounts as from 15 to 30 grains of a 1-per-cent. solu- tion. Hence it should be borne in mind that it is a powerful remedy and should not be given in large doses. 4. During chloroform narcosis it is wise to have prepared a fresh solution of suprarenal extract, preferably sterilized by boiling, in order to controvert any sudden col- lapse. 5. The best results, in cases of im- minent death due to chloroform, are ob- tained by means of combined procedures, such as intravenous injections of supra- renal extract, massage of the cardiac re- gion, and the subcutaneous injection of physiological salt solution. F. A. Jlagn- kovsky (Russian Archives of Path. Anat.; Araer. iledico-Surg. Bull., May 10, '98). Two drugs which promote contraction of the arteries, and in consequence roust antagonize the dangerous fall of blood- 86 CHLOROFORM. AFrER-EFFECTS. pressure produced by chloroform, are atropine and extract of suprarenal cap- sule. Extract of suprarenal capsule in- creases remarkably the rate and the force of the heart-beat. Schiifer (Lancet, Feb. 5, '98). Venesection. — This is an old measure which, nevertheless, has merit. The es- sential point seems to be that the veins to be opened should be as large and near to the heart as possible, in order that the issuing stream of blood should be of con- siderable volume and the relief to the heart as rapid and thorough as possible. Case of arrest of the heart's action and of respiration during chloroform anaes- thesia in -which the internal jugular vein was opened ; compression of the lower chest to relieve the distended right ven- tricle then resorted to. Several ounces of blood rapidly escaped, and, after the jugular had been clamped by two forceps, artificial respiration was resumed. In less than half a minute the patient made a faint inspiration, followed in a few seconds by another, and, artificial res piration being continued energetically, the heart was heard to beat, at first slowly; but soon the pulse and respira tions gained in strength and frequency The operation was now completed with out further administration of an anses- thetic. This case is deemed of impor tance, as demonstrating that the bleeding from the internal jugular vein, by reliev- ing the distension of the right heart, was the main factor in bringing about the recovery of the patient from an appar- ently hopeless condition. H. F. Water- house (Brit. Med. Jour., July 18, '90). Bhythmical Traction of the Tongue. — Laborde's method has been successfully employed in a number of cases. Labbe employed it in a case in which flagella- tion, artificial respiration, and galvanism had been tried in vain. Verneuil extols the method, especially when alternated with fla(.^e]lations of the epigastrium with a wet cloth. After-effects. — Headache, nausea, vomiting, Ijrnnchial irritation, and hys- terical symptoms frequently present themselves after the use of anesthetics, but less so after chloroform than after ether. When gastric symptoms — nausea, vom- iting, etc.-— prevail, milk and lime-water frequently succeeds in allaying them. If they are stubborn, lavage with a luke- warm solution of bicarbonate of soda will usually master them. An hypo- dermic injection of morphine, ^/^ grain, with ^/i„o grain of atropine, may be used with confidence when the means pre- viously indicated fail. It is a commonly observed fact that vomiting after ansesthetization is asso- ciated with a severe degree of circulatory depression and not infrequently with actual sj'ncope. Editorial (Lancet, Nov. 10, '94). [Several cases in the year's literature vividly sustain this point. Ed., Annual, '96.] The value of inhalations of vinegar to control nausea and vomiting after chloro- form is frequently extolled. Accord- ing to Lewin, the free chlorine — one of the products of chloroform and which is a marked irritant to the pharyngeal mucous membrane and induces vomit- ing — is neutralized by the acetic acid. Of 174 cases of vomiting following the administration of chloroform, 125 pa- tients were relieved by causing them to inhale the fumes of vinegar previously placed upon a towel and left over the face of the patient for a number of hours after the chloroform-mask had been re- moved. If tlie vomiting returns after this treatment is stopped a renewal of it will be sudicient to check the relapse. Lewin (La M6d. Mod.; Ther. Gaz., Mar. 15, '98). Value of hyoseine hydrobromidc in preventing vomiting after chloroform antesthcsia emphasized. The elTect was ohscrN'cd quite accidentally. At tlie writcr'H suggestion others have taken it up, all with the happiest results. Ho gives Vim grain hypodcrmioally as soon CHLOROKOKAl. THKRAPEUTICS. 87 as tlie iiiisesthesia is discontinued. It should be given at once, before sensa- tion returns. In the first case in which it was used the patient had been repeatedly anaesthetized, and it had al- ways been followed bj' severe sickness lasting two or three days. On this oc- casion, after the hydrobroniide of hy- oscine was given there was no illness. J. E. F. Stewart (Australasian Med. Gaz., Sept. 21, 1903). Paralysis sometimes ensues. It is usu- ally due to pressure against the edge of the table or to strained position of the members. Strychnine and electricity are indicated in such cases, with mass- age calculated to increase the activity of the local circulation. Case of musculo-spiral paralysis from pressure. Patient's arm pressed against an iron bar. Several similar cases have been reported. Commonest in laparoto- mies where operator stands at the side and the arm pulled up to be out of his way. Bruns (Archives Clin, de Bor- deaux, Nov., '95). Paralysis arises from several causes: First, from the position in which the patient is lying, whereby pressure is ex- ercised upon a supplying nerve, or as a result of tractions on the arm or leg of a violent nature. Second, the employ- ment of impure chloroform, which seems capable of poisoning the nervous system and producing such paralysis, at the same time developing transient or per- manent albuminuria. Tasse (La Semaine Med., Mar. 10, '97). Therapeutics. — -The therapeutic uses of chloroform are somewhat restricted. It is an invaluable agent, however, in the treatment of general convulsions of any kind and of whatever origin: eclamp- sia, epilepsy, etc. As a smaller quantity than is necessary for surgical purposes suffices, the inhalations are not attended with after-effects. One of the many elements in the toxjemia of puerperal eclampsia is the changing of urea into ammonium car- bonate. This salt is demonstrable in the faeces in eclampsia, and it is the result 01 the principal change in that complex blood poisoning which by its effects on the nervous system give rise to the con- vulsions which are so characteristic. It is also well known that chloroform pro- duces a temporary glycosuria; hence we may readily assume that we must have glucose in the blood. If we admit the presence of this sugar in the blood, we can easily demonstrate by our test-tube that it does prevent the changing of urea into ammonium carbonate. Hence chloroform, with its accompanying gly- cosuria, is the antesthetic par excellence in puerperal convulsions. Xot that i£ will inhibit the development of all the poisons in the toxaemia, but it will limit the production of the chief one. D. H. Stewart (Medical News, Jan. 3, 1903). Whooping-cough. — In whooping- cough inhalations of chloroform some- times act in a remarkable manner as a calmative. Violent attacks of cough may usually be stopped by pouring a few drops on the hand and holding the lat- ter a few inches under the child's nose. It is also credited with value in chorea, but the almost continuous abnormal movements in this disease render its use inadvisable. Pahtueition. — The suffering of labor may also be greatly mitigated without danger by a small quantity of chloroform inhaled from a cone just prior to the on- coming pains. The labor is not retarded and the success of the ease is not com- promised. The aim should not be to produce unconsciousness, but to blunt the sensibility; given in sufficient dose to produce surgical anaesthesia, the gen- eral relaxation of the uterine tissues pro- duced tends to increase the dangers of haemorrhage. Bedford Brown, however, states that the alterations in the vaso- motor system of the pregnant woman enable her to resist the to.xic action of chloroform to a greater extent than usual. 88 CHLOKOFOKM. A. C. E. iUXTUEE. Eekal and Biliaet Colic. — In renal and biliary colic inhalations of chloro- form offer the best source of relief when the suffering is beyond the influence of safe doses of morphine. It is superior to ether in that a much smaller dose is required to relieve the pain, while the after-effects are comparatively nil. A. C. E. Mixture. A. C. E. mixture is an anaesthetic proposed by Harley (as modified by Martindale), and composed of alcohol, as a menstruum, 1 part; chloroform, 2 parts; and ether, 3 parts; by bulk. It is termed the "A. C. E. mixture" from the initial letters of the names of its ingre- dients. It is thought to present many advantages over ether or chloroform, being less dangerous than chloroform alone and more speedy in its action than ether. Administration. — The A. C. E. mixt- ure does not seem to possess the advan- tages claimed for it in text-books. While entailing the dangers of chloroform an- assthesia, it tends to cause confusion in the recognition of the danger-signals. The fact, recently recognized, that chloroform is not as safe an anaesthetic for children as was generally thought to be the case, has caused the A. C. E. mixt- ure to be tried as a substitute, but only for the first stage, ether being then sub- stituted. Even in very small cliildren it is far safer to commence the indiietion with the A. C. E. mixture and substitute pure ether as soon as that driif; can be borne. Commencing with A. C. E. on an open or Skinner inhaler, the A. C. E. is then given in a celluloid mask of Rendle's pattern, gi'adually adding more and more ether; when a fair quantity of the latter is borne, without hesitation the sponge exchanged for one containing ether alone. The following advantages claimed: (1) the time required to produce good aniEs- thesia is rarely more than four minutes, (2) the guides to the anoesthetist are clear, (3) flaccidity and freedom from movement duiing the operation are com- plete, (4) the after-effects bear compar- ison with those after any other method, and (5) the method is safe. Even shoxild an inexperienced administrator encoun- ter stoppage of respiration from an over- dose, — the only accident to be reckoned with, — all that is needed is a little com- pression of the chest, the circulation not being prejudicially affected as in the case of such an event under chloroform. The method is recommended especially for children under five or six years, and for any chUd with obstruction in the upper air-channels. In children above that age the combination of gas and ether is so well borne that nothing need replace it. G. Rowell (Brit. Med. Jour., May 8, '97). Physiological Action. — Truman has shown that the depressing action of the chloroform upon the heart by the stimu- lating action of the ether is not based upon chemical facts, the latter vaporiz- ing out of all proportion to the chloro- form. In administering the mixed anesthetics, therefore, a vapor of vary- ing and uncertain composition is em- ployed. The disproportion indicated by Tru- man is desirable; the most dangerous period is the beginning, and this cor- responds with that of excess of ether. Marshall (London Lancet, Feb. 16, '95). TJntoward Effects. — The deaths occur- ring after tlie administration of the A. C. E. mixture seem to be associated with pathological conditions similar to those met with in fatal cases following the use of chloroform. Death from A. C. E. mixture in an alcoholic subject in whom three previous administrations of the anresthctic had produced no unpleasant symptoms ex- cepting slight prolongation of the strug- gling stage. The physical examination showed no lesion of the heart; the urine contained no casts, albumin, or sugar. After a few whiffs and before conscious- ness was entirely lost, the patient strug- CHLOROFORM. CHLOROSIS. 89 gled violently and ceased breathing. The pulse continued to beat for nearly a minute after respiration had ceased. No post-mortem permitted. H. S. Jewett (N. Y. Med. Record, Nov. 13, '97). Oxygen and chloroform combined with a view of avoiding asphyxia. The scrik- ing cfTeet of this chloroform-oxygen nar- cosis is manifested in the following symptoms: After several inspirations the skin and visible mucous membranes become light red. Extremely ansemic and weak patients exhibit a healthy color. The pulse becomes slower and fuller, similar to a digitalis pulse, and its rate is nearly always about 60. Nar- cosis has reached the surgical stage in little children in one-fourth of a minute; in larger children and women, in three to seven minutes; in men, five to twelve minutes. An insufficiency in the chloro- form-supply, with a consequent lighten- ing of the anajsthesia, increases the pulse-rate. Respiration is absolutely uniform, slow, and quiet. A stage of excitement is but rarely observed, and then, as in alcoholics, it is short and moderate in degree. Vomiting, during and after antcstliesia is comparatively rare. There is never an increase of se- cretion of mucus and saliva. The sen- sations observed when the patient is awakening are agreeable in character. Personal experience with this form of narcosis comprises more than three hun- dred cases. One hundred and sixty-six patients were fully conscious imme- diately after operation; 13 required be- tween 8 and 30 minutes; one woman, after the use of 55 grammes of chloro- form, slept 3 hours; 21 dispensary pa- tients got off the table and walked home. Kidney irritation was never ob- served. Heinz Wohlgemuth (Interstate Med. Jour., Oct., 1901). Charles E. de M. Sajous, Philadelphia. CHIOROSIS. — From Gr., ;^?.wpo5: greenish yellow. Definition. — An affection of the blood characterized mainly by a reduction of the percentage of haemoglobin and a greenish hue of the skin. By a slight stretch of the imagination the skin of a person of dark complexion suffering from chlorosis might be called greenish yellow; but chlorosis is very common in Sweden, where the inhabi- tants are, as a rule, of a very fair com- plexion; so that the very name of the disease is, to a certain extent, a mis- nomer. It has, however, the sanction of ancient usages, and it would be hard to find another to which greater objections could not be raised. Symptoms. — In investigating the clin- ical history of a disease which is practi- cally confined to the female sex our first inquiries are naturally directed to the organs of reproduction. We find that chlorosis makes its appearance at or about the time of establishment of men- struation, and the behavior of this func- tion in cases of the disease in question is twofold: It may be either premature or long delayed. Niemeyer states that he has never known the menses to ap- pear between twelve and thirteen years of age in a girl with undeveloped breasts without the supervention of chlorosis. A premature appearance of the menses is, therefore, one of the important events in the clinical history of chlorosis. In such cases, menstruation may appear but once, the discharge being followed by amenorrhoea and chlorosis. In the other class of cases the menses do not appear at the usual time; the breasts and uterus remain undeveloped, while, at the same time, a decided degree of chlorosis makes its appearance. The exact relation be- tween the amenorrhoea and tlie blood- change is not understood, although it is probable that, in cases of amenorrhoea with a properly-developed genital sys- tem, the suppression of menstruation is secondary to the blood-change, whereas in those cases with an undeveloped state of the uterus and its appendages the re- 90 CHLOROSIS. SYMPTOMS. lation is not so clear. The other symp- toms of chlorosis are secondary to the blood-change and include the yarions manifestations of anaemia in general. Analysis of 232 cases, showing that im- perfect evolution of menstruation, as evi- denced by scantiness of the flow and ir- regularity of the periods, is as regular a feature of chlorosis as the imperfect evo- lution of the red corpuscles of the blood. These constants were not related to each other as cause and effect, but were inde- pendent one of the other. At the same time there is a close relationship between them, whereby the reproduction and de- velopment of the red corpuscles of the blood are governed by, or formed part of, the menstrual cycle; and both are influenced by a greater rhythmic action which determined the time and activity of development, growth, and reproduc- tion. W. Stephenson (Brit. Med. Jour., Mar. 16, '89). It is in this disease that the inorganic cardiac murmurs are so frequently heard, especially over the base of the heart, i.e., over the points of the origin of the aorta and pulmonary artery. In 205 cases, 115 had cardiac bruits. Of these, 56 were audible at the base, 13 at the apex, 24 at base and ape.x, and 22 at base, apex, and back. The last group were always accompanied by distinct dilatation of the ventricle and strong im- pulse ; they were the first to disappear under treatment: a fact which shows that they are present in the more ad- vanced eases. In 2 of the 22 cases the murmur persisted after seven and nine months, respectively. These remain as permanent mitral regurgitations. Barr (Amcr. Jour. Med. Sciences, Oct., '91). Many of the bruits supposed to be in- tracardiac really due to the action of the heart against the lungs. Potain (L'Union Mf-d., Dec. 23, 30, '00). The bruit cal anremia as a synonjTn of chlorosis. Tliis theory of Clark is based upon certain signs and symptoms that are commonly encount- ered in chorosis. Chief among them are digestive disturbances. The tongue is generally heavily coated at the base, large, flabby, and with its sides indented with the teeth. The breath is disagree- able and sometimes, according to Clark, has a distinctly fsecal odor. The bowels are either confined or inadequately re- lieved, and the fceces consist of scybalous masses imbedded in mucus swarming with bacteria. Pain in the side, most marked on the left, is a common symp- tom, and is believed by Clark to have its seat either in the hepatic or splenic flexure of the colon. This view of the nature of the pain in the side is corrob- orated by the fact that it may be relieved by large enema ta of warm water. Accord- ing to the authority just named, it is a common thing for young girls to neglect the calls of nature, so far as the bowels are concerned. The faeces accumulate, and, by their decomposition, ptomaines and leucomaines are generated, absorbed, and, by their poisonous action, produce the multiform symptoms of chlorosis. A treatment based upon the theory that chlorosis is due to fascal retention is sometimes eminently successful, and will be referred to later in detail. Three cases of chlorosis characterized by the presence in the urine of a pe- culiar "chroniogen" — a colorless sub- stance which becomes converted into a pigment of oxidation. It is manifested by the urine becoming a rose-red color on the addition of nitrous-nitric acid: I.e.. pure nitric acid to which a small quantity of the common yellow acid of commerce has been added. Chromogcn is a derivative of skatol, and. therefore, derived from foecal absorption. In all cases there was marked constipation, the relief of which by large enemata consti- tuted the basis of his treatment. Res- toration to health coincided with disap- pearance of the urinary chromogcn. 96 CHLOROSIS. ETIOLOGY. George Herschell (Practitioner, May, '93). Chlorosis is of intestinal origin. Dim- inution of urobilin in the lu-ine an important sign. A toxic body foimd in the urine, "the exact nature of which it has been as yet impossible to determine," but which is believed to be largely ac- coimtable for the nervous phenomena of chlorosis. F. Forchheimer (Therap. Gaz., Xov. 15, '93). Another exciting cause of chlorosis is cold. Prof. Augusto Murri, of Bologna, has published an elaborate paper on the influence of cold in the etiology of chlo- rosis. He gives the notes of three cases, in which the symptoms of the disease were limited to the cold months of the year, disappearing in summer and re- curring at the onset of the succeeding winter, and he states that others pre- cisely similar have come under his ob- servation. He, therefore, styles them "winter chlorosis," or chlorosis hiemalis. It is well known that chlorotic patients are often affected unfavorably by such exposure to cold as is well borne by the healthj', and this Murri believes to be due to an instability of the vasomotor system on the part of the former. In fact, he regards chlorosis as a vasomotor neurosis, the blood-changes in the dis- ease being induced by cold, nervous shock, or long-continued irritation from the genital organs or elsewhere. Meinert, of Dresden, claims to have demonstrated a displacement of the stomach (gastroptosis) in sixty consec- utive cases of chlorosis. Fifteen per cent, of the cases were complicated with right movable kidney and in one case both kidneys were movable. The gas- troptosis is secondary to enteroptosis and this, in turn, to the pressure of the corset; so that, according to Meinert, it is to this article of female apparel that chlorosis is due. After the cure of a case of chlorosis, its anatomical sub- stratum, the visceral displacement, re- mains, and hence the notorious tendency of the affection to relapse. No one doubts the evil effect of tight- lacing, and all will admit that in a per- son predisposed by inheritance or other- wise to chlorosis the development of the disease may be accelerated by constric- tion of the thoracic base and consequent displacement of viscera. Chlorotic subjects often present a high position of the diaphragm. The liver- dullness begins at the upper edge of the fourth or the lower edge of the third rib. The heart-dullness is sometimes found to extend either to the right or to the left. This enlargement of the area of the heart- dullness is probably due in but a few cases to dilatation. Fi-equently it is of a' certainty due to the elevated position of the diaphragm, in consequence of the diminislied volume of the lungs. F. Mijller (Berl. klin. Woch., Sept. 23, '93). In a series of 29 cases dilatation of stomach without retention found in 8 cases; dilatation of stomach with re- tention found in 6 cases; flatulent dys- pepsia in 14 cases. Chlorotic patients are more concerned with the pale color, breathlessness, swelling of the feet, and palpitation than with gastric disturb- ances. In 17 cases, however, dyspepsia preceded the chlorosis; in 2 cases both appeared simultaneously, and in the re- mainder the relation could not be deter- mined. Mongour (Archives Clin, de Bordeaux, Nov., '9G). As to Meinert's contention that chlo- rosis is produced by the gastroptosis brought about by the pressure of the corset: It may be possible to define the outline of the stomach in cases of con- siderable gastroptosis where the upper curvature lies below the liver and the abdominal walls are lax; but in young subjects, such as chlorotic girls, the chlo- rotic walls are not lax. In a large num- ber of chlorotics, who wore corsets, to map out tlie lesser curvature of the stomach was found impossible. It is UHiial, however, in such cases to find the greater curvature extending lower down than usual; this is possibly due to an CHLOROSIS. PROGNOSIS. PATHOLOGY. 97 abnormal distensibility of the stomach: a condition occurring as a result of chlo- rosis. Leo (Deut. med. Woch., Mar. 19, '90). There are those who regard chlorosis as an infectious disease. Chief among them is Clement, of the Hotel-Dieu, Paris, who bases his opinion of its in- fectious nature on the enlargement of the spleen, which he has found in thir- teen cases; on the frequency of fever, the occasional complication of phleg- masia dolens, and the epidemic occur- rence of the affection. The hypothesis is well argued, but the facts upon which it is based are questionable. Blood of chlorotie patients exaiiiined for micro-organisms, and in ten or twelve cases either the streptococcus albus or the staph3'lococeus albus found, the former being the more abundant, and — in rarer instances — the bacillus coli. Lemoine (Le ProgrSs M6d., Nov. 17, '94). Thrombi ma.y form in the cerebral sinuses and cervical veins, though usu- ally they occur in the femoral vein. They necessarily cause death; the two recorded instances of thrombi in the jugular vein ended in recovery. Infection the cause. Bourdillon (Jour, de MOd. et de Chir. Prat., 8ept. 10, '92). Enlargement of the spleen observed in twenty-one out of fifty-six cases of chlo- rosis. Inasmuch as a "foetal state" of the spleen, marrow, and other h£emnto- poietic organs has been described as char- acteristic of chlorosis, this observation is interesting. F. Chvostek (Allgemeine med. Central-Zeitung, July 22, '92). Study of thirty-one cases: Chlorosis is, in the great majority of cases, the re- sult of mnlnjitrition. dependent vipon the consumption of an insufficient amoimt or of an unsuitable quality of proteid; in most cases a great diminution of the nitrogenous excreta of the urine found, while a common symptom of chlorosis is a perversion of the appetite to the excessive consumption of starches and sugars. The superiority of such prepara- tions as ferratin over the inorganic forms of iron suggests that there is value in the proteid material which they contain. Simon (Amcr. Jour, of Med. Sciences, Apr., '97). Chlorosis is due to a transient inca- pacity of the blood-forming organs oc- curring during puberty, or to an hypo- plasia of those organs, manifesting itself more or less throughout life, and occa- sionally resulting in the hypoplasia of the vessels described by Virchow. This weakness of the blood-forming apparatus manifests itself in the production of less valuable erythrocytes, deficient in hcemo- globin and altered in form. Hofmann (Munchener med. Woch., July 18, '99). Prognosis. — The prognosis of uncom- plicated chlorosis is invariably good, the response to appropriate treatment being prompt and decided. It should be borne in mind, however, that inter- current disease of any kind is apt to be unusually severe. Tiiis is especially true with reference to febrile disorders, which occasion great and rapid consump- tion of the blood-corpuscles in healthy persons. As a matter of course, the powers of resistance to such affections are much reduced in those whose blood is already impoverished. In forming a prognosis the tendency of the disease to relapse should not be forgotten. This is especially marked in those cases in which the development of the vascular and re- productive sj'stems is imperfect; in other words, in those in whom the tendency to anaemia is congenital. Predictions of permanent cure after a single course of treatment should, therefore, be made with great reserve or, better still, should not be made at all. Pathology. — Virchow endeavored to place chlorosis upon a distinct anatomi- cal basis by the demonstration that, in fatal cases, there is often found an im- perfect development of the aorta and arterial system generally. He has found the aorta of a full-grown woman so small as barely to admit the little finger, whereas, normally, it should admit the a-7 98 CHLOROSIS. PATHOLOGY. ttumb, and, with this condition of the liunen of the vessel, its coats were found to be much thinner than normal. He regards this condition of the vessels as congenital, and the importance of the observation depends upon the fact that the blood-vessels and the blood-cor- puscles are both derived from the same embrj'onic layer, — the mesoblast, — an imperfect development of the one nec- essarily entailing the same condition of the other. There is little doubt that Virchow's observation is true with ref- erence to some of the cases, especially those that run a fatal course. A con- dition of imperfect development of the vascular system might, doubtless, give rise to grave disturbances of nutrition eventually ending in death; but chlo- rosis is not a fatal disease, the great ma- jority of cases under appropriate treat- ment terminating in recovery, and with reference to them there is no proof that such a stunted condition of the blood- vessels is present. The only constant anatomical changes of chlorosis are those of the blood itself, and it is for this reason that the disease is classed among the primary ansemias. Even the blood-changes are not uniform. The researches of Duncan in 1S67 first established the fact that, in well-marked cases of chlorosis, the number of red corpuscles might be normal, while their percentage of haemoglobin might be greatly reduced, and this anomaly was, for a long time, regarded as the dis- tinguishing mark of chlorosis. It has since been establi.shed that this view of the blood-change in chlorosis is alto- gether too narrow, and at the present day it is generally admitted that the blood-changes in chlorosis may be at least threefokl: 1. They may be of nor- mal size and number, their only change being a deficiency of haemoglobin. 2. They may be diminished in number, with diminished percentage of hcemoglo- bin. 3. They may be diminshed in size and normal in number and in percent- age of hEemoglobin. Of these varieties, the second is the most severe, and in it there are often marked changes (poiki- loeytosis) in the shape of the red cor- puscles, such as are so commonly ob- served in pernicious anaemia. From these facts it is evident that there is nothing uniform in the be- havior of the red corpuscles in the dis- ease called chlorosis; so that an attempt to describe it as a distinct disease from an anatomical stand-point must result in failure. The essential point is that the percentage of hasmoglobin is reduced, but this is common to many forms of ana3mia. Chlorosis is due to oligoclirorasemia, the result of faulty htemopoiesis, in turn due to diminished htemoglobin produc- tion. HfEmoglobin is principally formed in the intestine; this is proved (a) by direct investigation upon lower animals, and {&) by direct observation upon the human being. Hfemoglobin formation can be increased by the introduction into the intestine of agents not containing iron, but preventing putrefaction. Chlo- rosis is due to a prevention of hfemo- globin formation by destructive agents acting upon the precursor of hsemoglobin in the intestine. Forchhcimer (Boston Med. and Surg. Jour., Aug. 24, '03). The albumin is diminished, owing to the diminution of hmmoglobin; the rela- tion of albumin to globulin is normal and the amount of fibrin increased. There is considerably more fat than nor- mal in both tlie serum and tlie erythro- cytes; the lecithin is diminished in the total blood and the seriun, but seems to be increased in the red cells. Choles- terin is present in smaller amoimts in both the scrum and red cells. In the ash, phosphoric acid, potassium, and iron are considerably reduced, calcium and mag- nesium are increased. The increase of sodium chloride is only apparent, since CHLOROSIS. TREATMENT. 99 chlorotic blood contains a higher per- centage of serum than normal blood; the amount of sodium chloride in the serum is not, however, increased. F. Erben (Zeitsch. f. klin. Med., vol. xlvii, Nos. 3 and 4, 1903). It has been contended by some writers, especially by Immermann, that chlorosis dillers from all other forms of anaemia in that the albuminous bodies of the blood-serum are present in that fluid in normal or increased amount. This has certainly been proved to be true in a few cases by chemical examination, but it has not yet been proved that the same may not be true of other forms. From the above it appears evident that the conditions of the blood and the other organs of the body are so various as to veto the present establishment of chlorosis as a disease with a distinct ana- tomical basis. With advancing knowl- edge, some etiological or pathological fact common to all eases of the affec- tion may be discovered, but at present none such is known. With our present knowledge, the most sensible view of the nature of chlorosis appears to me the following, which I have already ex- pressed elsewhere: At the time of pu- lierty there is an urgent physiological demand upon the blood, which is com- plied with by vigorous persons without detriment to the organism. The ordeal of puberty is safely passed. In less vig- orous, but still sound, healthy organisms a decided degree of anaamia, one calling for treatment, declares itself at this time. Finally, in those with any con- genital tendency to anasmia, whether this be due to general malnutrition during intra-uterine life or to a special hypo- plasia of the vascular system, the an- femia of puberty is intense; the case is a typical one of chlorosis. Cases of chlorosis may lie divided into three classes: (1) Chlorosis with vas- cular hypoplasia without change in the se.xual apparatus; (2) chlorosis with vascular hypoplasia and excessive devel- opment of the genital apparatus; (3) chlorosis with vascular liypoplasia and defective development in the genital ap- paratus. Even though later researches may show that the vascular hypoplasia is not constant, the lesions of the ves.sels and the heart will occupy, nevertheless, a prominent place in the pathological anatomy of chlorosis. Gilbert, of Paris (Moil. Record, Oct. 2, '97). Treatment. — As Immermann remarks, "there is scarcely any point in thera- peutics so fully established as the re- markable efficiency of iron in removing all the symptoms of chlorosis"; but it does not follow that iron should initiate the treatment in every case. Nearly all chlorotics are dyspeptic, and until the digestive disorder is relieved the full benefit of iron cannot be obtained. In cases of atonic dyspepsia, the simple bit- ters, such as quassia or gentian or ex- citers of the smooth muscular fibres, such as strychnine or brucia, may be administered before meals or, if there is gastric dilatation, naphthol, bismuth salicylate, or chloroform-water may be administered three or four hours after meals, as recommended by le Gendre, in order to arrest the abnormal fermen- tations usually present in that condition. Lavage is rarely, if ever, necessary. Hy- peracidity of the gastric juice should be treated with full doses of alkalies — soda, chalk, lime-water, or magnesia — from one to two hours after meals and ana- cidity with full doses of dilute hydro- chloric acid immediately after eating. The dyspeptic disorders so often met with may become a serious obstacle to active treatment: such cases should be looked upon and treated as simple dys- pepsias, until the stomach be brousht into condition for the treatment of the chlorosis itself. Hayem (La Scm. Miki., Xov. 4. '91). The first object is to improve the gen- 100 CHLOROSIS. TREATMENT. eral condition, then exercise in the open air. A. Hoessli (Deut. med. Woch., Sept. 15, '92). Such mUd laxatives as compound lioo- rice-powder and cream of tartar. The preparation of iron used will depend upon individual conditions. Blaud's pill and the tincture of the chloride of iron are preferred. Arsenic ought not to be used alone, but forms a good adjuvant, especially in the form of arsenical waters, like the Koncegno or Levico. Sulphur, so highly lauded by Schultz, acts prob- ably by stimulating the bowels. Noth- nagel (Wiener med. Presse, No. 52, '92). Sulphur bears very intimate relations to cellular protoplasm, and acts in a more important manner in chlorosis than as a mere laxative. It is indicated when iron does not seem to act and when there is not gastro-intestinal irritation. After it has been used for a time, iron may again be administered instead, and with better hope of success than before the sulphur was used. Schultz (Berliner klin. Woch., Mar. 28, '92). Dietetic treatment of chlorosis. This should vary somewhat, according to whether the patient is lean or fat. Lean patients sliould be given food "copious in quantity and favoring the deposit of adi- pose tissue." This includes large quanti- ties of butter and such "amylaceous foods as do not irritate the stomach," and about 3 ounces of meat per diem. Unnecessary muscular exertion and ex- posure to cold should be forbidden, and in some cases absolute rest may have to be enjoined. The fat chlorotics may be allowed as much as 4 ounces of albumin per diem, and, in addition, no more fat and carbohydrates than will cause the nutritive value of the food to exceed 18 calories per pound of body-weight. Carl von Noorden (Inter. Med. Mag., May, '94). Milk sliould be used, or, if this is badly borne, pure water or a hot, weak infusion of tea (hot drinks excite the gastric se- cretion), eggs, jiur/:n of vegetables, lean fish, fowl, and cooked fruits. One-half hour before the meal a small dose of an alkali, as sodium bicarbonate, 7 % grains, Hhould be prescribed for the purpose of exciting the flow of gastric juice. At the same interval after it a Madeira glass of hydrochloric acid in solution in water, 1 to 250. The hydrochloric may be re- placed by lactic acid, 1 or 2 grammes (15 or 30 grains) after meals. It is necessary to forbid the use of wines, cinchona- wine, strong beers, alcoholic drinks and stimulating food. If there are gaseous formations, lavage, either of pui-e water or water containing salicylic acid, 1 per 1000, is indicated. After two to four weeks of this treatment the use of the preparations of iron can be begun. Henri Huchard (Kevue G6n. de Clin, et de Th6r. Jour, des Prat., Jan. 19, '95). Kest in bed, when sufficiently pro- longed, is of the greatest importance, checking the too rapid destruction of the red globules. The choice of food is made subordinate on account of the dyspepsia which generally accompanies chlorosis. There is often an hyperpepsia of medium degree and some dilatation. In such cases the food at first should consist of milk and raw meat ; later on, of un- der-done eggs, the easily digested vari- eties of fish, piirie of gi'een vegetables, and stewed fish. No bread is allowed for four or five weeks. In about 20 per cent, of the cases the gastropathic state is more pronounced and needs more care. Sometimes there is intense parenchy- matous gastritis, with marked dilata- tion; again, there may be a gastritis which has caused diminished glandular secretion and an liypopeptic state. In the former case, in addition to restricted diet, massage is to be used, and lavage also, when abnormal fermentation exists. By the use of these measures it is gen- erally possible to begin ferruginous treatment in from two to four weeks. In liypopeptic conditions, however, iron (either Blaud's pills or the protoxalate) may bo used from the first before meals and hydrochloric acid a half-hour after eating. Ilayem (Le Bull. M6d., Apr. 21, '95). According to Dr. Ilaig, of London, who has done so much to increase our knowledge of lithasmic conditions, "iron cures ana3mia by clearing the blood of uric acid." When iron fails to cure chlorosis, he recommends its suspension CHLOROSIS. TREATMENT. 101 and the administration of mercurials and salicylates until the blood is cleared of uric acid, after which improvement may occur, without the resumption of iron. There has been much discussion con- cerning the modus operandi of iron in chlorosis. A study of a few cases, per- haps even of one, will lead the reflecting physician to the conclusion that the cause of chlorosis is not a deficient sup- ply of iron, but something that interferes with its assimilation. Nearly all our food-substances contain iron, and there is probably no drinking-water in which traces of it cannot be found. It is evi- dent, therefore, that there is something that interferes with the assimilation of the iron which is abundantly present in the food of chlorotic persons. Until quite recently, no satisfactory explanation could be given of the effi- cacy of iron in chlorosis and especially of the necessity of administering it in large doses, for it was known that very little of the drug was absorbed. Nearly all the iron given by the mouth can be recovered in the fajces, and, therefore, it would appear that a large portion of the drug is wasted and that equally good results might be obtained by its use in small doses. This, however, is not the case, and, thanks to the investigations of Bunge, we have, at the present time, at least a working-hypothesis on which to base our employment of the metal. In the first place, our food, which contains all the iron we need, does not contain it in inorganic form, but in an exceedingly complex organic combination. Now, in chlorosis, as is so emphatically insisted upon by Sir Andrew Clark, digestive disturbances are exceedingly common. Abnormal fermentations and decompo- sitions take place in the gastro-intestinal tract which give rise to the formation of quantities of sulphides. These decom- pose the iron contained in the food and completely unfit it for the purposes of nutrition. By administering an inor- ganic preparation of iron we protect the organic combinations of that metal in the food, for the sulphur in the intestine combines with the iron administered, and allows that normally contained in the food to be absorbed. This theor}' of Bunge also explains why it is sometimes necessary to administer colossal doses of iron, for, in such cases, the decomposi- tions in the intestine are usually active, sulphur is fonned in large quantity and requires a proportionally large amount of iron to take it up. It is only proper to add that Bunge's theory has lately been contested by Ealph Stockman, of Edinburgh, who claims to have cured cases of chlorosis with sulphite of iron, and who contends that bismuth, manganese, and other drugs which are just as capable of absorbing sulphuretted hydrogen as is iron, are inert in chlorosis. Stockman, nevertheless, acknowledges that the promptest curative effects are obtained with inorganic preparations of iron. There has been a great deal of dis- cussion concerning the relative merits of organic and inorganic preparations of iron, and there can be little doubt that both are effective. The protoxalate is a favorite preparation of certain emi- nent French practitioners, while others claim that the best results are obtained with the sulphate, either alone or com- bined with potassium carbonate, as in the well-knovrn pill of Bland. For my own part, I am accustomed to place the most reliance on the inorganic salts of iron, although I have obtained good re- sults with both the malate and the lac- tate. So far as iron is concerned, the efforts of pharmacists seem, of late, to be directed toward the production of 103 CHLOROSIS. TREATMENT. preparations which resemble the organic iron compounds of the food. This seems a misdirection of endeavor, for it is just this iron of the food which is not assim- ilated by chlorotics. All preparations of iron do not act identically. They may be divided into five groups: (1) the ferrocyanides, which have no action; (2) the blood from an organism of the same species, which may be useful during a certain period; (3) haemoglobin in solution, which probably penetrates rapidly into the circulation and is assimilated; (4) the ferruginous salts of vegetable acids, which, at least by subcutaneous injection, are taken up by the circulation, and deposited in the liver; (5) insoluble preparations and fer- ric-oxide salts, which dissolve in the stomach and later form albuminates and absorbable iron. Blaud's pills and acid lactate of iron have seemed to be the most active in chlorosis. A daily dose of 1 to 1 V» grains is sufficient. For hypodermic injection a 5-per-cent. solu- tion of ferric citrate may be used, a quantity containing from 1 to 1 '/, grains being injected daily. Quincke (LaPresse M6d., Apr. 10, '95). Results of treatment by inhalation of oxygen-gas at half the atmospheric pres- sure in three cases of chlorosis in women, all of whom had previously been treated with iron, and one of them with arsenic as well. In one case there were signs of phthisis. Oxygen inhalations were given three times daily with marked improve- ment. Iron is not indicated in cases where there is nervous excitement or where digestion is impaired. Such cases do better under arsenic combined with oxygen inhalations diluted with nitro- gen. Corish (N. Y. Med. Jour., Feb. 13, '97). Under the influence of iron adminis- tered hypodermieally menstruation is re- establiHhcd, and this efTect is dependent upon the general improvement of the organism and the excitant action or hypcraimia induced liy the drug. Under the injection of manganese tlie reappear- ance of the mcnBcs is more tardy, al- though the general health is much im- proved. The reappearance of menstrua- tion is always followed by an improve- ment in the general health and in the blood. Iron and manganese act espe- cially as reconstituents, not exclusively upon the hsemoglobin, but also upon the red cells. Arsenic does not materially increase the hfemoglobin, but it notably increases the number of red cells. Stefl'a- nelli (Settiniana Med., Xos. 40 and 41, '99). Hasmalbumin recommended for the re- lief of chlorosis. It is a powder readily soluble in hot water or alcohol, and con- tains all the salts and albumins present in the blood. Dose of hfemalbumin is 15 grains three times a day. Goliner (Deutsche med.-Zeit.; Med. News, Apr. 15, '99). Sanguinal recommended very highly in the treatment of anremia and chloro- sis. Sanguinal contains 10 parts of chemically-pure ha;nioglobin, 46 parts of the normal blood-salts of the human blood, and 44 parts of muscle-albumin. Each pill represents about 75 grains of fresh blood. Victor Reichsberg (Deut- sche med.-Zeit., May 21, 1900). In conclusion, I will describe the method of treatment so strongly advo- cated by Sir Andrew Clark. With care- ful attention to the diet and a tepid sponge bath, followed by brisk toweling night and morning, he prescribes the following mixtvtre: — ]^ Ferri sulphatis, gr. xxiv. Magnes. sulphatis, 3vj. Acid, sulph. aromat., 5j. Tinct. zingib., oij. Ini'us. gentian comp. vel quassiaj, oviij- M. Sig.: One-sixth part twice daily, about 11 and 6 o'clock. Occasionally this acid mixture pro- duces sickness, dries the skin, and is otherwise ill borne. In such cases he prescribes the following alkaline mixt- ure: — CHLOROSIS. TREATMENT. 103 ]^ Ferri sulphatis, gr. xxiv. Sodii bicarb., oij. Sodii sulphatis, 5vj. Tinct. zingib., 3ij. Spt. chloroformi, oj. Infus. quassijE, o'^iij- M. Sig.: One-sixth part twice daily, at 11 and 6 o'clock. Sometimes neither mixture agrees with the patient, in which he prescribes sulphate of iron in pill with meals and a saline aperient on first waking in the morning. By this plan Clark claims that nine out of ten cases recover in from one to three months, and by careful attention to the bowels, taking twice a week a pill com- posed of aloes, myrrh, and iron, the re- covery will probably be permanent. Summary showing the average gain in heemoglobin per week from the use of various agents: Betanaphthol, 2 grains three times daily (antisepsis), 30 cases, 1.85 per cent.; Blaud's iron pills, 5 grains three times a day, 31 cases, 5.07 per cent.; cathartics alone, 7 cases, lost 1.50 per cent. Twelve cases treated with Blaud's pills after a course of betanaph- thol showed an average weekly increase of G.70 per cent.; 19 cases treated with Blaud's pills without betanaphthol showed an increase of but 4.50 per cent. Series of 28 cases treated during an aver- age period of 4.3 weeks, with 2 grains of betanaphthol, in tablet form, and 5 grains of Blaud's iron pills three times a day. The average gain in hoemoglobin per week was 7.9 per cent., the maxi- mum gain being 20 per cent, per week for 2 weeks in one case, 14 per cent, for 3 weeks in another, 13 per cent, for 4 weeks in another, while another patient averaged a gain of 11.4 per cent, per week for 5 weeks. The average amount of hsemoglobin possessed by the patients before beginning the treatn\ent was 48 per cent. After 4.3 weeks of treatment it was 82 per cent. Conclusion that the results of combined treatment are con- siderably better than those obtained "'■'•h iron alone, and much better than tiiose obtained with betanaphthol alone. Town- send (Boston Med. and Surg. Jour., May 27, "96). Chlorotic cases can be divided into three classes: Those in which iron is absolutely useless, those in which it is fairly valuable, and those in which it is an absolute necessity. The cases in which it is useless are those which have been deprived of fresh air and sunshine, and only need proper food and outdoor life, with stimulant treatment, to regain their health. Those in which it is moder- ately valuable are the pseudochlorotics who have as an underlying cause a tend- ency to develop tuberculosis with gen- eral debility; but, as a rule, the more dyspeptic tlie patient, the less good will iron do. The cases in which the iron is most useful are those in which the patients are devoid of dyspeptic symp- toms, when any one of the common iron preparations may be given in large or small doses with advantage. Should there be a syphilitic dyscrasia underlying the ansemia, mercurials should be admin- istered in addition to the iron, preferably the bichloride of mercury. Huchard (Revue de Ther. Medico-Chir.; Ther. Gaz., Sept. 15, '97). In cases in which there is an accelera- tion of the heart-beats recourse has been had to medicaments, diminishing the ap- parent action of the heart, such as digi- talis. These therapeutic agents have very little success in such cases, their action being only temporary; so that the palpi- tations recur; while for some patients digitalis is even hurtful. Dependence should, hence, not be placed upon these agents, but rather upon those acting upon the nervous system, as bromide of sodium, valerian, camphor, etc. (Potain.) The salts of copper are especially valuable in chlorotics with cervical lymphadenitis. Cases without tubercu- losis do best under iron or arsenic. But scrofulo-tuberculous cases are most benefited by phosphate of copper. Men- (lini (Jour, des Praticiens, Apr. 27, 1901). The practice of Mendini in employing copper salts in chlorosis, amenorrhoea. 104 CHOLELITHIASIS. PHYSICAL PROPERTIES. CLASSIFICATION. and cervical lymphadenitis recommended. The acetophosphate is preferred, and in many of the eases imder observation for the past twenty-five years marked improvement in the blood condition has resulted. E. Li^geois (Jour, des Prati- ciens, vol. sv, p. 225, 1901). Bone-marrow and ovarian extract have been employed with some success in the treatment of chlorosis, but their value has not, as yet, been suificiently established to warrant more than an en- couragement for further trial. Ovarian substance tried in several cases. After the first treatment the pa- tients complained of pain in the lower abdomen, discomfort, headache, and mus- cular pain. Two had fever and rapid pulse. In three patients the result was good. The general health was improved, the ancemia disappeared, the number of blood-corpuscles was increased, and the menses returned. Spillmann and Etienne (Gaz. M6d. de Paris, No. 35, '96). Fhederick p. Henry, Philadelphia. CHOLELITHIASIS. — From Gr., xoX>7, bile, and /udiaaig, from /{.Wog, a stone. Definition. — The term "cholelithiasis" is applied to that condition which re- sults from the precipitation of clioles- terin from bile and from the combina- tion of bilirubin and lime, which form an insoluble compound. Tliese two make up nearly the whole mass of the biliary calculi. The calculi are of varying size and density. The presence of concretions in tlie biliary passages may produce obstruction of the ducts, ulceration and perforation of the walls, and the formation of fis- tulous channels. The process may be accompanied by cholangitis, cholecys- titis, and perihepatic abscess. Obstruc- tive jaundice, biliary cirrliosis, and in- testinal obstruction may be directly caused by gall-stones, and can be dis- cussed under the head of "cholelithiasis." Physical Properties ; Varieties. — Bil- iary calculi vary in size from that of a grain of sand to that of an English walnut or be even larger. Case in which a conglomeration of cal- culi formed a mass about the size and shape of a pear, which was passed during life. The patient was a female, 60 years of age. Case also mentioned, described by Fiedler, of a stone consisting of three pieces which was over twelve inches in length and weighed forty-sbc grammes. It completely filled the gall-bladder. Krauss (On "Gall-stones," p. 11). The smallest (gall-sand) are dark in color and are wholly made up of bili- rubin-calcium. Not infrequently a large number of small calculi, angular, fa- cetted, and grayish in color, are found in the gall-bladder or in a sac opening into the common duct. The larger ones are dark brown or of a dark-yellowish color, depending on the amount of bilirubin-calcium which exists in the outer layer. When calculi are small they are usu- ally very numerous. In one case over two thousand were removed. Case of choleeystotomy performed by Hatton in which 440 gall-stones were removed from a woman, 43 years of age, who stated that until five weeks before the operation slie was quite well, but at this time slie was seized witli an attack of hepatic colic. Rid- oiit (Lancet, Foli. 14, 1003). The larger ones exist singly or in small numbers. The shape depends on the number present. WJicn large and single they are round or more frequently oval, but when a number exist together in the gall-bladder or in a sacculated enlargement of the bile-duct they are facetted, the result of attrition. Occa- sionally a single stone is found facetted: an indication that others have already passed tlirough the ducts. Classification. — Biliary calculi have CHOLELITHIASIS. SYilPTOlIS. 105 been classified according to the propor- tionate amount of their two principal constituents: cholesterin and bilirubin- calcium. They may be divided into three principal classes: — 1. Pure cholesterin. 2. Mixed cholesterin and bilirubin- calcium. 3. Pure bilirubin-calcium. The mixed variety is altogether the most frequently met with, and choles- terin is the principal constituent. Naunyn, whose classification is now generally adopted, makes the following division: — 1. Pure cholesterin. 2. Laminated cholesterin. 3. The common gall-bladder stones. 4. Mixed bilirubin-calcium. 5. Pure bilirubin-calcium. 6. Earer forms. The common gall-bladder stones are altogether the most frequent. The larger ones are about the size of a cherry, and they may be of a lemon or brownish- yellow color. When fractured, the sur- face presents a crystalline, glistening ap- pearance, in which the light-yellowish color predominates. The cholesterin is arranged in layers between which bili- rubin-calcium exists in greater or less quantities. The nucleus is often com- posed of bilirubin-calcium; broken-down epithelial cells, bacteria, and foreign bodies have been found in the centre. When very numerous, calculi in the gall- bladder are often of a light-grayish color, and consist of an outer shell and a soft nucleus. The pigmentary, or bilirubin-calcium calculi gall-sand, are small, and uce found in greater numbers than the cholesterin and mixed varieties. They are sometimes found in the intrahepatic ducts, and appear to be the result of a catarrhal cholangitis. A rare variety of gall-stones, composed principally of calcium carbonate, is occasionally found. Besides the constituents already men- tioned, the following elements and com- pounds have occasionally been noted: Calcium sulphate and phosphate; cop- per and iron combined with bilirubin- calcium. Globules of mercury were found by Ferrictis. Symptoms. — The symptoms of gall- stones may be studied under three heads: 1. Those produced by the passage of calculi through the natural channels. 2. Those produced by gall-stones when they have found their way outside of the gall-bladder and ducts. 3. Complica- tions and sequelae. Passage of Gall-stones Through THE Natural Channels. — Gall-stones may remain for years in the gall-bladder without producing any marked symp- toms, although bile-pigment may be found in small quantities in the urine. It may, as Dr. Adler has pointed out, pass into the circulation through the base of the ulcer. It is said that the presence of calculi can be made out by palpation and percussion, but sounding for gall-stones through the abdominal walls is now almost universally con- demned as being more dangerous than a laparotomy. Krauss recently described a prodromal state of cholelithiasis. The symptoms, more marked in females, are constipa- tion, flatulency, loss of appetite, and a sense of pressure in the epigastrium. The skin of the face first becomes pale and yellowish, then j'ellowish b^o^vn. The lower portion of the conjunctiva is tinged yellow. The urine is scanty and with excess of uric acid. Bile-pigment, which is at first absent from the urine, afterward appears in small quantities. Bilious headaches and migraine are im- portant symptoms. 106 CHOLELITHIASIS. SYMPTOMS. When a gall-stone escapes from the gall-bladder, it is \isually arrested for a time in the cystic duct on account of its narrowness and of the structure of Heisters valve. In the common duet a calculus may be arrested in any part of its course, most frequently near the duodenal extremitv. In the first case The cut edges of the duodenum are stitched together, leaving a portion of the mucous membrane e.xpo.sed. A gall-stone pro- trudes partly through the duodenal open- ing of the common bile-duct. {Andcmon.) biliary colic without jaundice is usually present, and in the latter colic with jaundice. It must, however, be remem- bered that a calculus may pass through into the duodenum without pain or any other disturbance. This usually hap- pens when the ducts have been widened by the passage of stones previously. Biliary Colic. — Premonitory symp- toms — such as those of dyspepsia, a feel- ing of weight and distress with great restlessness — may be present. The onset is usually sudden: a severe paroxysmal pain is e.xperienced in the gall-bladder region, radiating upward to the right or left shoulder, across or down the ab- domen to the thighs. The pain is parox- ysmal and increases in severity until it reaches a climax. The patient becomes more and more restless, tossing upon the bed or throwing himself from the bed to the floor, rolling about in agony. When the suffering reaches its height, vomiting may occur, which may in turn, be followed by sudden relief. Intervals of comparative ease may follow parox- ysms of pain, and this may continue for hours and even days. [Dr. H. B. Anderson, of Toronto, wit- nessed the case (unpublished) of a woman, aged 50, who died after six months' illness. Had deep jaundice throughout; also pruritus, with, latterly, chills, fever, and purpura. Suffered no pain. Had previous attacks of cholelith- iasis with great pain, but no marked jaundice. Autopsy showed well-marked catarrhal cholangitis. Gall-bladder thickened, dis- torted, and atrophied, and contained a small quantity of bile. Common duct greatly dilated, bad conical-shaped cal- culus impacted at and partly protruding through th3 duodenal opening. (See wood-cut.) On bacteriological examination, the colon bacillus was found in the blood, spleen, and liver. J. E. GnAilAM.] The vomiting already mentioned oc- curs toward the end of the seizure, in a large number of cases. The contents of the stomach are first expelled, and bile follows. In some instances the vom- iting may be continuous and persistent, and may itself be a dangerous symi)tom. Two cases of persistent vomiting from calculi in the ducts, upon which opera- tion was performed. In one the vomiting CHOLELITHIASIS. SYMPTOMS. 107 continued for days after the cause had been removed. The patient, however, made a good recovery. In the second the emesis had been so persistent that the patient liad to be sustained by nu- tritious enemata for four weeks previous to the operation. Afterward the vomit- ing continued for two weeks, when death took place from exhaustion. Mayo Rob- son (Allbutt's "System of Medicine"). The severity of the collapse varies in different cases. It is marked by cold, clammy skin, pallor, and weakness and frequency of the pulse. It has, in some instances, proved fatal. Potain men- tions acute dilatation of the right heart as sometimes taking place in biliary colic. Case of a woman, aged 47 years, who died suddenly in collapse, preceded by agonizing pain, while under treatment for hepatic colic. There was found in the abdomen a blood-clot weighing GOO grammes (20 ounces), and some san- guinolent liquid. Pauly (Lyon M6d., Jan. 24, '92). Report of a cise from heart-failure dur- ing an attack of biliary colic in a dia- betic patient. Changes in the myocar- dium were found at the autopsy. Eisner (Med. News, Feb. 5, '98). The presence of a tumor below the costal line indicates dilatation of the gall-bladder, which takes place in early attacks. A distended gall-bladder may occasionally e.xist in more or less chronic biliary lithiasis as a result of impaction of the cystic and common ducts. It is, however, more frequently found in cases of malignant disease. Enlargement of the spleen is present in some febrile cases. Hepatic colic may also be due to a simple spasm. 1. Clinical proofs: hepatic colic is common in cases of hysteria, where no gall-stone is present. 2. Proofs from pathological anatomy: cases have been observed of jaundice and colics in which the only lesion found was contrac- tion of the bile-duct. 3. Experimental proofs: spasm of the lower part of the common duct can be set up in dogs. Lepine (Lyon M6d., Feb. 18, '94). At the commencement of an attack of cholelithiasis — i.e., at a time when pain has not set in — a tumor represented by the gall-bladder is tangible. This disap- pears directly the gall-stone reaches the intestine. Not infrequently the pains do not at once subside; these may be caused b\- slight circumscribed local peri- tonitis in the region of the gall-bladder, and may be lessened by ice-cold com- presses. Swelling of the gall-bladder may also be caused, however, by occlu- sion of the common duct by ascarides, Distoiiia hepaticum, or inflammatory ex- udations and by a tumor of the head of the pancreas pressing on the gall-duct. Gerhardt (Deut. med. Woch., Oct. 15, '93). Catarrhal jaundice; cancer of the pancreas, gall-bladder, or ducts; cancer or tuberculosis of the liver, malaria, or cardiac disease may give rise to symp- toms simulating those of stone in the common duct. G. W. Webster (Jour. Amer. Med. Assoc, June 22, '95). Possibility of confusion between a dis- tended gall-bladder and movable kidney. To distinguish between the two condi- tions it must be remembered that a dis- tended gall-bladder, as well as the kid- ney, is a frequent cause of movable ab- dominal tumor. The range of motion in the gall-bladder is, however, always in the are of a circle, the centre of which is a point beneath the right lobe of the liver. The history of a distinct attack of jaundice is an important factor in diag- nosis. A distended gall-bladder can gen- erally be felt, whereas a movable kidney often cannot. The gall-bladder, if dis- tended with stones, is much harder than the kidney. Henry Morris (Brit. Med. Jour., Feb. 2, '95). In cases of gall-stones in which biliary colic is not present diagnosis is usually not made till the autopsy. Dull pain in the region of the liver and vomiting noted in several cases. The gallbladder is not usually palpable; it could be felt in one of the cases described, but not in the others. A. L. Benedict (Med. News, June S, '95). 108 CHOLELITHIASIS. SYMPTOMS. Kraiiss, who was himself a sufferer from biliary colic, gives the following chief SYmptoms: — 1. Sudden onset between two and three hours after a meal. 2. Violent, spasmodic, paroxysmal pains over the hepatic and epigastric re- gion radiating upward over the right half of the thorax. 3. Labored respiration, feeling of dis- tress, nausea, and vomiting. 4. Slow, hard pulse and cold extremi- ties. 5. Sudden or gradual termination of the attack. 6. Onset of jaundice, which under certain circumstances follows the attack. The amount of pain does not depend so much upon the size of the stone as upon its shape. A small calculus with sharp projections will cause more pain than a much larger one which is round or oval. When the stone is arrested in the common bile-duct, similar symptoms to those already described manifest them- selves, together with jaundice. It is generally thought that the pain is not so sharp or severe when the calculus lodges in the common bile-duct as when it is arrested in the cystic duct. Icterus ensues a day or two after the commencement of the attack, and its intensity will depend upon the amount of obstruction. Bile-pigment may be found in the urine before any change is no- ticed on the skin or conjunctiva. In severe cases the liver may be slightly enlarged and tender and the skin of a dark-yellow color. The urine is dark and the faeces clay-colored. When the obstruction remains, symptoms of a chronic jaundice are observed, accom- panied by intense itching of the skin and extravasations. Want of appetite. foul breath, and slow pulse are symp- toms often met with. The jaundice of cholelithiasis is gen- erally more or less intermittent in char- acter, differing, in this respect, from that of cancerous obstruction, which is usually progressive. Jaundice may con- tinue some days after the stone is ex- pelled, when thickening of the wall may still cause obstruction. The presence of bile-pigment in the blood does not appear to cause any con- siderable disturbance of function and in any ease is only slightly poisonous. The bile-acids, on the other hand, when they enter the blood act as virulent poisons on the nervous and muscular systems and on the blood-corpuscles, as first shown by Dousche. Thoma ("Path, and Anat.," vol. i, p. 29). [This statement is not altogether in accord with the views of Bouchard, who regarded the bile-pigment vei^ poison- ous, and who ascribed its comparatively mild effect to the fact that it is either absorbed by the tissues or rapidly given ofT by the kidneys. J. E. Graham.] Gall-stone attacks are frequently ac- companied by fever, and in some in- stances the temperature may rise to 104° F. In such cases there is usually a rigor, followed by great heat of skin. The sweating stage is often absent. This has been called hepatic-intermittent, and is probably of the same character as that which sometimes follows the pas- sage of instruments through a con- stricted urethra. The fever is thought to he reflex by some, but it is more prob- ably the result of toxin absorption. The length of time required for the calculi to find their way through the cystic and common duct varies in differ- ent cases. They may pass through so rap- idly and easily that obstructive jaundice may not occur. Again, they may remain months in the ducts causing very fre- quently incomplete obstruction. This is CHOLELITHIASIS. SY.MPTOMS. 109 termed by some the irregular form of cholelithiasis. In some cases the calculus floats in a distended portion of the duct, usually the ampulla of Vater, causing an in- termittent or remittent jaundice. Fenger agrees with Courvoisier that gall-stones in the common duct give rise to a series of special symptoms by which the situation can often be diagnosed with a fair amount of certainty. Some of these symptoms and conditions are: — 1. Atrophy of the gall-bladder and absence of tumor. 2. Presence of icterus, which may be (a) intermittent: complete freedom from jaundice when the calculus passes into the duodenum, (h) Eemittent jaundice is usually caused by a floating gall-stone acting as a ball-valve. 3. Colic. Localization of pain out- side of the gall-bladder region indicates stones in the common duct. Eemittent pain is the sign of a stone floating in a dilated portion of the duct. This pain is sometimes relieved by change of posi- tion. 4. Intermittent or remittent fever. Histories of a number of cases. In one of these the first attack of colic with icterus had occurred two years before. These attacks then became more and more frequent and were accompanied by slight remittent icterus. There was also remittent pain every two or three days for three weeks, followed by fever, ic- trni.i prari.i, and death. The autopsy re- vealed one small floating stone in the dilated common duct. In a second case the first attack of biliary colic had taken place two years previously, followed by icterus. Second attack occurred on October 24th, fol- lowed by lighter attacks, loss of weight, slight icterus, but no tumor. Operation of choledochotomy. One stone, two cen- timetres in diameter, was removed; no leakage; recovery. The patient gained fifty pounds in three months. Fenger (Amer. Jour. Med. Sci., p. 286, '97). Symptoms of a gall-stone in the am- pulla of Vater acting as a ball-valve. Chronic jaundice, rarely deep, varying in intensity, at times almost or entirely disappearing, to deepen invariably after a paroxysm of pain. Often a constant sense of discomfort, which may be ago- nizing or griping or like an ordinary liver-colic. Fever occurring in paro.\- ysms; chills may be quotidian or ter- tian in type. The spleen usually enlarges with the febrile paroxysms. Although lasting for months or years, the health may not be much afltected, the patient being able to work between the parox- ysms. Such cases are often diagnosed as chronic malaria, abscess of the liver, or suppurative cholangitis. Osier (Lan- cet, May 15, '97). Passage of Gall-stones Ouxsiut THE Ordinary Channels. — The symp- toms will depend upon the course taken by the calculus. In some instances the stone passes through the ulcerated wall, and, owing to the presence of pyogenic organisms, an abscess forms, which gives rise to symptoms similar to those of ap- pendicitis; pain, high temperature, local- ized tenderness, and swelling. The ab- scess may open into a neighboring cav- ity, most frequently at the intestines, or it may extend outwardly. In other cases the stone may form a fistula witii very few localized or general symptoms. Large calculi have been passed by pa- tients which from their size must have made their way by ulceration from the gall-bladder into the intestines, although no history could be obtained tending to indicate that such a process had taken place. As a rule, however, there is more or less local pain, tenderness, and swell- ing. The broncho-biliary fistula is accom- panied by severe coughing and the ex- pectoration of bile. Gall-stones have been expectorated in some cases. I have reported a case in which expectoration of bile was present three weeks and then no CHOLELITHIASIS. COMPLICATIONS AND SEQUEL.E. ceased to retiirn; after ten years' time calculi were found in the common duct. Sudden death has been -^vitnessed in a case in which rupture took place into the pericardium. Dilatation of the stomach due to in- flammatory adhesions, closing the py- lorus, or to the presence of a gall-stone making its way through the pylorus is attended by the usual symptoms of such a condition. Calculi have been expelled from the stomach, which have either found their way into that viscus directly, or, as is more commonly the case, have been regurgitated from the duodenum. [The following case presents some pe- culiar features: The patient had been under the ^VI-iter's observation for many years previous to his death. Fifteen years before he suffered from biliary colic and obstructive jaundice. A hard mass remained, which was thought at the time to be cancer. The patient recovered and the tumor disappeared. He was after- ward troubled with a peculiar form of diarrhffia: awakening toward morning he had two or three watery passages, which weakened him very much. These attacks toward the close of his life be- came more frequent and were very dis- tressing. The cause was supposed to be want of tone in the pylorus, which allowed undigested food to pass into the bowel. Very little of the latter, how- ever, was noticed in the discharges. The following condition was found at the au- topsy: There were many old inflamma- tory adhesions in the region of the gall- bladder. The latter was much contracted and dislocated. The common duct was very small. There was a large secular dilatation of the duodenum, which formed a pouch four inches from the pylorus. Tlie pouch was continuous with the intestine below by a valve-like orifice about the size of the pylorus. This was probably formed in the passage of the gall-stones fifteen years before, and it is probable that the contents of the stomach accumulated in the poudi and were at times discharged, producing the sudden attacks of diar- rhoea. I am indebted to Drs. Powell and Anderson for the post-mortem notes. J. E. Graham.] (Case has not been pub- lished.) The arrest of calculi in the intestines produces at once a series of very grave sjTuptoms of gall-stone ileus. The most prominent are sudden and severe pain; nausea; vomiting; rapid, quick pulse; with other symptoms of collapse. The mortality in such cases is very high. The lower part of the jejunum is the usual seat of the obstruction. When the stone is arrested in the duodenum, the gastric symptoms are much more marked, and, when in the lower part of the small in- testine, indican may be found in excess in the urine. Fatal case of gall-stone ileus. The pa- tient had for a long time sufl'ered from attacks of pain, especially when tired from standing. At the operation the stone was found, after a long search, in the small intestine and removed. It was olive shaped and weighed 400 grains. Death from collapse took place two days after the operation. Bridon (Annals of Surg., Jan., '97). Case in which a tumor e.\isted in the pyloric region fifteen months and was generally thought to be a cancer. It was afterward shown to have been caused by an enormous gall-stone, which ulcerated through into the duodenum and brought on symptoms of intestinal obstruction. A stone (weighing 368 grains, 5 '/a inches in circumference, and 3 inches long) passed with some difficulty tln-ough the rectum. It was composed almost alto- gether of cholesterin. Eleven months afterward the patient passed another stone weighing 240 grains. Eisner (Med. News, Feb. 5, '98). Complications and Sequelae. — The most frequent complication of cholelith- iasis is catarrhal inflammation of the gall-bladder and ducts. In fact this oc- curs so often in the chronic form of the disease that it is generally regarded as an integral part of it. Thickening of CHOLELITHIASIS. COMPLICATIONS AND SEQUELAE. Ill the walls of the ducts may take place to a sufficient extent to produce perma- nent obstruction and chronic jaundice. Thickening of the walls and contraction of the cavity of the gall-bladder result in atrophy. Sometimes the process ends in a fibrous perihepatitis, and the calculus will be found imbedded in a dense mass of connective tissue. These attacks are accompanied by more or less pain and tenderness in the hepatic region and by a slight -elevation of temperature. Acute phlegmonous inflammation of the gall-bladder is a rare disease. Cour- voisier described it under the term ''Acute Progressive Empyema of the Gall-bladder," and collected notes of seven cases. This condition may exist when gall-stones are not present, but it is usually a complication of cholelith- iasis. Typhoid and typhus fevers, ma- laria, and septicsemia are the usual pri- mary diseases. The sjTnptoms are those of a low, adynamic fever, rapid and feeble pulse, great depression, with ten- derness and swelling over the right side of the abdomen. As a rule, general peri- tonitis supervenes and death takes place. Occasionally it terminates in a peri- hepatic abscess, which may be opened and a cure effected. Pyogenic organisms may invade the gall-bladder when distended on account of obstruction in the cystic or common duct and give rise to suppurative chole- cystitis and cholangitis. The patient experiences pain and tenderness in the hepatic region. A tumor more or less tender may be distinctly palpated. The general symptoms are those of fever, viz.: irregular and high temperature, rapid pulse, and great loss of strength. The symptoms of pya?mia may be present, viz.: rigors, heats, swellings, loss of appetite, nausea, vomiting, and great depression. This fever must be distin- guished from Charcot's hepatic inter- mittent, in which there is no pus present. Series of 14 cases illustrating compli- cations arising from gall-stone disease: 1. Impaction of stone in the cystic duct, followed by hydrops, empyema, and cys- to-duodenal fistula. 2. Sloughing of the gall-bladder and formation of a fistula between it and the stomach. 3. Per- foration of the gall-bladder and forma- tion of a fistula between it and the stomach. 4. Impaction of stones in the hepatic and common ducts. 5. Impac- tion of stones in the common duct. 6. Impaction of stones in the ampulla of Vater. 7. Primary carcinoma of the gall-bladder. When the surgeon opens the abdomen for gall-stone disease he must be prepared to meet and deal with any complication, and complications are met in from 20 to 30 per cent, of all gall-stone operations. Jloynihan (Brit. Med. Jour., Nov. S, 1902). Suppurative cholangitis presents the same general symptoms, but no tumor is felt, and the enlargement of the liver is more marked. Great tenderness may exist over the hepatic surface. Persistent jaundice is a constant and marked symp- tom. As described by Naunyn, hepatic ab- scess may arise from cholelithiasis in several different ways: — 1. An empyema of the gall-bladder may burst into the liver. 2. Purulent cholangitis of the intra- hepatic ducts leads to ulceration, which may exist in different places in the liver. 3. The hepatitis sequestrans of Schiippel. 4. Jletastasis or embolic abscess. Ulcerative endocarditis may arise from infection entering the circulation through the walls of the gall-bladder or ducts. Haemorrhage is a complication wliich may occur as a result of the action of biliary toxins on the blood. Gastric and 112 CHOLELITHIASIS. DIAGNOSIS. intestinal hsmorrhage may arise from this cause or from ulceration into the blood-vessels. Intestinal hemorrhage may also be caused by passive conges- tion, the result of thrombus of the portal vein due to the pressure of biliary cal- culi. Naunyn has not observed copious haemorrhages from this cause. Perforation of the gastric or intestinal mucous membrane is an occasional cause of haemorrhage. The writer has ob- served two cases in which he concluded from the history that hasmorrhage had arisen in this way; but he was not able to verify his conclusions. In Aufrecht's case, quoted by Naunyn, a large stone had partiallj' broken through from the gall-bladder into the hepatic tissues; this led to severe haemor- rhage, and the blood had entered the gall-bearer and thence had flowed into the intestine along the cystic and com- mon ducts. Ulceration of the portal vein and aneurism of the hepatic artery may also cause fatal haemorrhage. Diagnosis. — The diagnosis of the form of biliary colic produced by the arrest of gall-stones in the cystic duct is often difficult. The unbearable, cutting, tear- ing, paroxysmal pain seated in the gall- bladder region and radiating to the right or left shoulder is an important char- acteristic. The presence of a tumor in the hepatic region, after an attack, of the characteristic shape of a distended gall-bearer is a confirmatory sign. Of the conditions from which it is to be differentiated, the most frequent are: neuralgia, pleurisy, gastric colic, intestinal colic, and appendicitis. Pleurisy. — The presence of pleurisy may be made out by careful physical examination. NEunALGiA. — The painful points of neuralgia should be looked for. Gastric colic, especially that form in which there is a spasmodic painful contraction of the pylorus, is very dif- ficult of differentiation. When the pains rapidly follow, for instance, the taking of cold water and the symptoms are prominently of a gastric character, the condition may be recognized as one per- taining to the stomach and not to the liver. Intestinal Colic. ■ — In intestinal colic the seat of pain and the character of the latter differ from those of biliary colic. Chills and fever accompany bil- iary more frequently than gastric or in- testinal colic. Acute Appendicitis. — The differ- entiation of acute appendicitis is some- times very difficult, especially in cases in which adhesions to the under-surface of the liver follow an attack. Differ- ence in the seat of pain in first attack is nearly always marked. In biliary colic the pain often radiates upward to the shoulder, while in ap- pendicitis it is experienced in the region of the umbilicus. In the writer's experience, it is of the greatest importance to note down ac- curately the history of the case and to observe whether the symptoms are he- patic, renal, or intestinal. The presence of gall-stones in the freces is the crucial test in the diagnosis. These may escape observation unless great care is taken in the examination. The stools should be made as fluid as possible by the addition of water and passed through a fine sieve. The stools slioiild lie passed into a double paiize bag. The bag can then be allowed to hang in the hopper of the water-closet and be flushed as often as necessary, that is, until all the solu- ble matter has l>oen washcul away. This method of looking for gull-stones is accurate and less unpleasant than (ilbors, Tjili(!ni,lial (Medical Kecord, .Jan. n, 1901). CJIOLIlLITHIA.SLS. UIAUXUaiS. 113 The prJiicij);!! points in the diagnosis of chronic cholelithiasis are the attacks of pain more or less severe in the hepatic region, tenderness of the liver, the pres- ence of a tumor resulting from periheji- atic inflammation or abscess, exacerba- tions of fever with or without local pain ; jaundice, usually intermittent or remit- tent; not often persistent and increasing. The dilfercntiation between a dis- tended gall-bladder and a displaced right kidney is often difficult. It is not infrequently impossible to make a distinction by noting the shape and size of the tumor; occasionally all the meth- ods generally laid down, such as the movements of the gall-bladder by respi- ration, the limitation of its movements, and the relative situation of the colon, are all of little use. Sometimes by care- ful palpation the kidney and gall-bladder can be separated and a positive diagnosis made. Number of cases in which gall-stone crepitus was made out and proved to be of great diagnostic value. The crepitus may be obtained by palpating with the finger-tips dipped gently, but deeply, in the abdominal wall just below the fun- dus of tlie gallbladder and then dra'svn upward over the organ as though mak- ing an attempt to roll the fundus up- ward and forward. Deep inspiration is helpful and the tactile sense of the pal- pating fingers may be increased by press- ing on their dorsal surfaces with the dis- engaged hand. Auscultation is some- times successful when palpation fails, and a combination of the two has led to the detection of a friction-sound. In attempting the latter mode of examina- tion the stethoscope should be placed just below the costal arch, in order to allow space for the palpating right hand over the fundus of the gall-bladder. J. M. Anders (Inter. Med. Mag., Dec, '99). Palpation for the lower margin of the liver should be conducted in the follow- ing manner: The physician, seated to the right of the recumbent patient, 2—8 places the left hand fiatly on the abdo- men in the hepatic region, and endeavors by means of gentle pressure with the tips of the fingers to ascertain the situ- •ation of the lower edge of the liver. When he thinks he is near to the liver's edge, the fingers of the right hand are placed obliquely upon the left (the right indc.K finger corresponding to the left little finger, and vice versa) in such a manner that the tips of the fingers of the right hand slightly overhang those of the left. Firm pressure is exercised with the right hand upon the subjacent passive left. If by means of this "octodigital" pal- pation the liver-edge cannot be felt in the right mammary line, there is no hypertrophy of the organ. If the liver is enlarged — especially if its volume presents manifest fluctuations from time to time, augmenting during the attacks of pain and diminishing in the intervals — and in addition abdominal tenderness is found to be present, a diag- nosis of hepatic colic may be made. Pol- latschek (La Semaine M6d., Apr., '99). The characteristic signs of gall-blad- der enlargements are: (1) that they are continuous with the upper surface of the liver; (2) that they project sharply from the margin of the liver; (3) that the margin of the liver can be treated to a gradually diminishing edge attached to the upper surface of a globular mass. In the relation of jaun- dice to pain the author states that jaundice due to gall-stones is always preceded by colic; that jaundice due to malignant disease, or catarrh of the ducts accompanied with infection, is never preceded by colic. There are two striking, contrasting conditions under which pressing gall-stones do not pro- duce colic: (1) when they are very small, too small to produce obstruc- tions or spasm of the ducts; (2) when they are very large, so large that the wall is paralyzed by the overdistension and infiltration by the extremely slow advance of the stone. Murphy (Med- ical Xews, .May 2, 1903). If after a careful examination into the history and present condition, especially 114 CHOLELITHIASIS. DIAGNOSIS. an analysis of the urine, tlie symptoms and signs are found to be hepatic rather than renal, the tumor will probably be a distended gall-bladder. As before stated, a displaced kidney attached to the under-surface of the liver may cause jaundice by drawing the common bile- duct out of place. ^^^len anatomical conditions are fa- vorable, disease of the pancreas may occur as a complication of cholelithiasis when a calculus passes along the com- mon bile-duct. The lodgment of a stone near the orifice of the bile-duct where it may at the same time compress and occlude the duct of Wirsung, is not un- commonly a cause of pancreatic lesions and disseminated fat-necrosis. Should a calculus become impacted in this posi- tion, one of several conditions may re- sult: — 1. An individual, usually in fairly good health, with perhaps a history of previous gall-stone colic, is suddenly attacked with pain in the epigastric region, accompanied by vomiting ana followed by collapse. Death follows usually within forty-eight hours, and at autopsy gall-stones are found in the bile-passages, while that one which caused the fatal attack may be still lodged in the common duct near its ori- fice. The pancreas is enlarged, infil- trated with blood, and hsemorrhage may have occurred into the surrounding tis- sue. Foci of fat-necrosis are usually present. 2. A fatal termination may not follow rapidly the symptoms mentioned. Pain in the epigastrium persists, jaundice may be present, and a tumor-mass above the umbilicus may indicate a probable lesion of the pancreas. At the end of one or more weeks or months death occurs, often with symptoms in- dicating the presence of suppurative in- flammation, presumably in the neighbor- hood of the gland. At autopsy the di- agnosis of cholelithiasis is confirmed by the prcBcncc of gall-stones in the gall- bladder or in tlie bile-ducts, and occa- sionally the offending calculus is still lodged near the junction of the com- mon bile-duct and the duct of \Virsung. The pancreas is dry, black, and necrotic, and evidence of previous haemorrhage may be present. Secondary infection has occurred, and the pancreas lies in an abscess-cavity formed by the bursa omentalis. In the wall, and often widely disseminated in the abdominal fat, are foci of necrosis. Since the in- dividual has survived the primary le- sion, opportunity has been given for the development of secondary changes in the injured pancreas and neighboring fat. 3. In certain instances long-continued or repeated obstruction of the pancre- atic ducts by gall-stones does not cause the acute lesions described, but pro- duces chronic inflammatory changes. E. L. Opie (Amer. Jour. Med. Sci., Jan., 1901). A distended gall-bladder may require to be differentiated from pyloric and in- testinal carcinoma, foecal impaction in the colon, tumor of the liver and of the right kidney; also from a tongue-like projection of the liver, which is occa- sionally found. Attention called to cases of acute cholecystitis of sudden onset in patients of apparently perfect health, in which there is no history of gall-stones and which do not depend on typhoid fever, pneumonia, or other infective processes. Of 59 cases of cholecystitis personally operated on only 10 began without known pre-existing disease. Three of the 10 cases were diagnosed as acute appen- dicitis with such certainty that the in- cision was made over the appendix. In 3 the symptoms were those of acute in- testinal obstruction. Again, the disease may be mistaken for the sudden closure of an organic stric- ture, for an inflammatory process in a diseased kidney, an acute peritonitis, an acute pancreatitis, an extravasation from the stomach, a malignant abdominal tumor, or a tumor with a twisted pedicle. If the symptoms point to the gall- bladder rather than to the appendix the incision should be made over tlie former and vice versa. When tlicre is great CHOLELITHIASIS. FKOGNOSIS. 115 doubt as to which is affected, the cut may be made behind tlie c£ECum, high up and enlarged in whichever direction la required. When there is no localized pain or tumor or history pointing to a definite lesion, the incision should be in the middle line. Seven of the 10 cases recovered. Rich- ardson (Amer. Jour. Med. Sciences, June, '98). There are three prominent symptoms of cholelithiasis in infancy and in child- hood upon which the diagnosis is often based, namely: pain, vomiting, and con- vulsions. Pain is usually referred to the epigastrium and is indicated in children by paro.xysms of crying attended with severe vomiting. One of the most valu- able diagnostic signs is persistence of the sensitiveness of the gall-bladder after cessation of the symptoms of the colic. The best means of eliciting this symptom is by placing the child in a warm bath, which will serve to distract its attention and at the same time relax the muscular structures. The Rentini symptom, pain around the xiphoid cartilage from gall- stones during their expulsion, is deserv- ing of particular attention. Vomiting is usually persistent. Fever, chills, costal respiratory move- ments of a jerky character when the pa- tient is placed in a sitting posture, are some of the other symptoms that aid in establishing the diagnosis. In young persons jaundice caused by gall-stones without pain is rare. In doubtful cases the urine should be evaporated on a water-bath to abotit one-tenth its origi- nal volume and tested for biliary color- ing-matter and biliary salts. Acholic feeces in children are not necessarily white; frequently they present a green- ish color, with putrid odor and diarrhoeal tendencies. A. V. Wendel (Med. Rec, July 9, '98). Number of successful radiographs of gall-stones obtained. The longer the time of exposure, the clearer the liver and the more obscure the calculi. About five or six minutes gives the best results. The patient should lie upon the abdo- men with a pillow underneath his sym- physis and clavicles. The rays shall not penetrate the abdomen in a vertical di- rection, but should form an angle of about 45 degrees with the plate. A great deal also depends upon the composition of the stone, which is far more complex than that of renal calculi. Calculi con- sisting of pure cholesterin give but an indistinct shade, while those containing quantities of calcium are well shown. Calculi which consist of a compound of calcium and bilirubin, or carbonic acid, are distinctly brought out by the rays. Carl Beck (N. Y. Med. Jour., Jan. 20, 1900). Prognosis. — The presence of calculi in the gall-bladder is not of so much im- portance when they do not give rise to any pronounced symptoms; but in all cases they are to be looked upon as for- eign bodies which may at any time give rise to dangerous symptoms. When phlegmonous inflammation of the gall- bladder takes place, the prognosis is grave. Biliary colic is not always free from danger. Some cases of death from heart- failure have been recorded. Distended gall-bladder from calculous obstruction of the cystic duct when accompanied by elevation, and irregularity of tempera- ture, with local pain and tenderness, suggests the possibility of suppuration. Cholecystitis may result in rupture of the gall-bladder or in general septi- caemia. Both conditions usually ter- minate fatally. . Hepatic and perihepatic abscesses are of grave import. The prognosis of jaundice depends on the amount of ob- struction and the previous health of the patient. If the jaundice is intermittent or remittent, as is the case when a cal- culus floats in an enlargement of the common duct, the danger is not great, because the system will eliminate the poison in the interval. If the patient have a poor constitution or if the kidneys are diseased; a mod- prate amount of jaundice may prove 116 CHOLELITHIASIS. ETIOLOGY. serious. The grave symptoms of jaun- dice are a slow pulse, lethargj-, and the occurrence of hemorrhages through the mucous membrane or into the tissues. Gall-stone operations in jaundiced cases are much more hazardous than those done when that condition is ab- sent. The prognosis of cholelithiasis is much more favorable since the develop- ment of hepatic surgery, and the experi- ence of the last two or three years would seem to indicate that it is possible to remove calculi in the most difficult cases with comparative safety if the patient be not allowed to become too much poi- soned by the toxins of bile and by those resulting from membranous infection. Etiology. — Biliary calculi have been found at all ages, even in newborn chil- dren. The fact is well established that cholelithiasis increases in frequency with advancing years. According to Schroe- der's statistics as given by Waring, gall- stones were present in the following per- centages of cases: — Under 20 years, 2.4 per cent. Between 20 and 30 years, 3.2 per cent. Between 30 and 40 years, 11.5 per cent. Between 40 and 50 years, 11.1 per cent. Between 50 and 60 years, 9.9 per cent. Over CO years, 25.2 per cent. Krauss found in actual practice that gall-stones diagnosed by symptoms dur- ing life occurred most frequently in men between the 40th and GOth years, and in women between the 30th and 50th years. Recklinghausen's statistics of aU' topsies made between 1880 and 1887 give the percentage of all stones: 4.4 per cent, of men and in 20.6 per cent, of women. Of 0.3,000 patientB examined, stones were noted in only 133, making 0.14 per cent., while, on the other hand, at autop- sies fully 10 per cent, of the bodies are found to possess them if a careful exam- ination of the biliary system is made. The great frequency with which gall- stones are not diagnosed intra litam is thus shown. The Koentgen rays may be looked upon as a valuable diagnos- tic aid in the future, and already a num- ber of excellent photograms have been published. Best results will always be obtained with the strongly calcareous stones, while the rarer ones, consisting chiefl}' of cholestrin or bile-pigment, can hardly be expected to throw a shadow. H. Fiedler (Miinchener med. Wochen., Oct. 22, 1901). Pending the study of other series of cases from various parts of the United States, one may draw the following conclusions: — Nationality: On the basis of the analysis of the 1655 autopsies from the Johns Hopkins Pathological Depart- ment, as compared with 1150 (?) cases as given by Schroder, of Strassburg, gall-stones are less frequent in the United States than in Germany, the United States showing a frequency of 6.94 per cent.; Germany, of 12 per cent. Age: The frequency of gall-stones in a given number of cases will increase with the age of the patients examined. The American cases tend to confirm the statements of previous observers that gall-stones are rare before the thirtieth year and more frequent after that age. Color: Gall-stones are more frequent in the white man than in tlie black, the American cases sliowing a frequency of 7.85 per cent, in the whites and 5.51 per cent, in the negro. Sex: Women are more liable to have gall-stones than are men, the American eases showing the frequency in 018 women to be 9.37 per cent., and in 1037 men to be 5.94 per cent. Tlie American women have gall-stones only about half as freqiiently as the German women. In the United States only about 1 woman in every 10 has biliary calculi, while in Germany, according to Naunyn, gall-stones are found in 20.0 per cent., or in about 1 woman in every 5. C. D. CHOLELITHIASIS. ETIOLOGY. 117 Mosher (Johns Hopkins Hosp. Bull., Aug., 1901). In women the largest number of cases occur in the child-bearing period, and, according to Schroeder, 90 per cent, of the females were women who had borne children. The fact that cholelithiasis occurs in females in the proportion of 4 or 5 to 1 of males is established by all statistics. Tight-lacing has been given a very prominent place in the causation by some authors. In more than half of the female cases the liver has shown signs of pressure of the ribs. A pendulous abdomen is often found, which may favor the formation of cal- culi directly in causing a partial ob- struction of the bile by traction on the common bile-duct. Langenbuch is of the opinion that the traction of a displaced right kidney on the common duct is a predisposing cause of cholelithiasis to which suffi- cient importance has not been given. The capsule is attached to the cystic duct, the hepatico-duodenal being con- tinous with the hepatico-renal ligament. As profession and social position as causative factors, Krauss gives the fol- lowing statistics of 473 cases in men which came under his observation: — Physicians, 45. Officials, 74. Manufacturers, 19. Clergymen, 60. Large landed proprietors, 24. Merchants and bankers, 40. Small land-owners, 26. Military officers, 40. Professors and teachers, 103. Tenants, 41. Over 50 per cent, occurred in active brain-workers who at the same time lead sedentary lives. Krauss gives mental anxiety, chronic constipation, and fre- quent pregnancies as probable causes. He is also of the opinion that the de- posit of fat in the abdomen prevents the active peristalsis of the intestines. Heredity does not seem to play an important part. Naunyn claims that it would be difficult to estimate this factor in a disease so prevalent. In 60 per cent, of Krauss's patients the disease could be traced in the families of the patient. He has often treated mothers and daughters for cholelithiasis at the same time. Gout has been looked upon as a pre- disposing cause. It may act in two ways: by producing a stagnation of bile in one who cannot take sufficient exercise, and by means of toxins which, when excreted by the liver, may bring about a catarrhal inflammation of the ducts. The relation between diabetes and cholelithiasis has given rise to much dis- cussion. Bouchard found gall-stones present in 165 cases of diabetes. Mayo Robson states that they are rarely found in case of diabetes when nitrogenous food is largely taken. Cardiac disease tends to the formation of calculi by rendering the patient in- capable of much exercise, and by causing passive congestion of the liver. Brock- bank found gall-stones in 27 out of 49 cases of heart disease. Eenal calculi were found so frequently in gall-stone cases that a definite rela- tionship was thought to exist between the two conditions. On the other hand, Naunyn has rarely found tlie two dis- eases combined. A villous condition of the inner sur- face of the gall-bladder has been given as a predisposing cause. It is generally thought that cancer, with which cholelithiasis is so frequently combined, is caused by irritation of the calculi. It would, however, seem prob- able that roughening of the surface. 118 CHOLELITHIASIS. ETIOLOGY. catarrhal cholecystitis and cholangitis, which frequently occur in the early stage of the disease, as well as the par- tial obstruction which must often take place, would all predispose to the forma- tion of calculi. Gall-stones probably form around a nucleus of precipitated bile-salt result- ing entirely from local changes. The calcium salts and bile-pigments are read- ily precipitated Tvhenever there is an in- crease in the albuminous constituents of the bile, and this increase is par- ticularly marked when inflammatory changes occur in the bUe-passages. Cholesterin is especially abundant when any degenerative process is going on, as there would be in disease of the gall- ducts, and this cholesterin is deposited around the nucleus. The most frequent causes of such catarrh is infection by micro-organisms, the bacilli coli com- munis and the typhoid bacilli being par- ticularly apt to originate such disturb- ances. The latter may have laid dor- mant for many years before acting as an exciting agent. W. H. Thomson (New York Med. Jour., March 1, 1902). The relation which insanity bears to cholelithiasis has long excited interest. The more frequent occurrence of gall- stones in insane people is probably due, in large measure, to their sedentary habits. The opinion has also been given that great nerve-waste may produce an excess of cholesterin. Sedentary habits are, no doubt, a very important predisposing cause. The flow of bile, which under ordinary cir- cumstances takes place under very low pressure, is much influenced by the movements of the body and especially by the movements of the diaphragm. When, therefore, the body is in com- plete repose, stagnation of the bile will more readily take place, and the soft cholesterin masses which form the nu- clei of gall-stones do not pass out of the gall-bladder, but are coated by a more dense layer of cholesterin or bilirubin- calcium, and thus become too large to pass through the cystic duct. Condi- tions which interfere with the movement of the diaphragm — such as empyema and pregnancy — have the same efliect. Authoritative views with regard to the influence of diet have been divided, and of late years its importance has been much doubted. Experience has shown that, in cases of biliary fistula, fari- naceous and saccharin food will produce a dense, thick bile, whereas an albumi- noid diet will cause the biliary secretion to be more liquid. A dense, thick bile will act in the same way as if it were stagnant: in favoring the formation of calculi. Frerichs thought that a small number of meals, with too long an in- terval between them, prevented the proper emptying of the gall-bladder, and thus predisposed to the formation of calculi. It was at one time thought tliat too much lime in drinking-water predis- posed to cholelithiasis; this has, how- ever, not been substantiated. Climate does not seem to have any great influ- ence. A summary of our present knowledge regarding tlie etiology of cholelithiasis shows that gall-stones may originate either in the gall-bladder or in the intra- hepatic ducts. In a large majority of cases they occur in the former situation and are the result of catarrhal and other inflammations. The formation of bili- rubin calculi in the intrahepatic ducts is caused by catarrhal inflammation, probably the result of the excretion of some irritating substance. It is pos- sible, also, that a microbic invasion may take place either through the common bile-duct or from the blood-vessels; but the latter is not likely. Bilirul)in-ca]- cium calculi may form in the intrahe- CHOLELITHIASIS. PATHOLOGY. 119 patic ducts and pass through into the gall-bladder, becoming the nuclei of larger stones. The principal predisposing cause is the stagnation of bile, and this may arise ! either from its inherent density or from i partial obstruction. In the various pre- disposing conditions given it wll be found on examination that they all act in the same way, viz.: in lessening the pressure of the flow of bile through the common duct. It is not impossible that chemical conditions, such as have been described by Thudicum and the French writers, may underlie the formation of calculi, but certainly the existence of such conditions has never been demon- strated. Typical calculi produced in gmnea-pigs and following results obtained: Foreign bodies when introduced into the gall- bladder can stay there for an indefinite time, provided they are aseptic, without causing inflammation or precipitating the solids from the bile. When the foreign bodies are previously impregnated with virulent micro-organisms, however, they cause a more or less intense chole- cystitis and precipitate the solids from the bile. As long as the bacteria retain their virulence they cannot form a cal- culus, but only a sediment mixed with pus. This precipitate has no tendency to cohere or to adhere to foreign bodies. Five or six months are required for the formation of a perfect calculus. The kind of bacteria injected seems to be of quite secondary importance. Mignot (Arch. Gen. de Med., Aug., '98). Biliary calculi may be caused by cholestcrin, bilirubin calcium precipitated by changed reaction, bacteria of various types, and foreign bodies. Gall-stones are uncommon in childhood, rare under thirty, somewhat common between thirty I and sixty, usual after sixty years. Fe- | males suHer from them in the ratio of 4 ! to 2. Anything predisposing to stasis is a potent cause. The bacillus coli com- munis and bacillus typhosus are the i most potent generators of biliary calculi. 1 F. C. Shatluek (Phila. Med. Jour., Oct. 6, 1900). Patholo^. — FoRMATiox OF Calculi. — Cholesterin, the principal constituent of biliary calculi, is constantly found in the bile, being kept in solution by the biliary-acid salts: the glycocholate and taurocholate of soda. It is not found in the blood, nor in the liver, unless there be necrosis of the hepatic cells. It must, therefore, be produced by the epithelial lining of the bile-ducts and gall-bladder. Its precipitation will depend either upon its increased proportion in the bile, or upon the diminished solvent power of the latter fluid. TPTiere both conditions exist together, the process of concretion is still more favored. Although the quantity of cholesterin in the normal bile is fairly constant, it may be considerably increased by inflam- mation of the mucous membrane of the gall-bladder and passages. The same condition produces a lessened alkalinity of the bile, which diminishes its solvent power. It is thus seen that catarrhal inflammation at once produces the two conditions favorable to the precipitation of cholesterin. The process may be set up by such germs as the colon bacillus, the typhoid bacillus, and the pneumo- coccus. The fact that such organisms have been found in the nuclei of calculi confirms the theory of this method of their origin, which was elaborated by Naunyn in his work published in 1892. The presence of a nucleus of bilirubin- calcium or cholesterin is not of itself sufflcient to give rise to a calculus. This has been proved by experiments upon dogs. Cholesterin calculi, according to Naunyn, may form in two ways: either with small cholesterin masses as nuclei, or small aggregations of sediment be- come the centre of calculi. This sedi- r^o CHOLELITHIASIS. PATHOLOGY. ment consists of brownish particles and yellow, gritty masses in which fat-gran- ules and cholesterin crystals are often present. A comparatively-soft nucleus may be surrounded by a hard layer of choles- terin. When a calculus is once formed it increases in size, layer upon layer. The crystallization of the cholesterin takes place within the calculus after its forma- tion. The portal of entry of the micro-or- ganism is probably the duodenal opening of the common bile-duct. It is also probable that, in the great majority of cases, the germs pass into the gall-blad- der and not into the intrahepatic ducts. The possibility of entrance through the blood-vessels must be allowed, but has not been proved. Naunyn is of opinion that the colon bacillus is the principal agent in the production of calculi. Within the last few years the relationship between ty- phoid fever and cholelithiasis has been studied by Osier, of Baltimore; Hunter, of London; and others. The frequency with which the latter disease follows typhoid, and the fact that Eberth's bacillus has so often been found in the gall-bladder of those who die of typhoid fever, are interesting facts in this con- nection. Conclusions arrived at, largely from experiments upon animals: — L The presence of aseptic foreign bod- ies in tlie gall-bladder does not produce inflammation and does not soem to affect it8 function, if the cystic duct remain patent. There is no precipitation of cho- lesterin when the bile remains clear and free from microbes. 2. 15ilc stagnant in an aseptic gall- bladder has no tendency to precipitate. 3. There is greater tendency to pre- cipitation when the infection is from «n attenuated, than from a strong, virus. n. Mignot (Thfsf de Paris, '00). Xaunyn's theoiy tlmt gall-stones are the result of catarrhal inflaamiation of the lining mucous membranes not ac- cepted. In most cases they result from a decomposition of the bile into simpler substances, such as are produced more particularly during the process of so- called spontaneous decomposition after its removal from the body. Those who look at the formation of gall-stones as simply the result of local changes, and do not study the general constitutional conditions which give rise to them are like those of whom Stro- meyer speaks: "They bear the little grass grow while the thunder rolls un- observed in the upper ether." J. L. W. Thudicum (Med. Press and Circular, vol. Ixiv, 208-210, '97). Experimental formation of gall-stones. Three drops of a culture of typhoid ba- cilli were injected in the gall-bladder of a rabbit. At the autopsy, six weeks afterward, two small calculi about the size of grains of wheat were found in the gall-bladder. They were made up of a whitish kernel inclosed in a dark-colored shell. A pure culture of typhoid bacilli was made from the nucleus of one of them. Gilbert and Foumier (Deutsche mod. Woch., Dec, '97). Case of formation of gall-stones around sutures allowed to remain in the gall- bladder after a cholecystotomy. The gall-bladder was entirely emptied of stones in April, 1895, and in January, 1897, several round and oval calculi were found. Sutures formed the nucleus of each. {Seo colored plate.) John Homans (Surg. Annals, July, '!)7). The simple presence of organisms in the gall-bladder does not seem sufficient to set up inflammation of the mucosa nor to produce cholelithiasis. Some other factor, ijrcRuniably some form of irrita- tion, such as traumatism or some hin- drance to the proper evacuation of the gall-bladder, is essential. Gushing (Johns Hopkins Hosp. Pull., Aug.-Sept., '09). Elfects of introducing cholcHterin cal- culi or fragments of calculi into the gall-bladder of dogs, both in health and ill viu'ious morbid states. A series of CHOLELITHIASIS. PATHOLOGY. 121 five experiments all gave similar re- sults to the following experiment: Two cholesterin fragments were intro- duced into the gall-bladder; the dog was killed 2G5 days later and autopsy performed. Both gall-stone fragments had disappeared; the gall-bladder, cys- tic duct, and bile were all healthy in aspect. All the animals had remained in good health except one, which lost weight. In a second scries of experi- ments, besides the calculi, dry pus or pus containing the Bacillus coli was in- troduced. The dogs remained in ap- parently perfect health ; nevertheless the autopsy revealed cholecystitis, and no dissolution of gall-stones occurred. In two experiments where only gall-stonea were introduced the latter were found unaltered, but cholecystitis was pres- ent and bacilli were found in the con- tents of the gall-bladder. It would therefore appear that when the gall- bladder is healthy the gall-stones seemed to disappear; on the other hand, where cholecystitis was present the gall-stones remained unchanged. In the second series of cases the follow- ing changes were met with: The colum- nar epitheli\un of the mucous mem- brane of the gall-bladder was in every case covered with an amorphous or finely reticulated deposit, which could not be well stained with a fibrin stain nor with any of the other stains era- ployed. Sometimes this deposit con- tained micro-organisms. The epithelial cells themselves were swollen and pre- sented in the middle and upper part of their cytoplasm a clear, vacuolated as- pect. Lying among the epithelial cells, wandering cells could also be seen in sparse numbers. The connective tissue of the mucous coat sometimes appeared wide-meshed as if oedematous, and the capillaries of the mucous membrane were sometimes congested. V. Harley and W. Barratt (Jour, of Phys., Jime 15, 1003). Bilirubin-calcium is insoluble in water, and cannot be formed simply by concentrating tbe bile. It bas been found that egg-albumin will aid in the precipitation of bilirubin-calcium from bile. It is probable that albumin may act similarly in pathological processes. Formation of biliary calculi does not take place solely in the gall-bladder. Some are formed in the ramifications of the hepatic duet. Cholesterin and cal- cium (bilirubinate of lime), the chief chemical constituents of biliary calculi, come from the mucous membrane of the biliary ducts. Lithogenie catarrhs of the mucous membrane may be excited by microbes (coli bacillus, Eberth's bacillus, possibly also by others). Great virulence of the germs is by no means favorable to the formation of concretions. Slight in- fections may become developed as soon as there is stagnation of bile. Naunyn (Intern. Med. Congress; Brit. Med. Jour., Sept. 29, 1900). The formation of bilirubin-calcium stones, as has been already intimated, takes place in the intrahepatic ducts. Naunyn and others are of opinion that the calcium results from an inflamma- tion of the lining membrane of the ducts, from the presence of microbes. It would seem difficult to understand how micro- organisms find their way from the duo- denum into the smaller bile-ducts, and still more difficult to conceive of their entering the intrahepatic ducts from the blood without seriously affecting the parenchyma of the liver. As has been already noticed, William Hunter, of London, is of the opinion that calculi of the intrahepatic ducts is caused, not by micro-organisms, but by toxins ex- creted by the liver. The function of the liver as an excretory organ has been amply proved by Schiff and others, and a catarrhal inflammation from this cause seems reasonable. Spontaneous fracture of biliary calculi sometimes takes place. Morbid Anatomy. — The gall-bladder may be distended with calculi and little 122 CHOLELITHIASIS. PATHOLOGY. change found except erosion of the mu- cous membrane, with more or less thick- ening and infiltration in places. Chole- cj'stitis and pericholecystitis may cause these changes to be more pronounced. Phlegmonous inflammation of the gall- bladder sometimes occurs in acute dis- eases. Calcification of the gall-bladder some- times follows empyema, in which the mucous membrane may be coated or the whole thickness of the wall may become infiltrated with lime-salts. Distension of the gall-bladder usually arises from the arrest of calculi in the cystic duct. The contents in uncom- plicated cases are largely composed of mucus, more or less bile-stained: hydrops felleae. If at the same time there is an invasion of pyogenic organisms, an em- pyema of the gall-bladder results. Ulceration and perforation sometimes occur, allowing the contents of the gall- bladder to pass into the peritoneal cav- ity. Two case3 of distension of the gall- bladder from flexion of the neck. No gall-stones were found. A. H. Ferguson (Brit. Med. Jour., Nov. 6, '97). Fatal ease of rupture of the gall-blad- der. Patient 20 years of age. The gall- stones found their way out of the gall- bladder partly by ulceration and partly from expulsion. Some gall-stones and bile-stained fluid were found in the ab- domen, together with the results of gen- eral peritonitis. A perforation of the rectum, which allowed fa;ces to pass out, was also discovered at the post-mortem. The perforation thought to have been caused by pressure of gall-bladder stones on the peritoneal coat of the bowel. The patient lived twenty-five days after the rupture of the gall-bladder. Shadbad (St. Petersburgcr mcd. Woch., Jan., '90). FiSTULiE. — Gall-stones may pass out through the wall of the gall-bladder or ducts into the surrounding structures, producing tistuliP, which may take dif- ferent directions. In hepatico-bronchial fistula a series of cases of this rare form of disease studied by the writer showed that the opening through the diaphragm into the gall-bladder may arise from a distended gall-bladder passing over the anterior border of the liver, or that calculi could find their way by ulceration through the wall of the gall-bladder and duets, form- ing an abscess which may penetrate the convex surface of the liver and the dia- phragm. In such cases a cavity is often formed by the presence of intrahepatic calculi and of pyogenic organisms. A direct fistulous opening may take place between the gall-bladder and the stom- ach. Case of obstruction of the pylorus pro- duced by a gall-stone and surrounding inflammatory adhesions. There was a direct communication between the gall- bladder and stomach, a cystico-stomaclial fistula. Monprofit (Bull, de la Soo. d'Anat. de Paris, May, June, '97). Fistulous openings into the duodenum or through the abdominal walls are the most common. In tlie latter case open- ings may take place in the right hy- pochondrium, near the umbilicus and above the pubes. Interesting ease of biliary fistula into the urinary tract. The post-mortem re- vealed a fistula leading into an abscess and from this into the pelvis of the right kidney, where a large cholesterin calculus was found. Eisner (Med. News, Feb. ."i, '98). Courvoisier has reported seven cases of urinary fistulas. Cases of fistute into the uterus and vagina have also been re- ported. The chronic irritation resulting from the presence of calculi in the gall- bladder and ducts may give rise to atrophy or calcification of the gall- bladder and to the formation of diver- ticula and cicatrices. Tliickening of the CHOLELITHIASIS. TKEATIIENT. PREVENTIVE. 123 Burrounding tissues is also a common re- sult. In 255 autopsies in gall-stone cases given by Courvoisier, atrophy of the gall-bladder was found in 12 Yj per cent. It is the result of frequent ca- tarrhal inflammation. In such cases the gall-stones are found imbedded in the contracted gall-bladder or in diverticula. The obliteration of the cystic canal, the gall-bladder being aseptic, results in atrophy of the reservoir, the same as if it contained foreign bodies more or less irritating. ArmCnis {Th6se de Paris, '90). paratively rare, the connective tissue of the liver is increased, and a calculous biliary cirrhosis results. It is very dif- ficult, in many of these cases of cirrhosis, to e.xclude the possibility of their being caused by other toxins; alcohol, for in- stance. Treatment. — Prevextive. — The par- tial or complete stagnation of bile in the gall-bladder and ducts is the principal, if not the only, predisposing cause of the formation of calculi. Any means, there- 1 ^&i ^^ ^K^-%L wM^^l^^^sfWItlf^^ w c A, Distended gallbladder; LI. junction of cystic and hepatic ducts; C, cup-shaped depression in surface of duodenum at the entrance of the common bile-duct in which the gall-stone was lodged. (Dioycr.) A calculus in the common bile-duct will, after awhile, produce distension and thickening of the wall of the duct. It sometimes floats in a cavity, often in the ampulla of Vatcr, acting as a ball-valve, thus causing intermittent or remittent jaundice. The enlargement of the bile-ducts may extend backward to the smaller radicals. The hepatic cells become deeply stained with bile. In some cases, which are com- fore, wliich will increase the watery con- stituent of the bile and render the (low more rapid will be of value as a pro- phylactic agent. Means whereby the cir- culation is stimulated will also be of service. The emptying of the gall-blad- der and ducts may be brought about by exercise and by internal medication. Horseback and bicycle-riding are to be especially recommended, as well as tennis and lawn bowls and so forth. The occa- 124 CHOLELITHIASIS. TREATMENT. MEDICAL. sional administration of calomel followed by a saline cathartic is one of the most effectual methods of emptying the gall- bladder. The taking of large quantities of water, especially of Carlsbad or other alkaline water, an hour or so before meals is of service, as the liver is, in that way, flushed out, and the bile flows more freely. Ox-bile used internally in biliary colic. The bile is decolorized to get rid of the toxic coloring matter {especially bili- rubin), and then sterilized at 220° to 222° F. ; 3 ounces of bile produce 2 '/a drachms of the extract. Of this latter 3 grains in pill or capsules are given twice a day after meals. They may be con- tinued for years, or given intermittently, whenever there is any sign of colic. Ke- Bults obtained in several cases have been brilliant. It cannot, however, be regarded aa a certain preventive of colic, since if the gall-bladder is full of stones it does not cause them to disappear, though it prevents the formation of fresh calculi. The treatment is recommended after operations for the evacuation of calculi to prevent relapses. Gautier (Rev. M6d. de la Suisse Rom., June 20, '98). On the question of diet there is much difference of opinion. It is, however, safe to say that starchy and saccharin foods, which render the bile more dense, are to be avoided. Medical Treatment. — Some writers, particularly those who do gall-stone surgery, consider remedial measures of a medicinal character altogether futile. It is quite certain that valuable time should not be taken up after the failure of drugs if jaundice and fever are pres- ent, as the patient may soon be beyond surgical help. The administration of alkaline waters, especially of Carlsbad salts, has been, in many cases, followed by good results. Naunyn (quoted by Krau.ss) says: "I have not the slightest doubt but that the Carlsbad cures have the best influ- ence on the course of cholelithiasis. I have seen a considerable number of dan- gerous gall-stone incarcerations, which have lasted a long time, terminate favor- ably." Krauss states that the cures can be- taken at home and should last from four to six weeks. A bottle of Carlsbad should be taken each day as follows: Two tumblerfuls in the morning before breakfast warmed to 140° or 150°, at an interval of fifteen minutes. In the even- ing one tumblerful should be taken cold. If the water does not produce a free evacuation of the bowels, Spriidel salt should be given in addition. Krauss attaches great importance to diet. As a rule, he forbids: fat, vinegar, hot spices, pastry; vegetables, both dried and un- boiled; roasted potatoes, and cheese. He recommends the following diet in or- dinary cases: — Breakfast: A cup of tea or coffee, little milk; little sugar, if any; and two or three pieces of rusk or toast, one or two soft-boiled eggs, or some fish or cold meat. Midday meal: Fish (salmon and eels excepted), roasted meat without sauce, green boiled vegetables or mashed pota- toes, stewed fruits without sugar. Drink plain or slightly-effervescing water, red wine (one or two glasses), or weak whisky. Supper: Cold or hot meat (fresh roasted), tea, wine, or whisky (small quantities). He usually limits the bread to from four to six ounces a day. The use of olive-oil has still many ad- vocates. Olive-oil i.s useful in gall-stone, if properly administered. Not more than 1 to 2 ounces may be given. Its action produces a watery flow from the mu- cous membrnneH, and therefore helps to increase the flow of the normal duodenal secretions, namely: the biliary, the pancreatic, and the secretion of Brun- CHOLELITHIASIS. TREATMENT. .MEDICAL. 125 ner's glands. Quite good results have been reported. Indications for surgical interference are: (1) when tliere is con- tinued fever not traced to other to.xins; (2) complete occlusion of the cystic duct, usually by a single large calciUus; (3) in cases of chronic obstructive jaun- dice from impaction by one or more cal- culi in the common duct. W. H. Thom- son (New York Med. Jour., April 19, 1902). As a rule, too little water is taken in these cases. Alkaline saline waters stimulate peristalsis and increase the flow of blood to the abdomen, the bile- passages being massaged by the former and the diseased mucous membrane benefiting by the latter. These salines do not dissolve the stones, for such allowed to stand two weeks in a 1-per- ccnt. solution of sodium salicylate, ben- zoate, phosphate, sulphate, bicarbonate, or chloride; potassium sulphate, or amraoniimi chloride suffered no loss of weight. Allowed to stand in olive-oil, however, a gall-stone lost G8 per cent, of its weight in two days and then dis- integrated. The solid matter of a stone becomes viscid in a few hours in a 5- per-cent. solution of animal soap. Large doses of oil probably do not reach the gall-stone directly, but, by producing an increased proportion of fat, fatty acid, and soap in the bile, cause it to have a solvent action on the choles'terin of the stone. For this method of treat- ment from 2 to 10 ounces of oil should be given daily, and the results are very questionable. Massage of the gall-blad- der would, in many instances, be useless or harmful. During a gall-stone attack relief is urgently demanded. A pint of water taken as hot as possible, with hot fomentations over the liver, may give relief, or 1 cubic centimetre {15 minims) of spiritus a;thcris in 2 teaspoonfuls of chloroform-water every quarter of an hour. Exalgin, 0.06 gramme (1 grain), every half-hour for three or four doses is also of service. These failing, mor- phine must be used. Mayo Kobson (All- butt's "System of Medicine"; Medical News, ISIarch 29, 1902). In cases of cholecystotomy, when there is an external biliary fistula and gall-stones still remain in the common eholedoeh-duct, the injection of olive- oil into the gall-bladder has been recom- mended so as to enable it to directly ex- ert its solvent action on the calculi still remaining. A case is reported by Morris in which a cure by this means took place after six weeks' treatment. Calomel, followed by salines, may be of use in emptying the gall-bladder and expelling the calculi if tiiey are very small. Butter recommended to be taken in large quantities instead of olive-oil for the prevention and cure of gall-stones. Fifteen to 20 grammes (4 to 6 drachms) of butter spread on biscuits are to be given each morning. Felix von Oefele ("Artzliche Rundschau," '90-'97). Enemata of olive-oil recommended for the treatment of cholelithiasis. A more direct action on the liver is obtained by this mode of administration, while there is less danger of affecting the stomach. This is an addition to our present means of treatment of cholelithiasis. Blume ("Verhiindlungen der Congress f. innere Med.," Wiesbaden, '97). The most effective remedy for biliary colic is an hypodermic of V* or Vs grain of morphine with V120 grain of atropine. Hot applications applied lo- cally afford some relief, and a weak, hot solution of bicarbonate of soda taken into the stomach in large quantities haa been recommended. Olive-oil in from 5- to 10-ounce doses is said to shorten an attack. Glycerin is also credited with value when em- ployed in the same manner. Surgical Tre.vtmlxt. — Much has been accomplished within the last few years in the improvement of older meth- ods and in the introduction of new plans of operation on the more difficult cases of gall-stone surgery. Given a reasonable certainty of the presence of gall-stones in the gall-blad- der or ducts, it calls for their removal 126 CHOLELITHIASIS. TKEATMEKT. SURGICAL. by means of the surgeon's knife. Where, however, there exists some disease of other organs of the body, as the kid- neys or the heart, which would render the use of an antesthetic immediately dangerous to the health of the indi- vidual, it is questionable .whether oper- ation should be undertaken. If gall- stones are acute in their manifesta- tions, it is better to wait until th^ symptoms have diminished or subsided. if attended with jaundice, to wait a reasonable time to see if it does not diminish; and, if it does not, to at- tempt to improve coagulability of the blood by the use of calcium chloride. In recent years, by means of calcium chloride, the coagulability of the blood has been increased or improved to such an extent as to make a surgical oper- ation much less dangerous than before it was given. If there are symptoms of gall-stones in the common duct, and they have subsided, and if following that, within a reasonable length of time, there are further symptoms or indications of gall-stones, operation is indicated. Frank Billings (Annals of Surg., Sept., 1903). Cases have, from time to time, been reported in which a diagnosis of chole- lithiasis had been made, and when op- erated upon gall-stones have not been found. In some of these recovery has taken place in a remarkable way. The arguments in favor of removing gall-stones at the earliest favorable moment after the diagnosis has been made may be summed up as follows: The operation is, as a rule, easy and safe and all stones are quickly removed. The remote dangers of gall-stones are eitlier avoided or lessened. These are: serious disabilities, grave emergencies, and malignant disease. If the diagnosis of gall-stones proves to be wrong, other lesions may be discovered and remedied: lesions perliaps more serious than tliose of gall-stones. Late operations upon gall-stones arc, as a rule, difTicult and dangerous. Operations made imperative by progressive and lethal symptoms must be performed under great disad- vantages and dangers; the gall-stonec are generally more inaccessible, the dis- sections deeper, and the patient's power of resistance lessened. The arguments against early operation are: There is some danger in the operation, though it is but slight. The diagnosis may be wrong and the exploration unnecessary. There is the possibility of hernia in the scar. There is the possibility that the gall-stones may recur. There is the pos- sibility of spontaneous cure. There is also the possibility that, after offend- ing enough to prove the diagnosis, the gall-stones may give no further trouble. The last and decisive attacks of biliary colic may have been caused by the last remaining gall-stone, exploration show- ing that none of them remains. M. H. Eichardson (Boston INIed. and Surg. Jour., Sept. 5, 1901). In 720 operations the mortality was 15.5 per cent. From these operations, however, 185 can be deducted, either on account of operations at the same time on the stomach or intestines, the pan- creas, the liver, etc., or because there was inoperable carcinoma of the gall- bladder, gall-duct, or liver, or diffuse purulent nephritis, peritonitis, or cys- titis. This leaves 535 operations solely for gall-stones, with a mortality of 3.5 per cent. It must be remembered in these statistics that all patients who died within one hundred days of the operation are included. Death in many of these cases cannot be ascribed in any way to the surgeon's intervention. In tlie case of sepsis and carcinoma with a mortality of 97 per cent, the operation is justified because such patients are certain to die, and if 3 per cent, are saved it is a considerable gain. More- over, error in diagnosis sometimes oc- curs, and it is found at the operation that the condition is not so severe as was suspected. II. Kehr (MUnchener med. VVochcn., Oct. 28, 1902). Henry Morris (in Krauss, on "Gall- stones") states that there are several cases on record to prove that, where pain alone or pain with jaundice has been such as to reduce patients to the verge of suicide or death, laparotomy and digital examination of the liver and gall- CHOLELITHIASIS. TREATMENT. SUEGICAL. 127 ducts have restored the sufferer to com- plete good health, though no tumor nor gall-stones have been found to account for the symptoms. Morris found adhe- sions to the abdominal wall in one case, and in another a general enlargement of biliary ducts from some unknown cause. It is possible that in some of these cases a gall-stone in the ampulla of Vater may be pushed through into the duodenum during the manipulation. The indications for operation in chole- lithiasis are thus given by Mayo llob- son: "1. In frequently-recurring biliary colic without jaundice with or without enlargement of the gall-bladder. 2. In enlargement of the gall-bladder without jaundice, even unaccompanied by great pain. 3. In persistent jaundice ushered in by pain, and where recurring pains with or without ague-like paroxysms render it probable that the cause is gall- stones in the common bile-ducts. 4. In empyema of the gall-bladder. 5. In peritonitis starting in the right hypo- chondriac region. 6. In abscesses around the gall-bladder or bile-ducts whether in, under, or over the liver. 7. In some cases, where, although the gall-stones may have passed, adhesions remain and prove a source of pain and illness. 8. In fistuliE: mucous, muco-purulent, or biliary. 9. In certain cases of jaundice with distended gall-bladder dependent on some obstruction in the common bile- duct. 10. In phlegmonous cholecys- titis and in gangrene, if this can be seen and recognized at a sufficiently-early stage of the disease." (Allbutt's "Sys- tem of Medicine.") Kobson does not approve of sounding for gall-stones through the abdominal walls. He also condemns massage of the gall-bladder. .'\mong the cases of gall-stones not to be operated upon are those where the first paroxysm of pain is succeeded by all the typical manifestations, where the patient becomes jaundiced on the sec- ond to third day and passes small stones by the natural way. Repeated attacks are not indications for operations when each time small stones are passed. When there are numerous attacks with- out the passage of small stones then the question of operation arises on ac- count of the suspicion that, besides the small calculi, there may also be large ones impacted in the gall-bladder. Those eases should not be operated upon in which after repeated ineflfectual attacks larger calculi have been passed, for if a large stone has been passed others may follow. If ineffectual at- tacks continue to follow, an operation is indicated. But a single ineffectual attack, without jaundice, indicates operation. A state of latency may be partially at times brought about by aperients, but it is of short duration. Operation is indicated in those cases where, after repeated ineffectual attacks, the uppermost stone enters and becomes impacted in the ductus choledochus. This impaction must be determined by waiting, two to three weeks being suflS- cient. Riedel (Berliner klin, Woch., Jan. 21, 1901). In one-third of the cases the symp- toms were of ten years' or more dura- tion. In less than one-fourth the symp- toms had persisted for less than two years. Cholecystenterostomy is a make- shift at the best ; the cystic duct may not be patent. Expression of the stone into the duodenum or bladder is not easy. No cases have been operated upon by the transduodenal route. Crushing of the stone leaves debris. In none of the above methods can it be determined whether or not the ducts are patulous. In six of the cases only one stone was found. For the relief of the late des- perate cases a rapid cholecystotomy may be made. The method of choice consists in incising the duct, removing the stone, suturing the duct, and draining the gall- bladder. This procedure was carried out in 21 of the cases without a death. M. B. Tinker (Phila. Med. Jour., June 21, 1902). As soon as gall-stones give serious 128 CHOLEUTHIASIS. TEEATMENT. SURGICAL. trouble, operation is indicated, for it is onlj' from the complications which in many cases arise sooner or later that any danger after operation need be ap- prehended. Medical treatment may do much to relieve the catarrh associated with cholelithiasis, but no medicine can dissolve gall-stones or produce perma- nent relief. It is impossible to say what operation will have to be done imtil the abdomen is opened and the exact state of affairs made out. No surgeon shoiild attempt the re- moval of gall-stones unless he is pre- pared to perform any of the various op- erations on the biliary passages, and no operation should be concluded until it is determined that the ducts, including the hepatic and common, are free from con- cretions, otherwise dissatisfaction is cer- tain to follow. A gall-stone scoop is the only special appliance that need be em- ployed. Rubber gloves impair the sense of touch and cause delay. In jaundiced patients calcium chloride is given in 30- grain (2 grammes) doses by mouth be- fore operation and afterward in 60-grain (4 grammes) doses by rectum, thrice daily for two or three days or longer if necessary. A sandbag, placed under the patient at the level of the liver, will push the spine forward and with it the liver and bile-ducts; so that the common and hepatic ducts are brought several inches nearer the surface. The writer always makes his incisions over the middle of the right rectus and in line parallel with its fibres, which are separated by the finger. If more room is required, the incision is carried upward in the interval between the ensiform cartilage and the right costal margin as high as posBible. By lifting the lower border of the liver, first drawing the organ down- ward from under the cover of the ribs, the whole of the gall-bladder and the cystic and common ducts are brouglit to the surface. An assistant gently draws the gall-bladder upward with one hand and retracts the left side of tlie wound and the viscera with the other. The gallbladder, cystic and common ductB now form a straight passage from the fundus of the gall-bladder to the duodenum, and the wliole length of the ducts, with the duodenimi and liead of the pancreas, are in view. Stones in the ducts are detected by palpation and re- moved by incision into the ducts. If the common duct has been incised, a probe may be passed into the hepatic duct and down the common duct into the duodenum. The incision into a bile- duet is closed by a ciu-ved needle held in the fingers without a needle-holder, a continuous catgut suture being used for the margin of the duct proper, and a continuous catgut or celluloid thread being employed to close the peritoneal edges of the duct. When the gall-blad- der is contracted and a swollen pancreas presses on the common duct, a drainage tube is inserted into the hepatic duct, passing upward through the common duct, and here held by a catgut stitch. Prolonged manipulations are never made on a stone deeply impacted even in the cystic duct, but the duet is at once incised and the concretion removed. Drainage is effected by gauze surroxuided with a split drainage tube, which is brought out by the side of the gall- bladder drain. All bleeding points and all firm adhesions are ligated. Ideal cholecystotomy (cholecystotomy in two stages) and partial cholecystectomy (Mayo) are not regarded with favor. A contracted gall-bladder which caimot be brought to the surface may be drained by fixing a tube into it with a purse-string suture, the general peri- toneal cavity being protected by gauze packing. In many of these cases it is better to remove the gall-bladder. If a stone is impacted in the duodenal ends, a duodeno-choledoehotomy is sometimes the easiest operation. A cholecysten- terostomy is rarely used because the trouble is not removed; when it is nec- essary it will be found easier to anas- tomose the gall-bladder with the colon. In detaching adhesions a careful search m\iHt always be made for an opening into the hollow viscera. A. W. Mayo Robson (British Medical Journal, Jan. 24, 1903). ChohcysloLomy is the operation of choice in cholelithiasis, and it is consid- CHOLELITHIASIS. TREATMENT. SURGICAL. 129 Kg. 1. — The pouch described shown by draw- ing liver upward. X in all the figures ^"'e- 3.-Transverse section through centre of marks point for drainage. poucn. Fig. 2. — Vertical mesial section. Fig. 4.— Fouch (X) behind the right lobe of the liver having natural barricades from the general peritoneal cavity. Posterior hepatic pouch, {ilorison.) (British MediMl JoiirnitlJ 130 CHOLELITHIASIS. TREATMENT. SURGICAL. ered safer, after opening the gall-blad- der, removing the calculi, and ascertain- ing that the biliary passages are clear, to suture the walls of the gall-bladder to the edges of the wound than to perform the so-called '"ideal" operation of sutur- ing the opening in the gall-bladder and returning it into the abdomen. It is better to suture to the aponeurotic layer of the abdominal wall and not to the skin. Mayo Eobson prefers, when there is time, to stitch the peritoneal layer of the gall-bladder to the parietal perito- neum and the mucous layer to the apo- neurosis. A drainage-tube is then in- serted. When a fistulous opening is left, cal- culi not removed at the operation may find an exit. When the incised gall- bladder is returned to the abdominal cavity leakage may take place. When the gall-bladder is contracted and cannot be brought to the edge of the wound. Mayo Robson sometimes tucks down the parietal peritoneum to the gall-bladder and sutures it to the edge of the incision. When he cannot do this, he utilizes the right border of the omentum by suturing it to the gall- bladder opening and to the parietal peri- toneum around the drainage-tube and shutting out the general peritoneal cav- ity. If neither of these methods can be adopted, he passes a drainage-tube through the opening into the gall-blad- der and plastic peritonitis shuts off the general peritoneal cavity. The tube is sometimes packed around with gauze. He prefers to drain the peritoneal cavity by passing a tulje into the right kidney- pouch through the original abdominal incision or through an opening in the side of the abdomen. A flHtula does not eloHC because the mueouH membrane in sewed to the skin, but it does close when united to the cut edges of the peritoneum and transversalia fascia. Perkins (Boston Med. and Surg. Jour., Jan. 25, '94). In cases of obstruction of the common duct, no attempt should be made to suture the opening after the obstruc- tion has been removed, as the patient's condition is nearly always serious and a prolonged operation would terminate fatally. The obstruction should always be removed, if possible. Experiments demonstrating that the peritoneum is capable of bearing the presence of a small amount of bile, but that large quantities or the constant extravasation of it would produce a fatal peritonitis, usually In from twenty-four to forty- eight hours. W. E. B. Davis (N. Y. Med. Jour., Oct. 26, '95). Case of biliary obstruction complicated by peritoneal adhesions. A first incision was made in a line of and down to a dis- tended gall-bladder. A second incision was made in the right flank and about a pint of fffitid and bile-stained pus was evacuated. The abscess-cavity was bounded above by the liver, behind by the colon, the distended gall-bladder on inner and parietal peritoneum on the outer side. Ten ounces of healthy bile and forty-three gall-stones were removed from the distended gall-bladder. W. F. Brook (British Medical Journal, Feb. 5, •98). As results of 27 operations on cases of gall-stones, the following conclusions are reached: I. Tait's operation of simple cholecystotomy with drainage of the gall-bladder is the ideal operation in most cases. 2. Incision of the common and cystic ducts is the safest and most surgical means of removing stones in them. S. Excision of the gall-bladdrr may find a wider field than heretofore. 4. McHurney has shown that incision of the duodenum, and either dilatation or incision of the common duct through this incision, is, in skilled hands, both eriicient and safe for the removal of stones low down in tlie coinnion duct. In neglected cases with dense and many adhesions and dilated stomach, an additional gastro- enterostomy or pyloroplasty will save cases which would otherwise die. 5. The mortality of the simple cases is prac- CHOLELITHIASIS. TREATMENT. SURGICAL. 131 tically nil. W. VV. Seymour (Amer. Jour, of Obstct, Nov., '99). Choledoclwiomy. — Much attention has been given within the last three or four years to the improvement of this opera- tion, and, although in many cases diffi- cult, it can be performed with greater safety to the patient than formerly. The suturing of the incised walls can be much more easily and completely done, and leakage to a very great extent pre- vented. With our present experience and tech- nique we may safely say that choledo- ehotomy, in the majority of oases, is a diflicult and tedious operation wliich may tax to the utmost the resources of the patient, but its results usually are emi- nently favorable. Jaundice should not be allowed to exist too long. Let me emphasize once more that preservation of life and health in many cases depends upon the proper time being chosen for surgical interference. Lange (Med. News, May, '97). In many instances biliary calculi may be removed from the common bile-duct through an incision in the anterior wall of the descending duodenum. This is an exceptionally good route, if the calculus be situated in the lower third of the com- mon duct. The orifice of the duct may, if necessary, be incised for one-half inch, with perfect safety, and the duct itself is easily dilated. Method employed on si.x different occasions, and in each instance the intestinal wound healed kindly. Charles McBurney (Annals of Surg., Oct., '98). One of two incisions should be em- ployed in exploring the region of the gall- bladder or bile-ducts; the best one ex- tends from about V: inch below the free border of the costal cartilages to a point 2 or .S inches above the umbilicus, pass- ing just within the outer border of the rectus muscle. The second is a curved incision parallel with the free border of the costal cartilages and about 1 inch below them. None but the ninth dorsal nerve will have been divided by either of the two incisions as described. The longitudinal one is to be preferred. If the gall-stone be lodged in the gall-bladder the calculi are removed from an incision in the fun- dus of the gall-bladder after the latter lias been stitched to the abdominal wall. In order to avoid annoyance of a fistula's persisting for weeks or months after operation, McBurney recommends follow- ing modification of ordinary procedure: The circumference of gall-bladder about one-half inch below fundus is sutured to the edges of abdominal wound; a purse- string suture is passed around gall-blad- der between opening in fundus and line of suture to abdominal wall; the free edge of incised fundus is now inverted, a small rubber drainage-tube is inserted, and the purse-string is tightened, so as to prevent reversion of inverted edges. After tliis method the drainage-tube may be removed in the course of several days and in a short while the fistula will be permanently closed. C. McBurney and H. T>. Collins (Med. News, Nov. 26, '98). Dr. W. S. Halsted, in an article in Johns Hopkins Hospital Bulletin, April, 1898, on the use of small hammers and the suture of the bile-ducts, commences as follows: "The surgery of common bile-ducts is still in its infancy. 'Suture of the thickened duct is difficult enough and suture of the normal duct is out of the question,' saj's one. 'It is not worth while to exercise great care in sewing up a slit in the common bile-duct, for it is almost impossible to prevent leakage, and a little additional leakage can do no harm if one drains,' says another. 'Wait until the common duct dilates and thickens before venturing to open it,' say all surgeons." Halsted states that he has ascertained from operations on dogs and man that the normal bile-ducts can be sutured easily, accurately, almost infallibly, and without danger of leakage or constric- tion. He approves of Lange's suggestion to cut through one or two ribs and the diaphragm, if it is necessary thus to render the parts operated upon more ac- 132 CHOLELITHIASIS. TREATMENT. SURGICAL. cessible. He then describes small ham- mers, the heads of which, being of vari- ous sizes, he inserts into the common duct, after the incision has been made and the stone removed. The contents are thus prevented from escaping, and the duct can be raised or lowered at will by the operator. The wall is more easily sutured over the head of the ham- mer. He has a series of hammers which he attaches to a long handle, using one of proper size to easily enter the duct. The method is graphically shown in the annexed colored plate, while the ham- mer and the various diameters of the latter employed are illustrated here. Series of 209 laparotomies for gall- stones with special reference to 30 cases of clioledochotomy. He classifies his operations into five groups: — 1. Those in which the stone is found in the gall-bladder or cystic duct; 97 one-sided and 3 double-sided cholecys- totomies, 4 cystendysis and 23 cystecto- mies. Altogether 127 gall-bladder opera- tions with but 1 death. 2. Two cystectomies and 1 death. 3. Stone iTi choledoch-duct which could not be moved into the gall-bladder or duo- denum; 30 eholedochotomics, 2 deaths. 4. Seventeen cases with dense adhe- sions, fistula, etc. 5. Cases complicated by carcinoma and other conditions necessarily fatal in the end. The mortality bore a definite relation- ship to the pathological conditions pres- ent. In the 209 laparotomies there were 17 deaths, being 8 per cent.; but the mortality was reduced to a minimum in the case of stones on the gall-bladder and cystic ducts, while it reached per cent, when there were changes in the gall-bladder which demanded cholecys- tectomy. Suppurative cholangitis proved a very fatal condition. EmphasiH laid upon the following three points, viz.: ac- curacy in the diagnosis of gall-stones, a. thorough knowledge of the pathology of the disease, and perfection in the tech- nique of the operation. Hans Kehr ("Verhiindlungen der deut. Gesellschaft f . Chir.," XXV Congress, '96) . Hammers employed in suturing the bladder. (Ualstei.) r/m'u/. /7y.. Suture of the Bile, Ducts (Halsted JOHNS HOPKINS HOSPITAL BULLtTIN CHOLELITHIASIS. TREATMENT. SURGICAL. 133 Cases of cholelithiasis treated in the St. Hedwig Hospital at Berlin during ten years analyzed. Of these cases 89 were treated in the medical and 43 in the surgical wards. Fifty-seven of the med- ically treated were traced and it was found that, after from 1 to 2 years, 13 patients still suffered; after from 3 to 4 years, 5; and after from 5 to 8 years, 5. Twenty-two, or 41.5 per cent., were cured, 4 had to be operated upon subse- quently, and 4 died. The results of sur- gical treatment showed the mortality 12.5 per cent.; but when the cases in which death was due to causes inde- pendent of the operation were deducted, the remaining mortality was only 2 per cent. In none of the eases was there a return of stone-formation or of colic. Two cases suffered from cramps which ■were probably connected with disturb- ance in the coeliac ganglia and the abdominal sympathetic. H. Scheuer (Miinchener med. Woch., June 12, 1900). Cholecj'stotomy, in which the gall- bladder is immediately sutured after removing calculi, has come to be re- garded with such universal disfavor that it no longer has any place in the surgery of the gall-bladder. On the contrary, cholecystectomy, by which tho fntm ct orign mali is destroj-ed at a single blow, is being much more fre- quently performed, and is, indeed, ad- vocated by some as a routine pro- cedure, just as they would advise ex- tirpation of the appendix. The ad- vantages of cholecystectomy are: (1) The wound heals immediately, and the liability to subsequent hernia is there- fore slight; (2) there is no possibility of stones forming in the gall-bladder; (3) subsequent cholecystitis cannot oc- cur; (4) the formation of adhesions is reduced to a minimum; and (.")) there is no possibility of malignant growths starting in the gall-bladder. The chief disadvantages are: (1) It is impossible to drain the bile-passages except through one of the ducts, and that only after a difficult and usually un- satisfactory operation; (2) there is greater danger in the operation itself; and (3) redrainage of the biliary pass- ages is extremely difficult and danger- ous, should it be subsequently required. M. II. Richardson (Medical News, May 2, 1903). Morris mentions a case in which, after opening the gall-bladder and removing calculi, stones were found in the com- mon duct which could not be removed. During the convalescence olive-oil was daily injected through the fistulous opening. In six or eight weeks the pas- sage became patent and the patient made a good recovery. [Result of anastomosis of the gall- bladder with the colon. J. F. W. Ross reports a case operated on in February, 1896, as still in excellent health. The patient was suffering from a gall-stone impacted in the common bile-duct, pro- ducing intense jaundice. At the time of the operation the adhesions were so great that it was impossible to isolate the com- mon duct. The liver was torn in an at- tempt to accomplish this. As a conse- quence, an anastomosis was produced be- tween the gall-bladder and the colon by means of a small Murphy button. The button was passed about the sixteenth or seventeenth day after operation. The jaundice rapidly disappeared and the patient soon regained his health. He was seen a month ago in perfect health. The fact that the bile was side-tracked into the colon had no visible ill effect. Ross also reports having found gall- stones lying in the common and hepatic duct, one beside the other like a row of cobble-stones. The stones in the hepatic duct were found far up to the end of the duct. They were removed by a milking process. In the first place, a silk suture was placed like a running string on the wall of the duct. This was put in posi- tion before the duct was incised, so that by pulling on it like a purse-string the orifice could be readily closed and the bile kept from welling into the field of the operation. If the duct is incised first, the bile welling out through the orifice obscures the view. He has adopted this method of procedure on several occa- sions, and finds it of great service. After the suture was placed he then made an incision into the common duct 134 CHOLERA ASIATICA. ORIGIN AND TRANSJUSSION. inside the oval formed by the suture. With the index finger of the left hand on one side of the duct and the index finger of the right hand on the other side, the stones were gradually squeezed down from the hepatic duet and up from the intestinal end of the common duct to the opening just made and pressed out through it. In this way ten or twelve stones were removed. As the gall-blad- der had been previously opened and three stones removed from the interior of the gall-bladder, it was deemed ad- visable to stitch the gall-bladder to the abdominal wall and place a drainage- tube in its interior. The patient made an uninterrupted recovery and has since enjoyed excellent health. J. E. Graham.] J. E. Graham (Toronto) and Central Staff (Philadelphia). CHOLERA ASIATICA. Definition. — Cholera Asiatica is a mi- asmatic, contagious disease transmitted mainlj' by human intercourse, but whose epidemic character depends upon out- side conditions. Origin and Transmission. — The origi- nal seat of cholera is in India, where it most probably existed long before this century. In some parts, especially on the borders of the Ganges it is always en- demic, being produced and entertained by special conditions of the soil, by the infection of the water, etc., and often giving rise to epidemic outbreaks under the influence of high temperature, climatic variations, bad hygienic condi- tions, certain winds, etc. The epidemics may propagate themselves either by land or by sea, through the great roads of commerce, being conveyed to other coun- tries by caravans or by vessels, forming here and there many momentary, sec- ondary centres. The agents of trans- mission are persons infected with cholera or specific diarrhcea, and the linen, clothes, etc., soiled with choleraic dejec- tions, from such persons. The land-route was followed by the first great epidemic of 1S30 and 1848 (the last reaching America), while the second prevailed in the epidemic of 1869 and of 188-1. When the cholera pro- ceeded by land, its course was slow and its steps easily marked, by its invading successively Afghanistan, Persia, the Caspian shores, Astrakan, Russia, and then turning toward the west of Europe and America. The epidemics trans- mitted by sea generally made their first appearance at Mecca or other parts of the Ked Sea, and thence were propagated to Egypt, or reached Beyrouth, Constan- tinople, Marseilles, Toulon, Naples, etc., each of these places becoming a new starting-point for the infection. Countries spared by this scourge are exactly those places out of such com- mercial roads, as are the islands of the north of Europe, Faroe, Hebrides, Ice- land and Greenland, Baffin and Hudson Bays, Patagonia, western America, Poly- nesia, Australia, central Africa, etc. For several epidemics — those of 1852 and of 1859 in Europe afEordcd a striking example, for instance — a direct transmission of cholera from India could not be traced; so that they must be at- tributed to a local revival of the cholera germ, with all its primitive attributes, in places where it had previously been carried from India. It seems, therefore, that cholera germs of former epidemics may live as saprophytes and wait until conditions arise, when they again become virulent. The germs of cholera, when brought into some places, there to give rise to an epidemic of cholera, must find local con- ditions favorable to their development. Low, damp, marshy lands, large towns with crowded populations, narrow, dirty CHOLERA ASIATICA. ORIGIN AND TRAKS]VnSSION. 135 streets and generally every place in which the sanitary conditions are very imperfect and the inhabitants very poor are always the first and main centres of the disease. Decaying vegetable and animal mat- ter, bad drainage, and overcrowding are as much responsible for cholera as bad drinking-water. The regular removal of faecal matter and efficient surface- and subsoil- drainage will reduce the chance of introducing cholera into a town to a minimum. l!ai B. A. Mitra (Indian Med. Ecc, Feb. 15, '93). Koch's vibrios traced to farm-yard ma- nure, pigs' faeces being found to contain them. Nevertheless there had been no cholera for years in the region. Kutscher (Zeit. f. Hygiene u. Infectionskr., B. 19, p. 461, '95). According to Pettenkofer, indeed, the most important part in the development of cholera is played by certain geological conditions of the soil (especially porosity and dampness), and by the variations in the level of the ground-water; so that if such a soil become infected by choleraic germs, finding in it the best conditions for their growth, and, gaining there their virulent properties, the disease diminishes when the ground-water is high, and increases when its level sinks. Investigations on 78 choleraic patients at the HOpital Beaujon. In 67 cases the comma bacillus was isolated. During the epidemic the virulence of the micro- organism had diminished, for, in order to kill a guinea-pig. a much larger dose of a culture isolated in September, 1S92, was needed than of that isolated in April of the same year. Girode (Comptes-rendus Hebd. des Stances et Mem. de la Soc. de Biol., Oct., '92). Study of 251 cases of cholera, in no one of which was the spirillum fo\md, but always mixed with one or more bacteria of other kinds. Lesage and Macaigne (Ann. de I'lnst. Pasteur, Jan., '93). Kvcn by the various methods recom- mended by Koch for the recognition of the cholera bacillus, and, with the great- est care and the mostaccurate knowledge of the subject, it is often Impossible to come to a positive result. The cause of the disease is not the common bacillus, but some unknown noxious principle. 0. Liebreich (Berl. klin. Woch., No. 28, '93). Personal experiments carried out with a view to determine the specificity of the choleraic bacillus. A sufficient quantity of the micro-organism swallowed to give rise to the disease, and practically nega- tive results obtained. This invalidates the principle of specificity ascribed to the pathogenic microbe, and tends to prove that it is not constantly virulent and able invariably to give rise to cholera. (Pettenkofer and Emmerich.) Pettenkofer's experiment repeated without injury. At first the experiment- ers took only small amounts of choleraic cultures without result, then they took larger amounts, and one of them ate an entire culture of a third generation. In this case in thirty-six hours came pain in the bowels, tenesmus, and diarrhoea without particular characteristics. In one other experiment, in which not a sign of sickness occurred, the cholera ba- cillus was found in the normal dejec- tions. Hasterlik (Corres. f. Schweizer Acrzte, Apr. 1, '93). Such experiments prove nothing. Ev- eryone who has lived through an epi- demic of cholera knows that there always are a large number of slight cases. Such mild cases are really cholera, as it can be shown that the dejections contain large quantities of comma bacilli. Guttmann (Med. Press and Cir- cular, Jan. 25, '93). While accepting the comma bacillus as the etiological factor of Asiatic cholera, its presence in the intestine necessarily leads to the development of cholera or a cholera-like disease. The presence of comma bacilli in apparently healthy persons suggests that the bacilli may temporarily or permanently lose their virulence. Rumpf (Centralb. f. klin. Med., No. 25, p. 2, '93). Lesions of cholera produced by giving intravenous injections of cholera bacilli, 136 CHOLERA ASIATICA. ORIGIN AND TRANSMISSION. pure cultures being obtained from the faeces. If the animal received doses of absolute alcohol for two days before the injections, the predisposition to the cholera infection was very greatly In- creased. Thomas (Archly f. exper. Path, u. Pharm., vol. xxii, No. 1, '94). Experiments showing that the activity of the bacilli in the case of men is not parallel to their virulence in animals. The course of epidemics cannot be at- tributed alone to the biological charac- teristics of comma bacilli. It is very probable that the symbiosis of the comma bacilli with other species of micro-organ- isms found in the dejections and in the intestines of cholera patients plays an important role. Blachstein (St. Peters- burger med. Woch., Jan. 27, '94). Study of 293 cases of cholera in Arabia ; the comma bacilli found in 2S0. Also discovered bacilli in his own stools without having any of the symptoms of cholera. Immunity is possibly the result of an attack of cholera experienced in 1892. Karlinski (Centralb. f. Bakt. u. Parisitenk., May 19, '94). Very severe and even rapidly fatal cases of cholera occur with all the char- acteristic sj'mptoms of the disease, yet careful examination fails to show bacilli in the stools; and that, on the other hand, cases which are clinically identical with mild diarrhoea may yet have abun- dant bacilli in the discharges. Kadecki (St. Petersburger med. Woch., Feb. 17, '94). It is not sufficient in explaining ty- phoid and cholera epidemics to demon- strate tlie presence of the typhoid and cholera bacilli in the water (X),but that there is another factor: a local one con- nected with the soil (Pettonkofer's Y). Von Pettenkofer (Mllnchencr med. Woch., May 2, '99). Of course, a polluted water-supply may aggravate an epidemic of cholera by furnisliing a good medium of culture, and a good water-supply may, on the contrary, lessen an epidemic; but the spread of the disea-se, by means of drink- ing-water, is not satisfactorily explicable. .State of our knowledge regarding the cauHation of cholera, as Hhown by the epidemic of 1S92-93. The history of this epidemic shows that the disease does not spread by means of contaminated rivers, since it extended from large cities rap- idly toward the interior, in the direction opposite to the course of the stream. Neither did the contamination of drink- ing-water satisfactorily account for its spread. The dejecta contain cholera ba- cilli and the cholera contagium, — viz.: the spores which are produced by the bacilli, — the latter being more tenacious of life than the bacilli, and also more virulent. The disease is spread by arti- cles soiled by dejecta or by the diffusion of the dried pulverized dejecta through the air. Consequently cholera epidemics are most apt to arise in dry seasons. The contagium of cholera always enters the system 'through the digestive apparatus. These deductions teach us the great im- portance, from the stand-point of pre- vention, of bringing all dejecta and ob- jects soiled by them under water as soon as possible. Lachmann (Deutsche med. Zeit., Jan. 4, '94). Vibrios are present in sewage and Seine water, Paris, and in Verseilles drinking-water, when no cholera is pres- ent. Sanarelli (Ann. do I'lnst. Pasteur, vol. vii, p. G93, '95). Same observations in the Spree, Oder, and Havel streams and Berlin water- supply. In the latter two the vibrio was found pathogenic and gave cholera-red reaction. The Massowah vibrio and phosphorescent vibrios from Hamburg are probably the true cholera vibrios. Pfeiffer (Zeit. f. Hygiene u. Infcctionskr., B. 1, p. 759, '95). There are 1.50 varieties of vibrios differ- ing greatly from Koch's, but growing typical specimens for some time in water. Dunbar (Deut. med. Woch., p. 138, '95). Evidence showing direct, positive agency of polluted water in the causa- tion and spread of Asiatic cholera. Oetvijs (Le Bull. M(Jd., Jan. 9, '95) ; Fallot, Cassoute, and Bouissou (Mar- seille-mCd., Oct. 1, '94); KOrber (Zeit f. Hygiene u. Infcctionskr., p. 101, '95) ; von Heusingor and C. Fiilnkel (Berliner klin. Woch., Mar. 25, '95) ; Clemow (IJrit. Med. Jour., Oct. 13, '94). Experiments showing that vibrios may CHOLERA ASIATICA. ORIGIN AND TRANSinSSION. 137 survive an entire winter and freezing. Kasansky (Centralb. f. Bakt. u. Para- sitenk., p. 184, '95). Vibrios in fseeal matter, as a rule, die within the first 20 days, seldom living 30. Vibrios are sometimes present without diarrhoea or other choleraic symptoms, even in formed stools. Rumpel (Berliner klin. Woch., No. 4, '95) ; Abel and Clausen (Centralb. f. Bact. u. Parasitenk., B. 17, p. 77, '95). The water of a town containing sew- age in which faecal material, urine, etc., is present rapidly destroys the vitality of cholera vibrios, and the danger of a spreading of cholera by canal-water or sewage in which no ftecal material or only a very small quantity is present is much greater. Stutzer (Centr. f. Bakt., Parasitenk., etc., p. 200, '98). Correspondence between cholera and the prevalence of comma bacteria in well-water of Gujerat during the famine of 1900. The results of researches show that none of the comma-shaped bacteria isolated from Gujerat waters could be termed true cholera vibrio. There was, liowever, a marked resemblance mor- phologically, biologically, and tinctori- ally with the true cholera-producing microbe. So marked was this similarity that it is personally believed that the bacteria found belonged to the tribe of curved bacteria, which includes the true cholera-producing microbes. In many of the localities where these comma bacteria were found cases of true cholera were present, which shows an enhanced significance between the inci- dence of cholera in a locality and the presence of curved comma-sha])e(l micro- organisms. G. Lamb (Pliila. Med. Jour., from Lancet, Apr. 20, 1901). But, though Pettenkofer's theory is based upon serious arguments, on the other hand, it is not less demonstrated, according to the views of Koch, that cholera, in a large proportion of cases, is transmitted through drinking-water and several kinds of food, as milk, fresh vegetables, fruits, etc., soiled by the de- jecta, showing in the clearest manner possible, that germs, coming from stools of choleraic patients, are swallowed and find their way to the stomach and to the intestine, whose alkaline juice is neces- sary for their growth, and in which the entire process of cholera runs its course. Vibrios are destroyed in fresh milk within twelve hours. Hesse (Deutsche Viertel. f. offentliche Gesund., B. 20, p. G52, '95). Experiments showing that cholera vibrios live at least thirty-eight hours in milk, and that they develop until the milk coagulates at ordinary temperature. They may even live in coagulated milk. Basenau (Archiv f. Hyg., B. 23, H. 2, '95). The infection, however, may be still inhaled, coughed up, and afterward swal- lowed; so that a diffusion of the dried, pulverized stools through the air cannot be excluded. But in every case the con- tagion of cholera enters the system through the digestive apparatus. Indeed, we are of the opinion that both theories are in accordance with fact, and that, while direct infection through drinking-water and food is an important factor in the propagation of the disease, on the other hand, the de- velopment of epidemics and the prefer- ence shown by cholera for certain places can only be explained by certain unsani- tary conditions and a peculiar constitu- tion of their soil, especially favorable to the life and gro\s-th of the cholera germs. Asiatic cholera must be regarded, there- fore, as a contagious and miasmatic disease. E.\pcriments with files showing that they are most successful infection-car- riers. A fly, which had been infected by being put vipon a mass of cholera ba- cilli, was placed on a piece of beef, which, after a time, was found to contain an enormous number of living bacteria. riTelmnn (Lancet. .July 15. '93). Scries of experiments showing that not only the comma bacillus, but also other bacteria existing in the intestines of chol- eraic cadavers, arc preserved in the in- 138 CHOLERA ASIATIOA. ORIGIN AND TRANSMISSION. testines of flies at least three davs; bac- terium thought to be the vibrio Metsch- nikowi, when removed from the intes- tines of flies three days after infection, killed a guinea-pig and a pigeon after the same lapse of time (twenty-four hours) as a vibrio received directly from the intestines of a choleraic cadaver. Savtschenko (Wratsch, No. 45, '93). The danger of infection by the postal service is exceedingly great. A letter infected with cholera bacilli put, as in the ordinary way, into a post-bag was found, after twenty-three hours and a half, to be still covered with living bacilli. On post-cards they were found living twenty hours after infection. On coins the bacilli died with remarkable rapid- ity, whereas, on woolen and linen stuffs they enjoyed a particularly long life. Uffelman (Lancet, July 15, '93). It is possible for the cholera spirillum to be taken up in the air in dust, and thus transported. Uffelman (Berliner klin. Woch., June 26, '93). Account of an outbreak of cholera in Burdwan jail, furnishing strong presump- tive evidence in favor of the theory that flies may spread disease. Nine cases of cholera, 4 of which were fatal, occurred in G different sleeping wards. Just out- side of the jail-walls, at the corner where the ordinary prisoners were fed, were a deserted compound and row of dirty huts, where a year ago had been a number of fatal cases of cholera. Swarms of flies were blown by this wind from the huts into the jail-yard, wliere, on reaching the trees and corner of the high jail-wall, they obtained shelter from the storm and settled on the food exposed on plates before the gang which fed at this corner. All the affected prisoners were fed at this place on the evening of the storm. Surgeon Captain W. J. Buchanan (In- dian Med. Oaz., Mar., '97). But, whatever its origin may be, the disease does not attack all those who are exposed to it; in fact, during an epi- demic we see that it develops mainly in those who are predisposed to it, on account of previous diseases, dietetic er- rors, mental or physical strains, and other causes disturbing digestion or generally diminishing the organic resistance of the individual. The healthy human body does not furnish a congenial ground for the spe- cific bacillus. Out of 39 persons, mostly of the pauper class, who died of cholera, and were examined at the Hospital of St. Peter and St. Paul in 1S92, the fol- lowing results were found as to the presence of other diseases: — Cases. Per cent. Nephritis chronica in- terstitialis 35 90 Dilatatio ventriculi. . 28 70 Sclerosis eranii IS 45 Cirrhosis hepatis 16 40 Gastritis glandularis. 15 37 Pleuritis adhesiva.... 8 20 Atheroma aortoe et arteriarum cerebri. 7 17 Endocarditis vegeta- tiva 4 10 Pachymeningitis .... 3 7.5 In 21 women, in whom autopsies were made, abortion was found to have oc- curred 7 times. Eewowski (Archives des Sci. Biol., p. 517, '92). Alcohol increases six times the degree of predisposition, in a given individual, to choleraic infection, not only by modi- fying cellular function and causing vas- cular troubles, but also by decreasing the bactericidal power of the blood. Thomas (Arcliiv f. exper. Path. u. Pharm., Aug. 24, '93). In eases of alcoholics mild cholera, like trautmatism, is capable of producing de- lirium tremens, and may also account for a sudden aggravation of light cases. L. Galliard (Archives GCn. de MCd., Oct., '93). Natural immunity against cholera which, according to Koch, exists in half of the human race. The exact way in which this acts is not yet clear, but it is probable that the toxin generated in the intestinal canal by the vibrios of cholera becomes changed by the nuclein, during absorption, into an immunizing substance, or antitoxin. It is a pecul- iarity of the living cell to be able to preserve a free acid in an alkaline medium. When tlie life of tlie cell is destroyed the barrier is removed to the CHOLERA ASIATICA. SYMPTOMS. 139 entrance of tlie cholera bacilli. Klem- perer (Deutsche med.Woch., May 17, '94). Some persons exposed to action of vibrios remain unafTected. Immunity is not due to killing of all microbes in the stomach. Abel and Clausen (Centralb. f. Bact. u. Parasitenk., B. 17, p. 77, '95). We see that under certain meteorolog- ical clianges the epidemics show often quite marked exacerbations, and that, when the private and public sanitary conditions correspond to scientific re- quirements, the disease is always less grave and more localized than under con- trary circumstances. The marked influence of winda and moisture is undeniable. RosanofT (La Tribune M6d., Jan. 2, '95). Prevalence and mortality of Madras Presidency associated with two mon- soons caused by rains, induced rise of subsoil-water and development of condi- tions suitable for seasonable epidemic. W. G. King (Brit. Med. Jour., Feb. 2, '95). Pettenkofer's view of the important part played by the level of the ground- water in the cholera epidemic in 1892 supported by comparative charts show- ing the amount of rain-fall, the number of cholera cases, and the level of the ground - water. As the ground - water sank, cholera increased. P. Hauser (La MCd. Mod., June 9, 13, '94). Symptoms. — The duration of the period of incubation ranges in the ma- jority of cases from 36 to 56 hours; it very rarely extends over several days. The clinical course of cholera may be divided into three periods: (1) 'premoni- tory diarrhwa; (2) confirmed cholera; (3) reaction. Prenionilori/ diarrhoea begins more frequently at night, with or without colicky pains, under the form of liquid stools, at first faecaloid and then bilious and serous, with borborigmus, but with- out tenesmus. Generally there is no fever, and no trouble of the appetite and of the general well-being; so that pa- tients may not be obliged to go to bed. But, after it has lasted for a more or less long time (from a few hours to several days), the patient begins to feel a sense of weakness, pains in the limbs, dizzi- ness, shiverings, and mental torpor. Pre- monitory diarrhoea is always of choleraic nature, as the stools contain the specific germs and may disseminate the infection. It is not constant, being found only in one-third or two-thirds of the cases (ac- cording to the different statistics); but it may be the sole manifestation of a very slight cholera. Confirmed cholera is announced by a change in the aspect of the stools, which, while becoming more frequent, consist of an aqueous fluid, without any fcecaloid smell or appearance, in which many whitish, mucous flakes float, resembling grains of rice (whence their name of "rice-water" or "riziform" stools), formed by the epithelial detritus and containing the cholera vibrios. In the meantime vomiting sets in, also of an aqueous material and accompanied by cramps in the stomach and pra;cordial uneasiness. The thirst becomes burning and insatiable. The urine is scanty, often showing albumin and sugar (which disappear when recovery begins); but in many cases these are totally wanting, a complete anuria being the rule in grave forms. The tongue is whitish, large, and damp. Palpation of the abdomen shows the anterior wall depressed and somewhat hardened. In proportion to the increase of the diarrha?a and vomit- ing the patient grows weaker and weaker; the extremities become cold; the pulse small, weak, and accelerated; painful cramps develop in the calves; sinking of the features with sharpened, cold nose, sets in; and the circulation becomes sluggish, constituting together the "algid stage." 140 CHOLERA ASIATICA. SYMPTOMS. This period may last from a few hours to one or two days, and may end in recovery with a progressive amendment of all the symptoms, constituting then the form to which the name "cholerine" was given by some authors; or it may end in death with symptoms of profound exhaustion, or finally pass, as we have said, into the algid stage. This is announced by a lessened fre- quency and abundance of the dejections, which sometimes cease altogether. In a few hours, however, the patient's general condition grows rapidly worse; the countenance is altered, — the cheeks become hollow, the eyes sunk deeper in the sockets, are encircled by a black ring; there are pains in the head, ear-tinglings, dizziness, and blurred vision; the voice becomes hoarse and is soon extinguished. A feeling of anxiety assails the patient, who suffers from the most excruciating vomiting, hiccough, and cramps in the calves. Cooling of the surface increases, all external parts being, as it were, frozen; but the patient feels an internal, very troublesome heat, explained by the fact that the temperature of the skin, mouth, etc., is much lowered, while that of internal organs is raised and even febrile. At the same time the skin takes a bluish tinge, with black marble-like veins coursing over the hands, feet, penis, and with increasing cyanotic dark hue of the nails. The pulse becomes weaker and smaller, until it disappears, first from the radial arteries and then from the crurals and even the carotids, while the heart-beats gradually disap- pear, the sounds becoming weaker until finally only the second sound is heard. To this great emaciation is added, the body growing thin and the skin wrin- kled. Breathing is frequent and diffi- cult; every secretion is dried up, with the exception of that of the sudoriferous glands, a cold and clammy sweat cover- ing the cutaneous surface. At the end of this stage the patient becomes ex- tremely apathetic and somnolent, loses consciousness, slowly turning his eyes toward a person speaking to him, and at times answering some words with great fatigue, but immediately falling again into stupor. A period of agitation, dur- ing which the patient tries to rise and utter vague words sometimes precedes this stage of collapse, which generally — in more than three-fourths of all the cases — grows worse, and ends in death. The whole duration of the algid stage is from a few hours to two or three days. Signs of death in clioleraic patients. The cessations of respiratory and cardiac movements are not certain signs of death in this disease. The author proposes the following: 1. With an oesophageal sound, introduce by the mouth an abun- dant quantity of water into the digestive tube. The epithelial dibiis which covers the mucosa will become softened and the water be absorbed. 2. Place the body in a bath, at a surrounding temperature, the head naturally above water. 3. In a patient considered dead from cholera, make a small incision in the abdominal wall and inject an abundant quantity of warm water into the peritoneal cavity, — an operation which, in the event of re- vival, would be inoffensive. Netter (Re- vue M6d. de I'Est, Aug. 18, '92). Reaction. — When death does not take place during the algid stage, symptoms of improvement may show themselves: the cyanosis disappears, the skin gains some warmth, the urine begins to flow again and is deep colored, charged with urea and chlorides and very often albu- minous; at the same time the pulse re- sumes its strength, while its frequency decreases; the voice returns, breathing becomes regular, painful cramps disap- pear, little by little the different func- tions are re-established, and after some CHOLERA ASIATICA. SYMPTOMS. 141 days the patient enters into a state of complete convalescence. But the reaction does not always take such a favorable course. Many of the choleraic symptoms (anuria, cooling of the skin, difficult breathing, etc.) persist or reappear, and digestive troubles, head- ache, nervous disorders, fever, and gen- eral depression follow, ending in a form very like typhoid fever; whence its name of cholera-iijplwid. Such cases may run toward a lethal termination, delirium or coma and adynamic symptoms superven- ing; but they may also end in recovery. In other cases the reaction may be very sluggish, each function requiring a long time to become regular, and a remark- able degree of weakness, somnolence, with scanty, albuminous urine, persist until convalescence sets in. But how are the symptoms of cholera to be explained? Several theories have been proposed to solve the question; but it cannot be said to be definitely settled. It seems, however, that no better ex- planation can be given than that of the effects of the cholera vibrios after their penetration into the intestine; that is, a direct injury to the mucous membrane of the gut and the elaboration there of one or more poisonous substances ("chol- eraic toxins'"), which enter the circula- tion. The direct injury, under the form of a s]iecific enteritis, gives rise to de- hydration of the organism, for the great loss of water through vomiting and diar- rhoea, which not only deprives the blood of its water, but indirectly subtracts from the tissues their water-component. As a result, the blood can no longer get rid of the regressive products physio- logically eliminated by it, nor perform the function of liajmatosis, while tlie anatomical elements are affected in their metabolism. On the other hand, the toxins, acting on the nervous system, mainly through a lesion of the sympa- thetic system of the abdomen, exert a general depressing influence. The cholera vibrio is considerably mod- ified by micro-organisms which may sur- round it. The immunity and suscepti- bility depend upon other microbes in the intestinal tract. Koch's bacillus never- theless remains the specific cause of cholera. Metschnikoff (Ann. de I'Inst. Pasteur, Paris, p. 529, '94) ; Fawitzky (Wratsch, Nos. 47, 51, '94) ; Rontaler (Miinchener med. Woch., May 21, '95). There is no antagonism between the cholera vibrio and the comma bacillus. Kempner (Centralb. f. Bakt. u. Para- sitenk., B. 17, H. 1, '95). Several complications may be observed during the period of reaction, among which the following are more common: Cutaneous eruptions (papulous ery- thema, urticaria, miliaria, zona, roseola, petechia2, vibices, boils, etc.), oedema of the glottis, diphtheritic angina, mumps, thrush, dysenteric enteritis, bronchitis, pneumonia, cerebral congestion, men- ingoencephalitis, hjemorrhage, and soft- ening of the brain, which may give, of course, a great variety of clinical aspects to the disease. Cholera assumes an epidemic form of grave dimensions in Canton now and then. Small outbreaks have occurred since the great epidemic of 1894. Dur- ing this year that country sufTered from prolonged drought and intense heat. A comparison of the clinical course of cholera and the effects of the treat- ment has shown that the onset in every case was sudden, particularly in the earlier cases when the disease was most virulent, vomiting and diarrhoea being early signs. Delay in the treatment of this stage meant certain death, and the writer states that he has not seen one patient recover when treatment was de- layed, — that is: during the early weeks of the epidemic, while toward the end of the epidemic the virulence of the dis- 142 CHOLERA ASIATICA. DIAGNOSIS. ease decreased, and spontaneous recov- ery sometimes took place. The earlier the onset of cramps, the worse the prog- nosis, and experience shows that the pa- tient does not recover when cramps are a well-marked condition. W. J. Webb Anderson (Lancet, Sept. 27, 1902). Convalescence, as a rule, is long and often complicated with dyspepsia, diar- rhcea, palsies or spastic disorders in the limbs (sometimes in form of tetany), and mental troubles. Ansemia is present in a large proportion of cases. An attack of cholera does not give im- munity; so that even after recovery has taken place a new infection is possible. The clinical forms of cholera may be very different. The most common is that described, in which the disease runs through its typical periods; but it may limit itself to the first stage, being a choleraic diarrhoea or a cholerine, or it may, from the beginning, show the grav- est symptoms of confirmed cholera, rapidly passing into the algid stage. Between the slight and the grave form there are all the possible intermediate varieties. But there are two other forms worthy of mention: the "foudroyant" and the "dry" cholera. The true cholera foud- royant or cholera siderans is generally rare and mostly observed in India; the disease then kills in a few hours or even minutes; or — as observed in European epidemics — death ensues after 12 to 24 hours. The name of "dry" cholera is given to those cases in which there are no diarrhceic stools; intestinal exudation really takes place, but, probably on ac- count of intestinal paralysis, the fluid materials arc not thrown out. These cases are often rapidly fatal. Diagnosis. — In grave cases of cholera the diagnosis is not difficult, especially when an epidemic of the disease exists. Sometimes, however, the clinical appear- ance of the disease may be very like that of malarial choleriform pernicious fever and of various kinds of chemical poison- ing. The confusion between cholera and malaria may arise especially in countries where both infections are endemic, such as in India. Then, besides the bacterio- logical examination showing the specific germ in each of them, the effects of quinine may indicate an important dif- ference in the character, malarial fever ordinarily yielding to its action, while cholera generally runs its course despite the largest doses. It may happen, how- ever, that both diseases attack a person at the same time, and then symptoms of each are observed, giving rise to a mixed form, while necropsy shows the lesions of either infection distinctly developed. Poisoning by tartar emetic or arsenic, the symptoms of which resemble very much those of the choleraic algid stage, is recognized by the lesions of the mouth and lips, by the vomiting being painful, burning, and preceding diarrhoea, and, in doubtful cases, by chemical analysis of vomited matters. But a much more important diagnostic question, arising especially at the begin- ning of an epidemic or wlien an invasion of cholera is to be feared, relates to slight or suspected cases, which are marked only by a simple diarrhoea possessing no specific character. It is of the greatest importance to ascertain, on account of prophylactic measures to be at once adopted, whether they are or not of choleraic nature. Tlie diagnosis can only be made by means of bacteriological examination; fortunately this is quite easy, because the cholera vibrios always show themselves in tlie first diarrhreal stools, and because in many cases the simple examination of a cover-glass preparation of the stools may be siifTi- cient to make a very probable diagnosis. CHOLERA ASIATICA. BACTKKXOLOGY. 143 When mixed with tlie serum of im- munized guinea-pigs, and inoculated into the peritoneal cavity of susceptible ani- mals, virulent cultures of the spirilla in large dose remain innocuous; on subse- quent examination of the peritoneal con- tents the bacteria can be seen to have undergone disintegration to a greater or less extent, dependent upon the relative immunizing strength of the serum of the immunized animal. This power of de- stroying the cholera spirilla is believed to depend upon the presence in the serum of certain antagonistic substances which have a distinct inhibiting influence upon the vital processes of the bacteria. Investigations show that no other spe- cies of bacteria is afl'ected in the same way by mixing with the serum. Hence the following test proposed: A loopful of the culture to be tested is mixed with a cubic centimetre of bouillon, to which ten times the amount of serum necessary to protect a guinea-pig of 200 grammes weight from a similar dose of virulent cholera spirilla has been added, and the whole is at once inoculated into the peritoneal cavity of a young guinea-pig of from 200 to 300 grammes weight. In the inoculation care should be taken to avoid injury of the intestines, and the cultures employed should be recent and shoiild have been shown to consist of well-formed and actively moving germs. As control, a similar quantity of the same culture is mixed witli a cubic centi- metre of bullion as before, an amount of ordinary guinea-pig serum equal to the amount of immunizing serum made use of in the original test is added, and the whole is inoculated into another guinea-pig. In twenty minutes some of the peri- toneal contents in each case is with- drawn b}' means of glass pipettes, and is examined. If the bacteria are the spe- cific perms of cholera they present a very different appearance in the two cases. Those obtained from the control- animal are well formed, active, and seem to have multiplied. Those which were exposed to the action of the immunizing scrum arc small, misshapen, immobile for the most part, and apparently dead. Unless a distinct difTerence is observ- able between the bacteria in the two ex- periments the micro-organism under ex- amination must be regarded as probably twt tlie cholera vibrio, since the change described is very constant in the case of the cholera germ, and has not been observed to occur with any other under similar conditions. PfeifTer (Zeit. f. Hy- giene u. Infectionskr., vol. xix, p. 75, '95). Serum diagnosis: When the blood- serum of an animal gives a good reaction in the fresh state, the reaction may also be obtained by moistening a drop of the dried blood with water and mixing it with an actively motile choleraic cul- ture. Wyatt Johnston and E. W. Ham- mond (N. Y. Med. Jour., Nov. 28, '9G). According to Blachstein, chrysoidin produces agglutination in cholera cul- tures in exactly the same manner as the diseased serum of immune animals, and does not produce agglutination in any other form of vibrio. Personal experi- ments showing that the chrysoidin reac- tion was not specific for cholera. Several vibrios are affected, and among them is included the vibrio of Asiatic cholera, and it is not the most sensitive. Walter Englcs (Centralb. f. Bakt., Parasit., u. Infectionskr., Jan. 20, '97). In 11 cases examined the agglutina- tion of the cultures of the cholera vibrio was shown 10 times by the serum; twice on the first day of the disease, 4 times on the second day, 3 times on the third day, and once on the fourth day. The reaction was particularly distinct in 2 of the patients from whom the blood was taken on the third day. The phe- nomenon of agglutination ascertained by them was absolutely typical. Achard and Bensaude (Presse Med., Sept. 26, '97). Bacteriology. — The specific germ of cholera Asiatica is now — thanks to the researches of Koch and of many other authors — perfectly known. It is found especially in the mucous flakes of the stools (and in the vomited matter). Wlien these are spread upon an object- glass, dried, and stained with one drop of methyl-blue, it appears in the shape of rods, measuring 1.5 to 2.5 microns in 144 CHOLEKA ASIATICA. BACTERIOLOGY. length, and 0.5 to 0.6 micron in width, and being generally curved, whence the name of "comma bacilli" or "bacilli vixgula" given to them. Sometimes, when two of them are joined at their extremities, in a direction ' opposed to their concavity, the resulting form is that of an italic S, and when several bacilli are joined to each other, their shape becomes that of a spiral (choleraic "spirilla"). Cholera bacilli are very movable and endowed with oscillatoi7 movements resembling those of sperma- tozoa, and also with progressive move- ments. They are easily cultivated in several culture-media, as in broth and upon agar-agar at the temperature of the human body, upon gelatin plates, which become slowly liquefied, and upon pota- toes, meat, eggs, milk, and several other kinds of food. The broth-cultures pro- duce indol and nitric acid (indol-nitrous reaction) and give rise to a peculiar re- action with hydrochloric acid, assuming a violet-pink color, whose intensity rapidly increases during half an hour. This reaction, to which the name of "cholera red" was given, is a valuable diagnostic sign of cholera vibrios. Cholera vibrios can live only for a short time in fiEcal matter, seldom longer than two or three days; so that the advisability of immediate examina- tion of the dejecta is evident. They live, on the contrary, very long in the soil, especially when they find in it a proper nutritious material; it seems rather that their virulence is then heightened, the elaboration of their poison becoming more rapid and intense. They can live, also, on the outer surface of fruits and vegetables (the duration of their life be- ing then from one to six days) and even on the cut-surface of these, where their life may last for a time ranging from one hour (on very acid fruits) to two weeks. Cholera vibrios can grow freely in water, especially when it is stagnant and pol- luted with organic matter; and it has been shown that they can live for many days even in bottled water. The bacilli are destroyed if they are in free contact with the air while exposed to the sunlight, but the colonies in the interior of the culture-media are aided in their growth, the sunlight serving as a sort of incubator. When the medium is plentiful, there is more growth than destruction. Virulence is not diminished in those bacteria that show growth. Therefore bacteria in the deeper portions of water are not affected bj' the solar rays, while those floating on the surface maj' be destroyed ; conclusion drawn that "too much reliance slioukl not be placed on the bactericidal action of sunlight." F. F. Westbrook (Jour, of Path, and Ba«t., Jan., '96). As for the action of high or low tem- perature upon them, we know that the best temperature for their growth is between 30° and 40° C; that under 160° C. their growth is checked, but their vitality is preserved, even if zero or below zero is reached; they have been found to resist a temperature of — 31.8° C. (34° F.), so that it- may be supposed that the germs may survive an entire severe winter. On the contrary, they arc killed after some days by a temperature of 50° C, and in a shorter time by a tempera- ture of 75° C. Direct sunlight dimin- ishes, but does not destroy, their vitality and virulence. A distinct degree of alkalinity is neces- sary for their best growtli (this being the reason of their development in the in- testine), while nearly neutral media are very unsuitable, and acids are decidedly inimical to them; hence they cannot live in the stomach. Sulphuric, hydro- chloric, and phosphoric acids, fresh lemon-juice and wine and beers contain- ing a somewhat large proportion of acids, are all able, in a different degree, to kill CHOLERA ASXATICA. PATHOLOGY. 145 them. Among the chemical substances having a marked microbicidal action upon cholera vibrios, the most energetic are corrosive sublimate (1 to 10,000), sulphate of copper (1 to 25,000), and quinine (1 to 5000). Mustard-oil and volatile essences generally display a sim- ilar action. Asiatic cholera is a nitrate poisoning, the result of the growth of the specific bacterium. Emmerich and Tsuboi (Mun- chener mcd. Woch., June 20, '03) ; Klem- perer (Berliner klin. Woch., p. 74, '93). If the theory of Emmerich and Tsuboi upon cholera as the result of nitrate poisoning produced by the bacilli is true, more than one cause must act to produce cholera. Not only are the bacilli neces- sai-y, but the nitrites also, upon which they are to act to produce nitrates. The presence of carbohydrates is a further essential. R. J. Beck (Med. Corres. des wurttembergischen Arzt. Landesvereins, Dec. 18, 28, '93). The specific nature of the comma bacilli is proved by their being found ex- clusively in the intestinal contents of choleraic patients; but it is proved, too, by experimental production of a cholera- like disease in animals through ingestion or inoculation of their cultures. Indeed, Koch, liaving previously alkalinized the stomach-contents of guinea-pigs, intro- duced 10 cubic centimetres of broth- culture of comma bacilli and immedi- ately aftenvard injected into the peri- toneum 1 cubic centimetre of tincture of opium, and succeeded in producing an intestinal lesion with a flaky, diar- rhocal fluid: a pure culture of comma bacilli. Other experimenters, by inoculat- ing such a culture into the peritoneum, observed in guinea-pigs and rabbits a very grave disease, with extreme weak- ness, low temperature, and death in col- lapse. Inoculations of choleraic virus in man, however, gave no result. Cholera vibrios vary to a considerable 2- extent in their pathogenic attributes and chromogenic properties, not only when they grow saprophytically outside the body, but also when they are ob- tained directly from the intestine of a choleraic patient; so that many forms of them have been described as dillerent organisms, while they are only peculiar varieties of the same germ. Moreover, it seems highly probable that their sym- biosis with certain species of microbes found in the dejections and in the in- testines of cholera patients play an im- portant part in the increase of their virulence, while some other intestinal microbes may, on the eontrarj', retard their gro^vth and lessen their virulence. Peptone water cultures (eight hours), followed by agar cultures for eight hours, agglutination in hanging drop can establish the certain diagnosis of cholera in sixteen hours. The principal condition is the use of a serum of high valence, permanent and reliable. The result of this experimental work proves also the absolute specificity of Kocli's vibrio as the cause of cholera. W. Kolb, E. Gotschlich, H. Hetsch, 0. Lenty, and R. Otto (Deutsche med. Wochen., July 23, 1903). A new medium of great service in the diagnosis of cholera. To prepare it 20 grammes of agar, 10 grammes of Lie- big's extract, 10 grammes of peptone, and 5 grammes of salt are boiled in a litre of water for half an hour. The mixture is filtered and boiled for an- other half-hour; 15 giammes of lactose are added to it, and it is boiled again for a quarter of an hour. Sufllcient of a sterilized aqueous solution of carbon- ate of soda to turn litmus-paper just blue is added, and then 130 c. c. of Kulwl-Tiemann litmus solution and 10 c. c. of crystal violet solution (0.1 per cent, in hot distilled water) arc added, and the mixture is distributed in Petri dishes, 8 c. c. to a dish. Hirschbruch and Schwcr (Centralb. f. Bakter., No. 6, Sept., 1903). Pathology. — The cliaracteristic lesions 146 CHOLERA ASLATICA. PROGNOSIS. of cholera are found in the small intes- tine, whose inner surface is covered by a whitish, creamy lining, extending froin the pylorus to the ileo-cascal valve. Its contents are generally made up of the well-known rice-water material; this has a neutral or slightly-alkaline reaction, and contains only 1 to 2 per cent, of solid matter (chloride of sodium, carbo- nate of ammonium, a little urea, and traces of salts of potash); it is devoid of albumin, coloring substances, and biliary salts. The mucous membrane, after the lining has been removed, shows a red coloration, more or less marked, accord- ing to the period of the disease, and a number of small, round prominences, made by swelled folliculi: "psorentery." In a later stage the lesions are more pro- nounced: the intestinal contents are bloody, the folliculi are ulcerated, and the mucous membrane shows a more or less extended gangrene. The large in- testine is also extremely hypersmic, studded with htemorrhagic patches and ulcerations, and is filled with black, bloody, foetid, feecal matter. Deepening of the ulcerations may give rise to per- foration, with all its dire sequels. Mi- croscopical examination shows a vari- able degree of swelling and clouding of the epithelium, and extensive desquama- tion of the small intestine. The ade- noid tissue of the mucous membrane and of the villi is filled with embryonic cells, and this cellular infiltration is also found in the follicles and in Peyer's patches. The muscular layer is unafTected; the subserous connective tissue is infiltrated with leucocytes, while the epithelial layer of the peritoneum has disappeared. Anatomically, therefore, the intestinal lesion may be regarded as an acute des- quamative enteritis. In the kidneys the pathological changes are those of a more or less severe glomerular nephritis, or, according to Leyden, of a coagulation necrosis of the epithelium without any inflammatory action. In the former case the morbid changes would be explained by the elim- ination of toxins passing from the intes- tine into the blood; in the second by alterations in the circulation due to the profuse loss of water. An epithelial des- quamation is observed on the mucous membrane of the bladder, ureters, and the pelvis of the kidne3's. The spleen is hard and rather small; the liver is con- gested and its cells have undergone granular degeneration. As for the cerebral changes, both in the algid stage and in the period of re- action, they are likewise of the nature of acute degeneration and necrosis. Cerebral changes in Asiatic cholera in algid state, as well as in reaction period, of the nature of an acute degeneration and necrosis, and not of a perivascular inflammation. Tschistowitsch (St. Pe- tersburg med. Woch., Aug. 17, '95). Prognosis, — Cholera Asiatica is always a serious disease, even when its symp- toms do not apparently show a specially grave character. Considering its insidi- ous tendency and the probability, never lacking, of lethal accidents in every period of its course, the slightest forms of diarrhoea may be regarded, during an epidemic, as the onset of a fatal affection. In the algid stage, of course, the prog- nosis is still more unfavorable, and such symptoms as anxiety, agitation, collapse, weakness; quickness and, moreover, dis- appearance of the radial pulse; anuria, coma, delirium, and convulsions are almost without exception of very ill omen. As for the period of reaction, the prognosis becomes bad when cerebral or pulmonary complications occur, or if its course is irregular. At the beginning of an epidemic, the average mortality from cholera is 50 to CHOLERA ASIATICA. PROPHYLAXIS. 147 60 rer cent, and even higher, while at the end, slight forms generally prevail- ing, it grows progressively less. The largest proportion of deaths occurs in children and old people, the ill-nour- ished, enfeebled, paupers, drunkards, and those affected with debilitating diseases, especially dysentery, cancer, consumption, insanity, etc. Whatever may be the gravity of the symptoms during the algid stage, even if there be intense cyanosis, if the normal or contracted pupils remain mobile, — that is to say, if they dilate when the eyelids are closed and return to their primitive diameter as soon as the lids are opened, — a favorable prognosis may be given. Coste (Revue de MOd., No. 12, '90). The prognosis of Asiatic cholera in young children is exceedingly bad. Of 4129 infants, aged 1 year and under, 80 per cent, died; of 1701 children, from 1 to 5 years, 75 per cent, died; of 1731 children, from 5 to 15 years, 45 per cent. Hoppe (Deutsche med. Woch., Nov. 9, •93). There is a urinary crisis in patients who recover, characterized by the dis charge of abundant urine of low specific gravity, rich in urates, but poor in chlo- rides. As convalescence becomes more marked, the proportion of urea dimin- ishes, that of the chlorides increases, the specific gravity grows greater, and the quantity of urine returns to normal. Carriou (La Mod. Mod., Dee. 30, '93). Prophylaxis. — Prophylactic measures are of the utmost importance. The im- portation and propagation of cholera must be thwarted and healthy persons must be protected against contagion. The measures necessary may be summed up as follows: A careful examination of persons coming from infected places; isolation of those found ill or simply mspected and of their nurses; thorough disinfection of clothes, linen, premises, dejections, rooms, drains, etc. For in- dividual prevention it is necessary to drink only boiled water, to avoid every dietetic error, excess, mental or bodily strain, cold; and, while no radical change ought to be made in the ordinary ali- mentation, the food must be of good quality and vegetable products should always be cooked. Haffkine's prophylactic method, based on the inoculation of serum of immu- nized animals, has been tried with satis- factory results in India; but the dura- tion of the protection afforded by the inoculation, and for some authors the efficiency of the protection itself, is still a matter of doubt. An e.xperimental inquiry of the bear- ing on immunity of intracellular and metabolic bacterial poisons: As far as the cholera spirillum is concerned, (1) any one mode of immunization will pro- tect an animal against an infection by any other form of inoculation used; (2) the serum of an animal immunized by any one method also protects guinea- pigs against an infection by any other forms of inoculation; (3) the distinction between an "intracellular" and a "metab- olic" poison in their relation to artificial immunity must not be made too narrow. Kanthack and Westbrook (Brit. Med. Jour., Sept. 9, '93). The milk from an immunized goat has the property of conferring immunity to cholera, but not when introduced into the system by way of the stomach. It confers immunity at once, but is of no avail if given shortly after the injection of the cholera germs. Ketschcr (Archiv f. exper. Path. u. Pharni., Nov., '93). Endeavor to reconcile the various di- vergent views which have resulted from the studies of different observers: There are in the cholera vibrios distinctly-poi- sonous substances, which are insoluble in the ordinary culture-media, but which are set free after the death of the bacilli in the bodies of guinea-pigs used for ex- periments, and which then act as paral- yzants to the centres governing the cir- 148 CHOLERA ASIATICA. PROPHYLAXIS. culation and the temperature. Conclu- sion that, although the possibility of a successful protective inoculation against human cholera cannot be denied, the existence of such a possibility has not yet been proved experimentally. R. Pfeiffer (Zeit. f. Hygiene u. Infectionskr., Mar. 2, -94). Substances found in blood of conva- lescents afiord inconstant immunity. Sobernheim (Hyg. Rund., p. 145, '95). Haft'kine's inoculations in India in- creased safety of inoculated twenty times. W. J. Simpson (Brit. Med. Jour., Sept. 21, '95). Out of 3276 uninoculated persons there ■were 47 cases; while in 2936 inoculated, 3 cases. Powell (Indian Med. Gaz., No. 7, '95). ICitasato's anticholera serum used in 193 cases. The former rate of mortality (among Japanese) has been about 70 per cent. In these cases the percentage was lowered about 20. The subsidiary results were similar to those of diph- theria antitoxin: 1. Urticaria, veiy common. 2. Arthralgia, observed in only 18 cases. 3. Myalgia in 6 cases. A. Nakagawa (Brit. Med. Jour., No. 1855, p. 121, '96). Summary of all the observations in India upon HafTkine's anticholera inocu- lations. 1. The inoculations even in the larger doses hitherto used do not confer a complete immunity. 2. A con- siderable degree of immunity seems to be conferred when the doses injected are sufTiciently large to produce marked fe- brile reaction. 3. Smaller doses confer little or short-lived protection. Arthur Powell (Lancet, No. 3803, p. 109, '00). Complete report of the results of the anticholeraic inoculations performed in Calcutta during two years. Among 054 uninoculated persons there were 71 deatlis, while among the 402 inoculated individuals in the same households there were 12 deaths: a reduction of mortality of 72.47 per cent. The results in Cal- cutta are fully confirmed by reports from other parts of India, which are also given, Simpson (Indian Mcd.-Chir. Rev., July, '90). Epidemic in 1895 in the town of Midna- pore, Bengal, in which the method sug- gested by Hankin of disinfecting the wells by permanganate of potassium was used. It undoubtedly cut short the epi- demic, statistics showing the value of the method. O'Gorman (Indian Med. Gaz., July, '96). Referring to the researches which have shown that the protective action of the cholera serum is strictly specific, and is due to the presence of specific bacteri- cidal substances: The serum of persona inoculated with cholera vibrios contained these substances, and not bodies anti- toxic to the cholera poison belonging to the vibrios themselves. The value of inoculations emphasized in India, al- though the protection lasts only a year. Kolle (Deutsche med. Woch., Jan. 1, '97). Detailed statement of results of anti- cholera inoculation. In Gaya jail, of 433 prisoners, 215 submitted to inoculation, after cholera had appeared in the prison. Among the inoculated there occurred 8 cases, with 3 deaths; among the unpro- tected, 20 cases, with 10 deaths. Haff- kine (Dublin Jour, of Med. Science, Feb., '97). The number of micro-organisms in well-water may be materially reduced for several days by placing potassium permanganate in the well. Attempt to check choleraic outbreaks in India by putting the permanganate salt in the wells of villages in which the outbreaks occurred. Enough was used to give the water a pink color until the following day, generally two or three ounces, and the procedure was repeated every third or fourth day. As a result, the cholera outbreaks were of shorter duration, and cases fewer in these villages than in those using water from wells that had not been so treated. E. II. Ilankin (Brit. Med. Jour., Jan. 22, '98). A cholera vaccine which contains free receptors, and which has the power of building both uni- and amboceptors (agglutinins and bacteriolysins) in a cholera immune serum is obtainable by autolytic digestion of cholera spirilla in aqueous solution. When injected into rabbits this vaccine gives rise to the Hiipearance of bactericidal and ag- glutinative substances in the blood-sera (;f these animals which equal or exceed CHOLERA ASIATICA. TREATMENT. 149 those obtained from inoculation of virulent living cholera vibrios. One advantage gained by the use of the vaccine instead of the living or dead bacteria is the absence of local reaction following the inoculation. The vaccine filtrate may be evaporated to a pow- der, which when redissolved in water and injected into animals is capable of giving i-ise to an immunity. The author suggests that free receptors ob- tained by autolytic digestion and filtra- tion of otlier bacteria may be used as a vaccine in diseases such as typhoid fever and d.ysentery. Strong (Amer. Med.. Aug. 15, 1003). Treatment. — The treatment of cholera is still a much-vexed question, no specific remedy having been found to directly combat the infection, while serum-ther- apy is only yet in its incipient stage. It would be impossible to refer to the numberless methods which have been proposed and tried with variable result; I must, therefore, limit myself to the general rules which experience, a knowl- edge of the biology of the pathogenic microbe, and of the influence it exerts upon our system have indicated to be the most rational. From tliis knowledge tlie aims of treat- ment would be as follows: 1. To restrain the development of the germs in the intestine and to neutralize the poisons to which tliey give rise there. 2. To counteract the poison which has pene- trated into the blood-current. 3. To mitigate the effects of the twofold (local and general) action of the germs. 1. To restrain the development of the germs in the intestine and neutralize the specific toxins, no better means is at our disposal tlian acids, whose microbicidal properties against cholera bacilli are well shown. Therefore, internal use of acids under the form of hydrochloric, citric, or tartaric lemonade is higlily to be recommended, together with the in- jection into tlie intestine, by means of a special irrigator (enteroclysma) of a warm solution of tannic acid (1 '/< to 5 drachms for 1 '/a to 2 quarts of water or infusion of chamomile). These injec- tions were proposed by Cantani, who gave the preference to tannic acid on account of its neutralizing the alkaline reaction of the intestine, corrugating blood-vessels (and so restraining the ab- sorption of poisons), and acting as an antidote against the toxins. They must be repeated four times a daj', and, in grave cases, after each alvine evacuation. The beneficial effects of this treatment I was able to observe in the cholera epi- demic of 1884 in Naples, and my experi- ence is that, if it be resorted to at the first appearance of premonitory diar- rhoea, the course of the disease may be aborted, while in declared cholera many lives may be saved through its aid, when general poisoning has not yet taken place. French authors replace the hydrochloric, citric, etc., acids by the lactic lemonade, prepared with 2 Vj drachms of lactic acid to a quart of water. On the other hand, Genersich has modified Cantani's method by in- jecting a larger quantity of fluid (5 to 15 quarts of a 1- to 2-per-cent. solution of tannic acid) under a greater pressure; so that the liquid may irrigate the whole intestine and be at least partly ejected by the stomach. This metliod, to which he gave the name of di/adi/sis, has for its object to cause the remedial substance to act upon the whole mucous membrane of the gut; but its practical application is rendered very difficult, and it is not well borne. Effort to cleanse the digestive tract of its pathogenic elements by the fol- lowing procedure: Every patient at once made to drink as many tumblerfuls as possible of hot water, containing each 3 drops of hydrochloric acid. As soon as the patient had successively imbibed. 150 CHOLERA ASIATICA. TREATMENT. 6 or S tumblerfuls, manual abdominal pressure was resorted to in order to expel the liquid. Ten minutes after the vomit- ing had ceased the whole cleansing pro- cedure was repeated. Sometimes a third washing was performed three hours later. Simultaneously the intestines were cleansed by means of enemata, made of from 12 to IS tumblerfuls of a hot 2.5- per-cent. aqueous solution of tannin, or, in the absence of the drug, of the same amount of plain, hot water. The injec- tion was usually followed by decrease of diarrhoea: but sometimes a second enema became necessary, being then ad- ministered about two hours after the first. Wlien practicable, the measures were supplemented by a hot general bath, and a successive application of ab- dominal compresses soaked iu hot, strong solution of kitchen-salt, and wrapping the whole body with hot sheets and blankets. Internally, the patients were given claret (boiled with cinnamon and sugar) and lemonade made of hydro- chloric acid (10 drops to each tumbler- ful), a mouthful every ten minutes. In addition, some stimulant remedy (cam- phor, ether, caffeine with benzoate of sodium) was administered hypodermic- ally. But 10 cases out of 00 thus treated lost. I. F. Shorr (Yujno-Riisskoia Med. Gaz., No. 13, '92). Introduction of a soft-rubber tube one metre in length into the rectum, causing it to pass through the sigmoid fle.xure and enter the descending colon, and carry liquid as far, at least, as the ileo-ca;cal valve. A large quantity (2 or 3 gallons) of warm soap-water tlius introduced ef- fectively cleanses the intestinal canal; the secondary elTeot of irrigation of the colon is to cleanse and relieve the small intestine of its contents. Of 20 eases thus treated, 23 recovered. Elmer Lee (Med. Rec, Dec. 17, '92). Experiments carried out with a view of determining the competency of the ileo-cojcal valve, showing that in a cer- tain number of cases success may be looked for, even though the first attempt prove a failure. In four cases there was no difTleulty whatever in the passage of liquids from the anus to the stomach or even out through tlie mouth and nose. Judson Daland (Amer. Jour. Med. Sci., July, '93). Choleraic patients obtain real benefit from the use of tar-water given inter- nally, in small quantities, and in the form of enemata. It generally arrests violent diarrhoea and vomiting, and im- proves the bicn-ctre of the patients. Polubinski (Wratsch, No. 50, '92). For the purpose of cleansing the in- testine of the specific germs, and their noxious products, the use of purgatives has been recommended, especially in the first stages of the disease; calomel and castor-oil are generally preferred, and they may sometimes give good results. But, when they do not act favorably on the first or second day, their efl'ect can no longer be relied upon. Attention drawn to the views held by many, viz.: the risk that attends the use of purgative medicines, and salines especially, during periods of epidemic cholera, and at places where that disease happens to be prevailing. Physicians who practice in India seem to have recog- nized the danger of strong purgatives. Editorial (Lancet, Sept. 23, '93). [A large number of cases seen in which, under appropriate treatment, purging and vomiting had been stopped, and the patients apparently recovered, but who were afterward brought back to a fatal state of collapse by the admin- istration of purgatives of an in-itating nature. Neve, Corr. Ed., Annual, '94.J 3. To counteract the effects of poisons absorbed into the blood we have no effi- cient means, the greater number of drugs given for tliis purpose (especially antiseptics) having failed or given but very imperfect results. The only thing we can do is not to exert an antidotal action upon them, but to hasten and make easy their elimination from the blood, by largely diluting it through the introduction of an artificial scrum, a practice answering other important ob- jects, as we shall see shortly. 3. Among the noxious effects of local CHOLERA ASIATICA. TREATMENT. 151 inflammation and of tlie general tox- aemia, which require an energetic treat- ment, the principal are: diarrhoea and vomiting, with excessive loss of watery fluids; and danger of heart-paralysis. To control diarrhoea and vomiting, when excessive, is a vital indication, the profuse loss of water they involve con- tributing a very serious danger for the organism. Against diarrhrea, the same rectal injections of tannic-acid or ace- tate-of-lead solutions and internal use of opium. As a person shows the premonitory symptoms of cholera, by having one or two large watei-y motions passed with little or no pain, and begins to vomit, it is best to put him under the influence of opium at once. All physicians who have had much to do with the treatment of cholera in India are agreed in this; and it is noteworthy that many so- called cholera "specifics," which have from time to time been popular, contain opium in some form. F. C. Nicholson (Practitioner, Sept., '93). Carbonate of calcium, salicylate of bismuth, etc., may also be of some serv- ice; while, to subdue the vomiting and painful cramps in the stomach, ice, laudanum, morphine (hypodermically), cocaine, chlorodyne, essence of mint, menthol, camphor, or chamomile may be resorted to. Belladonna advocated. lllingworth (Med. Press and Circular, June 19, '93). Atropine most useful on account of the control that it would exercise over the cramps of the muscles and in spasm of the bile-duct. Scriven (Brit. Med. Jour., June, '93). Atropine of marked value in collapse. Lauder Brunton (Brit. Med. Jour., June, '93). Shortly after the development of first symptoms a subcutaneous injection of camphor, with musk, is rapidly followed by a striking ti melioration in the pa- tient's condition, vomiting cither greatly decreasing or ceasing altogether, the well- known distressing oppression about the chest similarly subsiding. PopofT (In- aug. Dis., No. 25, p. 55, '93). Blisters to the neck, along the course of vagus, cause both vomiting and hic- cough to cease. BlagovidofI (Wratsch, No. 34, '92). The following treatment employed with advantage, particularly for the re- lief of the cramps and vomiting: — R Dilute hydrochloric acid, 15 minims. Pure pepsin essence, 20 minims. Wine of opium, 20 minims. Peppermint-water, 4 ounces. ■ Syrup of orange-flower, 1 ounce. M. Sig. : A teaspoonful each hour. This dose can be diminished as soon as the medicine controls the attack to some extent, so that 4 teaspooufuls a day may be suflicient. Sometimes 15 minims of ether may be added to this mixture with advantage. Chauvin (La Mfid. Mod., Sept. 5, '90). But the effects of these remedies are only transient, and the use of some of them— especially morphine — should not be prolonged, in order to avoid the dan- ger of increasing the general depression. Solutions of benzoyl-acetyl peroxide are extremely active as germicides. In cholera it was at first given by mouth as frequently as possible in sobition of 1 to 1000, and by high rectal injec- tions every six hours. For stimulation, brandy and strychnine were given hypo- dermically, and, if the general condition of the patient was good, morphine was sometimes given to relieve pain. Tur- pentine stupes and hot-water bags were also used to relieve pain. Vomiting was generally stopped by cocaine and cracked ice. In some hospitals the administra- tion of double gelatin capsules contain- ing each 0.25 gramme (4 grains) of ben- zoyl-acetyl peroxide was resorted to, as it was found that the continued admin- istration of solutions per OS produced vomiting. The high rectal injections form an important part of the treat- ment, especially in the second stage, when the bowel movements are approxi- mately few, because the colon then con- tains a large amount of toxin which is 152 CHOLERA ASIATICA. TREATMENT. flushed out by this means. Omitting deaths occurring immediately after ad- mission to the hospital, and counting only those occurring six hours or more after admission, the mortality in one hundred and twenty cases was 45.71 per cent. The native mortality was prob- ably increased, owing to the difficulty in inducing native patients to take any medicine at all. Of six Americans treated, four recovered and two died. P. C. Freer (Government Lab. Bull., No. 2, 1902; Med. News, Feb. 21, 1903). When diarrhoea and vomiting are un- restrainable, and therefore loss of water is so large as to cause a rapid thicken- ing of the blood and drying of the tis- sues, an attempt must be made to re- store, as much as possible, the normal composition of the blood, to render it more fluid and to make circulation and hsematosis easier. For this purpose sub- cutaneous injections of a hot, saline solution were proposed by Cantani and Samuel and experimented on a very large scale and with very good effects by many physicians and by the writer. Cantani's formula is as follows: Dis- tilled water, 1 quart; chloride of sodium, 1 drachm; carbonate of sodium, 45 grains. Of this solution, warmed to 100.4° to 104° F., one or two quarts are injected into the subcutaneous tissue of the flanks. The results of this method are most striking, sometimes even in the algid stage; and, if it does not always save life, it at least gives tlie patient some relief from his sufferings. Its effect is shown by removing cardiac weakness and feebleness of the pulse, by bringing on the secretion of urine, by elevation of temperature, etc. Intravenous infusions of Ilayem's artificial serum (distilled water, 1 quart; chloride of sodium, 100 grains; hydrate of sodium, 20 grains; sulphate of so- dium, 1 ounce) are equally beneficial, but their use is more difficult, and they are no more prompt in their effects and not without danger. The subcu- taneous injections are, therefore, gener- ally preferable. Case of cholera in which intravenous injections of salt solution were followed by resuscitation sufficient to allow the patient to sit up and make a will. The operation was repeated six times, and it was noted that good eft'eet could only be obtained when the venous system was rapidly distended. Richardson (Ascle- piad, No. 4, '91). To avoid the danger of heart-paral- ysis, so far as this depends upon the thickening of the blood and the empti- ness of the vessels, we may have recourse to the same watery injections; but if they do not succeed, and whenever car- diac weakness is directly produced by the action of the toxins, the heart must be stimulated by hypodermic injections of sulphuric ether, camphorated oil, caffeine, strychnine, or quinine. Quinine recommended, 1 V. grains given every 2 hours for 24 hours, and repeated during a second 24 hours it necessary. If vomiting be present and beyond con- trol, the drug should be injected beneath the skin. Huberwald (Jahrbuoh fUr Kinderh. u. phys. Erziehung, B. 35, H. 3, '93). Treatment adopted in 944 cases with a mortality of only 20.7 per cent. 1. (o) Internal administration of Botkin's anti- cholera drops: — IJ Tincturro quinines compositas, Spiritus anodyni HolTmaimi, of each, V= ounce. Quinina: hydroohlorici, 1 drachm. Acidi hydrochlorici diluti, '/.. drachm. Tincturce opii simplicia, 1 drachm. Olei monthro piperita;, 10 drops. M. Sig.: Give from 15 to 20 drops every two hours. (/>) Caniani's higli eneniata with tannic acid; (c) internal use of salol with sub- nitrate of bismuth; {(I) calomel in small doacs. 2. In severe cases stimulate and sus- tain the cardiac and cutaneous action: Repeated and prolonged general hot CHOLERA ASIATICA. TREATMENT. 153 baths, heating tlie patient's body by any available means; free administration of wine, hot tea, or cofTee with brandy; and subcutaneous injections of camphor. SokolofT (Bolnitchnaja gazeta Botkina, Nos. 1, 2, '93). Large doses of quinine, 15 to 20 grains administered early, found to cheek the vomiting and purging in an hour or two. Tlie administration must be by the mouth, and not by subcu- taneous injection. E. B. FuUerton (Medical Record, April 25, 1903). The internal use of brandy, rum, champagne, liquor ammonia, inhala- tions of oxygen, etc., may also prove of advantage in cardiac failure. Ammonia internally and ether hypo- dermically, besides the free administra- tion of alcohol, highly recommended, the aim being to support the failing heart. Giaeich (Berliner klin. W()ch.,Sept.5,'92). Hydrochlorate of ammonia recom- mended for the same pui-pose. Besides the return of heat and perspiration caused by this salt, it increases diuresis, and therefore increases the elimination of the toxic elements of the disease. Dumontpallier (Le Bull. IMOd., Oct. 19, '92). For the same purpose, and to restore the warmth of the skin, hot baths (sim- ple or sprinkled with mustard) and the application of heat in every form (warm coverings, hot-water bottles or hot bricks around the body, Turkish baths, etc.), dry, energetic frictions, application of sinapisms, electric flagellations, etc., have proved very valuable. The state of the bladder should be carefully watched, and if examination shows the presence of residual urine, it should be emptied through the catheter. True choleraic anuria is best combated by hot, exciting drinks, hot baths, and hypodermic injections of caffeine and pilocarpine, a solution of the latter of Vs ^ain to 20 minims of distilled water being employed. During the whole disease no food should be allowed to patients; at the most, if any food is believed necessary and the stomach is not altogether in- tolerant, some iced milk can be given. The treatment of the period of reac- tion, when it runs a regular course, is only a hygienic one. Feeding must be carefully regulated, only liquid food being allowed the first few days, then passing gradually to more substantial nourishment. 'ttTien, however, the dis- ease assumes the typhoid form, hygienic rules must be assisted by symptomatic treatment; if adynamia supervene, cold packs and stimulants must be used; when, on the contrary, symptoms of nervous excitement prevail, lukewarm baths with cold affusions on the head, afford great relief. Cerebral congestion is best combated by the application of ice to the head, by local blood-letting, etc. Hydrotherapy successful in curing a large number of patients already sufTer- ing from cramp in the calves, vomiting, cold extremities, and discolored stools. Friction of the skin with a piece of linen soaked in the coldest water; then a sitz-bath, at a temperature of 44.4° to 59° F. during fifteen or thirty minutes. The parts of the body not in contact with the cold water are enveloped in woolen coverings, and the abdomen is energetic- ally rubbed. Winternitz (Blatter f. klin. Hydrotherapie, etc., Oct. 10, '92). By rubbing the affected areas with a piece of ice, cramps — an excruciating syiTiptom — are relieved with rapidity. Pasalsky (Provincial Med. Jour., Nov. 1, '03). Salol is an excellent remedy against choleraic diarrhoea, provided it is ad- ministered in larger doses than are usu- ally given; 2 to 2'/. drachms during the 24 hours, 30 grains to begin with, fol- lowed every 3 hours by a dose of 15 grains. Walkowitch (La Sem. Mfd., No. 5G, '93). Salol in 5-grain doses recommended, repeated hourly as long as required by the necessities of the case. The drug 154 CHOLERA ASIATICA. CHOLERA NOSTRAS. mitigates all choleraic symptoms. Piat- nitzky (Inaug. Dis., No. S, p. 97, '93). Against hyperthermia and general poisoning quinine by hypodermic injec- tions should be resorted to. Gastro-in- testinal disorders (tjTnpanites, abdominal pains, fcetid diarrhoea) must be treated by cold applications to the abdomen, by internal use of calomel, and by rectal injections of detergent and disinfecting solutions (hyposulphite of sodium 2 to 5 to 1000, boric acid and tannic acid, 6 to 10 to 1000), etc. Fifty-one cases with but 5 deaths under immediate use of calomel, not forgetting to give hydrochloric acid at the same time. The calomel is mixed with a little water and gum powder, placing the mixture on the tongue, thus avoiding touching the teeth. The first dose is 15 Vi grains, repeated several times. Opium avoided. Van Hasselt (Nederlandsch Tyd. voor Genees., vol. xxxii, '03). The administration of calomel in doses of '/j to 1 grain strongly advocated, given every hour. Treynmnn (Med. Press and Circular, Apr. 19, '93). Calhoun many years ago obtained far superior results to those reported. He prescribed calomel, 10 grains; gum cam- phor and tannin, each 5 grains; every half-hour or hour, as the urgency of the symptoms demanded, until the diarrhoea was checked and the secretions restored to a healthy state. In combination with the above substances he occasionally pre- scribed opium. F. Peyre Porcher (Med. Rec, Nov. 26, '92). Calomel most highly recommended as far back as 185.^, beginning its use as soon as the choleraic diarrhoea appeared. Two or three doses of 7 'A grains each are administered, followed by small doses of V» grain every two hours. A portion of the calomel becomes changed in the in- testine to corrosive sublimate; and as corrosivc-Hublimate solutions have a fun- gus-destroying action in a strength of 1 to 30,000, it is easy to believe that the bacilli in the intestine arc directly killed by the calomel. Ziemssen (Ther. Gaz., Mar. 15, '93). During this period, activity of the blood must be guarded against; and to this end enteroclysis with a salt solu- tion of 10 or 15 per cent, is very useful, and, if need be, hypodermoclysis with Cantani's solution can be continued. Cholera Nostras. This form of cholera resembles very closely Asiatic cholera in its clinical aspects; so that the distinction between the two diseases is sometimes most dif- ficult. Many authors, indeed, believe in their identity. Guerin, for example, claimed that cholera is always the same disease in every place, and that isolated cases, such as are met with every year in Italy, in the hot season, are identical to those which are developed in India. Leyden, also, does not think that there is a wide difference between cholera nostras and Asiatic cholera. Lastly, Talamon argues in favor of their identity, basing his theory on the fact that epi- demics of choleriform diarrhoea occur from time to time without its being pos- sible to attribute them to importation, in places where true .cholera had been previously observed. This author refers to two epidemics in the neighborhood of Paris, which had been recognized as cholera nostras, but in which the bac- teriological investigation had plainly shown the presence of the comma ba- cillus. On the other hand, several authors hold the view that cholera nostras is a disease etiologically different from Asi- atic cholera, appearing generally in spo- radic cases, but sometimes becoming epi- demic. It is produced very often by dietetic errors, or by the action of cold, or by the ingestion of iced draughts in persons exposed to intense heat. Tinkler and Prior found in the stools of patients affected with cholera nostras an organism in the sliape of a comma CHOLKRA ASIATICA. CHOLERA INFANTUM. 155 bacillus, and therefore greatly resem- bling the cholera vibrio. It differs from the latter, however, by the fact that, when cultivated in gelatin, it very soon becomes liquefied, and does not give the cholera-red reaction. But in many cases, instead of the vibrio of Finkler and Prior, other organisms (bacillus subtilis, bacterium coli commune) have been found; so that the etiological question is still unsettled and no decided opinion can be formed about the real nature of cholera nostras. Symptoms of cholera nostras are very 'like those of Asiatic cholera; very often, however, the stools are not riziform, but bilious and serous; vomiting is not com- . mon, and cooling of the skin does not reach an advanced degree. Moreover, the period of reaction is not accom- panied by the serious inflammatory changes which are so common in Asiatic cholera; finally, the disease shows a more marked dependence upon seasonal influences. When cholera nostras ends in death, this takes place after the signs of collapse have grown progressively worse in persons weakened by previous illness or in children and old people. Generally the disease lasts only twenty- four to forty-eight hours; then convales- cence ensues, leaving often a feeling of extreme weakness. The treatment of cholera nostras is essentially the same as in Asiatic cholera; and prophylactic measures are of no less practical import, though the contagious- ness of cholera nostras does not seem to be as great as that of Asiatic cholera. (See CiioLEn.\ JIorbus.) A. Ri'iuNO, Naples. CHOLERA INFANTUM.. Definition. — A particularly grave form of infantile diarrhrca, with sjTnptoms closely resembling those of true cholera; frequent persistent vomiting, copiouB serous dejections, high fever, and a rap- idly-developing condition of profound collapse. It is a comparativelj'-rare disorder, forming not more than from V; to 2 per cent, of all the diarrhccal cases met with during the summer months. Unfortu- nately for the accuracy of our statistics, the term has been applied indiscrim- inately to all cases of severe infantile diarrhoea. In the opinion of the best writers the name shoidd be limited to such cases as are characterized by intense choleriform symptoms. [Intelligent work upon this subject is still greatly impeded by coufusion in no- menclature. Many excellent articles are diminished in value or rendered actually worthless by the indiscriminate use of the terms "cholera infantum," "enteritis," and other indefinite expressions, render- ing it impossible to determine the form of disease to wliicli the author refers. The term "cholera infantum" is the one most frequently used incorrectly. It Is limited by nearly every author of promi- nence to cases characterized by large, serous stools, accompanied by profuse vomiting, high temperature, prostration, and marked nervous symptoms. If writers for the journals would observe the same rule it would save very much confusion, and render their work of decidedly more value. Holt and Cran- DALL, Assoc. Eds., Annual, '92.] Symptoms. — After a variable, but gen- erally brief, period, characterized by rest- lessness, abdominal discomfort, and a rising temperature, the infant begins to vomit, and simultaneously or shortly af- terward purging commences. The vom- iting recurs frequently. At first, the con- tents of the stomach are ejected; then a bile-stained mucus; and, lastly, noth- ing but a serous fluid. The evacuations from the bowels soon assume the same serous character. They lose their faecal appearance and acid reaction, and con- 156 CHOLERA INFANTUM. SYJlPTOilS. DIAGNOSIS. sist almost entirely of a colorless fluid, copious in amount, alkaline in reaction, and generally with, a peculiar musty odor. Examined microscopicall)', little has been found in this fluid beyond a large amount of epithelial debris, some round cells, and numerous bacteria. Such dis- charges soak into the diapers, leaving al- most no stain and scarcely any ftecal mat- ter to indicate that the fluid has come from the intestines. Although these evacuations are very frequent, recurring every half-hour or hour, pain is not gen- erally a marked feature. The temperature taken in the rectum is always elevated, generally between 103° F. and 105° F.; nevertheless the body feels cool to the hand. Thirst is extreme; but liquids and foods of all kinds are rejected by the stomach shortly after they are taken. "With such a drain upon the fluids of the body the infant rapidly loses weight and strength, and in a few hours its appearance is greatly altered. The face is of an ashy pallor, the eyes sunken, the features pinched, and the expression anxious. The open fontanelle is much depressed; the pulse is quick and weak and may be intermit- tent; the urine is scanty and in severe cases appears to be altogether suppressed. During the earlier hours of the dis- ease restlessness is a marked symptom; but, as the strength fails, this is gradu- ally replaced by a condition of apathy, which, later on, may develop into the hydrenccpbaloid state: the spurious hy- drocephalus of older writers. Should the disease take this course, the infant will be found lying in a semicomatose condi- tion, with head drawn backward, pupils sluggish and sometimes unequal, abdo- men retracted, and respiration possibly irregular and of the Chcyne-Stokes type. There may also be twitching of the arms and legs. Toward the end the infant be- comes more comatose, or an attack of conviilsions may supervene and usher in the close. In some cases a condition of hyper-- pyrexia may precede the fatal termina- tion. In others, the high temperature of the earlier hours may pass away and a more moderate pyrexia, or even, accord- ing to some writers, a normal or sub- normal temperature take its place. Nev- ertheless, if the graver symptoms of col- lapse persist, this fall must be regarded ' as an unfavorable omen. In such cases we sometimes find that both vomiting and purging cease a few hours before the end occurs. The course of this disease is very rapid, terminating in many cases in collapse and death within twenty-four or forty- eight hours after its commencement. Should hydrencephaloid symptoms set in, the end may be delayed for a day or two longer. In the few cases which go on to recovery, cessation of vomiting ap- pears to be one of the earliest symptoms of improvement; gradually the char- acter of the stools alters, and they be- come more faecal; the restlessness abates, and improvement may be noted in the pulse and general appearance of the in- fant. Convalescence, however, is always tardy, and relapses are not uncommon. Diaifnosis.- — The character of the on- set, the persistent vomiting, the profuse serous dejections, the high temperature, and the symptoms of profound collapse rapidly developing within a few hours, form a picture unlikely to be mistaken for any other condition. Tlie odor of t,hc stools makes it pos- sible to deteriiiiiio two general classes of fermentation. The fermentation of the carbohydrate foods leads to the develop- ment of acids and gases, but under no circumstances to products with a putrid odor. Proteids yield either odorless or putrid products. Fitch (Va. Med. Mthly., Mar., '94). CHOLERA INFANTUM. ETIOLOGY. 157 Etiology. — The exact nature of cholera infantum has not yet been proved, but analogy points strongly to its being a toxic condition produced by the absorp- tion from the intestinal tract of some special toxin originating in fermenting or decomposing food. The prolonged heat of July and August appears to be a distinctly predisposing factor. Infants living under faulty hygienic conditions, and supplied either with an injudicious dietary or with milk food in the prepara- tion of which due care has not been taken, appear to be among those most prone to attack. Although the disease may develop suddenly in the compara- tively healthy, yet we find that, in the majority of cases, there has been a more or less severe antecedent disorder of the gastro-intestinal tract. From 22 observations, the following conclusions are drawn: (1) the spores present in acute dyspepsia and intro- duced with the food will grow luxuri- antly at the body-teniperatui-e, and these are capable of withstanding the action of the acids of the stomach; (2) since severe dyspepsias, especially of the chol- era-infantum type, present the phenom- ena of acute intoxication, and increase in severity with the temperature of the atmosphere, their cause is to be sought in the poisons generated by the sapro- phytic germs of the stomach and intes- tines; (3) some of these cases have the general characteristics of acute infectious diseases in their etiology, but the ma- jority are not particularly endemic or epidemic, and the special characteristics of infectious diseases (stage of incuba- tion, typical course, etc.) are rare. Seif- fert (Jahrbuch f. Kinderh. u. physische Erziehung, B. 32, H. 4, '91). \. When the heat rises above 10.7° F. the galactozymose, or starch-liquefying ferment, is destroyed. It is present in cows' milk only in minute quantities. 2. A portion of the lactalbumin is coagu- lated. 3. The casein, after the action of prolonged heat, is less readily coagulated by rennet, and yields slowly and imper- fectly to the action of pepsin and pan- creatin. 4. Fat is so affected by the heat that, after the milk has stood for some time, small lumps collect on the surface. 5. Milk-sugar is completely de- stroyed by prolonged heating. Leeds and Hiesland (X. Y. Med. Jour., Nov. 7, '91). Careful bacterial examinations of the stools in ninety-two different cases of various degiees of intensity, and in the fatal cases similar examinations of the intestinal contents and of the various internal organs, were coupled with his- tological examinations with a view to determining the relation of the intestinal infections and lesions to the remoter changes in the body. Conclusion that the intestinal disorders of children are to be attributed to no one specific form of bacteria. That in many cases the actual damage is done more by the prod- ucts of the bacterial growth than by the germs themselves seems clear, since we know that these products are often strongly toxic, and since in many even fatal cases no penetration of the body- tissues by the bacteria can be demon- strated. In the milder forms of these disorders it is not unlikely that the acids, which Baginsky has shown are generated by the obligatory milk-fajces bacteria in moderate quantity even under normal conditions may be the irritant of the intestinal mucous membrane chiefly responsible for the symptoms; and this conception seems fully in accord with the decided acidity of the stools in these cases. In the severer cases, and particularly when pj'ogenic or necrotiz- ing species of bacteria are present, dis- tinct inflammatory changes in the intes- tinal mucosa are usually present and seem often to pcnnit the entry of the bacteria to the underlying tissues, whence they may be disseminated throughout the body and induce a gen- eral pyajmic condition of which pneu- monia is not an infrequent manifesta- tion. Booker (Johns Hopkins Hosp. Re- ports, vol. vi. 159, '00). The diarrheal disorders of childhood occurring in conjunction with elevated summer temperature appear first as functional (chemical) disturbances and subsequently as profound organic lesions 158 CHOLERA INFANTUM. PATHOLOGY. of the intestinal wall. For the develop- ment of these conditions the ordinary saprophytic bacteria of the intestinal contents, and not specific bacteria, must be held responsible. The active organ- isms cause injury to the intestinal walls through the putrefactive processes of toxic character or through products usu- ally non-toxic in character (ammonia and its derivatives), inasmuch as they act as inflammatory irritants; or they cause degeneration of the vegetative and the most important excretory organs (liver, kidneys, etc.) through the blood-stream and the lymph-stream. As a result of the interference with nutrition and the diminution in the resistance of the tis- sues thus brought about, the organism is exposed to the invasion of pathogenic bacteria of all kinds (staphylococci, streptococci, pneumococci, oidium albi- cans, etc.). There also results a predis- position to disease, as manifested by numerous complications. Baginsky (Berl. klin. Woch., Jan. 11, '97). Study of thirteen cases leading to the following conclusions: — 1. The bacterium coli appears to be the pathogenic agent of the greater number of summer infantile diarrhoeas. 2. This organism is the more often associated with the streptococcus pyog- enes. 3. The virulence, more considerable than in the intestine of a healthy child, is almost always in direct relation to the condition of the child at the time the culture is taken, and does not appear to be proportional to the ulterior gravity of the case. 4. The mobility of the bacterium coli is, in general, proportional to its viru- lence. The jumping movement, never- theless, does not correspond to an ex- alted virulence in comparison with the eases in which the mobility was very considerable without presenting these jumping movements. 5. The virulence of the bacterium coli found in the blood and other organs is identical to that of the bacterium coli taken from the intestine of the same in- dividual. C. G. Cumston (Inter. Med. Jour., Mar., '97). The toxic symptoms of gastro-intes- tinal infection depend upon the intro- duction into the alimentary canal of poisonous substances which are con- tained in the food: tj'rotoxicon, for in- stance, which originates in milk, and is poisonous for man and animals. Bac- teria may be introduced from without; or the ordinary saprophytic bacteria which inhabit the intestinal canal may take on a special virulence. But the most severe disturbances are caused by the metabolism of bacteria; these micro-organisms by their activity either produce acids or cause decomposition of albuminoid substances; the products act as powerful irritants to the intes- tines, and by injuring the intestinal wall gain access to the blood and lymphatics, in this way producing the local and con- stitutional symptoms. A. Abt (Medi- cine, Feb., 1900). Pathology. — There are very few changes found after death either in the intestinal canal or in any of the organs. The only lesion present may often be a desquamative catarrh of the gastro-in- testinal tract. In those cases which de- velop hydrencephalic symptoms, the ap- pearances found after death bear no proper relation to the gravity of the symptoms. The kidneys are generally found paler than usual, with a moderate cloudy swelling of the cortex, but not to a greater extent than may be present in other febrile disorders of infancy (Holt). The earlier symptoms may, therefore, reasonably be ascribed to the influence of some toxin upon the heart, nerve-centres, and vasomotor nerves of the intestines, while many of the later symptoms must be referred to the great abstraction of serous fluid from the body. In cholera infantum a bacillus found which was colored after the method of Gram. Cultivated in gelatin or bouillon, an alkaline product is obtained, having a distinctive odor, which it retains many months. It is more resistant to external agents than the common bacillus, and more tenacious of life. Isolated, it is capable of producing experimental chol- CHOLERA INFANTUM. PROGNOSIS. TREATMENT. 159 era, like several other microbes. It prob- ably plays an important part in the pro- duction of cholera infantum, as proved by the following reasons: 1. It exists only in cases of cholera infantum, fre- quently in large numbers. 2. It produces experimental cholera. 3. It produces a substance apparently identical with that produced by the comma bacillus. In doses of 4 to 5 milligrammes (% to Vio grain) it is toxic, and causes the death of the animal. 4. It produces choleraic intestinal lesions. Lesage (La Sem. M6d., Apr. 9, '90). In spite of the most careful researches, no constant micro-organism has been found, the comma bacillus not being present. At times, when cholera infan- tum is prevalent the temperature of the child is often considerably above normal, especially toward the end of the day. It is supposed that the high temperature indirectly induces some changes favor- able to the rapid growth of saprophytic germs already present. Alfred H. Carter (Provincial Med. Jour., July, '93). Study of the blood of three cases. The number of red cells is diminished; the total number of white cells is some- times augmented and sometimes normal. The lymphocytes are always aug- mented; the mononuclears always di- minished; the polynuelears and poly- morphonuclears are sometimes aug- mented and sometimes normal. The eosinophiles are absent or normal. Nu- cleated red cells were observed twice. D'Orlandi (Revue Men. des Mai. dc I'Enfance, July, '99). Prognosis. — Few diseases have a worse prognosis. The higher the rectal tem- ■peratiire, the younger the infant, the hot- ter the weather, and the more unhygi- enic the surroundings, the more hopeless is the case. Eotch considers the disease to be, to some extent, self-limited, and thinks that, if the infant survive the first three daj's, a crisis comes and the prognosis improves. Prognosis of cholera infantum is very unfavorable, especially when the child is artificially fed, and the mortality reaches very commonly 95 or 97 per cent. In naturally-fed children the death-rate is low. In cases where the brain is early affected, with coma or convulsions pres- ent, the prognosis is bad. H. N. Potter (Annals of Gynec. and Ped., Apr., '98). Treatment.— Kegarding the disorder as a toxic condition due to the absorption of a poison from the alimentary canal, our first efforts must be directed to clear- ing out this tract as promptly and thor- oughly as possible. For this purpose a few grains of calomel combined with sodium bicarbonate should be given in divided doses. As soon as practicable, the stomach should be thoroughly washed out with a tepid weak solution of sodium bicarbonate (V2 drachm to the pint). Following this the whole tract of the colon should be irrigated with a saline solution (1 drachm of sodium chlo- ride to the pint). To insure passage of the solution into the higher portions of the colon, the hips of the infant must be well elevated, and the tube passed well up into the bowel, due attention being paid to its curve. The solution should be allowed to run into the gut in a gentle steady stream from a fountain-syringe placed at a height not exceeding two or three feet. Its passage upward may be favored by a gentle massage along the course of the bowel. The temperature of the irrigating fluid (from 85° F. to 105° F.) will be determined by the con- dition of the patient and the degree of pyrexia. The use of antiseptic solutions for ir- rigating is, in our opinion, not to be recommended. To be in any degree ef- fectual they must have a moderate strength, and then there is always danger of poisonous absorption. The irrigations should be repeated during the earlier hours of the attack. In the meantime, only stimulants and ice or iced water in small quantities should be allowed by the mouth. No form of nourishment 160 CHOLERA INFAis^TUM. TREATMENT. should be permitted during the first twentj'-four hours. The digestive func- tions of the stomach and duodenum mast be in complete abeyance, and any food administered -(vill either be at once re- jected by the stomach, increasing its hy- persemic condition, or, if retained, will go on to fermentation. No food of any kind and no drugs given. Boiled water at the ordinary tem- perature, 3 V= ounces every hour for at least twenty-four hours and hypodermic injections of 1 Vi to 6 drachms, according to age, every five hours, of a solution of:— IJ Sterilized (not distilled) water, 10 ounces. Common salt, 37 grains. Citrate or benzoate of caflfeine, 12 grains. — M. These injections should be given slowly. In addition, warm baths {95° F.) twice or four times in the twenty- four hours should be given, each bath lasting from five to ten minutes. Wash- ing out the stomach and intestines, though useful in other forms of infantile diarrhoea, may give rise in choleraic diar- rhoea to convulsions or collapse. In con- valescence, if the diarrhoea persists, calo- mel or subnitrate of bismuth may be given. Not any satisfactory results ob- tained with salol, betol, benzonaphthol, lactic acid, tannin, or opium. Marfan (La M6d. Moderne, June lH, '97). To counteract the depressing action of the poison, and to prevent the paretic condition of the intestinal vasomotor sys- tem, an hypodermic injection of mor- phine combined with atropine is probably our best remedy. Holt recommends for an infant 1 year old an initial dose of not more than '/loo grain of morphine and V«oo grain of atropine. This may be repeated in an hour, if tlie desired sed- ative action is not obtained. Infants bear atrojiine wonderfully well. Almost adult doses of atropine given to children only a few months old; for instance, Vw grain of morphine and Vim grain of atropine, repeated two to four times in twenty-four hours. This controls the phenomena of cholera in- fantum, which would terminate life per- haps in a few hours without such treat- ment. William Bailey (Amer. Pract. and News, July 1, '93). There is no drug comparable to small doses of atropine for controlling the de- pression and purging of cholera infantum. Cecil (Amer. Pract. and News, June 15, '98). Morphine, it should be remembered, is contra-indicated in condition of drowsi- ness or stupor. Strychnine hypodermic- ally will also prove of some service as a cardiac and respiratory stimulant. The effect of these remedies must be watched and the injections repeated as may be necessary to secure the desired action. It is better to avoid giving powerful drugs by the mouth, as doubt must exist as to the rapidity and extent of their ab- sorption. For the pyrexia cool baths are de- manded, and should be administered in all cases when the temperature rises over 103° F. The bath, at the outset, should have a temperature of 97° F. and should be gradually cooled by the addition of ice or iced water till a temperature of 85° is reached. The infant should remain in the bath from five to fifteen minutes, according to the effect produced; while in the bath brisk friction should be em- ployed over the limbs and body gener- ally. If baths are impracticable, the cold wet pack may be employed. An ice-bag or cold cloths should be kept applied to the head. To counteract the effects of the drain of fluid from the tissues no method can compare with the injection into the cel- lular tissue of a sterilized saline solution (45 grains of sodium chloride to the pint of water). About '/, pint or more of this solution may be injected at once into the subcutaneous tissue of the thigh, abdo- men, or buttock; the injection may be CHOLERA INFANTUM. TREATilENX. 161 repeated twice a day. Marked improve- ment in all the symptoms generally fol- lows its employment. A suitable sy- ringe can be easily made by attaching an hypodermic needle to the nozzle of a Davidson syringe by means of a few inches of rubber tubing. Saline solutions or artificial serum suc- cessfully used. The physiological salt so- lution, which seems to be absorbed most readily, and Hayem's serum preferred. The most practical method of introduc- ing the fluid is subcutaneously into the lumbar or gluteal regions, antiseptic pre- cautions being observed. The fluid forma a swelling beneath the skin, the disap- pearance of which can be accelerated by light massage. Marois (Eevue Men. des Mai. de I'Enfance, Dec, '93). Hydrencephaloid symptoms call for a free use of stimulants; but opium, in this condition, is better avoided. During the course of the disease care must be given to insure all possible warmth for the extremities. Sinapisms over the stomach may be of occasional benefit. There is a growing tendency on the part of clinicians to consider even pure stiTilized milk as a source of danger, owing to the properties which it mani- fests as a culture-medium. French ob- servers are especially averse to its use, particularly in the acute stage. St. Philippe states that its suppression from the dietary often proves curative. Meat- and vegetable- broths given in small doses very frequently repeated are kept down when milk will at once be ejected. White of egg beaten up in cool water and sweetened with sugar of milk to precede the administration of broths recommended. Sterile water should be given nd libitum. Fitch (Med. Times, Sept., 1900). Method of treatment adopted by Ba- ginsky, who insists that this disease re- quires ceaseless observation of the clin- ical manifestations. The great and im- mediate danger is from the loss of fluids, felt specially in the functionin'i of the organs which are thus stranded. 2- as it were, from loss of their accus- tomed medium. The body may lose one-tenth to one-fifth of its weight in the diarrhoea of a single day in this dis- ease. The symptoms observed resem- ble in many respects those of ureemia, and are due to the lack of fluids and the consequent retention of toxins in the body. The diarrhoea carries away much of the causal agents and this may be supplemented by calomel and castor oil. A mustard bath is a sovereign means of stimulating the vasomotors and heart from the periphery. The in- fant is kept in the bath from five to eight minutes — the water colored a turbid, yellowish green by a couple of handfuls of mustard. It is well to give the mustard bath in the morning in- stead of the ordinary bath, and repeat it during the day If needed, carefully protecting against drafts to ward off otitis media. Camphor should be in- jected before the bath and again every three hours in urgent cases until dan- ger of collapse is past. Injections of artificial serum restore the loss of fluid, and a hypotonic sa- line solution should be preferred, as it is more rapidly absorbed and as salt is more or less contra-indicated by the nephritis generally present — a half a teaspoonful of salt to a quart of boiled water. The amount should be about 20 to 30 c. c. per kilogramme, and the injection repeated, if necessary, twice a day. It is supplemented by mineral waters. The practitioner must not be misled by the apparent mildness of the attack and postpone these measures until the opportune moment has passed. ^\'llen vomiting continues, notwith- standing abstention from food, lavage of the stomach is called for, and in many cases after lavage fiO to 100 e. c. of the above salt solution is pourol into the stomach and left to quiet the tliir^t. or it can be injected into the rec- tum. .Mbumin seems to bo the most harmful food in cholera infantum; its nourishing value is far outweighed by the danger from its putrefaction. Strict asepsis should be insured, both for the infant and for the nurse, in every measure undertaken. Roeder (Thcr. dcr Gegen., vol. xiv. No. 6, 1904). 162 CHOLERA MORBUS. SVMPl'OMS. (See also Cholera Morbus; Infaxts, DiAKKHOSAL DISORDERS OF; and NURS- TSQ AXD Artificial Feeding.) A. D. Blackader, Montreal. CHOLEEA MOEBirS. Synonyms. — Cholera nostras, sporadic cholera, summer diarrhcea, choleraic diarrhoea. Deinition. — An acute atlection chiefly involving the stomach and intestines and characterized by copious diarrhoea and vomiting, first of the ordinary contents and afterward of serous fluid, accom- panied by abdominal pains and rapidly- increasing prostration. It was recog- nized and clinically described with ac- curacy at an early period in medical his- tory, under the names of sporadic and endemic cholera. It frequently occurs in children and is frequently mistaken for cholera infantum per se, now re- garded by pediatricians as a separate disorder. Symptoms. — Cholera morbus is liable to occur at all periods of life, though much more frequently during infancy and early childhood than during adult age. For convenience of clinical descrip- tion, we may divide the cases met with at the bedside into two groups. In those belonging to the first group the patient is attacked suddenly with copious vomit- ing and purging, repeated at short in- tervals. The first discharges contain the ordinary contents of the stomach and bowels; the second are generally stained with the coloring matter of bile, while the subsequent stools consist of little else than large quantities of simple serous or "rice-water" fluid. The countenance soon becomes pale; the eyes sunken; the extremities cold and shrunken; the pulse small, frequent, and feeble; the urine scanty and sometimes suppressed. Fre- quent pains in the abdomen or cramps in the muscles of the extremities cause paroxysms of great sufl'ering. The mouth is dry and the thirst sometimes marked; the voice may be husky or feeble and the mind dull and inactive. In the most severe cases the foregoing symptoms develop with such rapidity and severity that a fatal collapse is reached in less than twenty-four hours. In much the larger number of cases, however, after the first few hours the discharges become less frequent and pro- fuse; the paroxysms of restlessness diminish; the pulse is less frequent, and at the end of twenty-four hours all the more active symptoms have ceased, and the secretions from the kidneys and salivary glands have returned to a more natural standard. The patient remains pale, languid, and weak for several days, during which much care is required in the regulation of diet, drink, and ex- ercise to avoid a relapse. In the second group of cases the symp- toms commence less suddenly and are generally more persistent in duration. They quite uniformly begin with diar- rhoeal discharges, soon becoming copious and watery or semifluid, frothy, and sometimes very offensive, with free vom- iting as often as either drinks or nourish- ment accumulate in the stomach. In from four to six days the patient becomes so much exhausted as to exhibit all the symptoms of approaching collapse de- scribed in cases of the first group. Ex- cept in children under two years of age, in whom there may be, as in cholera infantum, collapse and death during the first or second week of their progress, the symptoms dominate in intensity, about the end of the first week, and the vomiting ceases or recurs only when the stomach is allowed to become too full of fluids. The intestinal discharges become CHOLEllA MOKBUS. DIFFERENTIAL DIAGNOSIS. 163 less frequent, smaller in quantity, and mixed with some mucus and portions of whatever had been taken for nourish- ment. At the same stage of progress a moderate grade of febrile reaction takes place, causing the palms of the hands and surface of the abdomen to become dry and warm; the tongue and mouth are very dry; and the patient, if a child, is more peevish and restless. The ap- pearance and quality of the intestinal discharges vary much in dilferent cases, being sometimes like turbid water, at other times green or light yellow with little or no odor, and in other cases semifluid and very offensive. The urine continues scanty and sometimes irritates the urethra in passing; the emaciation continues, and in many young children it becomes so extreme as to cause death from asthenia in from one to three months. But, in nearly all of the adults and many of the children, after the dis- ease has continued from one to four weeks the discharges begin to improve both in quality and frequency, digestion and nutrition increase, and in a few weeks more the patients have regained a fair degree of health. Differential Diagnosis. — The diseases and morbid conditions which are most likely to be mistaken for cholera morbus, both in children and adults, are epidemic cholera, and the effects of direct irri- tants, such as toxic doses of arsenic, poisonous mushrooms, overripe fruits, and the ptomaines occasionally in ice- cream, cheese, and canned meats, and gastro-enteric inflammation. The clinical phenomena presented by severe cases of cholera morbus and of cholera Asiatica are so nearly identical that a reliable diagnosis cannot be founded on these phenomena alone. It is true that a very large proportion of the cases of epidemic cholera commence with painless, watery diarrhceal discharges continuing from one to three or more days, before the violent paroxysms of vomiting, purging, and cramps begin. When cholera mor- bus commences with diarrhcea the dis- charges are accompanied by more ordi- nary griping or abdominal pains and the early passages are more mixed with the ingesta and appearances of bile. In doubtful cases the discovery of the cholera bacillus of Koch in the intes- tinal discharges is claimed to be the only reliable proof that the case is one of true epidemic cholera. But there is so close a resemblance between the com- mon bacillus of Koch and that found by Prior and Finkler in ihe discharges of ordinary cholera morbus as seen under the microscope, that cultures are re- quired to complete the distinction be- tween them. Cases of sudden and severe vomiting and purging caused by irri- tating ingesta are more readily distin- guished from cholera morbus by their commencing very soon after the taking of bad food or poisonous substances, and by the existence of more constant burning sensations or distress at the epigastrium. The discharges also early show intermixture of mucus and some- times streaks of blood, which, in cholera morbus, seldom appear until in the ad- vanced stage of the disease. In gastro- enteritis the gastric and intestinal dis- charges are, from the beginning, less copious and are mixed with mucus; there is more epigastric distress, more febrile heat, and more frequent efforts to vomit, with the ejection oi only small quantities of mucus of a green or yellow color. In the advanced stage of some of the more severe cases of cholera morbus a condition of morbid vigilance, with roll- ing of the head, tossing of the hands, and moaning, supervened and sometimes 164 CHOLERA MORBUS. iiXIOLOGY. ended in a general convulsion. These symptoms have generally caused the friends, and sometimes the attending physician, to think that disease was de- veloping in the brain. I have seen a few of such cases treated with cold applications to the head and blisters be- hind the ears, while the real cause of the symptoms was cerebral anaemia or exliaustion. Microscopical examinations have shown the presence of a variety of micro-organisms in the discharges of cholera morbus, but no one of them has yet proved to be of diagnostic value. Etiology. — Abundant clinical observa- tions and vital statistics have shown that cholera morbus, both in children and in adults, prevails most in those parts of the temperate zone characterized by a wide range of temperature between the coldest days of winter and the hottest days of summer. Its prevalence is lim- ited almost wholly to the months of June, July, August, and September, gen- erally commencing with the first pros- trated wave of high temperature during the last week in June or the first in July and reaching its greatest prevalence by the middle of the latter month. Thus, of the 1119 deaths from cholera morbus and cholera infantum in Chicago in 1896, 1 was reported in January, 2 in April, 8 in May, 180 in June, 485 in July, 339 in August, 108 in September, 1 in October, and 1 in December. In 1895 the whole number of deaths from the same disease was 1345, of which 6 were reported in March, 3 in May, 187 in June, 554 in July, 315 in August, 275 in September, 2 in October, 2 in November, and 1 in December. So great a mortality occurring regularly during the hottest months of each year induced me to make the subject a special study during the decade following 1870. The facts gathered by such study justified the conclusion that cholera morbus, in both adults and children, commences uni- formly during the first period of high summer temperature continuing day and night not less than five days con- secutively, and new cases appear during each similar hot period for sixty of ninety days. It is not simply high tem- perature for a single day, or for three or four days while the nights remain cool, but high temperature both day and night, four or five days in succession, that favors the development of the dis- ease. If the air is stagnant from absence of wind, or overcrowding and narrow streets, as in populous cities, the number of attacks will be much increased. On the other hand, cities and towns so located that the nights are favored by cooler breezes from the sea suffer but little from ordinary choleraic attacks. Nearly all the writers on general prac- tice and on diseases of children mention high temperature and overcrowded and poorly ventilated dwellings as merely predisposing causes of the disease under consideration; while they enumerate, as direct exciting causes, the taking of im- proper food, as mixed salads, impure or changed milk, impure and confined air, and, in infants, the progress of denti- tion and the nursing of overworked, improperly fed, and unhealthy mothers or nurses. That all these causes exist and occa- sionally directly excite attacks of cholera morbus in both children and adults there can be no doubt. But as they all exist in all large cities and populous districts, and at all seasons of the year, if they were the chief causes of the disease it should prevail at all seasons of the year instead of being confined to three or four of the hottest months, and it should pre- vail as much in cities so located as to CHOLERA MORBUS. PATHOLOGY. PROGNOSIS. 165 receive cool breezes during the summer nights as in those that do not. There is. probably as much lack of ventilation and as much use of poor or adulterated milk and other articles of food during the winter as during the summer. And there are quite as many overworked and badly-fed mothers, and as many infants "cutting teeth," in the month of Janu- ary as in July, yet, as stated above, dur- ing the years 1895 and 1896 in Chicago only 1 death was reported from cholera morbus and infantum in January and 1039 in July. Such results show un- mistakably that high temperature, con- tinued through several consecutive days and nights, constitutes the ruling factor in the causation of the disease under consideration. The higher the tempera- ture of the atmosphere, the less amount of oxygen is contained in each cubic foot, and consequently less reaches the air- cells of the lungs at each breath and less is distributed to the tissues of the body in a given time. Hence the nerv- ous and muscular structures become re- laxed, the watery elements of the blood escape, the perspiration carrying with it the free salts of the blood, w^hich still further diminishes its capacity for taking up oxygen from the air-cells of the lungs. If this condition of things is continued through several successive days and nights, the capillaries of the mucous membranes of the stomach and intes- tines relax, and allow the serous element of the blood to escape more freely than perspiration from the cutaneous sur- faces, and choleraic discharges more or less profuse are the result. If the patient is confined in a close, ill-ven- tilated room, as is likely to be the case with young cliildren, especially at night, the evil efFects are much increased. And close investigation shows that the begin- ning of a large majority of the cases occurs during the last half of the night or early in the morning. Since the etiological study of patho- logical bacteria with their ptomaines and toxins has come to engross the at- tention of the profession, and especially since the discovery of the epidemic cholera bacillus by Koch, many writers have suggested that cholera morbus also depended for its essential cause on a specific bacillus or its toxins. But no such organism has as yet been identified as the essential cause. Pathology. — The essential pathological conditions involved in cases of uncom- plicated cholera morbus are a morbidly sensitive condition of the mucous mem- brane of the alimentary canal, a general impairment of the tonicity of tissues with deficient oxygenation of the blood, and so decided an impairment of the vasomotor nervous influence over the vessels of the mucous membranes of the stomach and intestines as to allow copi- ous exudation of the serous elements of the blood. The exudation constituting the cholera discharges results from these conditions and has no necessary connec- tion with any grade of inflammation, catarrhal or otherwise. This is proved by the fact that, in the most rapidly fatal cases, post-mortem examinations re- vealed no ordinary traces of inflamma- tion in the mucous membranes. It is only in the cases that run a more pro- tracted course in which febrile reaction occurs, followed by more or less mucous discharges, that we find appearances of ordinary catarrhal inflammation. Prognosis. — Cholera morbus, as it occurs in adults and in children over five years of age, runs a brief course and gen- erally ends in recovery. Only a small percentage of such cases terminate fatally. It is very different, however, when the disease attacks infants or chil- 166 CHOLERA MORBUS. TREATMENT. dren under three years of age. Only a small percentage of this mortality re- sults from the violence of the first stage and direct collapse. Much the larger part results from the occurrence of re- action and the establishment of a per- sistent grade enteritis and progressive exhaustion and emaciation. Treatment. — In the beginning of at- tacks of active cholera morbus the lead- ing objects to be gained by treatment are to allay the morbid sensitiveness of the mucous membrane of the alimentary canal; to restore the general tonicity of the tissues and of the vasomotor nervous system; to promote the natural secre- tions, especially of the liver and kidneys; and to properly regulate the diet, drinks, and general sanitary surroundings of the patient. In the treatment of all this class of patients it is of the greatest im- portance to secure for them a constant supply of fresh, pure air. The most complete ventilation possible and rigid cleanliness should be enforced day and night. To accomplish this is often a very difficult task among all the classes of people who occupy small or over- crowded lodging-rooms on the narrower and less-cleanly streets of our large cities. But a firm insistance upon keep- ing whatever doors and windows there are freely open during hot summer nights as well as during the day, and the prompt removal of all gastric and in- testinal discharges from the room, will accomplish much in this direction. To overcome the morbid sensitiveness of the mucous membrane, restore the tonic- ity of the nervous and vascular systems, and increase natural secretions, we need the combined or coincident use of ano- dyno.B, antiseptics, and tonics. In the early stage of active vomiting and diar- rhoea the following formula has been used with the most satisfactory results: — I^ Carbolic acid, T^/^ grains. Glycerin, 5 drachms. Camphorated tincture of opium, 2 ounces. Cinnamon-water, 2'/^ ounces. — ^M. To an adult one teaspoonful of this mixture is to be given immediately after each paroxysm of vomiting until the parox^'sms cease to recur. Vomiting is never a continuous process, and if a dose of medicine is given as soon as possible after a paroxysm a few minutes will elapse before the patient can vomit, and thus some impression of the medicine is obtained. But if we follow the inclina- tion of the patients and nurses and wait for the patient to "rest a little" and the stomach to become "settled," we simply allow time enough for the stomach to regain ability to vomit with another supply of serous exudation, and now the dose of medicine is likely to be ejected as soon as swallowed. The teaspoonful of the mixture may be given in half a tablespoonful of water; and in treating young children the dose should be ap- portioned to the age of the child. In addition to the above, small doses of calomel may be given every half-hour or hour until the discharges become less watery and show some indications of the presence of bile. Sinapisms of mustard may be applied over the epigastrium and to the back over the spine, but should be allowed to remain only long enough to redden the skin without vesicating it. As soon as vomiting has ceased and the intestinal discharges show evidence of hepatic secretion, it is generally only necessary to continue the formula recom- mended every two, three, or four hours until the diarrhoea also has ceased and the patient is inclined to sleep. In many cases no further use of the preparation is required, rest and a judicious regula- CHOLKRA MORBUS. CHOLURIA. 167 tion of the diet for a few days being suf- ficient to restore the patient to health. Sometimes, however, the patient's mouth remains dry, the pulse more fre- quent than natural, the palms of the hands and the surface of the abdomen warmer than natural, the urine scanty, and several diarrheal discharges each day accompanied by pain and restless- ness. In such cases a continuance of the carbolic-acid formula, already given, with a few drops of nitrous ether added to each dose, and giving, for nourish- ment only, a thin gruel or porridge made of good milk and wheat-flour, or pure milk with a little fresh lime-water added, will often insure recovery. A very great variety of other reme- dies have been used with more or less benefit, nearly all of them, however, combining anodyne, antiseptic, and astringent or tonic properties with strict regulations of diet. The use of potas- sium bromide in the cholera morbus of infants has recently been strongly rec- ommended by M. L. Brown. Prepara- tions of bismuth, generally given with small doses of codeine or other anodyne, have long been used with benefit in the protracted cases. In treating cases, espe- cially in young children, much care should be exercised in giving opiates and astringents, lest they add to the tardiness of the kidneys in secreting urine, and thereby increase the danger of coma or convulsions. (See Cholera Infantum and Infantile Diarrhcea.) Nathan S. Davis, Cliicago. CHOLERA NOSTRAS. See Cholera AsiATKw and Cholera JIorbus. CHOLTJRIA. Definition. — Choluria is a morbid con- dition of the urine observed in jaundice and characterized by the presence in it of the constituents of the gall, especially the bile-pigments and the bile-acids. In urobilinuria the normal constitu- ents of the bile are not found in the urine, but a derivative of the bile-pig- ments — the urobilin — is found instead. Symptoms. — Although the bile-acids are ordinarily present in the urine in choluria, they do not occasion character- istic symptoms, and can only be revealed by special tests. The presence of the bile is more easily detected. The urine containing bilirubin exhib- its a color varying from a light saflron- yellow to one resembling mahogany or porter; even when the color is dark brown or almost black the urine will show a tinge of olive-green or green- brown when it is seen in thin strata. The color of the urine may resemble that of a very concentrated urine or of urine con- taining blood; in the later cases the froth of the urine is white, while the froth of the icteric urine is yellow and tinges white a piece of linen or blntting-paper dipped into it. On standing, icteric urine ordinarily becomes greenish, because the bilirubin, by oxidizing, changes into biliverdin; by further decomposition of the urine the pigments are further changed into bili- prasin and bilifuscin. Although cholesterin is a normal con- stituent of the bile, it is not found in the urine in choluria, but in other morbid conditions of the urine: e.(j., chyluria. In some cases of cholurin renal cast observed in the urine without albumi- nuria. Nothnagcl (Deut. Archiv f. klin. Med., xiii, p. 487). Diagnosis. — Different remedies may give the urine a color resembling that observed in choluria. Wlien santonin. thallin, rhubarb, or picric acid have been ingested, the urine and its froth will pre- sent a yellow color. In poisoning with the fruit of Ci/tissus lahiimum a dark- 168 CHOLURIA. TESTS. green color of the urine is observed, whereas it is blue-green after the inges- tion of methylene-blue. The presence of the bile-pigments are revealed by differ- ent tests. 1. Gvielin's test consists "in bringing strong nitric acid containing some ni- trous acid in contact with the urine; if bile be present, a play of color is devel- oped from green to blue, violet, and finally red. These changes are due to the gradual oxidation of the bile-pig- ments. The green color is the most char- acteristic, being dependent on the forma- tion of biliverdin. It must be remem- bered that in most urines a reddish tint is brought out by nitric acid, while, if much indican is present, a blue or violet color may be developed. Gmelin's test is best performed by pouring a few cubic centimetres of nitric acid in a test-tube or a conical glass; the urine is then allowed to flow gently so as to cause it to fall on the surface of the acid. The play of color is then observed at the junction of the liquids. The urine may also be placed in the tube first and the acid poured in gradually so that it sinks down to the bottom. Only the green color is evidence for the presence of bile-pigment, since the other colors may be due to the action of the acid upon the normal urine-pigments. The presence of albumin is of no consequence; the green color is even more visible against the white albuminous deposit. Gmelin's test has been modified in dif- ferent ways. Rosenbaeh proposes to filter the urine through white blotting-paper and place a drop of nitric acid on the filter while still moist; or a drop of the urine and of the acid are placed separately on a white porcelain surface and allowed to come in contact. In both cases the characteristic color-rings will appear. Gmelin's test is very reliable when the quantity of bile-pigments is not too small; when this is the case, however, it is necessary to isolate the pigment by gently shaldng the urine with chloro- form; this agent will dissolve the bili- rubin and cause a yellow color. When the test-tube is left quiet for some min- utes the chloroform solution of bilirubin will sink to the bottom, the urine can be poured out, and the test performed ■fl-ith the chloroform solution. Indican is not dissolved by chloroform. Different oxidizing substances have been used instead of nitric acid. 2. The iodine test (Smith-Marechal) : ^Mien a few drops of tincture of iodine are added to urine containing bile-pig- ment an emerald-green color will appear. A watery solution of bromine will pro- duce a similar effect. 3. Huppert's test : A solution of am- monia and chloride of calcium is added to the urine. When bilirubin is present a deposit of bilirubin-chalk will be formed, which is filtered and washed down in a test-tube together with strong alcohol containing sulphuric acid. When boiled the liquid takes a blue-green or emerald-green color. 4. Jolles recommends the following method: To 50 cubic centimetres of urine, a drop of hydrochloric acid, chlo- ride of barium in excess, and 5 cubic centimetres of chloroform are added. The mixture is shaken and left standing for 10 minutes, then poured out and the chloroform heated in a water-bath; 3 drops of sulphuretted sulphuric acid con- taining one-fourth of its volume of fum- ing sulphuric acid are added. The char- acteristic rings are found at the bottom of the tube. !). When only bilirubin is to be re- vealed the sulpho-diazo-benzol test of Ehrlich may be of use. The reagent and CHOLURIA. ETIOLOGY AND PATHOLOGY. 169 diluted acetic acid are added to the urine. When the mixture becomes dark, a few drops of glacial acetic acid will bring out the characteristic violet color. Modification of Ehrlich's test: Three reagents are employed: (1) a 1-per-cent. watery solution of sulphanilic acid, (2) a l-per-cent. watery solution of nitrite of soda, and (3) pure concentrated hy- drochloric acid. In a test-tube a few drops of the first and second agents are mixed with as much urine; a drop of hydrochloric acid is added and the mixture shaken. It will then, when bilirubin, even if a very small amount, is present, get dark violet. ^Vhen the liquid is mi.xed with water the color changes into amethyst-violet. When only a very small quantity of bilirubin is present, the violet color will appear after a few minutes. This test regarded as the most reliable and delicate of all. Krokiewicz and Batko (Wiener med. Woch., Feb. 24, '98). The biliary pigments in the urine may decompose by standing, and then the above-mentioned tests will be without re- sult. Bilifuscin, which is formed by de- composition of the bilirubin, is revealed by moistening white blotting-paper with the urine; the paper will assume a brown color. Urobilin is dissolved by chloroform, and the solution takes a greenish fluores- cent color upon the addition of iodine and caustic potash. Von Jaksch recom- mends the test of Iluppert: when urob- ilin is present the deposit is red-brown and becomes brown or gray-brown by boiling ^vith sulphuric acid. Pettenliofer's test: The bile-acids are detected by means of this test, which de- pends on the development of a deep- purple color when these acids are acted upon by cane-sugar and strong sulphuric acid. This reaction is, however, for sev- eral reasons, most unreliable when ap- plied to urine, and the bile-acids must be separated from the urine by a compli- cated method before the original Petten- kofer test can be made. Strassburger, therefore, has modified the test in the following manner: Cane- sugar is added to the urine, and the solu- tion is filtered through white filtering- paper. After drj'ing the filter a drop of strong sulphuric acid is placed upon it, and after one-half minute a beautiful-red color will appear if bile-acid be present; the color finally changes into a dark purple. Physiological test for bile in the urine depending upon the fact that the bile- salts precipitate the peptones from solu- tion. The precipitate produced by urine containing bile-salts in a peptone solu- tion acidulated with acetic acid is soluble in acetic or citric acid, thus differing from all other precipitates in the urine produced by acidulated reagents. Fur- ther, the precipitate may only be par- tially cleared up by heat. Quantitative application of the same principle may also be made. George Oliver ("Bedside Urine-testing," '89). Etiology and Pathology. — Choluria takes place when the constituents of the bile are absorbed by the lymphatics and pass into the blood-vessels, from where they are excreted by the kidneys. It is, therefore, a constant symptom of jaun- dice, and is often observed before either the skin or the mucous membranes get stained with bile-pigment. The condi- tions which give rise to icterus will be discussed elsewhere, but by the examina- tion of the urine it will never be possible to discover the origin of the jaundice. In some cases the pigment contained in the urine does not seem to be due to absorption of bile in the liver, but to have been formed directly by decomposi- tion of the blood-pigments, either while circulating in the blood (ha^matogen ic- terus) or after the blood has been ex- travasated in the tissues (Quincke's in- ogen icterus). 170 CHOLURIA. Prognosis aad Treatment. — As cho- Imia is only a symptom of absorption of bUe by the blood, its prognosis is in close relation to that of the disease acting as cause. Even if the choluria is very con- siderable, it will quickly disappear when the obstacles for the regular flow of the bile are removed. The treatment must also be directed against the fundamental disease, while the symptom, choluria, needs no special treatment. F. Levisok, Copenhagen. CHORDEE. See Ukinart System, SuEGiCAL Diseases of; Gonoerhcea. CHOEDITIS VOCALIS. See Laryn- gitis. CHOREA. — From the Greek: j^opeia. Synonym. — St. Vitus's dance. Some confusion arises from the fact that under the name "chorea" are. in- cluded several forms of nervous disease and degeneracy having as their com- mon and characteristic symptom jerky, arhythmic, involuntary, inco-ordinate, muscular movements, while differing widely from one another in nature, causa- tion, pathology, prognosis, and general symptomatology. This confusion is further added to by the varying opinions held by those who write upon the sub- ject as to what conditions shall and what shall not be included among the choreas. The following forms are described: — 1. Sydenham's chorea. With several varieties, as "chorea insaniens," "hemi- chorea," etc. 2. Endemic chorea. 3. Electric chorea. 4. Hysterical chorea. 5. Saltatory spasm. 6. Oscillatory spasm. 7. Tic co-ordinc, or "habit spasm." 8. Post-hemiplcgic chorea. 9. Chronic adult chorea. 10. Huntington's chorea. Of these, the first in order is the com- mon St. Vitus's dance, chorea minor, or acute curable chorea, and much the most common and important of the choreoid diseases. It is the form meant when the word chorea is used without qualifica- tion. Those included from the second to the seventh belong to the functional neuroses, and may be regarded as ex- pressions of neurodegeneracy. The eighth, ninth, and tenth are attended by degenerative changes in the cortex cere- bri or spinal cord, or both. Sydenham's Chorea. Definition. — This is the well-known "St. Vitus's dance," an acquired func- tional neurosis, occurring during the middle and later periods of childhood, being rarely seen before the age of five years and after puberty; it is more com- mon in females than in males, is more frequently met with in urban than in rural populations, and during the spring months. Symptoms. — The onset of the disease is often foreshadowed by symptoms cov- ering a prodromal period of a few days to a few weeks. These premonitory symptoms consist in general nervousness, a tendency to fidget and uneasiness, a change in disposition; irritability and emotional weakness, headache, vague pains, some impairment of general health, and possibly the occurrence of some one of the acute diseases or unfav- orable circumstances enumerated below as exciting causes of the disorder. The disease always develops gradually and with varying rapidity in dilTcrent cases, the onset being marked by the appear- ance of the characteristic choreic move- ments. These are peculiar, jerky, often lightning-like, clonic spasms, involving the muscles of the face and head, neck, CHOREA. SYMPTOMS. 171 trunk, and extremities, usually more pro- nounced in the face and arms, and often more pronounced in one lateral half of the body ("liemichorea," when typically shown). The movements are sudden in onset and as suddenly cease; they are irregxilar in force and direction, markedly inco-ordinate, and differ in character from any other form of abnormal motor discharge known. They result in sudden grimaces and facial twitchings; sudden closure and opening of the eyes or mouth; sudden seizure and immediate dropping of any object it is attempted to grasp; twisting movements of the arms; pe- culiar dancing and bobbing movements of the feet, all of these movements seem- ing at times semipurposeful, leading to the idea on the part of the onlooker that they are due to bad habit or awkward- ness, and could be prevented. The movements vary in intensity from slight, scarcely-noticeable twitchings of co-ordinate groups of muscles, occurring at intervals, to violent and almost con- tinuous clonic spasmodic contractions of nearly or quite all of the voluntary mus- cles of the body, resulting in writhings and contortions which completely inca- pacitate the patient and render neces- sary confinement to bed. The move- ments may occur when the muscles are at rest, but they are often precipitated or intensified by voluntary muscular effort of any kind. They are increased by efforts to prevent them and by anything which directs attention to them. They cease entirely during sleep. In many cases speech is affected in consequence of implication of labial muscles and tongue, giving rise to peculiar jerking out of words, explosive utterances, hesi- tation, or indistinctness of articulation which may in some cases amount to en- tire inability to talk. The lips are occa- eionally bitten; the tongue rarely. The muscles of respiration may become in- volved, in which event there will be un- even, irregular respiratory movements, ■ndth, possibly, sighing, moaning, or other involuntary inarticulate sounds. Deglu- tition in severe cases is also more or less interfered with, and the patient natu- rally finds difficulty in feeding himself, on account of the inco-ordinate action of the muscles of the arms and hands. The urine and faeces may pass involuntarily. The gait is, in all well-marked cases, altered, and is usually shuffling and slow, the steps being unequal in length and in time, with difficulty in progress- ing in a straight line. There is no rigidity nor tonic spasm. The muscles may become tender to press- ure. There is usually some muscular weakness or paresis, which, in occasional cases, becomes extreme ("paralytic cho- rea"). The tendon-reflexes are normal. Trophic disorders are not the rule, but erji;hema, herpes zoster, or chloasmic blotches may be occasionally seen. The movements are rarely general at first. They begin in the upper ex- tremity, or the face, or, rarely, in the lower extremity. They spread over the corresponding half of the body, and finally attack the opposite side. In 144 cases studied, the onset was general in 25 cases only and hemilateral in 111 eases. G. Oddo (Revue de Med., Jan. 10, 1901). There is always some disorder, usually a general dulling of tactile temperature and muscular sense. In the early stages pain is frequent, but in later stages this gives place to well-marked analgesia. Prickling, formication, and other panes- thcsia; are common. In uncomplicated cases the pupillary reactions are normal. Psychical abnormalities are the rule. These vary from the slight irritability, weakness, and altered disposition com- 172 CHOREA. SYMPTOMS. monly seen in early stages to marked intellectual impairment with loss of memory, confusion of ideas, inability to concentrate attention, and grave emo- tional disorder of a melancholic cast. Occasionally a generalized outburst of acute insanity or delirium will occur, giving rise to the clinical subdivision "chorea insaniens." Chorea an infectious disease. Like all other infectious diseases, its toxic prin- ciple may give rise to insanity with hal- lucinations, modified in form according to individual peculiarities. Ihe onset of the insanity is, like all insanities of toxic origin, sudden, and its progress acute or subacute. Usually there is no parallel- ism between the choreic movements and the mental symptoms; but it is to be noted that, while chorea generally occurs in patients about 15 years of age, mental disturbance is generally found in choreic patients of 19 years of age. P. J. Mobiua (Miinchener med. Woch., Dec. 20, 27, '92). A true aphasia has been noted in a few instances, usually associated with a right hemichorea. Along with the nervous symptoms above described in detail there are, in most cases, some evidences of disorder of the general bodily functions. Fever is present at some stage, usually early, in a majority of cases. When slight and maniacal chorea is present a tempera- ture of 103° to 104° F. is often noted. A decided rise is usual in cases show- ing complications, such as rheumatism, pericarditis, or endocarditis. The renal function is, in mild uncom- plicated cases, normal. In the severe cases and in almost all febrile cases al- buminuria exists, and the amount of urea excreted is in excess of the normal. In maniacal chorea there is, as a rule, a dis- tinct nephritis. Cardiac irregularity with abnormal rapidity of action is not infrequent, and of all the complications of chorea, peri- carditis and endocarditis are most often seen, the latter, especially, occurring, ac- cording to Osier, in quite one-half of all cases. Cardiac murmurs, due to the en- docarditis and also in some instances to impoverished blood, are common. A true anfemia — diminution in liaBmoglo- bin-percentage and in number of red and white corpuscles — is often noted. In a limited number of cases symptoms of gastro-intestinal disorder occur, the sj'mptoms being those shown in cases of autoinfection. Since chorea occurs by preference in children of neurotic heredity, the psy- chical, physiological, and anatomical stigmata of degeneracy in greater or less prominence are often added to the symp- toms above detailed. Three grades of the disease are de- scribed: The mild, in which there is little disturbance of general health, no complications, and only moderately-well- marked choreic movements; the severe, in which fever, mental disorder, and other complications are present, and the inco-ordinate clonic spasms more severe and continuous, with well-pronoimced muscular weakness; and the violent "chorea insaniens," characterized by rapid onset and progress, violent and con- tinuous choreoid spasm, with fever and delirium, terminating not infrequently in death. Motor symptoms in chorea arranged in five clinical groups: 1. Cases in which there is at some stage absence of the mo- tions when at rest. 2. Cases in which tlie movements are less when the child is at rest, but are aggravated by volun- tary movements. 3. Cases in which the severe choreiform movements disappear during voluntary movements. 4. Cases in which voluntary exertion does not in- fluence the movements. 5. Cases present- ing at different stages more than one of tlie above types. Weir Mitchell and CHOREA. DIAGNOSIS. ETIOLOGY AND PATHOLOGY. 173 J. H. W. Rhein (Phila. Med. Jour., Jan. 22, '98). Ciagnosis. — In typical cases no great difSculties in diagnosis are presented, the characteristic muscular movements being, in themselves, sufficient to make the nature of the case plain. In atypical forms some doubt may arise, and there are a few other states which may be con- founded with acute chorea. Thus, in hysteria choreiform movements suggest- ing chorea may take place ("hysterical chorea"). The ansesthesia and accom- panying symptoms discoverable upon examination, together with the fact that in hysteria the movements are more rhythmical than in chorea, should make a diagnosis easy. The muscular weakness may be so ex- treme as to suggest acute anterior poli- omyelitis. The presence of the choreic movements are, however, enough to ex- clude poliomyelitis. Some forms of scle- rosis and degenerative changes in the cerebral cortex are attended by chorei- form movements, and may, when occur- ring in young persons, lead to thought of acute chorea. The presence of mental disorder, exaggerated reflexes, muscular rigidity, and other spastic symptoms should prevent mistake. Friedreich's ataxia was formerly and is still some- times mistaken for chorea by those un- familiar with the symptomatology of nervous diseases. The scanning speech, nystagmus, and the irregular, slow, and peculiar inco-ordinate movements of Friedreich's ataxia are sufficiently dif- ferent from the clinical picture of chorea to prevent confusion if a proper examina- tion is made. Involuntary movement, muscular weakness, and niu.tcular rigidity arc three symptoms belonging to the group that depends on impaired functional in- tegrity of the upper segment of the motor path. They are found in two diseases which are due, not to structural, but to functional or, perhaps, rather nu- tritional changes in the cortex, viz.: pa- ralysis agitans and chorea, which have a certain kinship to one another, the former being commonly heniiplegic in its mode of commencement and e.\tension, while the other is frequently hemiplegic in its distribution throughout its entire course. In the case of chorea the ab- normal movements are so obtrusive in comparison with the others that there is danger of the latter being overlooked, although weakness, at any rate, is now generally known as a frequent symptom. In exceptional instances weakness may be practically the only symptom, and the diagnosis may then be somewhat dif- ficult. The age of the patient, the limita- tion of the weakness to one arm, and the occasional manifestation of slight choreic movements in the affected limb or in other parts may furnish the neces- sary clue. Jlonroe (Glasgow Med, Jour., Feb., '97). Peculiarities of the knee-jerk. If, the patient being in the recumbent position, one raises the knee, allowing the heel to rest on the couch, making sure that all the muscles of the limbs are relaxed for the time being, and if one then tests the knee-jerk in the usual way, the foot is found to ri.se more or less smartly, but, instead of falling back im- mediately, it remains suspended for a variable time — hung up, as it were — and then slowly sinks back to its initial position. W. Gordon (Brit. Med. Jour., Mar. 30, 1001). Etiolo^ and Pathology. — In general terms, choreic movements of all kinds are primarily due to inherent neuronic weakness or instability, especially in motor sphere, with abnormally-devel- oped motor association-tracts, or to de- fective insulation in lines of motor dis- charge. An unstable condition of the higher nerve-centres predisposes to the condi- tion, and a poison affecting these centres might produce in one person epilepsy, in another general neurasthenia, and in a third chorea. Bishop (Can. Pract.. Nov., '97). 174 CHOREA. ETIOLOGY AKD PATHOLOGY. Chorea considered a condition of ex- hausted nerve-control. Upon this theory the association of chorea and rheumatism seems to be readily explained. As a re- sult of the rheumatic poison there oc- curs a failure in the nutrition of the nerve-cells regulating and balancing mus- cular movements, and thus in certain individuals of neurotic tendency rheuma- tism becomes the causative factor of chorea. G. M. Swift (Archives of Pedi- atrics, Sept., '99). The immediate exciting cause is irri- tation of cortical motor neurones from toxic substances in the blood due to in- fectious diseases, autointoxications, etc., nerve-cell fatigue, and in some cases tem- porarily induced abnormal "neuronic contacts" in sensorimotor sphere from sudden shock or emotion. In the form of acute chorea under consideration the neurotic constitution with the anatomical and physiological stigma of degeneration can usually be traced. Ancemia with general bodily en- feeblement is common. Study of 40 cases. The blood is rarely absolutely normal in amount of coloring matter and number of red corpuscles during an attack. There is usually a moderate diminution in the hjEmoglobin and a relatively slighter decrease in the number of red corpuscles; in other words, the anemia is chlorotic in type. There is no relation between the severity of the aneeraia and that of the attack, and when the latter is profound there is usually some complication competent to explain it. Ana;mia is not an immediate, direct, exciting cause, but frequently a predisposing one. Burr (Pediatrics, Feb. 1, '97). Nearly all tlie cases show blood- changes and leucocytosis. In a few cases marked increase in the amoeboid move- ment of the white corpuscles observed and a possible diminution of the eosino- phile or orthophiles among the white corpuBcleB. In all cases the condition of the blood is of great importance in estab- lishing a prognosis. In the further study of chorea its hiematology is of the great- est importance, and the clinical aspects of the disease point to an infectious ori- gin. Loudon (Clin. Med. Rec, Dec, '97). Two hundred cases of chorea analyzed. One hundred and thirty-six of the pa- tients were females and 64 males. After IS years, 3 cases were found among men and 10 among women. Thirty-seven cases occurred after the establishment of the menstrual function and 99 before. A neuropathic heredity and anomalies of the cranium play an undoubted rSle. This nervous heredity was clearly estab- lished in 73 cases, of which 49 were in females (with 9 cases of homologous heredity) and 24 in males (with 3 cases of homologous heredity). Anomalies of the cranium were very frequent, most often produced by rachitism, and belong- ing to an hydrocephalic type, more rarely to a Bubmicrocephalic type, and more rarely still to a phagiocephalic type. Among other causes responsible for nerv- ous predisposition are masturbation, acute diseases, concussion of the brain, and pregnancy. Exciting causes in a cer- tain number of eases were articular rheumatism and infectious diseases, in others psychical traumatism. Influence of infectious maladies was manifest in 75 cases; in 58 of these there was acute articular rheumatism, with or without cardiac lesions. Of 75 post-infectious cases a nervous predisposition was pres- ent only in 50. In cases in which chorea developed after a psychical traumatism the role of neuropathic heredity was much more manifest. Of the CO cases of this class such heredity existed in 64 pa- tients. Psychical traumatism most often was of the nature of a fright. In 59 cases the exciting cause could not be as- certained. Kraft-Ebing (Wiener klin. Woch., No. 43, '99). The urine in Sydenham's chorea presents the following characteristics: Diminution of the daily quantity; spe- cific gravity relatively high; total acid- ity increased; diminution during the disease of the quantity of nitrogen which is not eliminated as urea; in- creased elimination of uric acid; de- crease in elimination of chlorides; in- crease of phosphates; total quantity of CHOREA. ETIOLOGY AND PATHOLOGY. 175 sulphuric acid and allied substances, unchanged. De Marchis (La Riforma Medica, July 5, 1002). Some cases develop without any dis- coverable exciting cause, but in most instances the onset of the chorea is pre- ceded by mental strain, worry, or shock of some kind — overwork at school, fear, religious emotion, etc. — or by the occur- rence of some infectious disease or tox- emic state, such as rheumatism. Chorea is a symptom, and not a dis- ease, the principal cause being rheuma- tism acting on a nervous subject. Duck- worth (Brooklyn Med. Jour., May, '92). In 134 out of 19G eases of chorea rheu- matism was present. In the majority of cases chorea is the result of rheumatic diathesis, although cases occur which must be considered as true neuroses. SCe (La M6d. Mod., Oct. 15, 22, '91). Study of the seasonal relations of chorea and rheumatism for a period of fifteen years. Chorea and rheumatism are periodical, the least severe attacks in chorea occurring in October and No- vember and 'the most severe in March and April. It is the same in rheumatism. These two affections are considered to have the same causal relation with mete- orological conditions. Morris Lewis (Boston Med. and Surg. Jour., June 23, '92). Chorea is nearly always secondary to acute articular rheumatism, or to some infectious disease. An efficient part is played by the mental emotions. In 19 of 70 cases there was no family history of disease, but an unobserved previous infection suspected. In 14 cases there were cardiac lesions, and in G of the 14 the chorea was unmistakably of rheu- matic origin ; further, there is an etio- logical identity between chorea and en- docarditis. Marfan (Revue Mens, des Mai. de I'Knf., Aug., '97). Chorea is nothing else but one of the n\imorous manifestations of rhcunuitism, for the following reasons: It alTects the same geographic distribution: like rheu- matism, it is most frequent in cold coun- tries; it shows its preference for damp seasons; besides, if choreic patients are examined with care, it will be found that cardiac afl'ections are frequent, even though they may not have had rheu- matic antecedents. One of the argu- ments against a rheumatic origin is that the disease is not modified by sodium salicylate, but this same drug is equally ineffective as regards endocarditis, cu- taneous eruptions, etc. Simon (Jled. Press and Circular, Apr. 7, '97). Histories of 1400 cases of chorea seen in Vanderbilt Clinic shows proportion of females a fleeted compared with males was almost 2 to 1; the disease is more common in the poorer classes. Heredity and infectious diseases seemed to bear no definite relation to the disease, the most constant element being malnutri- tion. Fright immediately before onset was noted in 285 cases, and 290 had dis- tinct history of true rheumatism. Or- ganic heart-murmurs were present in 175 cases, functional in 123, and none in 871. Nine hundred and nineteen cases oc- curred between the ages of seven and fourteen years; of 1129 cases, 707 came on between March and August. Recur- rences present in one-fourth of the cases, were most common in the spring. Cho- reic movements were general in 951 cases, unilateral in 449, the right side being afi"ected slightly more than the left. Mental irritability was noted in 827 and speech was affected in 550. M. Allen Starr ("Abraham Jacobi Fest- schrift"; Phila. Med. Jour., May 20, 1900). The theory of the infective genesis of chorea (rheumatic) points out that a negative bacteriological result need not exclude micro-organisms as a cause, for this may result from several causes: for e.xample, spontaneous attenuation of the micro-organisms, germicidal action of organic fluids, plasmolysis, irregular distribution of the bacilli, occlusion (in- flammatory) of the communicating chan- nel between the internal cavities of the brain and the perimedullary spaces, stratification of the bacilli in different layers of the fluid, or insufficiency of material taken for test purposes. Any one of these causes might account for a negative result in testing for bacilli. 176 CHOREA. ETIOLOGY AND PATHOLOGY. and taken together they may explain the cases of rheumatic chorea where germs have not been discovered. And since every day seems to show more clearly an association between rheuma- tism and the various pyogenic organ- isms, it is these that one looks for in chorea. The non-rheumatic choreas may be due to germs not easily cultivated. Mircoli (Gazz. degli Osped., Nov. 23, 1902). Measles, whooping-cough, influenza, diphtheria, scarlet fever, endocarditis, malaria, urinary abnormalities, aggra- vated constipation, etc., are also impor- tant factors. Query whether chorea should be con- sidered a sequel of scarlet fever or not. Cheadle recognizes it as such, but quali- fies the opinion by adding that, in 1894 and 1896, 83G0 cases of scarlet fever were under treatment at the Northeastern Hospital, and of these 5355 were com- pleted there. Thirteen cases of chorea were observed, or 1 in 412 completed eases. Osier found 1 case of chorea to every 180 patients. Hence it would ap- pear that chorea is less frequent among scarlet-fever patients than among pa- tients in general. Of Osier's 13 cases, 5 had rheumatic manifestations, which, in each instance, immediately preceded, or appeared simultaneously with, the chorea. Rheumatism or joint-affection which occurs as a complication of scarlet fever sets in toward the end of the first week; but in these cases it was consid- erably later, indicating a difTerence in the nature of the joint-afTection. Priest- ley (Brit. Med. Jour., Sept. 25, '97). A case of paralysis and chorea as a sequel to scarlet fever. That the scarlat- inal attack bore a causative relation to the growth of the nervous condition there can be no doubt. Cornell (Medicine, Jan., '98). From a study of 239 cases of chorea gravidarum it was found that the chorea frequently appears in a patient who bus Buffered from Uie ordinary form on some previous occasion. Chorea gravidarum may come on gradually or suddenly, and in the latter case is not infrequently due to a sudden fright or emotion. The onset of the chorea may be accompanied by globus and other symptoms. Many of these cases show extreme constipation. Mastier (Th&se de Lyon, '99). In over 71 per cent, an infectious etiology could be obtained in chorea. Not only are endocarditis and articular rheumatism frequently mentioned in the past history, but often some catarrhal condition of the respiratory tract, as angina, bronchitis, laryngitis, or influ- enza, seems to be the precursor, alone or in various combinations. Of the non- infectious cases, the majority of patients possessed a neuropathic tendency and were considerably run down, through rapid growth, overexertion, or insuf- ficient nourishment, and frequently showed the stigmata of a past rachitis or scrofulosis. Here the most fre- quently mentioned cause seemed to be fright, and often hysteria played an im- portant part. G. Koster (Miinchener raed. Wochen., Aug. 12, 1902). Eheumatism is the most important eti- ological factor of chorea, the cardiac le- sions being closely associated with it. Both the rheumatic diathesis and cardiac morbid conditions predispose to the dis- ease. Study of the relations existing between chorea, rheumatism, and diseases of the heart: 1. Neither rheumatism nor heart disease is essential to chorea. 2. The preponderance of evidence points toward the conclusion not only that rheumatism and organic heart disease conjointly ap- pear more frequently in the choreic sub- ject than can be accounted for by coin- cidence, but that the same is true of each of these afl'cctions separately. It follows, therefore, tliat rheumatism predisposes to eliorea, and organic heart disease has the same tendency. 3. Fatal cases are gen- erally associated with organic heart dis- ease, and probably with organic disease of the central nervous system, notably cerebral embolism. 4. There is a largo class of functional cases, mainly reflex and fostered by circumstances tending to produce functional symptoms in gen- eral. 5. The pathological connection be- CHOREA. ETIOLOGY AND PATHOLOGY. 177 tween rheumatism and chorea, except- ing in the cases where emboli are pro- duced by accompanying endocarditis, is still obscure; probably no one theory is applicable to all cases. G. The meclian- ism by which the peculiar phenomena of chorea are produced is unknown. Walton and Vickery (Amer. Jour. Med. Sci., May, '92). Examination of 140 persons having suffered from chorea at least two years previously. In 51, heart normal; in 72, symptoms of organic lesion; in 17, car- diac disturbances. No rheumatic history in Cli per cent. Cause: an infection al- lied to rheumatism, but differing from it. Osier (Pacific Med. Jour., Aug., '95). Si.\ cases, all in young women of ages varying from 17 to 21, in which the dis- ease was very grave, and proved fatal in two. The previous association of scarla- tina or rheumatism — articular, endocar- dial, and prtecordial — noted in every case; likewise recurrence of chorea on the same side as the former rheumatic affection had existed. Napier (Glasgow Med. Jour., Feb., '97). Out of 20 choreic patients personally examined, in 7 there was a previous history of rheumatic fever in the pa- tient; in 4 there was a strong family . history of rheumatic fever, and in the remaining 9 there was no history of rheu- matic fever, but, out of these 9, 2 had mitral stenosis, 5 had mitral regurgita- tion, and only 2 had no valvular affection of the heart. Out of the 20 cases, 5 gave a history of fright or shock. In the 20 eases 18 came on between the fourth and the fifteenth year, 5 of which oc- curred at the fourteenth or fifteenth year. This refers only to first attacks of chorea. Sixteen occurred in females and only 4 in males. Purves Stewart (Med. Brief, June, '98). About 21 per cent, of all choreic cases give a rheumatic history, either in their parents or themselves prior to the disease. Chorea follows an atUick of scarlet fever in children in abotit 25 per cent, of all eases. Forcing children at school is a most important factor in producing the disease. Ocular defects may lie at the bottom of some cases of chorea. Edwin Williams (Memphis Lancet, Aug., '99). 2—12 View that chorea is associated with rheumatism opposed. Of seventeen con- secutive cases of chorea at personal clinic, only one had rheumatism before or dur- ing the attack, and of several who re- turned after recovery none had shown any sign of the latter disease. Gilles de la Tourette (Rev. Neurol., June 30, 1900). Forty-seven cases of chorea minor studied. Age of patients varied from 3 to IC years, and in 28 the disease had begun from seven to eleven years pre- viously; 39 were girls and 8 boys. In 24 cases there was the family history of rheumatism or of psychical affections. Among the 47 there were 15 who had had rheumatic fever, either before or dur- ing the chorea, and in 10 chorea had be- gun or had been accompanied by febrile phenomena with angina, articular affec- tions, or erythema nodosum. T. Frolich (Norsk Mag. f. Laegevidensk., Sept., 1900). The frequency of fibrinous accretions upon the cardiac valves and the undis- puted frequency of embolism of the cerebral arteries give origin to the often- mentioned "embolic theory" of the causa- tion of chorea, a theory first advanced by Kirkes and supported especially by Hughlings-.Tackson, according to which the inco-ordinate movements of chorea are due to multiple capillary embolism of the corpus striatum. This explana- tion is, however, somewhat far-fetched and it is also insufficient, since there are many cases of chorea which show no evi- dence of embolism and in which there is no endocarditis. A specific microbic origin has been suggested, but is, as yet, not demon- strated. Hints at the possibility of an infectious origin for chorea. Report of a ca^e of chnrca insanini.^ in a woman of 27, who had had two attacks of rheumatism, and, with the second, had had delirium and irregular movements of the limbs. The autopsy showed an acute endocarditis, abscess of the parotid, and catarrhal 178 CHOKEA. ETIOLOGY AND PATHOLOGY. pneumonia of both lungs. No special germ, however, could be discovered. Chorea is a general systemic affection, acting with greatest intensity upon the vascular system and the leptomeninges; its cause is to be sought for in a special bacillus. Berkley (Johns Hopkins Hosp. Eep., Aug., "91). Autopsy of a case in which micro- scopical examination showed a conspicu- ous chronic leptomeningitis involving the vertex of the brain ; a proliferating proc- ess, without exudation or much cell- infiltration. In the superficial layer of the cortex there was cellular infiltration with degenerative changes. At this point a diplococeus was found. The micro-organisms were observed only in the deep layer of the pia and the super- ficial part of the cortex. Dana (N. Y. Med. Jour., Aug. 19, '93). Study of 600 cases. The toxin of chorea may be a glycocin, for which reason micro-organisms will not be found in the blood. No light thrown upon the connection of arthritis and chorea nor any explanation advanced why the toxin settles in the brain when chorea occurs in rheumatic subjects. Failed to find any cases of rheumatism caused by fright or any of chorea primarily induced by chill. Churton (Med. News, Dec. 4, '97). Study of choreics bacteriologically, and discovery of a lanceolate encapsulated diplococeus extremely pathogenic to guinea-pigs, in which it determines an liffimorrhagic hypercemia with diminished fibrin and no cedema. The histological lesions in the nervous system of patients and in the viscera of the guinea-pigs showed that the effect was more toxic than septic, with an elective action on the vessels. The findings appear to sus- tain Leroux's theory that chorea is a syndrome determined by some infective or toxic agent on a soil prepared by an inheritance of neurotic and arthritic tendencies. Mci (Gaz. degli Osp. et delle Clin., Aug. 22, '07). Conclusions regarding etiology of chorea arc (1) rheumatic chorea is in- fective, and depends on the action of toxins of micro-organisms on the nervous Bystem; (2) staphylococci are the chief source of infection, in that they have been found twice as often as all the other organisms put together. Maragli- ano (Centralb. f. innere Med., xx, p. 489, '99). While the importance of the pyogenic micro-organisms in relation to chorea is generally recognized, recent bacteriolog- ical examinations of the spinal fluid of choreic patients go to show that the relation is a closer one than is usually supposed. Staphylococci found in the cerebro-spinal fluid in two personal cases. In a third case of erysipelas, which was followed by chorea of a se- vere type, not only had lumbar puncture a favorable therapeutic effect on the movements and the sleeplessness, but also streptococci were demonstrated in the fluid. In both the blood and urine of this case streptococci were also found. The statistics of Triboulet show that a third of all chorea cases furnish a his- tory of an antecedent febrile attack, of which the most common are scarlatina, measles, and erysipelas. In all cases of chorea the cerebro-spinal fluid should be examined. Fornaca (Riforma Medica, No. 74, 1901). Chorea is not infrequently an infec- tious disease ; it is, therefore, necessary to make a bacteriological examination of the blood in every case. Not rarely the disease is of streptococcic origin. In polyvalent antistreptococcic serum we possess a rational remedy for the treatment of appropriate cases of this disease. P. A. Preobrazshonsky (Meili- zinskoje Obozrcnije, vol. Iviii, No. 21, 1902). Other suggested causes are cerebral hyperseniia, capillary thrombosis, and prolonged arterial spasm; but none of these theories odor so rational an ex- planation of the observed symptoms as that which attributes the choreiform movements to inherent instability in sensorimotor sphere, together with a tox- lEmia or a shock sulTicient to disarrange the customary association- or contact- areas in cortex, basal ganglia, and cord. In mild cases, should death occur, it is likely that no characteristic nor well- CHOREA. PROGNOSIS. 179 marked anatomical alterations would be detected. In severe cases there are changes in the neurone bodies of the cerebral cortex and lenticular nuclei paralleling those of fatigue, as de- scribed by Hodges and others, together with, in cases of long standing, distinct degenerative changes in nervous ele- ments of the cortex, pyramidal tracts, and cord. Wlien these degenerative al- terations are well marked, it is likely that the clinical picture during life was that of chronic adult chorea, rather than Syden- ham's chorea. In addition to the changes in the nervous elements themselves, there are, in severe and long-continued cases, secondary changes in the con- nective-tissue structures and blood-ves- sels, perivascular dilatation, accumula- tions of round cells in lymph-spaces, etc. In acute cases there are often small areas of softening, with congestion and capil- lary dilatation in cortex and lenticular nuclei. In maniacal chorea the cortex and pia mater are chiefly involved, there being usually intense hyperemia, with ■evidences of acute inflammation. The changes resemble those of violent acute mania or delirium. Report of thirty-nine autopsies. The chief changes were just beneath the cor- tex, where the white matter was honey- combed with little spaces, round or oval. These spaces were empty or partly filled with blood-vessels. The process, he be- lieves, was non-inllammatory, and was due to abnormal dilatation and filtration of the vessels' contents. The same changes were found in the basal ganglia and the internal capsule, whose fibres were split up by interlaced and dilated vessels. There was also noticed a vari- cosity of the nerve-fibres. In the re- corded cases the most marked changes were hypcrsemia, periarterial exudations, erosions, softened spots, multiple htemor- rhagcs, and occasionally embolisms. The changes are most marked in the deeper parts of the motor tract ; but he con- siders chorea not as a local disease, but as a disease of the intracranial motor tract, including its starting-point in the cortex and especially in its co-ordinating adjuncts, — the lenticular nucleus and thalamus. Dana (Brain, Oct., '90). An aflection of cerebral cortex. Loss of control which sensitive areas possess over motor areas. Brush (New York Med. Jour., Mar. 9, '95). Case of a girl of 12, in whom chorea set in six weeks after a first attack of acute rheumatism and a fortnight after the first subjective signs of cardiac im- plication. Bronchitis, and eventually double pneumonia, supervened, and the patient died just a month after the commencement of the chorea. The ne- cropsy was made four hours after death, ■which was found to be due to double pneumonia, with staphylococcal endo- carditis and pericarditis. Multiple thrombi, colorless, red, mixed, and hy- aline, were found in the central nerv- ous system, particularly the cerebrum. There was a deposit of clotty masses in the adventitia, of a medium-sized vein in the globus pallidus, and of numerous fat-globules in and on the cerebral blood-vessels. There had been a con- siderable amount of sensory disturbance in the ease, due probably to the multiple thromboses. The symptoms of chorea due to vasomotor disturbances in the brain as the result of the rheumatic toxffimia. The thromboses are the extreme expression of these changes. Okada (Mitteil. der med. Facult. der kaiserl. Japan, Univ. zu Tokio, 1902). Prognosis. — The rule in chorea is a gradual and insidious onset, a slow rise in intensit}' and distinctness of symp- toms, followed by a stationary period of weeks or several months, and a gradual subsidence of the disease, with final re- covery. The malady is acute and quite curable, with a natural tendency to re- covery, even when not treated at all. Some mild cases recover in a few weeks; two to three months is the duration of the typical forms, although occasionally 180 CHOREA. TREATMENT AND PROPHYLAXIS. the symptoms may persist for six or more months. Some nervousness and slight twitchings noticed when the child is startled or excited may continue for months after recovery, and a species of chronic "habit chorea" may be the final result. A true chronic chorea rarely or never follows this variety of neurosis in children, but is occasionally seen after acute chorea in adults. In general, how- ever, a chronic chorea in adults or in children is apt to be associated with de- generation of the cortical motor cells and pyramidal tracts, thus differing widely from the form of acute chorea under consideration. The milder forms of chorea are \mattended by danger to life. Chorea insaniens is often fatal, and, where recovery from the acute affection occurs, there is danger of some perma- nent mental deterioration. Kelapses after apparent recovery are not rare. The existence of a compli- cating rheumatism or endocarditis is thought to favor relapse. The result in any case of chorea is largely influenced by the complications and underlying cause. Treatment and Prophylaxis. — In view of the frequency witli which chorea de- velops in intelligent and ambitious chil- dren of neurotic heredity who are over- worked at school, something may be done toward preventing the develop- ment of the disease by insisting upon moderation in study and a proper ob- servance of the rules of physical and mental hygiene. Competition for prizes and any other excess in school-work should be for- bidden, and the child encouraged to spend as much time as possible out-of- doors, in healthy games and play. Drop- ping back a year in classes will, by di- minishing amount of intellectual effort required, often prove of decided benefit. not only for the time being, but in all after-life. An epidemic of chorea-like hysterical spasm was observed in a girls' school by Laquer. Three cases of arhytliraic hysterical chorea in wliicli the hysteria sliowed all the features of Sydenham's chorea, thus confirming the facts previously advanced by Debove, Merklen, Chantemesse, Jof- froy, Sfglas, Reque, and Perret. B. Ouche (Le ProgrOs Med., Dec. 5, '91). Chorea never arises in healthy children from imitation, but in all cases of so- called epidemics we have to do with an hysterical afl'ection. In weak and poorly- nourished children chorea is often devel- oped in the schools from overwork. Kiierner (Deut. med. Woch., Apr. 2, '91). The co-existence of chorea and hysteria admitted in a certain number of cases, but more often common chorea does not arise from hysteria, but hysteria is capable of simulating it. Dettling (These de Paris, '92). Mental disturbances appearing in chorea divided into groups: 1. Cases of degenerative disturbance the exacerba- tions of which are often accompanied by choreic or amulsive anomalies of move- ment. 2. Lymphatic posthemiplegic chorea with distinct focal brain disease. 3. Imitative chorea or anomalous move- ments evoked primarily by psychical or traumatic indignity; these are mainly hysterical. 4. Cases of Huntington's chorea, which is analogous to paralytic dementia. 5. Senile chorea. 6. Syden- ham's chorea, which may be character- ized by elementary psychical disturb- ances, fleeting, light delirium, the symp- toms of profound neurasthenia, stupor and dementia, or by complicating psy- choses of the severest form. Von Krafft- Kbing (Wiener kliii. lUimlsclmu, July 29, 1900). Should any indication of chorea ap- pear, the ciiild should be removed from school at once and placed in as good hygienic circumstances as possible. The cliild's attention should not be directed toward the disease, and the nervous man- ifestations shovild not be openly noticed nor commented upon by others, since CHOREA. TREATIVLENT AND PROPHYLAXIS. 181 self-consciousness and suggestion play an important part in exaggerating the choreic symptoms. Eemoval of the pa- tient from home, relatives, and familiar surroundings will go far toward relieving the condition. A trip to the country or to the sea-shore when possible is always beneficial. Massage and hydrotherapeu- tic measures are almost always indicated, and do especial good in the cases in which anffimia and general debility are present. Hydrotherapy; wet pack best method, — sheet dipped in water at 50° to 54° F., then lightly wrung out, spread over mat- tress with oil-cloth; then closely wrapped around patient; latter rubbed from head to foot and placed with sheet in woolen blanket and returned to bed. Charyeux (Revue de Th6rapeutique M(5dico-Chir., Oct. 1, '95). In severe cases rest in bed for a few days or even for weeks is advisable, and in the severest cases is made necessary by the violence of the contortions, which may entirely prevent the child from walking or standing. With these non- medicinal restorative measures the pa- tient will usually recover within a month or two, but in most cases there can be little doubt that restoration is hastened by proper medicinal treatment. The drugs which experience has shown to be most useful are arsenic, strychnine, the zinc salts, silver nitrate, potnssium iodide, and cimicifuga. No routine treatment can be followed. The first indication is to remove every- thing that may be an irritating cause. The patient should be taken from school ; if the prepuce is too long, it should be cut ofT; if Ihore is evidence of worms they slioiild be got rid of, etc. The per- centage of hypermetropia, usually latent, he believes is extremely large, perhaps fully TO per cent.; and an investigation for latent heterophoria should always be made with tlie greatest care and patience. The relief of marked heterophoria should be finally attained only by graduated tenotomies upon the muscles exhibiting abnormal tension or by advancement of the tendons exhibiting defective power. Prismatic glasses are not curative and should not be given for constant use. Choreic subjects are usually rapidly cured by eye-treatnjent alone; the eye- problems encountered, however, are not, as a rule, so complicated and difficult to solve as those of epileptics. Sodium bro- mides employed with Fowler's solution of arsenic, and, if there is a chance of malaria being a factor in the trouble, quinine also. Tompkins (Amer. Jour. Obst., Mar., '97). Sedatives are of value combined with arsenic, the latter being given in the form of Fowler's solution or as a solution of arsenous acid in doses which are rapidly raised to twice or even three times what is usually accepted as the maximum. At the same time sodium or potassium bromide and antipyrine are given in large doses, while the relation- ship between rheumatism, endocarditis, and chorea is a sufficient indication for the routine use of the salicylates in con- junction with the other remedies. W. von Bechterew (Centralb. f. Ner\-enheilk. u. Psychiatric, Aug., 1900). Study of 1400 cases of chorea. Arsenic, pushed to the physiological limit, and then reduced slightly, is the best drug in the treatment, and antipyrine is sec- ond; exalgin, phenacetin. bromide, chlo- ral, and paraldehyde produced little effect. Better than any medicine is a change of air. M. Allen Starr ("Jacobi Festschrift"; Phila. :Med. Jour., May 20, 1000). Several cases of neuritis which super- vened after the cure of chorea by arsenic. In these cases 10 drops of liquor arseni- calis had been given thrice daily for three or four weeks, by which time the patients had taken an equivalent of from to 8 grains of arsenous acid. None of the cases gave any warning of the ad- vent of the neuritis during the adminis- tration of the arsenic, but the symptoms developed after an interval of from a week to a fortnight subsequent to its discontinuance. No dose amounting in the aggregate to more than 4 grains of 182 CHOKEA. TREATMENT AND PROPHYLAXIS. arsenous acid should be administered to a child suffering from an attack of chorea. Railton (Med. Chron., Feb., 1900). Experiments performed in 1S79 by Chapuis have shown that arsenic when combined with butter appears infinitely less to.xic than when given in solution. These investigations, personally repeated, show that the amount of butter should be invariably fixed to 10 grammes what- ever the quantity of active principle in- corporated with it. To prepare the mixt- ure a known quantity of arsenous acid is taken according to the dose to be ad- ministered. To this is added sodium chloride in such proportion that 0.1 gramme corresponds to 0.005 of arsenous acid. This mixture of sodium chloride and arsenic is triturated with 10 grammes of fresh butter, and this amount is given spread on bread: a form of medication which is extremely pala- table to children. The drug must never be administered while fasting. The whole dose should be given at a time, but two doses a day seem to be sufficient. Under this method of treatment it is not necessary to confine the patient to bed or to put him on a milk diet. A more liberal diet gives better results. L6vy (These de Lyon, 1900). Three cases of chorea treated with sodium cacodylate instead of arsenic. The former drug given hypodermically, first in doses of Vj grain, then of Va grain. The patients recovered in from one to three weeks. In all the ordinary treatment had previously been tried without benefit. Lannois (Revue de ThOrap. Med. Chir., Ixviii, No. 5, 1901). The treatment of chorea with arsenic is inadvisable in very acute cases with coma or paralyses, in those that have been treated for some time with small doses of arsenic, in those in which there is reason to suppose that the rheu- matic process is going on in the acute form, and in eases of advanced cardiac disease. The writer gives the following principles for the administration of ar- senic in the treatment of chorea; See that tlie tongue is clear before com- mencing treatment, and, if not, give a mild mercurial purge and a stomachic mixture for forty-eight hours. Put the patient on a bland and easily digested diet. Give the drug in a much diluted form and in the same dilution through- out. Do not discontinue on the first attack of vomiting, which may be due to accidental causes. Increase the dose daily. Keep the patient in bed through- out the treatment. If the vomiting per- sists, discontinue the drug for twenty- four hours and then give the same dose as the last. Examine the patient very carefully daily for any sign of toxic action. What must be aimed at is a form of shock action on the nerve-tis- sues, and this may explain why long- continued treatment with small doses fails. On discontinuing the arsenic, the w-riter usually gives a mixture contain- ing iron for a few days. F. M. Pope (Brit. Med. Jour., Oct. 18, 1902). The cases (86 in number) treated with arsenic were of the shortest dura- tion, but simple rest lying down, in new surroundings (29 cases) without medicament, proved to be little inferior as a method of cure. Antip3'rine (20 cases) was less useful, and bromide (47 cases) and quinine (31 cases) quite useless. The average time of recovery with the arsenical treatment was sixty- three days. Tscherno-Schwarz (Archiv f. Kinderli., vol. xxxv, p. 454, 1903). It is always to be kept in mind that chorea is a symptom, in many instances, of some general bodily enfeeblement or disease; a thorough and searching phys- ical examination should invariably be made. Chorea is usually started by some re- flex irritation, such as eye-strain, nasal irritation, tight prepuce, a bound-down clitoris, or lumbricoid worms; and sec- ondary attacks may not always be true chorea. TIic patients can be divided into two classes: those that tend to get well under almost any, or even without treat- ment, and those who fail to obtain relief from medicine. In the latter the percent- age of hypermetropia, usiuilly latent, is extremely large, apparently about 70 per cent.; and an investigation of latent heterophoria should always be made, in choreic subjects, with the greatest caro and patience. Finally, the spasmodic CUOREA. TREATMENT AND PROPHYLAXIS. 183 movements which accompany and indi- cate organic lesions of tlie brain — as, for example, tliose of leptomeningitis — exist in but a small proportion of choreic sub- jects, and are usually associated with other evidences of disease. Tompkins (Amer. Jour. Obst., Mar., '97). Especial attention should be given the intestinal tract and stomach, renal dis- order, or any state of autogenous poison- ing, anremia, malarial poisoning, the presence of intestinal parasites, etc. The use of morphia, chloral, chloro- form or other sedative for the suppres- sion of the muscular movements is of questionable propriety in any case, and will usually prove injurious. Antipyrine in large doses: 4, 8, or 15 grains, according to age, repeated 2, 3, or 5 times a day; may be continued weeks without ill effect. Comby (La France Mfd. et Paris MCd., Sept. 6, '95). Antipyrine had a beneficial effect in 40 out of 60 cases, but in three-fifths of these cases the affection recurred. Wliere the drug failed the failure was due to intolerance or cutaneous eruption, but in a few cases it seemed to have no efTect. It wa3 found necessary to give largo doses; doses from '/j to 1 'A drachms were well tolerated for some weeks. Le- roux (Revue Mens, des Mai. de I'Enfance, June, '91). Severe typical case of Sydenham's chorea rapidly cured with camphor bro- mide, increasing from '/j to 2Vj drachms a day during twelve days, again decreas- ing to 'A during next fifteen days. Bourneville and Katz (Progr&s Med., July 16, '98). Satisfactory results from antipyrine given according to Eskridge's method. The drug is given in increasing doses, beginning with 1 grain for each year of the child's age, and increasing 1 grain each day. In the mildest cases the child is allowed to sit up a part of a day, and the antipyrine is only given in the even- ing, but in severe cases absolute rest in bed is necessary, the dose of antipyrine being given three times a day. The drug is stopped as soon as the choreic move- ments cease or greatly diminish. Fow- ler's solution and iron are given until two or three weeks after the cure ap- pears to be complete. In giving such doses of antipyrine (20 grains three times a day to a child 8 years old) the child must be kept in bed and carefully watched; should there be heart disease or any fever, it is not given. Rapid cures were obtained in nineteen cases so treated. S. D. Hopkins (Philadelphia Med. Jour., Aug. 19, '99). Physostigma (Calabar bean) used in two extremely violent cases of chorea. Results were better than those usually obtained by the treatment with arsenic. Extract of physostigma was given in doses of Vio grain, three times a day. J. W. Russell (Birmingham Med. Re- view, Sept., 1900). Very many of these eases are habit cases, induced by some trivial local source of irritation or reflex influence not of central origin. In such, static electricity plays a double rOle, and is uniformly successful if applied early. (1) It lessens the irritabilit.v and (2) acts as a powerful suggestive influence when systematically employed. Most cases of central origin are not due to any traceable organic defect, but are induced by functional derangement. Such are capable of being cured if not of too long standing. For treatment, a metal electrode covering the affected muscles is applied and held in position with the hand, and the wave-current is employed with as long a spark-gap as can be used without causing painful muscular contractions. Sparks to the region will also render the results more effective in some cases. If the condition is suspected to be of central origin, a large electrode to the back or abdomen should be used, as in epilepsy, for an additional fifteen minutes for its general effect. Under this rfgimc there are few cases of not more than two years' stand- ing that will not yield. W. B. Snow (Journal of Electrotherapeutics, Dec, 1901). After recovery from chorea especial care should be exercised in the education 184 CHOREA. ANOMALOUS VARIETIES. and bringing up of the child. A display of good judgment and the intelligent di- rection of conduct and development will be well repaid in increased stability and safety from relapse or from the subse- quent occurrence of some otJier and more serious neurosis. The treatment of chorea insaniens is practically the same as that of an out- burst of acute mania. Active measures — eliminants and nerve-sedatives — are indicated. Anomalous Varieties of Chorea. The otlier conditions described under the name of chorea are: — Endemic chorea, or epidemic chorea, a form of acute chorea with hysterical symptoms which develops in a number of persons at or about the same time in the same school or community. Sug- gestion plays an important part in its etiology. Hysterical chorea: Closely allied to the above, but with the characteristic symptoms of hysteria superadded. The so-called "chorea major" is a purely hys- terical phenomenon, and is not a chorea at all. Electrical chorea is the name given to certain forms of acute chorea in which the movements are sudden and light- ning-like in onset, and also to a state in which sudden rhythmical muscular con- tractions occur, simulating a "lie co- ordine." The term is loosely employed, and is used in a different sense by differ- ent authors. Procursive chorea, or "chorea festi- nans," is a form of chorea with hys- terical accompaniments in which rhyth- mical dancing and procursive movements are prominent, vertigo being often pres- ent at the same time. Saltatory spasm is a choreoid affection sometimes occurring in epidemics, and characterized by peculiar jumping and dancing movements, which are executed when the patient is startled in any way. It is closely related to the forms of mus- cular clonic spasm affecting a few or many groups of muscles of the body to which the name "tic convulsif" is given. It is also spoken of as "lata." It occurs in degenerates of hysterical tendencies, is often accompanied by the uncon- scious and involuntary repetition of words and phrases and actions seen or heard, and by the involuntary repetition of obscure words. Oscillatory or nodding spasm, spasm nutans, is characterized by rhythmical wagging or nodding movements of the head occurring in paroxysms or continu- ing for hours, or even during the entire time the patient is awake. It occurs in extreme degenerates, and may be com- plicated with epilepsy or other neurosis, or may accompany a hemiplegia or other secondary degeneration. It shades im- perceptibly into "habit chorea." Tic co-ordine, or habit chorea, consists in the involuntary occurrence of tricks of speech or gesture — a twist of the head, shrug of the shoulder, etc. It is some- times a result of an early attack of acute chorea, but occurs also as a primary affection, and may be inherited. Post-hemiplegic chorea is a name given to the irregular rhythmical or arhylh- mical jerky movements sometimes seen in hemiplegic limbs. Similar move- ments may occur as a result of infantile cerebral palsies. Chronic adult chorea is characterized by choreic movements associated with spastic symptoms and progressive mental deterioration. There is always marked degeneration in cortical cells and in pyramidal tracts. If there is a history of chorea in ancestry this "chronic adult chorea" is called "Huntington's" or "hereditary chorea." The affection was CHROMIC ACID. 185 described fifty years ago in America, but has obtained general recognition only since Huntington called attention to it in 1872. In typical cases the disease de- velops insidiously, slowly progresses, and terminates in marked spastic paralysis with advanced dementia, or in death. It is closely related, in etiology, pathology, and clinical features, to general paresis, into which it probably shades by insen- sible degrees. Careful pathological study made of case of Huntington's chorea. Investiga- tion of family history showed that nine members, beginning with patient's grand- father, had been affected. The changes consisted in a chronic parenchymatous degeneration of the cortex, with consecu- tive changes in the interstices and vascu- lar system. The belief expressed that the cells are originally properly formed, but that they are not endowed with their normal longevity. In Huntington's chorea, drugs, if given at all, must be administered in the largest possible, almost toxic, doses, for a long period of time. The marriage of persons with a heritage of Huntington's chorea should be discouraged. Joseph Collins (Amer. Jour. Med. Sciences, Sept., '98). Case in which the essential lesion con- sisted in the diminution in size of nerv- ous elements generally, an increase in pigment content of the nerve-cells, espe- cially in those of the cerebellum; an overgrowth of neuroglia tissue, — the relation of which to the nervous ele- ments seems to be passive and possibly accounted for by the so-called "tissue tension," — a shrinkage of the cells in the dorsal root ganglia with the analogous proliferation of the endothelial cells of their capsules, a pigmentary degenera- tion of the neuroglia, and a degeneration of the white matter about the periphery of the cord. O. Y. Rusk (Amer. Jour, of Insanity, July, 1902). These forms of choreic movements with degenerations in brain and cord are, of course, incurable. It will be seen that the term chorea has been applied to numerous and widely-different affections, insuring some confusion, as previously remarked. It is unfortunate that the name of "chorea" cannot be entirely restricted to mean the acute or Sydenham's chorea, since this is a tolerably-well-defined group of clini- cal symptoms, with a definite course and character. The other varieties of chorea are symptoms of hysteria and extreme degeneracy or of chronic degeneration in motor cells and tracts, and should pref- erably be relegated to their proper noso- logical place. E. D. BONDURANT, Mobile. CHOROID. See Iris, Ciliary Body, AND Choroid. CHEOMIC ACID.— This is an anhy- dride, found as brilliant, crimson-red, acicular, deliquescent crystals that are most freely soluble in water. It is pre- pared by mixing a solution of potassium bichromate with sulphuric acid, reject- ing the crystals of acid sulphate of potas- sium which crystallize cut, heating the liquor, and adding more sulphuric acid, when the chromic acid is formed by crystallization. It is also soluble in ether that is free from alcohol and water. It is decomposed by most acids — lactic, sulphurous, hydrosulphuric, hydro- chloric, arsenous, etc.; by glycerin; and is likely to cause explosion if mixed with the latter or with alcohol. Preparations and Doses. — Chromic anhydride (chromic acid), external use only. Chromic-acid liquor (1 part to 3 of distilled water), external use only. Physiological Action. — Chromic acid possesses the power of killing all low organisms, oxidizing organic matter, coagulating albumin, and destroying the tissues with which it comes in contact. It is thus antiseptic, disinfectant, and 1S6 CHKOiUC ACID. CHKYSAKOBIN. powerfully caustic. Made into a paste with water, its action is exceedingly slow and gradual, but deeply penetrating; in saturated solution it is less penetrating and slower in action. By employing a solution more or less dilute, the action may be graduated according to the ef- fects desired. Death has resulted from absorption when it has been applied too freely. Its local effects are, for the most part, antagonized by bland neutral fats, applied in excess. The toxic effects are similar to those of potassium bichro- mate. Therapeutics. — As an Antiseptic AND Disinfectant. — Two drachms of chromic anhydride added to 4 or 5 quarts of water gives an inexpensive, but efficient, antiseptic and disinfecting lotion for leucorrhceas, ozasnas, hyperi- drosis, putrid sores, etc.; a lotion of 10 grains to the ounce has a decided effect upon syphilitic, gouty, and kindred maladies of tongue and throat. As a local application to cancerous and other ulcerations, it is preferable to all other caustics, since the pain attendant on its application is trifling; but it must be used cautiously and discriminatingly. Morbid Growths. — A concentrated solution is useful in removing syphilitic condylomata and warts and other mor- bid growths from the genital region. It has been applied to external and bleed- ing ha}morrhoids, to fungus hmmatodes, onychia maligna, and onychia parasitica with great benefit. Warts quickly yield to the application of chromic-acid crys- tals, after the surface of the growth has been slightly moistened. Trachoma. — Some years ago a French oculist (Hairion) employed, with advan- tage, a solution of equal parts of acid in distilled water, applied with a camel's- hair pencil to obstinate granular oph- thalmia. The applications were made at intervals of four, six, and eight days, and, although it was never very painful or followed by any great amount of re- action, it admits of great doubt how far so deeply a penetrating caustic can, with safet}', be applied to so delicate an organ on the eye. Diseases of the Air-passages. — But the greatest availability appears to be in treating diseases of the throat, upper pharynx, and nose. Owing to its hygroscopic character, no agent is so effective when applied to nasal polypi, and it is also highly recommended in hypertrophic rhinitis. In either case the most convenient method is to heat the tip of an ordinary probe and touch it to one of the acicular crystals of acid; enough adheres for two applications, but care must be taken not to overheat the instrument, lest decomposition of the chromic anhydride should occur, and an insoluble compound be formed. CHRYSAROBIN. — This drug, also known as "Goa powder," "Araroba powder," "Po de Bahia," and also (im- properly) as "chrysophanic acid," is the metamorphosed heart-wood of the An- dira araroha: a leguminous tree indig- enous to Brazil. It is a brownish -yellow crystalline powder, permanent in the air, tasteless, odorless, almost insoluble in water, slightly so in alcohol, completely in ether, containing a variable amount — 70 to 80 per cent. — of chrysophan, which latter, by oxidation, is readily transformed into chrysophanic acid. Chrysophanic acid is a neutral sub- stance, identical with rhein, the active principle of rhubarb. It is commonly found as a granular, orange-yellow powder, but sometimes takes the form of bright, shining-yellow needles: a transformation that is effected by subli- mation. It is odorless, acrid, soluble in CHRYSAROBIN. 187 alkaline waters, oils and fats, chloro- form, petroleum spirit, and glycerin; but is insoluble in water, alcohol, and ether. Preparations and Doses. — CJhrysaro- bin, Vs to 5 grains. Chrysophanic acid, Vg to V2 grain; as an emetic and purge, 8 to 20 grains. Chrysarobin ointment (acid, chry- sophanic, 1; benzoated lard, 24). Compound chrysarobin ointment (chrysarobin, 5; salicylic acid, 2; ich- thyol, 5; vaselin, 88). Chrysarobin pigment (acid, chryso- phanic, 1; solution of gutta-percha, 9). Araroba ointment (chrysarobin, 6; glacial acetic acid, 1; lard, 14). Bismuth chrysophanate, external use as an antiseptic only. Zinc chrysophanate, an antiseptic dusting-powder. Physiological Action. — In general the action of chrysarobin and chrysophanic acid, when given internally, is not un- derstood, but Brunton and Delepine be- lieve the latter to be an hepatic stimu- lant, and that it, at the same time, pro- duces a marked increase in the glycogen of the liver. It may be added, however, that chrysarobin is nn active irritant poison, and even in minute doses induces gastro-intestinal disturbances, such as vomiting and purging. There is noth- ing to the credit of either drug that should lead to its use as an internal remedy. Externally, chrysarobin is an irritant to the skin, staining it yellow; and, ap- plied in excess, produces irritation and inflammation, accompanied by swelling, itching, pain, heat, and sometimes a papular eruption; and the action is not always limited to the part to which it is applied, but extends to the healthy skin in the vicinity. Chrysophanic acid does not cause dis- coloration, but it is much less active than chrysarobin, and does not, in any sense, represent the true principles of the latter. Therapeutics. — Skix Diseases. — There is no doubt that chrysarobin is a remedy of value in parasitic skin dis- eases, and especially in psoriasis, but chrysophanic acid is far from upholding the repute of its derivative. Chrysophanic acid does not stain like chrysarobin, and is scarcely at all irri- tating; but comparative e.xperiments made .with the two substances in the treatment of psoriasis lead to the con- clusion that the former is not an effi- cient substitute for the latter in the treatment of this disease. Walter G. Smith (Brit. Jour. Derm., July, '96). Though at various times recommended in the management of acne and eczemas, chrysarobin is seldom of value. CHYLURIA. Definition. — A peculiar condition of the urine in which it presents a milky, or chylous, appearance and contains the constituents of chyle, especially fat and albumin. Varieties. — Two varieties of chyluria have been observed: (1) the tropical chyluria, which is of parasitic origin; (2) the non-tropical chyluria, the cause of which is unknown. Symptoms. — Chyluria presents an ex- tremely-varied clinical history, and the descriptions given of cases are most di- verse. Its course is marked by an irregu- larity and capriciousness which cannot be explained. The only constant symp- tom is the presence of so-called chylous urine. This fluid usually presents a peculiar whitish, opaque, milky appear- ance; sometimes the color is not whitish, but pink from the presence of blood. Occasionally the blood is not intimately mixed with the urine and very soon forms an adherent coagulum at the bot- tom of the vessel. In many cases, the 188 CHYLURIA. SYMPTOMS. urine, after some standing, will form a superficial stratum resembling cream or llanc-mange. The odor of the urine is ordinarily acid, rarely urinous; its re- action acid or neutral, rarely alkaline. Chylous urine ordinarily decomposes speedily and will then smell of sulphu- reted hydrogen. Sometimes it has been observed that chylous urine could be kept for months without fermenting. The specific gravity of the urine as well as its appearance varies greatly in the same person at different times, even at different periods of the day. The urine may, in some cases, contain coagula be- fore evacuation, which may cause local disturbance and pain while it is being passed. When blood-serum is added to chylous urine, large coagula will ordi- narily form. Microscopical examination of the urine shows that it contains fat in molecular form, but milk-globules or large drops of fat are not seen; the urine further contains leucocytes and blood-corpuscles, both white and red. In some cases crys- tals of uric acid have been observed, when the reaction of the urine is alka- line, the characteristic crystals of phos- phate of ammonia — magnesia — are ob- served. Frerichs relates that in one case he found the urine to contain a multitude of ripe and unripe sperma- tozoa. In the tropical variety of chy- luria, Lewis, in 1870, and after him many other investigators, found the em- bryos of Filaria sanguinis in the urine. By shaking the urine with ether, the fat molecules are dissolved and the urine clears up, completely or partially. Be- sides, the ordinary fat-cholesterin and lecithin have also licen found. Chylous urine always contains albu- min, generally in the form of serum- albumin; but globulin, albumose, and pepton may likewise be present. Casein has never been observed; sugar is not ordinarily contained in chylous urine, but Pavy and Habershon are said to have found it in one case. Quantitative estimation of the con- tents of chylous urine have been made in great number; the amount of fat varies from 0.028 to 3.3 per cent., while the albumin was found in a quantity of 0.12 to 2.7 per cent. As may be seen, their relative proportion varies much. The discharge of chylous urine usually occurs very suddenly; it may be con- stant, but more frequently is intermit- tent. The chyluria may cease for months and years and reappear without appreciable cause, even if the patient has made a complete change of climate. The urine is, in many cases, chylous only in the early hours of the day, or presents, at that time, a much larger quantity of chyle than at other periods of the day. This intermittence has been observed as well in the tropical as in the non-tropical varieties of chyluria. In some instances the position of the body — recumbent or erect — is found to bear influence. Case in a man, 57 years old, who had been in Florida for awhile. He can bring on a chyluria by lying down an liour, and more readily if he lies on the back than on the side. The Filaria sanguinis found by Dr. Ernst in his blood. Vickery (Boston Med. and Surg. Jour., Dec. 16, '97). 1. Chylous urine may result from a fialuloiis communication between tha lymphatic and urogenital system. 2. It may also be due to lipa^mia, the kidneys secreting a fatty urine. .S. Tropical chy- luria is always parasitic and due to the Filaria sanguinis hnminis or Distoma luvmntiihium ; non-tropical chyluria not d('[iciidcnt on lipirmia niiiy be caused by the KiiKtrongiilas gigas and possibly also by Tirnia nana. 4. The pathology of the non-parasitic types is not known, but these may depend on tumors, peritoneal lidhosionB, etc. 5. Certain peculiarities CHYLURIA. DIAGNOSIS. ETIOLOGY AND PATHOLOGY. 189 of the nontropical disease — such as the absence of sugar in the urine, the oc- currence of periodical attacks, and the varying composition of the urine during the twenty-four hours— require furtlier explanation. W. K. Predtetschenaky (Zeits. f. klin. Med., B. 40, H. 1, 1900). In most cases symptoms referable to the urinary organs are noticed, such as pains in the lumbar region, along the urethra, etc. Occasionally the urine co- agulates in the bladder, causing pain and difficulty during micturition. Persons suffering from chyluria may enjoy good health, but generally there is weakness, wasting, with mental depres- sion. Tropical chyluria is often accom- panied by fever and diarrhcea. Chyluria follows a very chronic course. Diagnosis. — Chyluria may resemble pyuria and lipuria; it can be distin- guished from both by microscopical ex- amination; in pyuria the urine contains innumerable pus-corpuscles; in lipuria the fat is not present in molecular form, but in large drops or in fine needles and crystals. Etiology and Pathology. — The tropi- cal, or parasitical, variety of chyluria is the best known, and its etiology has been elucidated by dilTerent authors. It has been observed in the United States, China, Japan, Siam, the Isle of France, Brazil, the East Indies, Egypt, Eeunion, Mauritius, Australasia, and recently also in Europe in persons who never had lived in tropical regions. Tropical chy- luria is caused by the presence in the blood of the embryos of Filaria san- guinis liominis: a nematoid worm. These embryos were first found in the urine by Wucherer, of Bahia, and later also observed in the blood by Lewis. Their natural history has been elucidated by many observers, especially by Manson. The adult filaria has a length of from 30 to 40 millimetres and is filiform: the embryo measures 0.0075 millimetre in diameter and 0.34 millimetre in length. Manson found that the parent filaria live in the lymphatics on the distal end of the glands; they are oviparous and their eggs are arrested in the glands and hatched there. The free embryos then pass along the lymphatic vessels and en- ter the circulation. Eesting in some organ during the day, they circulate with the blood during the night, or, as Mac- kenzie has shown, they rest during the sleep of their host, whether it be night or not. Manson describes four varieties of filaria: — Filaria nocturna, which can be de- tected in the blood only at night. Filaria diuma, which is found in the blood during the day only. Filaria perstans, which is always pres- ent in the capillaries. Filaria Demarquay, not half the size of the ordinary filaria. Filaria3 diurna and perstans seem to be confined to the western part of Africa, while filaria nocturna is always present in tropical countries and is endemic in some parts of the United States of Amer- ica. Study of the blood of about sixty negroes belonging to the different tribes of the Congo States. Embryos of filaria in the blood of the majority of them found. Filaria were also found in the blood of a negro from the Congo who had been living in Belgium for six years. Firket (Annual of the Univ. Med. Sci., vol. i, D-29, '96). It has not j'et been proved in what manner the embryos of the filaria give rise to chyluria, but it is commonly be- lieved that the parasites obstruct the lymphatics and cause their delicate walls to rupture, or that they perforate the walls of the chyliferous vessels and bring about abdominal communications. 190 CHYLUiUA. PROGNOSIS. TREATMENT. It has already been mentioned that chyluria presents an extremely varied clinical history and may be accompanied by divers other symptoms, such as chy- lurious discharges from various parts of the body, with elephantiasis, lymphan- gieetasis, etc. The diversity of the clinical manifesta- tions may, perhaps, find its explanation by the fact that it is not always caused by the same species of filaria. The non-tropical variety of chyluria is not of parasitical nature, and its origin is, as yet, quite obscure; it occurs even in cold climates, but is a very rare dis- ease. Hansen's observations seemed to show that the embryos were taken along with the blood in the stomach of a certain form of mosquito in which they undergo developmental changes. After some days the mosquito discharges its eggs in the water of some pool and the filaria there becomes free, and by this medium the animals are conveyed to the human sys- tem, through drinking the water. Mosquitoes seem to be the active agents by which the disease is propa- gated. The mosquito bites a man or an animal affected with the filarial disease. The filaria curls itself around the pro- boscis of the mosquito, is sucked into the stomach of the insect, passes into its tissues, grows, and develops there. When the mosquito dies the worm is set free, and, getting into drinking-water, is again introduced into the human subject through the stomach and alimentary canal. Byrom Bramwell (Brit. Med. Jour., July 31, '97). In some cases very small drops of fat have been observed to circulate with the blood and to be discharged through the kidneys; in some instances the authors favor the belief that the urine is secreted in its normal state, but that the fat is added during its passage through the ureters and the bladder. The dependence of the chylous change in the urine upon the introduction of fat into the intestinal canal is proven by the disappearance of tlie fat in the urine under starvation; by the appear- ance of fat-free urine under a diet very poor in fat; by the excretion of specific fats, such as olive oil colored with Sudan red, erucin, lipanin, by tlie urine following their introduction into the gastio-intestinal tract; and by the cir- cumstance that fat which is with dif- ficulty absorbed appears in the meas- ure of its absorbabilit}' ; the lack of re- lation between the excretion of fat in the urine and its introduction by other methods, as, for instance, by subcu- taneous introduction of colored fat; the early apfjearance of alimentary glycosuria, caused, probably, bj' the in- creased quantity of sugar in the chyle, resulting from the great amount in the intestinal canal; the appearance of chiefly mononuclear leucocytes in the chylous urine. Franz and von Stejskal (Zeit. f. Heilk., Bd. xxiii, ht. 11, Abth. F., ht. 4, p. 441, 1902). Prognosis. — Chyluria is ordinarily a disease of long duration. Sometimes the patients recover spontaneously; in other cases it leads to anemia and severe diar- rhoea and the patient dies from exhaus- tion. Treatment. — Medicine seems to have but little influence on chyluria. Eest, good nutritious diet which is not too exclusively animal, the use of pure water for drinking purposes, iron, and quinine have been recommended, as well as large doses of iodide of potassium. Against the parasitic chyluria anthelmintics have been tried, as methylene-blue (Austin Flint, Annual '96, vol. i, D-80) and thy- mol (Crombie, Annual, '96, vol. i, D- 81). In the tropics a plant — pcntaphyl- lum — is much relied upon; mangrove- bark is considerably used in Guiana. Case of filarial chyluria in wliom, other treatments having failed, thymol was ad- miiiiBtered in 1-grain doses every four hours, this dose afterward being doubled. CHYLURIA. CIAIICirUGA. lyi Under this medication the ILlarise disap- peared after a few weeks from the blood, and the urine gradually improved until in about two months it had resumed its normal character. Two months later no recurrence of the pathological condition had taken place. Lawrie (Indian Med. Rec, Mar., '90). Methylene-blue tried in a case of chy- luria due to the filaria sanguinis horn- inis. The effects of the drug were de- cided and prompt. After the administra- tion of 2 grains every four hours dur- ing the day, on March 5th, the parasites were very few at 11 P.M.; the only two found were deeply stained with blue and their movements were extremely slug- gish, the urine being clear, but intensely blue. On the fourth and the seventh days no parasites were found, although the treatment had been discontinued after the first day. On the eighth day the urine became milky, and on the night of the ninth day the parasites were found in great number, but their movements were not very active. On the tenth day the treatment was resumed and contin- ued for five days. Three days after, the blood being examined at night, a very few motionless filarite were observed. Since that time, and up to the present writing (more than a year), the urine has been normal and the patient has been restored to perfect health. Austin Flint (N. Y. Med. Jour., June 1.5, '95). Case of chyluria, the first of the kind observed in Philadelphia. Microscopical examinations of the blood drawn from the finger showed that the parasites were very few in number or absent from the blood during the day ; they were, there- fore, the variety known as the Filaria noctiinia. Methylene-blue in 2-gra;n capsules every three hours was ordered. After being taken continuously for sev- enty-two hours the blood was found to contain actively-moving unstained fila- riic. The urine and freces were stained a deep blue; the milk was uncolored. After being taken for nine days the drug proved absolutely inert so far as any in- fluence on the vitality of the embryos was concerned, and it did not stain them until they were dead. F. P. Henry (Med. News, May 2, '96). Two cases of chyluria in which re- covery took place rapidly under the use of ichthyol in daily amounts of 7 or 8 grains, in the form of pills. Moncorvo (Nouveaux Rem6des, Dec. 8, '97). F. Levison, Copenhagen. CILIARY BODY. See Iris, Ciliary Body, and Choroid. CmiCIFTJGA. — Black cohosh or black snake-root. The rhizome and root- lets of the Cimicifuga racemosa, a per- ennial plant found in the United States and Canada, contains an acrid, neutral alkaloid, soluble in water, dilute alcohol, chloroform, and ether, and two resins, one of which, cimicifugin, is precipi- tated from the tincture of cimicifuga when water is added to the latter. Preparations and Dose. — It is impor- tant that all preparations of this drug he made fresh, since they deteriorate upon keeping. Fluid extract, V2 drachm. Extract, 1 to 5 grains. Tincture (20 per cent.),l to 2 drachms. Cimicifugin or macrotin (resin), V2 to 2 grains. Physiological Action. — Cimicifuga was extensively employed by the abo- rigines of North America as an aborti- facient, its action in this particular greatly resembling that of ergot. It may be used when the latter drug cannot be obtained as an ecbolic, not only during parturition, but in post-parturition haem- orrhage. In moderate doses cimicifuga acts as a diuretic and tends to increase the bronchial and cutaneous secretions, while in small doses it stimulates digest- ive functions, acting as a bitter tonic. Its influence upon the heart resembles that of digitalis; large doses increase 192 CIMICIFUGA. POISONING. THERAPEUTICS. arterial tension and cardiac action, while the pulse is slowed. The latter resixlt being secondary, the use of the drug, when the walls of the organ are diseased, becomes dangerous in large doses. Poisoning by Cimicifuga. — A typical case of poisoning which occurred in the person of a physician will best illustrate the effects of an excessive dose. Dr. I. N. Brainard took 3 drachms of the fluid extract of cimicifuga, and the effects produced by the drug are by him described as follows: In about half an hour had a feeling of fullness in the head; the face was flushed; there was a sensation of warmth all over the body, with vertigo, which was increased when in the erect posture. There was con- siderable pain at the end of the spine. After an hour had elapsed all these symp- toms were accentuated. There was red- ness of the eyes, but the pupils were normal, as was also the bodily tempera- ture. The pulse was 100 and full, and there was marked increase in the arterial tension. At no time was there any slow- ing of the pulse or any signs of cardiac depression. The headache now became excessively severe, and the spinal cord was apparently much stimulated. The muscles in the back, arms, and legs were hard and trembling. Two hours later these symptoms continued with increased severity, and nausea then appeared. There was increased peristalsis, but no purging. Four hours after taking the poison he drank some warm water, and vomited three times during the next five hours. The symptoms continued, never- theless, until the eighth hour. The head- ache was so exceedingly severe that it was necessary for his wife to anaesthetize him with chloroform. There was a great deal of backache and restlessness. Eight hours after the drug was taken sleep came on, from which ho awoke several times with marked priapism. The ef- fects upon the spinal cord and nerves were felt for a little over two days. There was considerable increase of bronchial se- cretion, but no increase in the urinary flow or in the secretion of the skin was noticed during the entire period of the paroxysm. Therapeutics. — As may be surmised from its physiological properties, cimici- fuga has been recommended in almost every disease, but, being superior to very few drugs which possess special proper- ties of a more restricted kind, it has gradually been replaced by these. Its most marked effects are probably wit- nessed in the treatment of acute rheu- matism, and, according to Einger, in rheumatoid arthritis. N. H. Bentley found the fluid extract valuable in rheu- matic myalgia, while Balfour obtained considerable assistance for the relief of pain in disorders of neuralgic origin. Grouping the various results reported, it would seem to possess analgesic action, its diuretic properties tending, at the same time, to rid the economy of prod- ucts of metabolism: the keynote of re- lief in rheumatic disorders. Another disorder in which cimicifuga sometimes proves superior even to ar- senic is chorea, when administered in full doses. Its action in this disease is due to its influence upon the reflex centres of tlic spinal cord. Cimicifuga valuable in tinnitus aurium. Conclusions: — 1. Buzzing of the ear may bo considered as the reaction of the auditory nerve to direct or reflex irritation. 2. Gmlclfuga ruccmoHa possesses an action upon the auricular circulation and upon the reflex irritability of tlie auditory nerve; the average active dose is 30 drops of the extract a day. 3. Huzzing which has ex- isted more than two years appears diffi- cult to influence by cimicifuga. Albert Robin and Mendel (N. Y. Med. Jour., July 23, '98). CINCHONA. SPECIES. 193 As already stated, it may be substi- tuted for ergot in obstetrical practice when the latter drug cannot be obtained, but it is not as reliable. Its influence upon the uterine circulation and the in- voluntary muscular fibre causes it to be very effective in cases of uterine con- gestion whatever be the cause. It is, therefore, frequently employed in amen- orrhcEa, dysmenorrhcea, delayed men- struation, the menopause, etc., when con- gestion of the uterus and adnesa plays an active part in the morbid process. CINCHONA. — Cinchona, cr cinchona- bark, was first brought to Europe some time in the seventeenth century, but just exactly when or how is not really known, though a great number of idle and fanci- ful tales are extant that purport to ac- count for its introduction. It was cer- tainly employed medicinally as early as 1640, though its most prominent alka- loid, quinine, was not discovered until 1820 (see Quinine). Some thirtj'-six species of cinchona are recognized, and, when the number of hybrids is considered, the total is consid- erably augmented; but at the same time only seven constitute the source of the principle 'Tjarks" and alkaloids of com- merce, as follows: — Brown, pale, Loxa (or Loja) bark, ob- tained from Cinchona officinalis and the varieties condaminea, honplandiana, and crispa; red bark, from C. succirubra; gray, or silver, bark, from C. nitida, C. micrantha, and C. Peruviana; yellow bark, from C. calisaija and its variety Lcdgeriana; Columbian or Cartagenia bark, from C. lancifolia and C. cordi- folia ; Pitaj'o bark, from (7. pitai/ensis ; and Cuprea bark from Ecmijia Purdi- eana and 7?. pcduncuUta, the last two be- ing forms seemingly intermediate as to the true and false cinchonas. All are evergreen trees or shrubs that favor mountain-ranges and slopes at elevations varying from 400 to 11,500 feet above sea-level; they average from 30 to SO feet in height, and measure from 1 to 2 feet in diameter at the base. The leaves resemble those of the laurel, are entire, of varying shape, the best pitted — or with numerous small shallow depressions — on the under-side (except C. succirubra) and a prominent mid-rib; flowers tubular, fragrant, rosy- white, or purplish; fruit- capsule two-celled, splitting from the base upward, and containing many winged seeds. All are indigenous to the Andean region of South America, and the pale, red, and yellow barks constitute the chief imports; the euprea-barks are little used. Pale and red barks, the prod- uct of cinchona plantations in India, instituted and fostered by the govern- ment, are also obtained, arriving from Madras and other seaports on the Bay of Bengal. There are likewise plantations in Ceylon, the Malay Peninsula, in South Africa, Jamaica in the West Indies, and a very rich form of Ledgeriana and cali- saya is obtained by way of Amsterdam or Hamburg from the plantations of the Dutch Government in Java. Formerly the trees were felled close to the ground and stripped of bark, not even the branches escaping, but of recent years the discovery was made that a more profitable jizld. could be obtained by merely removing the bark in strips or sections from the standing tree, the de- corticated portion being renewed if pro- tected, and as rich in alkaloids as before; also that the yield of alkaloids could be materially increased by covering the bark with moss or matting, thereby prevent- ing the rays of the sun from converting the alkaloids into coloring matter. Again, it has been found that by careful selection of favorable species, and by 194 CINCHONA. SPECIES. crossing and again selecting, barks may be produced that will yield double or even treble the quantity produced by the best non-hybrid varieties. The calisaya is one of the most im- portant of the "barks," inasmuch as qui- nine constitutes from one-fourth to three-fourths of the total alkaloidal yield. The old •'•'natural flat bark," the product of felling and stripping, is no longer met with, but, instead, so far as the United States is concerned, the major portion is a yellow bark rolled from flat pieces, coming from Bolivia; there are also "quilled" and doubly-quilled varieties, of variable thicknesses, from 3 inches to 2 feet long, ^/< to 2 ^/^ inches in diameter and Vi2 to Ve inch thick, with a longi- tudinally-wrinkled and transversely-fis- sured, brown epidermis, the latter prac- tically tasteless and inert, and easily sep- arated from the inner or medicinal por- tion. This bark is of short, fibrous text- ure, compact, presenting shining points wherever broken, of brownish-yellow hue, faint odor, and bitter, slightly-as- tringent taste. The red hark has many alkaloids, but does not yield as much quinine as the calisaya. It comes in quills and flat pieces, varying in thickness from Vs to V< inch, is of deep-brown or brown-red color, and gives a short, fibrous fracture. The epidermis is covered with warts and ridges; the inner surface rather coarsely striated. It gives a powder of a deep brown-red hue that is slightly odorous, but astringent and bitter. Pale harks also come in cylindrical pieces of variable length, sometimes singly, sometimes doubly "quilled," are from Vo to 1 inch in diameter and from Vsi to Vo (more rarely V*) ^^ thickness. The exterior surface is rough, of a gray- ish color, with transverse, and sometimes longitudinal, fissures; interior surface either rough or smooth, according to the period of gathering; fracture smooth, with some short filaments on the inner surface; faintly-aromatic odor, and mod- erately bitter and astringent taste. Of the total alkaloids, from 50 to 65 per cent, is quinine. Thianuco, or g7-ay bark, of a cultivated variety and much richer than the pale forms in quinine, is now obtained from Jamaica. The quills are frequently somewhat spirally rolled, and on the epi- dermis are numerous short, irregular, transverse cracks; the edges are flat, scarcely separated or everted; the outer surface is whitish or of a clear silvery gray, or in the smaller quills of a uniform whitish-gray; inner surface yellow, yel- lowish-red, sometimes cinnamon-brown; smooth in small quills and fibrous in large; fracture smooth and resinous, odor claj'ish and pleasant; taste astringent, aromatic and bitter. The bark from C. nitida is not wrinkled longitudinally on the derm, and the inner portion is of a more or less brown hue; but the product of C. micranlha is often wrinkled longi- tudinally, though almost devoid of trans- verse fissures; it has a rusty-yellow in- terior. As obtained uncultivated from South America, these gray barks yield less than 3 per cent, of alkaloids, often but 1.5 per cent., of which but from "/,(, to °/i5 per cent, is quinine. Columbian, or Cartagean, barks are of two forms. That from C. lancifolia is chiefly from young stems and branches, are usually "quilled" and coated with a brownish-yellow epidermis, in turn perhaps coated with white crustaccous lichens, causing it to assume a grayish or silvery appearance. The quills vary in size from "/„ to 1 V2 inches in diameter, some being rather smooth, others rough, owing to numerous short, slight, longi- tudinal and transverse cracks; edges CINCHONA. PREPARATIONS AND DOSES. 195 slightly everted; extremely fibrous and moderately bitter. It is not uncommon to find the "quills" trimmed: i.e., with the epidermis removed. The interior may be reddish, orange-yellow, or yellow; hence it is not always easily distinguished from the gray barks. The cordifolia form occurs both as flat pieces and as fine, middling, and thick quills; the flat pieces more or less twisted, arched, and warped; from V2 ^o ^ inches broad, 4 to 8 or 12 inches long, and V„ to % inch thick. The quills vary from 5 to 12 inches in length, are from V4 to 'A inch in diameter, and V,., to V4 inch thick, and also are frequently deprived of epi- dermis. The interior surface of both forms varies from smooth to flbrous, the prevailing hue being of a pale-ochre yel- low, in old species brownish. The fibres often project obliquely, giving a scaly, fibrous appearance. The epidermis, when present, is observed of a whitish, yellow- ish-white or ash-gray hue, with irregular, flexuous, longitudinal, but not very deep furrows. The fracture, if transverse, is short, internally more or less fibrous, ex- ternally corky; longitudinally it is un- even, short, coarse, and splintery, and often eilected only with difficulty. The powder is of cinnamon-hue, moderately bitter and astringent. Both the fore- going barks vary materially in their yield of alkaloids. Pelaya harh is of little interest save to manufacturers of alkaloids, and con- tains from 1.5 to 1.8 per cent, of quinine. It comes in short quills or curly pieces of a brownish color, and is especially rich in quinidine. The cuprea barks come in short red quills and broken pieces, and are not true cinchona-barks, but are here men- tioned because they are a source of cin- chona alkaloids; they contain quinine, quinidine, cinchonine, but no cinchono- dine, and also cupreine: an alkaloid that exists in connection with the first named, and was formerly held to be a distinct entity to which the titles of "homo- quinine" and "ultraquinine" were given. The cinchonas are incompatible with tinctures of iodine, tannin, alkalies and alkaline carbonates; are antagonized by mercury, iodides, and the salts of lead, zinc, and copper. Preparations and Doses. — Cinchona- bark, powdered, — all forms, — 10 to 60 grains and upward. Cinchona decoction (cinchona, 10 drachms; distilled water, 16 ounces), 1 to 2 ounces. Cinchona infusion (cinchona, 1 ounce; water, 16 ounces), 1 to 2 ounces. Cinchona infusion, acid (red bark, 4 drachms; boiling distilled water, 10 ounces; aromatic sulphuric acid, 1 drachm), 1 to 2 ounces. Cinchona infusion, compound (red cinchona, 1 ounce; Virginia snake-root, 2 drachms; boiling water, 24 ounces; in- fuse and evaporate to 1 pint, and add 4 ounces of spirit of Mindererus), 1 to 2 ounces. Cinchona infusion, inspissated, 30 to 60 minims (obsolete). Cinchona extract, solid (pale and yel- low forms), 5 to 30 grains. Cinchona extract, solid (calasaya), hy- dro-alcoholic, 2 to 15 grains. Cinchona extract, solid (red), 2 to 30 grains. Cinchona extract, solid (red), alco- holic, 2 to 30 grains. Cinchona extract, fluid (pale and yel- low — 5 per cent, total alkaloids), 5 to 30 minims. Cinchona extract, fluid, aromatic, 20 to 120 minims. Cinchona extract, fluid (red), 5 to 30 minims. 196 CINCHONA. PREPARATIONS AND DOSES. Cinchona extract, fluid (red), com- pound, 20 to 90 minims. Cinchona extract, fluid (red), detan- nated, 20 to 90 minims. Cinchona tincture (pale and yellow forms), 1 to 4 drachms. Cinchona tincture (red), 30 to 130 minims. Cinchona tincture (red), compound (Huxam's), 30 to 120 minims. Cinchona tincture (red), compound ("\\Tiytt's), 30 to 120 minims. Cinchona tincture, ammoniated, 30 to 120 minims. Cinchona tincture, ferrated, 20 to 60 minims. Cinchona-wine (cinchona tincture, 10 parts; sherry-wine and .glycerin, of each, 30 parts), 1 to 4 drachms. Cinchona-wine, aromatic, 1 to 4 drachms. Cinchona elixir, B. P., 30 to 60 min- ims; TJ. S. P., 1 to 2 drachms. Cinchonine crystals, 1 to 40 grains. Cinchonine benzoate, 1 to 5 grains. Cinchonine bisulphate, 1 to 30 grains. Cinchonine iodosulphate, 1 to 3 grains. Cinchonine and iron tartrate, 3 to 8 grains. Cinchonine salicylate, 3 to 15 grains. Cinchonine picrate, 1 to 3 grains. Cinchonine sulphate, 2 to 30 grains. Cinchonine tannate, 2 to 30 grains. Cinchonidine crystals, 1 to 20 grains. Cinchonidine bisulphate, 1 to 20 grains. Cinchonidine borate, 1 to 10 grains. Cinchonidine dihydrobromate, 1 to 10 grains. Cinchoni'lino bydrochlorate, 2 to 20 grains. Cinchonidine salicylate, 1 to 10 grains. Cinchonidine sulphate, 1 to 30 grains. Cinchonidine tannate, 5 to 15 grains. Cinchonidine tartrate, 2 to 15 grains. Quinetum (chinetum), 1 to 8 grains. Quinetum sulphate, 1 to 8 grains. Quinidine (chinidine, conchinine), 3 to 30 grains. Quinidine bisulphate, 5 to 60 grains. Quinidine citrate, 1 to 12 grains. Quinidine dihydrobromate, 5 to 50 grains. Quinidine hydrobromate, 5 to 50 grains. Quinidine sulphate, 5 to 60 grains. Quinidine tannate, 5 to 15 grains. Quinoidine (chinoidine), 2 to 15 grains. Quinoidine borate, 8 to 15 grains. Quinoidine citrate, 5 to 25 grains. Quinoidine hydrochl orate, 5 to 25 grains. Quinoidine sulphate, 5 to 25 grains. Quinoidine tannate, 5 to 15 grains. Quinoline (true, from cinchonine), 15 to 30 minims. Quinine, alkaloid, 2 to 15 grains (see Quinine). Cinchona febrifuge (see Quinetum, on pages 197 and 200). Cupreine, 1 to 15 grains. Cupreine sulphate, 1 to 15 grains. Esencia de calasaya, 4 to 12 drachms. Compound elixirs of cinchona (all kinds), 1 to 2 drachms. ITeberden's ink (aromatic iron and cin- chona mixture), 1 to 2 ounces. Homoquinine (mixture of quinine and cupreine), 1 to 15 grains. Cinchonine and Salts. — The alkaloid appears as white shining prisms or nee- dles, at first without much taste, but after being swallowed developing a dis- tinct bitterness on tongue and palate; it is soluble in dilute acid, in alcohol 1 to 116, chloroform 1 to 163, and very slowly so in ether and water. The bemoaie is soluble in alcohol, slowly so in water, and comes in the form of small white crystals. The hisulphide appears in rainutc' CIAX'HONA. PKEPAKATIONS-AND DOSES. 197 trisnetric prisms, soluble in water and in alcohol. lodosulphaie of cinchonine is a dark- brown, odorless powder containing 50 per cent, of iodine, and, though some- times administered internally, it finds its principal use as an external application and substitute for iodoform; it is freely soluble in alcohol and chloroform; slowly soluble in water. Nitrate of cinchonine appears as color- less prisms, soluble in water; its value is about the same as any other ordinary salt of the alkaloid. Salicylate of cinchonine, introduced as a remedy for rheumatism, has never equaled the expectations; it comes in white crystals, soluble in alcohol. Cinchonine sulphate is a fair substi- tute at times for other cinchona alka- loids; is obtained in hard, white, lus- trous crystals of very bitter taste. It is soluble in 10 parts of alcohol, about 65 parts of water, and 75 to 80 of chloro- form. The tannate salt is of variable com- position, like most tannates; it is an amorphous, yellow powder, by no means constant as to color, slowly soluble in water, and readily so in alcohol. Cinchonidine is usually obtained from the red cinchona, and may appear either as white prisms, or a white powder, or in light, white masses, and has an intense bitter taste; is soluble in alcohol, ether, and chloroform, in dilute acids, and in water slowly. Cinchonidine bisulphate is soluble in water and alcohol, and comes in striated prisms. Another salt of no material value is the borate : a white powder that is soluble only in alcohol. The dihydrohrornate, h/drochloraic, and hydroiodatc salts appear, respectively, as slightly yellowish prisms, white prisms, and yellowish-white crystals; all are soluble in water, and the hydrochlorate in alcohol and chloroform as well. The salicylate of cinchonidine appears as white colorless microscopical crystals, soluble in alcohol, very slowly so in water. Cincho7iidine sulphate presents white, silky, acicular crystals that effloresce on exposure; is soluble in alcohol and hot water; slowly so in cold water. The tannate is a yellow, amorphous powder, practically tasteless, of uncertain and variable composition. Cinchonine tartrate, very slowly sol- uble in water, rapidly so in alcohol, is a white crystal powder. Quinetum, known also as chinetum, kinetum, and cinchona febrifuge, is a mixture of the alkaloids of red cinchona- bark, devised by East Indian authorities as a better, cheaper, and safer remedy than quinine, and it seems to have met with general favor. In the United States is prepared an elixir of all the cinchona alkaloids that is most palatable, known as "esencia de calasaya," which is in- tended for the same precise purpose. Quinetum is an amorphous, grayish- white powder, containing from 50 to 70 per cent, of cinchonidine; is soluble in dilute acids and slowly so in water. Quionin purports to be much the same thing, but is more uncertain as to com- position. There is also a neutral sul- phate of quinetum prepared. Quinidine, chinidine. or conchinine, has the form of colorless, lustreless prisms, and effloresces on exposure; is soluble, 1 to 20, in alcohol, 1 to 30 in ether, and 1 to 2000 in water. Both a sulphate and hisulphatc are had, the former as white needles, the latter as long, colorless crj'stals. both being ex- tremely bitter; the sulphate is soluble, 1 to 8, in alcohol, 1 to 14 in chloroform, 1 to 100 in water, while the bisulphate 198 CINCHONA. PHYSIOLOGICAL ACTION. is soluble (with fluorescence) in water only. The dihydrolromate, hydrdbromate, and hydrochlorate are all white cr}'stal salts, all soluble in water, and the last two also in alcohol. The tannate is an amorphous, taste- less, white powder only partly soluble in alcohol. Quinoidine, or chinoidine, is a mixt- ure of amorphous alkaloids that remain in solution after the crystalline alkaloids have been separated. It is a very bitter, brownish-black mass, lustrous and resin- ous in appearance, soluble in dilute acids, alcohol, and chloroform, and softens at a temperature of 212° or less. The borate and citrate appear as yellowish- brown and reddish-brown scales, re- spectively, and both are soluble in water and alcohol. The hydrochlorate and sul- phate are bitter white powders, alike soluble in alcohol and water. The tannate is a yellow or brownish amor- phous powder partly soluble in alcohol. Quinoline, for the most part, is a ter- tiary amine derived synthetically from aniline, or naturally from coal-tar, though it can also be had from cincho- nine. It is a colorless liquid of peculiar odor, that turns yellow with age, and is lauded as an antiseptic; a large number of salts are made, but these are not de- rived from the cinchonine product, which is five times as expensive as the synthetic or that had from coal-tar. For description of the quinine alka- loids see Quinine. Quinic, or Icinic, acid is another de- rivative of the cinchona-barks, with a decided acid taste, soluble in water and alcohol, and obtained in the form of hard, white, transparent, monoclinic prisms. Qiiinolinic acid is no longer had from cinchonine, but from the artificial prod- uct; and the same is true of the quino- sulphuric acids. Quinopicric acid is a yellowish-brown powder made by mixing quinine and cin- chonine picrates. Quinovic acid is secured from quino- vin, derived from certain cinchonas. These two, quinidamine, quinquinia, quinicine, quinone, and quinotannic acid are obsolete, reclassified, and rearranged, or no longer obtained from cinchona- barks or alkaloids, but as the result of chemical enterprise in connection with aniline and the coal-tar products. Physiological Action. — The physio- logical effects of the cinchona-barks and their alkaloids are so inextricably bound up with the action of quinine that they cannot well be separated; therefore only a brief resume can be here given; for more elaborate description, the reader is referred to Quinine. Cinchona is about fifty times more bulky than its alkaloids, is more astrin- gent, more apt to irritate the stomach, and much more difficult of absorption. Given in sufficient doses, cinchona and its alkaloids are antiperiodic, tonic, febrifuge, and to some degTce antiseptic. In small doses no sensible effect is pro- duced, except, perhaps, with the excep- tion of slight arterial excitement, though some, who may be particularly sensi- tive to the drug, may exhibit an in- creased flow of animal spirits. Taken in medium doses, just before retiring at night, they sometimes induce sleepless- ness. In large or long-continued doses headache may be induced, along with deafness, noises or ringing in the ears, flashings of light across the eyes, vertigo, nausea, and even delirium and coma if pushed to extremes. The supervention of any of these symptoms, called "cin- cbonism," indicates that the full physio- logical effects have been produced, and CINCHONA. POISONING. THERAPEUTICS. 199 that no further benefit can be obtained by persevering in administration. The action is much more rapid and energetic when given on an empty stomach, espe- cially after considerable abstinence from food, or when combined with an acid, than when given after meals or in merely a semisoluble state. The drugs, more- over, appear to be — at least in consid- erable proportion — taken up by the cir- culation with the result of depriving the blood to greater or less extent of its co- agulability; in fact, when the dose is sulKciently large the action is like that of any other poisonous agent. No doubt, the reflex excitability of the cord is diminished on occasions, though this has, in many instances, been denied. Small doses tend to increase the secre- tion, while large produce a diametric- ally-opposite effect. Respiration appears not to be influenced. Large doses ex- hibited during a febrile paroxysm ma- terially depress temperature. The alka- loidal salts may be detected in consider- able quantities in the urine in from 30 to GO minutes after ingestion, but where the bark is exhibited transformation and elimination may be materially delayed. Elimination is usually at its height, in any event, during the third hour; di- minishes in twenty-four hours; and ceases about the third day. Although traces of salts may be foimd in the saliva, perspiration, and the secretions and ex- cretions of the intestines, the bulk of elimination is by the kidneys, and the amount of uric acid in the urine, particu- larly in malarial poisoning, is apt to be decreased. Most of the salts have an oxy- toxic action. Poisoning by Cinchona.— The fatal dose of any cinchona alkaloid is un- known, and, as regards the bark, it would be difficult to ingest enough to cause fa- tality, because of the facility with which the stomach rejects enormous doses. Cin- chonism, already mentioned (see Physio- logical Action), moreover, affords am- ple warning of untoward effects. A full ounce of quinine has been ingested at a single dose without inducing any very alarming effects, but foreign literature records a case whore 5 ounces proved fatal. The skin of many persons is affected in a peculiar way by the internal adminis- tration of the alkaloidal salts; these erup- tions may present any of the forms of purpura, roseola, eczema, pemphigus, or even the exanthem of scarlatina. Case in which, two days after taking 15-drop doses of compound tincture of cinchona, a patient complained of in- tolerable itching, which was soon fol- lowed by vesiculation on the genitals, face, and ears; the whole general surface of the body rapidly became the seat of a scarlatinoid dermatitis. As this began to decline, the palms and soles became affected with blebs, as much as eight ounces of serum being evacuated. The blebs recurred, and it was five or six weeks before recovery was complete, the palms being the last to recover. The same phenomena had before occurred from the administration of quinine. The chief points of interest are the variety of the bulbous manifestations and the great disproportion between the violence of the cutaneous outbreaks and the small amount of the drug ingested. Johnston (M.d. Age., Aug. 25, '97). Therapeutics. — Cinchona - bark no longer receives general employment, partly owing to the large doses de- manded, and partly because of the su- periority of the alkaloids, either singly or mixed. Once in a great while it finds use in the application of a "cinchona jacket" in the agues of children, the powdered red bark being quilted between two folds of the garment, which is ap- plied next to the skin. Cinchona (red) and snake-root, with spirit of Mindererus is also often employed as a tonic and 200 CINCHONA. THEKAPEUTICS. stimulant in low forms of fever, typhoid more particularly. Cinchonine alkaloid is found chiefly in the pale varieties of bark. Its action (and likewise that of its salts), is very similar to that of quinine, but less ener- getic, and requires to be given in larger doses; it is sometimes substituted for quinine, being cheaper, and when the latter commanded a high price cinchona was often employed as an adulterant. In intermittent it has an unquestion- able, but variable, action; sometimes its action is slow, whatever the dose exhib- ited, and the paroxysms cease gradually. It is only about two-thirds as active as quinine: a fact that must be considered when prescribing. Again, in doses of 10 to 15 grains it sometimes induces cin- chonism, and which it is not usually prudent to exaggerate; further, its thera- peutic action is not always proportion- ate to the physiological effects; for, while it sometimes answers the purpose for which it is prescribed without the latter being manifested, on the other hand, the physiological effects may be most energetic, without any evidence of therapeutic activity. It certainly can- not wholly replace quinine or its salts in severe intermittents or remittents, but may prove a valuable adjunct. The hy- drochlorate salt is admittedly the best form for administration, though the sul- phate is, perhaps, more generally em- ployed. Cinchonine appears to act very much in the same way as quinine, but less pow- erfully; it depresses the heart more than quinine does. (Whitla.) According to Wood, it is about one- third weaker than quinine, and must be lised in correspondingly larger doses. Cinchonine is recommended as a feb- rifuge for children because it is nearly tastelcBB. The cinchona alkaloids, when swal- lowed in insoluble form, combine with the acids of the gastric juice and become soluble; so that, as a mere solvent, it is unnecessary to administer cinchonine with acids, and a large dose merely sus- pended in fluid is quite as efficacious as when dissolved. Many observers consider that cincho- nine is superior to quinine as a prophy- lactic. This alkaloid passes off in part by the urine, but a portion appears to be consumed in the blood or to be elim- inated in some other way. Cinchonidine is accepted as isomeric with cinchonine, and its alkaloids are used to a small extent as a substitute for the latter and its derivatives, or for qui- nine salts; like all the derivatives of cinchona, it is toxic and antiperiodic. It is distinguished from cinchonine by its solution being levogyrate, and from qui- nine and true quinidine by its acid solu- tion not being fluorescent. Cinchonine solutions are dextrogyrate, and its acid solutions are not fluorescent; like cin- chonidine, it does not give an emerald- green color with chlorine-water and am- monia like quinine and quinidine. According to Whitla, cinchonidine re- sembles both quinine and cinchonine in action, but is less powerful than the first, being about equal to the latter. Like cinchonine, it depresses the heart more than quinine. Clinical experience lias proved the cinchonidine salts to be reliable tonics and antiperiodics. They are said to be eliminated by the kidneys unchanged; also to produce less disagreeable symp- toms, both gastric and cerebral, than quinine; but Eafferty, who administered more than three hundred ounces, affirms that it is apt to cause nausea and vomit- ing. (Wood.) Quinetum. — This, as before men- CINCHONA. THERAPEUTICS. 201 tioned, is known also as "cinchona febri- fuge." It is an amorphous, dirty-white powder consisting of mixed alkaloids ob- tained from the red-cinchona grove at the government plantations, Darjeeling, India; the alkaloids are in the same pro- portion as found in the bark. The sul- phate is a more presentable salt, and re- sembles quinine sulphate. As the sub- stance known as quinetum consists chiefly of cinchonidine salts (from 50 to 70 per cent.), these latter probably will offer an efficient substitute. Neverthe- less, it has almost replaced quinine in India, and is said to be more readily absorbed into the system than the crys- talline alkaloids. It is a well-known fact that the com- bined alkaloids of the cinchona-bark are much more effective as a tonic than any one of them taken singly. They are to be preferred in combination also, in many instances, as an antiperiodic, particularly when the periodicity of the attack has been in some degree mitigated. It is for this reason that the East Indian Govern- ment now provides its officials with "cin- chona febrifuge," — which is merely a combination of cinchona alkaloids — in preference to quinine. While cases are encountered where quinine is practically indispensable for a time, there are few which will not readily yield, and more satisfactorily, to a combination of cin- chona alkaloids. Esencia de calasaya and cinchona febrifuge are practically iden- tical, save that the former is a fluid medicament, the latter a powder. The esencia, moreover, is an ideal general tonic, and is particularly useful in atonic dyspepsia. In the alcohol habit it satis- factorily neutralizes the craving for spir- its, and will be found of great service in treating this disease. Wingrave, Lond. (Jled. Age, Sept. 2.5, '93). Quinidine is believed to have the same action and medical properties as other cinchona salts, and to be equally as effi- cacious as quinine without giving rise to the disagreeable nervous effects occa- sionally observed when the latter is given in large doses. Hare says the dose should be double that of quinine, but it would seem preferable not to greatly surpass the dose of quinine. Quinoidine, or Chinoidine. — There is little to say regarding this substance further than that it partakes of the na- ture and characteristics of other cin- chona preparations. As before remarked, it is a bj'-product, chiefly a mixture of such alkaloids as are not readily ex- tracted, left after the major portion of the same have been crystallized out. It may be resolved into ordinary quinine, cinchonine, and quinidine alkaloids, but is not generally held a profitable measure. Solutions in either boric or sulphuric acid are employed as cheap febrifuges, but their taste is verj' nauseous. Quinoi- dine is neither as certain in composition or uniform in effects as quinetum. Quinovic, kinovic, or chinovic acid is little employed, as it offers no advan- tages over other cinchona derivatives: it poses rather as a chemical curiosity than as a medicament. Cupreine is nearly allied to quinine, and generally on extraction from cuprea- bark found conjoined with the latter: a combination that for a time obtained the title of homoquinine, it being supposed to be a specific alkaloidal entity. Both sulphate and muriate salts are manufact- ured, but neither the two latter nor the alkaloid — though purported to be equally as efficacious therapeutically as the qui- nine and its salts — have as yet secured a permanent position in the materia med- ica. For further consideration of the thera- peutics of the cinchonas and their de- rivatives, the reader is referred to Qui- NIXE. G. Archie Stockwell, New York. 202 CIXXAilON. PHYSIOLOGICAL ACTION. THERAPEUTICS. CINNAMON AND DERIVATIVES.— Cinnamon is the inner bark of the shoots of the Cinnamomum Zeylandicum and C. aromaticum : beautiful eyergreen trees twenty to thirty feet high and twelve to eighteen inches in diameter, cultivated in many portions of the East Indies-. The bark comes in long, closely- rolled quills, composed of eight or more layers; is of pale-yellowish-brown hue, the inner surface striated; fracture splintery; odor fragrant and warmly aro- matic, and taste sweet. Some forms are more coarse in taste and odor. Cassia- buds are the calyces surrounding the young germ. The term "cassia" is fre- quently applied to Chinese and Saigon cinnamon, which is less expensive and more generally marketed in the United States than Ceylon cinnamon. Preparations and Doses. — Cinnamon- bark (powdered), ad libitum. Cinnamon powder, compound, 10 to 30 grains. Cinnamon- (cassia) oil, 1 to 3 minims. Cinnamon extract, fluid, 15 to 30 min- ims. Cinnamon infusion, 60 to 120 minims. Cinnamon tincture, 60 to 180 minims. Cinnamon tincture, compound, 30 to 120 minims. Cinnamon spirit (essence), 10 to 30 minims. Cinnamon syrup, 1 to 2 drachms. Cinnamon-water, ad libitum. Cinnamic acid, ^/^ to "/^ grain. Cinnamic aldehyde, not employed medicinally. Cinnamyl-acetate, not employed. The compound, or aromatic, powder of cinnamon is made by adding 35 parts of ginger, 15 of cardamom, and 15 of nutrnofr, to 35 parts of cinnamon. Physiological Action. — Cinnamon is a warm aromatic, acting as a true sto- machic by a gentle stimulating action on gastric mucous membrane, increasing its secretion and assisting digestion; hence its general employment as a condiment. It is also hajmostatic, oxytocic, and slightly astringent. The oil and cin- namic acid are also antiseptic, and the acid is claimed to be antituberculotic: a claim not altogether satisfactorily sub- stantiated. By some, cinnamon is held to be contra-indicated in all inflam- matory states of the gastro-intestinal tract. Therapeutics. — The scope of the drug is not a very extended one, and it is chiefly employed to render mixtures more palatable. The eclectics generally regard cinna- mon a powerful specific styptic: a claim that appears to be fairly well substanti- ated by general therapeutic literature. It certainly has, on many occasions, proved most efficacious in epistaxis, hfemoptysis, hajmaturia, and uterine haemorrhage. In tedious labors depend- ent upon atony of the uterus and in- sufficiency of contractions, cinnamon proved quite efficacious in the hands of Mursinna and Thomas Hawkes Tanner. This drug specifically inlluences the uterus, controlling lioBniorrhage and stim- ulating contraction of its muscular fibres. In small and repeated doses it is capable of producing abortion; hence it is in- disputable that it exerts a powerful in- fluence on the nutritive functions of the womb. It is possible that more study and e.xperimentation will reveal the drug to be possessed of further remedial virt- ues. Webster ("Dynam. Therap.," '93). It acts upon the uterus like, though much less powerfiilly than, ergot, and probably also on the smooth muscular tissue in general — and as a styptic and astringent. It is employed, therefore, as an adjuvant to remedies for diarrhoea; in the second, non-febrile stage of acute intestinal catarrh; and in torpidity and slight hiemorrhages of the uterus, us\i- ally in combination witli ergot. Roth ("Mod. Mat. Med.," '95). CINNAMON. THERAPEUTICS. 203 Though used as an aromatic, its chief use is to control uterine hteraorrhage, and it acts promptly by contracting the bleeding vessels; it is also of consider- able value in some forms of diarrhoea. Locke ("Mat. Med. and Therap.," '95). Thirty cases of dysentery were perma- nently relieved by employing from one to six doses of the Persian remedy: a drachm of powdered cinnamon made into a bolus with a few drops of water and swallowed with as little fluid as possible. Avetoom (Lancet, Lond., vol. i. Mar., '95). As AN Antiseptic. — Cinnamon, cin- namic acid, cinnamic aldehyde, and the oil of cinnamon doubtless possess anti- septic power, and may be advantageously used in the treatment of purulent foci and necrotic processes. It is owing to this property that it has occasionally proved of some value in pulmonary tu- berculosis. No living disease-germ can resist for more than a few hours the antiseptic power of essence of cinnamon; even its scent will kill them. The essence is as effective as corrosive sublimate. An in- fusion of cinnamon is valuable in influ- enza, typhoid fever, and cholera. Chara- berland (Med. Age, Apr. 25, '94). Cinnamic aldehyde, or cinnamic acid, has recently been employed as an anti- septic in the various forms of tubercu- losis, with encouraging results. Stevens ("Man. of Therap.," '94). The oil of cinnamon is powerfully anti- septic and may be used in dilute form in the dressing of wounds, and by injection in gonorrhoea; in the latter disease it acts best in the early stage. Cinnamic acid is also used for the same purpose. Hare ("Prae. Therap.," '94). A solution of 1 part of cinnamic acid in from 10 to 20 parts of glycerin proves an excellent remedy in tuberculosis, par- ticularly of joint-cavities; it may be injected into the joint, into the fungous mass, or into the gluteal muscles. Like- wise it may be employed in pulmonary and intestinal tuberculosis. Leucocytosis begins in from nn hour and a half to two hours after the injection, and reaches the ma.ximum in eight hours. The leucocytes are increased, and there is no decrease in the red corpuscles or the haemoglobin. Landerer (Therap. Monats., Feb., '94). It is probable that oil of cinnamon cures consumption in two ways: In the early stage of catarrhal phthisis by so directly afi"ecting the bacilli as to stop their growth; in cases farther advanced by only allowing organisms incapable of growth to pass along the bronchi, and thus prevent the infection of fresh lobules. In this way the disease may be limited to small areas, where it can be dealt with by the vital processes of the body, and cut off from the system by the formation of fibrous tissue, and so cease to be an immediate source of danger. It is interesting to observe the order in which the symptoms subside: The expectoration and cough are the first to improve; then the temperature tends toward the normal; finally the weight begins to increase; and all these are accompanied by gradual diminution in the number of the bacilli in the sputum. Thompson (Brit. Med. Jour., vol. ii, '97). In advanced cases of phthisis personal results with cinnamic acid were distinctly unfavorable. In 12 cases not so far ad- vanced, treated intravenously, for periods of from five to seven weeks, 3 died, I be- came worse, 3 remained in much the same condition, and 5 were but slightly improved. Laryngeal complications were not benefited by the treatment. Hremop- tysis seemed to be rendered worse. F. Friinkel (Deutsche Archiv f. klin. Med., Ixv, pts. 5 and 6, 1900). Febrile Diseases. — In low stages of fever, and where there is persistent nausea and vomiting, some of the cin- namon preparations appear absolutely magical in effect, but the causes of the latter condition are so varied, and fevers so protean in their aspects, that no one remedy can be relied upon on all occa- sions. It has been recommended in malarial diseases, but, at best, it can only be con- sidered as a succedaneum. 204 CIRRHOSIS OF THE LI-\T;K. CLASSIFICATION. CIRRHOSIS OF THE LIVER. Definition. — Suggested by Laennec as a name for one particular condition of the liver, the term "cirrhosis" was not only found to be of immediate utility, but, like many other usefxil words, has rapidly acquired secondary meanings, and unfortunately the pathologist and the clinician disagree in the secondary meaning which they assign to the term. Hence a definition of "cirrhosis" satisfac- tory to all parties cannot well be given. In short, the word, by becoming too use- ful, threatens to outlive its usefulness. The pathologist employs it to indicate all those conditions in which there is a generalized, as opposed to localized or focal, development of increased amounts of fibrous tissue in the organ; the clini- cian recognizes as included in the term all those conditions characterized by con- nective-tissue overgrowth in connection with the liver, whether the overgrowth be focal or general, whether it affect the interior of the organ or the peritoneal capsule, and urges in favor of this view that all these conditions may give rise to a like series of symptoms; while, on the other hand, he is unwilling to include under the terms such forms of connect- ive-tissue overgrowth as give rise to no recognizable symptoms. According to this view, the gummatous liver of tertiary syphilis is cirrhotic, as is also the condi- tion of chronic productive perihepatitis in which the capsule alone is affected, while the development of fibrous tissue in the centres of the lobules which may accompany chronic venous congestion of the organ is not to be classed as a cir- rhosis. Remembering that Laennec employed the word in association with a general- ized fibrosis of the organ, and not to in- dicate the complex of symptoms induced by this condition, and recognizing, also. that it is impossible to restrict it nowa- days to the one form which he described, the definition accepted by the patholo- gists more nearly approaches the original acceptation of the term, and will be ad- hered to in this article. At the same time, adequate reference will be made to such conditions as are not included in that definition, but which are regarded as cirrhosis by a large number of clini- cians. Classification. — Starting, then, with this definition, and including under the term all those states in which there is a generalized overdevelopment of connect- ive tissue throughout the liver, it will be well, before attempting any classi- fication, to pass in review the factors which primarily induce this overgrowth. Our knowledge of the causes leading to fibrosis elsewhere, imperfect as it is, leads to the belief that inflammation is the main factor, — not acute, but, as it is termed, "productive." It may be brought about by the action of a mild Irritant extending over a relatively-long period, or by the recurrent action of a somewhat more severe irritant. In either case there is a stimulus afforded to the proliferation of the connective-tissue cells of the part — and the new growth corresponds to the granulation-tissue seen in a healing exposed wound. A prominent feature in fibroid tissue of this nature is its liability to contract. It would appear that in the commonest form of cirrhosis, the portal, or atrophic, this is the main process at work, the irritant reaching the liver by the portal vein and especially manifesting its ac- tivity by sotting up an irritation along the interlobular l)ranchc8 of that vein. This, however, is not the only form of inflarnniatory fibrosis. There may be a now development of connective tisBuc — a replacement fibrosis — to take the ])!ace CIRRHOSIS OF THE LIVER. CLASSIFICATION. 205 of cells of a higher order, which, through the action of some irritant or disturb- ance, have undergone destruction, and it is still a matter of debate whether, in portal cirrhosis even, such replacement- fibrosis is not largely concerned in the new gi-owth. Of more recent observers Sieveking, examining twenty atrophic cirrhotic livers by the Van Gieson method of staining, concluded that the connective-tissue growth was the first disturbance. Markwald came to the op- posite conclusion: that necrosis of the peripheral liver-cells is the first event in the disease; and Euppert describes both productive formation of connective tissues and inflammatory atrophy of the liver-cells. Personally I cannot but re- gard this last view as the one most in harmony with the appearances seen in the majority of cases of well-defined portal cirrhosis. In one form of cirrhosis, — the pericel- lular or interstitial, — of which in man the liver of congenital syphilis affords the best example, — replacement-fibrosis is the distinguishing feature. In this the various stages of cellular atrophy can be well followed, and the little groups of cells are to be seen surrounded by del- icate new tissues of a character very dif- ferent from that of the dense connective bands seen in portal cirrhosis. The dif- ference makes itself evidenced by the gross appearance of the organ, for this form of fibrous tissue does not contract, the surface remains smooth, and the organ is enlarged instead of being dimin- ished in size. It may be urged that this enlargement is a proof of the productive character of the process, but the enlarge- ment appears to be due, in the main, to a lack of pressure-atrophy of the he- patic parenchyma so characteristic of portal cirrhosis, coupled with a com- pensatory proliferation of the liver-cells to replace those which have been de- stroyed. A proliferation or hypertrophy of this nature is occasionally well marked in the portal form, resulting in the form- ation of islands of new liver-tissue and the production of a large hobnailed liver. Rarely the new growth of the paren- chyma advances to an adenomatous or even cancerous condition, and we meet with a greatly-enlarged irregular cir- rhotic liver with multiple neoplastic masses derived from the liver-cells. If this process be the explanation of the hypertrophied liver of pericellular cirrhosis, then the appearances in biliary cirrhosis proper present macroscopically and microscopically so many points of approximation to what has just been de- scribed, that the fibroid overgrowth here may well be largely of the nature of a replacement-fibrosis. The tendency is for recent observers to regard it as such, and to consider that biliary cirrhosis of the type which has especially been stud- ied by Hanot is a cholangitis in which either the bile-capillaries within the lobule, or the cells bordering upon these, are especially affected. These liver-cells undergo gradual atrophy and replace- ment by new connective tissue. Goluboff regards this form as being primarily due to the chronic, diffuse, catarrhal angi- ocholitis with chronic, diffuse periangi- ocholitis. Now, a catarrhal angiocholitis affecting the smallest bile-ducts affects the capillaries also, and is inevitably a process affecting the liver-cells them- selves. But, while accepting these views with regard to the main characteristics of the fibroid changes of these two im- portant forms of cirrhosis, it must, I think, be admitted that, save in rela- tively-rare instances, the organs affected by one or other form of the disease show a mixture of both productive and replace- ment chanjres. 206 CIRIIHOSIS OF THE LIVER. CLASSIFICATION. There are yet other ways in which fibroid tissues may be developed in vari- ous organs ^vithout recognizable iniiam- matory disturbance, and, as I have pointed out in the Middleton Goldsmith Lectures (1S96), there may be increased development of fibrous tissue of a func- tional type. Such fibrosis is to be recog- nized in connection with altered condi- tions of the arterial, venous, and lym- phatic circulation. It is difficult to say how far such forms manifest themselves in the liver. On the whole, the evi- dence is against there being any exten- sive development of new connective tis- sue in the organ from such a cause; but it may well be that the indurative form of passive congestion of the organ and the growth of fibrous tissue around the interlobular branches of the hepatic vein, in eases where there is long-continued obstruction of moderate degree brought about by either heart or lung disease, are to be regarded as due to a laying down of new connective tissue around the he- patic venules of non-inflammatory origin. It is evident that, inasmuch as our definition is based upon the one condi- tion of overdevelopment of fibrous tissue in the organ, a proper classification of the various forms of cirrhosis cannot be based primarily or adequately upon the disturbances occurring in other parts of the body as secondary results of the he- patic fibrosis, but must be either etiolog- ical and made dependent upon the vari- ous causes leading to the development of fibrous tissue or, on the other hand, must — anatomically — be determined by the parts of the liver which are the pri- mary seat of the development of the new tissue. Our knowledge of these cirrhoses is still insufficient for either the etio- logical or the anatomical classification to be ideally perfect. Against the etio- logical classification it may be objected that we are still uncertain as to how far the commonest form — portal cirrhosis — is due to the direct action of alcohol, how far it is due to the absorption of toxic substances from the intestinal canal sec- ondary to the gastritis and enteritis in- duced by alcohol; nor again does the mere enumeration of causes help us in every case to distinguish the special type of cirrhosis which those causes induce, and so, the sjTnptoms depending upon the form of hepatic disturbance, such a classification can be of little clinical value. On the other hand, the anatomical classification is imperfect to the extent that, while the disease may begin by af- fecting one special portion of the liver, as the process of fibrous-tissue develop- ment extends, it involves many other parts, and, consequently, in well-devel- oped cases cirrhosis is anatomically of a mixed type, and it is far from easy in such cases to determine how the condi- tion originated. The fullest etiological classification is that given by ChauSard, and this has, at the same time, the ad- vantage of being anatomical. He di- vides the cirrhoses as follows: — 1. Vascular (originating around the vessels). IA\ Tovip S^- Due to iiiKCStea poisons. (yi) lo.xii, j. 2. Due to autoclitlioiious poisons. (a) Local (B) Infectious '1. Hy tlie (lirool; nv.- lioii of microboH. 2. liy tliuir indirect .action till" on rIi - tlieir toxiiia (or, :is he tornm it, toxi- ^ infection). <, \. Arteriosclerotic. RoBtive. (i))Ext™- tiopatic. (C) Dystuopiiio ! 2. Biliary. (A) Dub to Diliaky Retention, (B) Dure TO ANOiociior.iTis ok tiiic Smai.leu lill.K-DUCTS. 3. Capsulah. (A) CiiiioNio Localized Periiiei-atitis. (/?) CHUONIO aENEUAI.IZEI) PEUITONITIS. Admirable as is this classification, it CIRRHOSIS OF THE Ll\ KK. PORTAL CIRRUOSIS. ETIOLOGY. 207 is difficult to see how we are to make the distinction which is here made between the toxic cirrhosis and the toxi-infective. Anatomically and clinically, poisons — whether absorbed from the stomach or developed in the system itself, or again passing into the blood as a result of the growth of micro-organisms, or again given off by micro-organisms within the liver itself — may produce similar lesions in the liver, and as a consequence bring about closely allied, if not identical, ana- tomical changes in the organ with the development of like symptoms. The dis- tinction thus raised by Chauffard be- tween these various forms is too fine for practical use; clinically, his subdivisions are almost valueless; hence, in this ar- ticle, I have divided the cirrhoses accord- ing to anatomical grounds alone, and shall recognize the following forms of cirrhosis according to the origin of the process: — 1. PoBTAL CIRRHOSIS, in which the process appears to begin especially around the branches of the portal vein. 2. BiLiART Cirrhosis. — (a) In which the process manifests itself around the larger bile-ducts. (6) In which the proc- ess more especially shows itself around the smallest bile-ducts and in connection with the bile-capillaries. 3. Pericellul.\r cirrhosis, charac- terized by the development of fibrous tis- sue throughout the lobule around the individual cells and groups of cells. 4. Arterial cirrhosis, in which are chronic periarteritis and develop- ment of fibrous tissue around the ar- teries. 5. Centrtlobular cirrhosis, char- acterized by the development of fibrous tissue around the interlobular branches of the hepatic vein. 6. Secondary, or cextripetal. cir- rhosis, due to the extension inward of a chronic fibroid inflammation secondary to chronic productive perihepatitis. 7. Sporadic cirrhosis, secondary to focal necroses scattered through the organ or to the development of inflam- matory foci in no one well defined por- tion of the liver-tissue, which act as centres from which there radiates a fibroid change. Of these different forms it must be repeated that all are not clinically recog- nizable and that it must be clearly borne in mind that a change beginning in one anatomical region of the organ is, by its extension, peculiarly liable to affect other regions. I will now proceed to consider these various forms, calling attention to those which are clinically important and those which are, up to the present time, clinically unrecognizable. Portal Cirrhosis. Etiology. — This form of cirrhosis is most frequently associated with alcohol- ism, more especially with the use of spirits, and as a consequence has become known in England as the gin-drinker's liver. At the same time a small propor- tion of cases is met with in which there is an entire absence of the alcoholic his- tory. Upon this continent all other causes are insignificant when compared with the one prime cause of excessive and long-continued use of alcohol. Wliile this is the case and while alco- hol must be regarded as a prime cause, much evidence has accumulated of late years to throw doubt upon alcohol as the primary cause. As Pa}Tie has pointed out, cirrhosis of the liver is the exception and not the rule in autopsies upon drunk- ards; the fatty, and not the cirrhotic, liver is typical of alcoholism. Besides this, the experiments of a large num- ber of observers have failed to demon- strate that ethylic and not amylic alcohol 208 CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. ETIOLOGY. is capable of producing any marked de- velopment of cirrhosis in the livers of rabbits, dogs, pigs, or rats. In fact, only three observers, Straus and Blocq in the rabbit, and de Eechter in the dog and rabbit, have observed such cirrhotic changes. Magnan, Euge, Pupier Xairet, Combemale, Strassmann, Afanassijew, von Kahlden, Lafitte, and Kerr have found almost entire absence of portal in- flammation, but have noticed more or less extensive fatty infiltration and fatty degeneration. It may be urged that these observers did not preserve their animals for a suf- ficient length of time; nevertheless, sev- eral of the observers kept their animals for several months, and, were alcohol the direct cause of the disease, there should undoubtedly have been more evi- dence of, at the least, a beginning in- flammation in the portal sheaths around the lobules. Importance of alcohol is much over- rated in the etiology of cirrhosis of the liver. Eosenstcin (Brit. Med. Jour., Oct. 1, -OS). Alcohol, in the main, leads to fatty liver, while, on the other hand, the evi- dence has steadily accumulated, notably in India, that extreme cirrhosis may attack children and adults who have never taken a particle of alcohol either medicinally or otherwise. J. George Adami (Lancet, Aug. 13, '98). To ascertain what influence alcohol had as a cause of hobnailed liver the records of 2020 necropsies made at the Middlesex Hospital were examined; of these, 149 were cases of cirrhosis of the liver, which was hobnailed in 30. Of the 30 cases, alcoholism was acknowledged in 15, denied in 9, and not noted in lH. Of 4278 necropsies made on children under 12 years of age at Great Ormond Street, there were 23 eases, and hobnail- ing was present in 13. Conclusions are that alcohol plays an important part in the prodiietion of cirrhosis, but in wliiit way is uncertain. Arthur Voslcker (Brit Med. Jour., Sept. 29, lilOO). This discrepancy between the experi- mental results and the history given in man of alcoholism is to be explained in two ways: Either it must be admitted that alcoholism is the primary factor in cirrhosis, in which case it has to be ac- knowledged that individual predisposi- tion plays a part of almost equal impor- tance; so that cirrhosis is to be described as being due to the fibrotic or cirrhotic diathesis manifesting itself under the in- fluence of alcohol. Or, on the other hand, we must regard alcohol purely as a predisposing cause, and must pass be- yond the alcoholism and admit that, at most, alcohol causes irritation and in- flammation of the gastric intestinal mu- cosa, whereby either toxic substances pass into the portal blood from the intestines (and regard these toxic substances as the direct cause of the inflammatory condi- tion of the organ), or it is possible to go further and regard the inflammation as set up by some form of micro-organism entering tlie liver along the same paths. Upon the whole, the toxic, as opposed to the direct alcoholic, view would appear to be the more correct. All recent work appears to be leading to the conclusion that portal cirrhosis of the liver is brought about by a condi- tion of toxicJEmia. Of special interest in this connection is the observation of Flexncr, who found that by injecting a 1-per-eont. solution of dogs' serum, which had been kept for twenty-four hours, into the vein of a rabbit, the ani- mal showed almost immediate evidences of profound blood disturbance in the shape of hfcmoglobinuria, and in a week began to lose weight, and, dying at the end of the second week, presented in its liver most marked evidences of begin- ning porlal oirrliosis. CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. ETIOLOGY. 20S This view that cirrhosis is the result of an intoxication following gastro-in- testinal disturbance is that held by Hanot and the majority of recent French work- ers. [L6vi has gone so far as to suggest that the condition may be set up directly by bacteria. In a case of a young male of 17, in whom he found periportal cirrhosis and greatly enlarged spleen, with, in addition, bacterial endocarditis of the pulmonary valve, albuminuria, and sup- purative meningitis, he discovered a diplococous pathogenic in guinea-pigs. From liis description, the cirrhosis was of a rather mi.xed type, for, along with the ■ ricli connective-tissue overgrowth, there was \vell-marked proliferation of bile- canalieuli directly connected with the liver-cells. The condition lasted for fifty- one days, and, while it is possible that such extensive cirrhotic changes might have been produced in this time, the other lesions make it doubtful whether he was dealing with a condition of cir- rhosis directly due to the micro-organ- ism; certainly it cannot be said that the case is one of ordinary cirrhosis. J. Geobge Adami.] The following facts are recorded in regard to cirrhosis of the liver: 1. That in at least a very large number of well- marked cases of progressive cirrliosis in man there is to be found, largely within the liver-cells and also in the lymph- spaces in the newly-formed connective tissue, a peculiar and very minute form of micro-organism, presenting on staining to the proper extent the form of a diplo- cocous, surrounded by a faint halo, or, when stained deeply, being a rather ob- scure ovoid bacterium, which may easily be mistaken for stained deposits within the cells. 2. That in the infective cir- rhosis of cattle a very similar micro- organism is recognizable, present in like positions within the tissues and showing similar appearances when stained. 3. That from at least thirty cattle affected with this disease the author has been able to isolate the micro-organism from the liver-bile, abdominal lymph-glands, and in some cases from the various organs in 2—14 the body. 4. That the micro-organism isolated from these cattle is a polymor- phous micro-organism, appearing as a small diplocoocus when grown upon broth, and tends to assume a distinctly bacillary form when grown on solid media. 5. That this micro-organism is pathogenic for the animals of the labora- tory, and that in them it is to be recog- nized within the hepatic cells as in other regions. G. That from a case of distinct atrophic cirrhosis in the human being the author has been able to isolate from vari- ous organs of the body a similar micro- organism, which, grown on broth, has a diplococcic form and grown upon agar is present as a short or longer bacillus according to the age of growth. The author does not believe that the micro- organism causes only cirrhosis, and sug- gests that it may be the cause of more than one disturbance in the liver, — in- deed, in other organs. J. George Adami (Lancet, Aug. 13, '98). On the other hand, the not-infrequent presence of inflammation surrounding the atrophic liver and the frequent pres- ence of a right-sided pleurisy (which is suggestive of an extension of the inflam- matory process through the diaphragm into the pleural cavity) make it not im- possible that some cases, at least, of portal cirrhosis are due to something beyond the action of toxins and irritants conveyed by the blood, and makes it probable that some cases are associated with the pres- ence of definite bacteria. Besides these toxins, whetlier elabo- rated in the intestinal canal and absorbed, or due to the groii-th in the system of bacteria, other poisonous substances may lead to the developing of cirrhosis. Of such absorbed toxins it has been suggested by Budd that the frequent cir- rhosis found in the natives of India, who never partake of alcohol, is secondary to the irritation and gastritis produced by highly-seasoned foods; and Segers de- scribes an atrophic form in the Terra 210 CIRRHOSIS OF THE M'STER. POKTAL CIRRHOSIS. PATHOLOGY. del Fuegians brought about by eating mussels. He obtained from these mus- sels a poison which was definitely toxic for dogs and rabbits. Such cirrhosis is not infrequent in lead poisoning, and Lafitte states that, giving lead to rabbits with their food, he induced a cirrhotic condition in their livers. Eichhorst's case of nodular cirrhosis due to chronic phosphorus poisoning would come under the same category. Cirrhosis of the liver manifested among the Fuegians, who eat from 12 to 25 pounds of mussels daily, whether good or bad. The mussels are toxic only at a certain period of their development; the toxic efTect is not due to microbes, but to some chemical product. Chronic mus- sel poisoning is curable up to a certain point, when it is manifested only by en- largement of the liver. AVhen it has ar- rived at its second period, that of atro- phic cirrhosis, it is rapidly fatal. Segers (La Sem. M6d., Nov. 4, '91). All these are cases of disease possess- ing a similar character, namely: charac- terized by the development of the in- flammatory new tissue in the portal sheaths and more especially around the branches of the portal vein. For the present time I leave out of account the other forms of cirrhosis which are of a different type brought about by other toxic agents and the consequent develop- ment of inflammatory foci or focal ne- croses irregularly scattered through the liver-substance. Neither drugs, — O.IJ., alcohol, phos- phorus, etc., — nor embolism of the portal vein, nor ligature of the hepatic artery or bile-duct, or other operative procedure, nor acute yellow atrophy, nor long-standing venous congestion, can produce a true hepatic cirrhosis. One or other of these causes might result in cellular degeneration or necrosis. Such necrotic foci might come to be incap- sulated by fibrous tissue, but this is not a cirrhOHiH, which, in the proper sense of the term, is a progressively-advanc- ing interstitial hepatitis. The same ob- jection obtains as regards the interstitial changes which are seen passing inward from the capsule as a sequel to long- standing and progressive cases of fibrous perihepatitis. There is marked differ- ence between the cin'hotic changes that follow upon parenchymatous degenera- tion and the tiue classical interstitial hepatitis, which arises as a primary con- dition. Siegenbeek von Heukelom (Zeig- ler's Beitrage, B. 20, H. 2, No. 221, '9l3). In venous cirrhosis of the liver, with- out any lesion of the biliary apparatus or of the pancreas, the insufficient emulsification of the fats points to a dis- turbance in the functions of the liver, while the ureogenic, biligenic, glycogenic, and antitoxic functions of the liver are not yet disturbed. Luigi Ferranini (Ri- forma Medica, Oct. 31, 1900). Age and Sex. — With regard to sex, the condition affects males more than twice as frequently as it does females; indeed, some authorities would make it as much as three times more frequent in males. From the more recent statistics of EoUes- ton and Fenton, and of Kelynack, it would appear that the most common age at which death occurs is between 40 and 50; two-thirds of the fatal cases occur between 35 and 50. Kolleston gives the average age in males having an alcoholic history as 48, without alcoholic history, 49, and in females 4G and 51, respect- ively. Kelynack gives the average of his 121 cases as: males, 45J; females, 42. But the condition may develop at almost any period of life; numerous cases have now been brought forward in children since Palmer Howard ptiblished his clas- sical article on this subject. Pathology. — In alcoholics, in whom the condition most frequently develops, the liver is, at first, large, owing to the fatty infiltration and hepatic congestion, both of which are the direct result of al- coholism. In what is taken to be the earliest stage there is observable an ab- CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. PATHOLOGY. 211 normal collection of small, round cells infiltrating the portal sheaths and caus- ing them to stand out prominently in the stained sections, the greatest accumula- tion being in the neighborhood of the vessels running in those perilobular sheaths. These small cells have rounded, and not polymorphous, nuclei, and are generally regarded as being, in the main, embryonic, connective-tissue cells. In somewhat more advanced conditions the sheaths have undergone definite enlarge- ment and are formed of dense, fibrous tissue, although there is still an abundant infiltration of small, round cells more es- pecially at the margins where they abutt upon the lobular parenchyma. Just as at the beginning the infiltration is not evenly distributed around the lobules, so in more advanced conditions the develop- ment of fibrous tissue is not even, and as a consequence the newly-formed bands of fibrous tissue tend to surround many lobules; the fibrosis is what is termed muUilohular. As this inflam- matory new connective tissue reaches maturity, it contracts and by its shrink- age is produced the nodular and hob- nailed surface of the organ. In regions or cases in which this process of connect- ive-tissue formation has reached its limit or is not progressing, the new bands are sharply defined from the included paren- chyma of the organ; where it is continu- ing to advance there is not the same sharp separation; small groups of liver- cells at the periphery of the lobules may be seen more or less surrounded by strands of newly-forming fibrous tissue and exhibiting well-marked signs of atrophy. There is still much debate as to whether of necessity the first stage of portal cirrhosis is characterized by en- largement of the organ, and some recent writers, including Osier, would draw a distinction between the ordinary atrophic and the fatty cirrhotic liver. It is true that patients may die of intercurrent disease when the liver is still enlarged and fatty, and that, on the other hand, patients may only exhibit symptoms of cirrhosis when the organ is already so contracted as to be scarcely, if at all, palpable. But, taking into consideration the direct effects of alcoholism and call- ing to mind three or four cases in which, by good fortune, careful notes of the size of the liver were taken during the months preceding sj-mptoms of portal obstruc- tion, I cannot but uphold the view that portal cirrhosis (where associated with alcohol) has a preliminary stage of he- patic enlargement. Where alcoholism is not intimately connected with the de- velopment of the condition there, such preliminary enlargement may not, of ne- cessity, form a stage in the development of the condition. Study of 37 fatal cases of cirrhosis of the liver. Cirrhosis with enlargement, without change in size, and with diminu- tion in size are equally frequent. The size of the liver is increased in one-third of the eases. The male sex is more fre- quently alTected. Cirrhosis with enlarge- ment is more common in younger people, and cirrhosis with atrophy in old. The average duration of symptoms is longer in the atrophic cases. The duration of symptoms, however, varies within wide limits in all varieties. Hcemorrhage is a not-infrequent cause of death in all forms, and a fatal htemorrhage may be the first symptom, even in the hyper- trophic form. An alcoholic history was obtained in every case in which the sub- ject was investigated. A history of pre- vious malaria, syphilis, or gall-stones was occasionally obtained, but in none did it seem of etiological importance. Mors* (Boston Med. and Surg. Jour., Mar. 10, '98). In ordinary or atrophic hepatic cir- rhosis the pancreas is enl.irged, though the head and bodv are relatively smaller 212 CEREHOSIS OF THE LIVEK. PORTAL CIREHOSIS. VARIETIES. than the tail. The enlargement is due to well-formed fibrous tissue, cirrhosis of the liver radiating out from the blood-vessels. The gland-cells undergo fatty and pigmentary degeneration. The areas of cells, Langherans's islands, share in the pigmentary change. In hypertrophic biliary (or Hanot's) cirrhosis the pancreas is not increased in size or in weight, but shows a very in- timate fibrosis of an embryonic type spreading out from the ducts of the gland. There is periduetular fibrosis and a little proliferation of the epithelium lining the duets. The gland-cells show fatty degeneration. In cardiac hepatic cirrhosis the condition of the pancreas is inconstant. Lefas (Archiv G6n6r. de Med., May, 1900). It is remarkable how extreme may be the atrophy of the organ as a result of this fibroid contraction. Cases are on record in which in place of the normal 50 to 60 ounces (1500 to 1800 grammes), the organ has weighed from 16 to 10 ounces and even less, and notwithstand- ing this the main symptoms of the dis- ease may not be referable to the dimin- ished activity of the organ so much as to the secondary disturbances of the portal circulation. Despite the great de- velopment of contracting fibrous tissue around the lobules, bile may yet find its way from the bile-capillaries into the bile-ducts, and the fibrous bands, instead of appearing to be anaemic, appear to possess abundant blood-capillaries. Ob- struction there is to the portal circu- lation, and yet these capillaries can be easily injected from the portal vein; so that it is not necessary to assume, as some have done, that the blood-supply of the liver in this form of cirrhosis is, in the main, conveyed by the branches of the hepatic artery. As a result of the process, the organ is dense, firm, and of almost leathery consistence, present- ing, on section, minute islands of red- dish-yellow parenchyma of varying size surrounded by the more glistening bands of connective tissue. If the condition be complicated with jaundice, then the isl- ands of liver-tissue more especially are tinged by the bile-pigment; if with hemochromatosis (pigmental cirrhosis), both fibrous and liver-tissue may show a darker, slaty tinge; if the liver-cells still retain a fair amount of fat the islands of parenchyma appear of a paler yellow; if the process has been of more acute development, then with the fibrosis there may be inflammatory congestion, and the organ, in general, have a reddish ap- pearance. In general, the left lobe is more af- fected and more shrunken than the right; sometimes it is singularly small, — a mere appendage to the larger right lobe; but this is not constantly the case, and the opposite may occur. It must be kept in mind that the right lobe may be con- tracted behind the ribs and the left still be prominent: a condition which has more than once led to the mis- taken diagnosis of hepatic or pancreatic tumor. Tlic anatomical picture presented by a cirrhotic liver is usually one in which tlie regenerative processes are the most strilcing, the destructive process being sometimes evident, sometimes entirely past and represented only by the wide- spread .scars. Cin'hosis of the liver may be deliniid iis a chronic disease in which destructive processes, probably often re- ])eated, result in a loss of the functional liver tissue immediately followed by the furniation of a scar, the healing process, :iMd later by an attempt at the restitu- tion of the liver to normal by regener- ative processes. W. G. MacCallura (.Jour. Anier. Med. Assoc, Sept. 3, 1!)0I). Varieties of Portal Cirrhosis. — Thus far I have treated of portal cirrhosis in general, but it must be recognized that there are several varieties and stages in which the condition may manifest itself. CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. VARIETIES. 213 The unfortunate employment of the term "atrophic" has led to not a little confu- sion and failure to recognize that these several varieties are but manifestations of one and the same process. It may, in the first place, be questioned whether the disease always presents the same slow rate of development. Appar- ently this is not the case; we may have either acute or chronic cirrhosis. The London school of pathologists is inclined to recognize the red atrophic liver, char- acterized by the presence of large islands of yellow, fattily-degenerated paren- chyma surrounded by greatly-reddened congested tissue, which, under the micro- scope, shows abundant signs of a sub- acute productive inflammatory condition, ■with leucocytic infiltration and the de- velopment of new connective tissue. It is still a matter of a little doubt as to whether this condition is truly a portal cirrhosis. The cases brought forward by Cayley and Carrington and others all appear to be of this nature. There is a history of excessive indulgence in alcoholism, of preliminary slight gastric disturbance with signs of epigastric oppression, con- traction of the liver, and development of ascites accompanied by more or less jaun- dice. The gross appearance of the liver is not greatly unlike that of acute yellow atrophy; but death takes place not in a few days or weeks, but in two or three months after the first symptoms are com- plained of. On the whole, therefore, I am inclined to classify this red atrophy as an acute condition of portal cirrhosis. As vrill be readily understood, the vast majority of cases are, in the nature of things, chronic. Thus, to classify the different varie- ties: — (A) Acute: Eed Atrophy of the Liver. This condition has just been re- vie v,ed. (B) Chronic: 1. Enlarged Fatty Cirrhotic Liver. The organ is mark- edly enlarged, shows but slight nodula- tion, and microscopically presents a not- far-advanced condition of cirrhosis. In a large number of cases it is unaccom- panied by ascites, although the spleen may be enlarged; it occurs essentially in alcoholics and may not be recognized until after death from some intercurrent disease. 2. The Atrophic Hobnailed Livek. — The characteristic form of the disease. The organ greatly reduced in size, with surface studded with nodules of varying size, generally small; very dense and leathery; generally accompanied by marked ascites and other evidences of portal obstruction, and enlarged spleen. On section, of yellowish-red color, show- ing well-developed, glistening bands of fibrous tissue separating ofif small islands of the parenchjTna. 3. Portal Cirrhosis with Second- art Parenchymatous Hypertrophy. — The hypertrophic, alcoholic cirrhosis of French writers. The organ larger than, but similar in character to, the preceding form. There is a considerable amount of confusion about this form, owing to the use of the term 'Tiy- pertrophic." It has often been con- fused with the biliary cirrhosis of the type studied more especially by Hanot; while, again, others confound with this the intermediate stage between the en- larged fatty cirrhotic liver and the small atrophic organ, and again cases of mixed biliary and portal cirrhosis. In the true hypertrophic cirrhosis of this type the organ presents a nodular surface, some of the nodules being of a relatively-large size. The weight is normal or above the normal, and the enlarged size appears to 214 CIKKHOSIS OF THE LIVEK. PORTAL CIERHOSIS. VARIETIES. be due, in the main, to compensatory overgrowth of some of the isolated lobu- lar masses and to a partial recovery of the organ from the effect of the cirrhosis. •i. PoKTAL Cirrhosis with Adenom- atous OR Adexocarcixomatous Over- growth. — The distinction between the last condition of cirrhosis with parenchy- matous h}T)ertrophy and cirrhosis with generalized adenomatous condition is very subtle, and, as shown in connection vrith Fussell and Kelly's first case (Trans. Assoc. Amer. Physic, vol. x, p. 116, '95), good authorities may differ as to whether a liver presents the one or the other condition. On the other hand, there may be such extensive overgrowth and multi- ple formation of large neoplastic masses, that there can be no doubt as to the can- cerous nature. In the majority of these cases the cir- rhosis seems to be of the mixed kind, being multilobular and at the same time presenting abundant formation of new bile-canaliculi: an indication that pos- sibly the following form is not truly a mixed portal and biliary cirrhosis, but a portal cirrhosis with parenchymatous hy- pertrophy, one of the indications of their hypertrophy being a proliferation of the bile-canaliculi. 5. Mixed CiRRnosis. — A very large number of cases must anatomically be classed under the heading of mixed cir- rhosis, thougli the gross appearance of the organ and the clinical history bring them definitely into the category of portal cirrhosis. The condition is, in the main, multilobular, but there is abundant formation of new bile-canalic- uli. The organ, again, in general, ap- proximates to the normal size, and there is not the extreme atrophy seen in the uncomplicated cirrhosis. 6. Portal Cinniiosis with Pigmen- tation. — It is well known that normally the liver contains a certain amount of iron. Lindemann (Ctbl. f. AUgem. Pathol., vol. viii, "QT) finds that this iron in the slightest grades exists only in the cells of the portal tissue; when more extensive, there is deposit of the iron-pig- ment in the capillarj'-walls, and Kupp- fer's cells are affected; in the highest grade of antemia the pigment is in the liver-cells at the periphery of the acini. This pigment is, in general, of a bro^vn- ish or ochrous tint, and, though Auscher and Lapicque (Soc. Med. des Hop., Feb. 12, '97) speak of it as a form of hydrated iron, it is, perhaps, more truly an iron albuminate. Within the last few years, Letulle, Hanot and Schuhmann, Gilbert, and Grenet have described several cases of pigmentary cirrhosis, occurring in gen- eral in association with the hypertro- phic type of the disease: i.e., with either mixed cirrhosis or portal cirrhosis with parenchymatous hypertrophy. In these cases the livers contain increased amounts of iron. In a recent case of this nature observed by me the liver was of normal weight, but diminished in size and markedly atrophic, showing this iron everywhere, not only in the portal spaces, but present in large amounts in the cells right to the very centre of the hepatic lobules. The Germans are inclined to consider these cases as examples of cir- rhosis complicated with the condition which von Eecklinghauscn has denomi- nated "hfemochromatosis": a condition of wliich a full account will be found in Hintze's paper (Virchow's Archiv, vol. exxxix, p. 459). Two out of five of Hintze's cases of this condition showed cirrhosis of the liver. In these states the iron-pigment is not only present in the liver, but is abundant more especially in the non-striated muscle, more especially in the intestines, in the lymphatic glands, and it may be CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. VARIETIES. 215 also in the pancreas, spleen, salivary glands, etc. Lubarsch {ibid., p. 495) ascribes this condition either to second- ary results of large haemorrhages or to the development of multiple capillary hffimorrhages whereby the iron of the haemoglobin is taken up and deposited in this modified form into the various organs. Possibly there is an intimate connection between the occurrence of multiple small hsemorrhages in the portal area and the production of this pig- mented cirrhosis; rarely the skin also be- comes pigmented and shows a bluish color. [Bronzed diabetes. In association with diabetes there also occurs, rarely, a combination of pigmentation and bronz- ing of the skin, and cirrhosis of the liver of the "mixed" portal type. The cases of this diabHe hronzi have been noted almost exclusively in France, though Saundby, in England, has re- corded one case. In many cases of diabetes, more especially in the early stage, the liver is found enlarged; Saundby, indeed, concludes that it is generally enlarged, weighing from 50 to 60 ounces. The enlargement is, in the main, due to chronic congestion, but a small amount of interstitial hepatitis is frequently present, and occasionally this is so extensive as to produce distinct cir- rhosis. In such cases the liver is some- times smooth, at other times it is found granular and scarred. Brault and Gil- lard are of the opinion that the new growth begins in both the hepatic and portal areas, by which I infer that they would indicate that the process is of the mixed type. The accounts given in the French journals are, in general, so meagre, that it is difficult to arrive at any satisfactory conclusions as to the intimate nature of the pigmentation which has, at times, been found to ac- company this cirrhosis. (For another form of pigmental cirrhosis, the "cir- rhosis arthracotica" of Welch, see later under Sporadic Cirrhosis.) J. George Adami.] Cirrhosis with pigmentation. Series of 49 cases of atrophic cirrhosis of the liver (Laennec's) treated in the wards of the Johns Hopkins Hospital. None showed permanent pigmentation. Eight cases of hypertrophic cirrhosis of the liver were also studied, and one of these presented bronzing of the skin. The clinical analysis made by Ansehutz, who studied 24 cases collected from the liter- ature up to 1899, shows that the symp- toms are those of rapidly fatal diabetes mellitus accompanied with cirrhosis of the liver, commonly of the hypertrophic variety. The pigmented cirrhotic liver is found at autopsy. This pathological manifestation was found in 23 out of 24 of Anschutz's cases; in all but I instance the liver was enlarged. It con- tained an ochre-colored, iron-containing pigment. This pigment was present in the liver-cells and in the connective tis- sue. In 15 of the cases there was also a marked increase in the amount of the connective tissue of the pancreas, and 18 of the cases revealed pigmentation of the pancreatic epithelium and con- nective tissue. The pigment of the liver is now generally believed to be the ex- citing cause of the liver changes. Opie designated this pigmentation of the liver and pancreas as a distinct pathological entity, and the term hasmochromatoais should be used to designate tliis con- dition. The conclusions of Opie were as follows: "1. There exists a distinct morbid entity, hiemochromatosis, char- acterized by the wide-spread deposition of an iron-containing pigment in certain cells, and an associated formation of iron-free pigments in a variety of locali- ties in which pigment is found in mod- erate amount under physiological con- ditions. 2. With the pigment accumula- tion there is a degeneration and death of the containing cells and the conse- quent interstitial inflammation, notably of the liver and pancreas, which become the scat of inflammatory changes, ac- companied by hypertrophy of the organ. 3. When the chronic interstitial pan- creatitis has reached a certain grade of intensity, diabetes ensues and is the terminal event in the disease." Report of a personal case in a male 216 CIRRHOSIS OF THE LI^-EK. PORTAL CIRRHOSIS. SYMPTOMS. 50 years of age. The skin, particularly that of the hands, wrist, and the legs, ■was deeply bronzed. The liver was markedly enlarged, and the urine did not contain albumin or sugar, but gave a reaction for indican and iron. T. B. Futcher (Jour. Amer. Med. Assoc, Sept. 2S, 1901). 7. ClEHHOSIS WITH CALCIFICATION. I am acquainted with only one well- marked example of this condition, de- scribed by Taggert (Trans. Path. Soc. London, '89), in which the deposit of calcareous matter in the cirrhosed liver was so extensive that a saw had to be used in order to make sections of the organ. Symptoms.- — The condition of portal cirrhosis begins insidiously and may con- tinue to an extreme condition without producing any symptoms which call at- tention to the existence of the process. Very frequently the earliest symptoms are associated with the alimentary tract; next in order are evidences of portal ob- struction, and only when the condition is very well marked may there be dis- turbances referable to the hepatic func- tion. \Vliether the gastric and intestinal disturbances are primary or secondary is a matter concerning which there has been debate. That they are not entirely due to the overfilling of the gastric and intestinal vessels in consequence of the portal obstruction is, I think, evident from the fact that they appear long be- fore any signs of such obstruction show themselves, and if we ascribe alcoholic cirrhosis not so much to the alcohol itself as to the pathological condition of the stomach and intestines whereby toxic substances are absorbed from the food, then we must regard this as being the earliest disturbance in the course of the against the proper performance of the disease. That at a later period the ab- dominal congestion further militates gastric and intestinal functions there can be no doubt. It would be well, there- fore, to subdivide the symptoms into: — 1. The disturbances occurring in con- nection with the alimentary tract. 2. Symptoms of vascular obstruction. 3. S}Tiiptoms referable to disordered function of the liver and to altered metabolism. Symptojis Referable to Gastric AND Intestinal Disturbance. — Of these the most noticeable are: at the very earliest stage slight dyspepsia, morning vomiting or nausea, and furred tongue; added to this there may be eructations and irregularity of the bowels. There is often an alternation of constipation and catarrhal diarrhoea. During the former of these the stools often present remark- able modifications: some days they are normal, then they become very dry and are covered with a thick layer of mucus; at other times they are colorless, and, as Graves has pointed out, in the same stool one may find portions which are gray, clayey, and others of normal color. To these disturbances of the digestive system may be largely attributed the emaciation of the later stages of the disease. Symptoms Eeferable to Disturb- ances OF THE Circulation. — So long as there is a well-established collateral cir- culation, for so long will there be no symptoms referable to obstruction. It is only when this collateral circulation be- comes inadequate to carry the portal blood to the heart that ascites and other obstructive disturbances supervene. Thus, not infrequently wo moot with ex- tensive portal cirrhosis without a sign of ascites. Very frequently, however, the nature of this collateral circulation is the direct cause of death; more especially is this the case with the plexus of submu- cous veins at the lower end of the oesoph- agus which plays a prominent part in CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. SYilPTOMS. 217 this collateral circulation. These veins, being practically unsupported toward the free surface of the oesophagus, become varicosed and relatively enormous; the patient may appear in very fair health and the liver be performing its functions satisfactorily with but a thirty-second of an inch or less intervening between life and death; for it is these varicosed sub- ccsophageal veins which are especially liable to rupture and to produce so ex- treme a hasmorrhage that death follows in the course of a few hours. The best account of this collateral cir- culation is given by Osier and we here recapitulate it: — "The compensatory circulation is usu- ally readily demonstrated. It is carried out by the following set of vessels: 1. The accessory portal system of Sappey, of which important branches pass in the round and suspensory ligaments and \mite with the epigastric and mammary systems. These vessels are numerous and small. Occasionally a large single vein, which may attain the size of the little finger, passes from the hilus of the liver in the round ligament and joins the epi- gastric veins at the navel. Although this has the position of the umbilical vein, it is usually, as Sappey showed, a para-umbilical vein; that is, an enlarged vein by the side of the obliterated um- bilical vessel. There may be produced about the navel a large bunch of varices: the so-called caput Medusae. Other branches of this system occur in the gastro-cpiploic omentum, about the gall- bladder, and, most important of all, in the suspensory ligament. These latter form large branches, which anastomose freely with the diaphragmatic veins, and so unite with the vena azygos. 2. By the anastomosis between the oesophageal and gastric veins. The veins at the lower end of the oesophagus may be enormously enlarged, producing varices which pro- ject on the mucous membrane. 3. The communications between the haemor- rhoidal and the inferior mesenteric veins. The freedom of communication in this direction is very variable, and in some instances the hemorrhoidal veins are not much enlarged. 4. The veins of Betzius, which unite the radicles of the portal branches in the intestines and mesentery with the inferior vena cava and its branches. To this system belong the whole group of retroperitoneal veins, which are, in most instances, enormously enlarged, particularly about the kidneys, and which serve to carry off a consider- able proportion of the blood." But in addition to the disturbance in the portal circulation, there appears to be also a frequent accompanying disturb- ance in the general circulation. It may here be more correct — inasmuch as this disturbance seems to be largely associ- ated with alterations in the blood brought about by the hepatic disturbance — to refer to this under a later heading. Case of alcoholic cirrhosis in which there were present enlargement of the liver, dilatation of the subcutaneous ab- dominal veins and ascites (necessitating four punctures in the course of a year). Small, erectile, venous tumors appeared on the face, in the pharynx, and on the internal surface of the last phalanx of the ring-finger of the left hand. The lat- ter became the source of a quite-active hemorrhage. Bouchard (Marseille-mfid., Oct. 15, '91). Ascites. — The ascites of portal cir- rhosis develops gradually, and in this way is to be distinguished from that follow- ing thrombosis of the portal vein. While it is a very prominent and characteristic sjTnptom of the condition, it must be remembered that it is far from being constantly present. Indeed, I may go further and point out that much of 21S CIRRHOSIS OF THE LR'EK. POKTAL CIRKHOSIS. SYIMPTOMS. the failure of clinicians to recognize portal cirrhosis is due to the erroneous belief that ascites almost constantly de- velops. It does not hij any means; only in advanced atrophic cases is it the rule. The older writers speak of it as being present in about 80 per cent, of the cases; more recent careful observers give a lower proportion, thus: Eolleston and Fenton (Birmingham Med. Eeview, Oct., '96) find, from the post-mortem records at St. George's Hospital in London, that of 114 cases only 36, or a little over 30 per cent., showed ascites. Kelynack in 121 examples {ibid., Feb., '97) of com- mon hepatic cirrhosis, as he terms it, coming to the post-mortem room at the Manchester Eoyal Infirmary, found as- cites in 56 per cent. With reference to these figures, it must be remembered that these are statistics, not of cases of portal cirrhosis recognized as portal cirrhosis during life, but in the post-mortem room, and this will explain the low percentage here given. Never- theless they show very clearly that ascites is not the frequent and necessary accom- paniment that is generally held. The fluid in these cases is clear, but may be slightly bile-stained; after repeated tap- ping it assumes more the character of an inflammatory exudate. According to some French observers, it begins as a subacute peritonitis; this is, however, doubtful. The fluid is alkaline, with a specific gravity varying between 1010 and 1015, though, if there has been any peritonitis, this specific gravity and the percentage of proteid are increased and the fluid may show spontaneous coagula- tion. Hale White, in his article on "Peri- hepatitis" (Allbutt's "System of Medi- cine"), holds that ascites proper is a late event in cirrhosis, for which more than one tapping is rarely required, and re- gards those cases in which multiple tap- pings are necessary as being complicated with peritonitis; indeed, he goes so far as to hold that, where ascites is directly due to cirrhosis and paracentesis is ne- cessitated, the patient rarely lives long enough after the first tapping for the second to be necessary. Of 10 cases which were recorded during life as hav- ing cirrhosis, but were tapped oftener than once, of 4 at post-mortem examina- tion, 3 were found to be cases of chronic peritonitis and perihepatitis and 1 of colloid disease of the peritoneum; the remaining 6 had more or less chronic peritonitis associated with the cirrhosis which was present. In fact, he would employ this as of diagnostic value as be- tween uncomplicated cirrhosis and peri- tonitis or perihepatitis with or without cirrhosis. Form of cirrhosis of the liver conse- quent upon the circulatory obstruction due to pericardial lesions. There is, at times, a clinical dilEculty as to whether an hepatic enlargement with more or less ascites is a primary or secondary disease, especially where there are obvious phys- ical signs of a valvular lesion and hardly any of back-pressure. Three cases of this form of pseudocirrhosis witnessed. Pick (Zeit. f. klin. Med., B. 29, H. 5, 0, '90). CEdema of the feet is not infrequently secondary to ascites, and is, in the main, due to a pressure of the distended ab- dominal contents upon the veins coming from the lower extremities. According to Osier, oedema of the feet may precede the development of the ascites, in which case it is to be ascribed to the malnutri- tion of the patient and the impoverished condition of the blood. The dropsy rarely becomes general. Enlargement of the Spleen. — This is far more frequent than is ascites. Thier- felder found, out of 172 cases, only 39, or 22 to 23 per cent., in which this symp- tom was absent; indeed, it may be re- CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. SYMPTOMS. 219 garded as the most common of the symp- toms associated with portal cirrhosis. Oestreieh is inclined to believe that this enlargement of the spleen is not entirely due to portal obstruction, in that it ap- pears at so early a stage of the condition before other marked signs of such ob- struction are evident; indeed, it is sug- gested that the toxic causes which are at work to produce the hepatic lesion bring about enlargement of the spleen. If passive congestion be the cause of splenic enlargement, why is the spleen so frequently small and hard in eases of chronic passive congestion of the ab- dominal viscera due to heart disease? F. P. Weber (Edin. Med. Jour., N. S., vol. ii, p. 579, '97). The average weight in the spleen in hepatic cirrhosis is 12.93 ounces, while in cardiac eases it averages only 7.32 ounces. Again, the greatest enlargement of the spleen is not found where the portal obstruction is greatest, but in those cases of portal cirrhosis where as- cites is delayed till the last or is wholly absent. Kelynack {Edin. Med. Jour., N. S., vol. ii, p. 579, '97). Weber, like Oestreieh, is of the opinion that toxsemia is the cause of the enlarge- ment. The organ is enlarged from one- half to three times its normal size; .in one case of portal cirrhosis which re- cently came under my notice, it weighed 720 grammes. Describing a similar case of large splenic tumor, Banti compares it with the malarial spleen, and urges the probable infectious origin of such cases. Case of hypertrophic cirrhosis of the liver in a boy 9 years old. At the au- topsy the liver was found to weigh 650 grammes, had a yellowish-green color and an irregular surface; a large num- ber of fibrous bands traversed the or- gan, the bile-ducts were dilated, the spleen hard. Dellemagne and Tordens (Jour, de Clin, et de ThOrnp. Inf., vol. v. No. 17, '97). Ilwmorrlioids. — While hcemorrhoids are frequent in cases of portal cirrhosis. the majority of recent writers are of the opinion that they are far from being as common as used to be taught. Pain and Tenderness over the Region of the Liver. — This latter is often most no- ticeable in the early stages, and is often accompanied by a sense of epigastric full- ness and tension, which may be present through the duration of the disease. As Ross pointed out and explained in his re- markable article in the tenth volume of Brain, besides these sensations referred directly to the diseased organ (or con- ditions of splanchnic pain), there may be other painful sensations which may be termed somatic, or referred pains. The liver is innervated from the seventh to the tenth dorsal, and, as a consequence, the pain affecting the organ may be re- ferred to the cutaneous branches of these nerves by overflow of irritation in the cord, and, as a matter of fact, pain is frequently felt in the region of the angle of the right scapula. Another pain at times experienced is that at the tip of the right shoulder, more rarely of both shoulders. Wliere this is the case there is an indication of involvement of the upper surface of the organ, extending to the diaphragm, for such pain is brought about by the overflow of irritation at the point of entry of the phrenic nerve into the spinal cord; and so there is reference to pain along the branches of the lower cervical nerves, the phrenic arising chiefly from the fourth cervical with a few fila- ments from the third. Symptoms Referable to Disturbed Function. — Jaundice. — One of the most constant symptoms of portal cirrhosis is a slight icteroid tinge of the conjunctivae accompanied by a bright, watery appear- ance of the eyes. The skin, in general, save where there is frank development of ascites, is pale rather than icteroid, but as 220 CIKKHOSIS OF THE LIVER. PORTAL CIRRHOSIS. SYMPTOr^IS. the disease progresses the face gains a sallow, ashy tinge. In the very rare ex- treme cases of pigmentary cirrhosis the skin may assume a slaty-bine or in some cases, as in diabetic cirrhosis, a bronzed appearance similar to that seen in Addi- son's disease. Jaundice, however, may show itself La any period of the disease; it is charac- terized by not presenting that continuous and progressive severity observable in cases of true biliary cirrhosis. Accord- ing to Fagge, at Guy's Hospital, out of 130 cases, only 35 showed this symptom, or just iinder 27 per cent., and, according to Price (quoted by Graham), the propor- tion is lower, namely: 17.5 per cent. Urine. — In the earlier stages there may ■ be little or no change, but, as the condi- tion progresses, the quantity diminishes in amount, the color becomes dark, and, as Hayem and von Jaksch have pointed out, the greatly-increased amount of urobilin is an indication of considerable value where the diagnosis is doubtful. Save where there is a frank condition of jaundice, bile-pigments are absent. The urea is often found diminished; the urates, on the other hand, markedly in- creased. Albumin is, at times, present, with casts, apart from those casts which may be associated with jaundice. Kely- nack found renal cirrhosis present in a little over 18 Va per cent, of his cases. Study of the urine in cirrhosis of the liver; conclusions: 1. The quantity of urea eliminated in twenty-four hours is much diminished, but presents variations from day to day. 2. Milk diet augments the elimination of urea and favors diure- sis. 3. With the diminution of the elimi- nation of urea, that of ammonia in- creases; with a milk diet this ia re- versed. 4. The chlorides keep pace with the urea. 5. 0.\idized urocliionie and urobilin are diminished during a milk regimen. Ajello and Solaro (II Mor- gagni, Feb., '93). Case of a patient in whom cirrhosis of the liver was combined with diabetes mellitus. He was under observation for nearly eight and a half years. The first symptom to appear was slight jaundice, followed some months afterward by cer- tain diabetic symptoms, namely: thirst, and sugar in the urine, to the amount of P/i to 2 per cent. This yielded to appro- priate treatment, but five years after- ward ascites appeared, along with slight jaundice, enlargement of the liver and spleen, and some dropsy of the feet, etc. At the necropsy, marked cirrhosis of the liver, with enlargement of the spleen and kidneys, as well as tubercular de- posits (both old and recent), were found. Hepatic cirrhosis in such eases is of a special kind and holds an intermediate position ; it is characterized by marked increase in the size of the liver and spleen, with but little tendency to con- traction on the part of the former, and also by the presence of pigmentation in the skin. Pusinelli (Berl. klin. Woch., No. 33, '90). The presence of a strong perchloride of iron reaction in the urine of several patients sufTering from hepatic cirrhosis noted. The color obtained was some- times similar to that seen in the pres- ence of diacetic acid in diabetes mel- litus, and sometimes to that obtained when salicylic acid has been taken. The appearance of the reaction sometimes coincided with very threatening general symptoms. AVcbcr (Brit. Mod. Jour., Jan. 2, 1904). The Blood. — There is very little that is characteristic about the condition of the blood in portal cirrhosis. There is no marked increase in leucocytes, no ex- tensive diminution cither of the hnemo- globin or of the number of red blood- corpuscles, but the tendency toward epis- taxis and the development of petechiiE in connection with the general, as op- posed to the portal, circulation would seem to indicate that either the blood is of such a poor quality or contains such abnormal and toxic substances as to lead to degeneration of the capillary walls, CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. DIAGNOSIS. 221 and, as already pointed out, the occa- sional occurrence of oedema preceding ascites is another indication of this toxic or impoverished condition of this fluid. While the hospital is of such relatively- recent estahlishment, and the number of cases of portal cirrhosis in post-mortem records too few to establish definite state- ment, I have been struck by the fre- quency with which, during life, the clin- ical records at the Royal Victoria Hos- pital, Montreal, note an apical systolic murmur, recognized as functional, the post-mortem confirming its functional nature. A further indication of the altered or thinned condition of the blood is the not-infrequent existence of a venous hum in the epigastric region noted by several recent observers and of a splenic souffle first noted by Bouchard. Other Symptoms Beferahle to Disturbed Hepatic Function. — Very characteristic toward the latter stage are certain nerv- ous symptoms, which also are, in general, attributed to a toxic condition of the blood. These are, by some, classed as manifestations of cholsemia, although, as they may be present when there is no evi- dence of the passage of bile into the blood, this use of the term is scarcely ex- act. I refer to the drowsiness of many patients and the more marked nervous conditions of coma and delirium. Wliere death is not due to htemorrhage or inter- current disease, such as tuberculosis, it is these nervous disturbances which are the pronnnent feature in the fatal event. Those nervous symptoms may be mis- taken for the onset of urrcmia. There may be marked excitation, or, on the other hand, a progressive and deepening stupor passing into complete coma. Case of lifBiiioirhage from the larynx in the course of alcoholic cirrhosis. Hteniatemesis and cpistaxis also occurred. Laryngeal htemorrhage ascribed to the interference with the biEmatopoietic functions of the liver by the atrophic cirrhosis of that organ. Lubet Barbou (Archives de Laryn., July, Aug., '97). Study of 8i.\ty cases of fatal gastro- intestinal hfcmorrhage due to cirrhosis of the liver. 1. Fatal gastro-intcstinal haemorrhage is an infrequent, but not rare, complication of cirrhosis of the liver. 2. In the great majority of the eases the cirrhosis is atrophic, but it may be hypertrophic. 3. In one-third of the cases the first hremorrhage is fatal; in the other two-thirds the haemorrhages continue at interi'als over a period vary- ing from a few months to several years, the maximum given being 11 years. 4. In one-third of the cases the diagnosis can be made at or before the time of the first htemorrhage. In the other cases the diagnosis cannot be made at all or only after months or years, during which time other symptoms of cirrhosis may have developed. 5. ffisophageal varices are present in 80 per cent, of the cases, and in more than half of this 80 per cent, the varices show macroscopical ruptures, and it is probable many other ruptures would be found if the varices were tested by injections of air or fluid. 6. Fatal haemorrhages occur in cases which show no oesophageal varices, and they are prob- ably due to the simultaneous rupture of many capillaries of the gastrointestinal mucous membrane. 7. The haemorrhages in this class of cases are usually preceded by other symptoms of cirrhosis, but the first symptom may be a fatal htemor- rhage. 8. In G per cent, only of the cases which showed cesophageal varices was the cirrhosis typical: i.e., showed ascites, enlarged spleen, and subcutaneous ab- dominal varices. R. B. Preble (Amer. Jour. Med. Sei., Mar., 1900). Differential Diagnosis. — The preced- ing pages will have given in fairly full detail the main features characterizing the different forms of hepatic cirrhosis. Here, however, it may be worth while to point out again that there are four forms of hepatic cirrhosis, or of conditions clin- ically regarded as cirrhosis, between which we have to distinguish, namely: 222 CIRRHOSIS OF THE LIVEK. PORTAL CIKRHOSIS. DIAGNOSIS. portal cirrhosis proper, biliary cirrhosis, chronic perihepatitis, and gummatous syphilis of the liver. All other forms, with the exception of the pericellular syphilitic cirrhosis of the infant, are clinically unrecognizable. Leaving aside, for the moment, the most important of these, — namely, portal cirrhosis, — the main features whereby the biliary form of the disease is to be differentiated are the progressive icterus, the enlargement of the organ, the ab- sence of marked digestive disturbances, the long continuance of the condition, and the retention of appetite and strength. The coloration of the stools by bile and the more extensive enlarge- ment of the organ must be the main factors in diagnosing between what we may term the catarrhal form of biliary cirrhosis and the very rare purely-ob- structive form. Gummatous syphilis is only likely to be confounded with portal cirrhosis when, through obstruction to the portal circulation, ascites supervenes. Under these conditions the organ may be either of normal size or greatly contracted by a multitude of syphilitic cicatrices. In the former case the coarse lobulation of the organ is more likely to lead to the diagnosis of cancer of the organ than of portal cirrhosis; in the latter case the signs and symptoms may be so closely allied to those of portal cirrhosis as to render diagnosis a matter of extreme dif- ficulty. The presence of syphilitic lesions elsewhere, and the history of the case, may help toward the diagnosis, which will be finally determined by the effects of antisyphilitic treatment. 0ENi;nAIJ7,KD FIBROID PERinEPATITIS may, with great difficulty, be distinguish- able from true portal cirrhosis. If the organ can be felt, the rounded character of the edge, the absence of roughness of fine nodulation on palpation, the pres- ence of a thickened omental mass below the liver, all are in favor of a diagnosis of perihepatitis. As already stated, ac- cording to Hale White, if a patient is able to stand a long series of tappings of the ascitic fluid, the diagnosis is against the existence of an uncomplicated portal cirrhosis, and is in favor either of chronic peritonitis associated with perihepatitis or of portal cirrhosis complicated by chronic peritonitis. The main points elicited in the pre- ceding pages with regard to portal cir- rhosis and its diagnosis are the follow- ing: — 1. That the small size of the organ is by no means the main diagnostic feature of this condition. Only in advanced cases, and by no means always then, is the organ markedly atrophied. Of far greater diagnostic importance is the de- termination of progressive diminution in size of the organ. 2. If the organ be palpable, the recog- nition of a finely-nodular, firm surface indicates with relative certainty the ex- istence of this condition. 3. Contrary to general opinion, in only about 50 per cent, of the cases in which the autopsy reveals a well-developed con- dition of portal cirrhosis is there ascites. 4. Enlargement of the spleen is a much commoner symptom, and this is present in more than 80 per cent, of the cases. 5. Jaundice is present in about 30 per cent, of cases. Such jaundice tends to be transient and to develop after other symptoms have been present some little time. 6. From the very onset of the condi- tion gastric and intestinal disturbances form a prominent feature in the disease. 7. The progressive emaciation and weakness are also characteristic, and with CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. DLA.GNOSIS. 223 this may be associated a peculiar, sallow, slightly-earthy complexion. 8. A urine free from sediment (mainly of urates) is against the diagnosis of cir- rhosis; -while the presence of increased quantities of urobilin is, in the presence of other symptoms, in favor of such a diagnosis. Of other conditions affecting the liver which may be confounded with cirrhosis are to be mentioned cancer, thrombosis of the portal vein, senile or marantic atrophy of the liver, and cyanotic indura- tion. Of these, portal thrombosis may oc- cur as a complication of cirrhosis. Where this occurs in the absence of cirrhosis the main distinguishing feature is the rapid development of the ascites and its rapid return after tapping. At the same time, such thrombosis is secondary to disease of other abdominal organs, more fre- quently of the intestinal tract, and the symptoms proper to such disease will have preceded the development of ascites. Cancer of the liter is characterized by the increase in size of the organ, the presence of large nodules presenting um- bilication, the absence of splenic enlarge- ment, the cancerous fades, and, in gen- eral, the presence of cancerous nodules elsewhere. Those cases in which cancer of the organ is present without the de- velopment of nodules upon the anterior surface of either lobe at times cause very great difficulty. Here the small size of the spleen, the character of the urine, the complexion, and other signs and symptoms, which ordinarily are regarded as of secondary importance, become of the highest value in diagnosis. Attention called to the occasional re- semblance between hypertrophic cirrhosis and hepatic carcinoma, and stress laid upon the di (Terence in the stools, which are bilious in the former, clay-colored in the latter. Freyhan (Deutsche med.- Zeit., May 8, '93). In cases of senile, or marantic, atrophy the organ, if it can be pal- pated, is smooth; there is absence of ascites and of jaundice. The atrophic nutmeg liver (cya- notic induration) and also the "hyper- trophied" nutmeg liver are also charac- terized by the smooth surface of the organ, as also by the prominent symp- toms of obstructive disease of the heart. Other forms of ascites and peritonitis are not infrequently mistaken for the results of cirrhosis; indeed, I think it may be said with confidence that the most frequent cause of false diagnosis of cirrhosis, is either cancerous or tuber- cular peritonitis. In such cases there may be present gastric and intestinal disturbances easily mistaken for those accompanying cirrhosis; the ascites may be of gradual development, as in portal cirrhosis; and the liver, being, by the accumulation of fluid, forced upward, may disappear behind the ribs and so be diagnosed as presenting great atrophy. Between cancerous and tubercular peri- tonitis the distinction may be drawn that in the former the spleen is not enlarged, and in the latter the enlargement may be as extensive as in portal cirrhosis. In these cases, again, it is the secondary symptoms and signs which are of the greatest value in arriving at a decision: complexion, urine, etc., and, in addition to these, the character of the abdominal fluid when removed. Most important, also are manifestations of disease else- where, either cancerous or tubercular. In cases of doubt, to determine the tuber- culous nature of the condition, it is well to inoculate a rabbit or guinea-pig, and, for the recognition of cancer, to make a careful search for cancer-cells in the re- moved fluid. 224 CmRHOSIS OF THE LIVEK. POETAL CIRRHOSIS. COMPLICATIONS. Complications. — Leaving out of ac- count the rare cases of development of a priman' adenomatous or cancerous con- dition, there may be other complicating conditions in the liver itself of the nature of degenerative changes; in advanced cases it is not infrequent to meet with evidence of fatty degeneration of the ceUs as distinct from the fatty infiltra- tion seen in less advanced conditions; more rarely is amyloid degeneration present. Thrombosis of the portal vein occurs occasionally. Tuberculosis. — The most frequent complication outside the liver is the de- velopment of tuberculosis. Eolleston and Fenton find pulmonary tuberculosis in 32 out of 114 cases, tuberculosis being the direct cause of death in 17. Kely- nack, out of 121 cases, finds tuberculosis either active, latent, or obsolete in 28: i.e., 23 per cent. Of these 28, in 14 the condition was active in the lungs, in 12 in the peritoneum, and in 7 both in the lungs and peritoneum. Twelve, or about 10 per cent., of the cases died directly from tuberculosis; in 8 per cent, the condition was latent or obsolete. Tuberculosis is a cause of cirrhosis of the liver. The liver becomes generally atrophied, indurated, and granular, like the cirrhosis which results from the abuse of alcohol, although in a less degree. More rarely, it becomes deeply furrowed and lobulated, as in syphilitic ciiThosis. Hanot and Gilbert (La Sem. Med., Feb. 3, '92). Other frequent complications are: EiGHT-siDKD PLEURISY with a serous or sero-sanguineous exudation. This con- dition has not, as yet, been thoroughly worked out; bo far as I can see it is not of a tuberculous nature, for I have come across cases showing such pleurisy in which there has not been a sign of tuber- culosis at the post-mortem. Where it is present I have also noted a co-existence of adhesions between the upper surface of the liver and the diaphragm, which might indicate an extension of the in- flammatory process from the liver to the pleural cavity. Were this so, it would be evidence in favor of microbic origin or microbic complication in the hepatic con- dition; but, as already stated, this sub- ject requires much further study; oc- casionallj' there is evidence of bilateral pleurisy. Pleuritic efi'usion on the right side only, in Laennec's, generally considered as an exceptional symptom is, however, a constant symptom. Found in nine cases of cirrhosis. It is of value in the diagnosis of doubtful cases, when it is difficult to determine whether ascites is due to cirrhosis of the liver, to throm- bosis of the portal vein, or to compres- sion of that vessel by tumors or swelled glands. G. Villani (Riforma Medioa, Mar. 9, '95). Another frequent complication is ne- phritis, either of the granular type or not infrequently as a mixed interstitial nephritis, of what Formad has termed the 'Tiog-backed" type, the organ being enlarged, more especially from before backward, and showing microscopically a condition of mixed interstitial and parenchymatous nephritis. The inter- stitial type is, in general, associated with evidences of some degree of general ar- teriosclerosis and with other complica- tions due to this process. Both the inter- stitial and the hog-backed kidney are, it need scarcely be said, characteristic of alcoholism. The statistics of the various authorities with regard to the frequency of renal complications are not sulficiently extensive to arrive at any very satisfac- tory conclusion. G. Foerster, in his 31 cases recorded at Berlin, found nephritis 3 times, granular atrophy 4 times, and "indurated" kidney 4 times. Kelynack found renal cirrhosis in a little over 18 Vj per cent, of his cases. Giirtner found 11 CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. TREATMENT. 225 out of 12 to show "chronic nephritis"; 10 of these were habitual drinkers of brandy. Other alcoholic complications may also be present, notably some extent of chronic pachymeningitis and thickening of the dura mater, and fatty degeneration of the heart-muscle. Lastly there is a liability for acute in- flammatory processes to supervene: pneu- monia, acute bronchitis and pericarditis, erysipelas of the cedematous skin, and acute peritonitis; this last often second- ary to paracentesis. There are two forms of recognized "appendicular liver," a purulent, infec- tious hepatitis, and a toxic hepatitis, characterized by degeneration of the parenchyma, neither of which is at all rare. Cirrhosis is another sequel which deserves careful study. In a boy, aged IG years, who died of acute appendicitis, the necropsy disclosed all organs save the appendix and liver to be in a healthy condition. The liver showed an early, but unmistakable, cin'hotic proc- ess. The personal history of the body had been excellent. Tuffier and MautC (Tresse MCd., June 20, 1004). Prognosis. — The condition begins so insidiously that it is difficult to make an accurate statement concerning its dura- tion. It will be generally agreed that Fitz is not too hopeful in stating that the fatal result may be expected within a year after hcemorrhage or other sign of portal obstruction. Von Kahlden in- stances a case (Miinch. med. "Woch., 4S, '97) of a very acute development of the disease in which death occurred three and a half months after the first symp- toms presented themselves. The form of cirrhosis in this was of a mixed tj'pe. If the cases of Carrington and Caylcy are to be regarded also as examples of portal cirrhosis, we have further evidence that the disease may be fatal in three months after the first occurrence of dyspepsia and of epigastric fullness, or two months after the first onset of ascites. At the other extreme, we come across many cases, in the post-mortem room, of well- developed portal cirrhosis which had given rise to no symptoms during life. Thus, clearly the condition may be pres- ent in a latent or it may be in an arrested form for months and it may be for years. It is difficult to explain otherwise a case such as that of Taggert's, in which the cirrhotic tissue had undergone calcifica- tion. It is difficult, also, to know how to regard those cases in which, cirrhosis being diagnosed, after one or two tap- pings the symptoms disappear and the patients apparently recover, because these cases may have been conditions, not of true cirrhosis, but of subacute perihepa- titis. If, by palpation and by other phys- ical signs and symptoms, and more es- pecially by the character of the urine, it is determined that portal cirrhosis is present, prognosis is very bad. Both Eolleston and Kelynack agree that a little under half the cases die di- rectly from the effects of hepatic cir- rhosis, though it is a little doubtful what effects they include under this term. Treatment. — There is no treatment known save the palliative, and it is, in- deed, difficult to see how to arrest the condition once there is marked develop- ment of this contracting, fibrous tissue in the organ. The avoidance of alcohol, spices, coffee, and other irritant sub- stances; avoidance of fatigue and of cold, together with maintenance of regular action of the bowels by mild aperients are all indicated. Several authorities have recommended a milk diet, but, ac- cording to Jaccoud and others, it has absolutely no effect in arresting the progress of the disease. In cirrhosis of the liver abstention from alcohol and all stimulating ingesta 226 CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. TREATMENT. is the first requisite. Diet sliould be je- strictfd to milk, eggs, simple proteids, bread, and fresh fruit and vegetables. Predigested foods are necessary in some instances. W. B. Cheadle (Lancet, Apr. 14, 1900). Some more recent writers recommend massage as improving the general con- dition of the patient. The treatment which affords most relief would appear to be the employment of alkaline mineral waters and saline purgatives, whereby some relief is given to the congestion of the portal system. TMiere ascites is present, tapping gives great relief, and, as pointed out by Murchison and recommended by Graham in his admirable article in the Loomis- Thompson "System of Practical Med- icine," after this tapping digitalis and diuretics are both effectual and useful. Special attention drawn to the. value of urea as a diuretic. Two and a half drachms given in the day, increased up to 5 drachms, continued for 2 or 3 weeks. No unfavorable effects witnessed. The unpleasant taste may be done away with by drinking milk immediately after taking it. G. Klemperer (Berl. klin. Woch., Jan. 6, '90). The treatment should be largely di- etetic and hygienic, great care being taken to see that the functions of the gastro-intestinal tract are kept in ac- tion and the renal secretions properly regulated as well as tlie action of the skin. Three deaths personally known to have followed the operative treat- ment of hemorrhoids, and at the ne- cropsy cirrhosis of the liver was dis- covered for the first time. In all cases of hccmorrhoidal disease a thorough knowledge of the stale of the liver sliould be obtained liefore any operative interference is advised. In the treat- ment of ascites mild purgation and calo- mel from time to time; calomel also UBcd in Vin-Rrain dose every three hours as a diuretic. The old-fashioned pill, digitalis, squills, and calomel and co- paiba are useful. Tapping is resorted to early and frequently. J. H. Musser (Phila. Med. Jour., June 15, 1901). After liEemorrhage from the oesoph- agus of the stomach, ice should be taken internally and morphine may be given. The operation of bleeding has so fallen into disuse that scarce any authority recommends this as a means of rapidly relieving the congestion. Personally 1 have been struck at autopsies by the amount of blood still present in the organs even when profuse hasmorrhage has been the cause of death; and it seems worth while to suggest that, where other means fail, the removal of blood from the general circulation, by temporarily low- ering the general blood-pressure, is ca- pable of aiding the more rapid flow of blood from the congested portal circula- tion into the inferior vena cava and vena azygos, and so is capable of aiding the development of a more satisfactory col- lateral circulation. Surgical Treatment of Abdominal Dropsy Following Cirrhosis of the Liver. — The operation devised by Talma consists of an abdominal section, preferably between the umbilicus and ensiform cartilage, evacuation of the ac- cumulated fluid, and scraping of the parietal peritoneum with a curette or rubbing off the epithelium with a gauze sponge. The superior surfaces of the liver and of the peritoneum covering the diaphragm are also rublied. The omen- tum for three or four inches around the incision is then stitched to the parietal wall, and is included in the sutures which close the abdominal incision. A broad surface is available for adhesions, and it is the additional collateral circu- lation thus obtained which constitutes the main feature of the operation. Its formation, however, is comparatively slow, and it is frequently necessary to lap CIRRHOSIS OF THE LIVER. PORTAL CIRRHOSIS. TREATMENT. ^27 the patients several times after the oper- ation, before the collateral circulation is complete. Since the first operation for cirrhosis of the liver, 13 have been performed. Of these, 5 have recovered, 2 were im- proved, in 1 there was no change, and 5 died. Operation is indicated in cases in which there is a distinct mechanical hindrance in tlie portal circulation with recurring ascites. The technique consists of a small incision into the abdominal cavity, through which a careful explora- tion is made of the liver, gall-bladder, and the surrounding parts. The peri- toneum is curetted over the anterior sur- face of the abdomen, and the great omen- tum is attached by sutures to the ab- dominal wall. The peritoneum has its epithelial covering removed over the lateral and anterior portion on the left side of the abdomen, to which the spleen is likewise attached. A glass drain is then inserted, and all ascitic fluid of the abdominal cavity is removed. This drainage is continued until no further fluid is formed, which shows that the collateral circulation has been estab- lished. F. Friedmann (Centralb. f. d. Grenzgebiete der Med. u. Chir., Aug. 8, 1900). The operation for creating compensa- tory circulation in hepatic cirrhosis is indicated in those cases in which the collateral circulation is not sufficiently established to relieve the rapidly in- creasing ascites. Although the cases operated on by Talma himself proved fatal, it was successful in 6.5 per cent, of cases operated by other surgeons. Two personal cases reported in which Talma's operation was performed. Two months later ascites again developed, six litres of fluid having been removed by tapping. After that the patient felt much stronger. The second case pre- sented a history of chronic alcoholism, and was far advanced in the disease when Talma's operation was performed. He improved after it for about two weeks, when he commenced to decline rapidly, and died within forty-eight hours. It is a simple and harmless inethod of treating ascites. N. M. Ben- isovitch (Vratch, Fob. 17, 1901). All well-attested cases of cirrhosis presenting ascites should be operated upon under local anaesthesia. Frazier's table of fifteen cases reproduced, per- sonal case being the fifteenth in the table. Frazier's list shows that 75 per cent, of recoveries had taken place. J. J. Jelks (Med. Record, Mar. 23, 1901). Case of hepatic cirrhosis in which Talma's operation was performed about a jear ago. The liver and spleen were In the same condition; the circulation had improved; collateral circulation was well established; and the ascites did not recur. Scherwincky (Med. Obos- renije, Mar., 1901). Statistics show that six cases at least have been cured of ascites by stitching the omentum to the anterior abdominal wall, and which remained well for a period of two years or more. Six others were relieved of this symptom for from two to six months, but died, either with- out a return of the ascites or have been under observation long enough to dem- onstrate that the cure is permanent. A ease of ha;raorrhage from the alimentary canal was promptly cured by the above operation. Thirty-eight cases recovered trom the operation, and, when we con- sider that in the majority of instances these patients were in the last stages of an incurable disease and would have died within a few weeks, it seems that if these cases were taken earlier there would have been more encouraging re- sults. G. E. Brewer (Medical News, Feb. 8, 1902). Six cases in which Talma's operation of suturing the omentum to the an- terior abdominal wall for ascites due to ciiThosis of the liver was resorted to. The omentum was sutured to the ab- dominal wall in such a manner that a part of it lay between the skin and the parietal peritoneum. The skin over this was sutured without leaving any space for drainage. One patient lived five months after the operation, and had to be tapped again on account of the rcaccumulation of fluid. Another patient lived only two weeks after the operation; a third lived eleven months after the operation. A fourth patient improved considerably and was dis- 228 CIRRHOSIS OF THE LIVER. BILIARY CIRRHOSIS. VARIETIES. charged from the hospital apparently cured, but was not followed afterward. The other two patients sunived the operation, but left the hospital too early to warrant any conclusion as to the permanent eflfects of the procedure upon their ascites. Ko?lovsky (Rous- sky Vratch, Nov. 29, 1903). Biliary Cirrhosis. Under the term "13111317 cirrhosis" two distinct conditions are to be Included: — 1. A condition rare, clinically, but pro- duced experimentally In the lower ani- mals by Charcot and Gombault by lig- ature of the common bile-duct. A condi- tion In which obstruction of the larger bile-ducts Is followed by Inflammatory condition of the intrahepatic and extra- hepatic bile-ducts, and the later devel- opment of fibrous tissue around them. 2. A condition in which the liver is fotmd permanently enlarged, with the development of much rather loose and non-contracting fibrous tissue, in which, as evidenced by the accompanying jaun- dice, there is some hindrance to the free flow of bile through the smaller ducts, for no obstruction of the extrahepatlc bile-ducts Is to be recognized. A further characteristic of this form is the peculiar extensive development of the already-described new bile-ducts in the hyperplastic fibrous tissue. 1. Obstructive Cirehosis. Definition. — The cirrhosis of obstruc- tion of the large bile-ducts. It may be laid down as a rule that the simple obstruction of excretory passages leads, not to fibrosis, but to distension and atrophy of the cells and tissues bor- dering upon the ducts, and, as a matter of fact, the majority of cases of long- continued biliary obstruction from gall- stones or from pressure upon the com- mon bile-duct is accompanied by no ob- vious increa.sed development of fibrous tifiBue in the organ. Certain rare cases, however, do occur where there is a very characteristic increase in the connective tissue around the bile-ducts In the liver. Why this should be so it is difficult to explain, unless there be some cause over and above the simple obstruction. What this cause is is Impossible to say, because in some of the best-marked early cases — as, for example, one of Kanthack and Eolleston and another of Heneage Gibbes — the condition shows Itself in children which have died at such an early age that the condition must be regarded as congenital. Possibly some constituent of the excreted bile acts in these cases as an irritant. [Well-marked cases of this type of cirrhosis in the adult are distinctly rare. That of Kelch (Revue de M6d., p. 969, '81) would seem to be the first surely of this nature. Goluboff's case (Zeit. f. klin. Med., vol. xxiv, '94), while referred to a chronic and intermittent gall-stone obstruction, dating back for 11 years, was anatomically found to be of the type to be immediately dealt with. It is only to be expected that the one form should pass into the others. One of the best descriptions of the condition is given by Giggs (Trans. Path. Soc, London, vol. xxxiv, p. 129, '83). A male infant began to show slight-yellowish tingeing of the skin and jaundice a few days after birth. The jaundice persisted, but was never very deep in color. Nutrition was main- tained until the sixth month, when wast- ing and ascites supervened, the child dy- ing during the next month. The liver in this case was hard and smooth; there was no trace of the common duct; the hepatic duct close to this organ was filled by a fibrous mass; the portal vein was nornuil. With these appearances it is difficult to conipreliend why the jaun- dice was not of the severest typo. Micro- scopically there was enormous increase of inlorlobuUir connective tissue grow- ing ludiind the bile-duets and extending toward the junction of tlieso with tlio livcr-cellH. 1 have been indebted to Dr. RolIcHton for material from this caae, CIRRHOSIS OF THE LIVER. BILIARY CIRRHOSIS. ETIOLOGY. 229 also one of congenital obstruction, and in this, coupled with evident dilatation of the intralobular bile-capillaries, there was an e.xquisite development of fibrous tis- sue, which was confined to the imme- diate neighborhood of the bile-ducts. J. George Adami.] In all such cases the organ is enlarged, smooth, and fibrous, and progressive jaundice is the leading feature. 2. Biliary Ciiieuosis Phopee. Synonyms. — Hypertrophic biliary cir- rhosis; Hanot's cirrhosis. So long ago as 1857 Todd drew atten- tion to the fact that two different forms of chronic hepatitis are to be recognized, and quoted cases of enlarged cirrhotic liver without ascites, but with jaundice. Thus, if the name of any person is to be associated with this form of disease, it would be that of Todd, and not of Hanot, who, while he was the first to give a full study of this form, was certainly not the first to clearly draw attention to its ex- istence. In 1859 Charcot and Luys called attention to the fact that, in some cases of cirrhosis witli enlarged liver, the new fibrous tissue penetrates into the lobules and becomes intralobular. In 1874 Hayem reported two cases of cir- rhosis with enlargement, and in the same year Cornil pointed out the pres- ence of groat numbers of new bile-ducts in cases of cirrhosis of this nature; only in the following year, in 1875, did Hanot's well-known thesis appear upon the "Enlarged Cirrhotic Liver," in which he pointed out that in this form the en- largement is constant throughout, the surface smooth, and, microscopically, the cirrhosis is of the unilobular type and sometimes pericellular, with a plexus of small, new bile-canaliculi; while, clinic- ally, he showed that this form was char- acterized by permanent jaundice with- out ascites, death being due to the jaun- dice. He described the condition as often due to a catarrhal condition of the smaller intrahepatic bile-ducts. The condition is a rare one, though each year two or three are reported in the journals. While in the majority of cases there is a definite history of hard drinking, the more recent observations of Hanot lead to the belief that the disease is of a pos- sible infectious or microbic origin. The liver in these cases may be en- larged symmetrically and may weigh as much as eight pounds. Observation on the form of hyper- trophic cirrhosis with chronic jaundice described by Hanot. L The splenic en- largement persists unaltered during the whole course of the illness, although the variations in the size of the liver may be considerable and of frequent occurrence. 2. The splenic enlargement precedes the alterations in the liver, or, at least, it precedes the outward manifestations of the disease. In one of the cases, a man who died at about 30 of this form of cirrhosis, a large spleen had been noted during youth. 3. The disease may some- times occur in different members of the same family. Children of patients may have a large spleen without any other sign of the affection. In one family the children are said to have a very pig- mented skin, and this has been observed likewise in some collateral branches of the family. 4. The large spleen may be considered as the essential part of the disease. 5. Although ordinarily malaria has nothing to do with the affection, the cause is probably analogous to that of malaria and dependent on drinking- water. 6. As Hanot and Riener ad- mitted, the affection seems to be a spe- cific one, or, at least, a peculiar infection of the spleen and liver, not a simple in- fection of the liver. E. Boix (Presse MC-d., Mar. 16, '98; Brit. Med. Jour., May 14, '98). Etiology.- — In tlie first place, there is a marked distinction between this and ordinary portal cirrhosis, in that it af- fects young adults. By far the greater number of cases are in males between 230 CIKKHOSIS OF THE Ln^EE. BILIAKY CIRRHOSIS. PATHOLOGY. the ages of 20 and 35. Scliochman, in the 26 cases which he collected, fonnd that it affected 22 males and 4 females. In the majority of cases there is a definite history of hard drinlcing; but, as in other cases there has been no alcoholic history, vre must conclude that alcohol is not the immediate cause. So, also, ma- laria is to be eliminated. On the other hand, there is increasing evidence at the present time — not, it is true, absolutely convincing — in favor of regarding this form as definitely of infectious origin. In favor of this view are the following facts: — 1. The febrile character of the disease. As Jaccoud was the first to point out, the fever may reach from 103° to 103 ^/j" F. 2. The very frequent extension of the inflammation, development of perihepa- titis, and surrounding adhesions. 3. The condition of the blood. As Hanot and Meunier have sho^vn (Soc. de Biol, de Paris, Jan. 25, '95), the number of white corpuscles in the blood of five cases was increased from 13,000 to 20,000 per cubic millimetre. No such leucocy- tosis is observable in ordinary portal cirrhosis. Hanot, in his recent communications, is strongly in favor of the infectious origin. On the other hand, no definite micro-organism has been discovered, save that the presence of the colon ba- cillus has been recognized in the ducts upon more than one occasion. The fre- quency with which this form may be present in the gall-bladder and larger bile-ducts and there set up mild chronic disturbances is, nowadays, being more and more recognized. But were the bacillus coli the causative agent, we should expect to find the dis- ease far more common and far more frequently associated with cholelithiasis. This fatal fovm of cirrhosis is pecul- iar to the Brahmin children. Brahmin women in childbed adopt a diet which may conduce to the disease in the new- horn infant, in whom it has been seen. They restrict themselves to the use of a strong decoction of black pepper to allay thirst, abstaining from liquid of any other kind, and as food use balls made up of boiled rice, ghee, and coarse sugar. E. Mackenzie (Lancet, Feb. 2, '95). Closely allied to this above variety of cirrhosis is the "pericellular cirrhosis" {vide infra): a form definitely associated with infection. Hence, on the whole, from all these considerations I am in- clined to regard this provisionally as be- ing a cirrhosis of infectious origin. Pathology.— The liver is sj'^mmetric- ally enlarged and may weigh as much as eight pounds; it is, in general, smooth, herein being distinguished from portal cirrhosis; more frequently in that dis- ease there are evidences of perihepatitis and of adhesions to the diaphragm and surrounding viscera. This perihepatitis at times gives a very liard surface to the organ. In the latter stages of the dis- ease, where the condition has been of long continuance as Goluboff more re- cently has pointed out (Zeit. f. klin. Med., vol. xxiv, '94), there may be a certain amount of contraction of the enlarged organ, and the surface may take on a slightly-granular appearance. On sec- tion, the organ cuts very firmly, and has an intensely-jaundiced, dark-green ap- pearance; the gall-bladder is full of bile of good color, clearly indicating that there is no absolute obstruction to the flow of bile from the organ, while the extrahepatic bile-ducts are free from ob- struction. Microscopically, the appearance is characteristic. Frequently, though not always, there can be made out around the larger bile-ducts, which arc very prom- inent, a more or less concentric over- CIRRHOSIS OF THE LIVER. BILIARY CIRRHOSIS. I'ATHULOGY. 231 growth of new, fibrous tissue, and this fibrosis, instead of being sharply defined toward the lobules of the organ, invades them, passing between the cells; so that there is developed a pericellular condi- tion. With this the fibrosis is very gen- eral, so that not only do we have large bands inclosing several lobules, but in addition each individual lobule tends to be surrounded, and, more than that, bands of the new tissue may actually cut off portions of lobules; there is thus de- veloped a unilobular cirrhosis, as con- trasted with the multilobular appearance in portal cirrhosis. Another very char- acteristic feature of the condition is the appearance of the new, fibrous tissue; this tends to be more transparent than, and not so dense as, that seen in the ordinary portal form, while it is perme- ated by great numbers of bile-canaliculi. Nature and distribution of the new tis- sue in cirrhosis of the liver: 1. In all forms of cirrhosis the white fibrous tis- sue is increased. 2. Along with the in- crease of white fibrous tissue there is a new formation of elastic tissue. This new elastic tissue is derived from -pre- existing tissue in the adventitia of blood- vessels and the hepatic capsules. 3. Both white fibrous tissue and elastic tissue, in all forms of cirrhosis, may penetrate into the lobules. This penetration takes place along the line of capillary walls or fol- lows the architecture of the reticulum. The chief distinctions between the histol- ogy of atrophic and hypertrophic cin'ho- sis depend upon the degree of extralobu- lar growth and the freedom with which the lobules are invaded. In hypertrophic cirrhosis there would appear to be less in- terlobular growth and an earlier and finer intralobular growtli. 4. The alteration.^ in the reticulum, per sc, consist, as far as can be made out at present, of hyper- trophy rather than hyperplasia of the fibres. It is still uncertain whether any of the dilTerential methods now in fse suffice to distinguish between the reticu- lum and certain fibres derived from the white fibrous tissue of the periphery of the lobules. Simon Flexner (Univ. Med. Mag., Nov., 1900). As to the nature of the canaliculi, opinion is divided, some holding them to be of the nature of new formation from the pre-existing bile-ducts, others hold- ing them to represent a late stage in the atrophy of the liver-cells. My own ob- servations lead me strongly to support the latter view, for, in several sections in which they have been abundant, I have clearly made out the transition from the liver-cell to bile-duct. From comparative anatomical grounds this would seem to be the most reason- able explanation of their development. That is to say, that following the suc- cessive stages of the evolution of the liver we find that in its earliest form the organ consists of a mass of independent finger- like follicles. Later these become joined together into a more solid mass, and with this a distinction can be made out be- tween the lower duct-like portions and the secretory terminations of the fol- licles. Later again the cells become ar- ranged more in reference to the blood- vascular system than to their primary connection as members of separate fol- licles. But still in the human liver the bile-capillaries must be regarded as the representatives of the lumina of separate hepatic follicles, and in peripheral atrophy of the lobules, where that atrophy is not extreme, the appearance which these sections present to me leads me to conclude that the secreting cells of the liver undergo what I have else- where termed "reversionary degenera- tion" (vide article on "Inflammation" in volume i of Allbutt's "System of Medi- cine"). The nuclei proliferate, and in place of obscurely arranged masses of typical liver-cells, we obtain small rows of cells resembling those of the bile- 232 CIRRHOSIS OF THE LIVER. BILIARY CIRRHOSIS. SYMPTOMS. ducts, with whicli they become continu- ous. [In this connection it is interesting to note the presence of tliese new bile-cana- liculi in cases of parenchymatous hy- pertrophy occurring in connection witli portal cirrhosis and in the transitional eases between such hypertrophy and actual adenomatous development. J. George Adami.] The general appearance of the larger bile-ducts, their abundant and proliferat- ing epithelium, supports the view of Goluboff and some of the recent French observers, that we are here essentially dealing with a chronic diffuse catarrhal angiocholitis with chronic diffuse peri- angiocholitis. At the same time it may be that the liver-cells are also directly affected, and that there is here a replace- ment-fibrosis in addition to the inflam- matory, for the character of the new connective tissue, especially at the mar- gins of and invading the lobules, is not of a productive inflammatory type. With regard to the other organs, the spleen is, in general, enlarged, and some- times there is great enlargement. The lymph-glands are not found markedly enlarged; the kidneys and other organs of the body are bile-stained, but beyond that present nothing characteristic. Sjonptoms. — Pain is felt in the region of the liver of a dull character, with some tenderness. While the general health ap- pears to be fairly good and the appetite to be excellent, there is a slight fever and very characteristic is the develop- ment of a series of more acute attacks of abdominal pain resembling mild hepatic colic, associated with each of which the jaundice becomes more marked. Gradu- ally the abdomen becomes enlarged, the enlargement being due to the increased size of the liver, which, on palpation, presents a perfectly-smooth surface. Tlie process is, in general, of slow develop- ment; only after months may the ab- domen become markedly enlarged, and the enlargement may slowly continue for as many as eight years; but the jaundice is progressive and becomes so intense that the skin takes on a dark-green color. The jaundice is not obstructive, as shown by the fact that the stools continue to be stained. The urine, according to Hanot, shows slight diminution of the urea, is high colored, and contains abundant pig- ment. Throughout the disease there is absence of marked ascites, though in some cases there may be evidences of intestinal ha2morrhage. Sometimes there is a little fluid in the abdomen, and where this is the case it would seem to be asso- ciated "nith the development of peri- hepatitis and perisplenitis. As the disease progresses, there is loss of strength, and with the progressive emaciation petechiae may show them- selves. Finally coma supervenes, and death occurs directly from the hepatic disturbance. Thus, clinically the distinctions be- tween this form of cirrhosis and ordinary portal cirrhosis are: — • 1. The life-period at wliicli the dis- ease develops. 2. The enlargement of the liver and its smooth, or but slightly-roughened, surface (from perihepatitis). 3. The persistent jaundice. 4. The characteristic exacerbations of hepatic pain and of jaundice. 5. The absence of any marked ascites and of portal obstruction, save at the very end. G. The preservation of an excellent ap- petite. 7. The long continuance of the condi- tion after the recognition of the first signs of hepatic disturbance, and, asso- ciated with this, the slow emaciation and the retention of bodily strength. CIRRHOSIS OF THE LIVER. BILIARY CIRRHOSIS. TREATMENT. 233 It is all the more necessary to keep these distinctions in view, inasmuch as there is the painful confusion between this true biliary cirrhosis and those cases of portal cirrhosis in which there is the enlarged liver, either of the fatty type or again of the mixed, brought about by the indiscriminate employment of the term "hypertrophic." Nothing has more conduced to confusion with regard to cirrhosis than the employment of this term, and of the relative term "atrophic." [Strictly speaking, the term hi/per- tropliy of the liver should be employed to indicate an overgrowth of the spe- cific liver-tissue, — i.e., of the parenchyma, — but ought never to be employed to in- dicate the overgrowth of the connective tissue of the organ, or the mere fact that the organ is enlarged. In short, he who wishes to make himself clearly under- stood will do well never to use the term in connection with the liver. Similarly if the term atrophic be banished the unity of the various forms of portal cir- rhosis will be better grasped. J. George Adami.] Seven cases of biliary cirrhosis in children, presenting all the symptoms ob- sen'ed in the adult, but with the addi- tion, in many cases, of hypertrophy of the spleen. The latter, in association with biliary cirrhosis, is peculiar to cases commencing in childhood. In some in- stances the ends of the femur and tibia were also enlarged. Gilbert and Fournier (Revue Mensuelle des Mai. de I'Enfance, July, '05). Case of Hanot's hypertrophic cirrhosis with chronic jaundice in which a very peculiar attitude of the body developed. The right shoulder was lower than the left, the right upper limb was also de- pressed, and the tip of the right middle finger was 4 centimetres below the cor- responding point on the left side. The right side of the body, as a whole, was lower than the left, the right half of the pelvis and the right hip being depressed. The right gluteal fold was 2 centimetres below that on the left. There was no spinal cunature, and no anatomical le- sion to account for it, and it appeared to be purely functional. Sicard and Remlinger (Revue de M6d., Sept., '97). Diagnostic points insisted on in cases of hypertrophic cirrhosis with icterus: (1) enlargement of the liver; (2) hep- atoptosis, or downward displacement of the liver; (3) icterus; (4) discoloration of the faces. In similar cases, but in which the fteces retain their normal color, Hanot's disease is characterized by per- sistent jaundice, enlarged liver (gradu- ally incieasing and slightly tender on pressure), gieat enlargement of the spleen, no clay color of the stools, and no ascites. Leopold L6vi (Gaz. d. HOp., Feb. 2C, '98). Prognosis. — To the best of our knowl- edge this disease is incurable, although it may be long years before death super- venes. A few cases have been recorded in which death has been of an acute course, occurring within a month. In one case recorded by d'Espine, in an in- fant, death occurred on the twenty-fifth day. Treatment. — AMiat has been stated concerning the treatment of hepatic cir- rhosis would appear to apply, in a large measure, to the treatment of this form. Special care must be taken that the diet is bland and imirritating, because in se- vere cases errors in diet have appeared to induce the exacerbation above men- tioned. stress laid on the importance and eflicacy, at the outset, of calomel, to- gether with milk diet. In the biliary form with intense jaundice, injections of salicylate of sodium, 15 to 30 grains to 1 pint of water, to be repeated daily. In addition, massage of the liver, chola- gogues, appropriate diet, hot baths (with massage in the bath), and a course at an alkaline spring. Liebreich (Practitioner, Apr., '94). Two cases of biliary hypertrophic cir- rhosis of the liver wliich recovered in consequence of operation. In the firat 234 CIRRHOSIS OF THE LR^ER. PERICELLULAR CIRRHOSIS. case the operation was accidentally un- dertaken; that is, it was due to a mis- taken diagnosis. The result in this fii'st case was so satisfactory that operative intervention was deliberately under- taken in the second case. The oper- ation the author recommends for this condition consists in sewing the omen- tum, gall-bladder, and liver to the pa- rietal peritoneum. The author advances a tentative theory to account for the favorable results observed. The opera- tion is in itself comparatively harmless, and, in the author's opinion, deserves a further trial. Rosenstim (Medical Rec- ord, Xov. 7, 1903). Pericellular Cirrhosis. As already stated, the condition of pericellular cirrhosis exists to some ex- tent in biliary cirrhosis, and in the so- called mixed type of portal cirrhosis a certain amoimt of pericellular or mono- lobular deposit of connective tissue is to be recognized. But there exist cases in which the pericellular change is mi- croscopically the most-marked alteration in the organ, and, inasmuch as these cases are, in general, unaccompanied by either jaundice or ascites, it becomes necessary to treat them as a separate class. We rarely, in the adult, meet with a generalized form of the disease. The most frequent examples are to be met with in the infant in connection with congenital syphilis. Not infrequently it is to be found well-marked in children bom prematurely, whether alive or dead, close upon term. It may, however, be very evident during the first months of extra-uterine life, and where this is the case it often indicates a syphilitic in- toxication 60 severe as to lead to death before the end of six months; rarely do the children survive if the hepatic en- largement is very extensive. Occasion- ally, however, there may be this diffuse pericellular cirrhosis in the adult, pos- sibly, according to some writers, among whom may be mentioned Tzeytliue (These de Paris, '96), of the nature of a delayed hereditary syphilis, in which case it is associated with the presence of gummata; in other cases too, more rarely, it is a manifestation of acquired tertiary syphilis. I have seen one case of this in which in addition to the pres- ence of numerous well-marked gummata, there was this general pericellular devel- opment of delicate connective tissue with signs of progressive atrophy of the liver- cells. In this case, however, while the process was diffuse, it was most advanced in the neighborhood of the gummata, and there were areas in the liver showing relatively little fibroid change. Very rarely in tuberculosis there may be a similar pericellular change, though not so extensive as in syphilis. In cattle, as first pointed out by Wyatt Johnston (Transactions of the American Veterinary Association, '93, and Appendix to Report of the Minister of Agriculture for the Dominion of Canada, '93), there exists in a strictly- limited region of Nova Scotia, around Pictou, a disease among cattle character- ized by very extensive cirrhosis. The disease appears to be chronic, and death occurs after a brief period of acute delirium or from a progressive paresis pa.ssing on to complete paralysis with stupor. The disease most often is first recognized by the acrid taste and odor of the milk, which rapidly diminishes in amount, and with this, or earlier, the coat becomes "staring," the eyes promi- nent and very bright, and there is con- siderable looseness of the bowels. There is no jaundice and but a slight accumu- lation of fluid in the abdominal cavity toward the later stages. Upon killing the animal the main pathological changes are, in general, a moderate CIRRHOSIS OF THE LIVER. PERICELLULAR CIRRHOSIS. 235 enlargement of the liver with some obtuseness of the angles; the surface is perfectly smooth. Microscopically there is marked evidence of parenchymatous and fatty degeneration of the cells, great diminution in their number, and replace- ment by a delicate and very transparent connective tissue, which in more ad- vanced cases is to be found more dense and more concentrated around the intra- hepatic bile-ducts. There is no Jaun- dice; indeed, in the twenty or so autop- sies which were performed in this dis- ease the gall-bladder was, in general, very full of bile or light color, the faeces were well stained, and, if anything, there appeared to be an excessive excretion from the organ. Other well-marked features are the presence of a clear, limpid fluid in the abdomen (though this ascites is never excessive), a moderate enlargement of the abdominal lymphatic glands and of the glands at the hilus of the liver, and a peculiar gelatinous cedema of the coats of the fourth stomach and small intes- tines and of the mesenteries. In the fourth stomach, also, there are numerous follicular ulcers, generally found in a cicatrized condition. Studying this dis- ease I constantly came across a minute bacillus presenting polar-staining, cult- ures of which were fatal to rabbits, guinea-pigs, and mice at periods varying, in rabbits, from a fortnight to a month, though in these cases the liver showed parenchymatous degeneration and al- most singularly-slight early cirrhosis. In some isolated regions in Germany and Switzerland the horses are said to BufTcr from a similar enzootic cirrhosis. Anatomical Changes. — Leaving aside these cases of pericellular cirrhosis of the lower animals, and referring more especially to the liver of congenital syph- ilis in the infant, the organ here is found very greatly enlarged, so that in some cases its edge may reach to the iliac crest; the surface is smooth and of a deep-red color, though I have come across cases in which there was a coarsely- mottled appearance of relatively-large areas of bright-yellow color standing out against the red. Upon section the organ is fairly firm, and, microscopically, the main feature is this infiltration, between the hepatic cells, of delicate connective tissue with, however, a fair infiltration of small, round cells, the hepatic cells showing evidences of marked atrophy. The portal sheaths are also greatly en- larged, and present considerable infiltra- tion with small, round cells. There are, in general, evidences of the existence of miliary gummata, as minute small col- lections of round cells not very sharply defined are scattered irregiUarly through the organ; only in rare cases has the presence of occasional caseous gummata been noted. According to Hochsinger, four distinct main anatomical changes can be made out: 1. Diffuse small-celled infiltration. 2. Connective-tissue hyperplasia. 3. Miliary gummata. 4. Very rarely true nodular gummata. Taking all these cases together, it is evident that this condition is distinctly of infectious origin, due, perhaps, not so much to the direct proliferation of the bacteria, for where that is the case, as in tuberculosis and syphilis, there is ac- cumulation of small, round cells at the various foci of proliferation, but due to a toxic effect of the bacteria upon the liver-cells, the development of the fibrous tissue being secondary to the atrophy of the parenchyma. Experimentally, according to Au- frecht, a somewhat similar interstitial or pericellular cirrhosis is producible by the action of small doses of phosphorus 236 CIRRHOSIS OF THE LIVEK. PEKICELLULAK. ARTERIAL. frequently repeated. Such minute doses do not, like larger ones, lead to com- plete necrosis of the liver-cells, but the protoplasm becomes paler, the nuclei more evident and closer together, and the cirrhosis is diffuse and interstitial, exclusively due to the diseased hepatic cells more especially at the periphery of the acini. As is to be expected, poisons introduced into the system from without act like those developed within the or- ganism (using this term in its broadest sense); so that some act primarily upon the intestinal walls and only secondarily upon the liver; others act directly upon the hepatic parenchyma, while all vary in their action according to their con- centration. Diffuse "interstitial hepatitis," leading to cirrhosis, is never the result of an in- terstitial inflammation; it depends en- tirely on an inflammatory process, affect- ing the glandular cells of the peripheral parts of the acini. Human cirrhosis cor- responds e.xactly with experimental cir- rhosis as produced by phosphorus. Au- frecht (Deut. Arch. f. klin. Med., vol. Iviii, p. 302, '97). Symptoms (Syphilitic Pericellular Cir- rhosis). — There seem no recognizable symptoms of this condition beyond the extreme enlargement of the liver, which is tender, and the co-existence of other evidences of the disease. There is, as above said, no ascites and no jaundice. As above stated, this variety of cir- rhosis frequently leads to intra-uterine death and to premature birth, and, where the child survives birth, death in general occurs before the sixth month. Where the enlargement of the liver is extensive, there appears to be little chance of re- covery, though mercurial treatment has resulted in some recoveries. Hochsinger (Zur Kenntniss des Ange- borenen Lebersyphilis dcr Siiuglinge," Vienna, '90) states that of 148 infants with congenital syphilis, 46 showed clin- ical enlargement of the liver. The large number of 30 of these are stated to have recovered. Five cases came to autopsy, and in 1 the enlargement was due to tuberculosis. In none of his cases was there icterus or jaundice; in these en- larged livers there was some extent of fat-infiltration. He is strongly in favor of immediate mercurial treatment. Arterial Cirrhosis. Contrary to what I believe is the gen- erally-received opinion, I find that in cases of general arteriosclerosis branches of the hepatic arteries resemble other arteries throughout the body in showing a distinct periarteritis [Recently Hasenfeld (D. Arch. f. klin. Med., '97) has noted similarly a slight chronic endarteritis in the hepatic ar- teries in arteriosclerosis. J. George ADAin.] This periarteritis is rarely extreme and clinically is incapable of recogni- tion, though Eichhorst is inclined to recognize a senile variety of cirrhosis due thereto, and analogous to the arte- riosclerotic nephritis resulting from ar- teritis and periarteritis in the renal ves- sels. This arterial change is only of interest in that a large proportion of subjects with alcoholic cirrhosis present also a condition of general arteriosclero- sis, and thus associated with alcoholic cirrhosis there may be independently a certain amount of fibroid development in the portal sheaths due to tlie arterial disturbance. Certain writers have suggested that the toxic substance leading to the devel- opment of what I have termed "portal cirrhosis" are brought to the organ by the arterial branches; if this be so, the anatomical evidence of the transmission is singularly small. CIRRHOSIS OF THE LIVER. CENTRILOBULAR. SECONDARY. 237 Centrilobular Cirrhosis. In cases of well-marked obstructive disease, either of the heart or of the lungs, the liver is the seat of great, passive congestion, with atrophy of the central cells of the lobule. There is no sign of fibroid development in these re- gions; all that is to be seen is the great dilatation of the central capillaries of the lobule, with atrophy of the cells. In cases of a more chronic type with less severe obstructive disease we occa- sionally meet with a well-marked devel- opment of fibrous tissue immediately round the central vein of the lobule. It is debatable whether this is of the nature of a replacement-fibrosis in consequence of the atrophy of the central liver-cells or whether it may be termed "non-func- tional" or "non-inflammatory," due to the increased pressure in the hepatic veins and the altered character of the blood-flow. This form, again, while it may be predicated in cases of long-con- tinued slight mitral or other obstructive disease, is associated with no clinical symptoms. Hanot and Gilbert have, however, de- scribed a venous "hypertrophic" liver with enlargement, the organ remaining enlarged. If this form truly exists, it will be clinically impossible to differ- entiate it from the enlargement due to accompanying passive congestion. Secondary Cirrhosis. Synonyms. — Cirrhosis following upon perihepatitis; Glissonian cirrhosis; zuck- erguss leber. While chronic perihepatitis may either be localized, and in patches over the surface of the liver, or generalized, it is with the generalized form that we have to deal in an article on "cirrhosis." Such generalized perihepatitis is a very characteristic condition pathologically, though clinioflllv it may be present in an advanced form without any signs of its presence, and, on the other hand, may ape and be almost, if not quite, indis- tinguishable from the atrophic and con- tracted form of portal cirrhosis. Etiology. — Such thickening of the capsule of the liver may be one of the results of a general peritonitis; indeed, it must be regarded as one evidence of such a condition. Of 22 cases of universal perihepatitis in the post-mortem records at Guy's Hospital collected by Hale White (All- butt's "System of Medicine," volume v, p. lis), in only 2 was it stated there was no peritonitis; in 17 it was distinctly stated to be present, and in the remain- ing 3 no mention was made of the peri- toneum. Hale White suggests that in his cases the peritonitis was always fibroid and so never owed to tubercular growth; this, however, is contrary to the observations of other writers, and I myself have seen a most-marked con- dition of universal perihepatitis accom- panying and evidently due. to a chronic peritoneal tuberculosis, though it is true the thickened capsule in such case does not show a characteristically tubercular appearance throughout, but is fibroid in its deeper layers and homogeneous. But a study of chronic tuberculous pleurisy shows that the process may assume this homogeneous fibroid character. In fact it may be said that this form of universal fibrous perihepatitis is distinct from lo- calized chronic perihepatitis in that it is an extension of inflammatory disturb- ance from without the liver, and not from within, as may often happen in the latter condition, and that anything ca- pable of setting iip a chronic productive inflammation in the abdominal cavity is also capable of producing this form of disease. Pathological Anatomy. — Tn conse- 238 CIRRHOSIS OF THE OVER. SECOXDARY CIRRHOSIS. SYMPTOMS. quence of the deposit of this thickened, new, fibrous tissue over the surface of the organ and its contraction, the liver becomes more globular in appearance than normal, though it is to be noticed that, in general, the thickening is more marked on the upper and anterior sur- face than on the under surface. Fre- quently, as Fagge, I believe, was the tirst to point out, the anterior edge is folded over on to the dorsum in a man- ner that is difficult to explain. Fre- quently, also, the omentum, shortened and thickened by the universal peri- tonitis, is adherent to the lower edge of the organ; and this thickened mass may be mistaken for the edge of the liver. Frequently, again, the productive inflammation on the surface leads to ad- hesions, more especially anteriorly and to the diaphragm. As Hale \Vhite points out, often little pits are to be seen on the surface of the thickened capsule; when seen they are very striking. I have only seen them upon the upper diaphragmatic aspect of the organ in regions where there have been no adhesions, and from their posi- tion and character I am inclined to be- lieve that they are brought about by little eddies opposite to the lymph-stig- mata in the under surface of the dia- phragm. A marked feature is the ease with which the thickened capsule can be peeled off, leaving, in general, a smooth surface. Authorities diifur as to tlie connection between this perihepatitis and cirrhotic change in the organ itself. According to Murchison and Osier, it is frequent, but Fagge, Hale White, and Cursch- mann (Deut. mcd. Woch., p. 564, '84) speak of the condition as, in general, unaccompanied by any interstitial in- flammation. And, in the not very fre- quent cases which I have come across, I also have found the liver soft and pulpj', rather than fibroid. Evidently both conditions may exist, and, speaking correctlj', it is only the former condi- tion where there is this extension of the inflammatory process inward along the lymphatics, leading to the development of fibrous bands within the organ; or, again, where there is an extension up- ward of the process into the organ along the sheaths of the portal vessels at the hilus, which ought properly to be spoken of as cirrhosis. With regard to other organs. The spleen, in general, shows a like capsular thickening, more especially of its dia- phragmatic surface, and, as Hale White, who has made the fullest study of the condition, points out, there is a very fre- quent complication of interstitial ne- phritis. Symptoms. — Frequently, as above stated, there are no symptoms recog- nizable; but, in a typical condition of the disease, we find the liver smaller than normal, with thickened uniformly blunt edge, and, associated with this, marked ascites. Hale White points out that the condi- tion is of long duration, and that the ascitic fluid can be repeatedly tapped. There is an absence of jaundice, while evidences of chronic peritonitis and, again, of interstitial nephritis, are well marked. At times a friction-sound can be made out over the liver, though this is rare; more frequently the organ, by adhesions to the abdominal wall, becomes fixed and it docs not move downward on inspira- tion. Tn TjoikIdii apparently this condition is fairly frequent, for Fagge makes the statement that, at Guy's Hospital, for every five cases that die showing portal cirrhosis with ascites there is one in CIRRHOSIS OF THE LIVER. SPORADIC CIRRHOSIS. 239 which the ascites is associated with peri- hepatitis. Treatment. — Where there is such ex- tensive perihepatitis, treatment cannot be curative, but can only be palliative, and, of palliative measures, tapping is the most important. Sporadic Cirrhosis. I would employ the term "sporadic cirrhosis" to indicate those cases in which there is a fairly-extensive devel- opment of fibrous tissue throughout the liver in scattered patches related defi- nitely in origin to no one special portion of the lobule or of its surrounding sheath. Where the development is slight, we can scarcely speak of cirrhosis; but in some cases the connective-tissue development may be very extensive, and here we must speak of cirrhosis. Two main series of cases are to be in- cluded under this heading: — 1. The fibrous-tissue development in consequence of the presence of multiple infectious granulomata: a condition seen in tuberculosis and syphilis. 2. The condition to which our atten- tion has been more especially directed by Welch, Flexner, Barker, and the Johns Hopkins School, in which, ap- parently from the action of toxins rather than from bacteria, multiple focal ne- croses are developed in the liver. These focal necroses pass through the success- ive stages of slow death, infiltration with leucocytes, and organization and forma- tion of fibrous tissue, leading eventually to the development of fibrous tissue; so that scattered through the organ are little, irregular nodules of fibrosis. Yet a third form may be recognized, for the recognition of which we are again indebted to Welch, namely: that form of cirrhosis due to the conveyance into the liver by lymph or blood of discrete par- ticles of foreign matter, as, for example, of carbon or of stone. Around about such little collections of foreign particles there may be developed here, as in the lung, a noticeable amount of fibrous tis- sue; but, in general, the condition is very slight. I have come across it both in connec- tion with anthracosis and again in con- nection with stone-mason's lung, or sili- cosis; but to the best of my belief Welch's well-known case of cirrhosis anthracotica is the only very extensive and truly cirrhotic case upon record. 1. Cirrhosis Due to Infectious Granulomata. — In general, tubercu- losis affecting the liver leads to no recog- nizable sjTnptoms, even though the liver be thickly studded throughout with fibroid tubercles; very rarely we have a caseous mass. Beyond, therefore, men- tioning the existence of this form, it is unnecessary for me to say an3'thing fur- ther concerning it. With syphilis it is different. Here dense bands of new tissue may radiate in various directions around the fibroid and caseous gummata. Wliere these gum- mata are frequent, the obstructive effect of the bands and again the deformity of the organ may lead to signs and symp- toms which closely simulate either the atrophic or parenchymatous hypertro- phic form of portal cirrhosis. But even in the most extensive cases the develop- ment of this fibrous tissue is so sporadic, and the condition of the other parts of the organ is so relatively healthy, that, strictly speaking, these cases ought not to be spoken of as cirrhotic. For its symptomatology, this gumma- tous form depends upon the number and the position of the gummatous growths in the organ and the amount of fibrosis developed in the immediate neighbor- hood. As these gummata have no points of election and may occur on the upper 240 CIRRHOSIS OF THE UVER. SPORADIC CIRRHOSIS. surface and away from the vessels at the hilus as frequently as they occur in its neighborhood, it follows that we may have, on the one hand, an advanced gummatous condition of the organ un- accompanied by jaundice or by ascites or by any recognizable disturbance; while, on the other hand, there may be but a few gummata, and yet these, being situated in such a position as to obstruct either the main branches of the portal vein or some of the main bile-ducts within the organ, may induce either as- cites or icterus, or both. In advanced cirrhosis, where there are numerous gummata, it may be possible to palpate the lower portion of the organ, and to recognize the scarred and coarsely-nodu- lar condition of the surface; or, again, as in advanced portal cirrhosis, the or- gan may be, by the contraction of the fibrous tissue, so retracted behind the ribs as to be incapable of being felt. ■^Tiere this is the case, it is impossible to make a diagnosis between tertiary syphilis and the liver of alcoholic cir- rhosis, unless the evidence of syphilitic infection of other organs is present. Where there is doubt as to the nature of the condition, progressive improve- ment manifested under the potassium- iodide treatment will clear up the diag- nosis. Osier distinguishes a group of cases in which the patient is ana3mic, and passes large quantites of pale urine containing albumin and tube-casts; the liver is enlarged and, perhaps, irregu- lar; and the spleen also is enlarged; while ascites may supervene. In such a case the presence of gummata is asso- ciated with amyloid degeneration of the organ, of the intestinal mucosa, and of the spleen. He further points out what is, perhaps, not very uncommon: that the large projecting masses of liver- tissue produced by the contraction of gummata affecting the left lobe are apt to be mistaken for new growths occur- ring in connection with the organ. Here, again, potassium iodide affords valuable aid in diagnosis. In brief, the history of syphilitic in- fection, and the effects of treatment by potassium iodide, are the main diag- nostic aids in differentiating syphilitic or other forms of cirrhosis. 2. The Cirrhosis of Focal Ne- croses. — As yet we know and patholog- ically have been able to recognize singu- larly few cases of cirrhosis originating from focal necroses. Such focal necroses occur in a large number of infectious dis- eases. Not only have they been recog- nized by Welch and Flexner in diph- theria, by Eeed and subsequent observers in typhoid fever, and by numerous ob- servers in tuberculosis, but by Guarnieri, Thayer and Hewetson, Barker, and others in malaria; and Flexner, in his experimental work upon toxalbumins, has been able to show that several vege- table poisons of the nature of toxal- bumins will produce them and follow the development of cirrhosis following upon these focal necroses. [Haiiot (Coniptes-rcndus de la Soc. do Biol., p. 4G9, '93) desciibcs as tachcs blanches du fiiie infcctioux certain ap- pearances wliicli, he points out, charac- terize the liver in all forma of infectious disease; small irregular areas of palo color, appearing more especially on the convex surface, in which upon micro- scopical examination a condition of di- lated capillaries with abundant intra- vascular and extravascular leucocytes are to be made out. The liver-cells in the regions show degenerative changes. The condition is allied to the focal necrosos. J. Georoe AnAMr.] As to the exact causation of the ne- croses, some doubt must, I think, still be expressed. While it is possil)le that, as many observers believe, they are directly CLITORITIS. SYMPTOMS. 241 due to the action of toxins, it is difficult to comprehend why such toxins should pick out only specially-isolated portions of the organ. One would expect to find that in addition to the action of the toxins there is some disturbance of the circulation, some thrombosis, or other change in the smaller veins or capillaries of the part, whereby the cells, being im- perfectly nourished, undergo destruction. [A full and interesting discussion of the matter is to be found on page 386 of Flexner's remarkable monograph ("The Pathology of Toxalbumin Intoxication," Johns Hopkins Hospital Reports, vol. v, '97). Barker, in his studies upon ma- laria, and Schmorl, in puerperal eclamp- sia, have drawn attention to the exist- ence of intraeapillary ihroziibi in con- nection with these areas of necrosis. Flexner in his ricin experiments was forced to conclude that there is no causal relationship between the thrombi and the necroses, and that the localized cell-death is due to the intensity of action of the toxic bodies upon the tissue-elements and not upon the circulating blood or its channels. J. Geoi!OE Adami.] J. George Adami, Montreal. CLEFT PALATE. See Plastic Sur- gery. CLITOKITIS. — Latin, from Greek, xlEiropigeiv, to titillate; and itis, in- flammation. Definition. — The question as to the freq\iency of this condition is one which involves great difference of opinion, and depends not a little upon the definition which one gives to it. If it is considered as an inflammation which involves the structiires, as a whole, of which the organ is composed, it is, indeed, of rare occur- rence; but if we include that adventi- tious form of inflammation, often of slight intensity, indicated by fibrous structures which are attached to and 2- bind down its terminal portion, it is of great frequency. If all female children were carefully examined to determine its presence or absence it would doubt- less be recognized much more frequently than it is. It would probably be found as often as the analogous condition which afl'ects the penis of male children. Symptoms. — The venereal variety of clitoritis may be associated with either of the forms of venereal infection; that is, with chancre, chancroid, or gonor- rhoea. True chancre of the clitoris is of rare occurrence. In a dispensary experi- ence of many years among women with every shade of venereal disease I do not recall a single instance. Dr. E. AV. Taylor has informed me that he has seen it several times, and that it was characterized by great pain, swell- ing, and induration, and reported a typ- ical case in a woman, 21 years of age, who contracted syphilis from her husband. The clitoris and prepuce were indurated, enlarged, and very painful, and there v/as an ulcer at the tip of the glans. Local treatment with solution of caustic potash and lead-and-opium lotion pro- duced relief. Other cases have been re- ported by Mauriac. Chancroid of the clitoris I have seen several times, though Taylor thinks it is of rare occurrence. Its phenomena are those of chancroid on other portions of the female genitalia, viz.: local sore with- out great attendant hyperajmia in the structures of the clitoris, and usually en- largement of the neighboring inguinal glands. Gonorrha?a involving the clitoris is not of infrequent occurrence. The phenom- ena are redness and swelling of the pre- puce and to a greater or less degree of the organ itself: the accompanying pain may be considerable. Traumatic clito- ritis is relatively of rare occurrence. It 16 242 CLITORITIS. ETIOLOGY AND PATHOLOGY. is the result of direct injury from violent coitus, from a blow, a thrust, or a fall, the clitoris sharing injurj' with the sur- rounding structxires. The inflammation follows the course of .inflammations of a traumatic character in similar vascular tissues, pain and swelling being the most prominent features. Etiology and Pathology. — It is some- what surprising that inflammatory phe- nomena of a decided character are not more frequently connected with the clit- oris when we remember its exquisite sensitiveness, its abundant blood-supply, and its constant exposure to irritation during the entire period of life in which the tissues of the genital organs are in an active functional condition. During childhood its conspicuous position in- vites the injuries to which childhood is unusually susceptible, and it is also in danger from uncleanliness, from para- sites, and from masturbation. After the external genitals have acquired complete development and the mature condition which follows puberty has placed the organ in a less exposed situation there is still danger from traumatism, though not to a great degree; from uncleanli- ness, from masturbation, from violence in coitus, and from the poisonous influ- ence of venereal disease. It would seem that the susceptibility to injury increased with the size of the organ, a large organ being an anomaly and requiring constant care and precaution. This fact empha- sizes the necessity that the family physi- cian be acquainted with the peculiarities of his patients in order to safeguard tliem from evils which may be avoided. The clitoris may be the seat of cystic disease from haemorrhage or other cause (Peckham), of syphilitic new growth (Kelley), of carcinoma, and loss fre- quently of sarcoma (Robb), of hyper- trophy, in addition to various congenital deformities and defects. Its appearance in spurious hermaphrodism is a very good illustration both of hypertrophy and of congenital deformity. These statements are made incidentally, since a true inflammation may be associated with either of these conditions, a true clitoritis being then present. Inflammatory disease of the clitoris may, therefore, be prenatal or postnatal in its origin, congenital or acquired. In the great majority of cases it is prenatal; that is, it originates during foetal life. Why such a condition should arise so frequently during this period is not known; but the fact remains that many female children come into the world with the glans clitoridis surrounded by more or fewer bands of adhesion, binding it down, interfering with its circulation and development, and furnishing cause for more or less subsequent irritation and disturbance. Of the postnatal, or acquired, form of the disease, while there are occasional instances in which it is caused by un- cleanly habits, by parasites, and by the extension of dermatitis aifecting the con- tiguous tissue, in the greater number of cases it will be due to venereal infec- tion or to traumatism. With reference to its etiology, there- fore, the disease may be classified as (1) congenital, (2) venereal, and (3) trau- matic. Of the causes of the congenital variety we are ignorant, as has already been re- marked. The bands and strands of fibrous tis- sue of greater or less density and firm- ness, which are its visible consequence, attach its glans to its prepuce, or hood, which is formed by the coalescence of tlie nymphas, and to the surface which lies immediately around it. The contrac- tion of this tissue, according to its abun- CLITORITIS. COCA AND COCAINE. 243 (lance and firmness, interferes with the development of the organ, produces irri- tation, and probably leads, in not a few instances, to the habit of masturbation. It is conceivable, as Baker Brown in- sisted, that certain forms of nervous dis- ease might result in consequence of such conditions, but the number of cases in which such a relationship has been care- fully observed must be quite small. In the great majority of cases it is believed that the resulting disturbance has been too slight to require attention and treat- ment from the gynascologist. Treatment. — There is little to be said concerning the treatment of clitoritis of whatever variety. Best in bed is essential; local cleanli- ness equally so. In the congenital va- riety the adhesions must be removed, and this can usually be done by retracting the prepuce with the thumb and fore- finger of one hand while the forefinger of the other is rubbed over the glans ■ndth sufficient firmness to remove all obstruc- tions. The bruised surface may then be ■dusted with iodoform, aristol, or no- sophen, and this process repeated daily as long as the surface remains broken. For the venereal variety a 10- or 20-per- ccnt. solution of nitrate of silver should be applied daily upon absorbent cotton until pain and swelling have subsided and the ulcerated surface has healed. For the traumatic variety only soothing lotions will be required. Load-and-opium wash, frequently applied upon absorbent cotton, will serve the purpose sufficiently well. Andrew F. Currier, New York. CLUB-FOOT. See Orthopedic Sur- r.KRV. CITJB-HAND. See Orthopjedio Sur- gery. COCA AND COCAINE. Erythro.xylon coca is a small tree that grows wild in Peru, Bolivia, Brazil, and Ecuador. The leaf, which contains the active principles, is the part used in medicine. Three alkaloids, hygrine, ecgonine, and cocaine have been isolated from the cocoa-leaves. Cocaine, the only one that has been found useful in medi- cine, occurs in colorless, transparent crystals, which are soluble in alcohol, ether, chloroform, and fats. Cocaine forms salts with the acids, the hydro- chlorate being official and the one usually used. The salts cannot be used for mak- ing ointments, as they are soluble in fats. Preparation and Dose. — Coca (leaves), V2 to 1 drachm. Extractum cocoe fluidum, ^/„ to 2 drachms. Cocaine carbolate, ^/^ to Ve grain. Cocaine hydrochloras, '^/ ^ to 2 grains. Coca is best administered either as a tonic or coca, such as vin Mariani, or in the form of the fluid extract. When ad- ministering coca or cocaine the pos- sibility of intolerance on the part of the patient should be borne in mind and the danger of inducing the cocaine habit re- membered. Solutions of cocaine hydro- chlorate are bitter, and provoke transient insensibility of the tongue. Aqueous solutions do not keep well, but decom- pose in a short time and lose their effi- ciency. Series of experiments indicating (1) that cliloral-liydrate is a decided antag- onist of cocaine, being able to counter- act tlie action of doublylotlml doses given to a dog; (2) other hypnotics, such as paraldehyde, are likewise an- tagonistic to cocaine: (3) the antag- onism is complete, influencing all the important organic functions; (4) it is a onesided antagonism, for cocaine does not counteract poisoning by the hyp- notics; (.5) the antagonism is a meehan- ieal one, similar to the antagonism be- 244 COCA AXD COCAIXE. PHYSIOLOGICAL ACTIOX. POISONING. tween the hypnotics and strychnine. Carlo Gioffredi (Giornale Inter, delle Scienze lied., Aug. 31, 1900). Physiolo^cal Action. — When taken internally, coca and its alkaloid produce a sensation of exhilaration and pleasure similar to that produced by a large dose of caffeine. There is a marked tendency to wakefulness, a feeling of increased mental and muscular strength and vigor, and an absence of hunger. The brain is stimulated, but the sensory nerves are not generally affected, and, if at all, the effect is very feeble and is due to an influence on the spinal cord (Mosso). When applied locally to the sensory nerves cocaine paralyzes them. This also happens if the internal dose be very large. The effect upon the muscles when taken internally is direct stimulation, most marked after fatigue. Maurel, of Toulouse, has shown that under the influence of cocaine the leuco- cytes undergo changes; they become spherical and rigid, increase in size, and no longer adhere to the vessel-walls. On the other hand, the capillaries contract, and thrombosis and embolism— particu- larly pulmonary embolism — may be pro- duced. Upon the heart and circulation co- caine in moderate amounts acts as a stimulant, the heart-beats being in- creased in number and force; but marked effects only follow a poisonous dose. Cocaine is a respiratory stimulant, large doses increasing the number of respira- tions; in poisonous doses it kills by fail- ure of respiration associated with exhaus- tion from the accompanying convulsions (Hare). Cocaine increases body-heat to a marked degree if given in overdose, this rise being due to increase of heat- production (Reichert). When applied locally to mucous membranes, cocaine produces an anesthetic effect, accom- panied with a blanching of the mem- brane, followed by a marked congestion. When injected beneath the skin cocaine produces a local-ansBsthetic effect. Ap- plied externally to the skin it produces little effect. The rise of temperature caused by cocaine is due to an increase of heat- production, and the latter depends upon two actions: one, of the cortex, causing motor excitement, and the other, upon the caudate thermogenic centre, by which heat is produced independently of motor activity. Cocaine possesses very little power as a thermogenic in ani- mals lightly curarized, because of both the motor quietude and the depression of some other portion of the thermo- genic apparatus. It is absolutely with- out thermogenic power in animals in which the pathways of thermogenic and cortico-spinal motor fibres have been cut, as after section of the spinal cord at its junction with the bulb and of crura cerebri. Cocaine is effective as a thermogenic when only a small portion of the caudate centre is left intact with the parts below. Cocaine and morphine are direct antagonists in their actions upon the caudate and cortical centres which are directly or indirectly involved in the changes of temperature and heat- production. E. T. Eeichert (Pliila. Mod. .Tmir., Aug. 2, 1902). Poisoning by Cocaine. — Acute PoTSONiNG. — When cocaine is given in poisonous doses the symptoms no- ticed are an exaggerated sense of mental and physical well-being, loquacity and mental incolierence, profuse diaphoresis, fall of temperature; shallow, irregular breathing; dilated pupils, disturbed vision, nausea, feeble pulse, and finally collapse. Epileptiform convulsions have also been noted with disordered circulation and respiration; the convulsions, both tonic and clonic in type, are of cerebral origin. SmallcRt hypodermic dose observed to produce faintncss and nausea was '/m COCA AND COCAINE. POISONING. TREATMENT. THERAPEUTICS. 245 grain: in tlie case of a man aged 65. Old people are especially susceptible, and it is advisable in every case to have brandy and amyl-nitrite at hand. J. Jackson Clarke (Lancet, Jan. 18, '96). Case of acute cocaine poisoning, an injection of '/, grain of the drug for relief of severe pain being given. Within five minutes the pain had all disap- peared. The next day V: grain only was injected ; within three minutes there was a faint feeling, with collapse, followed by rapid heart-action and respiration; after ten minutes clonic contractions with widened pupil, bulging globes, and other severe symptoms. These passed off, and by the ne.xt day the man was out. The pain, which had been of long standing in the region of the hip-joint, did not return. Bergmann (MUnehener med. Woch., Mar. 20, 1900). Instance of the toxicity of cocaine. A strong man, aged 46, was seized with severe epistaxis, which recurred in spite of treatment. The bleeding came from a spot in the floor of the left nostril. Two applications of a 10-per-cent. solution of cocaine were made to this, resulting in an alarming attack of an epileptiform nature, the clonic spasms continuing for nearly ten minutes. The epistaxis ceased during the convulsions, and did not re- cur. Kohn (Med. Record, Mar. 24, 1900). Case under treatment for the mor- phine habit, who was known to be very susceptible to cocaine, received by the mouth, 30 milligrammes (nearly Vi grain) of that substance. The pulse, which was normally weak and never faster than SO, rose to 104 and became hard and tense. A noticeable feature was the enlargement of the outline of the heart, with marked palpitation, which occasioned much alarm to the patient. The case terminated in recov- ery. J. Hofraann (Therap. Monats., No. 11, 1901). Thus we liave two phases of acute poisoning; one with symptoms of de- pression, the other convulsive in type. CnuoNic Poisoning. — Chronic poisoning by cocaine,, or the "cocaine habit," occurs sometimes alone, some- times associated with the opium habit. The symptoms after cocaine habit con- sist of marked loss of body-weight, dis- ordered circulation, loss of mental power and moral perception, and delusion, sim- ilar to those affecting the subjects of chronic alcoholism. (See Cocaino- MANIA.) Treatment of Cocaine Poisoning. — The treatment of acute poisoning where the symptoms are those of depression consists in the exhibition of sal vola- tile, coffee, strychnine, caffeine, digitalis, ether, and alcohol. If the symptoms are of the convulsive type, the treatment should be the same as that of strychnine poisoning: inhalations of amyl-nitrite, bromides with chloral; if convulsions prevent swallowing, use chloroform ansesthesia and give antidotes by rectum in starch-water. Amyl-nitrite and mor- phine by hypodermic injection are indi- cated if relaxation does not occur. From experiments upon animals in re- gard to lavage of organism in acute co- caine poisoning, the following deductions made; — 1. While the minimum fatal dose of cocaine muriate administered hypoder- mically is 0.025 gramme per kilogramme, one can inject, of the same drug, with- out fatal result: (n) gramme 0.03, if we follow the said injection with hypo- dermoclysis; (6) and 0.035 gr. per kilo- gramme if we follow the said injection with lavage of the organism by the in- jection of the physiological solution of sodium chloride. 2. \Miile the minimum fatal dose of cocaine muriate administered fasting by the alimentary canal is 3 '/» centi- grammes per kilogramme, one can, with lavage of the organism, administer as much as 5 Vi centigrammes per kilo- gramme without fatal results. Carlo Bozza (Gior. Internaz. delle Sci. Med., Feb., '98). Therapeutics. — The therapeutics of this drug may be conveniently treated under three heads: the internal, hj-po- 246 COCA AND COCAINE. INTERNAL ADMINISTRATION. dermic, and topical administrations. Coca and cocaine are contra-indicated in fatty heart, arterial atheroma, pernicious ansmia, hysteria, and epilepsy. The first and greatest precaution to be taken before the -hypodermic injection is the preliminary physical examination; this should be made with the utmost thoroughness; if the patient is suffering with organic disease of the brain, heart, lungs, or kidneys, or any confirmed neurotic disorder, injection of the drug must not be attempted. The patient should be placed in a recumbent posi- tion, with the head low, and he should not be allowed to rise for at least fifteen minutes after the cocaine has entered the general circulation. Where it is possible to use constriction, it should never be omitted. After the operation, tourniquet is loosened and immediately tightened. This is repeated at intervals of a few minutes until the cocaine has probably all entered the circulation. C. A. Dunmore {Codex Medicus, Dec, '95). Cocaine administration in medical practice can be rendered absolutely safe by refusing its use in persons with kid- ney and heart affections, and tlie em- ployment of means which will fortify against the possible occurrence of acci- dents. Accidents can be avoided by the administration of morphine and atro- pine. O.xygen-gas is the only true anti- dote. Charles Wilson Ingraham (Med. News, Jan. 22, '9G). Internal Administration. — For inter- nal administration the fluid extract of coca or a good coca-wine, such as vin Mariani, is preferred. The elixir and tincture are not sufficiently active or re- liable. Cocaine successfully used in several cases of seasickness. A cathartic was first administered, then 5 minims of a 4-per-cent. solution of cocaine repeated every hour or two until three doses were taken. A. D. Rockwell (Med. Record, Apr. 1, '90). Fevkii. — The stimulating and sup- porting effects of coca are well known and may be utilized in all forms of low fever. In yellow fever it is of especial value on account of its anti-emetic prop- erty. Vomiting of Pkegnanct. — Coca has been found useful in many cases of this distressing malady and in other forms of vomiting. From Vs to 1 wineglassful of vin Mariani or 1 to 2 tablespoonfuls of the fluid extract may be taken three or four times daily, preferably after meals, so as not to impair the appetite. Fatigue. — In persons suffering from fatigue, coca is found to rest and freshen the mental and physical powers, giving a feeling of comfort and well-being, and making possible the endurance of fur- ther work and strain. To those who are about to undergo unusual strain or fatigue, coca acts as a powerful stimu- lant. Overindulgence in this use of coca is strongly advised against, in view of the danger of forming the habit. Opium Habit.- — Coca has been em- ployed as a stimulant during the with- drawal of the opium, but its use is not without the danger that the one habit may be replaced by the other, or, indeed, become associated with it. Pyloric Carcinoma. — Cocaine car- bolate has been used with success in these and other cases where a combination of an anaesthetic and antiseptic was desired. The dose used was V12 to Vo grain in wine or diluted. Nervous Disorders. — In melan- cholia and neurasthenia coca has been used with advantage, especially when as- sociated with a moderately-anaemic con- dition, a feeling of depression, loss of appetite, and impaired digestion, other appropriate remedies being associated with it. A wineglassful of coca-wine every three hours usually brings about a Ijcneficiiil elmnge in a day or two. Hypodermic Administration. — |i'or hy- podermic use the salts of cocaine are used COCA AND COCAINE. LOCAL AN/ESTHESLA. 247 (generally the hydrochloratc), as the alkaloid requires 1300 parts of water for its solution. A 4- to S-per-cent. solution is generally employed, and not more than V< grain of cocaine should be injected. Solution employed by writer contains 10 per cent, of resorcin and 20 per cent, of the hydrochlorate of cocaine. The addition of resorcin diminishes tlie toxic effect of cocaine, while at the same time it increases the ancesthetic effect of the latter, and it moreover prevents the cocaine crystallizing out. The anti- septic properties of resorcin in the solu- tion are also of value. Use of the spray for applying cocaine to the nose dis- approved of. If after the application of a solution of cocaine the patient becomes pale, giddy, or faint, 1 drachm of the aromatic spirit of ammonia, in 2 ounces of water, should be given, and the pa- tient directed to sip the draught. E. de H. Hall (Brit. Med. Jour., Feb. 8, '90). Extra care should be observed and a smaller dose given where injections are made about the head, face, and neck. The hypodermic use of cocaine is em- ployed to relieve pain, and to induce local anaesthesia for the purpose of mak- ing some surgical operation. Neuralgia. — Sciatica, pleurodynia, etc., and all forms of muscular rheuma- tism are best treated by hypodermic in- jection. For all, except neuralgia of the head and face, ^/ ^ to '/„ grain should be injected over the seat of the pain; for the two latter, the injection should be made into the arm. The result is marked in nearly all cases. The pain disappears almost en- tirely for several hours, when, if it re- turn, it is in a milder form. Injections should be continued as long as the pain lasts. Cocaine anaesthesia is contra-indicated in all irregular and all great operations, as well as in abdominal surgery. Its principal use is in weakened subjects afl'ected by organic taints or otherwise. The cocaine should not be allowed to enter the general circulation. Local Anassthesia. — Several methods of producing local anaesthesia by the hy- podermic use of cocaine have been sug- gested other than the simple one em- ployed in medication with other remedies. The painless method is one in which, after the part to be injected has been sub- jected to antiseptic cleansing, the part is sprayed with rhigolene or ethyl-chloride until insensibility to pain is induced. The point of the needle is introduced just below the epidermis and a drop or two injected into the tissues. This produces an area of insensibility within the edges of which other injections are made, gradually increasing the extent of the area of insensibility. Coming, who suggests this method, advises the injec- tion of the subepidermal region first, and subsequently the deeper tissues. The endermic method consists in first producing a small blister, withdrawing the serum therefrom with a syringe, and replacing it with a solution of cocaine. This method has no practical value in surgery. Prolongation of Local Action of Cocaine for Surgical PuRrosE. — By arresting the arterial and venous circu- lation. Corning has demonstrated that when cocaine is injected into an ex- tremity its action may be prolonged for ninety minutes, if necessary. This arrest he accomplishes by the aid of appropriate ligature about the limb, or in the case of the breast or back by the application of rings, clamps, etc. He maps out the veins (to avoid puncture) by tying a piece of elastic webbing above the field of operation. As the veins become swelled he traces their course with a col- ored pencil and then removes the web- bing. The limb is next exsanguinated 248 COCA AND COCAINE. LOCAL AN.LSTHESLi. with an ordinary Esmarcli bandage car- ried up to (but not beyond) the field of operation and maintained in phice till the injections of the anaesthetic are com- pleted. A strong flat tourniquet is then applied about the limb alove the field of operation and dra'mi tight enough to in- terrupt the circulation in the vessels. The Esmarch bandage is then removed, and the field is ready for operation. : Case in which Esmarch's constrictor was applied immediately above the mal- leoli; a solution of cocaine (1 per cent.) was then injected in the position of the different nerve-tninks, a number of dif- ferent punctures being made with the needle. After an inten-al of three- ; fourths of an hour, the operation took place; this consisted in the removal of the great toe, its metatarsal bone, and of the cuneiforms, in addition to scrap- ing with the sharp spoon and stitching of the skin. During the hour employed in these procedures, the patient was quite unaware of their progress. It is essential, in all cases in which it is de- sired to completely ansEsthetize the hand or foot, that the rubber tourniquet be very firmly applied, and that a sufficient interval (not less than twenty minutes) be allowed to elapse between the injec- tion of the cocaine and the operation. Otto Manz (Centralb. f. Chir., Feb. 19, '98). Case in which an abdominal section was performed under cocaine ansesthesia for retroverted adherent uterus, owing to marked cardiac symptoms and goitre. Eight minims of .5-per-cent. solution of cocaine having been injected beneath the Bkin, an incision was made in the median line down to the muscle-sheath. Eight minims more were injected at dilTcrent points along the median line into the muscular structures, and the incision was tlien carried into the peritoneal cavity. The adhesions binding the uterus down to the rectum were then separated with- out any apjjarcnt discomfort to the [la- ticnt. I5ut even slight traction upon I lie ovaries Hceiiied to produce considerable pain. The uterus was brought forward and stitched according to the ordinary suspension method. The peritoneum was closed by means of a continuous catgut suture. The patient made an uninter- rupted convalescence. Hunter Robb (Cleveland Med. Gaz., Feb., '99). Amputation under cocaine anresthesia in a case of gangrene of the foot, the patient being too weak to take a general anaesthetic. Tlie limb was encircled with a broad elastic band, and two injections of cocaine solution made in the region of the main nerve-trunks. After waiting thirty minutes amputation at the knee was carried out almost painlessly. Berndt (Munchener med. Woch., July 4, '99). Case of poisoning in which the amount of cocaine hydrochlorate used during the operation was, roughly speaking, between 0.16 and 0.19 gramme (2V: and 3 grains), enough to cause the most serious outcome. The fault lay in the continued use of the strong solution without resorting to further infiltration dilution by means of the weak soda solution, and upon too groat reliance of leakage during the course of the dissection. Both chloral and opium in the form of morphine sulphate have been sug- gested as natural antidotes in cases of cocaine poisoning. In several unre- corded instances in the surgical work of other operators the writer has seen the prompt eff'eet produced by mor- phine. Frederic Griffith (Anier. Med., March 7, 1903). Therapkutic Thrombosis. — This is a method also devised by Corning for the localization and prolongation of the action of cocaine. Four principles are embodied in the procedure: — 1. Injection of the anaesthetic (co- caine) into the skin. 2. The subsequent introduction through the same hypodermic needle, and without its removal from the part, of a non-irritant oil (cocoa-butter). 3. Trccipitation of this oil, after its injfclioR inio iJic skin, by the aid of COCA AND COCAINE. LOCAL ANAESTHESIA. 249 moderate cold, but without freezing the tissues. 4. Taking up the slack of the skin near the seat of the injection, should the in- tegument be very elastic. By the appli- cation of these principles he has suc- ceeded in maintaining a limited zone of anaesthesia for considerably over an hour. Infiltration ANiESTHESiA. — This method of local anesthesia was devised by Schleich, of Berlin, and employed by him in all kinds of operations, including laparotomy. He uses a weak solution of cocaine (1 to 1000), the solvent being a saline solution (of 0.2- to 0.3-per-cent. sodium chloride). A small spot on the skin near the field of operation is sprayed with ethyl-chloride, and when insensible to pain is injected with a few drops of the cocaine solution. At the spot of infiltra- tion a wheal immediately arises, which is absolutely without sensation. Pushing the point of the syringe farther under the skin through this area of insensibil- ity a few drops are again injected. Another wheal rises close to the first, and by extending these injections far- ther and farther round the field of opera- tion, the whole is infiltrated and ren- dered anassthetic. The injection must always be made into healthy skin, other- wise a slough is likely to follow. The formula generally used is as follows: Cocaine hydrochlorate, 2 grains; steril- ized distilled water, 4 fluidounces; sol. carbolic acid (5 per cent.), 3 drops. The corium should be first filled with the solution. This is accomplished by using a very fine needle and introducing it almost parallel to the surface of the skin. A few drops are injected, causing a .slight wheal to appear, and after a pause of a few seconds the needle is pushed farther, and the process is re- peated until the whole of the corium is infiltrated. The siiboutaneous and deeper tissues are to be treated in a similar way. J. Jackson Clarke (Lan- cet, Jan. 18, '90). Spinal Subarachnoid Injections. — This method of producing anesthesia was first resorted to by J. Leonard Corn- ing, of New York. It consists in the in- jection of a solution of cocaine into the subarachnoid cavity. This soon acts upon the spinal centres and ganglia, and the whole or lower half of the body be- comes analgesic. The needle should be of gold or plati- num, from three inches and a half to four inches in length, and the bevel of the point should be short. It should be provided with a small steel nut, sliding freely upon the needle and fixable at any point of its length by a set-screw. When the needle is finally within the spinal canal, this nut is pressed against the skin and fixed in place so as to prevent any further entrance of the needle. The needle is left in silu until anesthesia supervenes, and is then withdrawn. The most rigid asepsis is enjoined. It is preferable to puncture between the sec- ond and third lumbar vertebre, as this causes the anesthetic to arrive at the cord more quickl}', and in a more concen- trated condition than when introduced lower down. Coming notes that there has been a singular immunity from fatality until now — but this will not go on indefinitely, and there should be a concerted effort by the invocation of every known precaution to keep the mortality as low as possible. While, as stated, the point of introduc- tion is a space between the fourth and fifth lumbar vertebre, one-half inch from the median line, the patient occu- pying a sitting position, in some cases of spinal deformity it has been impossible to insert the needle at this point. Injec- tions have been made between the sixth and seventh cervical vertebra?. The 250 COCA AND COCAINE. LOCAL AN.ESTHESL4. fluid should never be injected except when the cerebro-spinal fluid is flowing from the needle, and it should alwaj^s be injected slowly, requiring from forty to sixty seconds. The sjTnptoms as described by Mur- phy (Jour. Amer. Med. Assoc, Feb. 9, 1901) are as follow: First there is a sen- sation of heat passing over the entire body, then that of thirsty followed in a few minutes by nausea, which may last for ten minutes. Preceding the vomiting there is increased rapidity of pulse, pal- lor, and respiration. These symptoms last for a few minutes usually, but are in some cases very marked and make stimu- lation necessary. Murphy thinks that hyoscine hydrobromate, ^/^m grain, and nitroglycerin, Vioo grain, are the best stimulants under the circumstances. The analgesia usually appears in from 3 to 10 minutes, though sometimes it may be delayed from 20 to 30. It usually be- gins in the feet and gradually ascends, though in rare instances it may first ap- pear as a band around the body and then descend. And in rarer instances still it has been known to ascend from the level of the injection and involve the upper extremities, the neck, and face. The post-operative symptoms are: Headache, lasting several hours to sev- eral days; more or less prolonged vomit- ing; vertigo and some ataxia in gait, which may persist for some days; rise of temperature. Coma and delirium have been observed. Mental exaltation fre- quently so. Failure to obtain analgesia after the employment of this method ia ascribed by Murphy to faulty technique or personal idiosyncrasy. Alcoholism exposes the patient to be unfavorably affected. Bier, of Kiel (Deutsche Zeitschrift fiir Chirurgie, Apr., '99), first nnfes- thetizes the region for the fniiicliire Ijy Schleich's plan of infiltration. He then injects within the meningeal cavity a few drops of a dilute solution of cocaine, introducing from ^/m to ^/e grain. Four cases in which the method was used for major operations. A slightly larger quantity of cocaine was used than recommended by Bier (Vo grain of co- caine), but the effects produced were pi^actically the same, complete auEes- thesia following in every case and last- ing sufficiently long for the completion of the operations, the longest of which lasted fifty minutes. The operations per- formed were a Pirogoff amputation of the foot for carcinoma; amputation of the leg and extirpation of the inguinal glands for melanosarcoma of the calca- neum; removal of an extensive skin car- cinoma in the region of the knee and en- larged inguinal glands; and resection of the knee for tuberculosis. Sensation re- turned a short time after the completion of the operation, and there were no seri- ous after-eiTects in any case. Seldowitach (Centralb. f. Qiir., vol. xxvi, p. 1110, The technique of the lumbar puncture is not as simple as might be supposed. In stout individuals the spinous proc- esses are difficult of palpation, and even in cases where there are not consider- able fat a patient that was very nervous when placed in a direct posture would throw the muscles into such rigidity as to render it almost impossible to fix the point of the spinal process. Unless the lumen of the needlfe had become oc- cluded in its passage through the soft parts, cerebro-spinal fluid flows without any difficulty. In some cases aspiration either with the syringe that is being em- ployed or a special suction will still more facilitate the outflow of the cere- bro-spinal fluid. It is well to allow a full minute for the injection, thus giv- ing ample time for the solution to thoroughly mix with the cerebro-spinal fluid. The solution should be freshly prepared with a menstruum of sterilized water and boiled for a full minute be- fore using. It is believed that a con- centrated solution of a deflnite quantity will not produce disagreeable symptoms COCA AND COCAINE. LOCAL ANESTHESIA. 251 any more than the same dose in a di- luted solution, and that the effect will last longer. Analgesia is present in the soles of the feet from 1 to 5 minutes, and in from 5 to 15 minutes extends to the \imbilieus. In no personal case did it fail to reach the umbilicus when the solution proved at all effective; in 2 cases it reached to the vertex. In none of the cases did the analgesia subside below the umbilicus under 27 minutes. The amount of cerebro-spinal fluid pres- ent in each case has probably direct bearing upon the extent of the anal- gesia. With a reliable solution it is be- lieved that a failure to produce anal- gesia depends upon the failure to intro- duce the solution into the spinal cord. In the greater number of cases disagree- able features were present, among them being vertigo, nausea, vomiting, head- ache, chills, elevation of temperature and increased pulse-rate, pallor, cold sweat, and involuntary urination and defecation. The case of Tuffier, in which death occurrea, was found, upon a post-mortem examination, to have been affected with cardiac and pulmo- nary lesions. In some personal cases there were even heart-murmurs present, and in one case there was gangrene of the lungs, but no harm supervened. Insensibility to the surgical procedure is not all that should be required of an ideal anesthetic, and, on the other hand, such features as the knowledge by the patient of what is taking place around him and the perception of the gravity of the operation are to be distinctly avoided. A further trial and conscien- tious study of a large collection of cases is still required to ascertain the danger that may accompany employment of this form of anresthesia. G. R. Fowler (Phila. Med. Jour., from Jled. News, Jan. 5, 1901). In obstetrical and gyntrcological cases the following technical points are im- portant: 1. Surgical cleanliness in all things and a fresh, aseptic solution of cocaine, full strength. The method of sterilization used at the present time is to raise the temperature of the solution (in small bottles) to SO" C. for one hour on two successive davs. 2. The needle ' need not be longer than 7 centimetres and sliould be kept sharpened. 3. A nurse should stand at patient's head when the puncture is made to keep the back arched forward. A case was re- cently reported in this city of a patient suddenly sitting upright and breaking the needle. 4. During an operation the patient's ears should be kept closed with cotton and the eyes covered with a towel or cloth. The results, as far as they go, would tend to support the view that spinal antesthesia is not very dangerous, ex- cept perhaps to the child in utero. When it produces disagreeable symp- toms, they are usually transient. In the labor cases it usually retarded progress. Finally, the anaesthesia it produces is for a fairly definite period of time without affecting consciousness and with full control of the voluntary muscles. From a study of these cases the iise of the lumbar puncture in multiparte would seem to be less called for than inhalations of chloroform. The results obtained from its use in primiparse were also not very encouraging, but when good results can be obtained in a few cases the experiments should be con- tinued. It is doubtful if the puncture will ever replace general narcosis in abdominal operations. In vaginal cceliotomy and minor gyntecological work it seems to have its greatest field of usefulness, and will, it is believed, come more in vogue as its merits are more fully observed and understood. N. J. Ilawley and F. J. Taussig (Med. Record, Jan. 19, 1001). It is contra-indicated in children and in nervous and timid patients, particu- larly women; also in operations de- manding muscular relaxation, such as those for the reduction of fracture and dislocation, and in cases of difficult and prolonged laparotomy. In women, par- ticularly those who are young and nerv- ous, lumbar anaesthesia is not satisfac- tory, as it is so liable in such subjects to give rise to intense discomfort and a very rapid pulse, and to be followed by obstinate vomiting and severe and pro- longed headache. It should only be 252 COCA A^'D COCAINE. LOCAL AX.ESTHESL4. used in female patients who are calm and free from timidity, and in cases in which general anjesthesia is contra- indicated. Chaput (Bull, et Mem. de la Soc. de Chir. de Paris, Apr. 30, 1901). Conclusions based on fifty eases of spinal analgesia: 1. Cocaine is far more satisfactory than eucaine. The latter is less potent, more evanescent, the areas of analgesia are frequently "patchy," having the pain-sense retained all around them and not being so complete below definite levels. The cocaine pro- duces no more unpleasant after-effects than eucaine, and is decidedly more re- liable. 2. Analgesia to the level of the diaphragm can be depended upon in all cases where a moderate dose of a potent solution of cocaine has been introduced by lumbar puncture. In some the anal- gesia is sufficient for operation on the upper extremities. 3. Complete anal- gesia — including the eyes, mouth, and throat — has occurred. It does not en- tail more severe after-effects than when the lower extremities only are involved. 4. The preparation of the patient as for a general anaesthetic diminishes all the unpleasant effects of cocaine and eucaine and often prevents them altogether. 5. By moderate doses of bromides before the injection the initial vomiting is fre- quently avoided and the liability of headache lessened. 6. In neurotic pa- tients there are often hysterical symp- toms directly following the completion of the injection, but, as a rule, in a few moments a calm follows and the patient lies perfectly still. 7. Initial nausea and vomiting often occur soon after the puncture, but last only for a moment or two, and usually do not recur during the operation. As consciousness, as well as the muscular power, is preserved, the danger of the introduction of the vomi- tua into the lungs is practically till. 8. Analgesia lasts from 30 minutes to 4 hours. 9. Depression after the puncture is inconsiderable. The use of ethyl- chloride (Bcngue) largely prevents pain when the needle is introduced. 10. The preparation of the patient, the use of nitroglycerin by hypodermic injection, or the employment of coal-tar products with caffeine, control the headache, which is in many instances an after- effect of spinal pimcture. 11. In a few cases there may be motor paraplegia or vertigo. Both are temporary. 12. Spinal puncture has not affected normal or diseased kidneys. 13. L^sually the tactile power, muscular sense, and the ability to detect heat and cold are re- tained. The cautery at a dull-red heat causes no pain, while hot water pro- duces marked discomfort. 14 Usually the patient sleeps the first night. 15. There is often a temperature of a few degrees within eight or ten hours of the operation. Whether this is the direct result of the puncture or the effect of psychical disturbances is not deter- mined. The circulation and respiration are not seriously embarrassed. W. S. Bainbridge (Med. News, May 4, 1901). Series of 40G cases operated on under this method of anesthesia without a death. A solution of from 1 to 2 centi- grammes (Vo to '/, grain) of cocaine, made up with cerebro-spinal fluid which had previously been withdrawn by punct- ure, was used in all the cases. Although there have been no fatal cases, the author has observed nearly all the un- pleasant sequelte, such as headache, etc. The method has proved satisfactory, but should not be used in the presence of contra-indications. Sequen in his last series of cases reports 2 deaths. In 1 there was an incarcerated hernia with the phenomena of septicajmia, while in the other arteriosclerosis was present. In the discussion which followed Jon- nesco stated that he used the method in only 8 cases, and in 1 of these with a fatal result; no arteriosclerosis nor organic lesions were present, and death was attributed directly to the cocaine. The author has abandoned this method, for the reason that its mortality is higher than ether or chloroform, and the aftereffects, as a rule, are severe. Raeoviceano-Pitesci (Bull, et MCm. do la Soc. de Chir. de Bucarest, Dec, 1901). The injection of sterilized water into the arachnoid sac accomplishes the same antpsthesia, but is apt to cause the same (Hi-iilcnt as the sul)araehnoid injection of cocaine in the treatment of sciatica. For subarachnoid use, aqueous solutions COCA AND COCAINE. TOPICAL ADMINISTRATION. 253 of cocaine should not be diluted with water; after the injection, patients must be kept in bed for from two to three days. M. Guinard (Jour, des Praticiens, March 22, 1902). Adrenalin diminishes the poisonous effect of cocaine and it increases the latter's antcsthetic power in duration, in intensity, and in area. By intradural injections into cats he found that the simultaneous injection of cocaine and adrenalin diminished the to.xicity of the former one-third, and, by the previous injection of adrenalin, by ono-lifth. The aneemia caused by the adrenalin is not so dangerous to the sensitive ner\'ous elements as the poison of the cocaine. In man, no bad symptoms were noted, and the author is hopeful that the new method will entirely supplant the for- mer method of using cocaine alone for intradural anaesthesia. Diinitz (Miinch- ener med. Wochen., Aug. 25, 1903). Corning emphasizes the following pre- cautions: The puncture must not be made in the operating-room. The needle must be very thin, the solution one of 2-per-cent. of cocaine hydrochlo- rate. The patient should sit up, and the puncture should then be made on the level of the crests of the ilium. The in- jection should be made very slowly, tak- ing a mintite for injecting 15 minims of the liquid. The most common disad- vantages of this method are vomiting during operation and headache after- ward. Six cases, out of 2000 operations, died after lumbar puncture, 3 of them with tuberculous meningitis. Cocainization of the spinal cord has been carried out on 02 occasions in the clinic of von Mikulicz. In 40 cases the analgesia was complete, in 9 it was in- complete, and in 12 there was none at all. The injections were frequently fol- lowed immediately by such symptoms as sickness, vomiting, profuse sweating, a feeling of general oppression, and tremors all over the body. Twice there was genuine collapse. Among the un- toward after-effects were continuous vomiting, pains in the loins and back, and severe headache. On several occa- sions there was retention of urine. The unreliability of the method and the oc- currence of these unpleasant symptoms have led to the abandonment of the in- jection of cocaine into the spinal canal at von ilikulicz's clinic. (Beitriige z. klin. Chir., Bd. xx.\v, H. 2, 1903.) Topical Administration. — Cocaine is applied locally to the mucous membranes and the skin for the relief of pain, to in- duce local anaesthesia for operative pur- poses, to control haemorrhage, and for diagnostic purposes. When applied lo- cally to a mucous membrane, cocaine causes a temporary blanching and shrink- age, with an anjesthetic condition of the part. The former are due to a construc- tion of the blood-vessels, the latter to a paralysis of the peripheral filaments of the sensory nerves. The anemia pro- duced is only temporary, and is followed by a marked congestion. For therapeutic study we will observe the application of the remedy on the various organs, noting at the same time the strength of the solu- tions generally used in each case. If a 40-per-cent. freshly prepared so- lution of cocaine is applied from one to one and a half hours to the unbroken skin, there results a local antesthesia. Circumcision accomplished without pain by the simple external application of a 40per-cent. solution of cocaine. Before the operation the parts were carefully cleansed of all sebaceous and oily mat- ter, and well dried after the thorough use of an antiseptic. Then a solution of cocaine was applied to the line of in- cision by means of a pledget of ab- sorbent cotton. The saturated cotton was kept in contact with the parts for twenty minutes, when it was removed and the part allowed to dry for ten minutes. The cocaine was then reap- plied, and this was continued for from one to one and a half hoiirs. The skin may be quite as effectually aniesthetizcd by this method as by hypodermic injec- tions of cocaine, it only being necessary 254 COCA AND COCAINE. TOPICAL ADMINISTRATION. to keep the solution sufficiently long in contact with the parts. After such an application of cocaine numbness will persist in the skin for from four to five hours. W. P. Beach (Brooklyn Med. Jour., July, 1901). Cocaine should not be given for over- coming pain in the eye, because its effect is only temporary. The patients drop it in the eye too often, and cor- neal injuries result. For operation or with conjunctival injection the author uses cocaine, with suprarenal extract and morphine hypodermically. Schleich' infiltration anaesthesia is not recom mended for operations on the eyelid Cocaine is useful for photophobia and mydriasis. In place of cocaine for con- trolling the pain, warm or cold com presses, leeches, or dionin are ordered Fuchs (Wiener klin. Wochen., Sept. 18, 1902). Eye. — For use as an anesthetic in the eye cocaine in solution of from 1 per cent, to i per cent, in strength may be em- ployed, 1 to 5 or more drops being in- stilled. All operations of a painful char- acter, the pain of an acute inflammation, or that caused by the presence of a for- eign body are indications for cocaine. Its use in keratitis is not advised in that it has produced permanent opacities in the cornea. Nose, Pharynx, and Larynx. — The application of cocaine (5 per cent, to 20 per cent.) in the mucous membrane of these parts is useful not only for thera- peutic purposes and operations, but also for purposes of examination and diag- nosis. Before scarifications, etc., cocaine may be applied in a powder; cocaine hydro- chloride, magnesium carbonate, 2 '/, drachms. A moist compress is laid out- side, for ten minutes, which the patient is instructed to press lif,'litly against the part. If the skin is intact, pure basic cocaine must be used instead. Unna (.Tour. Amer. Med. Assoc, Apr. 30, 'OS). The following solution of cocaine is stable: — B Cocaine hydrochlorate, 4 grains. Distilled water, 2 '/j drachms. Salicylic acid, Vo grain. Editorial (Jour, de M6d. de Paris; Phila. Med. Jour., May 2G, 1900). The natural sensitiveness of the parts is obtunded by the anjesthesia induced; the shrinkage of the soft parts induced by the contraction of the blood-vessels makes more prominent the distinction between hypertrophy of the soft tissues and tumors of cartilaginous or bony character; again, by temporarily controll- ing the hfemorrhage (by contraction of the blood-vessels) and the shrinkage of the soft parts, the field of operation is made more clear and open. Nasal and laryngeal polypi are more easily diag- nosed and removed, and operations on the uvula, tonsils, epiglottis, and larynx are facilitated. The Eustachian catheter is more easily introduced after the appli- cation of a solution of cocaine to the nasal cavities and the naso-pharynx. In acute coryza or rhinitis the insuffla- tion every two hours of a small portion of a powder consisting of cocaine muri- ate, 1 part; bismuth subcarbonate, 5 parts; and talc, 15 parts, is useful. An- other formula for the same uses consists of cocaine and morphine, 1 part of each; bismuth, 5 parts; used as snufE like the preceding. Cocaine carbolate has been recom- mended in nasal catarrh and ozfcna, either pure or 5- to lO-per-ccnt. solutions in alcohol or spirit of ether, or 1-pcr-cent. solution in diluted alcohol containing 70 per cent, of water on cotton or by instil- lation, or 5- to 10-per-cent. triturations with acetanilid or boric acid for insuffla- tion. Cocaine solution is also used to anocs- thetizo ulcers or hypertrophies previous to the application of acids or instru- montfi. Liquid applications may lie made Ijy means of cotton pledgets dipped COCA AND COCAINE. TOPICAL AD.MIXISTRATIOX. 255 in the cocaine solution by the spray of an atomizer; in powder by insufllation as above. GENiTO-UitiNARY Teact. — The injec- tion of a few drops of a 2-per-cent. solu- tion of cocaine renders catheterization easy and painless, provided there is no stricture. Operations on the bladder (lithotrity, litholapaxy, catheterization of ureters, etc.) are rendered painless through previous injections of cocaine. Weak solutions (not strong, the 2 per cent.) must be used, as fatal poisoning has followed the injection of 5 drachms of a 5-per-eent. solution into the urethra. Wittsack, of Frankfort, advises the use of lactate of cocaine in the treatment of tubercular cystitis. He instills a solu- tion containing 15 grains of cocaine lactate and 75 minims each of lactic acid and sterilized distilled water, previously emptying the bladder, but not washing it out. GYNiECOLOGY. — For application to the mucous surfaces of the vulva, vagina, and the uterine cavity, stronger solutions (10 per cent, to 20 per cent.) are used. Here, as elsewhere, the use of cocaine anaesthesia should be confined to minor operations (curettage, dilatation of cer- vix, removal of uterine polyps, etc.). In operations extending below the surface parenchymatous injections should sup- plement the applications to the mucous surface. Eectum. — The anaesthetic solution (5 per cent.) is here applied to the mucous membrane by means of pledgets of ab- sorbent cotton saturated with the solu- tion. Parenchymatous injections may also be needed. In major operations or in complicated ones, general ana?stliesia is advised. Skin. — The topical application of cocaine has been suggested for the cure of cracked and fissured nipples, but is not advisable, as through its use lactation may be interfered with. This latter suggests the use of a 5-per-cent. solution of cocaine made with equal parts of glyc- erin and water as a solvent to inhibit lactation or cause its complete cessation. The glands are bathed four or five times daily with the solution and supported by means of a bandage. In zona cocaine not only relieves tlie pains, but also causes a regression of the eruption, bringing about its disappear- ance in the course of a few days. Twenty-three cases thus cured. The aflected surface is painted with equal parts of wool-fat and (wtrolatuni rubbed up together with I per cent, of cocaine hydrochlorate, and dressed with linen spread with the same ointment. Bleuler (Nouveau.x RemJdes, No. I, 1900). Incidentally it may be noted that Geley, of Bordeaux, has found that cocaine has an antipyretic action when applied to the skin, provided the appli- cations be made at a time when the tem- perature is no longer rising. This action is analogous to that of guaiacol, though less marked. Cocaine introduced by cataphoresis. Solution recommended consists of cocaine (the alkaloid, not the hydrochlorate), 6 grains, dissolved in a drachm of guaiacol. If a little of this mi.xture upon a piece of blotting-paper is placed on the skin, and a current applied through it, the co- caine quickly penetrates, and local antcs- thcsia can be produced in about four or five minutes. The positive electrode should be placed on the blotting-paper. It should consist of a flat disk of bare metal of suitable size. A platinum sur- face is the best, but tin or any other metal which docs not easily become cor- roded "ill do almost as well. Care must be taken that the metal itself does not touch the skin at any point. The cur- rent is then turned on until it reaches about 4 milliampi^res for an electrode half an inch in diameter. At first from 10 to 1.5 cells are necessary to produce this current, for the solution has a high 256 COCAIXOMAXIA. VAKIETIES. SYMPTOMS. resistance; but soon conduction im- proves, and the number of cells may be reduced. H. Lewis Jones (Clinical Jour., Mar. 8, '99). C. SUilXER WiTHERSTINE, Philadelphia. COCAINOMANIA, OE COCAINE HABIT. Definition. — Cocainomania is an irre- sistible craze, crave, or impulse to intox- ication by cocaine, or any of its salts or combinations, at all risks. Unless a cure of the "habit," or, more accurately, the disease of cocainomania be effected, the cocaine habitue cannot refrain from resorting to the employment of the drug, if a supply can possibly be procured, whenever the craze, crave, or impulse seizes upon him. Varieties. — The two leading types of the cocaine habit are (1) periodical; (2) continuous. In the former the halitue will, after an outbreak of cocaine intoxication, go on without cocaine in any form for a longer or shorter interval, till a condition of mental unrest, aris- ing sometimes apparently from within, ushers in a period of more or less com- plete temporary abandonment to the drug. Sometimes the outburst is in- augurated by a recurrence of the acute pain, or the asthma, or other physical trouble, for the assuagement of which the poison was originally taken. In some highly-strung women the menses act as the exciting provocative, partic- ularly when accompanied by acute dys- menorrhoea. In the latter variety, the continuous, the unfortunate victim keeps on steadily taking the drug daily in rapidly-increasing quantities till he or she is rendered incapable of exertion, sometimes of connected t]iniif.'lit. by ad- vancing paralysis or by insanity. In some instances the indulgence is social, in others solitary, the latter being the rule and the former the exception. Some variation is observable when co- caine addiction is associated with alco- holic or other narcotic indulgence. In this way the addiction may be double, triple, or fourfold: twofold, as alcohol or morphine with cocaine; threefold, as with alcohol and chloral; fourfold, as with alcohol, morphine, and chloral. Symptoms. — On taking a fresh dose, in chronic cocainomania, there are, gen- erally within ten minutes, exuberance of spirits, quickened pulse, general accelera- tion of the circulation, talkativeness, restlessness, hallucinations, with rapid and somewhat spasmodic breathing, in- tense joyous activity, and a remarkable overconfidence in one's capacities and strength. Even when actually weaker, during the cocaine-delirious intoxica- tion, the taker feels infinitely stronger and more agile. Occasionally there is vertigo, with some confusion of the in- tellectual faculties. There is usually great cerebral excitement, with dilated pupils, throat dryness, and headache, the last named frequently not severe enough to be painful. There is a rise of tem- perature, with a loss of the sense of time, though memory is usually intact. De- pression and prostration follow very often. When the dose has been rela- tively moderate, — i.e., not larger than the cocaine-taker has been gradually accus- tomed to take, — the period of nervous hyperexcitation has passed away by from half an hour to two hours. AVhen the dose taken has been relatively immod- erate, the depression and nervous debil- ity may remain for days or till the next dose. In chronic cocaine poisoning, though some habitual cocainists do not appear to show any symptoms of injured health or vigor, others appear wasted, with pale- yellowish skin, the extremities clammy, COCAINOMANIA. SYMPTOMS. 257 with cold perspiration. The eyes are glistening and sunken with dark, sub- ocular rings, the pupils being dilated. Anorexia and impaired digestion are present, with palpitation, dyspncca, tin- nitus aurium, tremors, neurasthenia, and uncertainty of step. Hallucinations, especially of sight and hearing; mis- trust; delusions of persecution; and general paralysis sometimes end the scene. Yet, in some cases, one sees occa- sional spells of brightness, brilliance, and mental activity. [The effects of clironic cocaine intox- ication are as follows: Physically there is the rapidly-developing marasmus so characteristic of chronic cocaine intox- ication. Psychically we find feelings of apprehension; delusions, chiefly of per- secution; and hallucinations, visual or sensory. Frightful forms appear every- where, or small living things creep upon the skin. Insomnia, loss of appetite, and impotence complete the picture of coeainism. Ohersteiner, Corr. Ed., An- nual.] Three cases of chronic coeainism in which the predominant symptoms were those relating to general sensibility, con- sisting chiefly of hallucinations produc- ing a sensation as if foreign bodies were under the skin. The first, a merchant aged 48, was continually sciaping his tongue, imagining that it was filled with small, black worms, and picking the skin to find choleraic microbes. The second, a pharmacist, attempted to ex- tract microbes from his skin with his nails and with a needle. The third, a physician, sought for crystals of cocaine under the skin. Hallucinations of cu- taneous sensibility are fir.st to develop; hallucinations of vision, hearing, taste, and smell occur later. Disturbances of ideation, as delirium, are consecutive to the hallucinations. The latter are less active than those prod\iccd by alcohol or absinthe. Epileptiform attacks oc- curred with two of the patients and cramps in the third. Toxic epilepsies, when there is no predisposition, disap- pear with the cause. Magnan and Saury (La Tribune Mfidicale, Feb. 3, Mar. 28, '89). Aphrodisiac effects of cocaine shown in the case of a woman, married and highly respectable, who became a victim of cocaine, and who, while under its in- fluence, would invariably utter expres- sions and do things which she would not even have thought of when in her normal condition. These effects appear to be more pronounced in females than in males, and hence the inadvisability of the indiscriminate use of cocaine. M. K. Bowers (Med. Age, Dec. 20, '91). Case of chronic coeainism, in which the patient sutTered from hallucinations, un- der the influence of which, according to his statement, he twice committed as- saults. Regarded as a case of cocaine epilepsy, on account of the suddenness of his attacks of furor and a certain amount of amnesia. He formed the habit by using it for a nasal trouble. Lewin (Deutsche med.-Zeit., Jan. 1, '91). Magnan's sign — an hallucination of cutaneous sensibility, characterized by a sensation of foreign bodies under the skin, which are described as inert and spherical, varying in size from a grain to a nut, or as living organisms, worms, bugs, etc. — observed in two cases. Ri- bakoff (Gaz. degli Ospedali e delle Clin., Aug. 4, '96). The first feeling a cocainist has is an indescribable excitement to do some- thing great, to leave a mark. But this disappears as rapidly as it came. The second sensation — at first, at least, no hallucination — is that his hearing is enormously increased. Very soon every sound begins to be a remark about him- self, mostly of an offensive kind, and he begins to carry on a solitary life, his only companion being his syringe. Every passer-by seems to talk about him. After a relatively short time, he begins the "hunting of the cocaine bug," and im- agines that, in his skin, worms or sim- ilar things are moving along. Personal opinion that there is a ques- tion of disturbance in the frontal cortex, originating, perhaps, in skin dysjEsthe- siir, and not a simple visual hallucina- tion or retinal projection. Springthorpe (Quarterly Jour, of Inebriety, Jan., '97). 258 COCAINOMANIA. DIFFEKENTLAL DIAGNOSIS. In acute cocaine poisoning there may, or may not, be the exhilaration stage, the poisoned sometimes falling rapidly into collapse and insensibility after ex- ceedingly transient symptoms of pale- ness, faintness, fullness of head and giddiness, skin creepings, profuse per- 6piration, praecordial distress, rapid hard or weak pulse, loquacity, restlessness, agitation, and hysterical excitement. The pupils are dilated and dull, the per- spiration, at first quickened, becomes spasmodic and labored, unconsciousness sets in, convulsive seizures appear after muscular cramps, sometimes with tetanic spasms, followed, it may be, by deepen- ing cyanosis, violent delirium, enuresis, and paralysis of the sphincters. Withal there are often localized areas of anaes- thesia. In non-fatal cases, though the acute symptoms may pass off in a couple of hours or so, feelings of languor, malaise, and local pains may linger for days. Differential Diagnosis. — Though, in many cases, unless the presence of co- caine can be determined by finding the drug or by the brown stain over the seats of hypodermic injection, this particular "habit" or mania cannot be diagnosed from other forms of narcotic addiction, there are one or two prominent symp- toms which point to cocaine as the spe- cial mania. Especially in the earlier stages, though to a larger extent in the more advanced, alcohol is excluded by the absence of symptoms pointing to organic functional bodily lesion. The cocainomaniac not only often shows no symptom of bodily or mental disturb- ance, but manifests simply a sense of satisfaction, and an appearance of in- creased capacity for intellectual and muscular work. In many cases the closest physical examination lias failed to reveal anything abnormal. Indeed, at times the only symptom discernible has been an apparently improved condition. In some instances only the closest con- tinuous scrutiny of a business partner or a wife has, after a time, disclosed even the slight falling off in the char- acter of the work and of the judgment, the actual amount of work having been occasionally increased. One point of differentiation, even from etheromania (which is more speedy in the appearance, progress, and cessation of toxic symp- toms than either alcohol, opium, mor- phine, chloral, or chloroform), is the greater quickness with which the char- acteristic phenomena of cocaine poison- ing set in and pass away. Still another discriminating symptom is the extra- ordinary self-confidence and elation arising from cocaine. In etheromania the odor of the breath is characteristic, and the activity more effervescent and demonstrative. A point of distinction from alcoholomania is that, while this is mostly social and less often solitary, cocainomania is almost always solitary. Yet another difference from alcohol and morphine is that the prevailing delusions of cocainomania are delusions of perse- cution. These rarely occur with alco- hol, except temporarily sometimes in delirium tremens or in chronic alcohol- ism, and still less often with morphino- mania. They are frequently seen, how- ever, with the chronic cocaine habit, and are at once more marked and more per- sistent with cocaine. Alcoholism. — The subject of this disorder shows greater evidence of mor- bid change; the subjective and objective symptoms are more marked. There is distinct attraction for social pleasures, whereas the narcomaniac prefers soli- tude. MoRPHiNOMANiA. — Characteristic symptoms set in and disappear more COCAINOIIANIA. ETIOLOGY. 259 quickly. Cocainomania is characterized by marked self-confidence and elation. Etheromania. — The odor of the breath is characteristic and the activity more effervescent and demonstrative. Etiology. — The chief predisposing in- fluence is, undoubtedly, the neurotic diathesis. On the nervo-sanguine and passionate temperaments cocaine has a special excitant power. Once taken in any form for the assuaging of acute pain, on such temperaments this drug fastens as if with a grip of iron im- bedded in velvet. In one case of a life- abstainer from alcohol, cocaine, taken once during a prostrating attack of agonizing pain, exercised so powerful a hold that only after a strenuous struggle of over a week's duration could the vet- eran nephalist overcome the imperious impulse to take a second dose. He felt that, if he yielded, his will would have been rendered powerless for the future against the tremendous fascination of the drug M'hich has banished his pain as if by magic, and of the name and other properties of which he was utterly ignorant. In "neurotics" I have seen a few doses, taken medicinally, set up the "cocaine habit." In transmitted gout, with irritable and susceptible brain and nervous system, this special predisposi- tion has been markedly present. It has also been noted in syphilis and scrofula with cerebral complication. Epileptic neuroses have been greatly in evidence. Exciting Influences. — Over and above the psychological excitation of the drug itself, the exciting causes seen by me have practically been confined to urgent clamor for relief from physical agony, such as occurs at times in asthma or neuralgia. Cocaine, which has b\it recently been introduced in India, is generally taken in the form of powder sprinkled on a paste of slaked lime, which is buttered on a betel-leaf. The mass is rolled up and chewed for about fifteen minutes. The first symptom of the so-called hilarity is a heaviness of the head. Then quickly follow a wild throbbing of the arteries of the neck and palpita- tion of the heart. The pulse never ex- ceeds 110. The inebriate wishes to be left alone; he will not speak lest saliva escape from the mouth. The ears be- come hot, the cheeks pale, the nose pinched and cold. The height of intoxi- cation is marked by coldness of the finger-tips and dilatation of the pupils. This stage lasts from thirty to forty- five minutes, when the victim longs for a fresh dose. The teeth and tongue of old habitufs turn absolutely black. The craving for an increased dose is pronounced. In one case it was so marked as to cause a jump from 1 to 20 grains in a month. The worst sequel® are very obstinate forms of diarrhoea and dyspepsia. Of the mental derangements, hallucinations, and delusions causing dejection and fear, are common. A more miserable object than a confirmed Hindoo cocaine-eater cannot be pictured. The drug is alto- gether more disastrous in its effects than is opium or any other narcotic used in India. To quote the words of a victim, "To eat cocaine is to court misery." Kailas Chunder Bose (Brit. Med. Jour., AprU 26, 1902). I have not seen insomnia incite to cocainomania as it frequently does to morphinomania. Physical pain has been the initial starting-point. The use, for any purpose, of cocaine is an unmistak- able influence inciting to the "cocaine habit" in constitutions predisposed to narcotic excitation. Other narcotic sub- stances also both predispose and ex- cite to the cocaine mania. Jlorphine, for example, long continued is apt to create a crave or impulse too imperious to be satisfied with morphine narcotism alone. Case of mixed addiction, morphine and cocaine, the habit for the latter drug having been acquired by its use as a 260 COCAINOMANIA. PATHOLOGY. substitute for the former, with the usual disastrous results, namely: loss of ap- petite and sleep, vertigo, syncopal and epileptiform attacks, and, finally, hallu- cinations and delusions, ideas of sus- picion, jealousy, and persecution ; also hallucinations of animalcules on the skin, which are so characteristic of the action of cocaine. Cocaine is a toxic agent far more formidable than morphine on account of the rapidity and intensity with which the sensory, motor, and in- tellectual derangements develop under its use. Warning against employing it as a substitute for morphine with those addicted to the latter drug. Laury (La Sera. M6d., Aug. 10, '90). In inorphinomaniacs cocaine is some- times resorted to simply with the object of heightening the pleasurable sensations of intoxication. In not a few instances cocaine addiction has been rapidly set up in the vain attempt to cure alcoholo- mania or morphinomania by substituting cocaine. This attempt at the cure of the original form of narcomania (a mania for narcotism by any narcotic) is sometimes openly attempted with the best intentions; but is more often un- knowingly tried simply because cocaine has been a component of the so-called "cure," though not disclosed by the manufacturers. In this way even some abstainers from alcoholic liquors who pride themselves on their consistent tem- perance have insensibly become cocaine slaves, they having had no idea that they and theirs were partaking of a nar- cotic poison more fascinating and peril- ous than the object of their aversion: alcoholic intoxicants. A striking object- lesson of medical unwisdom was the ap- pearance of a crop of cocainomaniacs in England shortly after the announce- ment, in a British medical annual, of the reputed cure of alcoholomania and mor- phinomania by means of cocaine, in another country. Below sixteen years of age there would appear to be a lessened susceptibility as the years go down, children showing less cocainomaniacal proclivities than adults, and not responding so readily to the narcotic properties of the drug in doses relatively corresponding to their years. Though the young are readily intox- icated by cocaine, they are not so prone to become subject to the mania for in- toxication by cocaine. As to sex, the majority of the cases have been male; but this has not arisen because of a lesser susceptibility that is found in man, but probably is owed to occupation exercising a stronger in- fluence. Occupation is a predominant factor, most of the victims having been medical men (I have seen a number of eases in members of the legal profession), literary men and women, and the cultured gen- erally. Climate exercises considerable influ- ence, which may account for the greater prevalence of cocainomania in the United States of America and northern France, as compared to Great Britain. Racial characteristics and atmospheric conditions modify purely climatic en- vironment, however; witness the prac- tical absence of cocainomania among the great community of the Jews, and the rapid electrical disturbances, as well as the tremendous temperature alterations, of North America. The cocaine inheritance has not had time to show itself, if it exist; but the "cocaine habit" as an outcome of trans- formed narcomaniac transmission I have seen in several families. Pathology. — Acute Cocainism. — Tliou^^^h a large number of cases of acute cocaine poisoning have been recorded by Germain S6e, Mattison, Schede, and others, comparatively few have proved fatal. Probably the fatalities have run COCAINOJIANIA. PROGNOSIS. 261 not much over 10 per cent. Even in exceedingly grave cases, when the suf- ferer appears almost moribund, the dis- tress and collapse often suddenly and unexpectedly give way and the appar- ently dying patient makes a good recov- ery. Hence there has been little op- portunity for post-mortem inspection. Clifford Allbutt says that the heart is found in diastole and the nervous cen- tres are congested. According to Ehr- lich, vacuolary degeneration is found in the hepatic cells, the latter being greatly enlarged and the nuclei atrophied. The convulsive respiratory paralysis is ascribed by Mosso to tetanus of the respiratory muscles, and the great rapid- ity of the circulation to paralysis of the vagus. The peripheral blood-vessels are contracted. Cocaine is stated to alter and injure the leucocytes; Maurel and Beaumont Small state that these become spherical and rigid, with increase of size. They seem also to have a tendency to locate next to the vessel-wall. Death may supervene at an early stage from syncope, or at a later from as- phyxia. Cocaine acts on the central nervous system, first exciting and after- ward paralyzing this. Doubts have been expressed as to whether the ansBsthesia produced by cocaine is due to the vaso- motor disturbance or whether the drug directly paralyzed the nerve-termina- tions. Brown-Scquard believes the latter, holding that cocaine acts through the peripheral nerves on the nerve-cen- tres, which reacts in inhibiting sensi- bility. I am inclined to think that the central nerve-centres are affected in both ways: by vasomotor paralysis and by peripheral excitation. CnnoNic CocAiNisjt, IxcLunixo the Mania for Cocatxe. — A distinction ought to be made between the physical poisoning by the drug (cocainism), and the overpowering mania for the drug (cocainomania, or the "cocaine habit"). Of the pathology of the latter little can be said specifically. Usually scavenger or spider- cells are found in the brain; but as most cocaine hahilues have pre- viously been indulgers in alcohol, no reliance can as yet be placed on these ap- pearances as pathognomonic of cocaine mania. Marasmus, with absence of fat, is usually the most prominent after- death appearance, and there has not been noted the darkish hue of the stomach's interior which has been seen in some cases of fatal opiomania. The post-mortem appearances include dark and fluid blood, with congestion of lungs and other organs, but these are not peculiar to cocaine poisoning. There have not been observed traces of cocaine tissue-degradation, and organic degrada- tion which axe so often met with in the stomach, liver, kidneys, and other vital organs of alcoholic cases, unless when chronic alcohol poisoning has preceded or accompanied the cocaine indulgence. When cocaine is contemporaneous with chronic morphine poisoning the wasting is even more marked. Though the minimum fatal dose in acute cocaine poisoning is not quite fixed, death has been recorded as the result of less than half a grain, and several deaths have occurred after 8 to 12 grains; yet the habitue can set up such a tolerance of the drug as to raise the daily consump- tion to some 30 or 40 grains. In some instances the daily average has been more than double this. In one case 80 grains a day were subcutaneously in- jected, besides 60 grains of morphine. One death occurred in 20 minutes, 1 in 4 minutes, and a third in 40 seconds (Hamilton and Godwin). Prognosis. — The prognosis of acuU cocaine poisoning is, on the whole, favor- 262 COCAINOMANIA. TREAT:MEXT. able. Even though death almost alwaj's Beems impending from the gravity of the symptoms, the great majority of cases recover if judiciously treated soon after the poisonous dose has been taken. Generally, after three-fourths of an hour have passed, the prognosis is even more favorable. This cannot so unreservedly be said of chronic cocaine poisoning (the cocaine habit, or cocainomania), of which the outlook is, under ordinary conditions, unfavorable. If, however, the patient siirrender his liberty and place himself absolutely under control in a special home or in a hospital for a sufficiently long period, the prognosis may fairly be considered to be more favorable. The prognosis of cocaino- mania is not nearly so favorable as that of alcoholomania or even morphino- mania. Cocaine exhausts the mental capacity more rapidly than either mor- phine or alcohol; it takes a greater hold on the brain and nervous system, reduc- ing his intelligence and benumbing his faculties, setting up a moral palsy which seems to annihilate inhibition and to deprive the victim of all desire for deliv- erance. There are, however, exceptional cases which exhibit a strong wish to be cured, which are hopeful and have been delivered under treatment at home. Treatment. — Acute Cocaine Poison- ing. — If the poison has been swallowed the stomach syphon-tube should be at once applied and the contents of the organ evacuated. The patient should be placed in the horizontal position on his back. Tannic acid, iodine, or charcoal may be given as possible chemical anti- dotes. Stallard advises the stimulation of respiration and circulation by flicking the chest and face with hot and cold towele, as in opium poisoning; but I cannot say that I have seen benefit from this practice unless it has been done lightly and occasionally for a minute or two. Ammonia or ether inhaled, drunk by the mouth, or introduced into the rectum, or administered hypodermically, is useful, as also is the administration of caffeine or coffee. The addition of small quantities of alcohol, in the form of 5- to 10- drop doses of tincture car- damom, comp., spirit of chloroform, or tincturiB lavandulaj comp. (separate or combined), is sometimes serviceable when coffee cannot be easily taken. Chloro- form may be inhaled to relieve the spasm. Strychnine, in minute doses (^Aoo grain), with or without a couple of drops or so of tincture of digitalis, is also of value. Some authors report ap- parent benefit from intravenous injec- tion of normal saline solution; but I think caution is requisite, owing to the risk of embolism in the lungs. When the blood-pressure has been raised or there is alarming respiratory spasm, a drop-dose of nitroglycerin, at intervals of half an hour if required, sometimes acts excellently. Clifford All- butt says that the inhalation of oxygen and artificial respiration against the as- phyxia may be indicated. I have found sips of hot water; and, where this could not be taken by the mouth on account of insensibility or collapse, hot-water enemata, of 3 to 4 ounces, of substantial aid. External applications, as hot as can be borne, such as a bottle, or jar, or tin filled with hot water and covered with flannel to protect tlie skin, I make it a rule always to apply, especially in unconsciousness, and, indeed, almost from tlie first. CnnoNic Cocaine Poisoning, or Cocainomania. — The treatment of the cocaine habit, or chronic cocaine intoxi- cation, is very much more diflicult. It is more essential to have complete control of the cocainomaniac and his actions COCAINOMANIA. TREATMENT. 263 than even in chronic alcohol or mor- phine mania. There is less to work upon in the brain- and nerve- centres of the chronic cocainist than in those of the chronic alcoholist or chronic mor- phinist. There is less mental and moral elasticity, less desire to be freed from the narcotic bondage, less consciousness of the bondage itself, a more helpless and hopeless wreck being difficult to find. Cocainomaniacs, however, are, in a few cases, cured without seclusion. In these hopeful cases there generally has been a greater stock of inhibition from the first. Again, the indulgence having been peri- odical and ordinarily provoked only by some recurrent neurotic pain or distress and leaving intervals of shorter or longer non-narcotic consumption between, in- hibition has not been so paralyzed, and thus there has been more resisting power left. In the latter group of cases it is imperative to direct the treatment to the abolition or counteraction of the exciting influences. In the mass of cases the main hope of cure rests in therapeutic seclusion. The patient must be treated as a dis- eased person. Diet, at first simple and readily assimilable, should be carefully attended to. Milk, with soda- or lime- water and effervescents if nausea and emesis are present; arrowroot or other farinaceous or malted food, and other peptonized preparations are excellent. Gradually, broths and plain soups, oys- sters, fish, poultry, and, lastly, mutton and red meat, with an ample supply of fruit and vegetables, may be given. But there are cases in which a non-fish-and- flesh dietary agrees better with the pa- tient. Each case mxist bo carefully ob- served to determine the most suitable dietetic instructions. In the first week exercise and fresh air may usually be insisted on, with massage to improve the wasted condition of the muscles. Meals should be regular, and exercise graduated. Alcoholic beverages are best avoided; and, though in a few cases tobacco in limited quantities may be allowed to aid in staying the morbid impulse or crave, most cocainomaniacs would be better without it in any form. Tobacco is apt, in many patients, to impair digestion and depress the heart's action, the healthy state of both vital processes being points of the highest importance in the treatment of this mania. To combat the wearing insomnia of most cases I know nothing better than the hot, wet pack. Of all the medicinal hypnotics, I have found phenacetin the most useful, in doses of 5 grains, re- peated, if necessary, every hour; no more than 3 doses (15 grains) to be taken in one night. Other physicians have found chloral and sulphonal serv- iceable. An important practical point is the method of complete withdrawal of the cocaine, which complete withdrawal is essential to cure. In most cases I have not felt justified in immediate with- drawal, though I have done this where practicable. I spread the reduction period over from seven to nine days, be- ginning, whatever the quantity which had been taken daily or how long, with a reduction of one-half. Dr. Welch Branthwaite informs me that in five cases he at once, after only one dose, stopped the cocaine, without trouble. These were cases in which morphine had also been freely used. In the cases in which I gradually reduced the dose of cocaine, morphine had not been habitually taken in large doses. Where morphine is also freely and regularly taken, it is easier to withhold the cocaine without delay. 264 COCAIXOJIANIA. COFFEE AND CAFFEINE. The sudden removal of the drug is the first step, with sharp elimination through the skin, kidneys, and bowels. The con- tinuous activity of the skin from hot air, sweating, and baths is essential, and this should be kept up for a long time. Nar- cotics are dangerous and are seldom of any value. Infusion of einohona-bark is very valuable, and can be used for a long time. Arsenic appears to be the best of all the mineral tonics, and acids are also excellent. Among foods, meats are to be used sparingly at first. The patient should remain in bed, reclining at full length most of the time during active treatment. Muscular exercise by massage for an liour a day should be given, or a walk in the open air with an attendant or a few moments' exercise with ropes and pulleys. Daily baths should be continued with regularity and care. Persistent watchfulness over all acts of the patient should be kept up for 6 or 8 weeks; then a rigid course of living and diet arranged, and its importance insisted upon, for a long period to come. T. D. Crothers (Phila. Med. Jour., May 2S, '98). All complications must be attacked, but, in the main, besides hygienic meas- ures, nervine tonics are indicated in the endeavor to restore the lost energy and will-power which really constitute the disease. Of these tonics nux vomica and strychnine are the most effectual. Ar- senic also is useful. I have found in this, as in other forms of narcomania, that an occasional replacement of the stronger nerve-tonics by milder ones is advantageous; I mean such as quinine, calumba, and gentian. Galvanism has, in appropriate cases, its value. Though it is often asserted that 3 to 6 months sulTice to efFect a cure, my ob- servation has been that 12 months con- stitute the shortest time in which such a result can be hoped for. There are, at the same time, a few exceptional cases in which a good result has been secured in a shorter period. Medico-legal Relations. — As many co- cainists will not apply for curative de- tention of their own accord, it ought to be the duty of the constitutional author- ities to lay hold on these miserable and utterly helpless diseased persons, and in- sist on their reception and therapeutic seclusion for a given time, in a retreat, home, or hospital provided for the spe- cial treatment of such cases, with pro- vision for persons with limited resources and for the very poorest. Such a pro- vision would, in the long run, prove as economical as it would be invaluable to the welfare, physical and moral, of the whole community. I am unaware of any trial for murder or for administering cocaine with intent to injure another person; but cocaine has been employed to commit suicide. It has been stated recently that forty cocainomaniacs appeared in the police- courts of Chicago within the period of a few months in 1897. The habit was said to have been induced, in some cases, by the use of popular preparations as cures for colds, etc. In the charters of various special institutions in the United States power is given to the managers to re- ceive and compulsorily detain habitual inebriates who are addicted to excess in any narcotic or inebriant, including co- caine; but, in England, only excess in alcoholic liquors renders applicants eligi- ble for admission into retreats under the voluntary provisions of the Inebriates' Acts. NouMAK Kerr (London) and Central Staff (Pliilndolpliia). COFFEE AND CAFFEINE. — The seeds or berries of Cafjea Arahica, so extensively employed for the prepara- tion of the beverage, are not olTicially recognized except as the main source of caffeine. A fluid extract of the green COFFEE. PHYSIOLOGICAL ACTION. POISONING. 265 berry was formerly employed as a stimu- lant, however, and the infusion is now considerably used for the same purpose in the treatment of shock, poisoning, etc. Before it is roasted coffee contains caf- feine, caffeotannic acid, and — accord- ing to Palladine — an alkaloid: caffea- rine. During the roasting process, how- ever, a volatile oil is developed, which, with the other substances, termed, col- lectively, "caffeone," give the coffee its agreeable aroma. Administration and Dose. — The infu- sion affects its users in different ways, some tolerating large quantities, others feeling the influence of one-half cupful. There is, therefore, no special dose to be recommended.. The fluid extract of green coffee may be given in doses varying from 1 to 2 drachms. Physiological Action. - — Marshall and Hare have studied the action of the em- pyreumatic oil of coffee. The percentage of oil obtained from an average browned coffee is 11.6 per cent.; in consequence, an ordinary breakfastcup of coffee con- tains about 45 minims of the oil, pro- vided all the oil in the coffee used is extracted. In their opinion, the oil pos- sesses none of the powers of a toxic char- acter heretofore supposed. The pure oil increases the pulse-rate by direct car- diac stimulation in small doses, and low- ers pulse-rate in large doses by a direct depressant effect on this viscus. On the highly-developed spinal cord of the frog it causes increased reflex activity; but, on the mammal with a well-developed brain, drowsiness and sleep. The virtues of coffee, in the wear and tear of active life, are entirely subjective, and depend upon a general excitation of the higher centres, and chiefly upon its powerful exhilarant action upon the men- tal processes. It must be said, however, that the assumed ability of coffee to re- place food, or to increase the power for work without corresponding tissue-de- struction, is deceptive. While a moder- ate consumer of coffee may be assisted by the stimulating action of the beverage, an intemperate consumer may be capa- ble of performing prodigious feats of strength and endurance, but, neverthe- less, at the direct expense of his tissues. Prosorowsky studied the influence of coffee and some of its substitutes upon pathogenic micro-organisms, and con- cluded that coffee possessed incontest- able antiseptic properties; in this respect it is superior to both its substitutes, rye and acorn coffee, the acorn being the more active of the two latter. The anti- septic action is due to the empyreumatic substances formed during roasting, and also partly to caffeotannic acids, the pres- ence of which is alone capable of explain- ing the antiseptic action sometimes shown by infusions of raw ground coffee. A cup of coffee left in a room remains free from bacteria for over a week. Poisoning by Coffee. — Eugh witnessed a case in which profound toxic effects from the drinking of large quantities of strong coffee were observed, a number of symptoms being those of beginning mania a potu. The patient's pulse was 06 and full, but weak; his respirations shallow and niimbering 24 to the minute. The pupils were normal, the tongue slightly coated, the bowels regular; the skin moist, but not flushed; his expres- sion was agitated with the fear of some impending danger. His muscles were in such a state of tension that, upon the slightest movement of arms or legs, clonic spasms occurred, though none was pres- ent when he lay perfectly relaxed, which, however, his exceedingly-nervous condi- tion would not allow him to do. If he tried to sleep, he would be seized with 266 COFFEE. THEKAPEUTICS. CAFFEINE. PHYSIOLOGICAL ACTION. hallueinations just before losing con- sciousness, imagining that disasters were about to overtake him and seeing all kinds and shapes of images and objects. Then he would start up with fright and find himself in the greatest nervous ex- citement. WTien he stood up, he could close his eyes or look at the ceiling without wavering. His knee-jerks were slightly exaggerated, but sensation was perfect. Case in which 2 cupfuls of an infusion made of 2 handfuls of coffee produced intense general tremors, lasting, in spite of bromide treatment, twelve hours after all other symptoms had disappeared. Cohn (Therap. Monats., Mar., '89). Therapeutics. — Coffee infusion is a most valuable stimulant for cases of nar- cotic poisoning, opium, belladonna, chlo- ral, etc. "^^Hiile it may prove effective when administered by the mouth, it acts with far greater rapidity when adminis- tered by rectal injection. It may be given ad libitum in such cases, and its effects will appear sooner in proportion as the infusion is strong. The rapidity of absorption is enhanced if the temperature of the infusion ap- proximates that of the intestine (100° F.), since cold or heat produce moment- ary shock from which the intestinal walls must recover before the absorption can begin. (Sajous.) In the collapse of ana3sthesia, the toxic effects of venomous stings and bites, it is an invaluable adjuvant when employed by rectal injection. It sustains all the vital functions while the poison is exert- ing its cfTects, and carries the patient throufrh the ordeal. Caffeine. Caffeine should be obtained from the dried seeds of coffee, but the caf- feine of the drug-stores is really thcine, since it is cheaper to manufacture the alkaloid from damaged tea than coffee. It occurs as long, fleecy crystals, silky in appearance, having no particular odor and bitter to the taste. It is soluble in SO parts of water and fixed proportions of ether, chloroform, and very soluble in boiling water. Caffeine is closely allied to theobromine, found in cacao, coca, and other plants. Administration and Dose. — Citrated caffeine is frequently employed, owing to its greater solubility; but, Tanret hav- ing sho\^Ti that the addition of equal proportions of the benzoate or salicylate of sodium caused a marked increase of solubility, this mode of prescribing the drug is now often used. A pleasant preparation is the efferves- cent citrated caffeine (U. S. P.), made by "triturating together 10 parts each of caffeine and citric acid, 330 of sodium bicarbonate, 300 of tartaric acid, and 350 of sugar, making the powder into a paste with enough alcohol to make 1000 parts, passing the paste through a No. 6 sieve, drying it, and reducing it to a coarse powder. It must be kept in well-stop- pered bottles." The dose is from 1 to 3 drachms. Physiological Action. — Cohnstein has formulated the following conclusions, which agree with those of most observers: 1. In small doses caffeine produces an increase of the arterial pressure, while larger amounts prevent this increase. 2. The influence upon the blood-pressure is the result of the changed condition of irritability of the vasomotor centre, caused by the caffeine. 3. Caffeine has a direct action on the heart, showing itself in the pulse-frequency and wave- height, first as an irritation and then as a paralysis. 4. The heart-muscle is af- fected by caffeine in precisely the same manner as the skeletal muscle. As to the effects of caffeine on blood- pressure, Gaetano Vinci found that in COFFEE. CAFFEINE. POISONING. 267 all cases there was a rise of blood-press- ure, whether the drug was administered by the mouth, intravenously, or hypo- dermically, with a consequent fall of pressure only in rabbits. In dogs and rabbits subjected to repeated blood-let- tings, there was a constant rise to the normal, and often far above. In dogs suffering from inanition there was a con- stant elevation of blood-pressure propor- tionate to the weakness of the animal, except in cases where the lowering of vital forces had gone so far as to affect the heart-muscle. Schneider found that after therapeutic doses caffeine could not be detected in the urine of cats or men, but that after comparatively-large doses it was readily obtained. Contrary to the opinion of Maly and Andreasch, he thought that the greater part of the drug was destroyed in the body. The discrepancy in the results of these various investigators may have been due, according to C. K. Mar- ehall, to differences in the dose adminis- tered, the animal iised, or the methods of estimation of the alkaloid employed. Caffeine acts chiefly as a stimulant to the nervous system. In this manner it affects the action of the heart, causing the beats to become stronger, and in some cases more rhythmical ; but, un- like digitalis and strophanthus, it has no specific action on the inhibitory nerves of that organ. Its action on the vasomotor centres is marked, causing contraction of the vessels and increased tension in the same, the blood-pressure rising. Pawinski (Zeitsch. i. klin. Med., B. 23, H. 5, C, '94). Caffeine facilitates muscular labor by increasing the activity not of the mus- cle itself, but of the corresponding cere- bro-spinal centre. As a consequence of this double action on the cerebrum and medulla, the sensation of effort is dimin- ished and keeps off fatigue. The drug further prevents loss of breath and pal- pitation due to severe muscular effort. It does not check tissue-waste. Caffeine allows more exertion through a kind of physiological economy. The drug would seem to place a person untrained in the position of one who had been subjected to perfect physical training. The inges- tion of food allows of a certain amount of exertion, but fatigue comes on before the assimilated products of digestion are used up, and thus a reserve is left. Caffeine seems to use up more or less of that reserve, and hence the drug is beneficial only temporarily. Germain S6e and Lapicque (Bull, de I'Acad. de Med., Mar., '90). Caffeine is thought by some observers to be one of the drugs instinctively de- sired by man, because of its exciting in- fluences. Caffeine in small, repeated doses, according to this view, may be ad- vantageously prescribed to soldiers on the march, as it increases muscular ac- tion and promotes the activity of the motor-nervous system, both cerebral and medullary. The result of this double action is to diminish the sensation of effort and to prevent fatigue. It pre- vents shortness of breath, with resultant palpitation. In this manner it supplies vigor to one who is engaged in severe and prolonged exercise. Caffeine and theobromine act as direct excitants of the renal parenchyma. In contrast with the saline diuretics, which appear chiefly to provoke elimination of water and at the same time of salts, and especially chlorides, the xanthin bodies increase the elimination of nitrogenous elements, and specially urea and uric acid. Anten (Arch. Inter, de Pharm. et de ThCrap., vol. viii, fasc. v and vi, 1001). As far back as 1721 coffee was con- sidered to "be excellent in the time of pestilence and contributes greatly to prevent the spread of infection." The writers review the work that has been done vip to the present time in the study of the deodorant and antiseptic properties of coffee, and conclude their paper with an account of their own ex- periments in this field of research. In- fusions of green coffee, they find, have 268 COFFEE. CAFFEINE. THERAPEUTICS. no antibacterial properties. Infusions of roasted coffee have. The latter are able to inhibit putrefaction and prevent the growth of many bacteria even in the most suitable culture media. To what coffee owes these qualities it is at present impossible to say. It is not probable that caffeine plays any part in the action of coffee upon bacteria. Crane and Piiedliinder (Amer. Med., Sept. 5, 1903). Poisoning by Caffeine. — James Fergu- son observed a case of tonic spasm follow- ing a medicinal dose of citrate of caffeine, repeated three hours later for severe headache, which became more violent than before. There was jerking of the hands and forearms, the fingers began to be rigidly clenched, and shortly after the head was seen to be drawn to one side, with the jaws tightly fixed together. At this stage the author found the fingers of both hands as described, and the mus- cles of the face tightly drawn, but with some imperfect articulation by this time possible. Friction of the affected parts did some good, and a dose of 30 grains of chloral was ultimately followed by recovery of control over the muscles. There had been no loss of consciousness throughout. The patient's sensation had been chiefly one of great faintness and nausea. The author suggests that the use of the drug be watched, since it has become a popular remedy for headache. Therapeutics. — European observers — Huchard, Ferrara, and others — state that cafTeine, given by the mouth, does not, even in large doses, show its best effects, because it is eliminated with great ra- pidity. The hypodermic method is the best, and is painless, producing no cuta- neous reaction. In diseases of the heart — both those depending on degenerative processes in the muscular fibres and such as are termed functional — the action of caffeine is striking and beneficial. In these affec- tions the use of digitalis is only indicated during a later stage of the disease, when the heart is no longer capable of fulfill- ing its duties, when cedema and dyspnoea have set in. Caffeine is further of great use in attacks of dyspnoea, such as are observed in cases of sclerosis of the cor- onary arteries, and also in cardiac insuffi- ciency following on overexertion, severe moral shock, or febrile maladies. Dropsy. — In dropsical effusions re- sulting not only from heart affections, but from disorders of other viscera, the diuretic properties of caffeine frequently manifest themselves advantageously. In cardiac dropsy digitalis is the most useful drug, but when it does not afford relief caffeine may be of valuable serv- ice. Case in which the heart was greatly enlarged, and the impulse strongly marked, the apex-beat being in the sev- enth space in the anterior axillary line. There were signs also of dilatation of the aorta. At the apex was a loud and long systolic murmur. The caffeine was used according to the following formula: — IJ Caffeines, 5 grains. Sodii salicyl., 4 grains. Aq., ad I ounce. — M. Given twice daily, this mixture af- forded considerable relief. Tickell (Clin- ical Journal, Feb. 2, "98). In cardiac and renal disorders the effect of caffeine is usually as follows: With doses of 3 to 4 'A grains two or three times a day, the blood-pressure rises steadily, slowly, and the quantity of urine is increased. CKdoma is lessened, but very slightly. Botwi'cn the fourth and the sixth day the jjaticnts begin to complain of a sense of constriction in the chest, dyspnoea, and restless nights. In some cases it can be made out by aus- cultatory percussion that the heart has diminished in size in all its diameters; this is a sign of impending tetanus of the cardiac muscle, and the caffeine must be at onco omitted. Caffeine continues to be excreted in the urine for at least ten to fifteen days after the last dose is taken. 'I'lic innic the kidneys are dis- COFFEE AND CAFFEINE. COLCHICUM. 269 eased, the slower it is excreted and the greater is the danger. Caffeine acts e.x- actly like strj'chnine on the spinal cord, the striated and especially the cardiac muscles. Zenetz (Wiener med. Woch., Dec. 9, '99). Febeile Maladies. — As a stimulant in febrile diseases, enteric fever, pneu- monia, scarlatina, diphtheria, etc., caf- feine is of great value. It supports the patient's vital powers and the cardiac action, and assists him in resisting the tendency to collapse. Caffeine is very valuable as a cardiac stimulant in the post-febrile stage of typhoid. Two to 4 grains every four hours should be given. J. B. Walker (Annual, '90). The ad^'namic state of typhoid fever and pneumonia is favorably influenced by hypodermic injections of caffeine. Benzoate of soda is added to the aqueous solutions of caffeine, and as much as 30 to 45 grains in six to ten injections may be given daily without bad results. Henri Huchard (Revue GCn. de Clin, et de ThCr., June 20, '89). In acute diseases of children it ia to be recommended as a remedy par ex- cellence, children supporting it better than any other. Subcutaneous injec- tions to administration by the mouth prefencd, G grains being given daily in two injections. Bruneau (Those de Paris, Feb., '94). Beonciiial Affections. — Caffeine is valuable in bronchial asthma and in bron- chitis associated with spasm of the bron- chial tubes. When a paroxysm of asthma is present, Skerritt gives 5 grains of the citrate of caffeine every four hours until relief follows. When the attacks come on regularly in the early morning, a dose of 5 or 10 grains at bed-time often serves to avert them. No ill effects have fol- lowed the treatment, even when con- tinued for years. The drug sometimes causes slight wakefulness, but, as a rule, patients go to sleep without difficulty after the nightly dose of 5 or 10 grains. Cephalalgia. — The various forms of headache, dependent upon nervous ex- haustion, and the migraine of neuro- pathic subjects, are generally relieved by effervescent citrate of caffeine. It may be advantageously combined with anti- pyrine or the bromides. COLCHICUM. — Colchicum auiurnnale, or "meadow-saffron," is a native of Eu- rope and Great Britain, and constitutes a remedy of great repute abroad, though in America it, of late years, has fallen largely into disuse, not through any lack of intrinsic therapeutic worth, but be- cause of the number of new substitutes offered. Indeed, the drug appears to have passed entirely out of the recollec- tion of the majority of teachers, as they are so unfamiliar therewith as to deny it proper attention. Both the bulb of the root (corm) and seeds are employed medicinally, and any choice between the two probably lies with the former, inasmuch as it yields more of the alkaloid colchicine. The corm is about one inch long, ovoid, flattish, with a groove on one side, wrinkled and of brownish hue, internally white and solid; inodorous, with sweet- ish, bitter, acrid taste. It often appears as cruciform transverse slices breaking with a short mealy fracture — if very dark hued, or it breaks with a horny fracture, it is inert, and consequently useless. It yields its virtues to alcohol, but not so readily or completely as to vinegar and wine. The seeds are at their best during late July and early August, which is the period of collecting. They are nearly spherical, one-eighth inch in diameter, of reddish-brown hue externally, white internally, and yield much the same bitter, acrid flavor as the corm. Colchicein is a decomposition product 270 COLCHICUM. PREPARATIONS. PHYSIOLOGICAL ACTION. of colchicine, and is had as small, yellow- needles; soluble in alcohol, ether, and chloroform; slightly so in water. Colchicine appears both as an amor- phous body and a yellow, crystalline powder melting at about 296.5° F.; in- soluble in water, alcohol, ether, and chloroform; it is very bitter and highly toxic. Colchicine tannate is a yellow powder, soluble in alcohol only. Preparations and Doses. — Colchicum abstract (root, corm), 1 to 3 grains. Colchicum extract, fluid (root), 2 to 8 minims. Colchicum extract, fluid (seed), 3 to 10 minims. Colchicum extract, solid (root), V2 to 2 grains. Colchicum extract, solid (root), acetic, V2 to 2 grains. Colchicum, powdered (root), 2 to 6 grains. Colchicum, powdered (seed), 3 to 10 grains. Colchicum-syrup, 1 to 4 drachms. Colchicum tincture, acetated (root), 10 to 60 minims. Colchicum tincture (seed), 10 to 30 minims. Colchicum-wine (root), 10 to 60 minims. Colchicum-wine (seeds), 30 to 120 minims. Colchicein, Viao to Vo* grain. Colchicine, Viso to Vao grain. Colchicine tannate, V04 to Vi„ grain. Scudamore's mixture (carbonate of magnesia, 2 drachms; Epsom salt, 8 drachms; wine of colchicum, 4 drachms; peppermint-water, to make 12 ounces), 4 to 8 drachms. Larger doses of wine may be em- ployed, but the drug then becomes very actively piirtralivo nnd likewise emetic. Physiological Action. — In small doses colchicum is a marked alterative and cholagogue, and further exercises some mysterious, but specific, action whereby it becomes sedative, and which cannot be accounted for, save in part, by its evacuant properties. It increases secre- tions generally, particularly those of the liver and the glands and mucous folli- cles of the intestines. In large doses it purges copiously, and may likewise prove violently emetic; yet many people will tolerate unusual quantities without any unpleasant efliects. Again, it is not un- common for colchicum to produce a marked degree of exhaustion — perhaps even to fatality — ere hypercatharsis and hyperemesis give warning that it is being pushed too far. The stools produced by the drug are of a highly-bilious char- acter, and, while at first solid or semi- solid, perhaps enveloped with mucus, later they are soft, liquid, of high color, and may even assume a dysenteric char- acter. Authorities are not in accord as to the diuretic powers; while some in- sist that it favors solution and excretion of uric acid and urea, others deny any such action. As a matter of fact, the drug does not always provoke diuresis; but this is to be accounted for, perhaps, by the character of the preparation em- ployed or the mode of administration. Strange to say, alcohol inhibits the ac- tion of colchicum, yet the wine is the most active of all the Galenical prepara- tions. Alkalies materially assist its diuretic and purgative properties, and, combined with potassium bicarbonate, not only is this observed, but also the antilithic powers of the latter are greatly enhanced. Colcliicuiri is one of llie most valuable ronipdics in the uric-acid diathesia, and the prejudice against it is absurd; and, far from it being a vascular depressant, it often gives strength and regularil.y to a feeble and irregular pulse, especially in COLCHICUM. PHYSIOLOGICAL ACTION. 271 chronic gout with acute exacerbations. Burney Yeo (Brit. Med. Jour., Jan. 7, '88). One of the very good reasons why it has failed in many hands is that it is generally given in purgative doses, wliich prevents its specific effects upon the cir- culation. In acute rheumatism or gout the circulation should be reduced with aconite or veratrum before giving col- chicum. Goss {"Mat. Med., Phar., and Special Ther.," '89). In small therapeutic doses produces gastro-intcstinal disturbances, the symp- toms difl'ering in degree only from those of poisoning. Before they come on, however, there is a lowering of the pulse- rate, sometimes as much as twelve beats per minute. Upon the skin it acts oc- casionally, producing, in some C£.se3, diaphoresis, and, it is believed, the amount of this action is in inverse ratio to the effect upon the bowels. Any nervous symptoms, such as vertigo, headache, and muscular weakness, which may be present as the result of the colchicum, are probably sympathetic upon the gastro-intestinal irritation. It is evident that the dnig infiuences the bowels powerfully, and probably in this way acts as an eliminative. But, with the minute doses often used with advan- tage in the disease, purging does not occur, and consequently increased elim- ination, if it takes place, must be through the kidneys; great interest, therefore, attaches to the influence of the remedy upon the urinary secretion. In considering this the effects of poisonous and therapeutic doses must not be con- founded, for it is very evident that an irritation which causes suppression of urine may, when present in a much milder degree, produce an increased flow. When the drug purges freely it is very probable that elimination by the kid- neys is lessened; and no account of | this is taken by any of the observers I who have studied its effect in the elim- j ination of urea and uric acid; all con- tent themselves with noting the propor- tion of urea and uric acid in the urine, when it is evident that the mere pro- portion, unchecked by the absolute amount of urine excreted in the twenty- ' four hours, is no criterion as to the absolute amount eliminated. H. C. Wood ("Therapeutics: Its Principles and Practice," '94). By some observers it is stated that there is an increased elimination both of urea and uric acid, while by others it is denied. It is possible that dif- ference in dietary of the patients may account for this discrepancy. Murrell ("Manual of Materia Medica and Thera- peutics," '90). Full medicinal or larger doses produce great depression of the circulation, with a small, rapid, and thready pulse. The marked cardiac depression and collapse which occur when poisonous doses have been taken are more the result of the severe gastroenteritis than of any direct action upon the heart. The nervous system is unaflected by medicinal doses; but large or poisonous doses may induce cerebral excitement. Large doses render the respiratory movements slow and shallow. Personal experiments are suf- ficient to satisfy the author that the excretion of urea and uric acid by the kidneys is considerably heightened un- der medicinal doses. Butler ("Text-book of Mat. Med., Pharm., and Ther.," '96). Colchicum induces fall of temperature during the period of emetocatharsia; when injected into dogs there is a marked fall in blood-pressure. The amount of urea and uric acid excreted in the urine is much increased by the drug; Lewins found the urea excreted to be almost doubled in amount. Biddle ("Mat. Med. and Ther.," '90). The most discordant statements have been made about the action of colchicum upon the renal secretion, but it has not been definitely shown that either the quantity or composition is altered. After death by poisoning, the alkaloid is found in the blood and in most of the organs of the body. Hale White ("Mat. Med., Phar., and Ther.,'' '90). Though the physiological effects of this drug are very similar to those of veratrum, yet one cannot be therapeutic- ally substituted for the other. It pro- duces mucli irritation of the fauces, with increase of saliva. It irritates the di- 272 COLCHICUM. THERAPEUTICS. gestive tract and produces these efEects whether taken into the stomach or in- jected into the veins. In large doses it considerably increases biliarj' secretion, and at the same time purges powerfully. Colchicum, it is well known, gives re- lief from the pain, inflammation, and fever of gout. But how? Does it cause the elimination of uric acid through the kidneys and so remove the condition on which the gout immediately depends? Since Garrod has experimentally shown that colchicum exerts no influence on the elimination of uric acid in gouty people, it is evident that the drug must control gouty inflammation without, in any way, afi"ecting the condition on which such inflammation, in the first in- stance, depends. Hence, colchicum should be merely palliative, removing, for a time, the patient's sufferings, but in no way protecting him from their recur- rence, ilany who suffer from gout are of opinion that, while the medicine will remove altogether an existing attack, it insures the speedy return of another. Ringer and Sainsbury ("Hand-book of Ther.," '97). Colchicine in a general way acts like colchicum, but the action of colchicein has not been determined with any degree of definiteness. On the heart and circulation colchicine produces very little effect, though large doses cause a fall of arterial pressure and slight slowing of pulse, due to de- pression of the heart. Colchicein, in poisonous doses, induces marked weakness, stupor, and lowering of bodily temperature; decreases reflex activity, not by depressing the sensory nerves as does colchicine, but by acting on the motor nerve-trunks. Leon (Univ. Med. Mag., July, Aug., '89). Two or three hours after the intrav- enous injection of colcliicine the symp- toms of general poisoning appear. The firBt symptoms are nausea, followed by more or less vomiting and diarrhoea; next, alteration in the motility, taking on the form of ascending central paraly- sis. When the paralysis reaches the anterior extremities, disturbance of res- ' piration occurs: the respiratory move- ments become greatly increased in power and greatly decreased in number, until death ensues, owing to arrest of respira- tion. In rare cases, immediately before death, convulsions occur, which are at- tributable to asphyxia. The heart re- mains beating for perhaps twenty min- utes after breathing has been arrested. Jacobi (Schmidt's Jahrbuch, Sept.; Therap. Gaz., Oct., '90). Severe case of poisoning by two "Blair's gout pills," which, as is well known, contain extract of colchicum. The patient had a typical abdominal facies; lips and nails, bluish; respira- tion, quick and shallow; pulse, small and quick; and skin, pale and clammy. He vomited a large amount of yellow fluid and nad several profuse and bloody passages fi-om the bowels. The temperature was 96.5° F. Under seda- tives and carminatives the patient re- covered. A month before the same pa- tient had taken two of the same kind of pills with similar, but much less in- tense, symptoms. L. G. Davies (Brit. Med. Jour., Nov. 14, 1903). Colchicum and its salts are contra- indicated when there is a great amount of debility, a profuse diarrhoea, and in asthenic gout. It is worthy of remark that most of the untoward effects chron- icled from time to time have appeared in conjunction with the administration of wine of colchicum-seed. On the other hand, much of tlie corm, or "root," em- ployed by manufacturers is worthless. Therapeutics. — Rheumatism and Gout. — In all forms of sthenic rheuma- tism and gout tlie relief that colchicum gives is incomparably greater than that afforded by any other single remedy, but the mode in which it is best given, tlie period best suited for its administration, and even the patients for which it is suited are points whicli demand serious consideration. It is by no means an agent to be prescribed hap-Iiazard and indiscriminately, nor one which will, in C(JLC1IICUM. THERAPEUTICS. 273 all cases, produce equally beneficial re- sults. The maxims laid down by Todd cannot be improved upon, viz.: Never give it at the outset of a paroxysm, not until the bowels have been acted upon by a mild purgative. Let the first doses, always, be small, and subsequently grad- ually and progressively increased. At first administer uncombined with any other remedy until assurance is had that it is not likely to disagree with the patient; and do not push to a degree that will excite nausea, vomiting, or purging: these should be regarded as in- dicative of unfavorable operation. It may be regarded as acting favorably when, under its use, the volume of urine is increased; when an abundant supply of bile is discharged; when the feeees, though solid, are surrounded by mucus; and when the skin secretes freely. Its effects should be carefully watched, as it is likely to accumulate in the system. It is inadmissible where the patient is advanced in years, who has had several attacks and in whom the malady seems too deeply rooted to be influenced by the temporary administration of the remedy. It is necessary to continue the use of colchicum for many days after the entire cessation of the symptoms; but the doses may be gradually diminished, and at the Bame time the intervals lengthened; also, if the malady does not give way by the time the bowels are affected by the drug, it is useless to push it further. Gout is the one disease in wliich col- chicum is almost universally recognized as a specific. It may be advantageou.sly employed both as a preventive of the paro.xysm and to lessen its severity when developed. It should always be borne in mind that, although looseness of the bowels may be useful, yet when colchicum purges the gouty patient actively it mostly fails in achieving the desired therapeutic result. Its action is most favorable when its influence is 2—18 felt chiefly upon the skin and kidneys; and to elTect this it is often well to restrain the tendency of the drug to act upon the bowels by combining it with opium. This is especially the case in debilitated subjects, in whom anything like overpurgation must be avoided with the most scrupulous care. By large purgatives doses of colchicum the paroxysm of gout may often be sup- pressed, but experience has shown this use of the drug is dangerous, the sup- pression being sometimes followed by serious internal diseases, apparently due to a transfer of the gouty irritation. Between the paroxysms colchicum mar be steadily exhibited to the gouty sub- ject in small doses, and often great ad- vantage is derived from its combination with potassium iodide; this combina- tion is especially useful in irregular atonic gout such as is frequently seen in women of feeble nervous organization who have inherited the diathesis, but is sometimes present in robust men. H. C. Wood ("Therapeutics: Its Principles and Practice," ninth edition, '94). While efficacious in chronic rheuma- tism and occasionally of some benefit in rheumatoid arthritis, it is of no value in acute articular rheumatism. Its value is more apparent in acute than in chronic gout, and in the first attacks than in succeeding ones. Chronic gout, as well as chronic rheumatism, yields better to a combination of potassium iodide than to colchicum alone. In combination with certain other agents this drug serves an excellent purpose as a cholagogue, full doses being frequently very effective in relieving ascites due to obstructive dis- eases of the liver. It is also sometimes employed as a drastic purgative in cere- bral and portal congestion, although when given in doses sufTicient for this purpose it occasions considerable nausea and abdominal distress. It has also been recommended in the treatment of gonorrhoea and chordee. Hypochondria- sis resulting from renal insufliciency is frequently benefited by this remedy. Butler ("Text-book of Mat. Med.. Ther., and Phar.," '96). Given during an attack of gout it most markedly relieves pain; in smaller doses, 274 COLCHICUM. THERAPEUTICS. given bet\Yeen the attacks, it diminishes their severity. It is often very useful for dyspepsia, eczema, headaclie, neu- ritis, conjuncti^'itis, bronchitis, and other conditions ^Yhich, when occurring in those suffering from gout, are prob- ably related to it. Occasionally it is combined with other eholagogues, espe- cially if it is desired to give these reme- dies to a person who is the subject of gout. Hale White ("Mat. Med. and Ther.," '96). Colchicum is a remedy of undoubted value in gout and the gouty diathesis. The larger doses of the drug should be reserved exclusively for able-bodied men of the brewer's-drayman kind, and the effect is marvelous, the patient usually being able to resume work on the third day; but the treatment is severe and produces persistent purging not uncom- monly accompanied by vomiting. In less severe eases give 10 minims of colchicuni- wine with 5 grains of potassium iodide in a mixture flavored with spirit of chloroform and syrup of orange-flower, three times a day; this often acts as a laxative, and produces a peculiar me- tallic taste in the mouth; many patients take this mi.xture at intervals all the year round. Murrell ("Manual of Mat. Med. and Ther.," '96). The efl'ect of colchicum on gouty in- flammation is very rapid; a large dose will often relieve the most severe pain in the course of one or two hours, and soon afterward the swelling and heat will subside. While the pain is thus quickly subdued, the temperature of the body falls very little during the first day, but on the following morning there is generally a considerable decline, and often a return to a healthy temperature; should the fall be postponed a longer time, then on the second day after the use of the colchicum a continuous de- cline of temperature will take place, and all fever gradually disajipcar. There are two methods of employing the drug: large doses which extinguish the pain at once, and small doses wliich give the same result only after some days. It is BOmetimcH used in chronic rheumatism and rheumatoid arthritis, b\it without any very apparent benefit. Ringer and Sainsbury ("Hand-book of Ther.," thir- teenth edition, '97). General Maladies. — lu dropsies — tlie anasarca of the aged, hydrocephalus, hydrothorax, anasarca following fevers, etc. — colchicum is often very efficacious, especially in combination with other diuretics and a diuretic alkali. It is one of the most satisfactory remedies in chronic and obstinate constipation, but the dose should be small, as the object is attained rather by gradual insinuation than by forcible impression. In gonor- rhea and other inflammatory discharges from the genito-urinary organs, in both sexes, in strangury, ardor urinse, and irritable states of the bladder, it has been employed with great success. At one time it was held to be the most effi- cient agent known to therapeutics in re- moving tape-worm. In jaundice and chronic hepatitis it has a value, but re- quires to be combined with soap, alkalies, or mild mercurials. Spasmodic attempts have been made toward popularizing the alkaloid col- chicine, but with little success; it does not sufficiently represent the virtues of colchicum. It has found its best applica- tion in the treatment of rheumatic iritis, and its value here is greatly enhanced by combining with methyl-salicylate. It has also been employed subcutaneously in chronic rheumatism and neuralgic joint- affections. A valuable remedy, and in conjunction with small doses of calomel may be pre- scribed with advantage for gouty people who have had no acute manifestation of the disease, but who sudor more or less continuously from joint-pain. A pill may be taken at bed-time, or three times a day after meals, composed of: Vm Krain of colchicine, Vs grain of calomel, and 1 grain of solid extract of henbane. In gouty neuritis a pill three times daily^of colchicine, '/«» quinine and extract of colocynth, of each, 1 grain — COLOCYNXH. PREPAKATIONS AND DOSES. 275 ia recommended. Murrell ("Manual of Mat. Med. and Ther.," '9U). For hypodermic use the alkaloid may be dissolved in distilled water in the pro- portion of 1 to 5G0 minims, the dose being 15 minims; but the injection causes sharp burning pain. Wlien deep, intramuscular injections have been tried in sciatica, the results have been un- fortunate and unprofitable. G. Abciiie Stockwell, New York. COLD ABSCESS. See Abscess. COLITIS. See Intestines. COLOBOMA. See This and Lens. COLO CYNTH.— This is the dried, de- corticated fruit, freed from seeds, of Ci- trullus colocynth, a perennial plant re- sembling the watermelon; it is also known as "bitter apple" and "hitter cu- cumber." Though grown in gardens in England since 1551, the plant is a native ■of the deserts and places of southern and western Asia, and of Africa; it is like- wise cultivated, medicinally, in Greece, Spain, Italy, and Japan. Two varieties of fruit are recognized pharmacologic- ally: one termed "peeled Turkey" colo- cynth, imported chiefly from Smyrna, Trieste, and Spain, and "unpeeled moga- ccially where CONJUNCTIVA. VERNAL CONJUNCTIVITIS. 283 many scholars are massed together, scrof- ulous subjects being particularly prone to be affected. As there are frequently no subjective symptoms, the physician is often the first to discover the presence of the follicles. Follicular catarrh is frequently noted among school-cliildren who do not com- plain of their eyes; confusion may arise from confounding this innocuous inflam- mation with the dangerous trachoma. H. Cohn (Berliner klin. Woch., June 20, '98). Pathology. — The follicles consist of a mass of round cells, identical with the lymphoid stroma of the conjunctiva. There is no capsule, and the epithelium is unaffected. In the acute form, when the secretion is abundant, the affection is contagious; but, when there is but little discharge, the follicles lie hidden in the cul-de-sac without giving rise to any acute symptoms, and contagiousness is not to be feared. The disease is one of childhood and adolescence, and may be associated with acute or chronic catarrh, but usually with the latter. The follicles disappear to- tally after a time; so that the prognosis is favorable, notwithstanding the chro- nicity of the process and its tendency to relapse, which serves to differentiate the disease from trachoma, with which it bears a close resemblance. Treatment. — Treatment is the same as for catarrhal conjunctivitis, with the ad- ditional indication of bringing about the disappearance of the follicles. This is best accomplished by insufflations of iodoform, aristol, or calomel. In stub- born cases excision or expression of the follicles has been recommended. The hygienic surroundings should be bet- tered, if need be, the health of the pa- tient attended to, and all near work pro- hibited. All errors of refraction should be carefully corrected under atropine. The confusion of diagnosis between follicular conjunctivitis and trachoma has led to an equal confusion in the treatment. In trachoma the essential element is lymphatic hyperplasia, and the treatment which he has found most suc- cessful has been based on the treatment of lymphatic enlargements in other por- tions of the body. First, so far as pos- sible the cause of irritation, whether chemical, mechanical, or bacterial, should be removed. This often involves not only frequent irrigations of the con- junctiva with boric acid solution, but we should consider the physical condition and surroundings of the child. Cod- livcr-oil and iodide of iron are valuable internally. Locally, on alternate days, he has found a combination of ichthyol, 15 minims (1 cubic centimetre); tinct- ure of iodine, 1 drachm (4 grammes) ; gh'cerin, 1 ounce (31 grammes), to be of value. On the other days an instil- lation of 1 drop of the following com- bination may be made at home: Zinc sulphate, 1 grain (0.06 gramme) ; wine of opium, 8 minims (0.5 cubic centime- tre) ; water, Vj ounce (15.5 cubic cen- timetres). Alger (Med. Record, Jan. 24, 1903). Vernal Conjunctivitis. Definition. — Vernal conjunctivitis is a chronic catarrhal inflammation of the conjunctiva, usually occurring in chil- dren and adolescents, which is attended with the formation of characteristic le- sions in the pericorneal and palpebral tis- sues. Symptoms. — The changes at the margin of the cornea consist in an ac- cumulation of the conjunctival epithe- lium with hypertrophy of the under- lying connective tissue. This gives rise to large, reddish-gray prominences, which may readily be seen. Although located in the palpebral fissure, these may ex- tend for some little distance into the corneal tissue; or surround the entire cornea. The tarsal conjunctiva is thick- ened in the neighborhood of the diseased 284 COXJUNCTI^'A. PURULENT CONJUNCTIVITIS. area; its papilla are enlarged and present a characteristic mammillated appear- ance. When the lids are first everted, the conjunctiva is covered with a fine, bhiish-white haze, which resembles a layer of milk. At the height of the process there is profuse lacrymation, hut rarely any discharge. Considerable pho- tophobia is complained of. The disease usually becomes worse upon the approach of spring, the eyes being comparatively free from irritation in the winter. It is quite rare and gen- erally affects males, being essentially a disease of childhood and adolescence. The prognosis is good, although the dis- ease runs a very chronic course and may persist from ten to twenty years. It finally disappears, however, leaving no trace, except in rare cases, in which a faint haze may remain on the cornea. Etiology. — The disease frequently oc- curs in malarial subjects of both sexes, and is at times seen in women with ir- regular catamenia. The primary cause is unknown. Treatment. — The disease is incurable, and palliation of the acute symptoms represents all that can be done. Van Milligen, who has had excellent oppor- tunities to study the disease in Constanti- nople, where it occurs more frequently than elsewhere, has employed a solution of acetic acid, 1 to 20 grains to the ounce, with marked benefit. I have ob- tained excellent results from the same remedy. In vernal conjunctivitis, applications of nitrate of silver or sulphate of copper are not always indicated, and do good only when the stringy, inuco-punilcnt se- cretion is very abundant. In the peri- corneal form the best treatment is mass- age of the cornea with mercurial oint- ment, made up with lanolin. Darier (Annals of Ophth., July, '97). Ab there is no discharge, the disease is not really a catarrh, and does not de- mand the same treatment as this class of cases. The eyes should be kept clean with a lO-grain-to-the-ounce solution of boric acid; dark glasses should be pre- scribed to protect the eyes from the light and other irritants, such as dust, smoke, etc. If there is much pericorneal in- jection, a weak mydriatic should be pre- scribed: either atropine in small doses or homatropine. Iced compresses dimin- ish the vascularity and alTord marked relief. Arsenic, quinine, and iron should be administered internally. Extirpation of the hypertrophied pa- pillaa by electrolysis, and obliteration of the superficial vessels supplying the growth in the limbus, have been resorted to with good results. Purulent Conjunctivitis. Definition. — Purulent conjunctivitis is an acute, contagious inflammation of the conjunctiva caused by infection with gonorrhoeal virus, and attended by a copious, purulent discharge. It is one of the most dangerous and virulent dis- eases of the eye. The contagion is car- ried by micro-organisms, the gonococci of Neisser, which appear not only in the pus, but also in the superficial layers of the conjunctiva itself. The gonococci may be found in isolated groups, either in the pus-cells or epithelial cells, and their virulence depends upon the severity of the urethral disease at the time of infection; the more violent the latter, the greater the ocular inflammation. Purulent conjunctivitis may be pro- duced during any stage of the uretliral disease, but about the third week of the existence of the latter is the most danger- ous period, the discharge being then very copious, thick, and noxious. The dis- charge from a gleet may, however, give rise to severe and even destructive gonor- rheal ophthalmia. CONJUNCTIVA. GONORRHCEAL OPHTHALMIA. SYMl'TOMS. 285 According as the afTection occurs in adults or infants, it is called gonorrhaeal ophthalmia or ophthalmia neonatorum. Not all forma of diplocoeei decoloring by Gram's stain are gonoeocei, and are not, therefore, due to tlie gonococeua in all cases of inflanimiition of the con- junctiva in which they are found. In fact, as this membrane is exposed, it is quite possible that other forms of infection occur. A.venfcld (Miinchener nied. Wochen., Jan. 13, 1003). Gonorrhoeal Ophthalmia. Definition. — Purulent or gonorrhoeal ophthalmia is a specific purulent in- flammation of the conjunctiva charac- terized by great swelling of the lids and conjunctiva, and by copious secretion of contagious pus, presenting a marked tendency to destruction of the cornea. Symptoms. — The period of incubation varies, according to the intensity of the contagion, from a few hours to three days. At first the signs of a simple catarrhal conjunctivitis may alone be present, but soon the lids become red and so tumefied and tense that the patient is no longer able to open them. The palpebral con- junctiva and retrotarsal folds also be- come intensely red and swelled, and the former is often speckled with hoemor- rhages. The membrane becomes hard and granular, owing to an infiltration of seroplastic lymph into its substance. The bulbar conjunctiva soon becomes simi- larly swelled, forming a hard rim about the cornea. The discharge is at first watery and sanious, but soon changes to a yellow or greenish-yellow pus. The eye is painful to the touch, and there is intense pain in the eye and temple. The constitutional symptoms are often severe, the patients being generally in a weak and feeble condition. Slight fever is also present in some cases. This stage — that of infiltration — lasts about three davs, when the disease attains its height. The lids then become less tense, the conjunctiva softer, and a copi- ous purulent secretion follows. After a week the discharge gradually declines, the tissues undergo restoration, and, at the end of four to six weeks, beyond a condition of chronic inflammation of the conjunctiva, which persists many weeks, the parts resume their normal appear- ance. Cicatrices rarely follow. At times the disease assumes more of a subacute type. All the signs of in- flammation are then less severe, the pal- pebral conjunctiva being alone afllected, and it is often only possible to diagnose these cases from catarrh of the conjunc- tiva by a microscopical examination. AVhen the disease is particularly virulent, it may simulate the croupous tj'pe, a false membrane being formed, which gives the conjunctiva a yellowish-gray appearance. In the prophylaxis of purulent con- junctivitis, which is generally gonor- rhceal in character, great care must be taken not to contaminate the eye with pus from the urethra or vagina. In purulent ophthalmic neonatorum the eyes of every infant are first washed outside with mercury cyanide or bichlo- ride, 1 to 20, and a drop of a 2-per-cent. silver nitrate solution is dropped into each eye. This, CredC's method, has greatly decreased the number of cases of gonorrhoeal ophthalmia in infants. A. Trousseau (La Presse Mi-d., March 2G, 1002). Complications. — The chief danger in purulent conjunctivitis is the implica- tion of the cornea. It results from the pressure of the swelled tissues; the cor- rosive action of the secretion, including the invasion of the gonoeocei; and direct continuity of inflammation to the sub- stance of the cornea. At first the cornea may look dull and slightly clouded; but soon circumscribed areas of grayish infiltration appear, which soon become more dense and yellow, and then form ulcers. The ulceration u?u- 2S6 COXJUXCTIVA. GOXOKKHCEAL OPHTHALMIA. TKEATMENT. ally occurs at the limbus, and may lead to rapid perforation. In many instances this is a relatively-farorable result, as fiirther infiltration of the cornea is fre- quently prevented thereby. In other cases, however, the infiltration may form at the margin of the cornea and extend a considerable distance around its circum- ference, giving rise to a marginal ring ulcer. Sloughing of a great portion or even the whole of the cornea usually fol- lows, and the eye is usually lost. The ulceration may also occur at the centre of the cornea, when the whole cornea becomes opaque. As a rule, the greater the severity of the conjunctivitis, the greater the liability to corneal in- volvement, especially if the bulbar con- junctiva be much chemosed. As a rule, also, the earlier the corneal ulcers form, the more likely are they to result seri- ously. Corneal ulceration usually appears on about the third day, but this depends upon the severity of the inflammation; in a certain number of cases it does not appear until late in the disease. Iritis may supervene when the ulcera- tion has extended to the deeper layers of the cornea or when perforation has oc- curred. It generally gives rise to great ciliary neuralgia, photophobia, and lac- rymation. The inflammation may extend from the iris to the other ocular tissues, and a panophthalmitis be set up. Prognosis depends entirely upon the degree of implication of the bulbar con- junctiva, for, if this be much chemosed, corneal ulceration will probably occur and vision be seriously compromised. Etiolo^. — Gonorrhoea! ophthalmia arises through infection with gonorrhoeal puB alone, the virus being conveyed di- rectly from the genitalia to the eyes, or from a diseased eye of another person, or from the patient's fellow-eye by the hand, handkerchief, etc. The serious ophtbaliuias are those pro- duced by streptococci or by au associa- tion of streptococci and gonococci, or by the combination of these two with others. The gonococci, when alone, are compara- tively harmless (?) and yield to treat- ment, which should be prompt and vig- orous, consisting of copious irrigations with potassium permanganate, boric acid, and cauterization with silver ni- trate. This combination acts on all the various species of microbes which may be producing the ophthalmia. Chartres (Arch. Clin, de Bordeaux, Dec, '90). Case of gonorrhceal conjunctivitis sec- ondary to a gonorrhoea induced by inter- course during menstruation. Formalin proved effective. Hansell (Editorial, Phila. Polyclinic, '97). There is a direct proportion between ease of transportation and a low rate of blindness, while a higher ratio is to be expected where travel is poor and incon- venient. L. Howe (N. Y. Med. Jour., June 26, '97). Sequels are the result of corneal in- volvement, for the conjunctiva is usually restored to a healthy condition; but, in the event of the corneal ulceration, all eventualities are possible; from a slight degree of opacity, on the one hand, to adherent leucoma, panophthalmitis, or even atrophy of the globe, on the other. Treatment." — The chief indication in the treatment consists in carefully and frequently freeing the eyes of the copious secretion; for this purpose bichloride-of- mercury or boric-acid solutions should be employed very often. To do this prop- erly will require the constant care of two intelligent attendants. The patient should be put to bed, and, if but one eye be afl'ected, its fellow should be carefully protected. For this purpose the device of Buller answers admirably. This con- sists in a watch-glass held in place before the eye by strips of adhesive plaster. It should be removed every forty-eight CONJUNCTIVA. GONOKRHCEAL OPHTHALMIA. TREATMENT. 287 hours and the eye thoroughly cleansed with a solution of boric acid. The sur- geon should warn the patient of the danger of carrying any of the urethral discharge to the eyes and should caution the nurses about exercising the most punctilious cleanliness as regards their hands, and care in the use of towels, handkerchiefs, etc. It is the duty of every physician at- tending a case of purulent conjunctivitis to warn tliose living with tlie patient of the very contagious nature of the dis- charge from the eyes, and, where pos- sible, to isolate both the patient and the nurse in charge. Johnson (Times and Register, Sept. IG, '93). In gonorrhoeal conjunctivitis, if only one eye is affected, the other should be hermetically sealed. The diseased organ should be washed, at least every half- hour, with a solution of mercury bichlo- ride, 1 to 5000, or a saturated solution of boric acid, and, every four hours, the conjunctival cul-de-sacs should be thor- oughly cleaned with pyrozone. In ad- dition, ice-compresses, to be changed every few minutes, should be applied con- stantly, day and night, in the first stage. When there is severe pain and swelling, relief may be afforded by canthotomy, slitting the conjunctiva, or leeching the temples. In the second stage, when the conjunctiva has become velvety, the care- ful application of a 3-pcr-cent. solution of silver nitrate is best treatment. After its use the conjunctiva should be thor- oughly cleansed with a saturated solu- tion of common salt. In the third stage, when acute inflammation has completely subsided, the silver is replaced by crys- tals of zinc or copper. In all stages atropine should be used when there is any appearance of haziness or ulceration of the cornea. A. T. Haight (Chicago Clinic, xiii, p. 317, IBOO). Great care should always be exercised in washing the eyes of these cases, as the pus frequently spurts out like a jet when the lids are separated. If the swelling of the lids prevents ready access to the cul-de-sac, canthop- lasty should be performed, as this pro- cedure not only gives access to the cul- de-sacs, but lessens the pressure of the lids, and gives room for the infection to spread. In the first stage, ice-compresses should be applied constantly night and day and changed every few moments. In robust subjects or when there is intense initial pain or swelling, marked relief may often be obtained by leeching the temples. In the treatment of fifteen cases of purulent ophthalmia good results were obtained by the mild and antiseptic method (silver, 5 grains; corrosive sub- limate, I to 5000). Campbell (Harper Hosp. Bull., Detroit, Dec, '93). In the second stage, when the con- junctiva has become velvety and the dis- charge purulent, the conjunctiva should be touched with silver nitrate (15 to 20 grains to the ounce of water), to reduce the swelling and the amount of secretion. The silver-nitrate solution should be ap- plied by the surgeon to the conjunctiva of the everted lids and then neutralized with a saturated solution of common salt, as directed in catarrhal conjunctivitis. Great importance of reaching all parts of the conjunctiva with 3-per-cent. ni- trate-of-silvcr solution in gonorrhoeal ophthalmia. Abadie (Bull. Gen. de Th6r., Jan. 15, '95). When cornea implicated, quinine sul- phate, 4 grains to 1 ounce, with smallest possible amount of sulphuric acid; to be used in intervals, but not as a .substitute for silver nitrate. Tweedy (Practitioner, Mar., '95). Purulent ophthalmia and dacryocys- titis successfully treated by potassium- permanganate solutions, 1 per cent, to 10 per cent. Case of diphtheritic conjunc- tivitis treated by crude petroleum-oil. Vian (Recueil d'Oplital., Aug., '95). Protargol in lO-per-cent. solution used for personal application in purulent con- junctivitis and 5-per-cent. solution for use at home. Furst (Fortsch. d. Med., No. 4, '98). 288 CONJUNCTIVA. OPHTHALMIA NEONATORUM. SYMPTOMS. Protargol in 5-per-cent. solution is practically a specific against purulent conjunctivitis. A. Darier (Ophtb. Klinik., Nov. 7, "OS). A 10-per-cent. ointment of the milky juice of the cassaripe plant is valuable in purulent disease of the conjunctiva ac- companied by corneal ulcers. S. D. Ris- ley (Phila. Med. Jour., Oct. 29, '98). It is best to delay the application of silver so long as the conjunctiva is hard and infiltrated and the discharge is watery. A croupous membrane also contra-indicates its use. In the third stage, when the signs of chronic conjunctivitis appear, the silver should be substituted by crystals of zinc and copper, but these should only be em- ployed when the cornea is quite free from all signs of acute inflammation and ulcer- ation. During the entire course of the disease, the cornea should be carefully inspected, and, at the first appearance of ulceration, atropine should be instilled. This drug frequently serves a double pur- pose in combating any existing iritis, as well as the corneal involvement. If corneal ulceration be present, great care must be exercised in making the applica- tions of silver to the everted lids, as press- ure on the globe might cause rupture of the ulcer. Care should also be exercised to prevent the silver coming in contact with the infiltrated cornea. Ophthalmia Neonatorum. Definition.— This is a purulent inflam- mation of the conjunctiva occurring in the newborn, characterized by great swelling of the lids and conjunctiva, and the copious discharge of contagious pus. This is one of the most frequent of eye diseases, and is responsible for more cases of blindness than any other affec- tion, the statistics showing that from 30 to GO per cent, of the inmates of the different blind-asylums throughout the country owe their infirmity to its rav- ages. Of the three hundred thousand blind in Europe, thirty thousand were rendered so by ophthalmia neonatorum. Symptoms. — The disease usually ap- pears on the second or third, more rarely on the fourth or fifth, day after birth. In the latter case, however, it is probable that infection is carried to the eyes after birth, either from the mother or the nurse or some other person suffering from gonorrhea. The active sj-mptoms are the same as the gonorrhceal conjunctivitis, except that they are not so severe. The swelling of the lids is not so great and the secre- tion is less copious. The bulbar chemosis does not attain such a high degree, and corneal complications are not so frequent nor so serious. The disease may occur in a severe type, with a tendency to invade the cornea; or it may run a milder course, without corneal complication. lu the mild form of conjunctivitis in the newborn there is little pus, much lacrymation, and moderate palpebral injection, although the pneuiuococeus is present. Parinaud {La Mfd. Mod., Jan. 19, ■95). Bacteriological examination of 100 cases of infantile ophthalmia, clinically ranging from a simple catarrh to a se- vere blennorrha?a. The following organ- isms were found: Gonococci, pneumo- cocci, and streptococci ; possibly in some cases staphylococcus aureus and bacillus coli. The etiological importance of other organisms was doubtful. The se- vere cases of blennorrhcea were, for the most part, caused by gonococci; but there occurred cases in which, in spite of most careful examination, gonococci were not found. The gonorrhojal cases nlwaya showed clinically certain pecul- iarities. The cases without gonococci were never complicated by corneal ulcer, and ran a much shorter and milder course. Also cases of slight and medium severity without gonococci showed after a few days' treatment marked lessoning or disappearance of purulent discharge, whereas the pus of gonorrlucal in nam- CONJUNCTIVA. OPHTHALMIA NEONATORUM. PROPHYLAXIS. 289 mation seldom disappeared under two weeks. Gonoeocci were the cause of the inflammation in 41 of the 100 cases; in 25 of these the alTeetion was severe. In gonorrhoea! cases for days and weeks after pus has disappeared gonoeocci may be found in the conjunctival sac; BO that the use of silver preparations must be continued long after purulent discharge has ceased. Groenouw (Arch. f. Ophthal., B. lii, p. 1, 1901). While the gonococcus is regarded as the sole evoking agent of gonorrhoea, it is not the sole etiological factor in ophthalmia of the newborn. The so- called pseudogonococcus has been al- leged to be one of the causes of the lat- ter, and the author doubts the truth of this contention. Schanz (Deutsche med. Wochon., Nov. 5, 1903). The prognosis depends upon the state of the cornea when the case comes under treatment. If this be uninvolved, the chances of recovery are favorable. Study of forty cases of ophthalmia neonatorum ; average duration of gonor- rhoeal cases, fifty-three days; average du- ration of non-gonorrha'al, thirty-six days. Francisco (N. Y. Eye and Ear Infirmary Reports., Jan., '95). Etiology. — The origin of the conta- gion is the morbid vaginal secretion, the infection, as a rule, occurring at the time of birth by some of the secretion of the vagina being transferred to the lids of the infant and being carried into the eye the first time that the child's eyes are opened. Twenty per cent, of all cases of blind- ness are found in youth, and, of these, 20 to 25 per cent, are caused by blen- norrhoea neonatorum. In 85 per cent, of these cases the afTcction begins within five days after birth, and, if immediately treated, 70 per cent, arc cured. Early corneal complications arc the gravest. Pflueger (Coitcs. fiir Schweizer Aerztc, Sept. 15, '95). Catarrh of the nc'vliorn duo to nitrate of silver studied. Results of 300 cases treated by CrcdC's method. In 4 out of 2- 100 there was no reaction, in 73 the secre- tion had disappeared entirely on the fifth day, in the others it lasted longer. Irri- tation was not caused so much by in- creasing the number of drops as by using it on successive days. .Small and ill- developed children are more sensitive to argentic nitrate than healthy ones. Catarrh for the first twenty-four hours is usually aseptic, and after that septic. Only 1 out of 300 cases had gonorrhoea! conjunctivitis. H. Cramer (Centralb. f. Gyniik., Mar. 4, '99). Prophylaxis. — The great aim should be the prevention of contagion during birth. If this be done there is no disease in which prophylactic measures are so efficacious and the results obtained so gratifying. Since the adoption by oph- thalmologists of adequate measures, the proportion of cases of ophthalmia ne- onatorum has been reduced from 7.5 per cent, to 0.5 per cent. Vaginal antisep- tics should be employed before labor. Immediately the child is born, the lids should be wiped with a piece of lint saturated in bichloride solution (1 to 8000). After the child has been washed, dur- ing which care should be taken that none of the water is permitted to gain access to the conjunctival sac, a drop of a 2-per- oent. solution of silver nitrate should be dropped into each eye. The solution of silver in this strength excites consid- erable irritation, and while its applica- tion should always be insisted upon in hospitals and the lilvc, in private practice, where no gonorrha?al contagion is sus- pected, the douche before labor and the cleansing of the lids by bichloride solu- tion, followed by a careful douching of the conjunctival cul-de-sac with boric acid will suffice. In making the applications the child should be laid on its back and its head placed between the knees of the physi- cian, while an assistant seated in front 19 290 COXJUNXTIVA. OPHTHALMIA NEONATORUM. TREATMENT. should hold its body in his lap and se- cure the hands. The lids should then be gently separated by pulling on the skin of the eyelids above the upper and below the lower tarsus, and complete eversion of both lids performed. Propensity of newborn infants to rub their eyes with their fists; source of con- tagion — face and hands, as well as eyes — to be cleansed at birth. Ayers (Amer. Jour. Med. Sci., June, '95). Theory advanced in favor of the method of Crede, that of direct inoculation of the eyes of infants by the vaginal secre- tions, opposed. It is contended that the lids are rolled inward to cover and pro- tect the eyes until after birth, and that when they are opened the portions hav- ing any secretion from the vagina upon them are remote from the edges of the lids. Merely rendering the lids antiseptic is enough; instillation of silver solution is not prophylactic. A piece of cotton dipped in 1 to 100 mercury cyanide should be applied over the lids to dis- infect thoroughly before bathing, and should be repeated after the eyes have been washed. De Wecker (Jour, de Clin, et de Ther. Inf., No. 42, '99). The douche fulfills the requirements of cleanliness, which are so essential. Critical case referred to which recovered under systematic irrigations with the douche of a l-per-cent. solution of boric acid. In this and other cases the other well-known methods had been tried and failed. Holt (Jour. Amer. Med. Assoc, Jan. .5, 1901). Treatment. — The treatment is the same as has just been given under the gonorrhceal ophthalmia of adults, with the exception that the protection of the sound eye and the application of com- presses are not, as a rule, feasible. Gonorrliiual conjunctivitis in fifty- Bfven newborn infants treated with calomel. The gonococcus of Neisser was found in the discharge in all the cases. The conjunctival mucous membrane hav- ing been syringed with a 2-pcr-cent. solu- tion of boric acid, and well dried witli absorbent cotton, was dusted with calo- mel. One day after the first application the discharge and swelling of the mucous membrane diminished, even in severe cases. Sometimes the dusting had to be repeated two or three times. The treat- ment lasted only for a week, and in neglected cases of long standing not more than a fortnight. The results were very satisfactory. Pukalof (Wratch, No. 27, '97). In purulent ophthalmia in the newborn the lids are first cleansed, then I-per-cent. to 2-per-cent. solution of copper sulphate applied; 5-per-cent. ichthyol salve is to be used three times daily. Elze (Woch. f. Therap. u. Hyg. d. Auges., Nov. II, '98). Silver-nitrate solutions should only be used in the later stages of the disease, after the intense swelling of the eyelids has begun to subside and the discharge is more purulent. A 2-per-cent. solution may then be applied to the conjunctival surface and neutralized with salt solu- tion. Nothing, however, should take the place of the constant cleansing. Solutions of protargol seem less reliable than silver nitrate. The edges of the eyelids and the surrounding skin should be protected with vaselin. In patients who are in poor physical condition, the application of heat will often prove bet- ter than cold. If the cornea becomes hazy and a small ulcer forms, the irri- gation should be continued and a I-per- cent. atropine solution applied three times a day, with hot applications. In some cases of marginal ulceration solu- tion of eserine, '/^ grain to the ounce, may be used every four hours, but with care. In adults, if the disease has only afl'eeted one eye, the other eye should be at once protected by covering it with a small pad of absorbent cotton and gauze. C. II. Williams (Boston Med. and Surg. Jour., Feb. 7, 1901). The best resiilts, as shown by an ex- tensive investigation, were obtained wlion a 2-per-cent. solution of silver nit-rate was used immediately after birth, following the suggestion of CredS. Only 0.8.5 per cent, were affected with tlie disease when this solution was used. Almost equally as good results were ob- tained from a l-per-cent. solution of CONJUNCTIVA. GRANULAR CONJUNCTIVITIS. DEFINITION. 291 sublimate, but weaker solutions were attended by higher percentages of oph- thalmia. Furthermore, irritant effects from this drug are so rare that they are hardly worth considering, and substi- tutes for silver nitrate seem to be un- necessary. Recently protargol in 20- per-cent. solution has been employed with good results, and it is claimed that it is unirritating. In the treatment of this affection it is said that the stage in which a case of infantile ophthalmia is seen should be its worst stage. From the time when applications of a 2-per- cent, solution of silver nitrate once every twenty-four hours to the inner surface of the everted lids are begun the condition should commence to improve. Cold compresses are also useful. E. T. Collins (Practitioner, April, 1902). Notwithstanding the application of Crede's method there are still a large number of cases of blennorrhcea in the newborn. This method was applied to 902 children born in the clinic for women in Berlin, and 1.5 per cent, suffered from blennorrhcea. The clinic for diseases of women in Gottingen shows better results with Crede's method. In the period since 1888 there were 1917 births in which no single case of early blennorrhcea oc- curred, and only 3 of late infection, and all of these were slight. Gonorrhoea is a frequent disorder in the maternity; in a series of cases in which this infec- tion was carefully looked for it was found present in nearly 2.5 per cent. In no case did more than slight con- gestion of the conjunctiva follow the in- stillation of nitrate of silver, and this only when 2-per-cent. solution was used. When the method was first employed the stronger solution was used, but in the last 928 children a 1-per-cent. solu- tion was instilled. The most important point in the technique is to instill the solution as soon after the child is born as possible. If an hour has passed, it may be too late to prevent the infection. It is probable that the neglect of this latter precaution has led to the reported failures in other clinics. Hirsch (Klin- isches Jahrbuch, Bd. iii, H. 3, 1902). Granular Conjunctivitis (Trachoma, Egyptian Ophthalmia, Miliary Oph- thalmia) . Definition. — Granular conjunctivitis is an inflammation of the conjunctiva, characterized by the hypertrophy of the tissues and by the development of small pinkish prominences or granulations on the conjunctiva, the chief tendency of which is to undergo absorption and pro- duce serious cicatricial changes in the Uds. Although it was generally supposed that the disease was introduced into Europe from Egypt by Xapoleon's army in 179S, it was subsequently shown that the disease had actually been endemic in Europe several centuries before. Ex- cellent descriptions of the disease were recorded by the ancients, and measures adopted by them for its relief have come to light again in our own day under the form of the operation of scarification. Nevertheless, to Napoleon is due, in large measure, the propagation of the disease, for it was doubtless owed to the fre- quency with which his armies came in contact with those of other countries, as well as with the ci-vil population, that the disease spread so rapidly during the first part of the present century. The Jews, the Irish, the inhabitants of the East, and the Xorth American In- dians are especially liable to the affection, while negroes are practically exempt. Geographically, the disease occurs more often in Arabia and Egj'pt, while western Europe is more exempt than eastern Europe. In the United States it affects those dwelling in tenement- houses, and is associated with unhygienic surroundings in large cities. It prevails in the Western prairies, and is found scattered widely over the country. High altitudes seem to render a certain im- munitv to the disease. 292 COXJU^'CTIVA. GRAXULAE COJTJXINCTIVITIS. SYMPTOMS. Verification of the law established by Chibret concerning the immunity given by a high altitude. A certain elevation above the sea-level offers the best con- ditions for cure, but there is no abso- lute immunity. Sattler (Kevue G6n. d'Ophtal., Aug., '90). In the City of Mexico trachoma is very rare. The hygienic conditions of the lower classes being of the very worst, it is the altitude of the city (6000 feet) that renders it free from this pernicious disease. Race has nothing to do with the question, as there are many foreigners living in the city who are alike free from any visitation of the inflammation. Chacon (Gaeeta Medica de Mexico, June 1, '92). Symptoms. — There is a great difEer- ence in the symptoms, not only on ac- count of the intensity of the changes, but also from the rapidity of the course of the disease. The signs of irritation are greater, the quicker the course of the disease. Usually, the irritation symp- toms are only moderate, but slight pho- tophobia, lacrymation, and pain being complained of. Xot seldom the disease is so insidious that the subject does not know of its existence, the disturbance in vision due to corneal complication giving the first indication. This is especially the case when the disease occurs in eleomoscenary acute trachoma. Here the disease begins with marked inflammatory symptoms; the lids are cedematous, the conjunctiva swollen, and there is a rich secretion of pus. Granular conjunctivitis may occur in either an acute or chronic form, accord- ing as it is or is not attended by the signs of acute inflammation. Acute Granular Conjunclivilis {Papil- lary Trachoma ; Chronic Blcnnorrhaa). — This is rare in this country and should be difTerentiated from the violent ex- acerbations to which the chronic forms of the malady are liable. In this variety there are all the signs of purulent con- junctivitis, with the development of th€ granulations. The lids swell and the conjunctiva, both bulbar and palpebral, becomes injected. The papilla are en- larged, and the characteristic granula- tions are about the size of the head of a pin, and are situated, for the most part, in the retrotarsal folds — chiefly the up- per. They are also found scattered throughout the conjunctival membrane. At first, lacrymation is usually marked, but, later, considerable dis- charge appears, and superficial ulcers form at the limbus. After several weeks the disease gradu- ally subsides, usually leaving some cica- trices in the lids to indicate its presence, although in other cases, after the ab- sorption of the granulations, the mucous membrane may be quite smooth. If the inflammation be but slight and not sufficient to absorb the granulations, the process may run into the chronic form. Chronic granular conjunctivitis is usu- ally primary, but it may be due at times to the imperfect disappearance of the acute granulations. The constant factor in this variety of trachoma is the tra- choma-follicle, as it exists in all of the different degrees in which these condi- tions are met with. The development of chronic granular conjunctivitis is often very insidious. Usually, at first, marked lacrymation is present, although there is but little secre- tion. If the cornea has become vascular, photophobia may be a most distressing symptom. The lids are swelled, and, upon their eversion, the characteristic granulations spring into view. They re- semble sago-like prominences arranged in parallel rows, and are found in the superficial layers of the conjunctiva, es- pecially in the fornix. Rarely a few CONJUNCTIVA. GRANULAR CONJUNCTIVITIS. COMPLICATIONS. 293 smaller isolated granules will be seen on the bulbar conjunctiva. At first they are found in the lower cul-de-sac, but the upper cul-de-sac is soon affected and shows the greatest development of the follicles. After a few weeks or months the gran- ulations give rise to a more or less active vascular reaction, attended with swell- ing of the papillae and a muco-purulent discharge. The papillas may become so large that they may obscure the granula- tions. Occasionally the granulations be- come absorbed, but in the majority of cases fresh eruptions of follicles present themselves during the period of regress- ive inflammation and go through the same changes as their predecessors. After a certain duration, grayish lines of fibrous tissue make their appearance, and the final stage of cicatrization be- gins. As a result of this, dense scar-tis- sue forms; this exerts traction upon the tarsus — already softened by the pre-exist- ing disease — and produces the deform- ities of the lids so characteristic of the affection. Complications. — The corneal compli- cation may take the form of pannus or of ulceration. Pannus consists in the formation of a vascular tissue of neoformation on the cornea, which begins at the limbus and invades the centre. At the location of the pannus the surface of the cornea is uneven and roughened, and there is a superficial gray and transparent haze, which is infiltrated by numerous vessels; these originate from the blood-vessels of the conjunctiva. The pannus usually be- gins in the upper part of the cornea and frequently stops below, in a sharp, straight, horizontal border-line. Later, it may develop at other parts of the limbus; so that the entire cornea may become covered. Vision is affected as soon as the pannus reaches the pupil, which, if the cornea be entirely covered, may be reduced to light-perception. 'WTien ulceration occurs, it is either at the edge of the pannus or upon a portion of the cornea which had hitherto been uninvolved. It usually occasions great photophobia and lacrymation. The hypertrophy of the conjunctiva increases until the diseased process has run its course, w^hen it begins to shrink, and is replaced by cicatricial tissue, with all its attendant evil consequences to the normal contour and function of the lids. The degree of cicatrization depends upon the severity of the early stages of the disease. The beginning of the scar-formation shows itself in the tarsal conjunctiva, narrow, whitish lines permeating the lat- ter. These lines become more numerous and form a fine net-work, which gradu- ally spreads; the conjunctiva included within the meshes becomes attenuated, until quite smooth and white. The hypertrophied conjunctiva in the fornix gradually shrinks, becoming shorter, and the folds of the conjunctiva in that location disappear. This is known as symhlepharon posterior. In ex- treme cases the cul-de-sacs are reduced to shallow fissures between the lid and the globe. The lids become distorted, through the cicatricial changes in the cornea and tarsus, the latter participat- ing in the inflammation, as well as the conjunctiva. It becomes much hyper- trophied, especially along its lower mar- gin, where the conjunctival vessels per- forate it. It is especially in this position that the shrinking of the conjunctiva, which follows later, makes itself most felt, and is the main factor in the pro- duction of the bow-like distortion of the lids, produced by trachoma. The cilia no longer occupy their normal position, 294 COXJUXCTIVA. GKAXULAK CONJUNCTIVITIS. ETIOLOGY. but become displaced, and cause great irritation by being brought in contact with the cornea. This irritation is further augmented if the shrinkage of the tarsus continues, cjnd entropion is produced. Ectropion, of the lower lid especially, may also be originated, due to the con- traction of the orbicularis and exerted upon the lids — already prone to ever- sion by the swelling of the conjunctiva. Xerosis of the conjunctiva occurs as a result of the cicatrices. The blood-sup- ply to the conjunctiva is shut off and its epithelium undergoes fatty degenera- tion. The surface of the membrane then becomes dry and smooth and almost leathery, and the corneal epithelium also becomes thicker and its transparency much interfered with. The eye finally becomes blind and a source of continued annoyance, by reason of the constant sensation of local drj-ness experienced. The pannus may clear up entirely, leaving a normal cornea beneath. If there be ulceration, however, opacities remain, which disturb vision according to the extent to which they involve the pupillary area of the cornea. Fre- quently, as a result of pannus, there occurs a connective-tissue metamorpho- sis, which greatly interferes with the transparency of the cornea. Another re- sult of pannus sometimes is a bulging, or staphylomatous, condition of the cor- nea, the tissues of which have become so altered that they give way before the normal intra-ocular tension. Etiolo^. — In general, the disease may be said to arise from poor hygienic conditions. It develops in institutions where the inmates are crowded together, in armies, orphan-asylums, almshouses, and the like. It is probable that the so- called lymphatic or scrofulous tempera- ment predispose toward it, although the disease may attack those in perfect health. Trachoma always arises through in- fection from another eye already in- fected, by means of the secretion; only under exceptional circumstances, when the air is heavily charged with the poison, can it be the medium of com- munication of the disease. The in- fectious nature of the secretion is doubt- less due to micro-organisms; but, while numerous bacteria are found in the secre- tion, gonococci, streptococci, etc., the specific germ has not yet been isolated. Etiological factor in acute contagious conjunctivitis a small, unknown bacillus. Weeks (N. Y. Eye and Ear Infirmary Reports, Jan., '95). It is always contagious, — frequently epidemic. The symptoms, which vary in severity, begin two or three days after infection, with gluing together of the eyelids on awakening in the morning, and small, yellowish masses at the base of the lashes. There is increased lacryma- tion, congestion, and turbid discharge. It usually begins first in one eye, but affects both in its course. There are burning pains and the sense of a foreign body; the lids are swelled and discol- ored; and the eyeball is of a rosy tint, which has given the affection the name of "pink-eye." The symptoms continue to increase for two or three days, and frequently a slight coryza arises. Victor Morax and G. W. Beach (Archives of Ophth., vol. XXV, No. 1, '97). Nine thousand one hundred and sixty- si.x cases of trachoma (1500 of which were complicated with corneal affections) ex- amined to discover whether there is any accountable pathogenic microbe or not. It was concluded that there is none, but that the morbid entity of trachoma has an histology which is characteristic and absolutely different from that of follicu- lar conjunctivitis. Lessening the alka- linity of the lacryma! secretion tends to the acquisition of conjunctival diseases. V. L. Matkovic (Rec. d'Ophtal., Feb., '98). Trachoma is due to encapsulated diplo- eoccus, 1 'A to 2 millinif'trus in Iciiglli CONJUNCTIVA. GRANULAR CONJUNCTIVITIS. TREATMENT. ■Zd5 and 5 niillimetres in breadth, which \s not decolorized by the Gram method of staining, and wliose septum at times has an affinity for aniline stains, causing the diplococcus to simulate bacillus. This organism is constantly present in the trachoma-follicle and secretions, before astringent and antiseptic remedies have been employed. E. F. Syndecker (Jour. Med. and Surg., Apr., '99). A thorough inspection of 36 public schools in New York in July of last year showed that, of 57,450 children ex- amined, GG90 were found to have some form of contagious eye disease. Of these, 2328 were severe trachoma, 3243 were mild trachoma, and 1099 acute purulent conjunctivitis. A large num- ber of cases were excluded from the schools, and there was a coincident in- crease in the number of trachoma cases treated in the New York eye hospitals. The question of the contagiousness of trachoma is still unsettled. It is prob- able that children suffering from eye diseases of this class should be excluded from the schools until the condition has been cured. Lambert (Med. Record, Feb. 21, 1903). As the secretion alone causes the in- fection, therefore, the danger of in- fection depends upon the strength of the secretion; the richer this is, the greater will the danger be to surround- ing persons. The transfer of secretion from one eye to another is usually accomplished by the fingers or toilet articles which are brought into contact with the eyes, as handkerchiefs, towels, sponges, etc. This is more apt to happen when num- bers are crowded together and are likely to use these articles in common. Pathology. — In trachoma we see an excessive degree of development of the papilliE of the mucous membrane and the formation of the granulations. Jlicro- scopically, the granulations may have an imperfect capsule or may have no cap- sule, but they seem to grow from, or in, the stroma of the conjunctiva. In the acute form the granulations consist of lymph-cells alone. They are to be re- garded as new growths in the conjunc- tiva, and, in addition to the lymphoid cells, the mass of cells and connective tissue is penetrated by blood-vessels. The chronic granulations consist of lymph-cells toward the surface, but their bases are formed chiefly of connective tissue. Gradually the cellular elements are transformed into connective tissue, and in this way cicatricial degeneration of the conjunctiva is brought about at each spot where a granulation was seated. The development of the papillae is not characteristic of trachoma, for it is pres- ent in moderate degree in every lasting inflammation of the conjunctiva, as in chronic catarrh, vernal and follicular catarrh, and purulent conjunctivitis. Prognosis. — Acute granular conjunc- tivitis, or trachoma, is characterized by its chronicity and by the serious conse- quences to vision; this, added to its con- tagiousness, makes it one of the most dreaded of eye diseases. Relapses occur frequently and persistently and may occasion all of the intense inflammatory symptoms of acute granulations. Its great danger lies in its contagiousness and the great rapidity with which it spreads through schools or any institu- tions where large numbers of inmates are gathered together, by the careless use of towels and common utensils. The prog- nosis is. therefore, always grave, and de- mands the adoption of great precautions to prevent a disastrous epidemic. Treatment. — Prophylaxis is obviously of the greatest importance, and, as the conspicuously-dangerous element is the secretion, cleanliness, adequate air-space, and proper ventilation of the sleeping- rooms must be insisted upon in all 296 COXJUXCTIVA. GRANULAR CONJUNCTIVITIS. TREATMENT. crowded institutions. Every patient should be provided with liis own basin and towel, or, better still, should be re- quired to wash under "running water." When the disease is once established, rigorous isolation of all those afflicted should be practiced. The chief aim of the treatment must be to check the development of the hy- pertrophy of the conjunctiva, and bring about absorption of the granulations in order to prevent the destruction of the mucous membrane, and to reduce the pre- vious results of the disease to a mini- mum. In the early stages, frequent washings of the conjunctiva with a 10-grain solu- tion of boric acid and bichloride solu- tions should be employed; especially is this true of acute granulations. If there be much pain and photophobia and some haze of the cornea, atropine should be instilled in conjunction with the cleans- ing lotions. A nitrate-of-silver solution should be employed so soon as the dis- charge becomes marked, in the same manner and to meet the same indications as already described in the treatment of other forms of conjunctivitis. Perfect rest indicated for trachomatous eyes. Instillations of atropine, together with use of bandages or cataract shields during the day, are of value. Before bandaging a weak iodoform ointment may be applied to conjunctivte and lids. At night the protection should be re- moved and the patient kept in the dark. Properly-fitting glasses sliould be used when the eyes are not at rest. Massage practiced every week or so by rubbing the granulations lightly with a strabis- mus-hook. N. B. Jenkins (N. Y. Med. Jour., May 19, 1900). The treatment of chronic granular conjunctivitis in the early stages must be non-irritating; but, so soon as the discharge becomes marked, silver nitrate becomes the sovereign remedy. When the acute stage has moderated and the discharge is less marked, the silver salt should be replaced by other caustics: copper, alum, zinc, etc. These drugs must be continued months and perhaps even years, until every trace of hyper- trophy has gone and the conjunctiva has become perfectly smooth and clean. The nitrate-of-silver solution should be applied but once daily, and at times when there are marked signs of irrita- tion, must be wholly withdrawn for a few days, while these are combated with atro- pine and milder antiseptics. The prognosis is quite favorable. It should be treated by applications of ni- trate of silver of the strength of 1 to 40 or 1 to 50, weaker solutions being less effective. The bacilli found were de- void of movement. Inoculation of a cult- ure on the human conjunctiva produced a typical attack. Victor Morax and G. W. Beach (Arch, of Ophthal., vol. xxv, No. 1). As it is necessary that the local treat- ment shall be continued for such a long time during the stage of cicatrization, to prevent relapses, an ointment of 1 grain of tannin to 1 drachm of vaselin may be ordered and may be applied by the pa- tient himself. Copper may be applied in the same strength. After an experience with 3000 cases of trachoma the medicinal management of trachoma is advocated, surgery being re- served for those cases (probably 40 per cent.) rebellious to medicines. II. Kuhnt (Klin. Monats. f. Augcnh., Mar., '98). In trachoma iodine dissolved in a petroleum preparation, as recommended by NesnamofT, is of value. Slight cases of granular lids may be cured in two or three weeks, while severe cases may re- quire as many months, but the pannua begins to improve markedly in the first week or two. For mild cases the 1-per- cent, solution is applied every other day; in more severe cases a 2-per-cent. solu- licin. IT. 11. Seabrook (N. Y. Kye and E;ir Tiifiimary Reports, Jan., 1900). CONJUNCTIVA. GRANULAR CONJUNCTIVITIS. TREATMENT. 297 Tlie writer poiiitdl out some years ago that the essentials of any treatment likely to prove effective were fairly well afforded by ichthyol. These essentials he laid down thus: The application must constrict the dilated vessels, re- move the infiltration and thickening of the conjunctiva, and alleviate the vari- ous subjective symptoms, particularly the pain, the lacrymation, and the pho- tophobia. He found that ichthyolate of ammonia, in 50-per-cent. solution, met these requirements better than any other application he had yet employed. Jacovides also, and Darier, have spoken highly of ichthyol in trachoma. The latter used it undiluted; but this does not seem to be a wise example to fol- low. The former employed the drug in a great number of different affections of conjunctiva and cornea, and found that its action on the pannus of trachoma was specially marked and beneficial. Denti, too, used ichthyol in trachoma. In his experience the aeuter forms were much more favorably influenced by it than the more chronic; its action was specially valuable in cases showing su- perficial ulceration along with pannus. Bialetti speaks strongly in favor of a lotion of ichthyol (50 per cent.) painted on the everted upper lid and then washed off with distilled water. The first effect of application is a slight burning sensation, which quickly passes off, and is succeeded by relief from pho- tophobia, blepharospasm, and pain, and this relief is not merely transitory. The vessels of the pannus shrivel up under its use, and the corneal opacity clcai-3. Eberson (Clin. Ocul., Palermo, June, 1901 ; Edinburgh Jled. Jour., June. 1002). Copper citrate does not cure tra- choma more quickly than other non- operative methods. It produces ab- sorption and disappearance of granula- tions and hyportrophied papilUis quiti> as rapidly as other applications. It produces less irritation in the lids; less pain and discomfort to the patient. Important, and a corollary to its al- most painlessness, patients will use it regularly in homo treatment. The remedy is host applied in the form of a 5-per-cent. to 10-per-cent. ointment of which white vaselin ia the base. Wright (Jour. Amer. Med. Assoc., Aug. 8, 1903). Numerous surgical procedures have been proposed for the excision of the granulations, and some observers advise the excision of the entire fornix of the conjunctiva. It is probable, however, that the resultant cicatrices cause more mischief than those which would result if the disease were allowed to take its course. This form of treatment has, therefore, met with but little favor from the more conservative clinicians. A less harmful method, and one which is frequently employed by the ophthal- mologists of this country at least, con- sists in the expression of the granula- tions by means of forceps. Knapp has devised a roller-forceps especially for this purpose. The reaction following this procedure is at times quite severe; so that it is advisable to employ ice-com- presses for some time afterward; to pre- vent a recurrence of the granulations it is always well to follow the expression by applications of silver nitrate. The amount of benefit obtained from the expression method is, in general, pro- portioned to the quantity of exudate in and beneath the conjunctiva; where there had been a considerable amount of exudation, the cure is immediate and apparently permanent. Jackson (Med. and Surg. Reporter, Aug. 20, '92). [a) In the first stage of trachoma the most efficient mode of surgical interfer- ence is that of expression, combined with superficial scarification and the introduc- tion of a germicide by the use of a brush. (6) In the second stage, where surgical interference is advisable, the treatment known as "grattage" should be combined with expression in some cases. Can- thotomy or canthoplasty, if necessary, gives the most satisfactory results, (e) The operations, as above advised, con- vert a contagious into a non-contagious condition, and the patient may be ad- 298 COXJU>"CTIVA. GKAXULAR C0^■JU^XTIVIT1S. TREATMENT. mitted to wards for ordinaiy surgical cases without fear of infection. Weeks (Jour. Amer. Med. Assoc, Sept. 3, '92). The procedure of Darier and Abadie used in seventir-five cases; but one grave complication resulting from its use wit- nessed: a case of total symblepharon due to neglect in the dressing. If a radical cure of the disease could be ob- tained by this method of treatment, the pain and great local reaction following the operation might be atoned for, but a single instance of permanent cure was never seen. Trousseau (Archives d'Oph- tal., Apr., '93). Conclusion from the results obtained by the treatment of two hundred cases: Rapid, perfect, and permanent recovery by expression alone, or expression fol- lowed by mild caustic treatment, takes place in the majority of cases, especially of the purely follicular type. Imperfect recovery — i.e., disappearance of tra- choma, leaving more or less shrinkage of the conjunctiva — results, as a rule, in old neglected cases of inflammatory tra- choma. Relapses that are cured by a second or third operation occur in both the simple and inflammatory forms. The operation itself has never injured an eye. Knapp (Archives of Ophthal., Jan., '93). Study of 101 cases of trachoma; ex- pression-treatment as practiced with Knapp's roller-forceps favored. U. Hell- gren (Mittheil. a. d. Augen. d. Carolin. mcd.-chir. Inst., Stockholm, '98). The greatest emphasis must be laid upon tlie necessity of placing the sub- jects under the best hygienic conditions. In the ease of patients confined to hos- pitals, asylums, etc., the utmost pains should be taken to secure good ventila- tion, nourishing food, and perfect clean- liness, personal as well as general. When pannus has occurred and the thickening of the conjunctiva subsides, the corneal disease will usually abate pari passu; so that the treatment of pannus and of ulcers of the cornea re- solves itself into that of the conjunctiva. Atropine should be instilled to combat any existing iritis. If the pannus is unusually dense and is partly made up of connective tissue, further absorption may be obtained by exciting a violent inflammation of the conjunctiva. An infusion of jequirity is frequently employed for this purpose. This is prepared by steeping the ground jequirity-bean for twenty-four hours in cold water. With this infusion, the con- junctiva of the everted lids is painted thoroughly two or three times daily. A croupo-purulent conjunctivitis is excited and is combated in the same manner as already described under this disease. When the inflammation has run its course, the cornea is frequently found to have regained, in a measure, its former transparency. Jequirity beneficial in those eases of granular conjunctivitis where there is superficial vascularity of the cornea. Also used the drug with advantage in the fibrous condition which often follows. Emerson (N. Y. Med. Jour., Feb. 11, '93). Pannus successfully treated with anti- pyrjne. As the insufflations are painful, cocaine should be used at first, and ap- plication made daily or every third day, according to the gravity of the case and the efi'eet desired. The violent reaction that follows should be treated by fre- quently-changed, hot, antiseptic com- presses. This method is not applicable to symptomatic pannus, in which the primary condition should be first reme- died. Vigncs (Rccueil d'Ophtal., Aug., '92). The operations of peritomy, which consists in the destruction of the vessels supplying the pannus, has also been much vaunted for the cure of this condi- tion. After a ring of conjunctival tissue about five millimetres from the margin of the cornea is excised by scissors, the underlying connective tissue is dissected off the sclera, which is then laid bare. Xerosis admits of palliation only by CONJUNCTIVA. PHLYCTENULAR CONJUNCTIVITIS. SYMPTOMS. 299 emollients — such as glycerin, olive-oil, or vaselin — applied freely several times daily. The distortion of the lids, with the resultant trichiasis and entropion and ectropion which it occasions, only yields to operative measures. Phlyctenular Conjunctivitis (Lym- phatic, or Strumous, Conjunctivitis). Definition. — Phlyctenular conjunctivi- tis is a frequent form of inflammation of the conjunctiva characterized by the eruption of one or more grayish eleva- tions or phlyctenuliE on the bulbar con- junctiva. It usually occurs in scrofulous children under ten years of age. Symptoms. — Children suffering from this disease have the characteristic stru- mous appearance. They are either pale and thin or bloated and flabby. The cervical lymphatics are enlarged and the nose and upper lip tumefied. There is a moist, eczematous eruption on the face and constant watering of the eyes and nose. Otorrhcea is frequent. A dis- tressing symptom — intense fear of light and blepharospasm, due to the corneal involvement, which occurs in most cases of phlyctenular conjunctivitis — com- pletes a clinical picture which renders an examination of the eyes almost su- perfluous. An inspection of the eye, however, will reveal the presence of phlyctenule. These appear as minute red eminences, either alone or in numbers. In the lat- ter case they are situated on the limbus of the conjunctiva and resemble grains of fine sand. In the simple, or solitary, variety the injection of the blood-vessels is localized immediately around each phlyctenule; but in the multiple, or miliary, variety the conjunctival injection is general and is usually quite marked. In the latter variety there is also much photophobia and lacrymation and rarely some dis- charge. Usually there is an eruption of these phlyctenule on the cornea as well. This is always accompanied by an increase in the photophobia and lacrj-- mation and adds greatly to the gravity of the disease. Etiology. — Phlyctenular conjunctivi- tis occurs chiefly among the poorer classes, and is fostered by the improper and insufficient nourishment which they receive and by their damp and unhy- gienic surroundings. It may be found, however, in children, otherwise healthy, whose vitality has been depressed by febrile disturbances, such as measles, whooping-cough, scarlet fever, and the like. The disease rarely occurs in adults, and only when a tendency toward this disease was manifested in youth. Emphasis upon the relationship exist- ing between phlyctenular diseases of the cornea and conjunctivitis and general malnutrition. Wallace (University Med. Mag., Apr., •92). Scrofula is the causative factor in 95 per cent, of all plilyctenular diseases of the conjunctiva. Baas (Woch. f. Therap. u. Hyg. d. Auges., Sept. 29, '98). Strumous diathesis present in 90 per cent, of 200 cases of phlyctenular con- junctivitis. It is a most important and perhaps a necessary factor. Phlyctenules are, however, not a local tuberculous process, since animals cannot be inocu- lated with tubercle for them. Axenfeld ("Bericht iiber die xxvi Vcrsammhing der Ophthal. Gesellschs. zu Heidelberg"; Med. and Surg. Reviews of Reviews, Dec, •ns). Pathology. — A phlyctenule consists of an accumulation of l3Tnphoid cells packed closely together around a nerve- filament, just beneath the epithelium of the conjunctiva or cornea. Soon after its formation the apex of the mass be- gins to undergo softening and liquefac- tion. The epithelial covering is thrown off and a shallow ulcer remains. The 300 COXJUXCTIVA. CROUPOUS CONJUNCTIVITIS. softening process continues, the epithe- liiun dips down into the ulcer, and heal- ing occurs in ten to fourteen days. After a time, however, a fresh out- break of these small grayish nodules occurs; so that the disease may extend over months and at times years, until the age of puberty is attained, when the eye seems to become protected against fur- ther attacks. In consequence of the corneal involve- ment, which is usually associated with phlyctenular conjunctivitis, there is al- ways a greater or less degree of cloudi- ness of that membrane; so that vision is interfered with and the patient rendered incapable of fine work. The scars left upon the cornea are often unsightly. Treatment. — This must be directed, in the first place, toward the improvement of the general condition. Notwithstand- ing the photophobia, open-air exercise should be positively enjoined, as it is absolutely essential for the well-being of the child. All bandages should be re- moved, the eyes being protected by tinted glasses or a generous shade. The skin should be rendered more active by cold or salt baths, followed by brisk rubbing. The nourishment should be strengthening and administered at regu- lar intervals. No feeding should be per- mitted between meals; all sweets and pastry should be prohibited, while milk, fresh eggs, red meat (once daily), and proper fruits should represent the bulk of the diet recommended. Internally, calomel is of value to im- prove the state of the mucous membrane of the alimentary tract; codliver-oil, syrup of the iodide of iron, syrup of the phosphate of lime, and arsenic may also be administered with advantage. If seen in the early Btageo, it is ad- visable to avoid all external irritants by the use of smoked glasses. Gorecki (Le Praticien, May 20, '90). Locally, any existing blepharitis or eczematous eruption about the eye should be combated with white-precipi- tate ointment (1 to 2 per cent.) and with silver nitrate, after the removal of all crusts with a simple soda solution. In the simple form, where there is but little irritation, calomel should be dusted into the eye once daily. This drug combines with the tears, and forms a weak solution of bichloride of mercury, which exerts a most beneficial action upon the conjunctiva. Care, however, must be observed that iodine is not being administered internally at the same time with the calomel, for the latter in this event forms with the iodine an iodide of mercury which is very irritating to the eye. A salve of the yellow oxide of mer- cury may be substituted for the calomel in many cases with great advantage. In the miliary variety, or when there is recent corneal involvement with signs of active irritation, these drugs, which are irritating, should not be applied. In these cases the eyes should be kept clean with frequent washings with boric acid, and atropine should be instilled at regular intervals. The photophobia and blepharospasm usually subside with the improvement in the conjunctival condition. Should it be very distressing, however, much relief may be had by cold baths or from im- mersions of the child's head in a basin of cold water. Croupous Conjunctivitis. Definition. — Croupous conjunctivitis is a catarrhal inflammation of tlie con- junctiva in which, owing to the intensity of the inflammation, there is formation of a plastic exudate upon the conjunc- tival surfaces. CONJUN'CTIVA. CROUPOUS CONJUNCTIVITIS. SYMPTOMS. 301 Symptoms. — It usually begins with the symptoms of an acute catarrh, but soon attains a severity not witnessed in ordi- nary catarrh. The lids become oedema- tous, the conjunctiva much reddened and swelled, especially in the forni.x, and a discharge, at first sero-purulent but later muco-purulent, appears. The tarsal mu- cous membrane and retrotarsal folds be- come covered with a grayish-white mem- brane, the bulbar conjunctiva being but rarely involved. The pseudomembrane can be stripped off, disclosing a raw and perhaps bleeding mucous surface be- neath, which serves to distinguish it from the diphtheritic variety. The pseudomembrane usually disap- pears after two weeks; the conjunctiva and lids reassume their normal appear- ance and the signs of an ordinary ca- tarrhal conjunctivitis reappear. There are no resultant cicatrices and vision is but seldom affected, the cornea being only involved when the false membrane spreads to the bulbar conjunctiva, which is of rare occurrence. Diagnosis. — The main affections from which croupous conjunctivitis are to be differentiated are diphtheritic conjunc- tivitis and ophthalmia neonatorum. Diphtheritic Conjunctivitis. — In- stead of being limited to the surface of the conjunctiva, the membrane in diph- theritic conjunctivitis involves its deeper layers. The lids are hard and the bulbar conjunctiva is involved, and there is fre- quent corneal ulceration. The diagnosis of diphtheritic conjunc- tivitis must rest upon the presence of pure diphtheria bacilli. There are whit- ish conjunctival patches containing dusky hffniorrhnges, enlargement of pre-auricu- lar glands, coincident diphtheria of the fauces, and subsequent loss of knee-jerks, or the occurrence of paresis or paralysis. S. Steplienson (l^rit. >red. Jour., June IS, •98). Fatal case of diplitlieria of the con- junctiva in an infant 11 months old wliieh was wasted and had evidently been neglected. A bacteriological ex- amination showed the Klebs-Loefller bacillus. Diphtheria of the conjunctiva is far from rare in London. Of 3412 eye patients seen at two hospitals for children there were 43 instances of the disease. Nearly two-thirds of the cases were met with in children under 3 years of age. The cases were most frequent during the period when ordinary diph- theria was rife. Three only of the en- tire number belong to the severe types of the disease. A significant fact in the case described is that the patient died from a toxajmia due to conjunctival diphtheria alone, as no membrane could be found in the nose, mouth, or fauces, ilost of the fatal cases so far reported have had involvement of the nose, throat, and eyes. S. Stephenson (The Ophthalmoscope, Aug., 1904). Ophthalmia NEONATORUii. — In this disease, purulent conjunctivitis, the dis- charge is much more copious and puru- lent. Pseudomembranous conjunctivitis is never found among the newborn. Pathology. — The local inflammation must be regarded as a severe form of catarrh only, in which, owing to the in- tensity of the inflammatory process, the secretion is richer in fibrin and more prone to coagulation. Various grades of this plastic quality appear. In light cases it may manifest itself as a simple condensation of the secretion, flakes of fibrin forming, which can be readily washed off of the conjunctiva. In some cases, however, the exudate has the tenacity of a true diphtheritic mem- brane. Case of chronic membranous conjunc- tivitis. A boy, 8 years old, had been under obser\'ation for eighteen months, with a thick, firmly-attached, yellowish- white membrane covering the conjunc- tiva of the upper lid. Treatment had exerted but little influence upon the membrane, although it was then becom- 302 COXJOsXTIVA. CROUPOUS COXJUXCTIVITIS. TEEATilEXT. ing thinner. The eyeball had not been seriously damaged. But at one time in its course there had been a severe ex- acerbation of the disease in the eye, with soreness of the tnroat and patches of similar membrane on the tonsils, and rise of temperature. Two children that he came in contact with in the same ward at this time developed diphtheria and died. A sister of this boy had presented a similar chronic membranous conjunc- tivitis. After it had lasted nearly a year and a half she developed scarlatina with diphtheritic patches in the throat. This Pathology of chronic membranous conjuncti- vitis. {Boice.) was accompanied by aggravation of the eye-symptoms, and necrosis of the cornea, with loss of useful vision in both eyes. Although both these cases were care- fully studied bacteriologically, and many micro-organisms discovered, the Klebs- LoefHer bacillus was present in each case only during the e.xaeerbation, and not at any other time. (See illustration.) Lucien Howe (Trans. Amer. Ophth. Soc, '97). In making a positive diagnosis of diphtheritic conjunctivitis the microscope does not aid very much. The xerosis bacillus gives exactly the same reaction to the stain that the Klebs-Loeffler bacillus does; it looks the same under the microscope, and without clinical symptoms is of no significance wliatevcr. The one fact which settles the diagnosis is the inoculation of rabbits or guinea- pigs, because there is no reaction to the xerosis bacillus and there is to the diphtheria bacillus. Pinckard (Ophthal- mic Record, Aug., '99). Ophthalmia from infection with the diphtheria bacillus is not rare in London. At the Xortheastem Hospital for Chil- dren about 2 per cent, of all cases are of this nature. Stephenson (Lancet, Feb. 17, 1900). Etiology. — Croupous conjunctivitis is a disease of childhood, and usually de- velops at first dentition. Its causal fac- tors are the same as those of catarrh, but certain pyrexias, particularly measles and pseudomembranous vulvitis, pre- dispose to it. It may be associated with croup of the larynx, trachea, and bron- chial tubes. Treatment. — Hot-water compresses should be applied night and day until the pseudomembrane is removed. The general health should be seen to, and purgatives administered to produce watery evacuations. All caustics and irritants should be avoided so long as the pseudomembrane is present, but the eye should frequently be washed with bichloride-of-mercury (1 to 5000), boric- acid, chlorate-of-potash, or chloride-of- sodium lotions. As soon as the stage of acute catarrh sets in, the treatment should be the same as in acute conjunc- tivitis. Instances of croupous conjunctivitis that was complicated by disease of the entire cornea, an abscess involving the lower half of this latter membrane. The usual treatment failing to arrest the progress of the disease, a dressing of aristol was applied. Tliis was followed in a short time by the most favorable results. Eliasberg (Archives d'Ophtal., Feb., '93). Irritating remedies, especially silver ni- trate, liariiiful in pseudomembranous con- junctivitis. Valude (Archives d'Ophtal., Oct., '94). CONJUNCTIVA. DIPHTHERITIC CONJUNCTIVITIS. TREATMENT. 303 Case of pseudomembranous conjuncti- vitis in newborn child, due to strepto- coccus, treated by Rou.k's serum; total loss of both corna?. Darier (Annales d'Oculislique, June, 'Do). Diphtheritic Conjunctivitis. Definition. — Diphtheritic conjuncti- vitis is an infrequent specific inflamma- tion of the conjunctiva, attended by the formation of a plastic exudate within the layers of the bulbar and tarsal mem- brane. Symptoms. — The exudation penetrates deeply into the tissue and causes its death, thereby destroying the nutrition of the cornea and causing subsequent loss of that membrane. The lids become hard, board-like, and tumefied. At first there is a scanty sero-purulent or sanious discharge, which is followed by a more purulent one as the disease progresses. The secretion is very contagious, and, if there be abrasions at the orifices of the mouth and nose, the membrane will quickly invade them. Patches of mem- brane are often found in the pharynx and nares. After the period of infiltration — which lasts from one to two weeks — has sub- sided, the membrane is thrown off, leav- ing a raw, granulated surface. At times the membrane may be absorbed. After a time vascularization sets in and the symptoms of an ordinary purulent con- junctivitis supervene. The termination of the process, however, is less favorable than in the catarrhal form, for during the period of cicatrization changes occur which cause atrophy and shrinking of the conjunctiva, and not infrequently occa- sions great deformation of the lids. Complications. — The chief complica- tion is corneal involvement, which oc- curs in the vast majority of the cases, and occasions the intense pain by which the disease is accompanied. As a rule, the cornea is affected earlv in the af- fection, either by ulceration or diffuse infiltration. Etiology. — The disease is of specific origin, and the constant presence of Loffier's bacillus has lead to the assump- tion of this germ being the causal factor in the diphtheritic process. Children between the ages of two and eight years are usually affected, both eyes being involved. The disease is rare in this country, but is not infrequent abroad, where it occurs in an epidemic form. The prognosis is decidedly grave on account of the tendency toward cor- neal involvement. Treatment. — In the first stage, when the lids are hard and board-like, and there is a necessity of limiting the amount of exudation, ice-compresses should be employed, but hot compresses are indicated as soon as the cornea shows signs of involvement. Treatment must be tentative. Mild antiseptic lotions should be employed to remove all secre- tions, either bichloride of mercury (1 to 8000) or potassium permanganate in 2- per-cent. solution. Silver nitrate is con- tra-indicated in the early stages, but may be utilized when the membrane comes away. Atropine should be in- stilled early on account of the tendency to corneal involvement. Great attention should be directed toward building up the general health. Mercury and quinine should be administered and stimulants ordered if the child shows signs of col- lapse. The isolation of the patients is necessary to prevent further contagion. Treatment by antitoxin of 25 cases of diphtheritic conjunctivitis occurring among SOOO cases of diphtheria at the Boston City Hospital. In nil these eases the Klebs-Loffler bacillus was present in the discharges from the nose. Eight cases were admitted for ocular diph- theria; the others were faucial diph- theria which had incidcntallv a mem- 304 COXJUXCTIVA. TUBERCtJLAK DISEASE. LUPUS. brace on the conjunctiva. All were treated with antitoxin, the first dose being 4000 units. Usually a second dose of like amount was given at the end of six or eight hours, and some had three or four injections. Such cases in twenty-four hours usually were doing well, and after forty-eight hours no more anxiety was felt for the eyes. In those cases in which there were corneal ulceration the antitoxin favorably af- fected the corneal lesion, and with the exception of 4 cases the patients left the hospital with good vision. In 1 of these 4 cases the cornea upon admission seemed to be wholly necrotic. Six months later there was considerable vision. An opaque scar occupied ap- proximately half the cornea. In the 3 other cases every cornea was lost. These 3 patients had diphtheritic infec- tion during an attack of measles. This probably accounted for the severity of the corneal process. M. Standish (Bos- ton Med. and Surg. Jour., Oct. 2, 1902). Tubercular Disease of the Conjunctiva. Symptoms. — Tubercular disease of the conjunctiva may be either present itself as a primary or a secondary manifesta- tion; in either event it is an extremely rare disease. In both varieties the dis- ease occurs in the form of small, yellow- ish-gray nodules on the palpebral con- junctiva. These break down and form ulcers with uneven and indurated edges. The floors of these ulcers have either a lardaceous appearance or are covered with grayish-red granulations. The con- junctiva is swelled and turgid, the lids are thickened, and there is considerable discharge. The bulbar conjunctiva and the cornea may become afTected, and in severe cases the ulcers on the palpebral conjunctiva may burrow down and in- volve the entire thickness of the lid. Although this gives a clinical picture which is almost characteristic, the diag- nosis may be verified by the discovery of the tubercle bacillus in tlie contents of the ulcers. Case of tubercle of the conjunctiva in a boy 15 years of age. The condition re- sembled that of trachoma; the mem- brane was greatly shrunken and the eye- ball was atrophic. ^Xicroscopical study showed giant-cells, but no bacilli. Rob- erts (Brit. Med. Jour., June 10, '93). Conjunctival tuberculosis may closely simulate trachoma. In one case a micro- scopical examination of a piece of the conjunctiva was necessary before an ex- act diagnosis could be made. H. Heiners- dorff (Klin. Monats. f. Augenh., Mar., ■9S). The disease usually affects but one eye and occurs almost witliout exception in the young. It manifests a great tend- ency to recur, and may become the start- ing-point of general tuberculosis. Etiology. — As a rule, tubercular con- junctivitis is a primary disease and orig- inates in a direct infection of the con- junctiva. When the disease occurs as a secondary manifestation, it is usually transmitted from the nasal or pharyngeal mucous membrane by means of the lacry- mal passages. Treatment. — This should consist in the removal of all the diseased structure if the process be localized, by the curette, knife, or galvanocautery; but, if the in- volvement of the ocular structure be dis- seminated, enucleation should be in- stantly performed. Case of undoubted primary tubercu- losis of the palpebral conjunctiva, veri- fied by the finding of a few Koch bacilli. Tlie eye in other respects remained un- involved. The palpebral ulceration was treated and cured by frequent application of silver nitrate, bathing with saturated solution of potassium chlorate, and cu- rettage. The patient died, two years later, from laryngeal and pulmonary phthinis. II. Arinaignac (Ann. d'Oculist., Aug., '97). Lupus of the Conjunctiva. Conjunctival ulcers occurring in this disease are distinguishable from tuber- cular ulcers chiefly by the fact that they CONJUNCTIVA. PEMPHIGUS. SYPHILITIC DISEASE. TUMORS. 305 have involved the conjunctiva from the skin, instead of from the mucous mem- brane, and, like cutaneous lupus, they undergo spontaneous healing in one place, while the ulcer keeps advancing in another. The disease occurs either as a primary process or as an extension of the disease from the surrounding skin. It appears as an ulcer, the bottom of which is covered with granulations, which bleed on the slightest touch and are filled with tubercle bacilli. Treatment consists in thorough re- moval of the contents of the ulcer with a curette, followed by careful cauteriza- tion. Pemphigus. Pemphigus of the conjunctiva is a very rare affection, and is usually seen in connection with pemphigus vulgaris of other parts of the body, although it may occur as an independent disease. BullaB form upon the conjunctiva and are attended with pain, photophobia, and lacrymation. The blisters break down and form cicatrices in the conjunc- tiva. Eepeated recurrence is the rule, so that the membrane finally becomes much shrunken and atrophied, and appears dry, smooth, and tense. The cornea be- comes cloudy and the lids are frequently distorted, aggravating the symptoms by the displacement of the cilia which this occasions. Treatment is of no avail, though the condition may be mitigated by emoll- ients, and protection from the light and air by coquillos. Arsenic may be admin- istered internally. Syphilitic Disease of the Conjunctiva. Chancres about the eye, as a rule, de- velop on the edge of the lids; they may also be observed on the palpebral con- junctiva and rarely on that of the globe. The disease is usually transmitted by kissing. At times, however, nJcers mav form from the breaking-down of gum- mata of the conjunctiva. Instance of a syphilitic ulcer of the bulbar conjunctiva. The initial )Bsion had occurred eighteen months previously. Under general antisj'philitic measures the local manifestation disappeared promptly. Fromaget (Gaz. Hebd. dea Sciences !Med. de Bordeaux, Aug. 0, '93). Case of mucous patch of the conjunc- tiva complicated by a pseudomembranous formation in a woman, 20 years of age, who exhibited other secondary lesions of syphilis. The conjunctiva of the lower eyelid was swelled and congested and covered by a pseudomembranous exudate. Schwartzschild (Med. Eec, Apr. 22, '93). Tumors of the Conjunctiva. Tumors of the conjunctiva may be both malignant and benign. Dermoid. — The most common among the latter is the dermoid, which is always congenital and is often found associated with wart-like growths from the skin in front of the ears, and with harelip. They are ascribed to an arrest of development. They occur as pale- yellow rounded or oval bodies the size of a split pea, usually at the extreme limbus of the cornea. Their surface is dry and smooth and frequently has a few hairs projecting from it. If, as sometimes happens, the growth shows a tendency to involve the cornea or cause irritation, it should be excised, care being taken to avoid injuring the deeper layers of the cornea. Polyp is a benign pediculated growth of the conjunctiva, which is but rarely seen. It is usually very small and is found in conjunction with the caruncle. P.\piT,LOMATA are occasionally con- founded with polypi, but may be readily distinguished from them by their rough. raspberry-like surface. They may be pediculated or sessile. Both forms of growths may be readily removed with scissors. 2—20 306 CONJUNCTIVA. MISCELLANEOUS DISORDERS. AxGiOiiATA are rare, but when they occur are usually found in association with a caruncle. They are congenital, but, as they usually increase in size after birth, their removal is usually demanded. The conjunctiva is rarely. the seat of malignant tumors, but both epithelioma and sarcoma may occur. They both arise from the tissue at the limbus. Epithelioma of the conjunctiva is non-pigmented, and occurs as a flat, red- dish tumor with a broad base. The tumor slowly increases in size, involving the cornea like pannus, and is prone to ulceration. Saecoma is usually pigmented and may attain large size, the growth being at times very rapid. They rarely attack the cornea. The early removal of both of these forms of growth is imperative, to pre- vent implication of the other structures of the eye. Enucleation is frequently demanded. Subconjunctival sarcoma removed from a patient 62 years old. Four years later there was not a trace of recurrence or metastasis. K. Joerss (Beit. z. Augenh., Jan., '98). . Cysts. — Simple cysts of the conjunc- tiva are very uncommon. They appear as translucent spherical bodies the size of a pea, usually on the bulbar con- junctiva, and may be regarded as dilated lymphatic vessels. Cysticercus. — Subconjunctival cys- ticercus is also an extremely rare affec- tion. It may be distinguished from the foregoing by the fact that it may be readily moved under the conjunctiva, while simple cyst cannot, as a rule, be moved from its position. The diag- nostic point, however, is the presence of a round, white, opaque spot on the ante- rior surface of the tumor, the recep- laculvm of the cyst. Excision of the growth by dissection is indicated. Miscellaneous Disorders of the Con- junctiva. Conjunctival Ecchymosis. — This may be originated by traumatisms or violent inflammation of the conjunctiva, or may occur spontaneously in the aged, from brittle blood-vessels, and in chil- dren in association with disease attended by spontaneous hjemorrhage elsewhere, particularly after whooping-cough. The meshes of the conjunctiva become filled with blood and the staining of the tissues may persist for some weeks. When the ecchymosis appears under the conjunctiva several days after an injury to the head, it becomes an important factor in the diagnosis of fracture of some of the bones composing the orbit. Chemosis. — Chemosis of the conjunc- tiva results when the connective-tissue layer is filled with serum, usually as the result of a severe inflammation of the conjunctiva or some of the deeper ocular tissues; it may, however, appear spon- taneously. Lymphangiectasis of the conjunctiva occurs at times as a small collection of blisters on the bulbar conjunctiva, due to distension of the lymph-channels as a result of interference with their circula- tion. It may occur at any stage and is not significant. LiTHiASis of the conjunctiva consists in the deposit of chalky matter in the ducts of the Meibomian glands, and gives the appearance of numerous, small, yellowish-white spots scattered through- out the conjunctiva. As they frequently occasion considerable irritation, they should be removed by incision. Amyloid disease of the conjunctiva is due to a peculiar degeneration of the conjunctiva in which pale-yellowish masses appear chiefly on the palpebral conjunctiva, but also in the bulbar por- tion. The lids become much swelled CONJUNCTIVA. PTERYGIUM. SYMPTOMS. ETIOLOGY. TREATMENT. 307 without the usual attendant signs of in- liammation. The conjunctiva resembles white wax. The disease is primary, although it may also at times be developed from granular conjunctivitis. Treatment should consist in removing sulTicient of the conjunctival masses to permit of greater freedom in the move- ments of the lids, which are often much restricted, and to gain better vision. Pinguecula is a small, yellowish ele- vation in the bulbar conjunctiva near the corneal limbus and usually situated to the inner side. It is composed of con- nective tissue and elastic fibres, in asso- ciation with a colloid substance; it is due to the action of external irritants. It has no significance beyond its cosmetic effect, except that it may originate pte- rygium. Pterygium. Symptoms. — Pterygium consists in a triangular fold of hypertrophied con- junctival and subconjunctival tissue of fleshy appearance, generally situated to the inner side of the cornea in the pal- pebral fissure. It may, however, be on the outer side of the cornea and in the traumatic variety may entirely surround the membrane. The apex of the triangle or the head of the growth is attached to the cornea, while the base spreads out like a fan into the semilunar fold. The neck of tlie growth lies between the apex and the base and corresponds to that part which lies on the limbus. At times the pterygium may push ita way across the cornea and disturb vision by involving the pupillary area of that membrane. But usually, however, it shows no tendency to advance into the cornea. In its early stages the growtli is thick and fleshy in appearance; but it becomes paler after a time and its blood-vessels are reduced to fibrous cords, giving the structure a tendinous appearance. Pseudopterygium may always be diag- nosed from the true variety by the fact that a probe may be passed under the neck of the latter, whereas this proced- ure is impossible in pseudopterygium, owing to the matting togetlier of the tis- sues by the preceding inflammation. Etiology. — Pterygium never occurs in children, although it is not an uncom- mon disease of adult life. Fuchs thinks that its starting-point is usually a pre- existing Pinguecula, and that it is due to the prolonged influences to which the conjunctiva in the region of the palpe- bral fissure is exposed. It is especially common among persons who are sub- mitted to the inclemencies of the weather: sailors, coachmen, farmers, and others. Pseudopterygium, or traumatic pteryg- ium, occurs as a result of some inflam- matory process which causes a lesion of the margin of the cornea. This variety is especially liable to form after burns or marginal ulceration occurring in puru- lent conjunctivitis or phlyctenular dis- ease. Treatment. — If the pterygium be small and shows no tendency to involve the cornea, it should be allowed to remain, for its removal for cosmetic purposes will be unsatisfactory, owing to the scar which remains upon the cornea and con- junctiva. A pterygium may be removed either by excision or by ligature. In the former method the head of the growth is grasped with fixation-forceps and is dis- sected off from the cornea by a sharp knife. This being accomplished, the growth should be separated from its base by two converging incisions. After tiie removal of the pterygium, the edge of the wound should be carefully united by 308 COXJUXCTIVA. INJURIES sutures. If the growth be very large, it may be split into an upper and lower haK after its dissection from the cornea, and the flaps thus obtained transplanted into the superior and inferior cid-de-sacs. Electrolysis is of value in the early stages of pterygium, in a strength of 3 milliamp6res, the needle (connected with the positive pole) being inserted at right angles to the axis of the growth. H. M. Starkey (Jour. Amer. Med. Assoc., Sept. 17, '98). A simple procedure in the treatment of pterygium described by A. Coe is cau- terization of the head of the membrane by means of a platinum wire, with a fine bulbar end, not larger than a very small pea, and heated in an alcohol-lamp. Practically complete cure obtained in an extensive pterygium by three cauteriza- tions of this kind, carried out at inter- vals of a few days. At the end of sev- eral months it was possible to make out only a light opacity, corresponding with the thickening in the conjunctiva, while the nearer tissues were entirely trans- parent. The same treatment in 24 cases, with invariably good results, ex- cepting in one patient, who presented a very extensive pterygium with large vascularities. F. B. Loring (Semaine MCd., No. 34, 1002). Injuries of the Conjunctiva. FouEiGN Bodies. — Small-sized foreign bodies frequently make their way into the conjunctival sac and cause consider- able pain by the pressure which they e.xert upon the cornea with every move- ment of the lid. If the body be found imbedded in the lower cul-de-sac, it is an easy matter to remove it, but if it be under the upper lid, it is necessary to evert the latter. This is accomplished by grasping the lashes and the edge of the lid with the thumb and forefinger of the right hand while the patient is di- rected to remain looking down, slightly pressing upon the upper edge of the tarsus either with a finger of the other hand or some convenient instrument: a blunt pencil, a probe, etc. Large bodies may remain buried deep in the cul-de-sacs for weeks at a time, and merely cause the symptoms of a chronic catarrhal conjunctivitis. Of this nature is the inflammation set up by the "eye-stones" which are frequently introduced into the eye by laymen to remove cinders or other foreign bodies. Having performed their function, they become imbedded in the folds of the con- junctiva. "Wounds. — The conjunctiva is not in- frequently involved in wounds of the globe itself or of its adnexa. If the wound be extensive, the edges should be approximated with stitches, but other- wise a simple boric-acid wash with a pro- tective bandage will suffice. Burns. — Burns of the conjunctiva are common. These are tisually caused by lime, acids, hot water, hot ashes, molten metal, etc., and are particularly serious on account of the subsequent contrac- tions and deformities which they occa- sion in the lids and damage wrought in the cornea. If the substance inflicting the burn is lime, the eye should be washed with a diluted or weak solution of a mineral acid, or, if this be not at hand, all parti- cles should be removed at once by forci- bly flooding the eye with water from a hose or spigot. If an acid has caused the burn, it should be neutralized by a weak solution of borax, bicarbonate of soda, or of com- mon salt if nothing else be on hand. Subsequent inflammation is best com- bated by cold compresses, boric acid, atropine, and some emollient substance, such as vaselin. Wm. CAMrnELL Posey, Pliiladelphia. CONSTIPATION. SYMPTOMS. 309 CONSTIPATION. — Lat., constipatis (from constipare, to pack together). Definition. — Prolonged retention of fjeces in the alimentary canal; retarded defecation; a symptom resulting from a variety of morbid conditions of the in- testines, and not a distinct disease. The strictly-natural law governing intestinal evacuations in man requires one, and sometimes two, discharges every twenty- four hours. Symptoms. — The symptoms produced by habitual constipation vary much in different cases. Many persons appear to enjoy fair health with an evacuation only once in two or three days. A smaller number continue well with only an evac- uation once a week; one woman came under my observation who claimed to have had no faecal discharge from the bowels for thirty days, and yet had been attending to her household duties all the time, with only a sense of fullness in the abdomen and some dizziness in her head. Case of Hindoo male, aged 50 years, 5 feet 6 inches liigli, who has been, since his 30th year, in the habit of passing stools once in six months or so, and even then only two or three hard scybala are passed. But every eight months the man gets a severe attack of fever, preceded by rigors, and then he passes, to his entire relief, sometimes consciously and at others in an unconscious state, enormous quantities of black, semisolid, feculent matter, which has evidently been ac- cumulating in his intestines all the while. Notwithstanding all this, the man looks well and healthy. He suffers very little from this e.xcopt a slight loss of appetite and energy. His abdomen is not bloated, but feels hard on pressure. He does not complain of flatulence; passes urine freely; and sleeps well. S. Kotayya Naidie (Indian Med. Rep., May 1, '90). In a large majority of persons, how- ever, constipation causes a sense of full- ness, lassitude, mental depression, or dull pain in the head, with some impairment of digestion, all of which symptoms are temporarily removed by a free movement of the bowels. In some cases after re- tention of the intestinal contents from three to five days, a spontaneous diar- rhoea supervenes for a single day, after which the constipation returns as before. In many other cases, protracted constipa- tion leads to a violent attack of head- ache every week or ten days, accom- panied by extreme nausea or vomiting for a day, during which the bowels are evacu- ated, and the next day the patient re- turns to his ordinary duties, though pale and impaired in strength. Most of the dyspeptic conditions, dila- tion of the stomach, etc., are really cases of constipation, and this may mechan- ically tend to produce haemorrhoids, hernias, vesico-uterine tumors, hyper- trophy of the prostate, etc. Germain S6e (Med. Rec, Feb. 3, '94). Hysteria in the female and hypochon- dria in the male, or even conditions bor- dering on insanity, may be the result of constipation. Staple (Amer. Med.-Surg. Bull., Aug. 15, '94). In many cases the middle and posterior part of the tongue is covered with a light coat and the urine is deeper color and less in quantity than natural; the appe- tite is variable. Sometimes the colon is distended with gases, with slight ten- derness on pressure and irregular peri- staltic movements. In such cases the operation of physic is liable to be accom- panied by pains across the abdomen and tenesmus, and some mucus may be evacu- ated with the faeces. Such symptoms in- dicate congestion or inflammation in the mucous membrane of the rectum, which is sufficient, in some cases, to cause fre- quent slimy discharges, while the ascend- ing and transverse colons remain filled with compact focces. Many cases of constipation are treated unsatisfactorily with medicine when the real cause is in the rectum. The pres- 310 COXSTIPATIOX. DIFFERENTIAL DIAGNOSIS. ence of thickening of the skin and mucous membrane, irritable ulcer or fis- sure, fistula, or hsemorrhoids frequently interfere with the treatment instituted. W. il. Beach (Pittsburgh Med. Kev., June, '95). A narrowing of the ileo-ctecal valve is the cause of certain caseS of obstinate constipation. W. J. Mayo (Annals of Surg., Sept., 1900). Differential Diagnosis. — Simple reten- tion of the fffical contents of the in- testines longer than natural may be considered as sufficient diagnostic evi- dence of constipation in an tmqualified sense. But as undue retentions of faces are often caused by a variety of mechan- ical obstructions, such as strictures, in- vaginations, concretions, morbid growths or tumors, and visceral displacements, all these have, by common consent, been classed as intestinal obstructions, while the words "costiveness" and "constipa- tion" are properly made applicable only to such cases as depend upon failure of one or more of the physiological condi- tions on which regular intestinal evacu- ations depend. Differential diagnosis involves, first, proof of the absence of mechanical ob- structions, and, second, proof that the physiological conditions concerned in natural evacuations are at fault in any given case. In all cases of intestinal obstruction the pains, distension, and tenderness are uniformly manifested at some one part of the abdomen or pelvis. If the obstruction is from the pressure of tumors or morbid growths these can gen- erally be detected by proper physical ex- amination of the abdomen. If from stricture or invagination there will be not only well-marked pains and fullness at some one location, but in strictures, especially, the past history of the patients will show them to have been the scquelic of dysentery, typhoid fever, or some form of primary intestinal ulcer- ation. Obstructions by uterine displace- ments or rectal concretions are readily detected by direct examinations through the vagina and rectum. [A result of chronic constipation often seen, which may not only simulate, but also cause uterine trouble, is enlargement and pouching of the lower third of the rectum. This condition is found very frequently in virgins, and gives the pain in the back, discomfort in standing or walking (more particularly in standing), and the sensations of dragging and full- ness, as if the parts would fall. This is due to the distension and varicosity of the vaginal and uterine veins, caused by the formation of a proctocele, press- ing the vagina forward. Efl'orts in def- ecation then cause intense pain, press- ing tlie vagina and rectum downward to the pubis and perineum ; instead of re- lieving the patient, however, the traction on the vagina forces the uterus down- ward, and prolapsus or retroversion re- sults. In this condition, the correction of the retroversion does not relieve the patient, since the cause is not the retro- version, but the rectocele, due to the constipation. The proper course to pur- sue is to cure the constipation, when the reposition of the uterus will cure the symptoms. Charles B. Kelsey, Assoc. Ed., Annual, '92.] Constipation not caused by mechan- ical obstruction may result from im- pairment or suspension of the natural peristaltic motion of the intestines, and from paralysis of the nerves of the rectum concerned in the act of defecation, from irregular contractions of the circular fibres of the muscular coat by which regular peristalsis is prevented, from the reversing influence of continuous nausea, from excessive obesity coupled with loss of tone in the abdominal muscles, and from deficient mucous and glandular se- cretions, by which the faces are per- mitted to become dry and hard. In all these cases a careful manual examination of the abdomen will detect the presence of fjccal accumulations in different parts CONSTIPATION. ETIOLOGY. 311 of the colon and rectum. And their loca- tion will vary from day to day, instead of uniformly appearing in the same place, as in cases of obstruction. Etiology. — Habitual constipation is more frequent in adults than in children, and more frequent in females than in males. Probably the most efficient causes of constipation are sedentary in-door habits with deficient out-door muscular exercise. The first necessarily lessens the efficiency of respiration and internal dis- tribution of oxygen, thereby lessening the tone and activity of the nervous and muscular structures generally; and the omission of the latter still further lessens tissue-metabolism and excretory proc- esses. If we add to the foregoing the depression of the transverse colon and the crowding of the abdominal and pelvic viscera down upon the rectum by well- known female habits of dress, we will have the chief causes why females suffer much more from constipation than the male sex. There is, beyond doubt, a form of habitual constipation in which there is either diminished irritability of the in- testinal nerves or defective development in the muscular coat of the intestine; an hereditary factor is often present. It may be acquired through habit of sup- pressing the desire, insufficient diet, or abundant diet difficult to digest, deficient in water, or too easily absorbed. Seden- tary habits are also a cause, but obsti- nate habitual constipation may occur even in those who lead an active life. Disturbances in the circulation — as in heart disease, mechanical pressure, and particularly pregnancy — may produce it; but displacement of the bowel, such as occurs in GlCnard's disease, is of doubt- ful inducncc. Adhesion of coils of in- testine together, or to some other organ, is an occasional cause. The relation of constipation to mental disturbance is well known, and the theory of intestinal intoxication, also, cannot be set aside. Prognosis, as a rule, is unfavorable. Ewald (Berl. klin. Woch., Mar., '97). It is generally recognized that wo- men for various reasons are most sub- ject to constipation; nevertheless rectal constipation, from which a large num- ber suffer, has received, at the hands of the profession, scant consideration. Eectal constipation may be, but is rarely, due to a nervous condition — i.e., ner\'ous rectum. ^Miile it may occur as the result of inflammatory condi- tions, such as haemorrhoids, fistulse, and fissures, which are common to men and women alike, in very many cases it is occasioned because of the peculiar an- atomical construction of the parts, ant — in fact, certain — to curl up at the edges; while in membranous croup the membrane is white, does not curl at the edges, is devoid of all peculiar odor, and the temperature is rather low. Carl Seller (Jour, of Laryngology, Aug., '90). Of 28G cases, reported by Park and Beebe, the Klebs-LoefTler bacillus was present in 229. In the remaining 57 cases it was not present, Init in 17 the examination was not satisfactory. The observations of recent years have shown that a pseudomembrane developing pri- marily in the larjoix is almost invariably associated with the Klebs-Loeffler ba- cillus; that is, it is true diphtheria. Pseudomembranous inflammation of the larynx secondary to diphtheritic inflam- mation of the pharynx is invariably true diphtheria. A pseudomembrane devel- oping in the larjTix secondarily to the pseudomembranes which develop during the course of the infectious diseases is commonly pseudodiphtheria. Such pseu- domembranes are associated with micro- organisms other than the Klebs-Loefller bacillus, generally the streptococcus. Case of pneumococcio croup in a child of S years, who, during an attack of influenza, manifested an erythematous angina. Laryngeal stenosis rapidly su- pervened and, despite the injection of Koux's antitoxin, called for tracheotomy on the evening of the same day. The wound gave issue to a false membrane of colloid appearance, which gave a pure culture of the pneumococcus. The case recovered. Seuvre (Revue Men. desMal. de TEnfanee, Mar., '98). A^Hiatever the cause of the disease, whether bacillus or streptococcus, it manifests itself simply as a pseudomem- branous laryngitis, stenosis being the im- portant symptom. Symptoms. — As the disease is so fre- quently diphtheritic in nature, it will be considered in detail in the section on diphtheria. Owing to the slow absorp- tion of toxins by the laryngeal mucous membrane and the comparatively short course of the disease when confined to the larynx, the constitutional symptoms of diphtheria are slight. Hence, croup pursues practically the same course whether due to diphtheria or pseudo- diphtheria. It is impossible from clin- ical evidence alone to determine whether CROUP. MEMBRANOUS. PATHOLOGY. PROGNOSIS. TREATMENT. 357 the disease is true or false diphtheria. As it is true diphtheria in a very large pro- portion of cases, the only safe rule in practice is to consider every case of croup to be diphtheritic and to use precautions accordingly. Pathology.- — In some cases the an- terior portion of the larynx alone is in- volved by pseudomembrane. In other cases the whole mucous membrane of the larynx is covered. In many instances the membrane does not pass below the larynx. In both true and pseudodiph- theria the membrane is but one element in the production of stenosis, oedema and swelling of the tissue underneath the pseudomembrane being an important contributing cause. Prognosis. — Unlike pseudodiphtheria of the pharynx, pseudodiphtheria of the larynx is almost equally fatal with true diphtheria, as it causes death by me- chanically obstructing respiration. Un- til a few years ago the age of the infant was the most important factor in prog- nosis, the younger the child, the more fatal being the disease. Tlie younger the patient, the higher the mortality, because of the small size of the trachea and larynx and because stenosis sooner results; the prognosis is unfavorable in the mildest cases; un- favorable symptoms are increasing de- bility and cyanosis, feeble and irregular pulse, and the development of bronchitis or broncho-pneumonia. Dodge (Med. and Surg. Rep., Mar. 21, '91). Age is still a very important factor, but prompt treatment with antitoxin must be considered of far greater im- portance in modifying the prognosis. Treatment.— The efficacy of the anti- toxin treatment of diphtheria has been too fully established to permit of doubt or argument. It is more effective in croup than in any other form of diph- theria. An injection should be given on a clinical diagnosis without waiting for a bacteriological examination. Its early use will, in a large proportion of cases, prevent the necessity of operation. Xext to the antitoxin treatment, calomel fumi- gations have, in my experience, proved most efficacious. [Vaporization of calomel: A powder consisting of from 15 to 30 grains (1 to 2 grammes) of calomel is placed upon a tin plate, and heat applied until all of the powder has been vaporized; this should be done under a tent erected over the patient's bed, the curtains of which should be kept closed for ten minutes to a half-hour after each fumigation. Dense, white fumes are evolved, which are not, however, irritating to the pa- tient, and the change in the respiratory sound, after the first burning of the calomel, is sometimes very marked. There have been no cases of salivation reported as yet in patients, but nurses and people who have to be in the room during sublimation of the calomel have, in several instances, been salivated ; so due care must be exercised. J. Lewis Smith and Frederic M. Warxer, Assoc. Eds., Annual, '93.] Calomel fumigation in the treatment of croup is the most valuable means of medication in this disease possessed at present (1893), and will save a larger percentage of cases without the aid of surgery than any other method of treat- ment. It is also capable of doing much harm. From 10 to 20 grains may be used, according to the size of the tent in which the patient is placed, every two hours during the first day, increasing the interval to three hours on the second day, and so on, according to the prog- ress of the disease. The patient should be left in the tent for fifteen minutes at each sitting and the flame of the spirit-lamp so regulated that the calo- mel all evaporates within this time. Nurses or attendants who remain much in the same room soon become ptyalized and older children occasionally show constitutional pfTects. In order to obtain the best results, the fumigation should be resorted to early, or before the mu- 358 CKOUP. MEMBKAXOUS. TER.A.TMEXT. cous membrane becomes lined with a layer of pseudomembrane. George Mc- Xa lighten and William Maddem (Brook- lyn Med. Jour., Aug., '93). Case of a child with true croup in which intense dyspnoea was present; be- fore resorting to tracheotomy, inhala- tions of vaporized calomel, 30 grains, were resorted to, with entire success; in ten minutes the patient was quiet and comfortable and without dyspnoea. The next day the same symptoms reappeared, and like treatment was resorted to with equal success; on the fourth day the child was convalescent. Eothn (Der Kinder- Arzt., Mar., '90). Intubation should be performed promptly when indicated. The following are indications for the performance of intubation: Given a case of membranous laryngitis, with hoarse- ness increasing to whispering, with cough short and explosive, becoming high- pitched and prolonged, diminution of or absence of the vesicular breathing, over the lower posterior lobes of the lungs, beginning recession of the epigastrium and beginning restlessness, the call is for immediate removal of the obstruction. Xote especially the character of the voice and cough; if these become pro- gressively worse, the child's best interests will be served by delaying no longer the necessary intubation. Ground (North- western Lancet, Sept. 1, '91). [There are only two impedimenta to the introduction of a tube of proper size in any form of acute stenosis of the larynx, viz.: entering one of the ven- tricles or a subglottic stenosis. Neither spasm of the glottis, nor pseudomem- brane, nor oedema, when situated in or above the chink, ever ofTcrs any serious objection to the passage of a tube. J. O'DwvER, Assoc. Ed., Annual, '92.] Result of a collective investigation on intubation in Germany including 1445 cases intubated for the relief of croup: there were 5.'>3 recoveries, or 38 per cent. One hundred and twenty-one of the cases were secondary to measles, scarlet fever, pneumonia, etc. Secondary trache- otomy was resorted to in 250 of the casts, with only 20 recoveries, or about 7 per cent. This number proves for it- self that the dangers which were for- merly charged against this operation must have been greatly exaggerated. Kanke (Jliinchener med. Woeh., No. 44, ■93). Individual experience in 500 cases treated by intubation: there was not a single death from pushing down mem- brane before the tube. When this acci- dent, which was uncommon, did occur, the obstructing membrane was usually expelled after the withdrawal of tlie tube. The string is always left attached, and, if passed through a piece of fine rubber tubing, which stands a good deal' of chewing, it will avoid being cut by the teeth. Bukai (Jalubuch fiir Kinderh. und physische Erziehung, June 5, '94), The results obtained by the use of anti- toxin, followed, when necessary, by in- tubation, have robbed one of the most deadly diseases of many of its terrors. (See DirnxHERiA.) Tracheotomy for croup from December, ISSO, to February, 1892, 115 times; re- coveries, 39.93 per cent.; 5 cases died during the operation. Bajardi (Archivio Ital. di Ped., July, '92). Five hundred and seventy-two trache- otomies performed in six years for croup; of these cases, 310, or 55 '/, per cent., died. Hagcdorn (Deut. Zeit. f. Chir., B. 33, H. 6, '93). Among the other measures recom- mended, turpentine and hydrochlorate of ammonia hold a prominent place, but the measures already outlined are to be pre- ferred. Turpentine in niembranous croup is of extreme value. The drug should be administered in dracliiu-doses, repeated every hour for from four to six doses, then suspended for six or eight hours. The membrane becomes of a muddy- yellow color, and is thrown ofT. If this change does not take place, recourse should be had again to the turpentine for three or four doses. S. L. McCurdy (Columbus Med. Jour., Apr., '90). Turpentine internally in large doses recommended. In 13 cases of croup treated willi diUflnnilDscH of turpentine, CUBEB. PREPARATIONS AND DOSES. 359 there were 8 recoveries. In only one case was any disagreeable effect of the remedy observed, and that was a stran- gury of temporary character, after 15 drachms had been given in twenty-four hours, to a boy 4 years of age. Kellogg (Med. and Surg. Reporter, July 9, '92). Hydroehlorate of ammonia is valuable (1) as a heart-stimulant, (2) in relieving the spasm and ccdema of the glottis, and (3) in softening the membrane. Hub- bard (Med. Rec, Apr. 11, '91). The following formula, suggested by Joseph Holt, of New Orleans, has been tried many times with the happiest re- sults: — R Chloralis, 7 grains. Potassii bromidi, 45 grains. Ammonii bromidi, 30 grains. Aquse cinnamomi, 2 ounces. M. Sig. : Teaspoonful, and repeat in twenty minutes if not relieved. This is intended for a child about 5 years old. For younger children the dose is slightly diminished. This prescription is of no benefit in true, or membranous, croup, when diphtheria antito.xin must be promptly used. H. E. Slack (Jour. Amer. Med. Assoc, May C, '99). Floyd M. Crandall, New York. CROUPOUS PNEUMONIA. See Pneumonia. CUBEB. — Cubeba officinalis is a climb- ing perennial found generally' through- out the East Indies, and abundant in Java, Batavia, Saranak, New Guinea, Nepane, and the Isle of France. The fruit is the part emploA'ed medicinally, and appears as partly shriveled or wrinkled berries, owing to the fact they are gathered prior to ripening, bearing considerable resemblance in point of size, and also in color, to black pepper and piments, but less globose and furnished with a stout stalk that is continuous with raised veins that run over the surface of the fruit and embrace it like net-work. The shell is hard, and contains a single loose seed covered with a blackish coat, but internally white and oleaginous with pungent aromatic taste and a peculiar aromatic odor that, once experienced, will never be forgotten. When reduced to powder the general tint is chocolate- brown, becoming darker with age, and an oily look and feeling. A good quality freshly ground yields about l-t per cent, of volatile oil, which, however, is readily dissipated with age; little powdered cu- bebs as found in shops will yield more than 4 per cent, of oil, and much of it is worthless. Oil of cubebs is a greenish-yellow fluid possessed of a warm, camphoraceous taste and aromatic cubeb odor, soluble in al- cohol, ether, and chloroform; it yields cubebic acid; cubeb-camphor, or stere- opten; and cubebin. Cubebic acid is a white, wax-like mass that, by exposure, acquires a brown hue and resin-like consistency; soluble in al- cohol, ether, chloroform, and alkaline so- lutions. Oleoresin cubeb is identical with the preparation formerh' known as ethereal extract. Cubeb-resin is an amorphous body sol- uble in alcohol and alkalies. Cubebin, at one time supposed to be identical with piperine, is a precipitate most easily ob- tained from the oleo-resin (ethereal ex- tract); it is white, crystalline, inodorous, and highly bitter, especially if dissolved in alcohol. Like cubeb-camphor, it is therapeutically inert. Preparations and Doses. — Cubeb ex- tract, ethereal (oleoresin), 5 to 30 minims. Cubeb extract, fluid, 10 to 60 minims. Cubeb extract, solid, 2 to 8 grains. Cubeb infusion (-l to 16), 1 to 2 ounces Cubeb-oil, 10 to 30 minims. Cubeb, powdered, 10 to 60 grains. Cubeb tincture, 15 to 120 minims. 360 CUBEB. CURARA. Cubeb troches, 1 to 5; each should contain 3 grains of powdered cubebs with fruit-paste. Cubebic acid, 5 to 10 grains. Physiological Action and Therapeu- tics. — Cubeb is stimulant, aromatic, sto- machic, diuretic, expectorant, antiseptic, and mild diaphoretic; cubebic acid is markedly antiblennorrhagic. Appetite and digestion are generally increased and improved by cubeb preparations; but too large doses or too prolonged use are apt to induce gastro-intestinal irritation, and, while exerting a laxative action, oc- casions a sensation of heat and discom- fort in the rectum; there appears to be also a selective action for mucous mem- brane, more particularly that of the blad- der and urethra. In very large doses (150 to 500 grains of powder) consider- able febrile action is observed, along with griping, drastic purging, headache, net- tle-like eruption, and, rarely, paralysis. Cubeb, like other peppers, readily en- ters into the circulation and increases the force and frequency of the heart's action. It is absorbed and eliminated with con- siderable rapidity, chiefly by the kidneys, but also through the skin and bronchial mucous membrane. Catarrhal Disorders. — In maladies of a catarrhal character, such as gonor- rhoea, gleet, leucorrhoea, vaginitis, in- fantile enuresis, chronic inflammation of bladder and prostate, chronic bronchitis and other pulmonary afPections, it is of great value, and much of the ill repute that accrues to the drug is due to the dispensing of inert preparations and er- roneous methods of application. As an example, the powder of cubeb is often recommended in such disorders as hay fever, chronic rhinitis, etc., in which local hyperaesthesia is an active factor. Such a use of the remedy serves only to discredit it. Considerable benefit sometimes follows its use, however, when eubeb-leaves are smoked in cigarettes in disorders of the respiratory tract characterized by free secretion. A spray of lanolin more or less strongly charged with cubeb, accord- ing to the intensity of the trouble pres- ent, is also of marked value in catarrhal inflammations of the nasal and pharyn- geal cavities. The troches of cubeb, 1 bean, slowly dissolved in the mouth every two hours, serve to maintain the benefi- cial action of the remedy. CURARA. — This substance — known also as curare, woorari, ourari, urari, woorara, wourali, and ourali, though it has been before the medical profession for more than half a century — is prac- tically unknown as to its source and composition. There is considerable evi- dence to show that it is derived in part from two or more trees of the strych- nine group, from the Menispermum coc- culus (Cocculus Indicus), and various un- known plants. It comes chiefly from the valley of the Orinoco, — Brazil, British and French Guiana, Venezuela, and Co- lombia, — where it serves certain savage tribes as an arrow-poison. It is by no means a stable or uniform substance; some appear to have mingled with it the poisonous principle of Jatropha (Mani- hot utilissima), known as ohi or dbiah poison in the West Indies, while that from Colombia is of lighter color, appear- ing as a yellowish-brown, amorphous, deliquescent powder. Brazilian and Guianian curare is a blackish, intensely bitter, hygroscopic mass of resinous ap- pearance. Both are soluble in dilute alcohol to the amount of 70 per cent, and in the water to 75 or 85 per cent., Imt insoluble in ether. Two alkaloids liave been segregated known as "cura- rinc" and "curine." CURARA. PHYSIOLOGICAL ACTION. 361 The Indians of the Orinoco prepare two kinds of curara: one a relatively- mild poison used in the chase, its chief source being Strychnos gubleri; the other much stronger, a war poison, from the S. toJfifera. Planchon (Provincial Med. Jour., July, 'SS). Preparations and Doses. — Curara, Vao to Vj grain. Curarine, V200 to Vso grain. Curarine sulphate, ^/joo to ^/loo grain. Curine, uncertain. Physiological Action. — Neither curara nor its alkaloids are ever employed ex- cept endermically (rarely) or hypoder- mically, since it is held that all are de- composed in the stomach and rendered practically inert. The latter is not true, however; but the process of absorption is extremely slow; but when employed subcutaneously it is rapidly absorbed. Elimination is rapid, chiefly by the kid- neys, causing sugar to appear in the urine, and partly with the faeces; per- spiration, saliva, nasal mucus, and tears, though greatly increased, do not seem to share in the eliminative process. It is not absorbed by intact integu- ments, but is absorbed (though with dif- ficulty) by mucous membrane. When introduced into the system and brought in contact with the systemic tissues, the drug develops identical biological effects in dogs, cats, rabbits, pigeons, amphib- ians, batrachians, reptiles, fishes, crus- taceans, insects, and amcebas. According to the duration of its contact with various organs and tissues, curara may paralyze either the central nervous sys- tem or terminations of motor nerves of any muscular structure (including the heart) and of the vagi; this least rap- idly in dogs and rabbits. In mammals generally it causes death by paralyzing the respiratory centres, but not the pe- ripheral respiratory nerves. The proxi- mate cause of tlie biological effects of curai'a is, probably, constituted by the drug inducing some alterations in the protoplasm of both nervous and muscular structures, though to a different extent, and not simultaneously. Dogiel and Nikolski (Medit. Oboz., No. 3, '90; Med. Chron., June, '90). Curarine paralyzes the motor nerve- endings, but has no eflect on sensory nerves. The irregularity and the early depression of the reflexes are not due to an action on the spinal cord or the sensory nerves, but to an inhibitory in- fluence exercised upon the cord by a stimulation of the higher centres. The alkaloid likewise exerts a tetanic action on the cord, but the reason why it docs not induce tetanic spasm, in the great majority of cases, when given hypo- dermically is because the circulatory changes produced are such as to prevent the diaig from having access to the cord, and because these changes of themselves produce spinal paralysis. With larger doses there is dilatation of the abdominal vessels, and hence accumulation of blood, little or nothing of this fl\iid entering the empty ventricle, notwithstanding that the heart may continue to beat. Curarine causes an almost immediate fall of blood-pressure in mammals; it occurs even after section of vagi, after a paralyzing dose of atropine, after division of all the cardiac nerves, after section of the spinal cord, and after paralysis of the central reflexes by urethane. The cause, therefore, of the fall of pressure must be due to a direct action upon the peripheral nerves or upon the muscles of the blood-vessel walls. It was found, however, that when an injection of barium was made into the circulation a rise of pressure was produced, while, on the other hand, no such action was effected by stimulation of the peripheral nerves. Again, the vasomotor centre was found to be active by the appearance of the "Traube- Hering" curves during the cessation of respiration by the action of the drug. This evidently proves that curarine causes a fall of pressure solely by a paralyzing influence exercised on the vasomotor nerves. The inhibition of the vagi is destroyed by curarine easily in cats, less so in dogs, and with diflSculty in rabbits. Small doses in a healthy rabbit caused the appearance of albu- min, blood-pigment, and blood in urine. 362 CURAEA. POISONING. TREATMENT. THERAPEUTICS. An infusion of the bark of the Stri/eli- nos toxifera caused the same effects as curara and curarine. Curine has no apparent effect on motor nerves, but acts on the heart like vera- trine or drugs of the digitalis group. Tillie (Med. Chron., Mar., "91). In poisoning by curara muscular power is notably diminished.' Grghant and Quinquaud (La Sem. Med., Apr. 22, '91). The action of the drug on muscle- tissue is a factor in the general paralysis induced. According to Keichert, doses insufficient to cause motor paralysis may increase the temperature, or primarily increase and secondarily diminish it. The use of quantities just sufficient to aholish voluntary motion act differently in different animals: the temperature from the first may be increased or de- creased, or primarily increased and sec- ondarily decreased, or primarily dimin- ished and accordingly increased; gener- ally there occurs a notable diminution or a decided increase, the former effect pre- dominating. A variety of curara from Colombia causes absolute paralysis of the muscle of the heart, the respiration continuing; and absolute paralysis and rigidity of tlie skeletal muscles at a much earlier period than happens in the case of an animal whose circulation has been arti- ficially arrested; also exemption of the motor nerves from paralysis until after death and until the muscles show signs of poisoning. In an experiment upon a rabbit the effects produced were mark- edly different from those caused by ordi- nary curara. With the new drug the motor weakness only appeared near death; but there was marked action on the heart, as well as an early total pa- ralysis of muscles and onset of rigidity. Tillie (Jour. Anatomy and Physiology, Oct., '93). Medicinal doses render the pulse more full and exceedingly rapid, — there is marked dilatation of the blood-vessels of the skin and the various glands, — and the blood-pressure, though little affected by small doses, is decidedly lowered by large ones. The action on the circula- tion is due to diminislred inhibition on the heart, owing to paralysis of the ends of the vagi, while the accelerator nerves are stimulated. It elevates temperature. Immoderate doses cause great mus- cular weakness and paralj'sis of all the voluntary muscles. The ends of the motor and sensory nerves are paralyzed, the former being soonest aft'eetcd. Be- yond a slightly-diminished contractility, the voluntary muscles are but little in- fluenced. The spinal cord may be par- alyzed by toxic doses, although the brain-centres remain unaffected until carbonic-acid narcosis sets in. It is like- wise a powerful respiratory depressant, paralyzing the ends of the motor nerves distributed to the respiratory muscles; if the doses are lethal, the paralysis be- comes central, finally producing death by its action on the respiratory muscles. Butler ("Text-book of Mat. Med., Ther., and Phar.," '96). Poisoning by Curara. — In poisoning the movements of the heart are greatly accelerated, the pulse weak and dicrotic, the temperature high, respiration de- pressed; extreme muscular weakness en- sues, with inco-ordination of movements; urine is saccharine; paralysis of extremi- ties and respiratory muscles supervene, and death ensues from the latter cause. Treatment of Curara Poisoning. — The treatment of the poisoning consists chiefly of artificial respiration and the employment of tetanizing agents, such as strychnine and picrotoxin. Alcoholic stimulants may be indicated. Caffeine, atropine, and cliloral are sometimes of benefit. Therapeutics. — Curara is more em- ployed in the physiological laboratory than as a medicament pure and simple, and study of the drug on therapeutic lines has, in a measure, been inhibited because of its unreliable composition; so true is this latter that the caution is gen- erally given that before any one sample CURARA. 363 is employed in the human subject its strength should first be tested on one of the lower animals. Merck, however, puts out a reliable article: one that is care- fully tested ere it is offered for therapeu- tic purposes. It is a powerful remedy for good when employed in convulsive diseases, such as hydrophobia, traumatic tetanus, and epilepsy, and sometimes yields good results in paralysis agitans, locomotor ataxia, nervous debility, and the dyspepsia of emphysema. Case of a boy, aged IG years, who had suffered with epilepsy since infancy and in whom the attacks occurred at inter- vals of a few minutes. After all other remedial measures had been exhausted Vio grain of curara was injected hypo- dermically, when the attacks recurred at intervals of hours instead of minutes. After six injections of curara, at five- day intervals, in doses of Vio or V» grain, complete relief was had; after several months no return of the epilepsy was experienced. Dobrorarow (La Sem. MCd., June, '04). It would seem, from Tillie's re- searches, that a preparation from the bark of Strychnos ioxifera would afford a remedy of the same scope as curara, and one, moreover, that would be uni- form in strength. Used judiciously, it would probably be a valuable addition to the list of antispasmodics, one espe- cially available in neuropathies. G. Archie Stockwell, New York. CYST. See Surgical Diseases of THE Skin. CYSTITIS.— Lat., from Gr., xvoric,, the bladder, and (T(^, inflammation. Definition. — Inflammation of the uri- nary bladder, involving one or more of its four coats: mucous, submucous, mus- cular, and serous. Varieties. — Cystitis has been divided into a large number of varieties, the sub- divisions being based upon the many etiological and pathological features of the disease. A further classification of this disease into the acute, the subacute, and the chronic is dependent upon the intensity of the symptoms and the length of time of their existence and is utilized in this article. Symptoms. — In acute cystitis the com- mencement differs somewhat according to the determining cause. When trau- matic, it may be ushered in with rigors or marked chill succeeded by burning pain in the bladder and glans penis, etc. In other instances, and when from other causes, it is announced by a feeling of uneasiness, which is located in the per- ineum. There is increased frequency of urination and spasmodic pain during micturition and more or less fever. Usu- ally the fever is absent, but, in the severe forms, there is moderate fever and some- times, in the pseudomembranous variety, quite high fever. Usually the tempera- ture in cases of fever range from 100° to 102° F., though it may be higher. These constitute the ordinary s)'mptoms. Pressure upon the bladder is intolerable. The urine may be blood-tinged through- out the attack, but more usually is re- placed soon by pus, and becomes am- moniacal. Acute retention is common. If complete retention ensues, the bladder gradually becomes more and more dis- tended and can be felt as a rounded tumor, giving a dull sound on percussion, rising higher and higher above the pubes. The tenesmus vesicae, or the feeling that the patient has not emptied the bladder after the viscus has been emptied, may occasionally be communicated to the rectum; and, in point of fact, all of the pelvic organs may participate in the pain- ful and distressing sensation. The frequent desire to pass water va- 364 CYSTITIS. SYJiIPTOMS. lies in intensity. It may be every few moments or almost incessant; several times an hour or once in a conple of hours. The constitutional disturbance, when the disease is of grave form, is very marked, as indicated by a frequent pulse, thirst, headache, and nausea, with great restlessness and mental anxiety. When cystitis progresses toward a fatal termi- nation, portions of the walls of the blad- der may suppurate or even slough, and ma}' be discharged in stringy fragments; the urine emits a vile odor, from the products of its own decomposition and the gases resulting from the dead mucous and submucous tissue which it contains; the patient is harassed with hiccough; the pulse becomes very small and fre- quent, the tongue dry and hard, streaked with a dark coat; the strength rapidly fails; the secretion of the kidneys di- minishes or is entirely suspended; the countenance becomes sunken and cadav- erous, the extremities cold, the surface moistened with perspiration, from which emanates the odor of urine, and the pa- tient at last passes into a state of pro- found stupor, from which he never awak- ens. (D. Hayes Agnew.) In chronic cystitis the symptoms are mainly those of the acute variety, but in a milder degree. Only slight fever is present, but the combination of pain and other distress rapidly undermines the general health. Case of cystitis without symptoms. The urine was pale, had a specific grav- ity of 1018, and contained much albumin and some leucocytes, with epithelial and granular casts. There was no uraemia. At the autopsy was found clironic cystitis, especially around the trigone. Martha Wollstoin (Med. Rcc, Jan. 23, '97). The urine is turbid, alkaline, and contains much mucus and pus, which forms a tenacious clot at the bot- tom of the retaining vessel. 'While the urine is usually alkaline, it occasion- ally is faintly acid, but, if so, promptly becomes alkaline, due to the formation of ammonium carbonate out of the nor- mal urea, the probable result of the oper- ation of bacteria. There seems very little doubt that we have to recognize the existence of two distinct types of cystitis: one associated with acid and the other with alkaline urine. In the latter some of the or- ganisms capable of decomposing urea and liberating ammonia are present, e.g., the diplococcus ureee liquefaciens, the proteus Hauser, the bacillus pyo- eyaneus, etc., with or without the bacillus coli communis; in the acid forms of cystitis tlie latter organism is alone present. The former type has long been recognized and its characters noted; but practitioners are not so fre- quentlj' on the lookout for cystitis with acid urine. Melchior (Centralb. f. d. Krankh. d. Harn- u. Sexual-organe, May, '97). In a case of cystitis the symptoms — pain, pus in the urine, and frequency of urination — must be present, and they must emanate from the bladder. They may come from other causes, singly or combined. If singly, the disease is not cystitis; if combined, tliey may result from two or more diseases. In tlie be- ginning of acute cystitis there is often fever, depression, nausea, loss of appetite, constipation, etc. Htematuria is also often present. In chronic cystitis the urine is generally light in color, alkaline, of a lowered specific gravity, containing a slight amount of albumin, perhaps some blood, and pus in abundance. When allowed to settle, pus forms a more or less dense deposit on the bottom of the glass, above which there is a cloud of muco-pus. Bladder-epithelium is found, especially in the forms wliere ulceration is present. In all cases cer- tain microbes of suppuration are present. Guitf'ras (N. Y. Med. Jour., Mar. 19, '98). Cystitis pai)illoniatosa occurs in the CYSTITIS. DIAGNOSIS. 365 female as a form of chronic cystitis, and may present the clinical picture either of the catarrhal or of the suppurative form. Its symptoms are frequency of urination, accompanied by more or less pain, and tenesmus, the urine passed be- ing clear or turbid. Bleeding does not occur spontaneously, although it may follow instrumentation. Its scat is at the trigone, which it usually covers, and it may extend over into the urethra, from which at times it appears to start. Its villi, or papilla?, spring from an in- llanicd base, and are discrete. Frederic Bierliofl' (Med. News, May 26, 1900). The greater alkalinity thus resulting reacts npon the pus and converts it into a glairy matter similar to mucus, thus further increasing the difficulties of uri- nation. (Tyson.) Diagnosis. — This is usually easy. Yet there sometimes occur mild forms which it is difficult to differentiate from mild degrees of interstitial nephritis, while it not very rarely happens that these two conditions are associated. In contracted kidney there are sometimes many leuco- cytes also. The presence of hyaline casts, even when scanty, points to nephri- tis, while hypertrophy of the left ven- tricle and increased arterial tension settle the question. Still more emphatic is the diagnosis if there be retinitis albumi- nurica (Tyson). According to the same authority, the question whether there is pyelitis, separate or associated with cystitis, is still more difficult to deter- mine. Catheterism of the ureter by the method of Howard A. Kelly, if a possible procedure in the given case, would, of course, clear iip all doubt. Tyson places most reliance on the symptom of tender- ness in the region of the kidney. TTsually the symptoms of the diseases under discussion leave scarcely any room for doubt; the sense of uneasiness in the neighborhood of the bladder, the fre- quent desire to empty the bladder, and the thick, purulent urine, taken in con- junction with microscopical examina- tions, will render the diagnosis certain. It is very important to ascertain whether the cystitis is idiopathic or the result of disease of the urethra, prostate, etc., and especially whether a foreign body, such as a calculus, is present in the bladder. It is also important to differentiate spasm of the bladder, which is also attended by pain and frequent micturition; but the quality and the daily quantity of the urine passed remain normal. There is a scries of diseases with blad- der manifestations in which no patho- logical condition exists in the bladder usually diagnosed as cystitis. The blad- der symptoms in such are the result of nervous reflexes, principally from an affected posterior urethra, but they may also come from the anterior urethra, from the ureter, and even from the kid- ney. The diagnosis is often extremely diflicult and depends finally on careful local examination. In cases of false cystitis the symptoms are always ag- gravated by intravesical medication. Gu6pin and Grandcourt (Med. Rec, Sept. 18, '07). Differential diagnosis between cystitis and pyelitis: 1. An alkaline reaction is not found with uncomplicated pyelitis. 2. The limit of albumin in the urine even with severest cystitis is 0.1 per cent, (maximum, 0.15). 3. If nearly all the pus-coi-puscles are crenatcd, the condition is pyelitis. 4. If the red corpuscles pres- ent are chemically or morphologically de- composed, provided the ha;raorrhage is only microscopic and there is no vesical tumor, pyelitis exists. 5. The character- istic symptom for diagnosis is the rela- tion of the albumin-content, which is from 2 to 2 '/: or even 3 times greater in pyelitis than in cystitis. Esbnch's albuminometer is valuable in determining the amount of albumin. George Rosenfeld (Berliner klin. Woch., July 25, '9S). In polyuria also the urine is voided frequentlj-, but without any pain or pur- ulent sediment. (Lebert.) 366 CYSTITIS. ETIOLOGY. Etiolo^. — Men are more liable than women to vesical catarrh. Traumatism is a frequent cause; injuries, such as blows and pelvic fractures, more particu- larly of the pubic bone, though both are rather rare conditions. Operations of lithotomy, lithotrity, catheterism, injec- tions; pressure, as in prolonged and in- strumental labors, in which class of cases gangrene of the walls of the viscus has been known to ensue, followed by a large vesico-vaginal fistula. Mechanical irrita- tion of foreign substances in the bladder, such as calculi; the poisonous effect of certain drugs, as the chemical action of cantharides and some of the mineral poisons; the action of the urine itself, retained and decomposed, as in stricture and in prostatic enlargement; inflam- mations of neighboring parts, as the kid- neys, prostate, rectum, urethra, and, when so developed, it is in consequence of a pre-existing gonorrhoea, a prostatitis, or the presence of a stricture, — urethral or rectal, — etc.; acute cystitis sometimes develops secondarily in the course of the infectious diseases. Frequency of cystitis in the course of infectious diseases attacking nursing children. Tliirty cases observed all un- der one year of age; all girls, suffering from broncho-pneumonia, acute gastro- enteritis, meningitis, etc., which nearly always ended fatally. The etiology is nearly always dependent upon retention, the result of the grave general disease. Finkelstein (Revue Prat. d'Obstet. et de GynC'C., July, '97). Regarding the bacterial origin of cystitis, James Tyson states that the question of whether the obstructive causes enumerated are of themselves suf- ficient, or whether they may simply sup- ply the conditions favorable to the opera- tion of bacteria, may be considered un- settled at the present day. J. W. White and Edward Martin, on the other hand, hold that all cases of cystitis are un- doubtedly due to the presence of patho- genic organisms. Among the organisms capable of producing inflammation may be mentioned the streptococcus pyogenes, staphylococcus pyogenes aureus, diplo- coccus, bacterium coli commune, tuber- cle bacilli, etc. The bacterium coli is one of the most common germs found in cystitis. It may enter the bladder by passing through the urethra, or from the neighborhood through the vesical wall; but it may also enter the blood-vessels and pass out again through the kidneys when the latter are in a morbid state. Thus this bacterium may be a cause of cystitis when predisposing conditions exist. Of 37 cases of cystitis examined, the colon bacillus was found in 13 (12 times soli- tary); diplocoeous urece liquefaciens 11 times (9 times solitary) ; proteus Hauser 5 times (3 times solitary), and staphy- lococcus pyogenes 4 times (3 times soli- tary). M. Melchior (Ugeskrift for Liiger, '97). Analysis of forty-six cases. Conclusion that cystitis (with certain rare excep- tions of chemical or toxic origin) is always due to micro-organisms, the bac- terium eoli commune being the most common. The mucosa of the bladder, however, must previously be in a condi- tion favorable to infection. Kargcr (Centralb. f. Gynilk., No. 2, '98). There is no better method of causing cystitis than the attempt to perform catheterization without full antiseptic precautions. The catheter should never be passed without tlie exposure and cleansing of the meatus urinarius. The cleansing should be done with bichloride solution 1 to 1000, and a sterilized cath- eter passed under^ the guidance of the eye. As a lubricant, the best is boro- glyceride solution. Noble (Gaillard's Med. Jour., Apr., '98). In cystitis coming on after catheterism in women it seema that the cause of tlie cystitis is injuries produced in passing the catheter, rather tluui the use of a dirty one. Walker (N. Y. Med. Jour., Mar. 19, '98). CYSTITIS. PATHOLOGY. 367 Cystitis is always caused by the pres- ence of bacteria. The mere presence of bacteria is insuflicient to cause cystitis; a further predisposing cause is necessary. Under favorable conditions any pathog- enic organism may give rise to cystitis. The entrance of pathogenic organisms into the bladder may be through the urethra, through tlie ureter from an in- fected kidney, from inflammatory areas in the neighboring parts, and through the blood-stream and the lymphatics. George T. llowland (Med. News, July 15, '99). Kesults of experiments on one hun- dred dogs: A lesion of the rectum in the vicinity of the prostate, whetlier superficial or deep, is not followed by cystitis, nor are intestinal bacteria foxmd in tlie urine in these cases, pro- vided the bladder at the outset is free from disease, and provided also that the rectal lesion is not followed by either general systemic infection or peritonitis. Serious lesions of the rectum may very readil}' produce general infection, how- ever. Omitting cases of sepsis, cystitis was noted in only one of many cases, and in but one case was there even a transient bacteriuria. Microscopical ex- amination showed that, following the slightest trauma of the epithelial sur- face of the rectum, numerous bacteria made their way promptly into the Ij'm- phatic spaces of the tissue surrounding the rectum, bladder, prostate, and semi- nal vesicles. If the bladder be injured by retention at this stage, the patho- genic germs which are sojourning in the neighborhood may succeed in finding en- trance and may thus set up a cystitis. Faltin {Centralbl. f. d. Krankh. d. Harn- u. Sexualorganc, Bd. xii, H. 0, 1902). The urine in cystitis, as a rule, con- tains both cocci and bacilli. The bac- teria found in cystitic urine include the staphylococcus aureus, albus, or cit- reus; the micrococcus aurcte, sarcina urinte, the urobacillus liquefacicns sep- ticus, tlie streptococcus pyogenes, zo- ogleic masses, the gonococcus, colon bacillus, the bacillus typhosus, proteus vulgaris, bacillus tuberculosis, and the bacillus dysenterieus of Shiga. The causative factors of cystitis in most cases are the colon bacillus, the difTer- ent varieties of the staphylococcus, the streptococcus, the tubercle bacillus, and the gonococcus. R. C. Longfellow (.Jour. Amcr. Med. Assoc, Apr. 4, 1903). Pathology. — The changes which are produced by cj'stitis consist in increased vascularity of the mucous membrane; its light-red color being exchanged for one of a dark-crimson hue throughout, deep- ening to purple or even black about the neck of the bladder; or the mucous membrane may be ecchymosed, and in places necrotic, and the muscular layer may be exposed. Iloemorrhages may oc- cur from bursting veins or separating sloughs; or perforation may occur into the surrounding tissues or into the peri- toneal cavity. Peritonitis may arise ^vith- out actual perforation (John B. Eoberts). In the more chronic cases the epithe- lium desquamates vary rapidly; mucus at first and then pus is poured out in large quantity. The urine soon becomes alkaline and is putrescent. Blood is fre- quently present. Decomposition precipi- tates the salts of the urine and calculi are found in the bladder or a calcareous deposit occurs upon the walls of that viscus. Wien the disease has been of long duration the muscular wall becomes either hypertrophied and contracted, or its fasciculi become irregularly stretched apart while the mucous membrane sinks into the intervals, giving rise to the con- dition known as sacculated, or ribbed, bladder. These depressions or sacs may become large and retain decomposed urine, act as receptacles for calculi, or perforate and give rise to peritonitis or perivesical abscess. The ureters and kid- neys soon become involved, and add ma- terially to the serious nature of the case. The commonest cause of infection of the female urinary tract is the bacil- lus coli communis, which a studv of 368 CYSTITIS. PKOGNOSIS. TREATMENT. the cases of acute cystitis definitely proves can and does in a large number of cases set up a true infection without the aid of any other micro-organism. Marked variations are seen in the ^•irulenee of this micro-organism and in its pyogenic properties. Other micro- organisms frequently found are the tubercle bacillus, various staphylococci, and the bacillus proteus vulgaris, while numerous varieties of micro-organisms have been less frequently and occasion- ally met with, as the baciUus pyocy- aneus and typhoid bacillus. The pro- portion of eases of infection due to the bacillus coli communis is greater in women than in men, probably due to the close proximity of the female ure- thra to the anus. Besides the entrance of the micro-organisms, other factors are in most cases essential to the de- velopment of a cystitis; the chief of these factors are aneemia, malnutrition, trauma of and pressure upon the blad- der, congestion of the bladder, and re- tention of urine. In cystitis the chief mode of infection is by the urethra, although one must also consider as pos- sibilities a descending ureteral infection from an infected kidney, pyogenic metastasis by means of the blood- and lymph- currents, and direct transmis- sion of the micro-organisms from the intestinal tract, or from some adjacent focus of infection. In pyelitis and pyelonephritis the usual modes of infec- tion are along the ureter from an in- fected bladder, and by means of the blood- and lymph- currents; in personal cases these modes of infection were found about equally represented. In the great majority of cases of cystitis, both acute and chronic, and in the majority of cases of pyelitis and pyelonephritis, the urine is acid. In cases in which the urine is ammoniacal the infection can be produced without the aid of any of the accessory etiological factors men- tioned above, the irritation of the am- moniacal urine apparently being suffi- cient to render the bladder susceptible to infection. In infections of the kid- ney due to a urea-decomposing micro- organism a stone is very likely to be present if the case is at all chronic. Certain conditions exist which present most of the symptoms of cystitis, but no infection; the most difficult of which to diagnose is probably urinary hyper- acidity of neuropathic origin, the suc- cessful treatment of which depends upon the successful recognition of both its urinary features and its general basis. Although the diagnosis of renal in- fections can be made with absolute cer- tainty only by ureteral catheterization, a probable differentiation between renal and vesical infections can be made by a careful study of the urine alone. Tuber- culous infections of the urinary tract frequently occur with no other demon- strable tuberculous lesions elsewhere in the body. Probably a tuberculous gland would be demonstrable post-mor- tem in most of these cases. The colon bacillus seems to be the commonest cause of pyelitis, while the bacillus pro- teus vulgaris and members of the staphylococcic group are also found less frequently. And finally to be able to thoroughly understand the cases of cystitis, pyelitis, and pyelonephritis brought to our notice, to make the proper diagnosis, to inaugurate and carry out a rational line of treatment, and to give a correct prognosis, a care- ful chemical and bacteriological study of the urine is absolutely essential. T. R. Brown (Jolins Hopkins Hosp. Reports, vol. X, Nos. I and 2, 1901). Prognosis. — The prognosis will depend on the ability of the surgeon to remove the cause and on the duration of the disease. Ordinary acute cystitis, when uncomplicated, is not attended by any great danger. Protracted cases of acute vesical catarrh do occur and may run a ver}' chronic course. The chronic form is to be regarded as troublesome and very intractable, rather than dangerous to life. In young and middle-aged patients, and in those of good constitution, the prog- nosis is more hopeful and the treatment is more effectual than in those who are advanced in years or enfeebled by disease. Treatment.— In the acute form the pa- CYSTITIS. TRKATMENT. 369 tient should be ordered to bed at once. The diet should be light and unstimulat- ing: milk, broths, eggs, etc. Stimulants are to be avoided. The bowels should be regulated by the administration of a saline. In point of fact, all such cases are better for the use of some drug as the citrate of magnesia, epsom salt, Ilun- yadi water, etc., employed to the point of free purgation. Tyson claims that leeches should be applied to the per- ineum more frequently than they are. If the urine is acid, it should be rendered neutral by alkaline drinks. For this pur- pose H. C. Bloom recommends Vichy water containing much soda. In most cases the urine is alkaline, though not as frequently in the acute cases as in those that are chronic. The best remedy for neutralizing an alkaline urine is benzoic acid, either administered in solution well diluted with water, or in capsules con- taining 5 grains of the drug, administer- ing every three hours until the desired result is obtained. Considerable water should be taken after each capsule. 'WTien there is much ammoniacal decomposi- tion, salol, in capsules of 5 grains each, given every two hours until the urine is rendered acid, is a valuable remedy. Boric acid, in 10- or 20-gTain doses is often efficacious. A weak nitrate-of-silver so- lution is recommended by some surgeons. When the urethro-vesical tract is in such a condition that interference can be tolerated, irrigations with a nitrate- of-silver solution, beginning with a strength of 1 to 16,000 and increasing gradually, are effective. Tliis is allowed to flow into the bladder through the anterior urethra by the force of gravity from a fountain-syringe, the height of the receptacle being sufficient to pro- duce enough pressure to overcome the resistance of tlie cut-off muscle. So soon as the patient feels the tension of the fluid in the bladder the flow is dis- continued and the patient is directed to stand and empty the viscus. These irri- gations may be given every day, or cvei-y second day, as the patient's symp- toms may indicate. Ramon Guittras (N. Y. Alcd. Jour., Mar. 19, '98). In cystitis the first and main indica- tion for treatment must be to render the urine antiseptic. Urotropin is a non- toxic and non-irritating derivative of formic aldehyde. In cases of cystitis and of phosphaturia its action has per- sonally been almost specific. In some cases it causes a slight burning s,ensa- tion in the bladder if large do'bes are taken, but no patient to whom it has been personally given has ever com- plained of this. In prescribing urotropin the reaction of the urine should first be discovered. If it is very acid a little citrate or acetate of potassium, or if it is very alkaline a little dilute mineral acid should be given in addition to the drug. T. G. Kelly (Therap., Oct. 15, '98). The value of urotropin depends more on whether (1) the cystitis, as a primary bacterial invasion, develops in a healthy urinary tract, in which condition 40 per cent, were personally cured, and 60 per cent, improved, or (2) whether it asso- ciates itself with a pre-existing disease of the tract, as stricture, hypertrophied prostate, tumor, paresis, nephrolithiasis, tuberculosis, gonorrhoea, etc. In these cases urotropin alone is useless, yet com- bined with local treatment, while there is little hope of cure, there may be much alleviation of the symptoms (in 49 cases, 4 cured and 30 improved). If (3) the cystitis is secondary to an infection of the urine, urotropin, like santal and salol, is utterly useless (10 cases, 10 fail- ures). B. Goldberg (Centralb. f. innere Med., July 14, 1900). In cases where the inflammation is too acute to tolerate irrigations, instillations of nitrate of silver are of great value. They should be given with the Ultzmann or the Otis syringe, beginning with a strength of a grain to the ounce and increasing the strength to ten grains if necessary. From 5 to 20 drops of such a solution may he employed at one time. Girl of 19, under treatment for gonor- rhoea which had distinctly involved the 24 370 CYSTITIS. TREATMENT. uterine mucous membrane, began to i complain of pain during micturition. On examining the urine gonococci were detected in pure culture. Through the cystoseope the vesical mucosa appeared very vascular, with superficial loss of substance at certain points. The cystitis was cured by washing out the bladder with warm boric lotion and injection of a 1-per-cent. solution of nitrate of silver. Lindholm (Cent. f. Gyn., No. 21, '97). Pyoktanin can be applied to the most delicate mucous membrane, not only in concentrated solution, but in powdered form with but slight, if any, irritation. It retards the development of pus even in solutions of 1 to 2000. When applied to inflamed mucous membrane, it stains it intensely blue; this color remains for a number of days. It is active as an antiseptic as long as any color remains. In treatment of inflammation of the bladder and urethra injections of pyok- tanin solutions into the bladder produced the happiest results in four cases. R. E. Graham (N. Y. Med. Jour., vol. Ixvii, p. 889). Irrigations and injections of perman- ganate of potash in V12- to Vrper-cent. Bolution is a most excellent remedy. In employing vesical irrigation it is impor- tant to observe the strictest attention to the cleanliness of all instruments used. Large injections should not be used. Better an ounce or so at a time fre- quently repeated, until the washings come away perfectly clear. The temper- ature of the solution should be about 100° to 105° F. When there are local causes for reflex irritability, as hemor- rhoids, varicocele, phimosis, adherent prepuce, or a narrow meatus, appropriate surgical treatment should be resorted to. Urethral causes of irritability of the bladder or of partial retention of the urine, such as stricture of either large or small calibre should be promptly at- tended to. (White and Martin.) In chronic cystitis, whatever be its origin, the treatment of the inflamma- tion of the bladder should be by both local and internal medication until it is in a condition that will permit of more radical measures. Operative interference is indicated when the symptoms of pain and fre- quency are very severe, and when no improvement has resulted from general and local treatment; distinctly, there- fore, a more serious group of cases. Curetting the bladder, through the peri- neum in the male and through the urethra in the female, followed by thor- ough drainage, has yielded the best re- ' suits. The perineal route is preferred, because it is easier, because it gives readier access to the usual situation of tubercle in the bladder, and because the drainage it afltords is the best. The only advantage of the suprapubic method is that of allowing one to see the seat and extent of the lesion. Banzet (Ann. d. Mai. d. Org. G6nito-Urin., June, '97). In women the lesions of cystitis are, in reality, more frequently localized around the neck of the uterus and of the trigonum, and for a long time they are rather superficial. It is only in e.t- trome cases that the condition of inter- stitial cystitis, which seems to be be- yond therapeutic resources, becomes established. In such cases amelioration is very distinct after vesical curetting. The operation is very simple and pre- ceded by thorough lavage of the blad- der. For this a solution of boric acid is used to which 1 per cent, of a solu- tion of corrosive sublimate of the strength of 1 to 1000 without alcohol is added. According to Guyon, this intervention does not completely cure the cystitis, but it renders the disease more amenable to other methods of topical treatment which before could not be tolerated. Treatment may be summed up as fol- lows; Treatment of the uterus and its adnexa and general treatment. Local treatment of cystitis, although easy in light cases, becomes insufficient in l)ronounced cases. Surgical treatment becomes necessary in cases in which the I)ain is intense. Cystotomy, particularly colpocystolomy, should bo reserved for very serious cases. Very often recov- ery or a step toward recovery, by means CYSTITIS. TREATMENT. 371 of local topical treatment, may be ob- tained by curetting the bladder through the urethra. This operation is simple and easy; it does not require any com- plemental operation, and it gives ex- cellent results. M. G. Camero (Gaz. Heb. de Mod. et de Chir., Sept., '97). The use of the curette advocated in cases of non-tuberculous chronic cystitis that will not yield to ordinary treatment, or even the radical surgical means, such as drainage of the bladder by either the perineal or suprapubic routes. N. W. Soble (BuiTalo Med. Jour., May, 1900). In chronic cystitis in the female subli- mate instillations will often produce a very great improvement in the distress- ing symptoms met with in both tubercu- lous and non-tuberculous cystitis. In some cases a complete cure may be ob- tained when the instillations fail to pro- duce the desired effect by curettement of the bladder in both tuberculous and non-tuberculous cystitis; in gonorrhceal cystitis instillations of sublimate are particularly efficacious; under favorable circumstances a radical cure of tubercu- lous cystitis may be obtained by curette- ment when the vesical lesions are local- ized and the kidneys free from the dis- ease. When the lesions are extensive, they should be directly treated by suprapubic cystotomy. When cystitis is caused by a prolapsus of the genital or- gans, and when hysteropexy, combined with anterior and posterior colporrhaphy does not relieve the bladder symptoms, curettement of the bladder, followed by sublimate instillations, is the proper treatment. C. G. Cumston (N. Y. Med. Jour., Sept. 22, 1900). The next step is to remove the cause of the trouble, if discoverable. Strict- ures of the urethra must be dilated, for eign bodies must be removed, retention of the urine from enlargement of the prostate or paralysis, etc., must be treated by the regular use of the catheter and then by such operative interference as is deemed best suited to tlic individual case. A soft catheter should be used and as often as the viscus will allow without adding to the irritability present, twice or three times in the twenty-four hours not being too frequent. A large percentage of female patients suffering with subacute vesical symptoms — as painful micturition, bearing-down sensation, and a feeling that the bladder is not emptied after micturition— can be readily relieved by dilatation of th« urethra. The greatest amount of prac- tical good that has been obtained in bladder troubles is by the use of the cystoscope. J. M. Baldy (Phila. Poly- clinic, No. 18, p. 100, '95). The ordinary bougie, either metallie or soft, can be rendered sterile by wash- ing carefully and drying with a towel or gauze rendered sterile by boiling. The use of antiseptic solutions is unnecessary. As soon as they become scratched or injured, metal bougies should be polished and replated, while soft ones must be thrown away. Metal or Jaques's soft- rubber catheters can be rendered posi- tively sterile by boiling or washing, and soaking in strong antiseptic solutions that do not injure them. It is impossible to render gum-elastic or varnished cath- eters sterile when, for any reason, they have to be employed. A gum-elastic catheter that is smooth and well finished inside may be rendered reasonably secure by having the patient hold it for a time under a tap and then lay it aside im- mersed in a boric solution, a weak per- chloride, or other weak antiseptic solu- tion. When the urine is purulent or sep- tic, the catheter must be destroyed if it is not metal or soft rubber. ^Vhere there is not much pus or infection, it can be washed, immersed in antiseptic solutions, and steamed internally. Nicoll (Annals of Surg., June, '99). The best internal remedies, — i.e., those usually praised — are benzoic acid, about 30 grains a day in divided doses; ben- zoate of sodium, 10 grains four times a day; salol, in a similar dosage; and uro- tropin, 7 '/, grains three or four times a day, well diluted with water. If there is residual urine in the blad- der, it is only a question of time as to 372 CYSTITIS. TREATJIENT. when that urine will decompose and give rise to cystitis. Women seldom completely empty the bladder while lying perfectly flat on the back. Hence, when, on account of illness, they are placed on the back sufficiently long, cystitis may occur. Cases cited in which cystitis supervened after an inters'al of ten days, and in another as soon as three days after operation. In appropriate eases, the recumbent posture should be changed to the sitting posture when at all possible. To correct the offensive odor, salol and betol are useful. A dose of 5 grains, three times daily, of betol, will, as a rule, completely correct the odor in twenty-four to thirty-six hours. TV. H. Bennett (Clinical Jour., Mar. 27, '95). In gonorrhoeal cystitis, rest in bed, avoidance of all local irritations, admin- istration of morphine, codeine rectal suppositories, or of extract of hyoseya- mus, use of local warm baths; forbid- ding of spices, alcohol, and carbonated waters, and the giving of laxatives. Priapism can be avoided by the bro- mides, with camphor or cannabis Indica. For the cystitis itself, salol, in three doses of 15 grains each, sodium salicy- late, or sodium benzoate are useful. If the digestion is excellent, oil of santal, cubeb, kava-kava, balsam of copaiba, balsam of Peru, and oil of turpentine may be employed. Of importance is the use of infusions, as of uva ursi, quite likely on account of their diluting the urine. M. Harovitz (Centralb. f. d. Gesammte Therapie, H. 2, S. 05, '97). Bladder lavage with salt-water, and the application of oil containing iodo- form and guaiaeol, is a method sug- gested by the good effects which arti- ficial serum produces in tuberculosis of the peritoneum, as well as the general- ized and stimulating action which it ex- ercisca upon the nutrition of the tissues. The phyHiological solution of chloride of sodium was left in the bladder in con- siderable quantity, directing the patient to hold it as long as posHible. To pro- duce a tolerance by the bladder, olive-oil containing 5 per cent, of guaiaeol and from 1 to 2 per cent, of iodoform was injected. The iodoform deposits itself upon the mucous membrane, especially at the points of ulceration, and thus forms a kind of protective film. These applications are attended with the irri- gations with normal salt solution. The pain, bleeding, and other well-known symptoms of this disease soon disap- pear. A. Montford (La Semaine M6- dicale, Dec. 10, 1902). The patient should be advised to drink freely of water and should be careful regarding diet. Locally the bladder should be washed out once or twice a day with a solution of permanganate of potash ^Aooo to ^/sooo ; silver nitrate in a similar strength; boric acid, 10 grains to the ounce; bichloride of mercury, ^/looo to Vmo ■ In cj'stitis due to enlarged prostate the question of operation has to be consid- ered, and includes such procedures as castration (White's operation); resection of a portion of the vas deferens; enuclea- tion of the prostate; incisions of the prostate (Bottini's method), etc. Anodynes are indispensable in many cases of cystitis to relieve the frequent desire to urinate and the extreme pain the patient suffers. They are best given per rectum and in the form of opium or its alkaloids. Many cases demanding operation for the relief of the distressing symptoms inevitably associated with chronic inflammation of the bladder are only relieved by such measures as a suprapubic cystotomy or a perineal sec- tion. [The severe pain attending the pas- sage of urine is often relieved by the use of 5-grain doses of chloride of ammo- nium every three hours, especially if lit- mus-paper show the urine to be acid. Ed.] Lewis H. Adler, Jr., Philadelphia. DEAF-MUTISM. DEFINITION. CLASSIFICATION. 373 D DACRYOADENITIS. Appaeatus. See Lacrtiial DACRYOCYSTITIS. See Lacrymal Appahatos. DANDRUFF. See Seborrhcea. DEAF-MUTISM. Definition. — Deaf - mutism, strictly speaking, signifies the abnormality which is characterized by the co-existence of deafness and dumbness. Various cir- cumstances, which will be treated of in the following pages, necessitate, how- ever, a more limited definition. Deaf- mutism may, therefore, be defined as a pathological condition dependent upon an anomaly of the auditory organs, either congenital or acquired in early child- hood, causing so considerable a diminu- tion of the power of hearing as to pre- vent the acquisition of speech, or — should speech have been acquired before the occurrence of the loss of hearing — as to prevent its preservation by the aid of hearing alone. Persons exhibiting this pathological condition are described as deaf-mutes, even when speech has been acquired by a special system of in- struction. Theoretically, deaf-mutism is an ill- defined condition, which cannot be dis- tinctly separated from other conditions related to it. This is a natural conse- quence of its being a pathological term founded, not only upon a symptom, deaf- ness, but also \ipon the intensity of that symptom and the period of its occur- rence. There is, also, an apparent con- tradiction in the fact that deaf-mutes in- clude, not only those who cannot, but, also, those who can, hear or speak. Prac- tically, however, there is seldom any dif- ficulty in determining whether a person is or is not a deaf-mute, just as it is, also, as a rule, easy to recognize deaf-mutism, when the subject in question has passed the first years of infancy. The reason is that the acquisition and preservation of speech in childhood is so dependent upon hearing that, as soon as the latter sinks below a certain degree, the former can- not be • developed, or is lost, and this secondary dumbness does not easily es- cape observation. Occasionallj', it may be difficult to decide whether a child should be described as a deaf-mute or as merely deficient in hearing and speak- ing. Such cases must be decided by purely practical considerations, and it may not be out of the way to observe that in Denmark — one of the few coun- tries where the education of deaf-mutes is compulsory — all children are consid- ered deaf-mutes who cannot, owing to their deficient hearing, take part in the instruction given to normal children. Classification, — Deaf-mutism can be classified (1) either according to the de- gree of its symptoms, or (2) according to its etiology. In the first case a distinc- tion must be made according as the deaf- ness or dumbness is absolute or not. True deaf-muiism may be described as being the state in which the hearing is posi- tively nil, and in which there is no power of speech, unless it be acquired by a special method of instruction. Persons with this form of deafness may be desig- nated as true deaf-mutes. Those who have some slight power of hearing or some power of speech (either because the hearing is not totally absent or because the deafness occurred after speech had been acquired) may be described as swnt- muics. Etiologically, deaf-mutism has been 374 DEAF-MUTISM. CLASSIFICATION. DISTRIBUTION. further divided into endemic deaf-mutism {i.e., that which attaches to certain dis- tricts and their natural conditions) and sporadic deaf-mutism (which is the re- sult of certain accidental causes). The most general classification of deaf- mutism is that which discriminates be- the cases of deaf-mutism are caused by acquired deafness. The relative propor- tion must, however, vary very much in different places and at different periods, epidemics of certain infectious diseases, for instance, increasing the absolute number of deaf-mutes with acquired Distribution Countrv. Europe : Switzerland Austria Baden Sweden Alsace and Lorraine. . . . Wiirtemberg Hungary Norway ■. Prussia Finland Bavaria Ireland Portugal Greece Denmark France Saxony Scotland Italy England- Wales Spain Belgium Holland America : Canada United States Africa : Cape Colony Asia : British India Australia : English Colonies OF DE.\F-MnTES IN VARIOUS COUNTRIES. Year. 1870 1890 I87I 1895 1871 1861 1890 1891 1880 1880 1871 1880 1878 1879 1890 1876 1890 1881 1881 1891 1877 1875 1889 1891 1890 1890 1891 1891 luhabiUut: 245 123 122 116 111 111 109 106 102 102 90 77 75 65 65 58 57 57 54 50 46 43 43 100 66 63 69 37 6,544 29,217 1,784 5,307 1,724 1,910 19,024 2,139 27,794 2,098 4,381 3,993 3,109 1,085 1,411 11,460 1,994 2,142 15,300 14,112 4,625 1,208 1,977 4,819 41,283 802 190,843 1,412 Proiiortioii between Mule iiiul FouiHle Detif- mutes. 100:74 100:89 100:90 100:76 100:87 100:84 100:81 100:83 100:77 100:94 100:87 100:73 100:89 100:87 100:85 100:86 100:76 100:83 100:05 100:89 100:81 100:80 100:81 100:78 100:64 tween the deaf-mutism resulting from congenital pathological changes of the or- gans of hearing and that resulting from Buch changes which are acquired after birth. We have reason to surmise, according to modern statistics, that at least half deafness. Future investigations will, per- haps, prove that acquired deafness has a still greater preponderance in tlio causa- tion of deaf-mutism than we are at pres- ent authorized in believing. Distribution. — We are only in posses- sion of information as to the distribution DEAF-MUTISM. SY^ilPTOMS AND SEQUELS. 375 of deaf-mutism in Europe, the United States of America, and some European colonies. Not even all European coun- tries have undertaken an enumeration of their deaf-mute population; Kussia, the largest of them, having, for instance, no deaf-mute statistics. The table on page 439, which includes the most recent enumeration of deaf-mutes, gives their numbers in different countries, also the proportion of males and females. It will be seen from this table that deaf-mutism is very variousl}' distributed in the countries from which we possess statistics. The causes of the remark- ably unequal geographical distribution of deaf-mutism, which will be seen from the table, are probably numerous and various. To begin with, we are involun- tarily struck by the fact that the Euro- pean countries, with large deaf-mute population, are the most mountainous, which is in perfect accord with the fact that deaf-mutism is more frequent in mountainous that in lowland districts. I shall later on have occasion to point out that this is not, in all probability, the result of great altitudes and peculiar geo- logical formations, but of the unfavor- able social and hygienic conditions com- mon to mountainous countries (consan- guinity, poverty, unhealthy dwellings, etc.), the importance of which as causes of deaf-mutism will be discussed after- ward. Further, wide-spread and malig- nant epidemics of cerebrospinal menin- gitis, an important cause of deaf-mutism, explain the frequency of this condition in the lowland countries of Central Europe. We must, also, observe that the coun- tries in the west and south of Europe are the most fertile and productive, while those in the north and centre are less favorably endowed by nature. That this circumstance is a factor in the distribu- tion of deaf-mutism has been proved by investigations made in different districts in Denmark, and especially in Saxony. Finally, the northern and central coun- tries are, on the whole, the most thinly populated in Europe, doubtless the re- sult of the barrenness of the soil. Sex. — The table on page 439 shows a greater frequency of deaf-mutism among males than females, the difEerence in sev- eral countries being considerable. The number of female deaf-mutes per 100 male deaf-mutes varies, according to the table, from 94 in Bavaria to 65 in Spain, the average rate in Europe and the United States of America being 82 fe- males per 100 males. The numerical superiority of male deaf-mutes is the more remarkable since females are more numerous than males in nearly all the European countries, Italy being the only country of those mentioned in the table which exhibits a slight inferiority as re- gards the female population. This nu- merical superiority of the male deaf- mutes must undoubtedly be considered principally as an expression of the greater liability the male organ of hear- ing has to be morbidly affected. Symptoms and Sequelse. — Of the s}Tnp- toms, the principal are, of course, deaf- ness and dumbness; but other symptoms closely connected with the ear disease causing deafness are often met with in cases of deaf-mutism. Deafness. — The term "deafness" is not only used to express the absolute ab- sence of hearing, — total deafness, — but also to express a condition in which some traces of hearing remain, but in which the human voice is not audible in the usual way: a condition to be described as partial deafness. From a theoretical point of view, it seems an easy matter to make a sharp distinction between the condition in which the axiditory nerve is entirelv out of function and that in 376 DEAF-MUTISM. SYMPTOMS AND SEQUEL.E. "whicli it still acts, though deticiently. As a matter of fact, however, it has been proved that it is sometimes difficult to decide, in particular cases, whether there are any remains of hearing or not; and, further, the results of these two condi- tions (if acquired in early infancj' or congenital) are the same, viz.: deaf- mutism. In other words, both subjects with total deafness and those with par- tial deafness may be met with among deaf-mutes. It is not always an easy matter to test and decide the amount of hearing pos- sessed by a child, especially an infant. As a rule, only ordinary loud sources of sound can be employed to discover whether the child in question reacts in any way to the sound produced; for instance, by turning or blinking its eyes. Generally, a loud whistle, a bell, clap- ping the hands, or such like devices are made use of. Such a rough mode of ex- amination can, however, only decide whether the power of hearing exists or not in individual cases, and even this is often difficult when the patient is an infant, and it is also no easy matter to determine whether the power of hearing is equal on both sides. With older chil- dren it is easier to discover whether the power of hearing exists, and, if so, in what degree. In the latter case less pow- erful sources of sound may be employed. Of these the principal is the tuning-fork, the vibrations of which are used in meas- uring the conduction of sound through the middle ear, by placing it outside the ear; and also in measuring the so- called bone, or cranio-tympanic, con- duction, by placing it on the mastoid process or on the teeth. The human voice is also an important means of in- vestigation. The best means of employ- ing it is by pronouncing certain vowels loudly and distinctly close to the deaf- mute's ear, without his being able to see the movement of the lips, the patient being asked to repeat the vowels pro- nounced. To prevent the possibility of guessing the vowels should be repeated several times. If the deaf-mute under- stands the vowels easily, consonants and even words and short sentences may be tried. In most cases this method can only be made use of when the deaf-mute in question has learned to articulate. A greater power of hearing is seldom met with, unless sound-increasing apparatus are employed. The hearing of deaf- mutes with considerable remains of hear- ing can also be tested with a loud-ticking . watch placed outside the ear or pressed against the outer ear. It is, however, very unusual for deaf-mutes to be able to distinguish the high notes represented by the ticking of a watch. In employing all these methods, it must be remem- bered that the hearing of deaf-mutes dif- fers greatly at different times in some cases, according to varying conditions in the ear, of which we have no immediate knowledge. The reports of various investigators, as to the relative number of deaf-mutes with total deafness, differ considerably, for, while some have found that only about one-fourth of the deaf-mutes ex- amined were totally deaf, others have found a much larger proportion, the principal cause of this discrepancy being probably the fact that there is generally a distinct relationship between the deaf- ness and its cause. This relationship is most distinctly seen by comparing the power of hearing of congenital deaf- mutes with that of deaf-mutes with ac- quired deafness. All investigators, with a few exceptions, have, namely, found a much greater number of cases of total deafness among deaf-mutes with ac- DEAF-MUTISM. SYMPTOMS AND SEQUELAE. 377 quired deafness than among deaf-mutes with congenital deafness. The reason why so many more cases of total deafness are met with among deaf- mutes with acquired deafness than among those with congenital deafness is owed to the fact that post-natal proc- esses in the ear causing deafness are much more destructive than the same processes occurring during foetal life: a circumstance which has been previously pointed out. Most authors have also found that congenital deaf-mutes are more frequently in possession of a con- siderable degree of hearing (hearing of vowels or even of words) than deaf-mutes with acquired deafness. It may be mentioned, finally, that Bezold examined the hearing power of deaf-mutes by means of a graduated series of tuning-forks and found that frequently "islands" of perception of notes alternated with total defects of hearing. These defects appeared most frequently in the lower end of the scale — a fact which has been corroborated by Uchermann. Mutism. — Mutism was in early times believed to be the primary and essential symptom of deaf-mutism, but it is known now to be a secondary phenomena which is the consequence of the deafness. That this is the case is also evident, from the fact that the degree of mutism is, as a rule, in exact relation to the degree of deafness, and also to the period at which the deafness makes its appearance. Thus congenital deafness, or deafness acquired in early infancy, is always accompanied by complete mutism (excepting in cases in which the mutism is removed by special methods of education), while in cases of acquired deafness, in which the deafness is either not total or arises after the child has learned to speak, a certain degree of speech is respectively acquired or retained. The explanation is simple, speech being, under normal circum- stances, acquired through the ear, the child imitating the words which it hears spoken by those about it. It may, how- ever, be mentioned that even children totally devoid of hearing produce sounds which sometimes resemble words, such as "ma-ma," 'T)a-ba," etc., and sometimes also imitate animals, often thus causing their friends to suppose that they are capable of hearing. This may be because the above-mentioned sounds and the voices of certain animals are produced by very simple movements of the vocal organs which can be imitated by spontaneous observation. Finally, it is possible that the vibrations caused by such loud soimds as the barking of a dog, bellowing of a cow, etc., may be perceived by the aid of touch, which sense is often highly developed in deaf children, and consequently guides them in imitating the sounds. The question as to the degree of deaf- ness which must exist, or, in acquired cases, the age at which the deafness must appear in order to cause mutism result- ing in deaf-mutism, cannot be answered decidedly. To begin with, the applica- tion of the term "deaf-mutism" is en- tirely arbitrary in cases in which there is some power of hearing or of speech, and the distinction between a deaf-mute child and a child with deficient power of hear- ing must in some cases depend entirely upon practical considerations, of which the method of instruction which is requi- site for the child's education is, as a rule, decisive. Thus, for instance, a child of well-to-do parents, who is able to hear tunes and to a certain extent reproduce them, will scarcely be considered deaf and dumb and sent to an asylum, while a child with the same degree of hearing, but of poor parents, will be treated as a 378 DEAF-iaTISM. SYMPTOMS AND SEQUEL.E. deaf-mute, because the parents are un- able to give it the special education which it requires. The non-development or deficient development of the power of speech in cases of congenital partial deaf- ness, and its complete or partial loss in cases of acquired deafness,' are also often dependent upon the assiduity with which a child's friends attend to its develop- ment or preservation. Some children, too, seem to have a greater aptitude for developing or retaining the power of speech than others, and this seems to be not only dependent upon their intellect- ual faculties, but also upon other un- known conditions. Thus, a child with comparatively very slight power of hear- ing, or with deafness acquired soon after birth, may exhibit a comparatively con- siderable power of speech, while another child with greater powers of hearing and later acquired deafness may be entirely without it. Future investigations will in all proba- bility decide how far total acquired deaf- ness results in total njutism. Hartmann states that deafness acquired before the age of seven causes secondary mutism, and this opinion is, no doubt, correct. On the other hand, there are reports from various places to the effect that deaf- mutism may appear at the age of 14 or 15 or even later. In these cases, however, it is probable that the term deaf-mutism is incorrect, though, of course, such acci- dental circumstances as feeble-minded- ness, blindness, etc., may necessitate the registration of persons who have lost the power of hearing so late in life as deaf- mutes, because they are unable to read from the lips, or unable to pronounce so distinctly as to be understood. As mentioned above, mutism in deaf- mutes may be either total — i.e., the power of speech may be entirely wanting — or it may be partial, in which latter case the power of speech is developed, or, in ac- quired deaf-mutism, it is retained to a certain extent. This power of speech is frequently considerable; so that such persons cannot, properly speaking, be termed mutes. There are, however, cer- tain peculiarities which always attach themselves to the speech even of persons who are only partially deaf from their birth, or who have become deaf during childhood. These peculiarities, which are still more pronounced in true deaf- mutes, consist in the absence of accentua- tion of syllables and of words, the result being that speech becomes monotonous. Besides this, the speech of such persons is generally dull-sounding and feeble, and the control of respiration is also de- ficient. The stock of words is also some- times limited, though this peculiarity is, under ordinary circumstances, not very noticeable, excepting in cases where the power of hearing is very slight, or where the deafness appears comparatively early. These physical deficiencies in the speech of deaf-mutes are easily accounted for, because the power of hearing is not only important in the development of speech by enabling a child to imitate the speech of others, but it also enables it to regulate the modulation, sound, and force of its voice by the aid of the vibrations which reach the labyrinth through the bones of the cranium. The power of hearing plays so great a part in the above-mentioned physical qualities of speech that its loss cannot be completely compensated for by any other sense. It is, however, possible, by aid of sight and touch, to teach a great number of deaf-mutes to speak well enough to be able to use speech as a means of commimication. Persons who have been totally deaf from birth can also be taught, by a special method of instruction, to speak so that they can be DEAF-MUTISM. SYMPTOMS AND SEQUEL.^. 379 understood, though with the peculiarities above mentioned. Owing to these pecul- iarities, such speech has received the name of "articulation." It is not always an easy matter for the deaf-mute to re- tain the power of speech which he has gained with so much difficulty, when he enters the world and comes in contact with persons who cannot, or can only partially, understand him. In such cases the deaf-mute generally abandons the use of speech as a means of communica- tion, especially as lip-reading requires great attention and well-developed sight. Disturbances of the Equilibrium. — It has been mentioned that acquired deafness is often accompanied by disturb- ances of the equilibrium, both at its first appearance and immediately afterward, and that this complication is most fre- quent in cases where the deafness has been caused by cerebrospinal meningitis. Mention is also made in literature of some few cases of congenital deafness accompanied by disturbances of the equi- librium, consisting in uncertain and stag- gering gait, both during the first years of childhood and later on in life. James was the first to draw attention to "im- munity from dizziness," under circum- stances which otherwise produce dizzi- ness and consequent disturbance of the equilibrium, as characteristic of deaf- mutes. He examined altogether 519 deaf-mutes and found that 18G — i.e., 36 per cent. — did not feel the least dizziness when spun round rapidly, no matter in what position their heads were placed. James was also informed by many of these deaf-mutes that they Experienced a remarkable feeling of helplessness and want of sense of locality when under water, several of them also stating that these sensations were unkno\\'n to them before the loss of hearing. Kreidl en- deavored to discover in a more rational manner, and by the aid of a specially- constructed apparatus, an objective proof of the above-mentioned phenomena in deaf-mutes, and also to decide their nature and strength. Pollak endeavored to produce dizziness in a number of deaf-mutes by conducting a galvanic current through their heads. Several exliibited signs of dizziness, accom- panied by movements of the head and eyes, also exhibited by normal subjects under like circumstances, while 29.3 per cent, were not affected in any way; in these, then, it was to be supposed that the semicircular canals were entirely de- stroyed, and Pollak points out the resem- blance between the figures thus obtained and the percentage of cases of entire ab- sence or destruction of the semicircular canals found by post-mortem examina- tion of deaf-mutes. Although deaf-mutism brings with it a long train of indirect consequences, which are of great importance as affect- ing the daily life of the deaf-mute, its more direct results are but few, and even these are the subject of dispute. Deficient Development of the Mental Faculties. — There can be no doubt that the want of such an important sense as hearing must at least result in a slow development of the mental facul- ties, as the psychological function of the brain develops not only in proportion to its receptivity to impressions from without, which are so necessary for mental growth {"nihil est in inteUedu quod non antea fuerit in sensibus"), and to the quality of these impressions, but also in proportion to their quantity, which must of necessity be diminished when one of the routes by which they reach the brain is closed or partly closed. This does not, of course, prevent a deaf- mute from attaining the same degree of intellectual development as a normal 3S0 DEAF-MUTISM. SYMPTOMS AND SEQUELS. person with the same amount of intelli- gence, if his physical deficiency is com- pensated for by energy, industry, etc. There is, however, no doubt that purely practical considerations — for instance, the necessarily-limited choice of profes- sions — often hinder such a complete in- demnification for the loss of so impor- tant a sense as hearing. The deaf-mute is thus deprived of one of the most im- portant incentives to energy, — namely, ambition; and it is, doubtless, in these external hindrances, that the reasons are to be sought why no deaf-mute has as yet written his name on the pages of history. Further, the morbid processes causing deaf-mutism often have their seat in the brain, as has been already pointed o\it, and these processes often leave other traces behind them. Hart- mann found also that one-half of the pupils examined by him in deaf-and- dumb asylums, whose deafness was due to brain disease, were but moderately or indifferently endowed with intelligence, and it was altogether doubtful whether many of these subjects were capable of instruction. There are also statistical proofs from other countries that deaf- mutism is often accompanied by want of mental power. It is not, however, cor- rect to infer that deaf-rautism can result in idiocy from the circumstance that deaf-mutes are often idiots. Idiocy, when it appears simultaneously with deaf-mutism, is the result of a congenital brain disease, or one acquired in infancy, and is of superior or co-ordinate impor- tance to the deaf-mutism itself; persons exhibiting both these abnormalities must, doubtless, not be considered as idi- otic deaf-mutes, but as deaf-and-dumb idiots. IT. Schmaltz and Lemcke have made some measurements of the heads of deaf-mutes in order to elucidate the question as to the intelligence possessed by deaf-mutes. Both these investigators found that the heads of deaf-mute chil- dren were, as a rule, smaller than the heads of normal children, especially in the younger age-periods. The reason is, doubtless, that the mental faculties of deaf-mute children are less developed than those of other children. Abnoemalities of the Ear Found BY Objective Examination. — While the section of this paper on morbid anat- omy will be mainly devoted to the path- ological changes of the deeper parts of the ear, it is my purpose, under this head- ing, to deal with the abnormalities found in those parts of the ear which are ac- cessible to objective examination. It would naturally be supposed that as deaf- mutism is often caused by anomalies of the ear, deaf-mutes would often exhibit congenital abnormalities of the external ear. This is, however, not the case, as congenital malformations of the external ear are but seldom met with. A close investigation of the cases of malforma- tion of the external ear reported in lit- erature proves also that these abnormali- ties are but very rarely accompanied by such a diminution of the powers of hear- ing as to result in deaf-mutism, which circumstance has been laid much stress upon by Toynbee. Abnormalities of the external meatus have been often met with. It is, however, often difficult to decide the nature of the abnormalities from the descriptions of them we possess, and a comparison of the frequency with which they have been found by various investigators is, therefore, of no interest. Contraction of the meatus would seem to be the abnormality most frequently met with. The greatest interest, how- ever, attaches to the closing of this pas- sage, which has been found l)y many in- vestigators without being accompanied by any malformation of the external ear. DEAF-MUTISM. SYMPTOMS AND SEQUELAE. DIAGNOSIS. 381 There can be little doubt that when the meatus is closed by a membrane situated close to the external ear this is due to congenital malformation; should the membrane, however, be situated in the neighborhood of the tympanum, it is pos- sible that the obstruction is the result of inflammation in the tympanic cavity. I have, at least, in two cases, observed such a closing of the external meatus of deaf- mutes resulting from scarlatinal inflam- mation, in the one case on both sides, in the other on one. As to otoscopic examinations of deaf- mutes, these have contributed very little to the pathogenesis or etiology of deaf- mutism. Such investigations have been published by various authors, whose re- searches, in spite of the care which has been bestowed upon them, have lead to very little result; in fact, the various authors differ very considerably in the results obtained. The difference ob- served in the results of examinations of normal children and pupils at deaf-and- dumb asylums lies in the greater fre- quency with which the abnormalities found appeared in deaf-mutes, and not in the nature and kind of these abnor- malities. All investigators who have classified the deaf-mutes examined by them according to the nature of their deafness (congenital, acquired, or doubt- ful) agree that the otoscopic examina- tion of the drum-heads in cases of con- genital deafness yields a negative result more frequently than in cases of acquired deafness, the latter more frequently ex- hibiting destructive inflammatory proc- esses or the traces of such. Abnorm.\lities of the Mucous Mem- BR.^NES AD.TACENT TO THE Eau. — Ca- tarrhal changes of the mucous mem- branes of the nose, naso-pharynx, and pharynx have been frequently observed. These changes have most frequently taken the form of hypertrophy of the whole mucous membrane, or of the aden- oid tissue (adenoid vegetations, hyper- trophy and hyperplasia of the tonsils), less frequently the form of atrophy (ozsena, atrophic catarrh of the naso- pharynx and pharynx). The frequency with which catarrhal changes of the up- per air-tract has been observed by inves- tigators differs greatly. The cause is doubtless to be sought in the circum- stance that catarrhal diseases of the nose, naso-pharynx, and phar3Tix appear with varying frequency in different countries and in different classes of society, as cli- mate, mode of living, clothing, hygienic conditions, etc., as is well known, play an important part in the appearance of catarrh in the air-passages. The results of such examinations of deaf-mutes will, therefore, first be of use in judging of the relation of such affections to deaf-mut- ism, when we possess information as to the frequency with which catarrhal dis- eases of the upper air-passages appear in normal subjects of the same age and living under the same conditions as the deaf-mutes from which to draw com- parison. It seems, however, to be, be- yond doubt, that deaf-mutes suffer with great frequency from adenoid vegeta- tions of the naso-phar}Tix. Abnormalities of the Eye. — Al- though we find several notices of abnor- malities of the eyes of deaf-mutes, it is often difficult to decide whether these are accidental phenomena or connected etiologically with deaf-mutism. Among the abnormalities of the latter category may be mentioned retinitis pigmentosa, various malformations of the eye; atrophy of the bulb caused by panoph- thalmia, a result of the same acute dis- ease as caused the deafness; finally syph- ilitic interstital keratitis. Diagnosis. — Although deaf-mutism 382 DEAP-irUTISlI. DIAGNOSIS. from a theoretical point of view is not a very distinctly-defined condition, still the majority of cases are easily recog- nized. The question whether a person is a deaf-mute or not must, according to what has been laid down in the fore- going pages, be principally decided by examinations as to the function of the auditory nerve. If this is entirely sus- pended, or so reduced that speech can- not be heard, and if the history of the case proves that this condition dates from birth or infancy, then the subject must be regarded as a deaf-mute. We are also justified in applying this term, as has already been pointed out, even where there exists some power of speech either acquired by special means of instruction or where the deaf-mutism has appeared at a more advanced age, retained to a greater or less extent. The circumstance that the pathological condition called deaf-mutism is based upon a symptom, the extent of which cannot be measured with any degree of certainty, but which, nevertheless, is decisive, naturally causes arbitrary decisions in some cases, which decisions generally depend upon purely practical considerations. In other words, there are persons as to whom it is difficult to say with certainty whether they are deaf-mutes or not. Such are persons who can hear the human voice to a certain extent, and who consequently learn to articulate by the aid of special methods of education, or such as have lost the power of hearing so late that they have retained the power of speech, although their voice is always somewhat peculiar. Such persons are, however, but few in number, and consequently the diiTiculty in diagnosing deaf-mutism mentioned here is of very slight practical impor- tance. Of much greater importance are the difficulties which present themselves when the person in question is an infant. It must, however, be pointed out that the term "deaf-mute" is incorrect when applied to children under a year old, as no children can speak at that age. It would seem, indeed, that great caution must be observed in drawing the con- clusion that deaf-mutism will necessarily be the result of even total deafness ob- served during the first year of infancy, since, according to the experience of many etiologists there are some children who are unable to react, or who react very slowly, to sounds during the first year of infancy, but whose hearing, nev- ertheless, when older, is perfectly normal. In any case it is extremely difficult to arrive at any decided opinion whether an infant possesses the power of hearing or not, and especially as to what degree of hearing it possesses, and, as a rule, the younger the child, the greater is this dif- ficulty. The reason is, doubtless, that the sound-conducting apparatus of in- fants is not complete at birth. The ex- ternal meatus and the tympanic cavities are transformed after birth from cavities filled with cellular tissue to pneumatic cavities. It was formerly supposed that infants did not react to sound, but it has been proved that this is not the case, even with newborn infants, and infants can also perceive musical notes. Even in the second half of the first year of childhood it is, however, very difficult to decide whether the power of hearing ex- ists or not. No great confidence can be attached to the statements of a child's friends as to its having heard certain sounds, as the vibrations of the air caused by certain sources of sound may produce efTects upon the sensory nerve wliich may be mistaken for the result of vibrations of air acting upon the auditory nerve. It is, therefore, of the greatest impor- tance, in experimenting with the hearing DEAF-MUTISM. DIAGNOSIS. 383 of infanta, to make use of such sources of sound, or to make use of them in such a manner, that only the vibrations of sound produced can be perceived. Loud dinner-bells are suitable for this pur- pose; the so-called watchman's whistle, Galton's whistle, clapping of hands, and the firing of small pistols, which the child should not be allowed to see. If the child reacts to these sounds it will blink its eyes or exhibit either joy or fear. Should the results of such experiments be negative, it is not necessary, as before mentioned, to conclude that the child will become a deaf-mute. After the com- pletion of the first year of infancy, how- ever, the older the child, the greater the importance which must be attached to such negative results. After that period we may look for another symptom to help us in our diagnosis, viz.: the ab- sence of speech. This, too, may be de- lusive, as some children, although in full possession of normal powers of hearing and intellect, do not begin to speak at the end of their first year, but later, some- times much later. The cause may be some hidden condition or constitutional disease; for instance, rickets. Another condition which may be mis- taken for deaf-mutism is simple mutism (aphasia) uncomplicated with deafness or idiocy. This abnormality, which is not at all rare in adults as the result of cer- tain brain diseases, is but seldom con- genital or acquired in infancy, at least, there are but few references to it in lit- erature. This form of aphasia must, ac- cording to some authors, be regarded as the result of a disease which is localized in the central nervous system, causing total inability of speech in the person afTected, or inability to speak more than a few indistinct words. This infantile aphasia, which seems, as a rule, to be congenital, differs from the mutism of deaf-mutism, principally inasmuch as it is not accompanied by deafness, and often, also, in the subject affected being able to produce certain words or sounds resembling words, which are always em- ployed in attempts at speech. Aphasia accompanying feeble-mindedness, imbe- cility, or idiocy is a much more frequent abnormality, which is still more easily mistaken for deaf-mutism, especially in such cases where the imbecility is so con- siderable that the interest for sound is diminished. In these cases, however, the imbecility, which must be regarded as the primary disease, will generally show itself in the patient's appearance, move- ments, gestures, etc. Hysterical mutism may sometimes simulate deaf-mutism. It is, however, generally accompanied by pronounced symptoms of hysteria, and exhibits itself by the patient's making no attempts to speak, or even to articulate. It is gener- ally of short duration and easily recog- nized, the diagnosis only offering some difficulty in cases where the mutism ap- pears in deaf, hysterical subjects. The question whether deaf-mutism is congenital or acquired is, doubtless, that which offers the greatest difficulty in forming a diagnosis of deaf-mutism. In all cases, however, when the deafness ap- pears- after the child has begun to speak, or where the immediate causes of deaf- ness are known, the diagnosis is an easy matter. If, on the contrary, the deaf- ness has made its appearance prior to the period at which speech is generally de- veloped — whether the morbid changes of the organs of hearing causing deafness are congenital or acquired — a decision as to the fcctal or post-fa?tal origin of the deafness is accompanied by groat, indeed often insurmountable, difficulties. In such cases it is, therefore, of the greatest 384 DEAF-MUTISM. ETIOLOGY. moment to obtain the most explicit in- formation from the deaf-mute's friends, especially the parents, who are most likely to be able to give reliable informa- tion as to the diseases and pathological conditions which exist in the family. An opinion as to the origin of deaf-mutism can, as has been previously mentioned, only in exceptional cases be based upon objective examination of the subject. Such exceptional cases are, for instance, those in which visible and pronounced malformations of that part of the ear which is accessible to examination clearly indicate that deaf-mutism is the result of congenital changes of the auditory organs. Such cases are, however, very rare. Malformations in other parts of the body also indicate, though with a much less degree of certainty, that the condition in the ear is congenital; but these cases are rare. The objective ex- amination of the ear, in the great ma- jority of cases, offers nothing which can be relied upon with any degree of cer- tainty, since, on the one hand, patholog- ical changes of the external and middle ear, which may, according to their na- ture, be acquired after birth, may very well exist in persons whose deafness is due to congenital malformations of the auditory organ; while, on the other hand, less-pronounced congenital changes of the external and middle ear (for in- stance, lesser degrees of microtia and ma- crotia, contraction of the external meatus, abnormal position of the drum- head, etc.) may very well appear in per- sons with acquired deafness. A final decision as to the congenital or acquired origin of a case of deaf-mut- ism must, then, in the majority of cases, be entirely based upon inquiry, and, even when explicit information is obtainable, it is often diCTicult to arrive at a definite opinion. It will be always advisable to make inquiries whether the child's speech has developed in the same way as that of ordinary children of the same age, because non-professional persons' statements as to a child's power of hear- ing are often unreliable. Should the answers be in the affirmative, and should it be proved that the power of speech has been lost, or is arrested in its devel- opment from some or other cause (acute brain disease, scarlet fever, measles, etc.), it may be safely concluded that the deaf- mutism is of post-fcetal origin. This diagnosis is also justified, though with less certainty, when the above-mentioned causes have shown themselves during the first years of infancy, unless, of course, ample and satisfactory proof can be pro- duced that the child has never possessed the power of hearing, or that the more remote causes of deaf-mutism (unfavor- able social conditions, heredity, consan- guinity, etc.) have appeared in great force; in such cases a decision must re- main doubtful. Should, however, the possibility of the direct causes (scarlet fever, brain diseases, measles, etc.) be excluded, and it is proved that the child never possessed the power of speech, it may be supposed that the deaf-mutism is the result of congenital changes of the organs of hearing. This supposition is the more warranted the greater proof there is that the more remote causes of deaf-mutism have played their part in the case in question. Etiology. — The causes of deaf-mutism may be subdivided into two groups: (A) the remote causes, and (/?) the immediate causes. (A) Remote Causes. — Among these are to be mentioned principally natural conditions, unfavorable social and hygi- enic conditions, heredity, consanguinity and a few others of minor importance. Natural Condilinns. — In considering DEAF-MUTISM. ETIOLOGY. 385 the unequal distribution of deaf-mutism, we are involuntarily led to the supposi- tion that this phenomenon may be caused by varying natural conditions, among which soil and elevation seem to play an important part. To H. Schmaltz is due the honor of having investigated the question of the importance of geological conditions and elevation in Saxony so thoroughly that his results are entirely to be relied on. In these investigations, which have em- braced the minutest details which could possibly be of importance concerning the appearance of deaf-mutism, the author has weighed each separate point care- fully. His conclusions are as follow: There is nothing to be said 'in favor of the hypothesis that soil, climate, or other territorial conditions influence the deaf- mute rate, neither can the composition of the water be proved to affect it in any way, but it is the social and hygienic conditions which are decisive. Lemcke, in Mecklenburg-Schwerin, and Ucher- mann, in Norway, were also unable to prove that geological conditions are a cause of deaf-mutism. Unfavorahh Social and Hygienic Con- ditions. — Almost all authors who have considered the question of the connec- tion between deaf-mutism and unfavor- able social and hygienic conditions, agree in ascribing to them great importance as causes of deaf-mutism. The statistical proofs in support of this hypothesis are not, however, on the whole, very satis- factory. The best statistics are furnished by H. Schmaltz, who has come to the following conclusions: "The industrial population, and especially that part of it which is worst off pecuniarily, — in fact, all who are in danger of degenerat- ing both morally and physically on ac- count of insufficient means, or poverty, and who consequently are unable or un- willing to take the necessary care of their children, — all such persons exhibit the highest percentage of deaf-mutes among their descendants. Finally, when, in ad- dition to all these unfavorable condi- tions under which children are born, they are brought up by a family which, from various reasons, is, perhaps, more or less degenerated, and have to undergo all sorts of diseases in infancy without hav- ing sufficient power of resistance, thus deaf-mutism is an only too common re- sult." On the other hand, Uchermann states that in Norway unfavorable social and hygienic conditions are far from in- creasing the deaf-mute rate, it being higher among the better-situated classes. Ueredity. — Opinions have differed greatly as to the heredity of deaf-mutism, the reason being that not only are the laws which govern the hereditability of pathological changes and diseases sub- ject to different interpretations, and that the statistics employed have given dif- ferent results, but also that the term "heredity" is used in different ways. The term "heredity" is used by many authors to express the frequent appear- ance of the same pathological condition in two consecutive generations, otlier in- fluences having, of course, been excluded. The statistics which have been employed in attempts to solve the question of the frequency with which deaf-mutism ap- pears in two consecutive generations have been based on two diflcrent meth- ods: the one calculating how often deaf- and-dumb persons had deaf-and-dumb parents, the other how frequently unions where the one or both parties were deaf and dumb resulted in deaf-and-dumb offspring. The first mode of ascertaining tlio fre- quency with which deaf-mutism appears in two generations, consisting in discov- ering how often deaf-and-dumb subjects 386 DEAP-MUTISil. ETIOLOGY. belonging to large groups of deaf-mutes are descended from deaf-and-dumb par- ents, everjTvhere gives the result that deaf-mutes very seldom have deaf-and- dumb parents. This is even the case when only congenitaUy deaf have been the objects of investigation, Uchermann, for instance, finding in Xorway among 921 deaf-mutes with congenital deafness only 2 with deaf-and-dumb parents. This seems to prove that deaf-mutism is rarely inherited in the strictest significance of the term, or, as it might also be ex- pressed, inherited directly. It must, how- ever, be borne in mind that marriages contracted by deaf-mutes are, and es- pecially have been, comparatively rare in Europe, and also that their fertility is smaller than that of other marriages; there can certainly be no doubt that the direct hereditability of deaf-mutism is certainly of much greater importance than might be supposed from the above- mentioned statistics. This opinion is corroborated by sta- tistics founded on the second mode of estimating the frequency with which deaf-mutism appears in two consecutive generations, viz.: by calculating how fre- quently unions where one or both parties are deaf and dumb result in deaf-mute offspring. The European statistics of this kind are but few and small, the reason being mentioned above, while the excellent American statistics collected by E. A. Fay are very comprehensive, mar- riages contracted by deaf-mutes being so much more frequent in the United States. The principal results of Eu- ropean statistics have been that a deaf- and-dumb child was bom in about every thirtieth or thirty-first union where one party was deaf and dumb, and that deaf- mute ofTspring were much more fre- quently the result of unions where both parties were deaf and dumb. The sta- tistics published by Fay are based on in- vestigations of over 5000 marriages con- tracted by deaf-mutes and have given the result that over 9 per cent, of these re- sulted in '"'deaf oft'spring, and, curiously enough, the marriage where both parties were deaf did not result more frequently in deaf offspring than those where only the one party was deaf." Fay also found that marriages of congenital deaf persons and of deaf persons with deaf relatives gave a far greater liability to deaf off- spring. If, now, the term "heredity" is used to express the conspicuous frequency with which the same abnormality appears in the same family, the hereditability of deaf-mutism becomes still more evident. The frequency with which deaf-mutism appears among the parents of deaf-mutes has been mentioned above. Cases of deaf-mutism among the grandparents, great-grandparents, etc., of deaf-mutes, which should prove the direct heredity per saltum, as it is termed, must neces- sarily be still less frequent, as marriages between deaf-mutes were very rare in the first half of this century. If we, how- ever, look for cases of deaf-mutism in other branches of the deaf-mutes' family- tree, we find in all statistics that — con- sidering that deaf-mutism is a compara- tively - rare pathological condition — a great number of deaf-mutes are to be found among the uncles, aunts, great- uncles, great-aunts, cousins, and second cousins of deaf-and-dumb persons. Ac- cording to European statistics, embrac- ing a large number of deaf-mutes, about every sixteenth deaf-mute has one deaf- and-dumb relative among tlie category al)ovc mentioned (parents, grandparents, brothers, and sisters excepted), the point where deaf-mutism most often appears corresponding to generations co-ordinate with the parents. These statistics have DEAF-MUTISM. ETIOLOGY. 387 also shown that it is almost exclusively congenital deafness which plays a part in this respect. Deaf-mutism, finally, is to be met with more frequently among the brothers and sisters of deaf-mutes, and there are statistics as to congenital deaf-mutes according to which 50 per cent, of these had one or more deaf-and- dumb brothers or sisters. The appear- ance of deaf-mutism in two or more children of the same parents is very characteristic, and there are few patho- logical conditions which show such a tendency to appear in the same branch of a family, there even being cases on record where ten deaf-and-dumb chil- dren were born in the same marriage. frequency among the relatives of deaf- mutes and with about double the fre- quency among the relatives of congenital deaf-mutes as among the relatives of deaf-mutes with acquired deafness. Their appearance is particularly clearly demonstrated by several genealog- ical tables published by Dahl and Ueher- mann, of w^hich the one depicted below is an interesting example. [Albinism, retinitis pigmentosa, and malformations are also frequently found among the relatives of deaf-mutes; these anomalies are probably to be considered as signs of degeneration, deaf-mutism it- self being undoubtedly in several cases a degenerative phenomenon. These anomalies, however, might also be con- Si St (XDIOTJ I l.± _L ,_L (—') [V. f !^ r (EPILEn"lt)(llllOT)^.UfiATKj ' I (idiot) (Li/N'vricl (lunhtic; (it), or) (BE/iF-MurrJ I (pzuF-nuTt) ^EAF-r-iuTE) (ochr-fiurc) (xbiot) .V, male. /■. foiuale. Finally, if by heredity we understand the frequent appearance in a family of not only one pathological condition, but of several others related to it anatomic- ally or etiologically, we shall see that he- redity is a most important factor in the etiology of deaf-mutism. It is, namelj', proven by several comprehensive statis- tics that partial or total deafness due to different car diseases (which have not led to deaf-mutism, on account of the lesser degree of the loss of hearing or of its unilateral appearance, or of its later development in life), insanity, epilepsy, idiocy, stammering, and other defects of speech, hysteria, and several other nerv- ous diseases appear with conspicuous sidered as "nervous abnormalities." HoL- OEB Mygind.] The laws which may, then, be sup- posed to regulate the heredity of deaf- mutism are difficult of interpretation, and seem in many respects to differ from those which relate to other pathological conditions and diseases. This may be accounted for by supposing that, as the causes of deaf-mutism in general are numerous and varied, so are also the causes of each individual case. The cir- cumstance that deaf-mutism, so far as its etiology is concerned, must be divided into two distinct classes, the congenital and the acquired, the latter of necessity including numerous cases in which deaf- 3SS DEAF-MUTISil. ETIOLOGY. ness is to be traced to accidental causes, is alone sufficient to render the interpre- tation of the laws of heredity, by the help of investigations ■which embrace deaf-mutes in general, of the greatest difficulty. When we add to this that, although the importance of heredity in deaf-mutism is undoubted and consider- able, there are other factors of at least equal importance, and that there is much which tends to neutralize the transmis- sion of morbid tendencies (favorable so- cial conditions, crossed marriages, etc.), it will be evident that there is much which renders a just explanation of the laws of heredity anything but an easy task. If we compare deaf-mutism with haemophilia, which it resembles so far as heredity is concerned, we shall see how correct the above statements are. Hsemo- philia — which, like deaf-mutism, may pass over several generations and accu- mulate in a single, being also most fre- quent among males and in the children of fruitful marriages— is, etiologically, but little complicated, partly because it is not related to any other anomaly, and partly because heredity is the governing cause. With deaf-mutism it is very dif- ferent. It, too, may accumulate in single generations, being most frequent in brothers and sisters and much less fre- quent in the older generations. In these, however, there can be found a compara- tively large number of cases of partial or total deafness, insanity, epilepsy, etc., which seems to indicate that deaf-mutism is, in many cases, a combined result of the transniission of various influences. These influences fall into two groups: those which originate in ear diseases, and those which originate in nervous disease in the family. Now, as the morbid anatomy of deaf-mutism proves that in the majority of cases the deafness caus- ing deaf-mutism arises from altmrmnli- ties of the nervous parts of the auditory organ, — the labjTinth, — there is reason to suppose that in many cases deaf-mut- ism is caused by the transmission of the above dual influences through the par- ents. Supposing this hypothesis to be correct, our knowledge of the laws of heredity in deaf-mutism assumes at once a more distinct form, though we cannot ever expect it to be as clear as it is, for instance, in regard to the laws which govern liDsmophilia, for, as above men- tioned, the causes of deaf-mutism are too numerous and varied. Even twins, who would seem to be exposed to exactly the same influences during fcetal life, are sometimes the one a deaf-mute, the other a normal subject. Consanguinity. — The question of the importance of consanguinity as a cause of deaf-mutism has been a fruitful sub- ject of discussion. The first decidedly- expressed opinion upon this topic ap- peared in 1846, when Meniere and Puy- bonnieux, who were, respectively, med- ical attendant and teacher at the State Deaf and Dumb Institution in Paris, laid great stress upon the important part which consanguinity played in deaf-mutism, without, however, produc- ing statistics in support of their theory. Such, however, appeared shortly after in the returns of the Irish census of 1851, which was the first to include this ques- tion in its rubrics, and, from the results thus obtained, Wilde came to the con- clusion that "among the predisposing causes of mutism the too-close consan- guinity of parents may be looked upon as paramount." Vulliet, Landes, Chaza- rain, Bemiss, Ilowe, Dahl, Boudin, Mitchell, and the undaunted defender of the doctrine of consanguinity, Devay, were all in favor of the importance of this factor in the etiology of deaf-mutism, while Bourgeois, P6rier, Iluth, Voisin, DEAF-MUTISM. ETIOLOGY. 389 and G. Darwin were more or less op- posed to the hypothesis that consan- guineous marriages predispose to degen- eration in the offspring, deaf-mutism be- ing generally the principal object of their arguments. Statistical information as to the frequency of consanguinity among the parents of deaf-mutes has also been forthcoming, the frequency with which deaf-mutes are reported as being born in consanguineous marriages varying from 1.6 to 9.4 per cent., while the percentage for deaf-mutes with congenital deafness varies from 2.8 to 23.0 per cent. It will be seen, then, that statements as to the frequency with which deaf- mutes are born in consanguineous mar- riages differ considerably. This can most naturally be explained as resulting from various circumstances. To begin with, such marriages vary in frequency in different countries; thus, in Prussia they form only 0.8 per cent, of all mar- riages; in France 1 to 2 per cent.; and in England 3 per cent, at the outside; in Denmark 3 to 4 per cent., in Saxony 4, and in Norway over G.65 per cent. Fur- ther, there is no doubt that the frequency of consanguineous marriages differs in the different confessions and classes of society, in cities, and in the country, and liere, also, in different districts. It must also be observed that the various statis- tics sometimes embrace whole countries, sometimes single districts, and sometimes deaf-and-dumb institutions, clinics, etc. Tlie information in question has also been obtained in different ways; for in- stance, by reports, censuses, individual investigations, etc., and finally the dif- ferent authors liave included different degrees of relationship. Although many investigators have found comparatively few deaf-mutes born in consanguineous marriages, there are several circumstances which seem to prove that consanguinity is an impor- tant factor in the etiology of deaf-mut- ism. They are the following: — Several statistical reports, the relia- bility of which cannot be doubted, are to the effect that deaf-mutes are com- paratively often born of consanguineous marriages, and there seems to be reason to lay greater stress upon such positive results than upon those pointing in a negative direction. All authors are unanimous in declar- ing consanguineous origin to be more common among congenital deaf-mutes than among deaf-mutes in general. This indicates that it is deaf-mutes with ac- quired deafness who reduce the rate that expresses the frequency with which deaf- mutes in general are born in consan- guineous marriages. That consanguinity plays a part in congenital deafness only, or almost only, may be seen from the circumstance that all authors who have occupied themselves with this subject have come to the result that deaf-mute children born of consanguineous mar- riages are, in the majority of cases, born deaf, while only a small majority become deaf after birth. That consanguinity is of importance in the etiology of deaf-mutism is evident from the circumstance that several au- thors have proved that, among the mar- riages of which the deaf-mutes are born, the consanguineous unions produce a larger number of deaf-mutes than the crossed. Finally, several statisticians have proved that, the closer the degree of re- lationship between the parents, the larger was the number of deaf-mute cliildren born. It will be seen that there are various circumstances which clearly indicate that the intermarriage of relatives plays no insignificant part in the etiology of deaf- 390 DEAF-MUTISM. ETIOLOGY. mutism. Everything, however, tends to prove that it is entirely, or principally, in congenital deafness that consanguinity is an important etiological factor. It is, however, imdecided whether con- sanguinity in itself is a remote cause of deaf-mutism, or whether it is through the intensiiied transmission of heredi- tary, morbid conditions or tendencies prevalent in a family that it makes itself felt. Theoretical considerations and a few lately piiblished investigations in Xorway by I'chermann are strongly in favor of the latter supposition; still it is but fair to say that up to the present there have not been many or convinc- ing facts brought forward in its support. There are, then, but few facts which serve to elucidate the question whether the influence of consanguinity upon deaf- mutism is direct or indirect. Further in- vestigations of the same nature will, per- haps, throw more light upon this sub- ject. The final solution of the question ^^•ill, however, in all probability, only be brought about by means of information as to the family, supported by an exact knowledge of the relatives of the deaf- mutes, and supplemented by their thor- ough objective examination. It is only thus that it will be possible to find less pronounced, but not on that account less important, abnormalities in the family, and to discover with what frequency the influence of heredity can be, with cer- tainty, excluded in consanguineous mar- riages resulting in deaf-mute children. There are, besides the above men- tioned, several other remote causes, which are, more or less properly, sup- posed to play a part in the etiology of deaf-mutism; of these the most impor- tant are the following: — Alcoholism in the Parents. — Although the abuse of alcohol is extremely com- mon, and although we have no informa- tion as to its frequency, on the whole; still, several reports seem to indicate that alcoholism in the parents plays some part in the etiology of deaf-mutism. Among the most important facts as to this ques- tion must be mentioned those stated by Uchermann in Norway, where, in cases of deaf-mutism of non-hereditary origin, alcoholism was found with double fre- quency among the parents of the deaf- mutes with congenital deafness than among parents of deaf-mutes irtdth ac- quired deafness. It is at present im- possible to form any accurate opinion as to whether alcoholism makes itself felt by weakening the parents' constitution, or whether it is an expression of a nerv- ous disposition. Syphilis in the Parents. — This disease has, on the whole, been found compara- tively seldom among the parents of deaf- mutes. This does not, however, prove that syphilis plays no part in the etiology of deaf-mutism, for it is often difficult to discover, by questioning, whether a person has, or has not had, this disease, and it is also possible that investigations have, up to the present, been deficient in this particular. It is, at all events, cer- tain that syphilis in the parents may produce a form of deafness in the chil- dren, appearing in the later years of childhood, and often leading to deaf- mutism. This form of deafness will be mentioned more particularly under the special etiology of acquired deaf-mutism. Age and Difference in Age of Parents. — Meniere was the first to draw atten- tion to these two factors in the origin of deaf-mutism, stating that, according to his experience, deaf-mutes were often the children of young parents, and that such marriages were frequently sterile or re- sulted in weakly offsprings. Later inves- tigations have, however, not confirmed this. DEAF-MUTISM. ETIOLOGY. 391 Fertility of Marriages. — All authors who have directed their attention to this subject agree that marriages producing deaf-mutes are remarkable for their fer- tility. According to Uchermann, this may be explained by supposing that, the greater number of children there are born, the more strongly the hereditary disposition to deaf-mutism, haemophilia, etc., shows itself. (B) Immediate Causes. — According to recent statistics, in about one-half of the cases of acquired deaf-mutism the deafness is acquired during the first three years of infancy, the greater number of cases falling in the third (statistics from the United States) or the second (Euro- pean statistics) year of life; then comes the fourth, the first, the fifth, sixth, and so on. Brain Diseases. — These play an im- portant part in deafness acquired after birth and resulting in deaf-mutism. The Irish statistics of ISSl show the lowest figure, viz.: 11.9 per cent.; and the Pom- eranian report the highest, viz.: 5-1.5 per cent. It will be seen that the im- portance of brain diseases in tho etiology of deaf-mutism varies considerably in the different countries; this is not only due to the circumstance that the expression "brain disease" includes different affec- ■ tions in the different reports, but also to the varying intensity with which cer- ebral disease appears at different times and at different places. All modern in- vestigators agree, however, that brain diseases are at present the predominant cause of acquired deaf-mutism. There can be no doubt that the most frequent brain disease leading to deaf- mutism is epidemic cerebrospinal menin- gitis, the deleterious influence of which has been especially pointed out by lloos. We possess various clinical observations of partial or complete deafness caused by epidemic cerebrospinal meningitis, and post-mortem examinations of persons whose deafness is due to this disease or other similar brain diseases, which eluci- date the manner in which cerebral affec- tions act deleteriously upon the infantile organs of hearing. The great conformity which exists between the changes in the auditory organs caused by cerebrospinal meningitis and changes declared to be due to inflammation of the brain in gen- eral, or to other diseases with pronounced cerebral symptoms, authorizes us to sup- pose that the facts related in the follow- ing paragraphs hold good for the ma- jority of cases of deaf-mutism caused by acute brain disease. Clinical experience teaches us that the very considerable defects in hearing which appear during epidemic cerebro- spinal meningitis may have a dual origin, viz.: inflammation of the middle ear or an affection of the labyrinth. Loss of hearing from the former cause is, how- ever, seldom so considerable or so lasting as to result in deaf-mutism. Deafness resulting from labyrinthine disease is more rare, but, at the same time, of more importance, since the loss of hearing is, as a rule, very considerable, often, indeed, total, generally affecting both sides, and nearly always permanent. According to iloos and Ivnapp, labyrinthine deafness in epidemic cerebrospinal meningitis generally appears suddenly, seldom grad- ually. As a rule, it appears in the course of the first two weeks, but may also show itself later; Knapp reports a case where it appeared even six weeks after the com- mencement of the disease. Acute Infections Diseases. — The im- portance of this group of diseases in the etiology of deaf-mutism is doubtless at present less marked than that of brain diseases. If, however, epidemic cerebro- meningitis is included amon? acute in- 392 DEAF-MUTISM. ETIOLOGY. fectious diseases, — ^to which group it doubtless belongs, — they immediately as- sume a very prominent place, and there can be no hesitation in declaring that the great majority of cases of deaf-mutism caused by acquired deafness are the re- sult of acute infectious diseases. The importance of the parts played by the different diseases varies greath^, as will be seen, scarlet fever predominating. Scarlet fever (scarlatina). This dis- ease has always and in all countries been recognized as a very frequent cause of infantile deafness, and, consequenth', of deaf-rautism. The influence of scarlet fever on deaf-mutism differs, however, in different countries and at different times, which is doubtless due to the varying intensity and character with which the disease appears. The lowest figures are represented by statistics from Italy (1.5 per cent.), the highest from Saxony (47.6 per cent.). The origin of deafness in scarlet fever has been elucidated by clinical research, which proves that ear diseases caused by scarlet fever generally consist of inflam- mation of the middle ear, with a marked tendency to destroy the mucous mem- brane and osseous walls of the tympa- num, and also the auditory ossicles. The inflammations of the middle ear, which are most frequently propagated through the Eustachian tubes, but which may, perhaps, appear independently, are not, as a rule, in themselves capable of caus- ing a diminution of hearing in infancy so lasting and so considerable as to result in deaf-mutism, unless the labyrinth is affected. Scarlatinal deafness resulting in deaf-mutism is then, doubtless in most cases, due to a partial or entire destruc- tion of the membranous contents of the labyrinth. This destruction is, in many cases, caused 1)y the propagation of the inflammation to the internal ear either through the fenestras (fenestrje rotundis et ovalis) or through the vessels leading from the tympanum to the labyrinth. Some post-mortem examinations of deaf- mutes, whose deafness was the result of scarlet fever, support the former theory, indications of an inflammation of the middle ear being found, also abnormali- ties in one or both fenestra, doubtless the result of an inflammatory process. On the other hand, there are various circumstances which indicate that scar- latinal affections of the labyrinth may appear independentl}' of an inflamma- tion of the middle ear, or that, if such inflammation had existed, it has been very slight. Thus, for instance, it is often found, on otoscopic examination of deaf-mutes, who have become deaf after scarlet fever, that the drum-head ex- hibits but slight or no abnormalities. Measles (morbilli). The reports relat- ing to the frequency of measles as a cause of deaf-mutism vary greatly, though not so much as was the case with scarlet fever, which disease also assumes a much more prominent rank in the eti- ology of deaf-mutism; the lowest rate is Wurtemburg and Baden (1.0 per cent.), the highest Mecklenburg-Schwerin (8.3 per cent.). Among other infectious diseases which now and then cause deaf-mutism may be mentioned the different varieties of typhus (typhoid fever, exanthematic ty- phus), diphtheria, small-pox, chicken- pox, erysipelas, dysentery, influenza, ague, whooping-cough, mumps, inflam- mation of the lungs, and rlicumatic fever. Conslilulional Diseases. — Of these may be mentioned rickets, scrofula and syph- ilis. Altliough sy])hi]is is represented in most statistics relating to the causes of deaf-mutism by only a fraction or not at all in modern statistics, there can be DEAF-JIUTISM. MORBID ANATOMY. 393 no doubt that when inherited from the parents it plays some part in deafness ac- quired in infancy and resulting in deaf- mutism. Inherited syphilis may, as is well known, produce a peculiar form of deafness accompanied by certain ocular affections, which, it is true, generally appears after the age of puberty, but which, however, also shows itself before that period, even as early as the age of four. The circumstance, however, that hereditary syphilitic deafness often ap- pears without any other marked symp- toms of syphilis, and that it is extremely difficult to discover syphilis in the par- ents, especially by questions alone, ex- plain why this disease is so seldom no- ticed in the parents of deaf-mutes in hitherto-published statistics. It seems, also, that acquired syphilis may cause deaf-mutism; but no investigators have, up to the present, touched upon this sub- ject. Injury (Trauma). — Although it is probable that traumatic influences, such as falls, blows on the head, etc., to which children are especially subject, are some- times stated as being the cause of deaf- mutism in cases of really congenital ori- gin, there is no doubt that such causes may produce deafness resulting in mut- ism, as ear diseases of traumatic origin are not at all unknown, even among adults. Injury also is included in the causes of deaf-mutism in nearly all the more considerable statistics, the figures, however, being but small. Morbid Anatomy. — Although a partial examination of the auditory organs of deaf-mutes during life-time is possible, still it can only embrace the peripheral parts, and there must always be a dif- ficulty in deciding whether the morbid changes thus revealed are of primary or secondary importance, or, indeed, only accidental. It is, therefore, only possible to arrive at an intimate knowledge of the morbid changes causing deaf-mutism and hence, at the just comprehension of its nature, by means of post-mortem ex- amination. We have but few reports of such examinations dating earlier than the commencement of this century, and they yield so little information that we can only surmise that the examinations have been incomplete. Before discussing the different parts of the auditory organs in which morbid changes have been found, it must be ob- served that several investigators have found no changes whatever in some of the cases examined by them; indeed, Ibsen's and Mackeprang's investigations gave negative results in no less than one- third of all their cases. As, however, these investigations date from a period when the microscopical examination of the labyrinth was but little developed, and as no mention is made of an exam- ination of the brain or of the auditory nerve, the negative results arrived at lose considerably in importance, for it is pos- sible that the parts of the auditory- organ above mentioned have been the seat of undetected abnormalities. Morbid Changes of the Middle Ear. — If we take a survey of the pathological changes of the middle ear which have been found in post-mortem examina- tion of deaf-mutes, we shall find that such changes are remarkably frequent. It is only exceptionally that these have been the result of malformation; they have, in the majority of cases, owed their presence to inflammatory processes or the remains of such. These inflammatory processes have sometimes been of ca- tarrhal nature, but generally suppura- tive, in which cases they have been in- tense and destructive. The abnormali- ties which are characteristic of the mor- bid anatomy of deaf-mutism have had 394 DEAF-\[UTISM. MORBID ANATOMY. their seat about the two fenestrje, es- pecially in and around the fenestra ro- tunda, which has exhibited anomalies in not less less than one-fourth of all the dissections which yielded positive results, and has in particular been frequently closed by osseous masses. In the ma- iority of cases, however, the abnormali- ties of the middle ear have been accom- panied by marked changes of the inner ear. Morbid Changes of tlie Labyrinth. — These have affected either the whole labyrinth or only parts of it. The so- called entire absence of the labyrinth plays an important part among the former class, partly on account of its comparative frequency, and partly on ac- count of its origin. The majority of authors have hitherto regarded the ab- sence of the labyrinth as the result of ar- rested development. I have, however, in several of my works proved that par- tial or complete absence of the labyrinth, or of parts of it, may be, and probably most frequently is, caused by the de- posit of osseous tissue in the labyrinth- ine cavity, which becomes thus more or less completely filled up, under which process the normal outlines may disap- pear entirely. Such a formation of osseous tissue is without doubt the re- sult of a previous inflammatory process; that is, of an otitis intima. I have also pointed out that it is impossible to dis- tinguish between foetal and post-fojtal morbid changes by post-mortem exami- nation, unless accompanied by exhaust- ive and reliable information as to the cause and date of the affection. From the following it will be evident that the deposit of osseous tissue in the cavity of the labyrinth is one of the most frequent labyrinthine anomalies found upon post- mortem examination of deaf-mutes, the osseous mass sometimes filling the whole cavity, while sometimes only a section exhibits a parietal deposit which has merely caused a diminution of the cavity in question. The most extensive forma- tions of osseous tissue in the labyrinth are apparently the result of a post-natal otitis intima. It is interesting to ob- serve that various investigators have dis- covered siich osseous deposit sometimes on the one side only, sometimes on both, some having also found osseous tissue on the one side, and deposits of chalk or fibrous tissue — which may also, as is well known, be the result of inflammatory processes — on the other side, while both the latter deposits have also been fre- qiiently found in the labyrinths of deaf- mutes when there was no formation of osseous tissue on either side. Inflam- matory and also degenerative processes may leave other products behind them, which may appear in like manner in other parts of the body. I would not, however, imply that the partial or total absence of the labyrinth may not be the result of arrested development, which, on the other hand, may be due to foetal in- flammatory processes. Still, it is often difficult to find proofs that such has been the origin of the abnormalities in indi- vidual cases. A case observed by Michel is, however, of this nature, as the petrous bone was entirely deformed, and it seems as if we might be justified in expecting important malformations of the laby- rinth to be reflected in the shape and ap- pearance of the petrous bone. In many cases the inflammatory process in the labyrinth causing its partial or complete destruction was secondary to an inflam- mation of the middle ear. According to the reports of several post-mortem ex- aminations, the inflammation of the mid- dle ear was due to acute infectious dis- eases, in particular scarlet fever and measles. In conformity with the above, DEAF-IIUTISM. MORBID ANATOMY. 395 it will be seen that in dissections, in whicli the complete or partial absence of the labyrinth was discovered, toler- ably well-marked changes were found in the middle ear, consisting, in great part, in the remains of inflammatory processes; and this was true of many of the cases which will be mentioned further on as examples of circumscribed deposit of osseous substance in the labyrinth. On the other hand, the absence of inflam- matory processes in the middle ear, or the traces of such, and in other cases the histories of the cases seem to indicate that the labyrinthine inflammation is not of necessity propagated from the middle ear, but that it frequently originates in the membranes of the brain. This is especially probable in all cases where meningitis is with certainty stated to be the cause of deafness. There is, perhaps, a third kind of labyrinthine inflamma- tion, — viz., primary inflammation, — which has been especially defended by Voltolini and called after him otitis intima of Voltolini. The existence of this affection cannot be proved or dis- proved by arguments drawn from the material here under discussion. As far as the seat of the labyrinthine changes in deaf-mutes is concerned, the vestibule (with the exception of its aqueduct) is the part of the labyrinth which has been least frequently found to be the seat of morbid changes. The reason is that the vestibule is, compara- tively speaking, seldom found to be abnormally changed on post-mortem examination of deaf-born deaf-mutes, anomalies in the two other principal sec- tions of the labyrinth being twice as frequent in these cases. It is also re- markable that in no hitherto-published post-mortem examination of a deaf-mute with acquired or congenital deafness, or where the origin of the deafness is not stated, has the vestibule been the only section of the labjTinth which has been the seat of abnormalities, the other sec- tions being also changed when this has been the case \^ith the vestibule. The semicircular canals are decidedly the portion of the labyrinth which is most frequently the seat of pathological changes; these are, indeed, so frequent here, that more than one-half of the dissections have yielded positive re- sults. Indubitable cases of congenital malformations have been observed by several investigators, but it is question- able whether such abnormalities as the union of the two canals into one, short- ening or lengthening of the canals, etc., are to be regarded as of vital importance. In not less than one-fifth of all the dis- sections yielding positive result the semi- circular canals were the only part of the labyrinth which exhibited morbid changes. In the majority of cases in which the semicircular canals have been the seat of abnormalities they, or a part of them, have been filled up by osseous tissues, or must have been supposed to have been so; for instance, in the many cases where the reports simply mention "absence" of these canals. The poste- rior canal has been most frequently at- tacked, either above or together with the superior, but principally together with both the superior and the external. There is no reason to presume the fre- quent occurrence of abnormalities of the semicircular canals to be a frequent cause of deaf-mutism, but only a conspicuous proof of the frequency with which laby- rinthine inflammations are a cause of that anomaly. The abnormalities dis- covered in the semicircular canals point also in another direction when it is re- membered that it is an approved fact that disturbances of the equilibrium are verv common among deaf-mutes. In this 396 DEAT-MUTISM. MORBID ANATOMY. respect post-mortem clinical observations of deaf-mutes speak strongly in favor of the theory of the influence of the semi- circular canals on the equilibrium of the body: a theory which has lately found much support in Ewald's work. Morbid changes of the cochlea are somewhat more frequent than those of the vestibule, and are very equally di- vided between congenital and acquired cases of deaf-mutism. In several cases the cochlea was the only part of the lab}Tinth which was the seat of morbid changes; in the great majority of cases, however, other parts of the inner ear have been abnormal, the semicircular canals having been at the same time es- pecially frequently the seat of anomalies. The more or less entire tilling up by osseous or calcareous masses is the anom- aly most common to the cochlea, and under this heading may doubtless be in- cluded all cases in which the cochlea is reported to be entirely absent, or in which only one or two cavities remained. Abnormalities of this nature are men- tioned in about one-eighth of all hith- erto-published post-mortem examina- tions. Morbid Changes of the Auditory Nerve. — It is a fact that, although atrophy and degeneration of the auditory nerve, or a part of it, are frequent in deaf-mutes, they are far from being always present, as believed by many, since Hyrtl put fonvard that supposition, based upon post-mortem examinations performed by him. As it is to be supposed that the auditory nerve of the majority of deaf-mutes examined post-mortem has been out of function some time, with- out there being found any atrophy or degeneration in it or its branches, it would seem that this nerve is not par- ticularly disposed to become atrophied or degenerated from inactivity. The correctness of this hypothesis is con- firmed by morbid anatomical examina- tions hitherto published of persons who have become deaf at a more advanced age, which examinations all point in the same direction. The cases of atrophy or degeneration of the auditory nerve which have been found by post-mortem exam- inations of deaf-mutes, seem, therefore, as a rule, to be due to some other cause, and we are obliged to regard them as the result of either centripetal atrophy or degeneration subsequent to labyrinthine destructive processes, or as the expres- sion of a centrifugal change arising from primary disease of the central nervous system. It is impossible as yet to give any satis- factory reason why the auditory nerve in some deaf-mutes is atrophied or degener- ated while in others it is not. The ques- tion will doubtless be cleared up by a larger number of post-mortem examina- tions of deaf-mutes, accompanied by re- liable information as to the origin of the deafness. K.vamination of 415 young deaf-mutes, in regard to primary cauae and to the condition of the ears, the nasal chambers, and organs of phonation. (Med. News, Nov. 19, '92). Condition of the Ears. Plantic otitis media Adherent and immovable drum-heads. . Very feebly movable drumheads Atrophic drum-heads Kngorgement of manubrial vessels and pinkish tint of drum-head A. A. Bliss lup 1. (;nm|)2. flnHipM. Tntl.l 75 20 10 111 94 28 3 125 43 12 4 59 2 2 DEAF-MUTISM. MORBID ANATOMY. 397 Condition of the Ears (continued). Calcareous deposits in drumhead Double perforations with otorrhea Single perforations with otorrhoea Cicatrized perforations, many of them covered with new membrane Double impactions of cerumen Single impactions of cerumen Atresia of external auditory meatus. . . . Undeveloped auricles with absence of auditory meatus Foreign bodies Desquamative otitis e.\terna A slight trace of hearing Hearing on contact only Fair hearing Mipl. Gk.M1i 2. Gn.upS. Total. u 2 10 9 5 3 17 10 5 1 IG 32 13 3 48 U 5 19 15 7 2 24 2 2 1 1 G 6 4 4 17 2 25 02 G 10 73 2 2 Primary Cause. Spotted fever 43 Scarlet fever 66 Measles 17 Meningitis 29 Typhoid fever 5 Pneumonia 2 Diphtheria 2 Malaria 2 Small-pox 1 "Colds" 13 Convulsions 10 Black fever 3 Traumatism 9 Spinal meningitis 5 Inflammation of bowels 2 Cholera infantum 1 Shock 1 Mumps 1 Bronchitis 1 Catarrhal fever 1 Sun-stroke 1 Otitis media 9 Whooping-cough 2 Teething Croup Eczema Unknown (exclusive of 137 pupils credited as being deaf-mutes from birth) Pathological Conditions Present. ^Vfl'-M. Group 1. Grm,,, Deformities consisting of deviated septa, exostoses, hypertrophied turbinals, causing partial or complete occlusion of one or both nares 65 14 Posterior hypertrophies of turbinals 21 1 Impactions of middle turbinals against the septum 14 3 Synechial bands between the septum and lower turbinals 2 2 Sclerosis of mucous membrane in the anterior nares 35 7 Sclerosis in posterior nares 13 8 Atrophy of nasal mucous membrane.... 20 2 General catarrhal condition due to vaso- motor paresis without deformities.... 13 3 Gioiii)3. Total. 4 83 2 24 17 4 5 47 21 22 398 DEAF-MUTISM. MOEBID ANATOMY. Pathologicai. Conditions Present (coiilinued). Adenoids in vault of pharynx, causing Groiin l. Group 2. Group 3. partial occlusion of this space or press- ure upon the Eustachian openings. ... 67 14 8' Tongue. Abnormally-short frsenum 24 1 Hypertrophy of the lingual tonsil worthy of note 12' 1 O Palate. Abnormally high, narrow, and Gothic- arched 8 2 Deflection of raphe from median line, most frequently to the left side 6 Double uvula 2 Relaxed and pendulous soft palate 2 Tonsils. Large tonsils filling the spaces between the faucial pillars of their own sides of the throat, but not adherent to these bands, or not causing serious occlusion or pressure upon surround- ing parts 32 Iti 1 Tonsils greatly hypertrophied, diseased, and causing pressure upon the palate or tongue, and greatly occluding the faucial space 18 5 4 Adhesion between tonsil and faucial pil- lars, the tonsil being incapsulated 30 6 5 Narrowing of fauces by broad posterior pillars with high attachment to the pharyngeal walls 11 Pharynx. Simple hypertrophy of mucous follicles. .23 3 2 Sclerosis of mucous membrane with follicular hypertrophy 9 6 Simple sclerosis of mucous meiubrane.. 55 20 5 Atrophy of mucous membrane 8 11 Venous engorgement worthy of note... 22 2 3 Larynx. Epiglottis abnormally depressed 14* 2 "Infantile" epiglottis 2* Vocal Bands. Apparently normal in color and ordinary movement 83 63 12 Total. 79 163 ' Blx of tlicHC wore in pupils between U and 22 years old j tlio other six in pupils under H years of ogo. 'Tliciic eight eiiHCH all occurred In subjects between 12 and 10 years old. ' Only four being In pujillfl under 14 years of ago. • Both being In pupllH over 14 years of ago. DEAF-MUTISM. MOREID ANATOMY. 399 Examination of 175 deaf-and-dumb children. Tested by a large bell, a large tuning-fork, and the human voice. The children were found to divide themselves into: — 1. Those stone-deaf or having no aCiial hearing, 9 2. Those hearing vciy loud sounds, — shouting, etc., . . . .81 3. Those hearing and distinguishing the voice : — (a) Vowels only, . . . 20 ) gg (6) Consonants and words, . 13^ Dlsqualifled for testing be youth, idiocy, etc.. Dumb, hut hearing perl'ectly. Of the 9 totally deaf, by far the larger number were cases of congenital deaf- ness. Of those who could hear and dis- tinguish the voice, much the larger num- ber were cases of acquired deafness. The causes of acquired deafness were found to be, in half the eases, primary disease or injury in the brain or internal ear, without apparent disease of the mid- dle or external ear. Measles and scarlet fever were found responsible for 13 cases. Sixty-one cases of normal membrane were found among the 175 children; 32 showed suppurative disease, and nearly 80 catarrhal changes. The pharynx was diseased in most of the cases. J. K. Love (Glasgow Med. Jour., June, '93). Post-mortem examination of the ears of a deaf-mute. The case was that of a young man, aged IS years, who died from pulmonary and intestinal tuberculosis. When 2 Va years old lie suiTered from scarlatina, and, as a result, became a deaf-mute. In the right ear the patho- logical conditions were confined to the labyrinth, and consisted of destruction of its integral parts, the various spaces having undergone ossification. The drum-head and tympanum were quite normal. The ligamcntum annulare sta- pedis and the mcmbrana fcnestrte ro- tunda; were ossified ; but this process was confined to the sides adjoining the in- ner ear. In the left car were found otor- rhoea, ossification of the spongy portion of the pars petrosa and of the processus mastoideum, and ossification of the membrana fenestrse rotundse; the liga- ment of the stapedius muscle was mov- Fig. 2. Auditory ntiophy and anomalies of development In the nienibianous labyrinth of both ears in a case of deaf-mutism. (Seheibe.) Fig. 1. — CO, Corti's orsraii ; z, increased cells in the sulcus spiralis ; 6, arrlied layer of cells, ex- tending to the llmbus lamlua) spiralis ossesB ; m, Corti's membrane. Fig. 2, — s. Stratum scmilunare ; b, beginning of basilar membrane; ;>, prominentia spiralis; /, ridge on the stria vascularis ; «, flat cells on the rest of the stria ; r, a piece of Roissncr's membrane, bulged forward toward the scala vcstlbuli ; Inserted somewhat peripherally, and extending, farther on, in a thicker layer of cells. (ZpiUchria Tur Ohr«iih«ilkuDd«.) able. The inner ear showed no sign of pathological fluid or new formations. The surface of the brain showed no ab- 400 DEAF-MUTISM. MORBID ANATOMY. normality. Broca's convolution appeared smaller than normal. The superior tem- poral convolution of the left side was also smaller than xisual. The micro- scopical examination did not show any positive signs of abnormality. These cerebral changes, are supposed to result from atrophy consequent upon the in- activity of the parts, it being worthy of note that this left-sided atrophy is asso- ness (field of vision) with the instrument of Landolt. Conclusions: The reactions to general sensitiveness and to pain, in the deaf-mute, are very little inferior to the normal. In early life, indeed, there is no difl'erence worthy of note. So also with regard in general to the field of vision; ii is normal both in extent and form, except for a readiness to fatigue, which by itself is anything but a serious Auditca-y atrophy and anomalies of development in the membranous labyrinth of both ears in a case of deaf-mutism. {Scheihe.) Fig. .3. — r, Rosenthal's canal ; la, lamina spiralis ossea; g, ganglion-cells; I, lacuna; nl, enter- ing nerve-fibres; nS, departing nerve-Hl]res ; b, connective tissue. Fig. 4. — », Semilunar stratum; c, crista splniliB; 6, basilar membrane; co, Corti'e organ baJly preserved; ;;, prominentia spiralis ; br, Ijridge ; I, lacuna in tlie stria vascularis; Is, ridge with attaclimcnt to the lower part of tlie bridge ; m, rudimentary Corti membrane. (ZeitHclirift fiir Ohronhonkiinde.) ciated with destruction of the right labyrinth. Conclusion that there is good ground for the belief that the fibres of the acoustic nerve cross in the brain. V. Uehermann (Annual, '93). Examination of the reactions for gen- eral and painful sensations in forty-four deaf-mutes with the faradimeter of Edelmen, and of the retinal sensitive- sign of marked degeneration. The sensi- tiveness of the deaf-mute evidently ex- presses a mental development of a very satisfactory quality, and clearly differ- entiates him from such classes as the criminals, the epileptics, and the feeble- minded (partial imbeciles), not to men- tion more marked forms of degeneration. In spite of the absence of one sense, the DEAF-MUTISM. MORBID ANATOMY. 401 sensitive zone of the deaf-mute is not deficient. Various stimuli from all the sources in the sensorium reach his cortex, and this is in such condition as to be able to normally elaborate the stimuli; hence comes ease of perception and at- tention. All the other sensorial sources, if exercised, can supply the want of a source so full of ideas as is that of hear- ing, when the centre is normal. This fact should help our judgment in form- ing the scientific diagnosis of the deaf- mute. Deaf-mutism, by itself, does not mean serious degeneration. S. Ottolenghi (Jour, of Laryn., Jan., '9G). Case in which there were atrophic changes in the fibres of the cochlear branch occupying the first whorl, the corresponding portion of Corti's organ being reduced to a mere trace, while in the upper whorls it was lower than nor- mal, the membrane being rolled up in the rudimentary way. This and other allied conditions indicated a congenital defect or anest of development. A. Scheibe (Arch, of Otol., vol. xxiv, Nos. 3 and 4, '97). Deaf-mutism is the result of aural dis- ease acquired in infancy consecutive to acute rhinitis. From neglect there fol- lows atrophy of the acoustic nerves. These cases would be curable if the nerves could be stimulated to proper de- velopment by vibrations carried through the cranial vault. Twelve deaf-mutes thus cured, but it required several years. The naso-pharynx received particular at- tention; the drum was mobilized by means of Politzer's inflator and by the apparatus of Delstanche, the patients also receiving oral instructions. Acute rhinitis in children should be carefully watched and treated. Verdos (Annales des Mai. de I'Orcille du Larynx, No. 5, •97). Unchermann found in 1885 about 1841 deaf-mutes in Norway, of whom 51 per cent, were hereditary, and the remain- ing percentage were acquired, with the exception of 0.5 per cent., in whom it could not be determined. It is not al- ways possible to determine, even by ex- amination after death. Most cases of acquired deaf-mutism are caused by dis- eases of the labyrinth, most of which have spread from the brain or middle car. Mygind, in his work in 1894, re- ported over 139 cases in which the mid- dle ear only was diseased, but he stated nothing about the labyrinth or the his- tological examination of the labyrinth. Thus, Matte could completely deny the occurrence of deaf-mutism due solely to middle-ear disease. Two personal cases in which the middle ear only was de- monstrable as a cause of the deaf- mutism. J. Habermann (Archiv f. Ohrenh., Bd. liii, S. 52-07, 1901). Morbid Changes of the Brain {Cere- Irum). — The defective development of the surface of the third convolution and of the insula Eeilii of the left side may be mentioned as an abnor- mality several times discovered in deaf- mutes, but which has no causal rela- tion to deafness. Eiidinger and Wald- schmidt found this abnormality in sev- eral deaf-mutes who presented no his- tory of disease, and whose labyrinths were not examined, while other investi- gators found it in two deaf-mutes who had both become deaf after birth, in the third year, after meningitis and scarlet fever, respectively, and vrho both exhib- ited pronounced abnormalities in the ear. The flattening of the cerebral convolu- tions is doubtless due to atrophy, caused by the inactivity of the parts of the brain which are known to be the motor centre of speech, on account of the inactivity of the muscles of speech. In the two latter cases, also, there was information proving that the deaf-mutes in question had never learned to speak. Case of deaf-mutism, in an adult, found at the autopsy to have been due to symmetrical lesions in the two tem- poral lobes. The entire cranial capacity was less than normal, the brain weigh- ing 935 grammes (30 ounces), and the left hemisphere was almost one-fourth smaller by weight than the right. The first and second temjioral convolutions were destroyed, normal being replaced by cicatricial tissue, while the third convo- 403 DEAP-MUTISM. PROGNOSIS. TREATilENT. lutions — the supramarginal and the angular gyri — were atrophied and scle- rosed. The convolutions of the island of Reil were intact on the right, but largely destroyed on the left; acoustic nerves very thin. The patient presented notable deficiency of intellect, with absolute deafness and dumbness. She possessed a certain amount of intelligence, how- ever, and could comprehend, to a certain degree, mimetic language. No motor paralysis of trunk or limbs existed, nor was there any defect present in vision or cutaneous sensibility. Seppilli (Alienist and Neurologist, Apr., '93). If we cast a retrospective glance over the foregoing facts it will be seen, first, with regard to the nature of the morbid changes met with in the hearing organs of deaf-mutes, that they do not differ, so far as their quality is concerned, from those generally found in ear diseases, but that the difference must be rather sought in the intensity and extent of the morbid processes. The abnormalities found in deaf-mutes may, at least in a great number of cases, be most naturally inter- preted as being the results of intense and wide-spread inflammatory processes. This is particularly evident in cases re- ferring to deaf-mutes who had become deaf after birth. It will further be seen that the abnormalities found in eases of congenital and acquired deafness often present exactly the same appearance; so that in many cases it is impossible to decide, from the post-mortem examina- tion alone, whether the changes are of foetal or post-foatal origin. It is, thus, evident that the formerly accepted opin- ion, that deaf-mutism arising from con- genital deafness was due to congenital malformations of the auditory organs, has not been confirmed, since abnormali- ties which are the indubitable expression of such malformations are but seldom met with. So far as the seat of the abnor- malities was concerned, it was found that these were, as a rule, bilateral, but have often differed greatly on either side, both as to character and localization, and es- pecially as to intensity. The few cases in which the principal abnormalities were confined to the one side, while the other was normal or only the seat of unimportant anomalies, must, for the present at least, be looked upon with sus- picion. Finally, it has been proved that the middle ear has very frequently been the seat of changes, accompanied, as a rule, by important abnormalities in the inner ear. These were most frequently situated in the semicircular canals, least frequently in the vestibulum, and were to be considered as the principal cause of deafness. The auditory nerve in many cases exhibited signs of atrophy and de- generation and a few other abnormali- ties, while in a considerable number of cases no changes were visible. In some few cases the brain deviated somewhat from the normal. Deaf-mutism is, therefore, from an anatomical point of view, in most cases to be considered as a result of an abnor- mality of the labyrinth. Prognosis. — There is no doubt that the prognosis of the deafness which is the cause of deaf-mutism is highly unfavor- able, still there exist some well-authenti- cated cases of deaf-mutes whose power of hearing has been at least partially re- stored. Treatment. — It is as yet difficult to say in what cases treatment is indicated, as we have not reached further than to the first experiments in that direction. I have latterly endeavored to act accord- ing to the following rules when deaf- mutes have been brought to me for treat- ment: Treatment is most decidedly in- dicated when the deaf-mute suffers from suppurative inflammatory processes of the middle ear. Treatment can, at DEAF-MUTISM. TREATMENT. 403 least in such cases, remove or diminish the danger which always attaches to sup- puration of the midde ear. Uchermann's experience also proves that the defects in the power of hearing may be dimin- ished in cases of this nature. Treatment is also, I think, indicated in cases in which there are some traces of the power of hearing, and especially when this power exists with varying intensity, and where there are also symptoms of ca- tarrhal conditions in the middle ear (ca- tarrhal changes of the membrana tym- pani, retraction of the manubrium of the malleus, occlusion of the tubaa, etc.); also catarrh of the mucous membranes ad- jacent to the ear, especially when there also exist hypertrophy of the adenoid tis- sue in the naso-pharyngeal cavity. If the cranio-tympanic conduction still exists, the chances in this group of cases seem more favorable still. In cases of catarrh of the middle ear and adjacent mucous membranes, where no signs of hearing can be discovered after repeated examination, I have also attempted treat- ment; though I am not certain that such a course gives any hopes, as my experi- ence has not been very favorable in this group of cases. Useful hearing obtained in a deaf- ' mute aged 19 years. On examining the nasopharynx a dense band of hyper- trophy in each RosenmtlUer fossa was found. The hypertrophied tissue was removed, and her ears were regularly politzerized. Tliis was followed by a very great improvement in hearing, so that words distinctly spoken at the dis- tance of a few feet in the ordinary voice could be understood. Gibson (Aus- tralasian Med. Gaz., Oct., 1900). To all the above-mentioned groups the indications are the same, whether the deafness is congenital or acquired. Va- rious circumstances, which have been pointed out in the foregoing pages, indi- cate that total deafness resultinsr from acute infectious diseases, especially cere- brospinal meningitis and scarlet fever, and accompanied by slight catarrhal changes, is due to a constant labyrinth- ine disease which defies all treatment. So far as the nature of an ultimate treatment is concerned, it must be ob- served that general and special otological principles must be used as guides, and the treatment, in the majority of cases, should be local. Treatment in other than the above- mentioned cases of deaf-mutism is, of course, justified when it is not accom- panied by any danger to the patient, when it is indicated by otological princi- ples, and when it is certain that the ana- tomical cause of the deafness is not situ- ated in the brain. It is for the future to show what chance of improvement such cases have. Urbantschiseh's treatment is also worthy of mention. It consists in regu- lar acoustic exercises, intended either to awaken or improve the power of hear- ing in deaf-mutes; and there is every reason to look forward to more exhaust- ive information as to the results of such treatment with considerable interest. Instrument intended to facilitate treatment by Crelle's auditory exercises, and produce the voice automatically by means of clock-work with an intensity which is subject to regulation. It con- sists of a horizontal cylinder run by clock-work, on which wax is spread for receiving the registration. An apparatus placed in front of the cylinder bears a membrane with a rounded style, to which is attached a little special micro- phone, with micrometric vise, springs, and levers. An electric current is passed into the special microphone, and into a receiver like that of a telephone. When the receiver is brought to the ear. the words, or sounds, repeated by the phono- graph are heard with an intensity which can be regulated at will by increasing the number of cells. By increasing the 4^04 DEAF-MUTISM. force of the current the sounds can be made so intense as not to be endured without violent pain. Dussaud gives the receiver of a similar instrument devised by him to the deaf of all kinds and de- grees. He is said to be able to make even deaf-mutes keep time to music and distinguish vowels and words. Each cylinder can repeat 10,000 times what it contains without any alteration. Re- engraved, this can be repeated forty times; thus each word can be repeated 400,000 times, and there are fifty words on a cylinder. A sixty-cell current is at first needed for the worst cases. At the end of a few months one cell will complete the process where a cure is being effected. The number of cells used makes the instrument an audimeter which measures the degree of deafness. On the principle of Urbantschisch and Gelle, who claim that many deaf ears need only education to give them a cer- tain amount of hearing power, this ap- paratus should be of signal service in the teaching of deaf-mutes. Laborde (Practitioner, Apr., '98). The above remarks on the treatment of deaf-mutism have exclusively dealt ■with the deafness from which the mutism results. I will not go further into the treatment of mutism by special methods of instruction, because this subject is not included in the aim of this article, which is prepared for those who are to give their attention to the diseases involved. It will then be seen that when a child is proved to have such deficient power of hearing that mutism is the result, re- moval of that deaf-mutism by treatment can only be hoped for in very exceptional cases. Therefore, there is still greater reason for considering the question of the prevention of deaf-mutism. The prin- ciple method of obtaining this object must be to submit all children who suffer from deafness which threatens to cause, or has caused, deaf-mutism to a rational examination of the ears and of the ad- jacent mucous membranes, and eventu- DERMATITIS. ally to make the existing disease the sub- ject of rational treatment. HOLGER MyGIND, Copenhagen. DELIRIUM TREMENS. See Alco- holism, Acute Alcoholic Delirium. DEMENTIA. See Insanity. DENGUE. See Specific iNFECTioua Fetees. DERMATITIS. Definition. — Inflammation of the skin. Varieties.- — -There are seven varieties of dermatitis: dermatitis traumatica, due to traumatic irritation of the derma; dermatitis venenata, due to contact with poisonous agents; dermatitis medica- mentosa; dermatitis herpetiformis; der- matitis gangrenosa; dermatitis maligna; and dermatitis exfoliativa. Dermatitis Traumatica. Under this heading are included such superficial inflammations of the skin as follow pressure, violence, contusions, abrasions from scratching or rubbing, or the action of mechanical irritants of any kind. Case of dermatitis from Roentgen rays in a boy aged 16. On October 13th, to radiograph the spine, a Crookes tube was placed about 5 inches from the epigas- trium, a flannelette shirt intervening between the tube and the skin, while the trousers were turned down on each aide. An exposure of one hour was made, the the coil being run by means of an accu- mulator. The next day the akin felt irritable and was of a deep-red color in the area subjected to the rays. The irritability increased, and, six days after the experiment, the skin felt stiff when he bent his body. Vesicles began to form, and they inereaaed in size and number. The general surface was of a dusky or purplish red, forming an ir- regular band three-quarters of an inch wide round the umbilicus. On October 31st the whole of the epidermis had sep- DERMATITIS TRAUMATICA. TREATMENT. 406 arated, and the skin was quite sound and level with the surrounding skin, except where the vesioulation had been most pronounced. The downy hairs with which the abdomen was rather thickly covered were still present on the site of the affected area. H. Radcliffe Crocker (Brit. Med. Jour., Jan. 2, '97). The inflammation of the skin some- times noticed in connection with fluoro- scopic or sciagraphic observations is due to the absorption of radiant energy by the cells of the skin, and comparable to the changes effected in the photographic emulsion. Dermatitis appears more likely to ensue from exposure to low than to high vacuum-tube, the vast majority of rays with the former being unquestion- ably absorbed by the skin, while with the latter but few are absorbed. Jones (Jour. Amer. Med. Assoc, Nov. 6, '97). While the condition and position of the tube and the time of exposure are the essential features in x-ray treat- ment, yet, with every ordinary precau- tion, cases are sometimes met with which defy them all, and with hardly a note of warning a violent dermatitis suddenly breaks forth. Case observed which can only be explained by the combination of personal idiosyncrasy and cumulative action of the x-rays. Another case referred to in which, even when no appreciable dermatitis was evi- dent, the slightest e.xposure caused . most unpleasant sensations of burning and itching. It was afterward learned that the patient was markedly suscep- tible to the influence of the poisonous ivy. Idiosyncrasy is not a negligible quantity in x-ray therapeutics, and sug- gests intervals of some days between each of the first six sittings. A. D. Rockwell (Medical Record, Jan. 10, 1904). The inflammatory action is usually simple, unless the tissues become in- fected by staphylococci or streptococci, when pus-formation or erysipelatous in- flammation may follow. A common form of simple dermatitis is that result- ing from chafing; while this, under the name intertrigo, is usually classed among the congestive erythemas, it more fre- quently runs into true inflammation. The most frequent sites for the in- tertriginous dermatitis are the armpits, perineum, and insides of the thighs and the under-surfaces of pendulous breasts, especially in corpulent women. It is more frequent in summer than in win- ter, as free perspiration, macerating the upper layers of the skin, and undergoing decomposition, with the formation of irritant compounds, promotes the oc- currence of the inflammation. Intertriginous dermatitis is very fre- quent in infants and young children, especially if great care is not taken to keep the genital and anal regions clean and dry. The most aggravated derma- titis of the genitals, insides of the thighs, and lower part of the belly may develop in a few hours in an infant allowed to lie in a wet and dirty napkin. The pain, itching, and burning are sometimes very intense, preventing sleep and keeping the child in a state of high, nervous tension, crj'ing and irritable. Treatment. — In simple traumatic der- matitis any soothing application will be useful. Cold cream, oxide-of-zinc oint- ment, or simple vaselin are usually suffi- cient to allay the inflammation. One of the best applications is hot water, ap- plied for five or ten minutes several times a day. The water should not be merely warm, but as hot as can be borne without discomfort. For intertriginous dermatitis the writer has found black-wash the best application. Applied on lint saturated with the preparation, it usually gives prompt relief from the burning and pain and controls the hypera?mia. A mild calomel ointment, V; drachm to the ounce of vaselin is also useful. In other cases Ivassar's paste is useful. This is made as follows; — 4:06 DERMATITIS VENENATA. DEFINITION. ^ Acidi salicylici, gr. s. Pulv. amyli, Zinci oxidi, of each, oij. Taselin, §ss. M. ft. pasta. Great care should be taken that only the finest powdered salicylic acid be used in making this and other ointments containing it. The crystallized acid usu- ally proves extremely irritating to an inflamed or sensitive skin. For the moderate grades of intertrigo or chafing, a simple dusting-powder of starch and oxide of zinc is generally sufficient, if the irritated skin be kept clean and dry. The interposition of a fold of lint or soft linen between oppos- ing surfaces of skin is an aid to the cure as well as the prevention of inter- triginous dermatitis. Dermatitis Venenata. Definition. — Inflammation of the skin produced by external irritating agents derived from the vegetable, mineral, or animal kingdoms. Records of some unrecognized forms of dermatitis venenata. Thus, a papulo- vesicular eruption, accompanied by much heat and itching, may attack the hands and arms of persons employed in weed- ing parsnips, or in otherwise handling them. The upper part of the body of a man who had applied to his shoulder, on account of rheumatism, a mixture of hamamelis and laudanum, became cov- ered with large vesicles, papules, and oozing areas. Here, no doubt, an idio- syncrasy to opium may have existed. The hands of a gii-1 employed in dipping wooden toothpicks in oil of cassia, to give these an agreeable odor, were, in a few days after she commenced this oc- cupation, inflamed, and covered with vesicles and moist areas; her face was red and blotchy, and the lower portion of the abdomen was similarly afTcctcd, probably from contact during sleep. A number of firemen, to whom new black cotton shirts had been issued as part of their summer uniform, became aflccted with a brilliant-red infiltrated erythema on those portions of their body where the sliirt came in contact. Solar heat and consequent perspiration seemed to have brought out the activity of the dye. Analysis proved the pigment an aniline one. James C. White (Boston Med. and Surg. Jour., Jan. 28, '97). Outbreak of 34 cases of acute derma- titis among a number of workmen who had just been provided with new over- coats. On first wet day following the wearing of coats inflammation of the skin began to manifest itself on the back of the wrists, the only point at which the coat came in contact with the skin. The patches were sliglitly depressed and had the appearance of a necrosis of the epidermis such as follows the appli- cation of a strong irritant. Tactile sen- sation was entirely lost in the afl'ected areas, and the appearances were most marked in the neighborhood of existing abrasions. In three cases there was some inflammation of the arm, with en- largement of the axillary glands. In- fusion of the cloth from which the over- coats were made yielded an acid reac- tion, and was found to contain zine chloride, which caused the skin condi- tion. Taunton (Lancet, Dec. 6, '98). There are many common plants that will cause dermatitis, idiosyncrasy, how- ever, playing an important part. The common plants are those of the rhus group — the poison-ivy, dogwood or poison-sumach, and the poison-oak. Japanese lacquer may cause it even in handling pictures. Among the ordinary wild flowers are the butter-cup, fleld- daisy, golden-rod, wood-anemone, clema- tis, and garden-nasturtium. Among the drugs used in applications, dermatitis may be caused by tincture of arnica, balm of Gilead, hamamelis, common salt in strong solution, belladonna, and many proprietary remedies containing the es- sential oils. Kerosene may cause an eruption. Glycerin, almond-oil, iodoform, carbolic acid, salicylic acid, quinine, sul- phur, tar, and chrysarobin occasionally cause inflammation. Among substances brought into contact with the skin on account of occupation, and which may cause a dermatitis, are strong alkalies, DERMATITIS VENENATA. VARIETIES. 4or Boaps, "pearline," "soapine," metal and shoe polishes, paint-pigments, arsenic, potassium bichromate, the various salts of mercury and even the metal, and cliocolate. Animal irritants are the mos- quito, Ilea, bed-bug, black fly, wasp, bee, hornet, spider, caterpillar, and jelly-fish. G. F. Harding (Boston Med. and Surg. Jour., Sept. G, 1900). Varieties. — (A) Dekmatitis From Vegetable Irritants. — A large num- ber of plants, some of them used medic- inally, possess irritant properties when brought in contact with the skin. Fhus, or Poison-ivy. — Among the above the most important are various species of rhus ; namely BMis toxicoden- dron, or poison-ivy; Bhus venenata, or poison-sumach; and Rhus diversiloia, or poison-oak. The latter, according to J. C. White, is a native of the Pacific coast, although the common R. tox- icodendron is also vulgarly known as poison-oak. When a person, susceptible to the poison of one of these species of rhus, touches the plant, or, in some cases, even comes within a short distance of the same, the skin shows signs of irritation manifested as follows: There may be redness, but more frequently the first objective sign is the eruption of groups of small vesicles, accompanied by swell- ing and intense itching. In consequence of the scratching set up, the vesicles are ruptured and exude an abundant serum. The swelling is sometimes very great, especially about the loose tissues of the face and the genital regions. The eruptions usually begin upon the hands, as these are the parts of the body most frequently brought in contact with the poison. From the hands it is generally transferred to the face, and next, in the male sex especially, to the genitals, be- cause the face and genitals are the parts most frequently handled. The face and head are often so intensely swelled as to be almost unrecognizable. Death from ivy poisoning in a man 42 years old after two montlis of in- tense suffering. Some persons are af- fected by merely passing the plant with- out coming in contact at all, while otliers can -handle it with impunity. Case observed in a child 6 years old who died from tlie effects of severe ivy poisoning produced by having his skin rubbed wliile wet by tlie hands of a boy who had been rooting up plants of the poison ivy, and although the boy had previously washed his hands thor- oughly, under supervision, first with soap and hot water, and afterward with vinegar. The boy who had been work- ing with the plants had a full and ap- parently permanent Immunity to poi- son ivy. Reynolds (Bull, of Chicago Health Dept.," July 2.3, 1904). Sometimes the skin is very much reddened and the exudation abundant. Excoriated patches are frequent. The itching varies from mild grades to the most severe intensity, but is generally a prominent symptom. It is said that death has followed the poison, but the testimony upon this point is rather vague. The common belief that an eruption caused by rhus poisoning is liable to recur annually without renewed exposure is not based upon sufficiently-definite evidence. The fact that the dermatitis recurs at about the same time each year is to be attributed to a new exposure. 'WTiite, however, mentions a number of cases in which a different eruption fol- lowed — after an interval — the attack of rhus poisoning. The chemical nature of the poison of the various species of rhtis is somewhat obscure, but a number of researches in- dicate that it is a volatile acid. A num- ber of cases are on record showing that handling dried specimens of the poison- ous plants may produce an eruption. 408 DERMATITIS VENENATA. TREATMENT. The time after exposure when the erup- tion appears differs in different persons. The shortest is, perhaps, four or five hoirrs, while in some eases it may be as many days before the effects of the poi- son on the skin are manifested. That the poison before volatilization may be transferred from one portion of the body to another — as from the hands to the face or to the genitals — is beyond ques- tion. Case of dermatitis venenata conveyed to a patient in the obstetrical ward of a hospital by the attendants, who had, just before the patient's delivery, gath- ered a quantity of poison-ivy, and then, although having previously carefully washed their hands, had manipulated the patient's abdomen. J. Abbott Cantrell (Med. News, Oct. 24, '91). It has been hitherto accepted that the toxicodendric acid described by Maisch was the active principle of rhus poison- ing, but found to be merely acetic acid. A poisonous oil, however, termed "toxi- codendrol," is the toxic element, — a very intense skin irritant, even in minute quantity. Like cantharides, it can pro- duce nephritis and fatty degeneration of the kidneys, and it is probable that fatal results of rhus poisoning may have been due to renal complications. It is non-volatile; actual contact appears necessary. The activity of toxicodendrol in minutest traces may make it possible for a few pollen grains of poison-ivy to cause skin eruption; and the few cases of action at a distance, which are so often quoted, may conceivably be thus explained. The rational indication is to get rid of the poisonous oil which may be on the skin as quickly as possible; the parts should be well washed, and scrubbed with soap and water, or alcohol. Fatty preparations, being oil solvents, if used, tend but to spread the evil. PfafT (Jour. Exp. Med., Mar., '97). Poisoning from the action of the Rhus toxicodendron is differentiated from ec- zema by the vesicles being much more numerous, swelling and oedema being greater, and exposed parts being more likely to be afl'ected, particularly the inner surfaces of the fingers, while the eczematous eruption is more frequently polymorphous. Sun-burn sometimes re- sembles dermatitis venenata, but it is more diffuse, and is usually localized en- tirely to exposed parts, while rhus poisoning alfeets the breasts and geni- talia also. Scabies is excluded by the history and by the absence of the Acarus scabiei. 3. Sobel (Med. Rec, Nov. 5, '98). Blastomycetie dermatitis is due solely to the invasion of the skin by one of the plant forms of the yeast family. In its clinical aspect it resembles lupus vul- garis in the ulcerative stage. Hyde, Hektoen, and Bevan (Brit. Jour, of Derm., July, '99). Treatment. — The most effective ap- plications in the early stages of rhus poisoning are alkaline solutions, soap being especially useful on account of its detergent effect. By its early use, the greater portion of the poison can be removed, or its effects neutralized, be- fore it has had time to penetrate the skin and act as an irritant. Solutions of bicarbonate of soda, 1 ounce to the pint, and black-wash usually relieve the itching promptly. Hardaway, of St. Louis, recommends very highly a lotion of zinc sulphate, ^/j drachm to the pint of water. Fluid extract of grin- delia robusta, either full strength or diluted with water in various propor- tions, is highly lauded by Van Har- lingen and others. When the vesicles have ruptured, drying or absorbent pow- ders of starch, chalk, oxide of zinc, orris- root, lycopodium, etc., may be used with good effect. Astringent lotions, among which acetate of lead holds a high place, are especially useful when the eruption is fully developed. James C. White, of Boston, recom- mends the following prescription: — DERMATITIS VENENATA. TREATMENT. 409 I^ Zinci oxidi, oiv. Acidi carbolici, oj. Aquse calcis, Oj. — M. This should be applied freely and re- peatedly over the affected parts. It alleviates the intense itching and hastens the involution of the inflammatory proc- ess. Internal remedies are unnecessary and useless. In the treatment of dermatitis ven- enata, good results obtained with a modi- fied "Cunow solution," containing 1 drachm of lead acetate and 3 drachms of alum to a quart of water. Picric acid, in a 1-per-cent. solution, is also useful. Salol in a 3-per-cent. solution is espe- cially good. J. Sohel (Med. Eec, Nov. 5, '98). Remedy for dermatitis venenata upon which most reliance is personally placed is sodium hyposulphite, in the strength of Vj ounce to 2 ounces dissolved in a pint of water. The affected part is mopped freely and frequently, or wrapped up in a cloth or bandage satu- rated with the fluid, which is renewed as soon as the dressing has become dry. E. S. Gans (Med. Bull., Aug., '99). Dermatitis venenata successfully treated by using locally a lOper-cent. solution of ichthyol and a 1 to 5000 so- lution of mercury bichloride; internally, a calomel purge followed by capsules of quinine, guaiacol carbonate, and phenace- tin every four hours. J. A. Colnane (No. Anier. Jour, of Diag. and Pract., iii, 4, p. 13, 1900). Arnica and Other Toxic Agents. — The tincture of arnica is so freely used as an external application to bruises and sprains that it may be useful to the practitioner to know that it sometimes produces a decided dermatitis, which may be accompanied by vesiculation. The cessation of the application, and dressing the affected part with a sooth- ing or mildly-astringent lotion (bicar- bonate of soda, borax, sulphate of zinc) will generally suffice to restore the nor- mal condition of the part. Among other agents used for medic- inal purposes, which produce dermati- tis of varying intensity, are mustard, cowhage, chrj'sarobin, ipecac, capsicum, mezereuni, thapsia, cantharides, oil of turpentine, tar, creasote, paraffin, petro- leum, pyrogallic and salicylic acids, chlo- ral-hydrate, sulphur, iodine, mercurial preparations, and the more active alka- line, acid, and mineral caustics. The knowledge may also be useful that the juice of the common buttercup of the fields and the garden nasturtium may cause inflammation of the skin. Dermatitis caused on four occasions by using iodoform in as many patients operated on. In tlie second instance the hand also had accidentally come into contact with the iodoform; this lead to dermatitis of the area thus exposed. On the two latter occasions the derma- titis was accompanied by erysipelas, and led to prolonged pigmentation. This shows that no breach in the skin is re- quired to produce this inflammation. Matschke (Ther. Monats., Oct., '93). Case showing untoward effect of re- sorcin applications: a single application sufficient to set up a violent dermatitis. R. W. Taylor (Jour, of Cut. and Uenito- Urin. Dis., Apr., '95). [These artificial eruptions provoked by resorcin are relatively frequent, and this substance should only be used with much precaution, beginning with almost infinitesimal doses and suspending its use at the slightest sign of irritation. L. Brocq, Assoc. Ed., Annual, '96.] (B) Dermatitis from Animal Irri- tants. — Among cases of dermatitis ven- enata of animal origin may be included the cutaneous inflammations caused by the stings and bites of insects, such as bees, wasps, fleas, bed-bugs, lice, and mosquitoes. The inflammatory effects vary in different persons. While in most cases the bite of a mosquito will produce simply a small, itching papule, in others, large red, painful lumps are raised, which 410 dek:matitis medicamentosa, definition, varieties. give rise to great discomfort and often alarm. The treatment is purely symp- tomatic. Alkaline lotions are generally most effective. [See Wounds, Poisoned. Ed.] Dermatitis Medicamentosa. Definition. — Inflammation of the skin caused by the action of medicinal agents taken into the sj'stem. Very many medicines when adminis- tered for therapeutic purposes pro- duce, among other by-effects, inflamma- tion of the skin. This may find ex- pression in erythematous, papular, vesic- ular, bullous, tubercular, or ulcerative lesions. No distinctive diagnostic marks can be given for these eruptions, but the occurrence of any eruption, not readily explained by other causes, should lead to an inquiry concerning the possible effect of medicines ingested. Thus, an eruption almost identical in appearance with that of scarlet fever at times fol- lows the administration of quinine. In the quinine eruption the high fever and sore throat of scarlatina are absent. A bullous eruption, resembling pemphigus, may follow the ingestion of iodide of potassium, which drug may also produce tubercular, pustular, and ulcer- ative lesions. A papulo-erythematous eruption, suggestive of measles, occa- sionally follows antipyrine. Copaiba may cause a macular eruption resem- bling the erythematous syphilide. The scarlatiniform rash of belladonna is well known. In some susceptible subjects opium preparations, in addition to itch- ing, may also give rise to an urticarial or erythematous eruption. Varieties of Eruption Observed AFTER Ingestion of Different Drugs. — Erythematous and erythemato-papu- lar eruptions are sometimes observed after taking belladonna, hyoscyamus, stramonium, quinine, nitrite of amyl, chloroform, arsenic, opium, turpentine, cubebs, copaiba, antipyrine, and ben- zoate of sodium. Sometimes these are attended with more or less severe itch- ing, and may resemble urticaria. (See various remedies in which these mani- festations occur.) Case of dermatitis medicamentosa dif- fusa following upon a dose of opium. The whole skin became red and covered with large scales. The skin was dry. jMovements were interfered with on ac- count of the pain in the skin. The epi- dermis was shed in large plates so as to form complete casts of the hands and feet. The normal lines of the skin were accentuated. The mucous membrane of the mouth was dry and red. The patient complained of tenseness of the skin, chilliness, thirst, loss of appetite, head- ache, and insomnia. Lanz (Monats. f. Prakt. Derm., No. 309, '93). Mixed erythematous rashes (polymor- phous erythema) have occurred after the administration of arsenic, quinine, digi- talis, copaiba, and bromide of potassium. Vesicular and bullous eruption may follow arsenic (herpes zoster), cannabis Indica, iodide and bromide of potassium, quinine, salicylate of sodium, and phos- phoric acid. Pustular and phlegmonous eruptions (pustules, boils, abscesses, diffuse phleg- monous or erysipelatous inflammation) have been noted after taking iodide and bromide of potassium, arsenic, quinine, hyoscyamus, opium, chloral-hydrate, digitalis, iodide of mercury, calomel, and pilocarpine. Superficial ulcerations about the roots of the nails sometimes follow the pro- longed administration of chloral-hydrate. Purpuric extravasations have been noted after iodide of potassium, salicylic acid, quinine, chloral-hydrate, and cam- phor. Treatment. — The treatment of drug eruptions must be symptomatic. The DERMATITIS HERPETIFORMIS. DEFINITION. SYMPTOMS. 411 administration of the remedy must be stopped, and other indications met as they arise. Dermatitis Herpetiformis. Definition. — An inflammatory, super- ficially-seated, multiform, herpetiform eruption, characterized mainly by ery- thematous, vesicular, pustular, and bull- ous lesions, occurring usually in varied combinations, accompanied by burning and itching, pursuing usually a chronic course with a tendency to relapse and recur. (L. A. Duhring.) The acute observations and logical reasoning of Duhring with reference to this disease have led to a general ac- ceptance of his views on the part of dermatologists. At one time Duhring classed the disease first described by Hebra under the name of "impetigo herpetiformis," as the pustular variety of D. herpetiformis, but in his latest publication ("Cutaneous Medicine," Part II) he regards it as advisable to consider the two diseases as distinct "from a clin- ical stand-point, at least." Uima and Stephen Mackenzie lay stress upon the neurotic origin of D. herpetiformis. Symptoms. — Duhring, upon whose ex- haustive studies the following descrip- tion is based, recognizes five varieties of the disease, namely: the erythematous, vesicular, bullous, pustular, and multi- form, indicating the prevailing type of lesion present. There is usually a prodromic febrile stage, which, however, rarely amounts to more than slight chilliness, flushing, or heat, ^Y\th the accompaniments of ma- laise and constipation. Itching may pre- cede the outbreak of the eruption. Any one variety of lesion may appear, or there may be from the beginning a com- bination of two or more of them. The type of lesion may change during the course of the disease, or, as is more rare. may remain constant throughout the at- tack, and may also show the same feat- ures in subsequent attacks. The sub- jective sensations are burning, itching, and prickling, which may be severe. In one case of the vesiculo-pustular variety, the itching and burning were most in- tense, relief being obtained only after the application of strong ointments or lotions of cocaine. The erytliematous variety occurs in patches or diffused over the surface. There is usually slight elevation of the afl^ected skin. The red color of the erup- tion may be varied by a yellowish or brownish tint, and is usually followed by more or less pigmentation. The vesicular variety is the most com- mon. The vesicles are irregular in size and shape, usually tense, and rising abruptly from an apparently normal base. They may be disseminated or ag- gregated in groups or clusters. They sometimes coalesce to form small blebs. The itching is usually more intense than in other forms of eruption. After the vesicles rupture there is often some relief from this symptom. Excoriation is usu- ally not very marked. In the bullous variety the bullae are usually tense, standing out from the level of the skin. They are usually ir- regular in outline, differing from the bullre of pemphigus. They are also more likely to appear in groups or clusters. Vesicles and pustules may accompany the blebs. Case of recurrent bullous dermatitis in a woman 23 years of age, who wa8 distinctively hysterical and of a tiiber- culous parcntafre. During the past three years she had sulTcred from a re- current bullous dermatitis, which had attacked one part of the body, each at- tack lasting about a week and leaving no mark behind. It is an example of an extraordinary hysterical dermatosis. It seemed impossible to regard these 412 DERMATITIS HERPETIFORMIS. ETIOLOGY. one-sided, periodical, progressive bul- lous outbreaks as due to the ingestion of drugs or to the infliction of self-in- juries, and the writer knew of no cu- taneous disease with such character- istics, outside of the mysterious derma- toses which he had learned to associate with hysteria. ^^Tiite (Medical Record, Sept. 19, 1903). The pustular form appears pustular from the beginning. The lesions are either acuminate, discrete, up to a pea in size, or fiat, not elevated above the skin, aggregated in small groups, and miliary in size. The larger pustules often have a puckered appearance. The multiform variety is made up of all the various types of eruption in com- bination, and has suggested one of the names by which the disease is known, viz.: dermatitis multiforme. The lesions are macules, papules, vesicles, pustules, and bullae of all shapes and sizes. There are excoriations and pigmentations of a brownish color. The character of the lesions is constantly changing. Dermatitis Herpetiformis. — The course of the disease is a chronic one, and it may last, appearing and disappear- ing at intervals for many years. Treat- ment has usually little effect upon its progress. Two cases of symptomatic dermatitis occurring in puerperal women. In the first case the eruption appeared as a papular erythema on the fifth day post- partum, while in the second it was a bright-red flush on the eighth day after labor. Wilson (Annals of Gynec. and Ped., May, '91). Herpetiform dermatitis in pregnancy is a rare disease, little known even to obstetricians. It is distinguished by five principal characteristics: 1. A poly- morphous eruption, with a predominance of bullous vesicles; simple vesicles, bullcc, pustules, erosions, crusts, and spots were met with at vhe same time. 2. An accompanying pruriginous disease, really painful. 3. Good general health. 4. SuccesHivc attacks of the disease. 5. A chronic character, aggravated by each attack of the disease, which may last for some years. Fournier (Jour, de Med. et de Chir. Prat., Oct. 10, '92). Four cases of Duhring's disease in which glycosuria was a symptom. Win- field (Jour, of Cut. and Genito-Urin. Dis., Nov., '93). Two cases in two sisters living apart, interesting as showing family tendency, liability to onset in a predisposed person on change of climate, and general in- tractability of the complaint. J. J. Mooney (Med. Age, Aug. 10, '95). Case of typical recui'rent dermatitis herpetiformis, the lesions consisting of a central bulla surrounded by an areola of spreading centrifugal erythema. Be- tween this areola and the collapsed original bulla a ring of vesicles fre- quently made their appearance. It is uncommon to have the lesions of derma- titis herpetiformis so closely simulating erythema multiforme. John Liddell (Brit. Jour, of Derm., p. 385, '96). Etiology. • — • It sometimes begins in childhood, but most frequently between 30 and 40 years of age. There seems to be some connection between the disease and instability of the nervous system, but nothing is definitely known upon this point. There seems to be a frequent relation between the eruption and preg- nancy, the puerperal state, or menstrual disturbances. The disease described by Bulkley and others as "herpes gesta- tionis" is probably a vesicular or vesic- ulo-buUous form of D. herpetiformis occurring during pregnancy. There seems, also, some connection between renal defect and D. herpetiformis. It has been observed after septic infection. Case of dermatitis herpetiformis in a woman of 42 with a rheumatic history. Slie sufFercd in 1895 from a stufTed-up feeling in the eyes, nose, and throat, and soon after blisters came out on the tongue; a little later on the chin; a hot bath was followed by a copious eruption of vesicles on the face and arms, which swelled greatly, and also on the chest and thighs. Fresh eruptions DERMATITIS HERPETIFORMIS. PATHOLOGY. DIAGNOSIS. 413 appeared consecutively, with soreness in the mouth, eyes, and nose, and vio- lent paroxysmal itching and burning of the affected areas. The attacks con- tinued, and in November, 1896, the vesicles were both discrete and confluent, and also multilocular. Considerable eosinophilia of the compound-nuclear, coarsely-granular type were found in the blood, the eosinophiles reaching 4.9 per cent, of all leucocytes present. Again, when the eruption was at its height, the eosinophiles reached 12 per cent, of all leucocytes present in four specimens. The disease seems to exhibit the same features of multiformity, re- currence, and obstinacy in the natives of India as among white races. Morris Fig. 1 shows two vesicles (F„ F,) which have been formed entirely be- neath the epidermis. Macroscopically both vesicles were about the size of a small pin-head. The entire upper half of the corium is the seat of acute inflam- mation. S is a sweat-duct; B indicates small blood-vessels, and G is a sebaceoua Fig. 2 shows the stage preceding the formation of the vesicles. Large num- bers of eosinophiles (E) are to be seen scattered throughout the papillae. Fig. 3 shows the first stage in the formation of the vesicles. Immense ■- ' ^^•aWBf'^i ^¥^22 1 ■rr '"'^mi^'S^'^M .y^''^"- ^ - x-J-f^\-^)J^'\-- Dermatitis herpetiformis. (Liddcll.) and Whitfield {Brit. Jour, of Derm., June, '97). Case of dermatitis herpetiformis in a child, 3 years of age, cured by circum- cision. The disease was being kept up by the reflex irritation caused by phimosis. J. N. Roussel (New Orleans Med. and Surg. Jour., June, 1900). Patholo^. — The pathological his- tology of dermatitis herpetiformis has been most thoroughly studied by Gil- christ, and the histological characters of the affection are shown in the illustra- tions on page 414, representing sections from a case of dermatitis herpetiformis (Duhring). numbers of polynuclear leucocytes are massed in the papilla;, having replaced the normal tissue. Post-mortem in a case. 1. Absence of bacterial specificity in contents of bullee. 2. Coincidence noted by Brocq of lesioni of nervous system. 3. Co-existence of bullous lesions and nephritis. Gastou (T,e Bull. Med., Apr. 21, '95). Diagnosis. — The multiformity of the lesions and the tendency to their herpetic arrangement, which Duhring regards as characteristic; the chronicity of the dis- ease, and its frequent recurrence; the burning and itching, and general ab- sence of marked constitutional disturb- 414 DERMATITIS HERPETIFORMIS. DIAGNOSIS. ance will usually enable a diagnosis to be made without difficulty. Among the dis- eases which may cause doubt are pem- phigus, herpes, erj'thema multiforme, and eczema. Pemphigus. — The lesions are usually well-formed large blebs, rising abruptly tended by moderate pain and burning; no itching; the blisters are usually small and aggregated in groups. The course of the disease is acute. Erythema Multiforme. — In this affection there are rarely vesicles, blebs, and pustules, thoiigh these may be pres- ^i=f.^i, fe\| '^i/i Sections from a case of dermatitis herpeliformis (Qilclirist) from a normal skin, usually discrete, not attended by itching or burning, and dry- ing up in the course of a week. Succes- sive crops of these blebs are likely to ap- pear. Herpes. — The lesions are vesicular, appear upon an inflamed base, and at- ent. The extremities are usually at- tacked, and the distribution of the erup- tion is symmetrical. The color of the lesions is a dusky red or brownish; no itching and but slight pain and burning. Eczema may cause most difficulty in differentiation. The vesicles in this dis- DERMATITIS HERPETIFORMIS. PROGNOSIS. TREATMENT. 415 ease are usually easily ruptured by scratching, and the discharge of serum is abundant. Except in very acute cases, the burning sensation is not as severe as in D. herpetiformis. The scratching is followed by much more notable excoria- tion in eczema than in the disease under consideration. Impetigo heepetiformis of Hebra, which was at first regarded by Duhring as merely a variety of D. herpetiformis, is now conceded by him to be a distinct disease. Its lesions are always pustular. It nearly always occurs in pregnant women, or during the puerperal period; is attended by symptoms of grave con- stitutional involvement, and generally terminates fatally. In some cases, pro- longed observation will be necessary to make a definite diagnosis. The value of the new diagnostic sign between pempliigus and dermatitis her- petiformis first formulated by Leredde and Perrin confirmed. This consists in the simultaneous presence, in the latter disease, of eosinophile-cells in the blood and in the serum of the bulla;. In two cases examined at intervals of fifteen days the eosinophile-lcucocytes and granules were found in abundance. On the contrary, in an instance of pem- phigus foliaceus the eosinophile-cells were entirely absent from the blood and serum on the first and second examina- tions; also at an interval of fifteen days; in the blood only were found a very few cosinophile-leucocytes con- taining well-stained eosinophile-gran- ules. Hallopeau and Lafitte (Ann. de Derm, et de Syph., Dec, '9G). Case resembling pemphigus and der- motitis herpetiformis, though a history of recent illicit intercourse seems for a time to have raised a suspicion, ap- parently erroneously, of syphilis. It occurred in a lad of 21, depressed and slightly feverish, with a profuse bullous eruption, discrete and well formed, on the lower limbs, but sparingly on the trunk, present also on the mucous membrane of the mouth. Itching was marked. In the course of two or three months tlie entire body became attackea. With this there was a dark-brown pig- mentation and a disagreeable odor, and the temperature was continuously above 101.5° F. No e.vamination for eosino- phUes was made. Riddle (Jour. Cutan. and Genito-Urin. Dis., May, '97). Prognosis. — The prognosis, so far as life is concerned, is usually favorable, but the disease is generally chronic in dura- tion, and has a marked tendency to recur. Duhring has reported cases lasting thir- teen and fourteen years. Treatment. — The treatment of derma- titis herpetiformis is far from satisfac- tory. In some cases the lesions yield promptly to local applications, while in others, as Duhring states, the lesions de- velop, relapse, and recur from time to time in spite of the most varied measures employed. The internal treatment should be directed toward the improve- ment of the general health, and the ascer- tainment and removal, if possible, of dis- ease or disorder of the stomach, intes- tines, or kidneys. The apparent close connection of the nervous system with the etiology of the disease would lead one to expect benefit from neurotic remedies, such as arsenic, phosphorus, and str}-ch- nine. Unfortunately, neither of these can be relied upon in all cases, though some show distinct improvement after the use of the first named. Cannabis Indica, chloral, opium, and antipyrine have been tried as sedatives and anod}'nes; but little benefit can be expected from them. Local applications likewise are often disappointing. Dr. Duhring has had most success — in the vesicular, bullous, and pustular forms — from a strong sul- phur ointment, 3 drachms to the ounce, applied with sufTicient friction to rupt- ure the lesions. In the erythematous form soothing applications are indicated. 416 DERMATITIS GAXGEKN'OSA. DERMATITIS IMALIGNA. Tar, in the form of liquor picis alkalinus, 1 drachm to 8 ounces of water, or liquor earbonis detergens of the same strength may be used ■with beneiit in some cases. They relieve the itching, but have ap- parently little influence upon the prog- ress or duration of the eruption. A 2- per-cent. ointment of cocaine is also of value as a local anodyne when the burn- ing and itching are severe. Ichthyol, resorcin, carbolic acid, sali- cylic acid, and thiol have been used, but without much success. A hot bath be- fore retiring sometimes gives grateful re- lief from the subjective symptoms. In dermatitis herpetiformis most relief gained by lotions of chloroform-water, followed by dusting with powdered talc and inunction with a calomel-and-bella- donna ointment. Dubreuilh (Revue de Th6r. Medico-Chir., Mar. 1, 'S9). Case of a man, aged 51, who suffered from general furunoulosis followed by a general bullous eruption. The author considered it a malignant form of der- matitis herpetiformis. After failure of other treatment, cacodylate of soda was given up to 20 centigrammes (3 grains) daily. This was afterward changed to hypodermic injections. After several weeks of this treatment the whole dis- ease improved, and a considerable part of the body became healthy. Davezac (Gaz.desHop.deToulouse, July 13,1901). Dermatitis Gan^enosa. Definition. — Inflammation of the skin accompanied by sloughing or gangrene. Etiology. — Gangrene or sloughing may follow any lesion of the skin severe enough to destroy its vitality. Thus it sometimes follows intense or long-con- tinued pressure, severe contusions, vio- lent inflammation, or some profound nervous disturbance. The ordinary bed- sore is an example of gangrenous derma- titis from pressure; the acute or neu- rotic bed-Bore follows a neuritis or other disease of the peripheral nerves. In se- vere contusions, the application of caus- tics, deep burns, or frost-bite the slough is dxie to the sudden and violent arrest of nutrition in the part. Diabetes is not rarely accompanied by gangrene. The interesting affection known as Raynaud's disease, whose most marked manifesta- tion is symmetrical gangrene of the ex- tremities, cannot properly be described as a gangrenous dermatitis. A gangrenous dermatitis of infants has been described under various names. It occurs most frequently after varicella in children debilitated by innutrition or constitutional dyscrasise. The lesions consist of ulcerations under a black slough of varying thickness, and occupy- ing the site of one of the pustular or bul- lous lesions of the disease. The same lesion is not infrequently observed in vaccination, especially with bovine lymph. It is probable that the gangrene is due to an infection by micro-organ- isms, but the nature of these has not been determined. This form of local- ized gangrene may also follow other skin diseases. Ten cases of typhoid fever complicated by gangrenous dermatitis. All the pa- tients were young men who went out as soldiers in the Spanish war. Bacterio- logical examinations from unbroken vesicles and from ulcers showed the staphylococcus albus and aureus; indif- ferent bacteria, as cocci and diplococ'ci, were found in cultures from an ulcer. The disease is inoculable. The gangre- nous patches appeared on the trunk, face, arms, thighs, and in two instances on the scrotum. The extremities were attacked in but one ease. B. F. Stahl (Amer. Jour. Med. Sci., Mar., IflOO). Treatment. — The treatment of gan- grenous dermatitis consists in the appli- cation of stimulant and antiseptic lo- tions or ointments. Dermatitis Maligna. Definition. — An inflammation of the DERMATITIS MALIGNA. SYMPTOMS. PATHOLOGY. 417 skin with a tendency to malignant de- generation. Symptoms. — The terms "malignant dermatitis" and "malignant papillary dermatitis" are applied to an inflamma- tion, almost exclusively limited to the mammillary portion and areola of the mammary gland, and generally known as "Paget's disease of the nipple." It has much the appearance of an eczema ru- brum, and is nearly always followed by epitheliomatous infiltration. Sir James Paget, who first described the affection in a classical paper in the St. Bartholomew's Hospital Eeports for 1874, gives the following account of its clinical history: — "The patients were all women, vary- ing in age from 40 to 60 or more years, having in common nothing but their dis- ease. In all of them the disease began as an eruption on the nipple and areola. In the majority it had the appearance of a florid, intensely-red, raw surface, very finely granular, as if nearly the whole thickness of the epidermis were removed; like the surface of very acute diffuse ec- zema, or like that of an acute balanitis. From such a surface, on the whole or greater part of the nipple or areola, there was always copious, clear, yellowish, viscid exudation. The sensations were commonly tickling, itching, and burn- ing, but the malady was never attended by disturbance of the general health. I have not seen this form of eruption ex- tend beyond the areola, and only once have seen it pass into a deeper ulceration of the skin after the manner of a rodent ulcer. . . . But it has happened that, in every case which I have been able to watch, cancer of the mammary gland has followed within, at most, two years, and usually within one year. The eruption has resisted all treatment, both local and general, that has been used, and has continued even after the affected part of the skin has been involved in the cancerous disease." The only fact that can be added to this description, after twenty-four years' further observation, is that the disease is not exclusively located upon the nipple of women, but that it may involve the nipple of the male or may occur upon other portions of the body. The in- flamed patch of the nipple and areola is usually decidedly indurated, with an ele- vated border, and gives the sensation, when pinched up, of a button inserted in the skin. Pathology. — It is not definitely known whether the disease is epitheliomatous from the start, or whether it begins as an eczematous dermatitis and becomes ma- lignant in consequence of the epithelio- matous degeneration of the skin. The glandular structures of the nipple are especially liable to malignant degenera- tion, and it is probable that any long- continued irritation of the epithelial ele- ments would be followed, in persons with a predisposition to epithelial overgrowth, by malignant disease. Upon this as- sumption, the view that the primary dis- ease is an eczema or a dermatitis, and that malignancy is secondary, is a ra- tional one. Microscopical studios of the disease by Thin and Wile have shown the epithelial Infiltration present at a very early stage. It may be said, however, that when the diagnosis of malignant dermatitis or Paget's disease can be made, the trouble is no longer an eczema, whatever it may have been at an earlier period. Case of iiiaUgnnnt papillary derma- titis occurring on the breast of a woman of 45. The morbid changes are inflam- mation of the papillary layer, with (cdema and vacuolation of the epidermic cells, the latter being followed by 418 DERAIATITIS ilALIGNA. DERMATITIS EXFOLIATIA'A. complete destruction or by abnormal proliferation in different situations. Sec- ondary to these changes there is pro- liferation of the lining of the galaetif- erous ducts and glands. The prolifer- ated cells finally break through the basement-membrane into the surround- ing tissue, at which point malignant in- fection begins. F. H. Wiggin and J. A. Fordyce (N. Y. Med. Jour., Oct. 2, '97). Diagnosis. — Diagnostic features of malignant dermatitis as differentiated from eczema of tlie nipple are: — 1. Its occurrence in women over 40 years of age, while eczema of the nipple is more frequent in the child-bearing age, and especially during lactation. 2. The affected surface is red, raw, and granular-looldng. 3. There is decided superficial, well- defined induration in place of the dif- fuse, leathery infiltration of eczema. Finally, while eczema is often ob- stinate, it usually yields to proper local treatment; while malignant dermatitis is not curable by any means short of cauterization or removal with the knife. Treatment, — In reference to the treat- ment of malignant dermatitis, Sir James Paget said in his paper above referred to: "In practice the question must be some- times raised whether a part, through whose disease or degeneracy cancer is very likely to be induced, should not be removed. In the member of a family in which cancer has frequently occurred, and who is at or beyond middle age, the risk is certainly very great that such an eruption on the areola, as I have de- scribed, will be followed within a year or two by cancer of the breast. Should not, then, the whole diseased portion of the skin be destroyed or removed as soon as it appears incurable by milder means?" The answer to tlie question is self-evi- dent, in view of the history of the dis- ease. If a diagnosis of malignant derma- titis is positively made, there can be no other rational treatment than such as would be appropriate for epithelioma; namely: destruction of the diseased skin by cautery or caustics, or removal of the entire breast. In cases of doubt, the ap- proved remedies for eczema may be tried, but too much time should not be wasted in temporizing expedients. Pyrogallic-acid ointment, 3 drachms to the ounce; lactic acid; chloride-of- zinc paste, of varying strength; chromic- acid and arsenical pastes, the best of which is Marsden's (IJ acidi arsenosi, pulv. g. acaciffi, of each, p. e.; mix and make a stiff paste with water just before using), may all be used with good effect. Chromic acid in concentrated solution is the least — Marsden's paste the most — painful of these applications. The ar- senical paste should not be applied over a surface of more than one sqtiare inch at a time, as otherwise sufficient arsenic may be absorbed to cause symptoms of poisoning. The pain of the application is very severe, and as the caustic must remain upon the part at least twenty-four hours, the suffering is always consider- able. Wlien the paste is applied a piece of lint is pressed upon it which absorbs the surplus and prevents its spreading. After twenty-four hours, a poultice is applied, which soon causes a separation of the slough. The resulting ulcer is usually healthy in appearance and heals readily under simple applications, if all the degenerated tissue has been de- stroyed. The galvanocautery and thermocaii- tery are trustworthy methods for destroy- ing the morbid tissue. When the area involved is large, the best treatment is thorough extirpation of the entire Ijreast. Dermatitis Exfoliativa. Definition. — Tiiflanimiitinn of the skin, General Epidemic Exfoliative Dermatitis iByrom Bramwell.l »S OF CLINICAL MCDICINE DERMATITIS, ACUTE EXFOLIATIVE. SYMPTOMS. DIAGNOSIS. 419 acute or chronic, accompanied by exfolia- tion of the epidermis. Varieties. — (A) Acute exfoliative dermatitis of infants. (B) Chronic general exfoliative derma- titis. (C) Local exfoliative dermatitis. {D) Epidemic exfoliative dermatitis. (A) Acute Exfoliative Dermatitis of Infants. Defnition. — An acute inflammatory affection of the skin of infants, accom- panied by exfoliation of the epidermis in flakes, running a rapid course, and in most cases ending fatally. Symptoms. — The disease was first de- scribed by Prof. Bitter von Eittershain, of Vienna. He had observed nearly three hundred cases in the course of ten years. The children attacked were nearly all between 3 and 5 weeks old. A pro- dromal stage, characterized by abnormal dryness of the integument, with furfu- raceous epidermal desquamation, usually occurred. The skin of the lower part of the face, especially about the angles of the mouth, becomes red and slightly tumid. The margin of the redness, which rapidly spreads, is indistinct, not being sharply defined against the healthy skin. The skin at the angles of the mouth becomes fissured and covered with scabs. The mucous membrane lining the pharynx and buccal cavity is reddened, and the palatal arch is the seat of super- ficial erosions, covered by a grayish-white exudation. The appetite and digestion remain un- impaired. There is no fever. The red- ness and thickening of the skin extend over the entire body. The face becomes covered by yellowish, translucent scabs upon a reddened base, intersected in vari- ous directions by fissures. The skin be- comes wrinkled, and the upper layer sep- arates from the cutis. The epidermis may be detached in large flakes or in scales. This process, continuing until the entire surface is denuded of epi- dermis, presents an appearance similar to that following an extensive scalding. In favorable cases the dark, raw-flesh color of the cutis soon gives way to a lighter red, and in some cases the normal color of the skin is restored in twenty-four to thirty-six hours. In unfavorable cases, on the other hand, the color is a dirty brownish-red, and the cutis becomes dry and parchment-like. In those cases which terminate in recovery, the normal condition is entirely re-established in a week or ten days, the skin for a few days being covered by a fine, branny desqua- mation. As sequels, eczemas of considerable ex- tent, or small, superficial boils and ab- scesses, sometimes in large numbers, oc- cur, and delay recovery. At other times extensive phlegmonous infiltrations oc- cupy considerable tracts of skin, and may result in gangrenous destruction of tis- sue and death. In the latter conditions pneumonia and colliquative diarrhcea not rarely precede the fatal termination. Re- lapses are rare. The disease is ascribed to a septic or pus infection localized upon the skin. Diagnosis. — In typical cases, no ditfl- culty should occur in diagnosis. Ery- sipelas, which sometimes closely resem- bles this disease, is easily excluded by the high temperature of the former. In pemphigus there are distinct bulls sepa- rated by normal skin. In exfoliative dermatitis the redness and thickening are progressive and finally occupy the entire surface. Case of dcniiatitis exfoliativa pig- mentosa in which the disease hore a close resemblance to the pityriasis rulira of Devergie. with the exception of the pigmentation, which was very intense. 420 DERMATITIS, CHROXIC EXFOLIATI^■E. SYJIPTOMS. Henry Handford (Brit. Jour, of Derm., Mar., '94). Prognosis. — This is decidedly unfa- vorable. In Eittershain's cases the mor- tality was about 50 per cent. Treatment. — Xo internal treatment is indicated in uncomplicated cases. Suffi- cient nourishment is, of course, impor- tant. Locally, cool baths, or bran-baths, afterward drying the skin with fine, soft cloths and carefully avoiding friction, will meet the indications in most cases. Eagged and loose patches of epidermis should be clipped o£E with scissors, and all denuded and fissured surfaces dusted with finely-powdered calomel. The crusts which accumulate at the angle of the mouth and render nursing difficult and painful are best got rid of by soak- ing with oil of sweet almonds and care- fully removing the loose ones by means of dressing-forceps. Slightly astringent baths (decoction of oak-bark, 1 pint to the bath) are sometimes beneficial. The most efficacious treatment is the creolin bath: about 15 gallons of com- fortably-warm water at 95° F., to which 2 Vs pints of a 1-per-cent. solution of ereolin are added. A bath is taken regu- larly once a day — in very bad cases twice — remaining in it twenty minutes. It is best given at night, the patient being subsequently dried and put to bed. Creolin ointment ('A, 1. and 2 per cent., rubbed with lanolin and water in almost equal parts) ranks ne.xt to creo- lin baths in ellicacy, especially if used in quite an early stage. Savill (Edin- Ijurgh Med. Jour., Apr., '95). (B) Chronic General Exfoliative Der- matitis. Definition. — A chronic generalized dermatitis, accompanied by constant ex- foliation of the epidermis in dry, papery scales: the pityriasis rubra of Ilebra. Symptoms. — The disease begins with the appearance of red patches, gradually increasing in size, uniting with others until finally the entire surface is a sheet of red, dry skin. There is no thickness or infiltration. In about a week the epi- dermis begins to scale off in large, thin, white or grayish scales, which soon be- come very profuse and shed in large sheets. The skin, at the same time be- comes of a dusky- or brownish- red. The inguinal glands also enlarge. Later the skin becomes infiltrated to some extent, and looks tense and shiny in places. The mouth becomes puckered, and the skin of the joints may be fissured and some- times moist. There may also be boils or pustules, the hair may fall out, and the nails atrophy and exfoliate. There is often fever at the beginning and at in- tervals during the course of the disease. There is little itching. The subjective symptom mostly complained of is a sen- sation as if the skin were too small, and the patient frequently is chilly. The cotirse of the disease is chronic, lasting months or years, with exacerba- tions of greater severity, alternating with remissions. There is usually progressive emacia- tion, and the patient dies of inanition, or is carried off by some intercurrent affec- tion. Happily the disease is rare. Case of dermatitis exfoliativa in an infant, which appeared on the tenth, day of life and gradually (five weeks) spread over the entire body. It was characterized by dilTuse redness, more- intense in some places than in others, and by foliaceous desquamation. Small vesicles also appeared. The eruption caused itching, but did not interfere with the patient's general condition. There were no lesions in the mouth, and the hair fell in certain spots. Raymond and Barbe (Le ProgrCs MC'd., Jan. 23, '92). Case of dormatitia exfoliativa in a girl aged 11 years. She was first seized with fever and nausea. Three days later her tongue was heavily coated, the breath oirensivc, and sores were present. The- face, neck, and upper chest presented a. DERMATITIS: LOCAL EXFOLLAiTIVE, EPIDEiUC EXFOLIATIVE. 421 scalded appearance, the epidermis being lifted from the true skin, rolling up like tissue-paper, and being broken in a number of places. The temperature was 103° F.; the pulse 144. The disease pursued its usual fatal course, carrying off the patient two days later. No drug was held accountable for the symp- toms. H. M. Beatty (Archives of Fed., Feb., '90). The cause of chronic general exfolia- tive dermatitis is not kno^vn. Diagnosis. — The only disease likely to be mistaken for chronic exfoliative der- matitis is scaly eczema. Still, this is never so universally distributed; has usu- ally a history of moisture and exudation at some time in its course; is attended by intense itching and considerable infiltra- tion. Lichen planus is a papular dis- ease, and, while the papules are some- times aggregated in solid sheets, has a different history from this disease. Treatment. — The treatment is unsatis- factory. Arsenic, which seems indicated, has little effect on the course of the erup- tion. Good results are sometimes ob- tained from codliver-oil, both internally and externally. Saline diuretics and aperients are occasionally beneficial. Externally bland ointments may be ap- plied. The extensive surface involved prohibits the use of mercurial applica- tions, as salivation would be likely to follow. Glycerite of starch or Lassar's paste may at times relieve the uncom- fortable sensation of tightness of the skin. (C) Local Exfoliative Dermatitis. Definition. — A localized dermatitis of mild character, occurring in rounded or oval spots; rosy, red, or mottled in color, and attended by furfuraceous desquama- tion. It is the pityriasis rosea of Gilbert and Duhring. Symptoms. — The most thorough study of the disease in this country is by Duhr- ing. It begins with the eruption of small macular or maculo-papular lesions, of a rosy or reddish color, sharply defined against the surrounding skin, being sometimes on a level with it, sometimes slightly raised, and sometimes depressed. The patches are covered with fine, branny scales and spread at the margin while healing in the centre. The subjective symptoms are usually slight, only mod- erate itching being sometimes com- plained of. The disease lasts from one to three months, recovery taking place spontaneously Causation. — It is apparently a vege- table parasitic affection, but no charac- teristic parasite has been demonstrated in the skin or the scales. Diagnosis. — The erythematous syphi- lide most nearly resembles this affection. The history of the case or observation of the patient for a week or two will clear up the diagnosis. Treatment. — Lassar's paste or other mild salicylic-acid or carbolic-acid oint- ment may be used. Sulphur is also recommended. As the disease gets well of itself in a short time, not much atten- tion need be given to the treatment. (D) Epidemic Exfoliative Dermatitis. This has recently been described by Thomas Savill, of London, who ob- served a large number of cases in the Paddington Infirmary. The disease be- gins as an erythematous or papular eruption, spreading peripherally like ringworm. This is followed by exuda- tion and desquamation. The skin is red, thickened, and indurated, the epidermis being shed in flakes or scales. There is moist exudation in most cases, especially in the flexures of the joints or behind the ears. Exfoliation is continuous. As the disease subsides, the skin be- comes brownish, indurated, and thick- ened, and mav be smooth and shinv or 422 DEKM.\TITIS, EPIDEMIC EXFOLIATIVE. '^^i^'i^J^'^'^ \ Fig. 2. Epidemic exfoliiiUvc ilcnMiiUtis: Ravill's disease. {KmlHn Echeverria.) Fig. 1. — Lfiw power. SalkowBki, Kiilz), inosite, etc. A mixture of dextrosazone and pen- toHazone found in the urine of 76 out of 80 caBea of diabetes. In 04 reaction posi- tive, in remaining 12 cases doubtful. Kulz and Togel (Zeit. f. Biol, B. 32, p. 185, '95). In 12 cases of diabetes the excretion of calcium salts was considerably in- creased in the severe forms of diabetes, while in mild forms the excretion was the same, or only a little in excess of that met with in the urine of healthy persons. This increased lime excretion is due to the greater amount of food and water taken, especially to the increased amount of nitrogenous food. In those cases in which very large quantities of lime salts are excreted (1 to 1 Vs grains of calcium oxide) in the twenty-four hours, the destruction of the albumin of the body is playing some part in the production of this condition. E. Ten- baum (Zeit. f. Biol., pp. 379-403, '96). Several important chemical substances are found in diabetic urine. Next to sugar, those having the gi-eatest signifi- cance are acetone, diacetic acid, and oxj'butyric acid. E. L. Munson (Jour. Amer. Med. Assoc, May 1 to 22, June 1, '97). Albuminuria exists in diabetes, in at least one-third of the cases, but in only a few cases is it symptomatic of Bright's disease. One of the most common complications of diabetes mellitus is an albuminuria, doubtless in most instances secondary to the action of a urine rendered irritant by the presence of sugar upon the renal structures. In 1300 diabetics in whose urine the condition was sought for, 824 were also subjects of an albuminuria. In a large number of these cases the cause of the albuminuria is probably the excessive amount of eggs consumed in the diabetic diet, while in others the albuminuria is symptomatic of some complication, as tuberculosis, cardiac disease, renal inflammation, or a cystitis or pyelitis, depending upon the irritating nature of the sugary urine. Schmitz (Berliner klin. Woch., Apr. 13, '91). in pancreatic diabetes albuminuria is quite exceptional; in traumatic diabetes it is a little more frequent; albuminuria is by far most frequently met with in diabetes with obesity. In grave form of albuminuria of diabetes well-marked DIABETES jVIELLlTUS. SYMPTOMS. 429 nephritis is always found at autopsy; in the benign form but slight nephritic changes are sometimes found; more rarely no changes are detected in the kidneys. Replacement of sugar by albu- min is always an extremely grave sign, but the case may not immediately termi- nate fatally. Jacobson (Gaz. des HOp., Aug. 25, '94). Analysis of 17 cases showing that al- buminuria in connection with diabetes may exist for a long time without lead- ing to any sj-mptoraatic indication of its presence. It is, therefore, less signifi- cant in these cases than in ordinary conditions of nephritis, making it evi- dent that albumin and casts have a dif- ferent signification according to the conditions with which thej' are asso- ciated. Experience shows that, even apart from diabetes, they are met with frequently in persons of advanced age who present no other symptoms of renal trouble. That they are insignifi- cant is often shown by the fact that time may pass without the development of further symptoms. F. W. Pavy (Lancet, Dec. 5, 1903). Owing to the polyuria, urea is nat- urally only present in the urine in a very small propori;ion, but the daily quantity of this substance is increased. Its relation to the total of nitrogen is not noticeably altered, except in grave cases of diabetes, in which the propor- tion of ammoniacal salts is, as is well known, greatly increased, in order to overcome the acid dyscrasia. In serious cases the excretion of lime is also increased. Thirst is usually, but not always, predominant. Hunger is much less frequent, and a great many diabetic patients do not eat any more than a healthy person. Constipation is the rule, being either due solely to the impoverishment of the system with re- gard to water, or to an exaggerated tonus of the splanchnic nerre. It may be stated, in support of the latter hy- pothesis, that this symptom frequently precedes the appearance of the diabetes. The saliva is more abundant. Ex- ceptionally it has been found to con- tain sugar and sometimes lactic acid. The skin is dry and perspiration is rarely modified from the normal. The blood contains a variable proportion of glucose, usually more than 3 grammes per litre, and quite frequently from 4 to 5 grammes. In exceptional cases, when the Iddneys have undergone altera- tion, the proportion may be greater. [I have recently seen a case in which there were more than 10 grammes of sugar per litre. K. LiipiKE. ] There is no close relation between the percentage of sugar in the blood and urine. That more sugar is excreted by the urine on certain days than on others does not depend on the fact that the amount in the blood has reached a cer- tain quantity, but on other complex conditions. The administration of a diuretic diminishes hyperglycsEmia and retards the decrease of glycosuria. Lu- pine (Lyon Med., July 21, '95). When treated by certain aniline colors, the red globules (as found by Bremer) take on a different color in diabetic pa- tients from that assumed in other pa- tients or in healthy subjects. The pulse is full, but of normal fre- quency, except in the case of complica- tions, when it may be rapid. The majority of diabetics excrete more nitrogen than healthy persons of the same weight. This results from the fact that the sugar not being completely utilized, they must necessarily consume more albuminoid matter (and fatty sub- stances), as has been proved by com- parative experiments made upon a dia- betic patient and a healthy subject. [Pettenkofcr and Voit formerly be- lieved that diabetics absorbed less oxy- gen and excreted less carbonic acid than healthy subjects. Later on Voit formu- lated certain reservations upon this sub- ject, and Leo, in an important article, affirmed that, with an equal weight in 430 DIABETES MELLITUS. SYMPTOMS the diabetic and the healthy person, the respiratory exchanges are the same. This opinion has again been contradicted. K. Lepine.] Twenty experiments upon 5 diabetics, two having a grave form of the disease, which prove that the absorption of oxy- gen and the exhalation of cjirbonio acid are not diminished in diabetics, if their weight is considered. The following are the figures obtained by causing the pa- tients to breathe for several minutes into the apparatus of Zuntz and Gep- pert, the volume of gas being calculated by minutes and the kilogrammes by ■weight: — CO.. O. Quotieut. First patient (grave), . . 3.L'1 4.01 SO.O Second patient (mild), . . 2.83 3.S7 74.4 Third patient (mild). . . 3.21 2.84 81.0 Foarth patient (mild), . . 2.30 3.4S SO.O Fifth patient (very grave), . 2.64 4.27 60. J Hans Leo (Zeit. f. klin. Med., B. 19, '92). Hanriot, Weintraub and Laver, Eb- stein, and others positively assert that, when subjected to the same regime dia- betics e.xhale less carbonic acid than healthy persons. The diminished CO; is the result, not the cause, of the diabetic condition; there is less CO; because there is less combustion of glycogen. Arnold Cantani (Deut. raed. Woch,, Nos. 12 to 14, '89). The diminished elimination of CO2, which is characteristic of diabetes, ia the cause of the large sugar production, be- cause in healtli the action of the dias- tatic ferment upon glycogen is held in check by COj, Ebstein (Annual, '90). Estimations of the carbon dioxide in the blood and its alkalinity in 23 sam- ples of blood from 15 patients, 8 being cases of diabetic coma, 3 of diabetes without coma, and 4 being from eases of oedema of tlie lung, pancreatic dis- ease, pernicious antemia, and ascites, re- spectively. In all tlie cases of diabetic coma tlie quantity of carbon dioxide was one-lialf, or less than one-half, the normal, and in the blood of the non- comatoHe there was also less COj than in normal blood, but more than in comatose patients. In (lif iliiilK'tif: cases, diacetic acid ami Mutonc were present in the urine. In 2 cases they found that the amount of total nitro- gen excreted as IVH3 was high. The writers did not lind the amount of gas in the urine in diabetes to be above the normal. Tliese experiments and others in progress indicate that in diabetic coma the respiratory symptoms are not entirely to be explained by the assump- tion of a chemical disability of the blood to combine with carbon dioxide. Beddard, Pembrey, and Spriggs (Lan- cet, May le, 1903). 'When a diabetic subject has been made to absorb a large proportion of starchy matter or sugar, the difference in the respiratory exchange between the diabetic and the healthy subject becomes particularly evident. The healthy per- son, soon after this ingestion, exhales a large amount of carbonic acid; in the diabetic there are no very noticeable modifications. This important fact, added to many others, proves that the diabetic is incapable of utilizing the carbohydrates as effectively as a healthy subject. Views based upon experience with 1004 cases. In diabetes mellitus we have a non-combustion of carbohydrates, whether introduced from without or pro- duced within the organism. The fact that the ingestion of sugar is always followed by its appearance in tlie urine at a very short interval disposes of all theories which make diabetes the result of increased sugar-production in the tissues. Diabetes consists, in the first place, in the non-combustion of some part of the carbohydrates, the excess of non-assimilated sugar a])])caring in the urine. As the disease progresses, a smaller and smaller amount is burned, until none is oxidized, Arnold Cantani (Deut. med. Woch., Nos, 12 to 14, '89). Nearly all cases of diabetes show fluct- uations in the twenty-four hours. Gen- erally diabetics cannot assimilate the car- bohydrates which are taken for break- fast on an empty stomach, but they may assimilate these substances if taken for luncheon or dinner. There is prognostic DIABETES MELLITUS. SYMPTOilS. 431 value in the fluctuations which occur in the elimination of sugar; if these are regular, they indicate a mild case; if they are not marked and are irregular, the case is relatively severe. F. Fred- erick Grouse, Jr. (Albany Med. Annals, Aug., '99). General Symptomatology. — I shall successively take up (1) those of the nervous system, (2) those of the vascu- lar system, (3) those of the respiratory tract, (4) the digestive apparatus, (5) the urinary tract, and (6) the sMn and the locomotor apparatus, ending with a summary statement concerning the dia- betic coma. Nervous System. — The most common secondary nervous lesions of diabetes are certain peripheral neuroses, especially those which cause the abolition of the knee-jerk. The condition of the knee-jerk tested in 184 cases of diabetes mellitus. As only 1 examination was made in 56 of the cases, they are excluded from con- sideration. Of the 128 remaining cases, the knee-jerk was normal in 113 and increased in 2. In the latter cases the patients were suffering from a severe form of diabetes. In 4 cases of severe diabetes the knee-jerk was absent or greatly diminished. The phenomenon was absent in 9 slight cases. Excluding 3 of these, — because 2 of the patients were tabetic and the third was too obese to admit of satisfactory examina- tion, — there were only 10 patients (7.6 per cent.) in whom the knee-jerk was abolished or much reduced. Grube (Bull, de la Soc. Anat., Nov. 1.5, '93). Analysis of 50 cases of diabetes with relation to the knee-jerks. They were both absent in 50 per cent., both pres- ent in 38 per cent., and feeble or one absent in 12 per cent. In patients under 25 years the knee-jerks were absent in 80 per cent.; under 30 years, absent in 75 per cent.; over 30 years, absent in 46 per cent. R. T. Williamson (Med. Chronicle, No. 2, '93). Three hundred and thirty-two cases of diabetes mellitus in which the knee-jerk was tested. The knee-jerk was lost in 49 per cent, of the cases of slight diabetes and but 24 per cent, of the severe cases. In 11 cases there was neuritis on both sides, no cause but diabetes being pres- ent, e.xcept possibly alcohol in 2 cases. Three manifestations of nervous disturb- ance were caused by increase of sugar in the blood: (1) cramps, or an acute irri- tation of nerves; (2) neuritis, or acute inflammation of the nerves; (3) a slow degeneration, or nutritive change, in the nerves, seeming to have a preference for the crural nerve, and thus causing loss of knee-jerk. Grube (Lancet, July 22, '90). The other neurotic symptoms are pain and, more rarely, paralysis. It has been known for a long time that the neuralgia of diabetes is very painful and difficult to cure. Worms has noted that it is very often symmetrical, and states that the pain increases and decreases with the hyperglycemia, which is certainly in- constant. Ziemssen was the first to refer this neuralgia to a neuritis. There are also shooting pains that somewhat re- semble those of ataxia, and which may, in some cases, suggest the question as to whether there is not actual tabes: a very difficult problem to decide. Vergely reported a case in which there were pains resembling those of angina pectoris. The paralyses of diabetes present themselves as follows: 1. Limited and incomplete paralysis; this is, by far, the most prevalent form, as has been stated by Bernard and Fer6 in ISS-i. 2. Mon- oplegia. 3. Hemiplegia. 4. Para- plegia. The various forms of diabetic paralysis are sometimes associated, or are combined, with some unusual phenom- ena; for instance, facial hemiplegia pre- ceded by facial neuralgia and a falling of the upper eyelid (Charcot, quoted by Bernard and F6r6), or paresis of the ex- tensors of the left thigh, impeded speech, 132 DIABETES MELLITUS. SYMPTOMS. and deviation of the mouth to the left (Charcot, ibid.), etc. The progress of these paralyses is also somewhat pecul- iar: the}' are sometimes migratory and transitory. Some of them are undoubt- edly of central origin,, but the majority are of peripheral origin, a neuritis form- ing their anatomical substratum. The peripheral variety is not exempt from this rule, as is proved by the existence, in diabetic paraplegia, of the symptom- complex which Charcot has given the name of steppage, which is characterized by the lowering of the forward part of the foot in walking. This we know is due to the paralysis of the extensors of the foot, and it occurs in peripheral neuritis, but not in myelitis. Cramps are another motor disturbance met with in diabetic subjects. These occur principally in the lower extremi- ties, and at night they give rise to in- somnia, which, according to Bernard and Fere, appears to be, in diabetic sub- jects, the first symptom of disturbance of the cerebral circulation, and may sometimes prove to be the forerunner of serious symptoms. Frequency of cramps in the calves in diabetics. Disease frequently begins in form of an obstinate gastric catarrh ; ex- amination of urine for sugar in all pa- tients sufTering from rebellious catarrh of stomach, recurring in spite of all treat- ment, desirable. Jacobson (Brooklyn Med. Jour., Nov., '94). [Convulsions arc rare. Some time ago I reported a case in which they, as well as aphasia and hemiplegia, depended upon microscopical cortical lesions. R. Llil'INE.] The complication of ajihaHia may occur in cither pronounced or latent cases of diabetes, and may be associated with ob- stinate neuralgia, disturbance of vision, headache, or impairment of hearing. The apliasia may occur at any period in the course of the disease, and may last from a few hours to a month or more. The prognosis is always good. The con- dition can be said to resemble very closely the various forms of toxic aphasia that attend ursemia, pneumonia, gout, and tobacco-poisoning. Corneille (Gaz. Hebd. de Med. et de Chir., Jan. 20, '9S). Perforating ulcer sometimes compli- cates diabetes. Folet and Auche have observed the falling ofE of the nails. In Folet's case they fell without giving rise to pain or inflammation. Case of diabetes in an infant 4 to 5 months old. The urine contained large quantities of sugar. Polyuria, poly- phagia, autophagia, and boils were pres- ent. At autopsy there was found acute broncho-pneumonia with pulmonary oedema, acute intestinal catarrh, oedema of the dura, and a serous effusion in the third ventricle. N. A. Orlow (Vratch, Mar. 3, 1901). Organs of Special Sense. — Cataract is the most common symptom; it nearly always develops in both eyes; if not simultaneously, at least after a short interval. It is characteristic of this form of cataract to be relatively soft. Eetinitis is next in order, with white exudations along the vessels and in the perimacular region. Many causes may lead to ocular le- sions in this disease. Among them are (1) diminution of water; (2) diminu- tion of resistance of the vessels, due to general weakening of nutrition; (3) the existence of a toxic substance in the blood, produced by abnormal processes; (4) various complications. Mauthner (Inter, klin. Rund., No. 2.5, '93). From a study of 2.'5 cases in which lesions of various character were found in association with diabetes, three groups are distinguished: (1) a characteristic inflammation of the central region of tlic retina, with small, bright areas, and frequently, also, small hnemorrhages; (2) retinal hemorrhages, with the conse- quent inflammatory and degenerative changes; (3) rarer varieties of retinitis and degeneration, the relation of which to the constitutional disease remains to DIABETES MELLITUS. SYMPTOMS. 433 be demonstrated. Hirschberg (Deut. med. Woch., Dec. 18, 25, '90). This form is nearly always accom- panied by slight hjEinorrhages. True optic neuritis is much more rare. The retinitis of diabetes distinguished from that of Bright's disease as follows: 1. The patches are irregularly distrib- uted around the centre of the retina, not specially near the macula, and are met with on the nasal as well as on the temporal side of the disk. 2. The patches are never arranged in a fan shape. 3. They are never associated with papillitis or diffuse retinitis. 4. The h.iemorrhages are, as a rule, punctiforni, and not striated. 5. Hfemorrhages into the vitre- ous are common. Saundby (Birming- . ham Med. Rev., Jan., Feb., '93). Out of 140 diabetics, 34 were found who were the subjects of retrobulbar neuritis, which could not be attributed to abuse of alcohol or tobacco. Schmidt- Einipler (Annal. d'Oculist., Sept., '96). Unusual case of neuroretinitis where the changes were very characteristic of albuminuric retinitis, with two excep- tions, namely: the star-shaped figure that is commonly seen at the macula in albuminuric retinitis was found below and to the nasal side of the disk, and the papilla was swelled more than is usually found in the albuminuric form. The round, white patches, the numerous small and flame-shaped hsEUiorrhages, and the oedema were found. Lens and vitreous were clear. Vision equaled '"/n- The man complained only of decreasing vision. The urine was repeatedly examined, but showed no trace of albumin or sugar. It was abnormally abundant, very rich in phospliates, and of normal specific gravity. At first he passed seventy-nine ounces daily. Hansell (Phila. Poly- clinic, Jan. 30, '97). This condition would e.xplain the ex- istence of the central scotoma sometimes met with in diabetes. Case of diabetic neuritis with central scotoma. At autopsy zone of degenera- tion in optic nerve. Eraser and Bruce (Edinburgh Med. Jour., May, 'O.'i). Besides the ocular lesions mentioned, Panas, and, after him, Hirschberg, have insisted upon visual disturbances caused by a defect of accommodation. Out of 717G eye-patients, 113, or 1'/, per cent., were diabetics. After ten years' existence this disease regularly causes alterations of the eye-structures, particularly of the lens and retina. In a third of the cases diabetes was found associated with some of the following significant changes: (1) uncomplicated paralysis of accommodation in middle life; (2) late myopia occurring between 40 and CO years, without changes in the lens; (3) retinitis; and (4) quickly de- veloped cataract in young persons in poor health. Hirschberg (Deut. med. Woch., Mar. 20, '91). There may be functional ocular dis- turbances with diabetes, either of ac- commodation> refraction, or visual acuity. It may be paralysis of accom- modation, yet it is always partial, prob- ably toxic in origin. Myopia is not un- common, or cataract, or diminished re- fraction; or there may be disturbed central or peripheral vision, amblyopia, hemianopsia, etc. Separate muscles may be paralyzed; there may be diplo- pia. F. Terrien (Jour, des Prat., Feb. 14, 1903). Paralysis of the intrinsic muscles is very rare. Paresis of the abducens some- times occurs; also a combined paralysis of the motor oculi, which gives rise to imperfect lateral motion of both eyes. A nuclear origin is evident in these cases. Gell6 states that suppuration of the ear is not rare in diabetics. The progress of acute otitis is the same as that ob- served in gout: rapid tumefaction, pro- trusion, and redness of the tympanum. During the second day severe pain, and afterward abundant suppuration. Inflammation of the mastoid is very frequent in diabetes mellitus. R. A. Urquhart (Med. News, Mar. 21, '90). Two cases of acute mastoiditis in per- 434 DIABETES MELLITUS. SYMPTOMS. sons suffering from diabetes mellitus. In the first case, the patient, a woman aged 50, induced the acute ear inflam- mation as the result of snuffing salt- water up the nose. At first she made good progress under treatinent. Soon, however, began to complain of consid- erable pain in the right half of the head, with continued discharge, renewed pul- sating tinnitus, and commencing mastoid tenderness, until it became requisite to open the mastoid process. The interior of the process was found made up of small cells, in many of which were un- healthy granulations. In the second ease, the patient, a man aged 58, had suffered from diabetes for about one year. The attack of middle- ear inflammation was induced as the result of influenza, and was soon com- plicated by mastoid involvement. When opened, extensive bone disease was found present. J. E. Sheppard (Med. News, May 2, '9G). Bouchardat dwells upon the diminu- tion of the memory and the existence of a growing indifference; the loss of apti- tude for any intellectual work, a tend- ency to anger, melancholy, and hypo- chondria. It appears to me that this author has laid the colors on rather heavily in painting his picture; mental symptoms are not usually met with in diabetic subjects independently of the many cases in which heredity plays an important part. Sugar in the urine is not at all com- mon among the insane. Forty cases ob- served who had diabetic relations, 10 of them having diabetic parents or grand- parents, 14 having diabetic brothers or sisters, 12 having aunts or uncles and . 3 cousins suffering from tliis disease. Besides these there were 12 insane pa- tients who had insane and diabetic rela- tives and 10 patients wlio were both insane and diabetic. Nearly all the cases of insane diabetics were affected with melancholia. Tlie patients who had been diabetic and had then become in- sane had almost all lost some or all of the symptoms of tlic diabetes during the period of their insanity. Mallet (Bull, de la Soe. Anat., Nov., '90). Diabetes is a disease which often shows itself in families in which insanity pre- vails; the two diseases are certainly found to run side by side, or alternately with one another, more often than can be accounted for by accidental coin- cidence or sequence. Maudsley ("Pathol- ogy of Mind," p. 113, 79). The psychoses which develop in the course of diabetes usually take the form of melancholia. It is rarely that mani- acal excitement is observed, circular in- sanity being oftener seen. Finder (In- augural Dissertation, '92). Three cases of diabetes seen com- plicated with mental disturbances. In the first case there was melancholic de- pression with suicidal ideas; in the sec- ond, mental debility; and in the third considerable pruritus vulvae with . gen- eral uneasiness. In all three cases there were no hereditary influences. S. lerzy- kowski (Nowiny Lekarske, July, Aug., '93). Investigation carried on at the Ban- stead Asylum and extending over a period of eighteen months. Between the 11th of January, 1894, and the 25th of June, 1895, there were (excluding transfers) 208 males admitted to the asylum; and in 175 of these an examination of the urine was made within forty-eight hours after admission. In 12 in.stancca, or in C.85 per cent, of these 175 cases, sugar was almost certainly proved to be pres- ent. The following table indicates the varieties of mental disease under which these admissions labored, and the dis- tribution among them of the 12 exam- ples of glycosuria: — Congenital Cases.... 2 Epileptic Insanity... 18 General Paralysis. . . 30 3 Mania 43 Melancholia 55 6 Delusional Insanity. . 5 Organic Dementia... (5 2 Senile Insanity 10 1 Totals 175 12 C. Hubert Bond (Jour, of Mental Science, Jan., '90). DIABETES MELLITUS. SYjMPTOMS. 435 However, when, as has been remarked by Bernard and Fere, an improvement in the mental condition occurs during the antidiabetic treatment, one would be inclined to admit a certain relation be- tween mental symptoms and the diabetic dyscrasia. The same conclusion is reached when the glycosuria and mani- acal symptoms alternate. Cases of this kind have been reported. Vascular System. — The lesions of the heart have been indifferently studied until of late. Among 380 diabetics Mayer has observed cardiac complica- tions in 82. Of 380 cases, 337 were in the first stage of diabetes and 47 in tlie second stage; of the latter 20 were under observation during both stages. Increased cardiac volume, either from hypertrophy or dila- tation, is much more frequent in dia- betes than one would suppose from the literature, it being found without other anatomical lesions in 82 of the 380 cases. J. Mayer (Zeit. f. klin. Med., B. 14, H. 3, '88). These patients are either of very deli- cate constitutions, with the heart weak and irregular, or they are obese diabetics, with the face red or cyanosed, who pre- sent a strong cardiac impulse, and signs of dilatation of the heart, either with or without atrophy. These patients are liable to die suddenly. Such cases should not be confounded with the true diabetic coma; moreover, they differ from the latter by the absence of ace- tonuria and by the suddenness of death. Very often it is after a voyage or fatigue of some kind that these patients fall into a state of collapse, with cold ex- tremities; small, feeble pulse; a loss of consciousness, more or less rapid; and -death in a few hours. Five cases of diabclic ansina pectoris; in one sudden dcith during attack. Vergely (Jour, de Mfd. de Bordeaux, '94). There are also mixed cases, where, with a weak heart, there is, at the same time, autointoxication. I have myself observed three such cases. The anatom- ical examination of the heart shows the myocardium rather atrophied and pale. In Virchow's necropsy the heart was enlarged in nine cases out of si.\ty-nine, and exclusive of those in which there was enlargement from anatomical causes (vascular, valvular, or renal disease), a percentage of 13. JIayer (Zeit. f. klin. Med., B. 14, H. 3, '88). Of the patients who died of diabetes at the Berlin Charite 10 per cent, had cardiac enlargements without valvular or arterial lesions or renal disease. 0. Israel (Annual, '89). Arteriosclerosis is exceedingly com- mon in diabetics. Ferraro dwells par- ticularly upon generalized endarteritis. According to him, the atrophic and ne- crotic lesions reported in various organs are due to this endarteritis. In the last 11 years there have been 26 cases of diabclic gangrene admitted to the wards of St. Thomas's Hospital. From a study of these cases the follow- ing conclusions may be noted: 1. That it yet remains to be proved that true gangrene (excluding death from acute specific processes, wliich may occur in any subjects and at any age) occurs in diabetic patients unaccompanied by such arterial disease as would of itself produce the gangrene. 2. That the glycosuria may or may not precede the gangrene, but is not usually accompanied by other signs of diabetes. 3. That septic wounds may produce a glycosuria, which van- ishes when the septic process is removed. 4. That individuals suffering from sep- tic processes are often on the border-land of glycosuria. 5. That gangrene may aggravate a preexisting glycosuria. 0. That the arterial disease is sometimes that which accompanies, or is produced by, chronic renal disease. 7. Tliat it has yet to be proved that neuritis can pro- duce any gangrene comparable to that of the so-called diabetic gangrene. 8. That the best chance of recovcrv is ofTered 436 DIABETES MELLITUS. SYINIPTOMS. by removal of the limb near the trunk, and that this measure should be under- taken before the patient is reduced by septic absorption. 9. That the presence of glycosuria may be an indication, in- stead of a contra-indication, for opera- tion. C. S. Wallace (Lancet, Dec. 23, '99). (Edema, which is quite common in diabetes, is not alwaj's symptomatic of an affection of the heart. It may pos- sibly be due to a complication of Blight's disease of the kidneys, but this is extremely rare; to a venous throm- bosis, of which examples have been re- ported by Pavy, Gull, Dionis des Car- rieres, Leudet, Potain, and others. Sometimes there appear to be active tumefaction and other inflammatory phenomena that are apparently due to vasomotor disturbances. In many cases the cedema depends upon the impaired nutrition of the vessels caused by the dyscrasia. Pulmonary Apparatus. — The most frequent complication in this direction is pulmonary phthisis. At least one- third of the cases of diabetes treated in the hospitals are on account of this. The lesions of diabetic phthisis are al- most always those of bacillary tuber- culosis. The exceptions met with are cavities following pulmonary gangrene, which, as has been remarked by some clinicians, have not the usual foetidness. There are also ulcerations due to a fibrous ulcerative pneumonia (Mar- chand). Dreschfcld, Fink, and others have reported similar cases. After phthi- sis, pneumonia is a serious complication of diabetes. Pneumonia is rare in diabetes. In 700 cases of diabetes only 7 cases of [ineumonia observed, not counting 1 case of l)ronf!ho-pn0, + C.H.O -f O = C.H.O, + 11,0 formic acid The quantity of o.vybutyric acid elimi- nated per day is not insignificant, for 4 grammes of ammonia neutralize about 30 grammes of oxybutyric acid, and some diabetics excrete more than 4 grammes of ammonia daily. There can hardly be a certain parallel- ism between the excretion of ammonia and that of the oxybutjTic acid. The ammonia may either be saturated with other less known acids or its forma- tion may be due to other factors. It must, moreover, not be forgotten that oxybutyric acid is not peculiar to diabetic coma. Minkowski has elimi- nated 3 grammes from a non-diabetic woman, attacked by pseudoscorbutus in a case of lateral amyotrophic sclerosis. To sum up, there seems to be no doubt that in a certain number of cases of severe diabetes the blood is less alkaline. Is this lesion the cause or the effect of the symptoms? I am inclined to believe, with the majority of authors, that it is in part the cause, and I am surprised at the opposite interpretation given by Klemperer, who says that the blood is acid because there is coma. Clinical ob- servations seem to me to contradict this view, for the lack of alkalinity of the blood precedes the beginning of the coma. Finally, the cases in which purely-alkaline treatment, according to Stadelmann's method, has been mani- festly useful would seem to favor the opinion which I defend. I have myself seen several such cases. It is likewise an incontestable fact that the acid intoxication is merely an ele- ment of the diabetic coma. It is certain that the kidney is not healthy when the symptoms present themselves (see above the lesions of Ebstein and of I'ichtner). Finally I may mention lipajmia, to which English physicians attach a pathogenic value. From a review of opinions of various well-known surgeons, and from personal limited ol)servutians, it appears that the presence of glycosuria in those indi- DIABETES MELLITUS. SYJIPTOMS. 443 viduals who may have surgical diseases does not in itself constitute an absolute contra-indication to any and all surgical relief. Very great judgment must be exercised in the selection of cases, in the determination of the kind and extent of the operation to be performed, and the strictest surgical asepsis must be rigidly observed throughout. Infection, when it occurs, is from without, and is the result of an error in the technique. When in- fection does not occur, the operative wounds heal kindly, but slowly, espe- cially in granulating wounds. The vas- cularity of the tissue must be interfered with as little as possible. Tliis is par- ticularly so in gangrene of tlie extremi- ties, in which the statistics of Heiden- heim, Kuster, and Smith and Durham sliow most conclusively the necessity of high amputations in these conditions. Personal opinion is that it is better to cut down upon and ligate the artery in gangrene of the extremities rather than to attempt the bloodless amputation by means of the Esmarch band. A. L. Fisk (Annals of Surg., Apr., 1900). Acute Form. — Diabetes, in the great majority of cases, is an affection pro- gressing in a chronic condition, but in some cases the onset is sudden and the progress of the disease acute. Out of 77 cases of children traced to their termination, 14 recovered, 7 im- proved, 4 remained unimproved, and 52 died. C. Stem (Archiv f. Kinderh., B. 11, H. 2, '89). Gravity of prognosis of diabetes in children. Of 108 cases, G4 per cent, terminated fatally. Prognosis graver in proportion as children are younger. Wegeli (Archiv f. Kinderh., B. 19, H. 1, 2, '95). In adults proportion of grave cases does not exceed 5 per 1000. Worms (Bull, de I'Acad. de M6d. de Paris, July 23, '95). The rate of mortality from diabetes has risen, in Paris, within the last ten year.=i, from an average of 8 in each 100,000 population to an average of 13; while in Copenhagen it has risen from 5 to 8; and in England and Wales it has increased, in fourteen years, 70 per cent., alter allowing for the increased population. Saundby (Editorial, Modem lied, and Bact. Rev., Apr., '97). Authentic cases of this nature are rare, because the evolution of the disease may actually have been an incipient one, and have remained unnoticed up to a certain period, when there is a sudden aggrava- tion. [Loeb reports the case of a chemist who, while in good health, examined hia own urine and found it normal. Soon after he became ill, and experienced vio- lent thirst. At this time the urine con- tained 8 per cent, of sugar. Death took place in five weeks. R. Lepine.] Death is not invariably the termina- tion of acute diabetes. Several cases of recovery have been reported. Holsti saw, in a man 41 years old, diabetes having a very sudden beginning, to judge by the thirst, and which was only subjected to the dietetic treatment six weeks later. After three days abstinence from amy- laceous food the urine, which had con- tained 8.8 per cent, of sugar, ceased to contain any, and the future use of amy- laceous food did not cause a return of the diabetes. This is assuredly a rare case. More frequently a diabetes having an acute beginning passes to a chronic condition. A mild form of diabetes has sometimes been described as intermiitent ; it is due in a measure to the influence exerted by a too liberal alimentation. As soon as a proper diet is followed the glycosuria does not exist. This is not, properly speaking, an in- termittent diabetes. Such cases belong rather to the type of alimentary glyco- suria. Study of six cases of recurrent transi- tory diabetes. The proportion of sugar was very variable, but usually 30 to 40 g. a day. The glycosuria diminished rapidly under a rigid diet. The amount of sugar was invariably less in the sec- ond and third attacks than in the first, 444 DIABETES MELLITUS. DIAGNOSIS. but the attacks lasted longer with each relapse, 1 or 2 g. of sugar persisting for weeks or months. As a rule, there was albuminuria, which subsided with the glycosuria. The proportion of uric acid was high. In all cases there was a mod- erate degree of polyiiria. Thirst and hunger were never marked, but emacia- tion, sense of physical exhaustion, and depression were prominent symptoms; these recurred with diminished intensity with each attack. Months or years of perfect health sometimes intervened with the attacks. In one case ordinary dia- betes supervened. The recurrent transi- tory variety of diabetes is connected in certain cases with a constitutional ar- thritism, in others with an acquired ar- thritic tendency. Transitory diabetes is not dangerous in itself; it is the ex- pression of an enfeebled constitution or a passing dyscrasia. Dreyfus Brissac (Sem. Med., Feb. 12, '97). IVue intermittent diabetes is almost independent of the alimentation. It has been reported by Bence-Jones, Baudre- mont, and others. Saundby reports one case. I have myself seen one alternate with albuminuria. This form of dia- betes is principally met with in arthritic and hysterical subjects. Its appearance depends principally upon nervous causes, moral or otherwise. Diairnosis. — A well-defined diabetes cannot be mistaken by an experienced physician. The general symptoms and the glycosuria establish the diagnosis. Diagnosis by Examination of the Urine. — If the percentage of sugar found in the urine is considerable, doubt is impossible. If, on the contrary, a minimum quantity is found, it may be questioned whether there is not merely a condition of temporary glycosuria. This should never be lightly decided; it requires a careful watching during sev- eral days to make sure of the actual con- dition. All caHCB with Bugar in the urine are cases of true dialx-tcs, whether the sugar be extremely small in amount or even be entirely absent for a time. Ebstein (Centralb. f. innere Med., Nov. 21, '96). The urine of persons taking rhubarb, santonin, or some other substances gives a reaction that might be mistaken for that of sugar. S. A. Hazen (New York Med. Jour., Jan. 29, '98). It is in the cases in which lesions of the nervous system, and particularly of the brain, exist that the diagnosis be- comes most difficult, and the common tendency to regard glycosuria as a con- secutive symptom must be guarded against. The diagnosis is usually easier where paraplegia and glycosuria co-exist. It is a known fact that a neuritis of the lower members in a diabetic patient may simulate iahes dorsalis, but it would, however, be a rare condition when co- existing with glycosuria. The following are the differential characteristics: — 1. The walk of the patient. Were symptoms of diabetes present before the motor disturbances? 2. The symptoms proper of diabetes: the abundance of the urine and of the glycosuria, the presence of acetonuria, etc. 3. The symptoms peculiar to tabes, particularly motor inco-ordination, which is not present in diabetes; in the latter affection "steppage" exists, which symptom does not occur in tabes. Among symptoms characteristic of both tabes and diabetes are irregular areas of anaesthesia or analgesia; pares- thesitB, especially about the legs and sexual organs; increased sensitivenesB toward cold; lancinating pains; dimin- ished sexual vigor; and trophic and secretory disturbances, such as malum perforans pedis, decubitus, liypcridrosia, and muscular atrophy. Both diseases rorely occur together. W. Croner (Zeits, f. klin. Med., vol. xli, Nos. 1-4, 1900). Besides these fundamental differences, there are several other signs of second- ary importance, such as shooting pains, DIABETES MELLITUS. DIAGNOSIS. 445 which, although they may exist in dia- betes, as reported by Charcot, llaymond and Oulmont, Bernard and Fere, and others, are of sufficiently-rare occur- rence. The vesical disturbances existing in diabetes have nothing in common with the vesical and urethral attacks which occur in tabes; the ocular paraly- sis, which is a frequent symptom in tabes, very rarely occurs in diabetes; in those cases in which there are disturb- ances of vision, an examination of the fundus will dispel all uncertainty: in diabetes retinitis will be found; in tabes atrophy of the optic nerve. If the latter lesion is not sufficiently pronounced to be recognizable, it should be remembered that in the amblyopia of diabetes the optic disturbance is bilateral from the beginning, while in tabes it most fre- quently begins in one eye. The above refers to the diagnosis be- tween diabetes and glycosuria of nerv- ous origin; but the latter variety is not the only one which may be mistaken for diabetes. I will first refer to ali- mentary glycosuria, which occurs in cer- tain subjects after a very copious in- gestion of the hydrocarbons; it also occurs in nearly every subject after the ingestion of a sufficient quantity of glu- cose during a short space of time {at least 200 to 300 grammes for certain persons). Alimentary glycosuria was first observed in certain cirrhotic sub- jects by Cotrat, afterward by myself and a number of others (Quincke and oth- ers), but the affection is not best seen in cirrhotic patients. Krauss and Lud- wig observed a young girl suffering from Basedow's disease who, after the inges- tion of from 100 to 200 grammes of pure glucose, excreted very nearly 17 per cent, of the glucose ingested. It often happens that very fat people will show glucoss in their urine after a meal containing a fairly large quantity of sugar. The glucose disappears from the urine of those fleshy, diabetic pa- tients who are being treated for obesity though not placed upon a strict diabetic diet. The glycosuria which so often fol- lows traumatic neurosis is due to an ex- cessive diet combined with a lack of active e.xercise. Hirschfield (Med. News, Jan. 28, '98). Eecognition of the "alimentary" form of diabetes is effected not only by the elimination of sugar being susceptible of control by the exclusion of carbohydrate matter from the food, but also by the absence of the products, diabetic and oxybutyric acids, of tissue breaking down. If the ferric-chloride test for these products gives no reaction, case is thus far only in the alimentary form. F. W. Pavy (Lancet, June 23, 1900). Chvostek, at Meynert's clinic, was also able to produce alimentary glyco- suria with great facility in patients suf- fering from Basedow's disease. Evi- dently these patients, owing to their nervousness, are particularly predisposed to glycosuria. In some subjects, on the other hand, it is almost impossible to induce alimentary glycosuria. The glycosuria which sometimes fol- lows certain acute maladies, and some surgical affections and cases of poison- ing, cannot well be mistaken for dia- betes, as the other existing conditions would arouse the attention of the phy- sician. Moreover, this form of glyco- suria is alwaj's very mild. Case of myxtrdema in which the in- gestion of thyroid tablets caused gly- cosuria. Ewald (Deut. med. Zeit., No. GO, '94). Under fresh thyroid-gland diet animals are affected with tachycardia, consider- able emaciation, polyphagia, polydipsia, and temporary glycosuria. Gcorgiewski (Centrnlb. f. die med. Wissenschaften, No. 27, '95). Marked polyuria with glycosuria is produced in animals by caffeine-sul- phonic acid. Jacoby (Archiv f. exper. Path, und Pharm., B. 35, H. 2, 3, '95). 446 DIABETES MELLITUS. DIAGNOSIS. CUoralamid, 1 'A to 3 drachms per day, frequently causes glycosuria. Man- chot (Virchow's Archiv fiir Path. Anat. und Phys. und f. klin. Med., B. 136, p. 368, '95). This is not always the case when the glycosuria is due to the ingestion of phloridzin. Phloridzin diabetes appears more in- tense when the liver contains no gly- cogen. Pick (Archiv f. exper. Path, und Pharm., B. 33, p. 305, '95). It is known that the proportion of glucose contained in the urine may be as great as in very severe diabetes; con- sequently, there are only two ways to avoid being deceived by a patient who hides the fact of having taken the phlo- ridzin. The patient must be closely con- fined and be deprived of phloridzin. On the other hand, the blood-corpuscles must be carefully examined for the re- action of Bremer (see farther on). In cases of phloridzic glycosuria, this re- action will not be present, or, in the worst case, will be exceedingly doubtful. Since the works of Blot it is known that sugar is frequently present in women during parturition. Forty-si.\ women examined, 9 of whom were pregnant, 25 delivered, and 12 nursing. In pregnancy in the last month no trace of sugar was observed; in 10 women recently delivered the presence of sugar was positively ascertained; in 3 cases but slight traces were found, and in 12 others there was no sugar present. The glycosuria appeared about from three to five days after delivery, during the increased secretion of milk, disap- pearing when the secretion diminished. No glycosuria was ob.served in nursing women. The condition appears only when the secretion of milk is in excess of that required for the child. Berberoff (Wratseh, No. 10, '03). Diabetes is a rare complication of pregnancy. Study of one personal case, and twenty-four reported by other ob- servers. About one-half of these ac- quired diabetes during pregnancy, the other half already having the disease before pregnancy occurred. In the former class recovery took place in about three-fourths, with, however, an exhibition of a tendency to recurrence in subsequent pregnancies. In the class in which pregnancy occurred in women already subjects of diabetes, safety through delivery and the lying-in period was apparent in about two-thirds of the cases. Death of the foetus is noticed in about one-half of the cases. Pi'ema- ture delivery is observed in a large pro- portion of the reported cases, due to the presence of the dead foetus rather than the direct influence of diabetes. Tliere were deaths in coma or collapse during or near the time of labor: 1 in a woman who had diabetes before gestation, while 5 were in patients who acquired the dis- ease during pregnancy. Partridge (Med. Record, July 27, '95). It may be necessary in some cases to question the existence of a true diabetes. To establish the diagnosis, reliance may be placed upon the fact that, in the case of a false diabetes, the secretion of milk is always arrested, and that the sugar contained in the urine is not glucose, but lactose, which fact has been estab- lished by Hofmeister, and, after him, Kaltenbach. It would appear, however, according to Blot, de Sin6ty, and sev- eral more recent observers, that the lactose may be partially transformed into glucose; so that the presence of a fermentable sugar (glucose) in the urine of a parturient woman would not in- contestably prove the fact that tlie pa- tient was a diabetic. I may liere call attention to the fact that Mathew Dun- can found true diabetes in a pregnant woman. The child was also said to be a diabeticl A gross error committed by inexperi- enced persons consists in regarding a subject diabetic whose urine reduces cu- pro-polnssic fluid, but which, in reality, does not contain a trace of sugar. This DIABETES MELUTUS. DIAGNOSIS. 447 error is the more regrettable through the fact that the restriction to an animal diet may aggravate the condition of the patient instead of improving it, for the animal diet favors the production of reducing substances in the economy. Among these substances are uric acid, creatinin, allantoin, mucin, oxyphenol, pigments, and above all the components of glycuronic acid. How is this error to be avoided? 1. In non-albuminous urine deprived of the greater part of its uric acid by a preliminary cooling (on ice) and by filtration, the existence of sugar may be admitted if the reduction of the cupro- potassic fluid takes place in the cold state, as the reducing substances only exert their action at the boiling-point. Sugar, itself, in the cold state, only causes a reduction at the end of several hours. If one does not wish to wait, recourse may be had to the following process, which is a modification of that proposed by Worm-Mueller, to determine whether the reduction by heat is partially due to a small quantity of sugar. The exact quantity of urine required to discolor 1 cubic centimetre of Fehling's solution must first be determined, then a portion of the same urine is fermented; this being accomplished, it must then be as- certained whether a greater number of cubic centimetres will be required to discolor the same quantity of Fehling's solution. It is clear that, if a larger quantity is required, a portion of the reducing power was due to a certain quantity of sugar. This method is exact, and its only defect is that it is not within the reach of the ordinary practitioner, owing to the precision of the dosages required. To lessen the error due to the reduc- ing substances, it has been advised to dilute the urine to the fifth and even the tenth degree. Indeed, this should al- ways be done when the urine is very highly charged with sugar; but when there exist only doubtful traces of it, the dilution of the urine is a positive means of not being able to obtain the sugar. This process should consequently be rejected. On the other hand, the following method, which is, moreover, a classical one, is perfectly reliable. About 4 grammes of Fehling's solution are poured into a tube; it is heated to the boiling-point, then one to two centilitres of urine, non-albuminous, which is sup- posed to contain sugar, should be made to flow along the side of the tube, which should be inclined. It is well to first heat the urine slightly; otherwise the inclined tube should be held above a flame for several moments in order to sufficiently raise the temperature at the point of contact of the two liquids. After a few moments, if sugar is pres- ent, a green ring will be seen to form, which will then rapidly change to yel- low, and afterward to red, which will contrast decidedly with the blue color of the subjacent liquid. This reaction is easily accomplished, and, if a red ring is obtained, it is of great value, for the reducing substances only produce hy- drate of oxydule, which is of a yellow color. Jastrowitz recently advised examina- tion, by means of the microscope, of the precipitate of oxide of copper. As a matter of fact, none of the reducing sub- stances, uric acid, creatinin, nor the components of glycosuric acid, etc., pro- duce a crystalline precipitate. Accord- ing to the author, these crystals are tctrahcdral and octahedral. These are actually the forms obtained when a watery solution of glucose is made to 448 DIABETES MELLITUS. DIAGNOSIS. react upon Fehling^'s solution, but, ac- cording to Jastrowitz, small spheres maj' also be produced with urine containing a slight amount of sugar. Thus, when, under the microscope, these (spheres) predominate, provided they are accom- panied by tetrahedral and octahedral crystals, it may be affirmed that sugar is present in the urine. It is possible to partially rid one's self of the reducing substances, by means of a. process described a long time ago by Seegen, and which is to be recommended on account of its simplicity. The urine is filtered through animal charcoal as many times as are necessary to discolor it; then the charcoal is washed in distilled water, and the two filtered liq- uids — the urine and the distilled water — are treated separately by Fehling's solution. The reason is as follows: — The charcoal not only retains the col- oring matter and the uric acid, but like- wise certain substances, as yet not well known, which prevent the precipitation of the oxide of copper. Therefore we are better able to search for the sugar with the filtered water than with the urine. Furthermore, the charcoal has retained a large portion of the sugar con- tained in the urine, and gives off into the distilled water a larger portion of the sugar than of the other substances which it had retained. Consequently the re- duction of Fehling's solution is much more easily accomplished by this water than by the urine. These are the advantages of Seegen's method, by means of which the author is able to discover a one-thousandth part of sugar in the urine. Even with a smaller proportion there will be a reac- tion, but this will only become apparent, says Seegen, after several minutes' heat- ing. No other method surpasses this in sensitiveness, and it is most easy of appli- cation, provided a perfect animal charcoal is at hand. To summarize what I have already stated in the beginning, Fehling's solu- tion, provided one knows how to use it, is capable — all statements to the con- trary notwithstanding — of alone deter- mining the existence of sugar. The re- ducing action of glucose upon the oxide of bismuth in the presence of an alkali has also been resorted to for a long time. This reaction, called that of Bottiger, which is described in all the treatises on urology, is far from being valueless, es- pecially when made use of with the modi- fication indicated by Nylander. Leaving aside several other reactions, which have not come into general use, because they are not sufficiently accurate, I pass on to the reaction of phenylhy- drazin, described by Fisher, and em- ployed by von Jaksch for the discovery of glucose in the urine. This reaction is based upon the property, peculiar to phenylhydrazin, of forming, when in combination with glucose, a crystalline substance of a decidedly-yellow color. Jaksch obtains this reaction as follows: 10 cubic centimetres of the urine to be tested are poured into a tube, adding three pinches of the acetate of soda in crystals, also two pinches of hydrochlo- rate of phenylhydrazin. The mixture is placed for a time in a water-bath. After it has cooled a yellow, crystalline deposit is formed, which, under the microscope, appears to be composed of fine needles, some isolated, others in bunches, and some assuming star-formations. It has been said that this reaction is not absolutely characteristic, and that glycuronic acid will also cause needle- formations; but Ilirschl has ascertained that by leaving the tube one hour in the w(itcr-l>atli the glycosuric components do DIABETES MELLITUS. DIAGNOSIS. 449 not give rise to a crystalline precipitate, and Binet, who has made a very complete study of this important reaction, consid- ers it as absolutely reliable with the fol- lowing slight modifications: — Ten cubic centimetres of the urine to be examined, deprived of albumin, are taken and cleared by means of a few drops of an acetate-of-lead solution. It is then filtered, and a few drops of acetic acid, three pinches of acetate of soda, and two of hydrochlorate of phenylhydrazin are added. The whole is left in the water-bath for one hour. The tube is then allowed to cool, and on the follow- ing day the urine is examined with a very powerful magnifying-glass. Under these conditions no balls or granular masses are found, but yellow or silvery crystals, characteristic of phenylglucosazone. Ac- cording to Binet, by proceeding in this way, one two-thousandths of sugar is distinguishable — an exceedingly small proportion. The reaction, which is abso- lutely correct, is, therefore, an extremely- sensitive one. I do not believe that fermentation sur- passes it in this respect. Beer-yeast alone, and likewise the urine itself, when left undisturbed, give rise to some gas- bubbles. Thus, in order to arrive at the certainty of the existence of the sugar, a test experiment must be made. Two similar test-tubes are prepared, the sus- pected ■urine is placed in one, and normal urine in the other, an equal quantity of yeast is added to each one, and they are left under the same conditions during twenty-four hours. One thousand specimens of normal and pathological urine examined with the view of ascertaining whether traces of s\igar must be looked upon always as pathological. Using the phenylhy- drazin and the fermentation tests as the most delicate tests for sugar, 58 per cent, of the analyzed urine showed no trace 2—29 of sugar; traces of sugar cannot, there- fore, be looked upon as normally pres- ent in the urine. Of the tests which, in doubtful cases, prevent the possibility of a mistake, the phenylhydrazin test must be cited. The only drawback of the test is the forma- tion of crystals similar to the phenyl- glucosazone crystals, if glycuronic acid be present in the urine. However, the microscopical appearance of the two sets of crystals is sufBciently distinctive. The phenylglucosazone crystals occur in the form of bundles of long needles and of separate needles; the crystals of glycuronic acid appear in tlie form of rosettes, the needles are thick and plump, and the whole resembles the crystals of ammonium uitite. The deli- cacy of the test is interfered with in albuminous urines and in urines which are concentrated or rich in urates. A. Jolles (Centralb. f. klin. Med., Nov. 3, 10, '94). Glucose is not a normal constituent of the urine; high specific gravity does not always indicate the presence of sugar; not infrequently concentrated urines with a specific gravity of 1028 to 1032 contain no sugar; small quantities of sugar influence the specific gravity very little. Trommer's and Worm-JIuel- ler's tests are confusing. In the Fehling- Wendriner test results did not always agree. Hoppe-Seyler's test with alpha- nitro-phenylpropionic acid is not adapted as a single test. Its delicacy lies at about 0.4 per cent. JoUes (Amer. Med.- Surg. Bull., July 5, '95). In two clean and dry test-tubes 10 cubic centimetres of normal and diabetic urine, respectively, are placed; 0.5 milli- giamme or less of fincly-rubbed-up gen- tian-violet is then allowed to drop on to the surface of the urine. In diabetic urine the superficial layers of varying depth are colored blue or violet-blue, and this color does not disappear on shaking. In normal urine, even after shaking, no color, or only the faintest trace, is developed. Merck's gentian- violet B is the best. In low tempera- tures the reaction is not so marked. The addition of mineral acids or sugar to normal urine will not lead to the 450 DIABETES JIELUTUS. DIAGNOSIS. development of this color-reaction, which 13 really due to the presence of reducing substances in the diabetic urine. Bremer (Centralb. f. inn. Med., Apr. 2, '9S). To 10 cubic centimetres of the urine are added 5 cubic centimetres of a con- centrated solution of neutral lead ace- tate, and then, after shaking, 5 cubic centimetres of basic lead-acetate solu- tion. When the whole is filtered, an almost clear colorless fluid should be obtained. Then equal parts of the fil- trate and a watery solution of methy- lene-blue (0.3 per cent.) are placed in two difi'erent test-tubes, and to the tubes containing the methylene-blue is added 1 cubic centimetre of a 10-per-cent. caustic-potash solution for each 5 cubic centimetres, so as to make it strongly alkaline. This latter tube is then heated over an open flame, and the contents of the other tube are poured into it, and the whole boiled. If sugar is present, the dark-blue color is changed to a whitish one; the solution then becomes transparent, and finally a pale yellow. The lowest limit lies at about 0.04 to 0.05 per cent, of sugar; the reaction with a urine containing 1 in 1000 sugar is slow. Frolich (Centralb. f. inn. Med., Jan. 29, '98). To recapitulate, Seegen's method with Fehling's solution, the phenylhydrazin reaction, and fermentation are the three methods capable of recognizing with cer- tainty the presence of a small quantity of sugar. The first is by far the most rapid. The phenylhydrazin requires at least two hours and the fermentation test twenty-four hours. Nitropropiol test: A tablet is dropped into 10 or 15 drops of urine, diluted with about 10 cubic centimetres of dis- tilled water, and warmed slightly. If sugar is present the solution turns first green and then blue. If but a small quantity is present, tliis can be con- centrated by shaking with chloroform, as in the indican reaction. The reac- tion docs not occur with biliary pig- ments, uric acid, albumin, blood, or phosphates. Neither does it occur in the urine of patients wlio have been taking benzoic acid, chloral, carbolic acid, guaiacol, iodine, the salicylates, senna, or turpentine. Gebbart (Miln- ehener med. Woch., Jan. 1, 1901). A new test for sugar is to take about 20 drops of urine in a test-tube and add a small amount (about Vm gramme) of pure hydrochloride of phenylhydrazin, about '/; gramme of crystallized sodium acetate, 2 cubic centimetres of water. This is heated over a flame until it boils, then 10 cubic centimetres of a 10-per- cent, sodium-hydrate solution is added, the tube being inverted five or six times and then stood aside. After a few sec- onds a striking reddish-violet color should make its appearance. The color is seen by holding the test-tube up to the light, when the whole fluid should be colored, not merely the deposit upon the bottom of the tube. The color should appear within five minutes. E. Rieglar (Deutsche med. Woch., Jan. 17, 1901). I have yet to refer to certain very rare cases in which, although the urine re- sponds to Fehling's test and becomes brown by the addition of caustic potash, it does not actually contain sugar, but instead alcaptone. In these cases there is no polarimetric deviation nor any alco- holic fermentation. The diabetograph is an instrument de- vised for the purpose of rapidly and automatically estimating the amount of sugar contained in the urine of diabetic patients. It consists of a glass cylinder 20 centimetres in length, bell-shaped at the moutli, tapering to the other ex- tremity, where tliere is a stop-cock. Figures are marked along the tube. The cylinder is filled with tlie urine to be analyzed, and by careful management of the stopcock allowed to flow drop by drop into a small glass receptacle in wliich 2 cubic centimetres of Fehling's solution diluted with six times its volume of distilled water has been al- lowed to come to the boiling-point. When the desired reaction is obtained, the number opposite the level of the urine in tlie tube will indicate the urrioiiiil, fif gliii'OHi! to (lie litre of the DIABETES MELLITUS. ETIOLOGY. 451 urine. F. Coulon (Archives G6n. de I M6d., Sept., 1900). The Diagnosis of Diabetes by Means of the Blood. — Bremer, as we have already mentioned above, has found that the red corpuscles of diabetic blood cannot be stained with aniline colors in the same way as the blood-corpuscles of the normal blood. The latter are dis- tinctly acidophilous, while in the dia- betic blood they become basophilous; they no longer take up eosin, the pre- ferred color of the normal blood-cor- puscles. This reaction, which Bremer has sub- jected to several variations, is of great importance in cases in which a diabetic patient, who has no actual sugar in his urine, wishes to conceal his disease from the physician of an insurance company. It is important to know, however, that this reaction is, as Bremer ha's stated, independent of the glucose, not pathog- nomonic of diabetes. It may, also, take place in the corpuscles of leukemic blood. (L6pine and Lyonnet.) See Complica- tions. Bremer's test of the blood of diabetics modified by staining two minutes in a 2-per-cent. methylene-blue solution and then ten seconds in a 25-per-cent. eosin solution. This reaction was obtained in the blood in all cases of diabetics whose urine contained more than 2 per cent, of sugar. Loewy (Fort, der Jted., Mar., '98). Reaction of diabetic blood may be ob- tained as follows: 4 cubic millimetres of water arc placed in the bottom of a small, narrow, test-tube. To this are added 20 cubic millimetres of blood, 1 cubic centimetre of a watery solution of methylene-blue (1 to GOOO) and 40 cubic millimetres of liquor potassoo. The test- tube is then placed in boiling water for four minutes, at the end of which time, if the blood is diabetic, the blue color of the mixture will have disappeared and a dirty-yellow color will liave taken its place. The reaction has been obtained in all of forty-three cases of diabetes. K. T. Williamson (Lancet, Aug. 4, 1900). Etiology. — Statistics referring to thou- sands of cases show that diabetes is most prevalent between the ages of 50 and 60 years. Age is usually regarded as a factor in the etiology, and, according to a per- sonal analysis of 2115 cases, the period of its greatest frequency extends between 30 and CO years of life (the greatest number fall between 50 and 00 of any of the decades). Diabetes mellitus pre- vails to a much greater extent in some localities than in others; for example, in Malta it is a scourge of greater sever- ity even than tuberculosis is in Germany. It is common in Sweden, and very fre- quent among Jews, wherever they may live. Schmitz (Berliner klin. Woch., July 6, '91). It is probable, however, in view of the difficulty frequently experienced in de- termining the exact onset of the disease, that it often begins before the age of 50. The disease is relatively rare in child- hood. No cases were known in which the disease existed in early childhood until very recently (during the past few years), when several cases have been pub- lished. One hundred and seventeen cases in children collected. The disease is not near so rare in children as has been commonly supposed. As to sex, of the 117 cases, 47 were females, 31 males; of the remainder, the sex was not de- terminable. The proportion of males to females was 5 to 3. As to the age itself, G were found under 1 year, 1 seeming to be bom with it, as it was noted a few days after birth; 7 were over 1 year, 3 over 2 years, " over 3 years, 6 over 4 years, 5 over 5 years, ) over 6 years, over 7 years, and 2 cases had completed 8 years; 8 were 9 years old, were 10 years, 9 were 11 years, 8 were 12 years, were 13 years, 5 were 14 years. 4 were 15 years old. Of the re- maining 28 the age was not given. The children appeared generally of the better class. As to the etiology, heredity was 452 DIABETES MELLTTUS. ETIOLOGY. conspicuous, since the parents were often diabetic. Nest to heredity, previously- existing disease was found; the most fre- quent cause was notably gastric catarrh. C. Stern (Archiv f. Kinderh., B. 11, H. 2, 'S9). The urine of 50 nurslings between the age of 1 day and 4 weeks examined. This number included 24 healthy chil- dren, 1 premature child, 1 case of hy- drocephalus, 14 cases of acute and chronic gastro-enteritis, and 10 cases of other forms of dyspepsia. Among the 50 cases the urine of 10 caused a reduc- tion of Trommer's test with cupric sul- phate. In 2 cases the results were con- firmed by observations made with the polarimeter. These 10 cases included 7 of aggravated gastro-enteritis which terminated fatally, and 3 of mild dys- pepsia. Grosz (Pester Med.-Chirurgische Presse, No. 37, '92). It appears upon a study of 108 cases of infantile diabetes that children of both sexes seem to be affected in an equal proportion, and that the disease is most frequently observed about the age of 5 years. As a cause, traumatism was found in 11 cases; dentition, chill, excesses of various kinds, rapid growth, insufficient food, violent emotion, or sor- row in others. Wcgeli (Archiv f. Kin- derh., B. 19, H. 1, '95). The disease is exceedingly fatal in young children. "SVhenever a child is brought to the physician with a rapid atrophy he should examine the urine for sugar. H. D. Chapin (Jour. Amer. Med. Assoc, Sept. 15, 1900). Men are much more likely to be at- tacked by diabetes than women. In childhood sex has no influence. Out of 1004 cases of diabetes, 837— or 83.37 per cent.— were males, and 107 —or 16.C3 per cent.- were females. A. Cantani (Deut. med. Woch., Noa. 12 to 14, '89). Tlie proportion of males and females in tlie white race who suffer from dia- betes is about 3 to 2. In children, how- ever, the ratio is not the same; girls have it more frequently than boys. In the colored race the cases occur more frequently in women than in men. Futcher (Johns Hopkins Hosp. Bull., Feb., '9S). The frequency of diabetes varies very much in diiferent countries. In Danish cities the mortality from this disease has almost quadrupled itself during the last thirty years. In Paris, between the years of 1865 and 1873, only 2 to 3 in each 100,000 died annually from diabetes. By 1892 the numbers had risen to 13 in 100,000. The disease is exceedingly common in India, in Rus- sia it is very uncommon, and in Nor- mandy it is wide-spread. L6pine (Rev. de Mfd., '96). In the absence of sufficiently-reliable statistics, it is preferable to abstain from giving any figures. In the same country different races are very unequally af- fected, and on this point, also, it is neces- sary to await further researches. A fact which may be positively stated at pres- ent is the relative frequency of diabetes in the Jewish race. In Frankfort-on-the-Main 171 persons died from diabetes during a period of nineteen years. Of 156 of these cases, 51 were Jews and 105 belonged to other denominations. The mortality from dia- betes is six times as great among Jews as in other religions. Wallach (Deut. med. Woch., Aug. 10, '93). Two hundred and two deaths from dia- betes in the city of New York during 1899 shows that the greatest mortality occurred between the fifty-fifth and sixty- fifth years, and diminished rapidly toward the end and beginning of life. Fifly- seven were born in Germany, 51 in United States, and 37 in Ireland. At least 54, or 25 per cent., were Jews and 51 were Irish. The potent influence i» believed to be the breeding in and in, to which the Jewish and Irish races still adhere. Coma was direct cause of death in 00 cases. Gangrene was the most fre- quent complication, and appeared in the foot or leg in 32 cases. H. Stern (Mod. Record, Nov. 17, 1900). Diabetes is frequently hereditary, inas- much as several members of one and the same family are frnqiiently affected with DIABETES MELLITUS. ETIOLOGY. 453 the disease; Lut the heredity is seldom direct. The diabetic predisposition is heredi- tary. In 998 cases out of 2115 it was dis- covered positively that there were, or had been, 1 or 2 cases of diabetes among their blood-relations, and in some cases more. Schmitz (Berliner klin. Woch., July 0, '91). In June, 1900, a man, aged 48 years, consulted the writer for symptoms which proved to be those of diabetes mellitus. The disease had followed an attack of influenza contracted in the previous February. The patient's father had died of diabetes also. Sev- eral months later the writer was con- sulted by the patient's wife, a wo- man aged 40 years. She was found to have exophthalmic goitre. The exam- ination of the urine showed a large amount of sugar present. The writer considers this a typical case of conjugal diahetes, although some objection might be taken to this opinion, owing to the not infrequent occurrence of glycosuria in exophthalmic goitre. He states that he observed four cases of conjugal dia- betes in his practice during the year 1903, and does not believe that the con- dition is extremely rare. At the beginning of this year the mother of the first patient, aged 66 years, came under treatment for a phlegmon on the right hand, which de- veloped very rapidly after being pricked with a needle. The examination of this patient's urine also showed abundance of sugar. She lived with her son. In this family the patient, his mother, and his wife had diabetes, and his father died of the disease. Tlie writer lays down the following axiom: If one discovers diabetes in one or several members of a family, the urine of all the other members should be examined for sugar, eapecially if the various mem- bers live together. Martinet (La Presse M6d., Feb. 10, 1904). It has been justly remarked that these diabetic families are tainted with the uric-acid diathesis, and that obesity, gout, and neuropathic aflcctions exist in extra- ordinary frequency in such families. Frequently obesity and diabetes co-exist in the same person. A too exclusively- starchy diet and the abuse of wine and ciders are predisposing causes of dia- betes. In 200 cases there were found 4 in- temperate, 107 temperate, 89 total ab- stainers, 09 opium habituCs. Mitra (Indian Med. Record, June 1, '95). In GOT persons engaged in manual labor or requiring great muscular and respiratory activity, no sugar was found in any case; in 100 persons engaged in intense intellectual work, sugar was found in 10. Worms (Bull, de I'Acad. de Med. de Paris, July 29, '95). Diabetes appears more frequently in March, April, July, and November; in- creased mortality in winter, but not in relation with average temperature. Davis (Amer. Jour, of the Med. Sciences, July, '95). The increase of diabetes is much more pronounced among the wealthy classes than among the poor, the average in the poorer parts of the city being only 7 to 9 in 100,000, while in the wealthy quarters the average is IG to 20. Ber- tillon (Editorial, Modem Med. and Bact. Rev., Apr., '97). The causes which we have so far men- tioned are predisposing causes. As to eiRcient causes of diabetes, acute infectious diseases cannot be considered in this categor)', for the affection does not come on after typhoid fever, eruptive fevers, etc. With regard to malaria, sev- eral French physicians have noted a temporary glycosuria after attacks of in- termittent fever; but in malarial coun- tries true diabetes does not appear to be any more common than elsewhere. The question of sj'philis will be re- ferred to later. The part played by contagion in dia- betes is, so far, not based upon any very exact observations. The occurrence, said to be quite frequent, of diabetes in hus- band and wife, has been a mooted ques- tion. 454 DIABETES MELLITUS. ETIOLOGY. Man aud wife may both be diabetic. From an analysis of 2320 cases, 26 ex- amples of such occurrence have been accumulated. Quite healthy persons, ■without hereditary predisposition, may become suddenly diabetic after attend- ing to a diabetic for a time, living in the same room, sleeping with and espe- cially kissing him often. In the light of these data, embodying somewhat over 1 per cent, of several thousand cases, the possibility of an infectious nature in diabetes mellitus is strongly sug- gested. Schmitz (Berliner klin. Woch., May 19, '90). Twenty-six examples recorded where husband and wife both suffered from dia- betes. These were examples chiefly of married females who had become sud- denly diabetic after nursing a diabetic husband. There was no indication of hereditary predisposition. No family relationship between the patients, no excess of sugar taken in the food, and the patients had not suffered from gout. The question raised of the possibility of contagion or transmission of the disease. The numerical relation between dia- betic mamcd couples and other diabetic cases is shown in the following table: — Betz Hcrtzka . LecorchO Schmitz . Seegen . . KUlz Married Diabetics. Total Diabetics 1 31 1 86 G 114 26 2320 3 938 10 900 Totals 47 43.89 or 1:03'/, or 1.08 per cent. B. Oppler and C. KUlz (Berliner klin. Woch., Nos. 20 and 27, '90). Among 770 cases of diabetes observed there have been 9 instances of man and wife suffering from the disease: 1.19 per cent. When all the cases arc excluded in which there is a family history of the diseaBe, or a history of any of the well- known etiological antecedents, the cases remaining are so few that it seems prob- able that the occurrence is accidental, or tliat both man and wife have been Bubjcctcd to the same anlcccdentB. II. Senator (Berliner klin. Woch., July 27, '96). In a series of 5000 cases 1.8 per cent, of conjugal diabetes found. The facts thus far published do not shed much light on the two theories of causation now held, viz.: (1) that the ordinarily- accepted causes of diabetes are active in both husband and wife, aud (2) that the disease is contagious. Cases have been reported with almost conclusive evidence of contagion, but the nature of the con- tagion and how it is conveyed are mys- teries. Schram (Med. News, Jan. 1, '93). This coincidence, if it actually is of frequent occurrence, would be an argu- ment in favor of contagion. The ques- tion is now being studied. Nervous affections are certain causes of diabetes. The disease is often met with in people who have suffered from much anxiety or worriment. Diabetes should be classed among the neuroses; its varied phenomena result by reflexes from the nervous system. The disease obviously arises in the sympathetic chain which controls the secretory functions of the kidneys. J. Blake White (Amer. Medico-Surg. Bull., '95). A number of cases are reported in the literature in which diabetes has fol- lowed a shock or psychical trauma. For the most pai-t, these cases have not been severe, but in the two reported by the author both died. Lorand (St. Petcrsburger med. Wochen., May 31 (June 13), 1903). Diabetes also occurs very frequently where there has been traumatism of the head. According to certain statistics, 20 per cent, of all cases of diabetes are due to this cause. It is possible that this proportion may bo exaggerated, but I am willing to admit that there is surely one case of traumatic diabetes in thirty diabetic patients. The lra\iniati8ma most often followed by diabetes are those affecting the head (25 in 4.')) ; Homctiiucs also those affect- ing the vertebral coliiiiin. Oerebral dia- DIABETES IHELLITUS. ETIOLOGY. 455 turbance mentioned twelve times. Sugar does not always appear in the urine im- mediately after traumatism; if the dia- betes succeeds rapidly to traumatism, it is almost always mild; on the con- trary, almost all the uncured cases of traumatic diabetes begin late. Progress is at times rapid; radical cures have been observed fairly often (14 cases out of 45), but they seldom take place where diabetes has persisted more than six months or a year. Bemstein-Kohan (These de Paris, '91). Review of 212 cases of traumatism of the head admitted into the Boston City Hospital within thirteen months. Ranged in five classes: (1) wounds of the scalp; (2) wounds with denudation of the bone; (3) commotion, including cases followed by loss of consciousness, but without fracture; (4) fracture of the vault; (5) fracture of the base. Of the first class there were 84 cases, 5 of wliich, or 6 per cent., presented glycosuria; in the sec- ond class, 43 cases, 4 with glycosuria, — 9 per cent.; third class, 40 cases, 1 with glycosuria, — 2.5 per cent.; fourth class, 24 cases, 5 with glycosuria, — 20.8 per cent.; fifth class, 21 cases, 5 with gly- cosuria, — 23.8 per cent. In all, 20 cases of glycosuria in 212 cases. F. A. Hig- gins and J. B. Ogden (Boston Med. and Surg. Jour., Feb. 28, '95). Since the time of Claude Bernard we are aware of the fact that lesions of the floor of the fourth ventricle are particu- larl)' liable to give rise to diabetes. Sev- eral cases have been observed in man. Lesions in various parts of the encepha- lon may bring about the same result. It is extremely probable that syphilis is not a cause of diabetes, except through the influence of diffuse lesions of the nerve-centres. There is conseq\iently no syphilitic diabetes, but a diabetes de- pendent upon cerebral lesions, whether due to syphilis or any other cause. Out of twenty-seven records of exam- ination of the brain in cases of diabetes mellitus, the organ normal in but five instances, the abnormalities consisting most frequently of ccdematous brains with thickenings of the membranes. Less frequently the organ was ansemie, cystic, particularly in the frontal lobes, in the pons, and in the medulla. Care- ful examination with the microscopB failed to indicate any histological clianges, except in one instance where the capillaries of the vagus nucleus seemed to be abnormally numerous and full of blood. Saundby (Jled. Chron- icle, Jan., '90). Two cases of diabetes, in which changes were found in the spinal cord. In the first case on naked-eye exam- ination of the spinal cord, after harden- ing in Jliiller's fluid, degeneration was found in the posterior columns. This was most marked in the cervical and lumbar enlargements. In the lower cervical and dorsal regions the lesion was confined to Goll's columns; above and below it extended laterally into Burdach's columns. The sacral region was unalTected. In the lower dorsal region the right posterior column was distinctly more markedly affected. In the second case degeneration of the posterior columns was also found. It was limited to Goll's columns in the upper cervical region. In the lower cervical region it spread to Burdach's columns, and was most extensive in the lower cer\'ical and middle dorsal regions. Below the lumbar enlargement the de- generation ceased. The spinal changes regarded as the result of the action of some toxic sub- stance in the blood of diabetic patients. Similar changes have been found in the posterior columns of the spinal cord in pernicious anoemia, leucocytha:mia, Ad- dison's disease, etc. E. Kalmus (Zeit. f. klin. Med., B. 30, H. 5, G). Relationship between diabetes mellitus and epilepsy. Cases in which the dia- betes is the cause of the epileptic attacks may be divided into two categories, ac- cording as the attacks are due to cere- bral lesions or to disturbance in the intra-organic exoliange consecutive to the glycosuria. Cases belonging to the former group are rare. In the cases of epilepsy due to diabetes the convulsive spasms are determined by toxic products of intra-organic exchange, and take more 456 DIABETES ilELLlTUS. ETIOLOGY. or less the form of coma. The aceto- nsemic diabetic epilepsy rapidly leads to fatal coma, but when it develops in a chronic and intermittent manner is said to determine epileptic seizures. The cases in which diabetes seems to depend upon epilepsy are divisible into two clinical varieties: those in which the elimination of sugar merely follows the convulsive attack — these have rarely been found; and those in which the glycosuria is a more or less constant accessory symptom of the epilepsy. The cases in which diabetes and epilepsy ap- pear simultaneously are of two kinds: 1. Epilepsy often alternates with dia- betes and mental disorders in neuro- pathic families, and it would, therefore, not be a matter of surprise to find the two conditions present in one person of such a family. 2. There may be a pre- disposing cause of both in the same sub- ject. A case belonging to this latter class. The patient had an apoplectic stroke resulting from ischsemia of the left hemisphere due to a cardiac lesion. There was aphasia and pollakiuria, but no polj'dipsia, polyphagia, nor polyuria. Some months later epileptic seizures, with complete loss of consciousness and convulsions in the previously-paralyzed half of the body, supervened. Ebstein (Sera. Mfd., May 22, '96). Twelve hundred and fifty cases studied in tlie psychiatric clinic at Leipzig with regard to presence of sugar in the urine, with positive results in thirty cases. The -cases were divided into two groups: those of chronic diabetes, which was usually associated with chronic brain disease of the type of dementia, and those of transitoi-y glycosuria, usually associated with acute forms of insanity, particularly of a maniacal type. Often the excitement preceded the appearance of sugar in the urine. Four possibilities may be considered: (1) the glycosuria may be merely an accidental complication of the men- tal disturbance; (2) diabetes may be the result of insanity, (3) or it may be tlie cause, (4) or the two conditions may be the result of some common cause. The second HometimcH occuth because ex- cessive emotional disturbances have been known to produce diabetes. E. Lauden- heimer (Berliner klin. Woch., May 23, •9S). The pancreas is veiy frequently found altered in diabetic subjects; sometimes it is simply atrophied, sometimes slightly indurated, and, under the microscope, periglandular sclerotic lesions have been noticed. There are some rare cases in which the tissue of this organ is almost entirely destroyed in consequence of the presence of calculi. Results of an examination, niacro- scopical and microscopical, of the pan- creas in 23 consecutive cases of diabetes mellitus. In 8 cases the pancreas was found to present a nornuxl appearance both niacroscopically and microscopic- ally; and in 4 more there was atrophy, but not more than could be accounted for by the general wasting. In 5 cases there was atrophy more or less marked, and out of proportion to the general wasting; and in one of these the atrophy of the gland was so extreme that the pancreas weighed less than one-fourth ounce. In 4 cases cirrhosis of the pan- creas was present, and in 2 of these the changes were marked. In one case cancer of the pancreas was present, and in one the gland had undergone ex- tensive fatty degeneration. Results of the investigation of 54 cases of diabetes. In 40 of these the pancreas was found to be diseased, and in 30 the lesion was a simple atrophy. In 3 others fibrous induration was present, and in 1 case the pancreas was cystic. In 8 cases out of the 54 the pancreas was normal, and in there was no record as to the state of the gland. The atrophy of the pancreas in dia- betes dill'crs from the simple atrophy accompanying general wasting in the fact that in the diabetic pancreas the stroma of tlie gland is not only not wasted, but tlie pancreas shows signs of an interstitial inllamiiiation, and the stroma occupies spaces left by the atro- phy of the parenchyma of the gland. Ilanscmann (Med. Chronicle, May, '97). In 70 i)fr cent, of diabetic patients DIABETES ]SIELLITUS. ETIOLOGY. 457 some alterations in the pancreas were found. Of special interest in this con- nection is a lipomatosis of the pancreas, which may exist either in connection with tlie general excess of fat, or, on the other hand, may be found in lean subjects. liansemann (Med. News, Jan. 22, '98). Pancreatic diabetes is always grave. In view of data recently furnished by experimental pathology, there is no possible doubt as to the pathogenesis of the diabetes in this case: it is evidently due to the suppression of the secretions of the pancreas. Diabetes never fails to appear after complete removal of the pancreas, if the animals live a sufficient time after the operation. This statement is founded on fifty-five experiments made on dogs. Minkowski (Berliner klin. Woch., 1092, No. 20, '92). Coincidence of disease of pancreas and diabetes occurs more frequently than diabetes alone or pancreatic disease alone, and oftener than these two com- bined. Commonest disease of pancreas found in diabetes is an atrophy which differs from atrophy as the result of diabetes or of cachexias; comparable with certain forms of contracted kidney. Hansemann (Zeit. f. klin. Med., B. 20, '95). Extirpation of pancreas of two dogs, leaving Vo to V» of organ; animals be- came diabetic: one 4 and the other 13 months after. Sandmeyer (Zeit. f. Biol., B. 31, p. 12, '95). Eels survived operation of removal of pancreas 7 to 12 days; 7 out of 11 showed no sugar in urine; 2 of them did. Former, perhaps, retained pan- creatic remnants. Caparelli (Archives Italiennes de Biol., vol. xxi, p. 390, '95). Extirpation of pancreas of 19 ducks and 5 carnivorous birds; 4 ducks. showed slight glycosuria; 3 carnivorous birds manifestly glycosuric until death. Wein- traub (Archiv f. cxpcrimcntelle Path. u. Pharm., B. 34, p. 308, '95). The existence of pancreatic diabetes is established, but disease of the pan- creas does not necessarily cause diabetes. Of 29 cases from the Massachusetts Gen- eral Hospital that showed lesions of the pancreas, glycosuria was found in but 2, although in 12 cases there were no records of tests for sugar. Fatty stools are usually absent in cases of diabetes, and there is no record of their occurrence in 100 cases treated in the Massachusetts Hospital. R. H. Fitz (Yale Med. Jour., Mar., '98). The specific element of the pancreas which controls carbohydrate metabo- lism is not the secreting parenchyma, but the groups of cells known as the interacinar, or islands of Langerhans, which are independent of the secret- ing parenchyma, having no connection with the excretory duct. Fifty to 60 per cent, of all cases of diabetes show destruction or marked changes in the interacinar islands, accompan3ing es- pecially interacinar pancreatitis, hepatic cirrhosis, haemochromatosis ; also espe- cially prone are these islands to hyaline degeneration, often unaccompanied by any marked changes in the secreting parenchyma. For the remainder of cases of diabetes, those which show no pancreatic change, no adequate explana- tion of their etiology can at present be offered. G. F. Zinninger (Cincinnati LancetClinie, Aug. 13, 1904). In the cases where the lesion of the pancreas is a minor one (slight indura- tion, slight atrophy, etc.) it is not neces- sary to regard this slight lesion as the cause of the diabetes, for this disease is often accompanied by a generalized en- darteritis, — a cause of sclerosis; or some- times the diabetic cachexia engenders fatty degenerations. Contrary to the opinion held about half a century ago, experimental physiology has demon- strated that hepatic lesions are not a cause of true diabetes. Tliey may, at most, cause an alimentary glycosuria. Extirpation of liver prevents ablation of pancreas to cause diabetes in the dog. Marcuse (Zeit. f. klin. Med., B. 26, p. 225, '94). A patient, aged 48 years, who, in 1887, 458 DIABETES MELLITUS. PATHOGENESIS. DUKATION. suffered an attack of jaundice lasting sis or eight weeks. The following year sugar was discovered in his urine, to the extent of 1 '/. to 2 per cent. Dur- ing an annually-repeated "Carlsbad cure" the sugar disappeared from his urine, but after 1S92 it was continually pres- ent. In 1S93 icterus reappeared, and there developed ascites, (Edema of the legs, dyspnoea, and wasting. The liver and spleen were much enlarged. Ascitic fluid was withdrawn four times in all. After the last puncture the fluid did again collect. The amount of fluid in- gested was at first greater than that eliminated, but eight weeks after the last puncture this relation was reversed. With the excessive excretion of urine the ascites and (edema disappeared. The pa- tient increased in weight and gained strength, the jaundice disappeared, and the liver decreased in size. The patient remained for a long time in good health, then albumin appeared in the urine and (Edema of the feet. During the per- sistence of the ascites the sugar disap- peared from the urine, to return again as soon as the ascites was gone. After two and a half years of good health the patient died. The necropsy revealed cirrhosis of the liver with some con- traction; tubercles in lung, pleura, and peritoneum; diabetic kidney, and atro- phy of the pancreas. Pusinelli (Ber- liner klin. Woch., No. 33, '90). Bronzed diabetes is the result, and not the cause, of the accompanying hepatic cirrhosis, which is thought to be due to augmented function of the liver-cells. Gilbert, Castaigne, and Lereboullet (Gaz. Hebdom. de MC-d. et de Chir., May 17, 1900). Pathogenesis. — It wouM appear, from what has already been stated, that the causes of diabetes are miiltiplc; it is evi- dent that nervous diabetes dilTers from pancreatic diabetes. In obese diabetic subjects there is usually no appreciable lesion of the pancreas, and certainly no primary lesion. On the other hand, there are no nervous elements in these cases. This is, again, a dilTercnt type of diabetes, and it would be easy to multiply the number. As for the im- mediate cause of diabetes, it is generally complex, consisting most frequently in an increased production of sugar and a diminution of glycolysis. In the light of our present knowledge it would be difficult to say much more upon this point if one ■\\'ishes to refrain from mere hypotheses. The pancreas is always the cause of glycosuria. Case of diabetes mellitus in an infant of six months, ascribed to the reflex effect of teething upon the pan- creas. Calcium lactophosphate, by as- sisting the evolution of the teeth, cured the glycosuria. Baumel (Archives de M6d. des Enfants, Mar., 1901). Autopsy of a diabetic negress aged 54 years. The pancreas weighed SO grammes, was soft and of a gray-yellow color. Almost every island of Langer- hans showed microscopically a homo- geneous material that stained -(vith eosin. This substance at times lay in the midst of groups of cells, but was usually in contact with the walls of the capillaries penetrating the island, or next the peripheral fibrous tissue, and was therefore usually between the re- maining cells and the capillary walls. The cells of the island were in largo part replaced, so that between the hyaline particles only an occasional compressed fusiform or irregular nucleus co\ild be seen. The hyaline metamorphosis was strictlj' limited to the islands of Langer- hans, the glandular acini remaining in- tact. In this pancreas, therefore, a le- sion of obscure etiology had destroyed the islands of Langerhans, while those of the secreting acini, as well as those of other organs, were unaffected. The association of diabetes mellitus affords convincing proof that the islands of Langerhans are intimately connected with the glycogenic metabolism. E. L. Opie (Jour. Exper. Med., Mar. 25, 1901). Duration. — There is so little resem- blance between the various cases that an average duration, even supposing that it could bo rigorously established, would be of no ini|)nrtance. It suffices to say DIABETES MELLITUS. TERmNATION. PROGNOSIS. 459 that in a general way the average dura- tion of diabetes is several years. I am consequently much surprised at the results given by Griesinger concern- ing 100 cases. In 13 the disease only lasted from 6 months to 1 year; in 39, 1 to 2 years; and in 20, 2 to 3 years, which would make the duration of the disease in three-fourths of the cases from 6 months to 3 years. In order to explain such remarkable figures it must be supposed that the dia- betes was latent, in the beginning, in a large number of the patients, and that these statistics include a great many seri- ous cases. The duration in children varies greatly. Out of 34 cases the shortest duration was two days; the longest had not termi- nated at the end of five years. In 7 cases it did not last one month, and of these 1 was cured. Seventeen lasted less than a year, and of these 7 were cured. Ten lasted over a year, and not one of these recovered, and it may be said that re- covery scarcely occurs where the dura- tion is more than one year. C. Stern (Archiv f. Kinderh., B. 11, H. 2, '89). The main prognostic features are: Age, power of assimilation of carbohy- drates, early recognition of the affec- tion, the presence of intercurrent and complicating diseases, condition in life, state of the urine, and the power of ab- sorption of other foodstuffs than carbo- hydrates. II. S. Starr (Med. Record, Apr. G, 1901). Termination. — It is evident that dia- betes, which is but seldom cured, gener- ally ends in death. In explanation of this rather naive statement, which might lead to a false interpretation, it must be borne in mind that the duration of the disease is a long one, and that in a great number of cases mild diabetes allows the patient to live to an advanced age. In referring to the complications of the disease, I have already mentioned the frequency of phthisis, and the even greater prevalence of coma, in diabetics enjoying a certain affluence. To these should be added gangrene, pneumonia, and the numerous complications which may affect the organism when already debilitated by diabetes. In a certain number of cases, particu- larly in arthritic subjects, the diabetes may be changed into another malady. Following traumatisms, it may end (after a certain duration of the glycosuria) in simple polytiria. Principal reasons why diabetes inter- feres with operative success: 1. The sugar circulation in tlie blood is hygro- scopic, and it draws water from all the tissues of the body until the tissues are actually too dry. This must interfere with the normal process of repair, and it probably does so in several different ways. 2. The surgeon must give these cases special attention, because the fluids of a wound loaded with sugar are, in all probability, excellent culture- media and particularly susceptible to the attacks of bacteria. Rigid asepsis is, therefore, demanded. 3. Certain aUEesthetics may precipitate an im- pending nephritis because of the un- usual labor involved in excreting sugar. In these cases nitrous oxide and oxygen used instead of the other antesthetics, especially avoiding the use of ether. R. T. Morris (Med. News, June 29, 1901). Prognosis.— It may be inferred from the preceding statements that it is diffi- cult to speak of the prognosis of diabetes in general; this can only be established in each individual case. It may be said, however, that arthritic diabetes and many cases of nervous dia- betes are usually not very severe. In (he nervous variety the glycosuria is often quite moderate, and may even disappear, leaving behind a simple poly- uria. The type developed under the in- fluence of gout in arthritic subjects is associated with an intermittent, but abundant, glycosuria, and is compara- tively benign. Certain diseases of the pancreas, such as calculi of Wirsung's 460 DIABETES MELLITUS. TREATMEiS^T. canal, and sclerosis of the whole paren- chyma, may be followed by a rapid and dangerous diabetes. There are other varieties difficult to classify. Lfipine (Sem. M^d., Aug. 27, '97). Deductions based on twenty-two origi- nal observations as well as the literature of the subject in respect to the influence of diabetes upon the functions of the female organs of reproduction. In dia- betes mellitus menstruation is generally diminished, but not always to a degi-ee parallel to the sugar in the urine. Preg- nancy in GG per cent, is undisturbed, in the remainder is prematurely inter- rupted, but more often by miscarriage (seven or eight months) than by abor- tion. The prognosis for the mother is likewise doubtful. Pruritus vulvae, boils, and acuminate condylomata are well- known diabetic symptoms. Affections of the vaginal mucous membrane and uter- ine, and necrosis of the ovaries are not so common. Kleinwachter (Zeitschrift f. G. u. G., xxxviii, H. 2, '98). A relative cure (urine free from sugar on a diet containing 200 grammes of car- bohydrate a day) is to be anticipated if at the onset of the disease 80 to 85 per cent, of the carbohydrate consumed is completely burned up in the body. F. Hirschfeld (Berliner klin. Woeh., June 18 and 25, 1900). The progress of a not essentially grave case varies considerably according to the treatment to which it is subjected. It will be much more benign if the patient is intelligent and docile, for there are few chronic diseases in which proper care and attention are as beneficial as in dia- betes. During the period from 1889 to 1899, inclusive, the total number of deaths from diabetes in New York City was 1867. H. Stein (Jour. Amer. Med. Assoc, Jan. 20, 1901). Treatment. — In my opinion, the treat- ment of diabetes should not be a system- atic one. The first thing to be done, and this is a precept to be applied in the treatment of any disease, is to make a careful study of the patient — to indi- vidualize him, as it were — to watch at- tentively the effects of the treatment, and to have no hesitation in modifying the same according to the results. The diet is more important than the medicinal treatment. As in all diabetics the power of assimulating sugar is more or less diminished, it is important to limit the ingestion of hydrocarbon food. The rule is to forbid it as far as possible, and to advise a diet of meat, fish, eggs, green vegetables, particularly those which con- tain but little starch, also salad, cheese, nuts, etc. Too great a quantity of meat should be avoided. In healthy persons submitted to diet from which carbohydrates are absolutely excluded, quantity of acetone increases progressively for seven or eight days, then becomes stationary at from ^/j to Vj grain. Diabetes complicated by ace- tonuria is rather rapid in its evolution and terminates in death from twelve to twenty months in cases in which there is no gangrene. Treatment: hyperali- mentation (carbohydrates in small quan- tities, albuminoids in not too great abundance, fat, and alcohol); rest. Hirschfeld (Zeit. f. klin. Med., B. 28, H. I, 2, '95). Some patients will not thrive on any diabetic treatment. Old people often emaciate if carbohydrates are dropped. In the diabetes of young people carbo- hydrates must be withheld as much as possible. Under a proteid diet young patients live longer. Patients generally improve on milk. Jacobi (Boston Med. and Surg. Jour., Sept. 9, '97). The exclusion of carbohydrates can never be complete and many patients do better on a diet not too rigid. The pa- tient should be put on a rigid proteid diet to see what can be aocoinpliBhed. Then one article after another contain- ing more or leas starch or sugar may bo added, watching the urine, and finally the diet may be made as liberal as the individual case will permit. Tyson (Boston Med. and Surg. Jour., Sept. 9, '07). DIABETES MELLITUS. TREATMENT. 461 It is of great importance to prescribe definite quantities, and to test the effect of tlie diet by weekly body-weighing, urine-measurement, and sugar-estima- tion. Carbohydrates should be excluded as rigidly as possible without damage to the nutrition and general condition of the patient, the case being very carefully watched. Robert Saundby (Boston Med. and Surg. Jour., Sept. 9, '97). A diabetic should be placed under no different conditions of diet than are granted to the healthy person. Con- clusions: — 1. Sugar is always present in the blood. 2. The absence of carbohydrates from the diet does not cause a disappearance of the blood-sugar. 3. The systemic and ingested albumin is capable of furnishing sugar by its decomposition. 4. An increased decomposition of albumin due to the enforcement of a purely-nitrogenous diet means an in- creased metabolism and consequent loss of body- weight. 5. The administration of carbohy- drates retards metabolism. 6. The diabetic has an especial pre- disposition toward increased metabolism. 7. The diabetic has not lost the power of o.xidizing sugar. 8. The abnormal metabolism of albu- min results in the production of toxic bodies. 9. The depressed nervous condition of the diabetic is especially favorable for the action of these bodies. 10. The production of toxic bodies is prevented or retarded by the administra- tion of carbohydrates. The diabetic should live upon a diet which keeps his body-metabolism at its lowest, and for this carbohydrates are' necessary. There is no cure for the con- dition; the treatment must simply be directed to prolong life, and this a rigid protcid diet is not capable of doing. Munson (Jour. Amer. Med. Assoc, May 15, '97). An absolute diet without vegetables should not be given, as in bad cases it leads surely to more rapid accumulation of acids in the blood, and diabetic coma is an acid intoxication. Even in the lightest cases, however, for two or three weeks three or four times a year abso- lutely no carbohydrates should be taken, as thus the metabolic faculty for sugar which has been injured is given that strictly-physiological rest so conducive to its recuperation. Lee (Med. Record, May 7, '98). In diabetes the effort now is to so spare the faculty for the absorption of sugar as to lead to its recuperation, and yet not to precipitate a fatal termination by feeding exclusively on albumins and so leading to increased acidity of the blood. For this the sugar-metabolic limits of the organism having been found by a series of urinary examina- tions, these are never overstepped, a greater quantity of carbohydrates are never allowed than can be consumed, and then three or four times a year, for a period of two or three weeks, the pa- tient is put upon an absolute diet, with all carbohydrates excluded. Leo (Phila. Med. Jour., Mar. 17, '98). The proper dieting is of the greatest importance in the treatment of diabetes. Drugs have practically no influence on the process. The benefit derived from a stay at some watering-place is ascribed to the diet, which consists exclusively of fat and proteid. In saccharin we pos- sess an excellent substitute for sugar, and one which can be taken for years with impunity. Notwithstanding the many preparations on the market, the proper substitutes for bread have not yet been found, for those which have been tried either become disagreeable to the taste after awhile or they are too rich in carbohydrates. If the condition permits the use of any bread at all, Graham bread is to be preferred. One should never forget that the diabetic needs more actual food than the well, since he loses so much, and underfeeding should be avoided. As with morphine, it is generally better and more agreeable for the patient to \>-ithdraw the forbid- den articles of food slowly than rapidly. The scales should be used freely to watch the body-weight. If the urine has been free from sugar for several weeks small quantities, say, 25 grammes 46S DIABETES JklELLITUS. TREATJIENT. (6V« drachms), of bread daily are per- mitted, and the amount is increased daily 10 grammes (2Va drachms) till 70 to 100 are reached, which is suffi- cient for most. As soon as traces of sugar again appear the bread must be reduced in some and in others entirely withdrawn. H. Eichhorst (Therap. Monats., Sept., 1902). The abiise of the albuminoids by dia- betic patients may cause not only the usual disturbances, but it may also in- crease the sugar in the urine, as Naunyn has justly remarked. It has also been noticed that an exclusively-meat diet may bring about some particular dys- crasia, ending in diabetic coma. This exclusive diet, which was formerly lauded by Cantani, is consequently not to be recommended. It is very difficult to ab- solutely deprive the patient of bread, so a small quantity, as small as possible, may be allowed, or, in place of this, an equally-small portion of potatoes. Levulose can be given in moderate quantities in slight forms of diabetes, without injurious results as regards sugar-excretion, urine, etc. Utilized in the system, though dextrose and cane- sugar excreted. Grube (Zeit. f. klin. Med., B. 20, H. 3, 4, '95). [Levulose may generally be given in small doses to patients sufTering from mild diabetes; but, if small daily dose be e.xceeded, excretion of sugar increased without benefit to patient. R. LiSpine, Assoc. Ed., Annual, '96.] In eases of diabetes the addition of a small quantity of alcohol (1 to 2 '/« ounces per diem) has no ill effect. In cases where there is already cardiac weakness or vascular disease, alcohol should be u.scd cautiously. Beer is for- bidden, as it contains the most extractive matters, which are chiefly carbohy- drates. All sugar-containing liqueurs and Bweet wines are, of course, forbid- rlcn. Wine, cognac, certain forms of brandy, etc., may be allowed. Hirsch- fcld (iierlincr klin. Woeli., Feb. 4, '95). Eight diabetic patients could com- pletely oxidize levulose in daily amounts of from 6 to 25 drachms. Levulose not only does not increase, but rather dimin- ishes, the amount of nitrogenous output, both urine and fteces being examined. E. de Renzi and E. Eeale (Wiener med. Woch., '97). There are carbohydrates that seem to have little influence on glycosuria, such as levulose, inulin, and mannite. Cer- tainly the rule is that the group of sugars which deviate polarized light to the left are less injurious than those tliat deviate it to the right. Bouchard (Sem. Mod., Mar. 26, '97). Flour made from edible pine-nuts recommended for diabetics. It is fine, slightly yellow, bland in taste, contains no starch, and 7 per cent, of cane-sugar. If raised with yeast, sugar is decomposed so that only a fraction of 1 per cent, can be found. Bread and cake made from it are relished, and it is an agreeable sub- stitute for wheat-bread. The flour is known as the "Chicago Sanitary Flour." N. S. Davis, Jr. (Jour. Araer. Med. Assoc, Nov. 5, '98). Strict milk diet in diabetes combined with hydrotherapeutics, systematic exer- cises, fresh air, and sunshine advocated. Winternitz and Strasser (Centralb. f. inncre Med., Nov. 11, '99). Diabetics must be taught to use fats in abundance. They are the only sub- stances that can succeed in stilling the craving for the starches and sugars and can properly replace them. Editorial (Med. News, Feb. 17, 1900). Thirty-four difl'ercnt kinds of potatoes subjected to examination, the most nota- ble result of the proceeding being that the potatoes employed for diabetic feed- ing should be fresh and mature, and that the central portion of the tuber, being the most watery, the richest in nitroge- nous matters, and the poorest in starchy ingredients, is the best suited for the purpose. A. Mosse (Klinisch-tlierap. Woch., Oct. 7, 1900). Ebstein has recently very highly rec- ommended aleuronat bread, which con- tains a much greater proportion of vege- table albumin than any other thus far recommended for diabetics, and which may consequently be taken in larger DIABETES IIELLITUS. TREATMENT. 463 quantities. With regard to drinks, the abuse of beer, alcohol, and wine should be forbidden. The above are the main features in the diet; it is necessary to conform to them as far as possible, at the same time avoiding all exaggerations. Sugar-free milk contains approxi- mately 3 per cent, of proteid and 5 per cent, of fat. If 3 pints are talcen in a day, the food-value amounts to 990 calories, or nearly one-third of the total amount required, while the amount of fat -which the patient obtains is equiva- lent to fully 3 ounces of butter. In cases in which a small amount of carbo- hydrate is desirable, it is sometimes best to substitute sugar-free milk, and give carbohydrates in the form of potatoes or bread, as this enables the patient to ingest a larger amount of fat. Robert Hutchison (Lancet, June 22, 1901). In the severe forms of diabetes, the diet must naturally be much more lim- ited, except in cases where coma appears imminent. The marked reaction of the urine with the perchloride of iron, and especially the diminution of the appe- tite, are the chief premonitory symptoms of this danger. In such cases every one is agreed that it is well to abolish the restricted diet. Opium is of temporary service, at least, but I have never found it beneficial for any length of time. It causes a reduc- tion in the quantity of sugar. Villemin advised the addition of belladonna. I have never been able to convince myself of the advantage of its use, and have found it to cause dryness of the throat. Antipyrine is sometimes most useful; it frequently diminishes excessive polyuria and reduces the sugar. The value of antipyrine in three cases of long standing (one of twenty years') verified. The results were immediate, and all traces of the condition promptly disappeared — in one case permanently, in another for a long time after a with- drawal of the remedy; in the third case the quantity of urine at once rose to its former amount upon the withdrawal of antipyrine, but upon readministration fell again. Beginning the treatment, the medicament should be given to the amount of 31 grains, per diem, this amount increased by 15 V, grains daily until 1 'A drachms are reached or the amount of urine diminished; and after eight days should be omitted in order to see if the results are permanent. Opitz (Deut. med.-Zeit., Aug. 8, '89). Antipyrine tried with the object of di- minishing the amount of sugar, uric acid, and urea, but the diminution only fleet- ing. Beer-yeast of no use. Pancreas in the fresh state in daily doses of 30 grammes given with no better success. The corner-stone of treatment in dia- betes is diet. Mousse (La Sem. JIf'd., Aug. 19, '96). Antipyrine is not always indicated, however. It is only used in certain cases of diabetes, probably those in which the hyperproduction of sugar is very great, for my researches have sho\\Ti that it tends rather to counteract the destruc- tion of the sugar; moreover, the use of antipyrine cannot be long continued. Salicylate of soda has also been of serv- ice; its action is similar to that of anti- p}Tine, with the exception that it does not equally diminish the polyuria. Qui- nine acts in the same way as the anti- pyrine and the salicylate of soda, and has the advantage of being tonic. Sodium salicylate, as recommended by Ebstein, used in twenty patients. Diet and regimen being the same, it seemed in large doses — 75 to SO grains daily — to have a marked eflfect in diminishing the amount of sugar in the urine. Stopping of the drug would cause the sugar to re- appear, to disappear on resuming the medication. R. T. Williamson (Brit. Med. Jour., Mar. 30, 1901). Ebstein's plan of treating diabetes by large doses of salol tried in nine cases. Three severe cases showed no improve- ment, but the other six, moderately se- 464 DIABETES MELLITUS. TREATMENT. vere cases, were markedly benefited. Id the latter, strict diet ca\ised the sugar to disappear; but the improvement was very gradual. Salol, on the other hand, caused the sugar to fall at once. Al- though the drug was administered in 15- grain doses, four times a day, for five days, no case showed gastric disturb- ances or tinnitus. The action does not seem to last long, as the sugar gradu- ally reappeared after the drug was stopped. Tesehemacher (Therap. Mon- ats., Jan., 1901). Jambul is also recommended; but in many cases it fails completely. Its mode of action requires to be further studied. In the treatment of glycosuria, using the rind instead of the fruit in the prep- aration of the extract of jambul makes it more agreeable in taste and much cheaper than the fruit. As much as 1 '/, ounces per day can be administered for a long period without disagreeable effects. It is best given in water or wine. Vix (Ther. Monats., Apr., '93). Eugenia jambolana is almost a specific in diabetes, best given in syrup or juice of ripe fruit mixed with water to form a sherbet. The powdered seeds or a fluid extract of the seeds is an exceed- ingly valuable form in which to exhibit it. Rudolf (Bull, of Pharm., Jan., '98). For a number of years, particularly in fatty diabetes, I have been using perman- ganate of potassium: an agent which in- creases the oxidation. I use a 5-per-cent. solution, the patient taking 2 or 3 tea- spoonfuls, or even more, per day. Fourteen patients treated with forms of calcium, generally as phosphate and carbonate. This treatment has appar- ently no efTect upon tlie excretion of sugar, but the patient feels better and increases in weight. Of these patients three were young subjects who were markedly benefited. Upon the others there was no result. The treatment, however, produced no detriment. Karl Grube (Ther. Monats., II. 5, S. 258, '9C). The efTccts of uranium nitrate are (1) to diminish the thirst, (2) to reduce the amount of urine passed, and (3) to re- duce the percentage of sugar. Like all the other drugs used in the treatment of diabetes, uranium nitrate does not in- fluence all cases alike favorably. Samuel West (Ther. Gaz., Sept., '97). Hepatic extract, prepared as follows, should be given daily per rectum : 3 '/, to 5 Vi ounces of fresh pigs' liver are minced in a machine and macerated for 2 hours in 7 to 9 ounces of water at 95° to 100° F., then filtered through muslin and expressed. This amount is usually well borne as an enema; if it is not, divided doses nmst be given. The cases of diabetes which derive the most benefit from the treatment are those of definite hepatic origin. If the hepatic cell is too diseased, the treat- ment fails. Summing up 12 cases, 3 were benefited temporarily, 5 were im- proved permanently, and in 4 the gly- cosuria ceased completely. It is inter- esting to note that in most cases urea and uric acid are increased while liver is taken. One deduction is certain: that the extract lessens the excretion of glucose; whether by increasing the power of storing up reserves of sugar, or by caus- ing a more rapid destruction of ingested hydrocarbons, remains uncertain. The antitoxic function of the liver is little, if at all, — the biliary but slightly, — while the glycogenic and uropoictio functions are markedly increased. Gilbert and Carnot (La Sem. Med., May 10, '97). 1. In diabetes mellitus there is a dis- tinct loss of phosphorus, lime, and chlo- rine by every form of diet. 2. Addition to diet of phosphate of lime induces a slight saving of nitrogen; addition of salt docs not do this. 3. Addition of fatty matter produces the same elfcot as phosphate of lime. 4. Addition of phosphate of lime to the diet causes diminished excretion of sugar. W. v. Moraczewski (Zcit. f. klin. Med., B. xxxiv, II. 1, 2, '08). In diabetes, Fowler's solution and co- deine give best rosultH, together with tonics, such as muriatic acid, strych- nine, and quinine, as indicated. H. G. Norton (Med. News, July 9, '98). Arsenous acid in doses as large as '/• grain a day recommended in diabetes. DIABETES MELLITUS. TREATMENT. 465 In cases of progressive emaciation a mixture of 100 grammes of glycerin and 2 grammes of tartaric acid with some rum, added to a quart of water, is verj useful. Jaecoud (MC-d. Mod., No. 14, ■98). Methylene-blue used in two cases of diabetes mellitus, in average doses of 5 grains daily. In one case, after treat- ment for five weeks, subjective symp- toms were relieved, and glucose reduced to mere trace. In second case, in which urine contained about one ounce of sugar per quart, the saccharin content was re- duced to 1 V. drachms per quart after treatment for four weeks. Estay (Bull. GOn. de ThOr., No. 2, '98). Where aperients fail in diabetes, co- caine in small doses (Va-grain doses twice or thrice daily) will not only brace up the muscular system generally and re- move the sense of fatigue so frequently present in these patients, but overcomes constipation. Thomas Oliver (Lancet, Aug. 13, '98). Eulexine used with gi'eat satisfaction in diabetes. E. C. Skinner (Louisville Med. Monthly, Oct., '98). Diabetes believed to be due to pto- maine poisoning or to bacterial invasion of the organism. Therefore mercuric chloride has been used in beginning doses of Vi: grain three times daily, increasing within a week to ^/o grain. Three weeks of this treatment are sufficient to cause a marked reduction in the amount of svigar and improvement in the general health. After this time the dose is de- creased to '/, grain in the day. Abraham Mayer (Med. Record, Dec. 10, '98). Cases in wliich the administration of liver-subslnnce brings about improve- ment are those in which the diabetes is connected with a functional inadequacy of the liver (characterized by diminution of urea, urobilinuria, etc.). On the other hand, cases of diabetes that are not bene- fited or are even made worse by the treatment are those in which the glyco- suria appears to depend on overactivity of the organ. Gilbert (Inter. Congress of Med.; Brit. Med. Jour., Oct. 13, 1900). Opium, arsenic, and bichloride of mer- cury are the drugs of most service. Opium, which is of the greatest general use in controlling various annoying symptoms, should not be used continu- ally, but interruptedly. It should be given in small doses (not more than V, grain three times a day at first), and its constipating effect should be coun- teracted by cascara sagrada or other laxative. There are certain cases of diabetes, generally occurring in middle age, which were like a bacterial invasion or ptomaine poisoning. In these the bichloride of mercury has a certain, per- haps specific, value. The dose, at first small, should be increased to '/» grain. Even if the sugar is not entirely elimi- nated, many patients can get along very comfortably for years. The diabetic's attention should be diverted as much as possible from himself, and he should be free from professional or business cares and other sources of worriment. He should wear warm clothing and avoid fatigue and all excesses. Massage and carbonic-acid baths are often of great service, and visits to various health re- sorts, with the use of mineral waters to aid digestion, have a good eflfect. About 2.5 per cent, of diabetics die from phthisis. Abraham Mayer (Boston Med. and Surg. Jour., Apr. 18, 1901). Alkaline waters perceptibly diminish the sugar in the urine. Their use should consequently not be restricted, unless the patient be very much debilitated. Vichy water, taken at the springs, is particularly recommended for fatty dia- betics. Carlsbad water also appears to be use- ful. For diabetic patients who are already somewhat cachectic, Bourboule water, which contains considerable arsenic, is preferable. If the kidnej-s are inactive, Contrexe- ville should be recommended. Independently of the use of mineral waters, it is better not to neglect baths. ITydrotherapy may be advised for dia- betic patients who are still young and, as a rule, lotions of cold salt water in sum- mer, and warm baths followed by friction 30 466 DIABETES ilELLITUS. DIGITALIS. in winter. At Aix warm douches and massage are resorted to. Generally speak- ing, massage is always useful for patients whose weak condition does not allow of prolonged muscular exercise. Active movements, if they do not fatigue the patient, are preferable to the passive movements. Warm climates have a fa- vorable influence; when the patients are not greatly debilitated, mountain-air has also been recommended. Physicians are sometimes consulted as to the advisability of allowing the use of saccharin in diabetes, to replace the taste of sugar. I have not seen any bad effects follow- ing the use of saccharin when employed in small doses. An equal quantity of bicarbonate of soda should be added. In diabetic coma the following intrav- enous injection should be used: — 5 Chloride of sodium, 1 drachm. Bicarbonate of sodium, 2 V2 drachms. Distilled water, 1 quart. A strict milk diet should be instituted at once, and the elimination of poisons should be assisted by the administration of saline purgatives. Should the heart be feeble or irregular, full doses of digi- talis and ergotine are to be given. Results of obsci-vation on treatment of diabetic coma by subcutaneous or in- travenous injections of bicarbonate and chloride of sodium. 1. Alkaline injec- tions have given incontestable results in diabetic coma. 2. These injections are best intravenous, the subcutaneous method being too slow. 3. If possible, intervention should precede coma, as Lu- pine points out. When the patient shows progressive aggravation, a feeble pulse, lowered urine, slow respiration, witli increasing dyspna'a, nausea, and vomiting, an intravenous alkaline infu- sion of from .300 to 375 grains of bicar- bonate of sodium with 112 '/> grains of chloride of sodium to 1000 parts of water is indicated. jM. A. Berson (Jour, dea Sci. U6± de Lille, Aug. 6, '9S). Nineteen eases of diabetic coma treated by saline injections, mostly published in Germany and England, collected; of these only one, a case of LOpine's, re- covered from the coma; but few or none appeared to have received such copious injections. Koget and Balvay (Lyon JKd., Jan. S and 15, "99). If there is any reason to fear coma, an energetic use of alkalies should be prescribed. In these circumstances an hypodermic injection of strychnine must be given, and '/= ounce of soda bi- carbonate should be administered as an enema in hot water, and repeated every hour until improvement tflkes place. Saundby (Practitioner, July, 1900). Good results follow the prophylactic administration of sodium bicarbonate: 15 to 30 grains daily. In the fully de- veloped diabetic coma it has proved a failure. The use of calcium carbonate has been productive of good results. H. Stern (Jour. Amer. Med. Assoc, Dec. 8, 1900). R. Lepine, I-yons. DIAKRHCEA. See Intestines, Dis- orders OF. DIARRHCEA, INFANTILE. See In- fantile DiARRiifEA and Cuolera In- fantum. DIGITALIS.— Digitalis is indigenous to Great Britain, Ireland, and many parts of Europe, where it grows wild on gravelly or sandy soils in young planta- tions, at hedge-sides, and in hill-past- ures. It has been introduced into America, but is more grown as an orna- ment to gardens and in hot-houses than for commercial purposes, and, moreover, it is claimed that it is not so active medicinally as that obtained abroad. Digitalis purpurea is the ofTicial plant, though some pharmacopreias take cog- nizance of other forms, notal)ly H. Am- DIGITALIS. PKEPAIiATIOXS AND DOSES. 467 higua, Murr., ^vhich was extensively ex- ploited by Paschkis a few years ago; and all seem to possess much the same gen- eral activity, though purple digitalis alone has been at all carefully studied. The Digitalis purpurea, which is the source of all our medicinal preparations, is a biennial or perennial with numerous drooping, purple-spotted (occasionally white) or purple flowers, an erect stem from twelve to fifty inches high, and large alternate, ovate, lanceolate, crenate, rugose leaves of downy character, espe- cially on their pale- or light- reddish- brown under-surfaces, and tapering into winged roof-stalks. The leaves, which constitute the official digitalis, should be of the second year's growth — when they are much more oval, and also more active than those of the first year — and gathered either in July or late in June, before the small, round, graj'-brown seeds begin to ripen, and when about two-thirds of the flowers have expaudod ; they should also be dried in the dark, in baskets, over a mod- erately-heated stove or in a brick oven, and if properly cured will exhibit a dark-green hue and an almost total lack of odor, except that which generally ac- crues to dried herbs and leaves and fre- quently is described as "tea-like"; they have a decided nauseous and bitter taste. Much of the uncertainty that accrues to the medicinal use of digitalis is doubt- less due to improper seasons of plucking, improper drying or packing, and age; for even the best qualities and most care- fully collected and husbanded, even when pressed and wrapped in stout paper, or kept in tins that are not her- metically scaled, manifest distinct loss of remedial virtues after a few months, and may become practically inert at the expiration of a year. Digitalis-leaves, too, as found in open market, more espe- cially the cheaper varieties, are probably not of D. purpurea; or the latter may be adulterated with leaves of the com- mon potato, the black nightshade or black mullein {Solarium tuberosum, S. nigrum, and Verhuscum nigrum) or all three, or Coniza squamosa, which, in a dry state, somewhat resemble those of the purple fox-glove. Such sophistica- tion, however, may be detected by boil- ing one of the suspected leaves in the smallest possible quantity of water, pour- ing upon an opalescent plate, and adding a drop of ferric chloride: if a green re- action occurs, the leaf is digitalis; if blue, it is not. Preparations and Doses. — Digitalis- leaves, powdered, ^/^ to 3 grains. Digitalis abstract, V2 to 1 grain (Squibb's, 2 to 5 grains). Digitalis infusion (B. P.), 1 to 4 drachms (U. S. P., 2 to 8 drachms). Digitalis extract, solid, V« to Vj grain. Digitalis, fluid extract and nonnal liquid, 1 to 2 minims. Digitalis tincture (B. P.), 5 to 40 minims. Digitalis tincture (U. S. P.), 3 to 30 minims. Digitalis, ethereal tincture, 2 to 8 minims. Digitalis-vinegar (G. P. digitalis, 1; alcohol, 1; vinegar, 9 parts), 10 to 30 minims. Digitalisin (concentration), '/,, to V« grain. Digitalein (Schmiedeberg's), '/,« to V35 grain. Digitaleine (Xativelle's). See Digi- TONIN. Digitalin (U. S. P. and B. P.), ob- solete. Digitalin (Homollis & Qucvenne's "French Codex"), V«o to V,, grain. 468 DIGITALIS. PKEPAEATIONS AND DOSES. Digitalin (Schmiedeberg's, or digi- talin verum, Kiliani), Vei to V32 grain- Digitaline (Xativelle's), V250 to Vao grain. Digitonin ( Xativelle's digitaleine), not employed. Digitoxin (Schmiedebergs), V250 to Vi:5 grain. Digitalis Abstract. — This is merely a dried solid extract powdered and mixed with some material to prevent its sub- sequent firm agglutination, and should be made without heat by the substitute process. It presents a green color and the characteristic digitalic odor. Within a few days after making and placing in a bottle, the powder contracts very much and adheres in a fairly-solid mass that is, however, easily broken up by means of a stiff spatula, and then readily rubbed to powder again. The abstracts in market, however, vary in strength and are obsolescent. The solid extract possesses the same odor, somewhat intensified, as the ab- stract, and properly made is of so dark green a hue when seen in mass as to be nearly black; but, when thinly spread, the green is very marked and intense. A brownish solid extract is suspicious and suggestive of too much heat employed in manufacture, in which case it is apt to prove inert. Infusion. — The infusion requires to be made with great caution and from carefully-selected leaves of bright color and distinctive odor, also without undue heat. That of the U. S. P. is only about half the strength prescribed by the B. P.: a fact that is to be taken into ac- count according to the residence or locality of prescriber or patient. Fresh leaves are nearly one-third more active than the infusion. Whr>n nn infuBion of digitalis is given to indivi'Iiinls with normal eironlatory apparatus in quantities equal to that ad- ministered to persons with valvular dis- ease, there is no increase in tlie blood- pressure nor in the quantity of urine excreted, while the reverse is true of persons who have heart disease. Ernst von Czyhlarg (Wiener klin. Rund., Apr. 15, 1900). Fluid Esteact. — A good tluid ex- tract should represent a definite amount of drug, viz.: one gramme of leaves to the cubic centimetre of fluid. So called "normal liquid"' is merely a fluid extract containing the regulation amount of drug which is also proved by assay to exhibit a uniform proportion of digitalin (total glucosides). Tinctures. — "Concentrated" and "specific" tinctures should have the same strength as the fluid extract. The tinctures of the B. P. and U. S. P. vary slightly: the former exhibits a strength of 3 to 24, respectively, of bruised leaves and proof-spirit; the latter 3 to 20, of drug and dilute alcohol. The ethereal tincture is twice the strength of the U. S. P. alcoholic tinct- ure. Owing to the rapid deterioration of digitalis-leaves after curing, the most re- liable preparations are those obtained from responsible homoeopathic and eclec- tic pharmacists, both being in duty bound to employ the fresh leaves of the uncultivated plant in its second season when about to bloom. The homojo- pathic pharmacist chops and pounds the leaves to a pulp, incloses in a piece of new linen, subjects to pressure, and mixes the expressed juice by brisk agita- tion with an equal amount, by weight, of alcohol, the whole being then allowed to stand for eight days in a well-stoppered bottle in a dark, cool place, after which it is filtered. The eclectic macerates eight ounces of fresh leaves in a pint of alcohol (7G°). DIGITALIS. PRKPAKATIONS AND DOSES. 469 Active fluid preparations of digitalis do not lose in activity by being made into tablets, nor do the tablets become less active by keeping than do other preparations of digitalis. E. M. Hough- ton (Ther. Gaz., Xo. 4, p. 217, '98). DiGiTALiN. — Digitalin, as it formerly appeared in the pharmacopojias, is now obsolete, and where the same was used as the title of a concentration it is now replaced by digitalisin. The latter is a very uncertain production as regards strength, and consequently should not be employed. Vinegar. — Vinegar of digitalis, which still retains a place in some Continental pharmacopreias, offers no advantages over other fluid preparations, and conse- quently has been dropped by the British and U. S. authorities. Liniment. — Digitalis-liniment is merely a mixture of equal quantities of official tincture of digitalis and soap- liniment. Ointment and Poultice. — Digitalis ointment may be made with any desir- able fat and of any required strength, the usual proportions are 1 to 9 of solid extract and base, respectively. Digitalis poultice may take the form of a fomenta- tion of the leaves, or be made by adding an ounce of the tincture to a linseed poultice. Active Principles. — The so-called active principles consist of a number of glucosides: digitalin, digitalein, dig- itonin, digitin, and digitoxin. Unfort- unately, great confusion exists regarding these preparations, which has been fos- tered by pharmacopoeial errors. Thus the digitalin of ITomolle & Quevenne, recognized by French authority, is an amorphous, yellowish-white powder, in- odorous, intensely bitter to taste, ex- tremely irritating to the nostrils, and highly poisonous; it is sometimes found n.^ small scales. It is chemically a mixt- ure of the digitalin of the German phar- macopoeia and the digitoxin of Schmiede- berg. Another form that has the sanc- tion also of the French Codex is digi- taliiie (mark the final e) crislalliste, or the digitaleine of Nativelle, and appears as white, crystalline tufts or needles, and consists almost wholly of Schmicdeberg's digitoxin; it is very bitter to taste, slowly eliminated and consequently cumulative in action, and dispensed only when "crystallized digitalin" is ordered. Both the foregoing are insoluble in water or ether, but the crystallized form yields readily to chloroform and rectified spirit. The digitalin of the German Pharma- copoeia is also the digitalin verum of Kiliani. It is a white or yellowish, amorphous product, consisting of digi- talein and digitoxin (Schmiedeberg's); is soluble in water, 1 to 1000 in alcohol; almost insoluble in chloroform and ether. Digitalein (Schmiedeberg) is also an amorphous, yellowish-white powder of intense bitter taste; soluble in water and alcohol, slightly so in chloroform and ether; as before remarked, this is the chief constituent of German digi- talin. Digitoxin. — The digitoxin glucoside of Schmiedeberg is the most poisonous of all the digitalis principles and likewise markedly cumulative in action, owing to the difficulty with which it is eliminated. It occurs as a white, crj'stallized powder, soluble in chloroform and alcohol, slightly soluble in ether, insoluble in water. DiGiTONiN. — Soluble in water and alcohol, appears in the form of yellow granules, but possesses none of the prop- erties for which digitalis is celebrated. It appears to be identical, or at least closely related, to saponin, the active principle of quilliai bark. 470 DIGITALIS. PHYSIOLOGICAL ACTION. DiGiTix. — Digitin is a coai-sely-granu- lated, crj-stalline powder, soluble in alco- hol, ether, and alkaline solutions, and is physiologicall}- and therapeiitically inert. DIGITALIEESI^■'. — Digitaliresin and digitoxiresin purport to be derivatives, respectively, of the digitalin and digi- toxin of Schmiedeberg, but beyond this nothing is known of either. A comparative study of digitalis and its derivatives shows that: 1. Digitalis and digitoxin each represent the full circulatory powers of digitalis. 2. Digi- talis, digitalin, and digitoxin stimulate the cardio-inhibitory mechanism both centrally and peripherally. In larger doses they paralyze the intrinsic cardio- inhibitory apparatus. 3. They all cause a rise of blood-pressure by stimulating the heart and constricting the blood- vessels. 4. Very large doses paralyze the heart-muscle of the mammal, the organ stopping in diastole. 5. Digitalin of Jlerck is a stable compound, 1 gramme of it being equivalent to about 70 cubic centimetres of tincture of digitalis. G. Digitoxin is not to be recommended ior human medication on account of its irri- tant action, which makes it liable to upset the stomach when given by the mouth, or to cause abscess when given hypodermically, and on account of its insolubility, which renders it slowly ab- sorbed and irregularly eliminated, having a marked tendency to cumulative action. Arnold and Wood (Amcr. Jour, of Med. Sciences, Aug., 1900). Digitalis as obtained from various re- gions shows entirely regular alterations at dillercnt periods of the year. These alterations are always in direct associa- tion with certain definite periods of the year, the general result being that the old leaves found toward the beginning of August have customarily only about one-fourth the activity of the new leaves. D. Focke (Zeits. f. klin. Med., vol. xlvi, Nos. 5 and 6, 1902). When digitoxin is employed, it is rec- ommended that a solution be made in alcohol, chloroform, and water, and that it be administered by clyster: digitoxin, V»s to Vei grain; chloroform, 4 minims; 90-degree alcohol, 1 drachm; water, to make 14 drachms; at one dose. Physiological Action. — Though digi- talis per se has been before the medical profession for more than three centuries, the fact remains that its physiological attributes are by no means thoroughly understood; indeed, they constitute a subject on which there is great differ- ence of opinion. It may be affirmed that experiments upon mammals, birds, and batrachians have added practically nothing to the knowledge already pos- sessed regarding the action of digitalis when introduced into the economy of man. Part of the trouble may have arisen from the fact that many of the preparations as found in shops are prac- tically inert, while the different dosage and forms of exhibition as employed by different observers inhibit uniformity. The action on the two-chambered heart of the frog, or three-chambered heart of the bird, both of which animals excrete solid urea, cannot coincide with that on the four-chambered heart and the fluid- excreting renal gland of the mammal, while, as is well known, there are few drugs toward which individual mem- bers of the human family are so generally and differently idiosyncratic. Again, the actions of watery and alcoholic prep- arations are by no means identical, owing to the differences in the solubility of the various glucosides in these menstrua; an infusion, for instance, holds in solution chiefly the digitonin, while tlie tincture contains digitalin and digitalein, — neither contains much digitoxin, but the tincture necessarily carries more than tlie infusion. Notably the infusion is more directly and promptly diuretic, and the B. P. tincture more so than that of the U. S. P., but the latter two afford the best results when the heart alone is DIGITALIS. PHYSIOLOGICAL ACTION. 471 to be acted on. But it is doubtful if the tincture alone ever acts as a true diuretic, except in the presence of a heart-lesion, such as is found in connec- tion with some form of hydrops. The drug often fails completely in securing the desired action clinically, because the wrong preparation is employed, and it may here be noted that little reliance is to be put on the glucosides, at least not until we are possessed of more definite knowledge regarding their composition and physiological relations. Xot only is their use to be deprecated, but they are generally dangerous and sometimes re- nedially worthless. Digitoxin especially is so highly toxic and so difficult of elimination as properly to bar it from official recognition. How often is seen the statement that digitalis is a power- ful sedative, and again that it is a heart- stimulant? This conveys little informa- tion, because it is conflicting; yet it may be true, and depends solely upon the dosage, and the peculiarities of the in- dividual patient. In fact, there is no drug in the materia medica that requires more careful handling or more careful study of effects in each and every one for whom it is prescribed; and again there is no drug more certain in secur- ing definite results, when intelligently exhibited. Regarding action on heart and circula- tion, it is deemed best to give in abstract the various views: — Wood sums up the action of the drug by saying that in moderate doses it stimu- lates the muscular portion of the heart (probably of its ganglia), increases ac- tivity of the inhibitory apparatus, and produces contraction of the arterioles. As a consequence of the first action, the cardiac beats become stronger; as a re- sult of the last, there is narrowing of the blood-pnths, and to the passage of the vital fluid an increased resistance which, acting on the already-excited inhibitory system, aids in slowing the pulse. De- cided therapeutic doses produce great re- duction and sometimes dicrotism of the pulse, and increase the size and force of the wave; at the same time the arterial tension is augmented. Murrell states that the greatest and characteristic action of the drug is that it affects elasticity of cardiac muscle without at first modifying its contractile power, as indicated by increase in the volume of the pulse, although the abso- lute working power of the heart is neither increased nor decreased; at the same time the quantity of blood driven into the aorta is greater than before, not only at every beat of the pulse, but even in a given unit of time; notwithstanding the number of pulsations be diminished, the result is a better filling of the arteries and an increase in blood-pressure. Ac- companying this condition there is slow- ing of the pulse due to stimulation of the inhibitory mechanism of the heart. Finally, in conjunction with continuous high pressure there is irregularity both in the action of the heart and in the fre- quency of the pulse. Digitalis does not exert a sedative action on the muscular substance of the heart; and although the organ may be beating more slowly it may also be doing more work. Ringer and Sainsbury teach that digi- talis undoiibtcdly does affect directly — i.e., immediately — the muscular tissue of the heart, including persistent contrac- tion. Inasmuch as this action on the heart is independent of the agency of nervous tissues, it seems presumable that it may affect other muscular tissue in the same way. It does undoubtedly cause strong contraction of the blood-vessels when these are quite cut off from the cen- tral nervous control; hence it must act 472 DIGITALIS. PHYSIOLOGICAL ACTION. either directly on the muscular tissue of the ■walls of blood-vessels or on some pe- ripheral nervous apparatus that governs the muscular tissue of the blood-vessels. In therapeutic use it may be conceived that digitalis ■will act in different ways: by strengthening the action of a weak heart; by reducing the strength of the beats of a heart acting too powerfully; by lessening the frequency of the heart's beats; by correcting irregular action of the organ; by increasing tonicity and BO lessening the size of the cavities, thereby obviating the condition of over- distension in which the stretched ven- tricles are unable to contract upon the contents, a condition threatening com- plete asystole — the second of these prop- ositions a different and fuller dosage will probably be required. It has been the general view that each preparation is capable of producing effects peculiar in some respects to itself. But the physiological effects of digi- talein and digitoxin are identical with those of digitalin, except that they do not stimulate the vasomotor centre or the pneumogastric apparatus, and so do not directly raise blood-pressure or slow the heart. In other ■nords, they increase the force of ventricular contraction. The effect of digitonin is to depress the vagus nerves, so it antagonizes the vagal effect of tlie digitalin and prevents digi- talis from slowing the heart to the ex- tent that would result from the use of digitalin alone. It also depresses the heart-muscle. H. A. Hare (Therap. Gaz., Aug. 10, '07). Attention called to the vasomotor ac- tion of digitalis; with a rather generous dose, migraine due to cerebral congestion can be overcome, where a small dose, acting on the circulatory centre, would fiimpty aggravate the condition. Diuresis is produced only in those cases in which there is anasarca, and is due to ana- sarca; often there is diuresis without increase of blood-pressure. When the dropsy lias di.sappoared the diuresis ceases. Diminution of the dose is indi- cated on the disappearance of dropsy. Chief indications of digitalis are in- creased frequency and irregularity of the pulse and the presence of cedema. In cases the reverse of these it is useless or harmful. AVarning is given against its careless use in myocarditis with fatty degeneration and in cardiac asthenia with dilatation. In cardiac dilatation of gastric origin digitalis is harmful, for it is not tolerated by the stomach. Ar- teriosclei'osis is not a contra-indication if caution is used, ^^^lere increased fre- quency of the pulse or dropsy are pres- ent in aortic insufficiency, digitalis is distinctly indicated. The same is true in mitral stenosis. In mitral insuffi- ciency it has its widest use, but it la late in the disease that digitalis is most needed. ^AHien tricuspid accompanies mitral insufficiency, the former, unless great care be taken, is made to disappear too rapidly by digitalis, and pulmonary apoplexy results, through increase of capillary pressure. Of the preparations, digitalin is preferable. M. Potani (Jour, de Mfd., '9S). The chemical composition of digitalis is complex, some of its active principles antagonizing others; the various prepa- rations of digitalis differ widely in their composition and action; the so-called cumulative action of digitalis is due to its contracting the arterioles and shut- ting off nutrition; it is both a useful and a dangerous remedy, and has a very limited range of usefulness ; it is of use only in lesions of the mitral valve, and then only for a short time, and should be discontinued as soon as those have been overcome; it is of value as a di- uretic only when there are low arterial tension and engorgement of the kidney. Digitalis decreases the excretory action of the normal kidney and impairs its nutritive activity. The tincture of digi- talis, made from the fresh leaves, is the most valuable and the most certain of the preparations of digitalis. It eon- tains the largest percentage of those constituents which are moat useful in the treatment of cardiac disease. W. H. Porter (Amor. Medicine, Apr. 27, 1000). Investigations carried on in the Phar- macological Institute in Heidelberg, and DIGITALIS. PHYSIOLOGICAL ACTION. 473 based on experiments on cats witli dif- ferent pure preparations of digitalis, the influence of each drug being continued for a period of several weeks. All dig- italis preparations were used in grad- ually increased doses. At first a simple therapeutic action occurred, which finally became cumulative. Digitoxin exhibited the strongest cumulative action, and is, therefore, not to be recommended for continued daily use. Digitalicum, on the other hand, is rapidly excreted, and may be used in certain cases for considerable periods. Strophanthin is usually more evanescent in its action than digitalis, but a preparation of strophanthin re- cently prepared by Professor Thorns, of Berlin, is particularly active and lasting. In none of the preparations was there observed any tendencj' to become habit- uated to the drug. Frankel (Amer. Medicine, May 31, 1902). Action on Brain and Cord. — It is now generally held that digitalis, in therapeutic doses, has little effect upon either the brain or the spinal cord, but earlier writers laid great stress upon its "mildly-irritant" properties as regards both, and that as it became cumulative it tended to "confuse the mental fac- ulties." There are some observers who, to this day, ascribe the antithermic ac- tion of the drug to an effect upon the cord, whereas it becomes an antipyretic solely by its influence upon the circula- tion. In pyrexias there is partial vasom- otor paralysis with dilated arterioles, low blood-pressure, and increased tissue- change in and around the dilated ter- minal vessels; consequently by contract- ing these vessels digitalis raises blood- pressure, it being well understood that, as the latter takes place, the tempera- ture falls, and vice versa. In other words, there is always an antagonism between temperature and blood-pressure. While ordinary doses do not affect the brain, as the drug becomes cumulative, or it is pushed to a point approaching toxicity, the reflexes of the spinal cord seem to be somewhat lessened. As be- fore shown, under ordinary dosage, there is probably some stimulation of the vasomotor and pneumogastric nerves. Action on Urinary Apparatus. — Under certain conditions digitalis seems to increase the flow of urine without altering, in any essential respect, the quantity or proportion of its solid in- gredients; but, strange to say, this ac- tion is seldom manifested in the healthy human subject, though it is apt to be very pronounced when there is an accu- mulation of fluid to be removed. In truth, the manifestations of digitalis are often inconsistent and varying as regards renal secretion, and are probably in great measure indirect and secondary. As before intimated, the infusion is the most reliable form to exhibit for such purpose, and doubtless here the watery menstruum should receive a due portion of credit. That the drug is, in any sense, adenagic or a stimulant to glandular tis- sue, and consequently diuretic because of such action, receives little credence these days. A fairly free use of alco- holics in connection with the infusion seems to enhance the activity of dig- italis as regards the kidneys, but a better method is to combine with the latter a minute portion of cantharides. Digitalis has no pronounced constant elTect upon nitrogenous elimination. Alexeevsky (St. Peter., Inaug. Diss., '00). The drug increases the consumption of the chlorides, sulphates, and phosphates. Beljakow (Schmidt's Jahrb., B. 219, '91). Digitalis increases the amount of solids eliminated in the urine, except urea and uric acid, which are diminished under its use. Biddle ("Mat. Med. and Therap.," '95). Conclusions regarding physiological and therapeutic actions of digitalis and of its active principles summarized as follows: 1. The physiological action of 474 DIGITALIS. PHYSIOLOGICAL ACTION. digitalis is exerted chiefly (a) on the heart, (6) on the blood-vessels, and (e) on the secretion of urine. 2. Its action on the heart is that it (a) slows the car- diac beats chiefly by stimulation of the roots of the vagus in mammals, (6) in- creases the force of systole, and (c) in- creases the extent of expansion in dias- tole. Both & and c are due to an action on the cardiac muscle. 3. It contracts the peripheral vessels, and thus slows the current of blood through them. 4. By its combined action of contracting the peripheral vessels and of increasing the power of the heart it raises the blood- pressure. 5. The diuresis which digitalis produces is chiefly due to increase of blood-pressure. 6. Digitalis contracts the arterioles in the kidney sooner than those in other parts of the body. The renal vessels may contract so much as to arrest the secretion of urine altogether, although the general blood-pressure is high. 7. When blood-pressure is already high, digitalis cannot be expected to have a powerful diuretic action; but if the blood-pressure be low, from natural con- stitution or disease, digitalis will have a diuretic action. 8. Digitalis is a local antesthetic, but also produces pain. It therefore belongs to the class termed by Liebreich "ansesthctical dolorosa." 9. In large or in accumulated doses it gives rise to gastric irritation. 10. The action of digitalis is due to digitalin, digitalein, and digitoxin. These principles all have an action similar in kind, but differing in degree. 11. The therapeutic actions of digitalis and of its active principles are that they («) regulate the heart's action, (6) assist a failing circulation, and (c) act as diuretics. 12. The regulating ac- tion of digitalis is useful in palpitation and functional disturbances of rhythm. l.'. The most important use of digitalis and of its active principles is in the treatment of mitral incompetence due cither to disease of the valves or dihita- tion of the ventricle. 14. In cases of aortic regurgitation digitalis is (a) un- nccPBsary and not without danger when compensation is complete, but (b) very useful when compensation fails. 15. When the blood-pressure is already high, digitalis may be injurious by increasing it still farther, and thus causing symp- toms of angina pectoris or tending to produce apoplexy. T. Lauder Brunton (Inter. Hed. Congress; Brit. Med. Jour., Sept. 29, 1900). As a diuretic, digitoxin is superior to digitalin, since it actually dilates the renal vessels, while stimulating the heart. Furthermore, its action is prompter and more certain than that of digitalin. It manifests its efl'ects oftentimes within twelve hours, and is less liable to cumulative action than digitalin. JIasius has used as much as Vw grain a day. After discontinuing the use of the drug the influence of digitoxin is said to persist, sometimes, for eight to ten days. To avoid di- gestive disturbance, Wenzel employed it chiefly by enema, giving about V»o grain in 10 minims of alcohol and 4 ounces of water. The action upon the heart, as observed in these experiments, was quite pronounced; at* first three rectal injections were given daily (pre- vious thorough cleansing of the bowel being presupposed), afterward only two injections were used, and, finally, only one was found necessary, in order to maintain the first efl'ect produced. In personal experience digitoxin has been given in a series of cases — of late, chiefly hypodermieally, but also by the mouth {always after meals). It was the ex- ception to see any digestive disturbance when '/too grain or less of digitoxin was being given three times daily. In no case did an abscess ever result from the hypodermic syringe. Digitoxin has been especially recom- mended in chronic myocarditis and in eases of ruptured compensation. A solution of digitoxin is liable to precipitate on coming in contact with tlie secretions of the body. To avoid this, and yet not use too much alcohol in the pliarmacoutical preparation of the solution, it has boon recoinmondod to add a little chloroform to the solu- tion. The following solution has, after experimentation, been found to bo stable, and will not precipitate upon contact with blood-scrum, water, or Bodiumchlorido solution: — DIGITALIS. IXCOMPATIBLE.S. POISOXIXG. 475 I^ Digitoxin, ■■/.„ grain. Chloroform, 1 '/: minims. Alcohol at 00 per cent., 23 minims. Water, sufficient to make 'A ounce. — M. L. L. Solomon (N. Y. Med. Jour., Feb. 9, 1901). Action as an Antipyretic. — Why toxic doses cause a fall of temperature, even in health, is one of the physiolog- ical problems that yet awaits solution; and with this depressed temperature muscular paralysis is apt to supervene. Action on Uterus. — The muscular substance of the uterus is powerfully contracted by digitalis. It was long sup- posed that this action was the result of stimulation of uterine ganglia, but it is now believed to be due to the affinity of the drug for unstriped muscular fibre. In uterine ha?morrhage, when admin- istered, the patient (usually in about ten minutes) complains of very severe pain in the region of the sacrum, which passes into the hypogastrium, and in every respect seems to resemble the pain of the first stage of labor; very shortly afterward a considerable quantity of blood, generally in part coagulated, is forced out from the womb. As digitalis has been employed some- what extensively and successfully in sim- ple monorrhagia, its affinity for the re- productive apparatus of the female seems well established; some authors go so far even as to accredit it with phenomenal emmenagogic properties, though the evidence adduced appears to be of rather a hazy and uncertain character; and yet digitalis is employed as an ecbolic or abortifacient in some European coun- tries. Incompatibles. — Digitalis is incom- patible in fluid preparations with salts of iron and lead; likewise with tannin and all vegetable solutions containing them. Therapeutically it is antagonized by aconite and its alkaloid, by scoparine, muscarine, saponin, staphisagria and the alkaloid of the latter, delphinine, and by drugs of the belladonna group. Digitalis Poisoning. — Digitalis poi- soning is of extremely rare occurrence: a fact that may be, oftener than not, perhaps, ascribed to the practically-inert character of most of the preparations marketed. The symptoms are, for the most part, the same as when too large or too-long-continued doses have been ex- hibited, but in greatly-aggravated degree: disordered state of prima; vice; slow and irregular pulse; coldness of extremities; syncope or tendency thereto; giddiness; confusion of vision, external objects ap- pearing of yellow or green hue, mist or sparks before eyes, which are prominent, with pupils fixed and perhaps dilated; weight and pain in forehead; weakness of limbs; insomnia; stupor or delirium; urine suppressed, perhaps; there may be abundant salivation. Fatality is usu- ally preceded by stupor or convulsions and a dilated, insensible pupil. According to Tardieu, an almost diag- nostic symptom of digitalis poisoning is a blue color of the sclerotic. The minimum fatal dose of digitalis is not known, and, owing to the incon- sistency of its action, probably never will be. The treatment after evacuat- ing stomach and bowels should be tan- nin, opium, stimulants, and recumbent posture; aconite may be employed, but it requires to be administered with cau- tion. Treatment of digitalis poisoning must be symptomatic. The administration of the drug is to be stopped; the ali- mentary canal is to be cleared of any impurities it may contain; elimination must be increased by diluents; sickness allayed; arterial tension reduced when high; sleep procured if necessary, and other symptoms treated as they arise. 476 DIGITALIS. THERAPEUTICS. Xitroglyeerin is the best remedy for the reduction of arterial tension. If the blood-pressure is low, alcohol will prove of great senice. Taylor and Marshall (Brit. Med. Jour., Nov. 4, '99). After the drug had been administered to a woman of 40 for six weeks (5 drops of the tincture every four hours), symp- toms of profound mental disturbance appeared. At first simulating mere hys- terical excitement, the disorder rapidly developed into a violent mania. The drug was immediately discontinued, and she recovered promptly. A. W. Dunning (St. PaiU Med. Jour., May, 1902). In spite of a vast amount of evidence adduced in favor of medicinal use of the glucosides of digitalis, the fact remains that all are uncertain bodies, and that no one definitely represents the thera- peutic activity of the drug itself. They are practically worthless in heart dis- eases. Even for hypodermic use tincture of digitalis is preferable and it is less irritating. In any event, the only glu- cosides worthy of attention are the dig- italeine of Nativelle, or d. cristalUsee, and the digitoxin of Schmiedeberg; even these are highly irritant to the skin and likely to produce eczematous and other eruptions that are also often, as well, results of the use of digitalis ointments or poultices. Some nocturnal delirium is one of the first bad results of digitalis. Pallor, coldness of the extremities, trembling, and contraction of the pupils are im- portant indications to suspend the drug. Some patients die suddenly of syncope, others gradually. Deatli from digitalis is most frequently met with in Brighl's disease, artliritic and ana:mic subjects, and in persons with aortic incompetence or delirium tremens. Occasionally there is melancholia and niglit-tcrrors. An unusual result is pulmonary apoplexy. Potdin (.Tour, de Mf-d., Apr. 10, 1900). Therapeutics. — Digitalis is one of the niost abused drugs of the materia medica. One of the most universal abuses is the habit of prescribing it for a pa- tient without advising him to abstain from exercise while under its influence. There are very few physicians who have not been disappointed by its results from the counteracting influence of exercise. All patients taking digitalis should live in perfect physical and mental quietude, as otherwise there is danger of adding to the perils of the diseased conditions demanding its use. English (Med. and Surg. Rep., Aug. 22, '96). In disease, rest in bed and a regular diet will alone cause diuresis in 60 per cent, of cases in from 2 to 5 days. The ureal excretion is similarly increased. In 2G cardiac cases treated by digitalis an increase in excretion of solids and fluids took place in 22 eases, and the best results were obtained from the tincture, 15 minims every four hours, or from Nativelle's granules, one three times per day. Out of 13 cases in which strophan- thus was used, S showed diuretic effects, thougli not so marked as from digitalis, and much more disagreeable gastro- intestinal symptoms followed. Diuretin increased the urine in 6 out of 12 cases, its advantage being the rapidity of its action, but its toxic symptoms were more marked than digitalis and its effect less prolonged. In Briglit's disease, however, it acts more favorably than digitalis or strophanthus. In cardiac dropsy digi- talis is the drug par cxceUcnce. J. A. MacCaren (Med. Cliron., Sept., 1900). Diseases of the Heart. — Digitalis is, above all, a cardiac remedy; but there is as much dispute over the classes of cases to which it is applicable as over its physiological action. In pediatric practice digitalis is indi- cated in cardiac disease whenever the nuiscular contractions become of insuffi- cient strength. It is especially valuable in mitral disease, but is contra-indicated in aortic insufTicicncy until the pulse be- comes rapid and irregular. It is useful for its diuretic action in respiratory dis- ease, like liydrothorax and i)leurisy, and for its effect upon the heart in pneu- iiHiiiia, severe bronchitis, and influenza. In repeated severe luemoptysis it is of DIGITALIS. THERAPEUTICS. 477 value. In acute infectious diseases it is valuable if given before the myocardium has undergone marked degeneration. It should never be given for a longer period than 7 or 8 consecutive days, and then its use must be suspended for from 8 to 10 days. Comby (Kevue Inter, de Jl6d., etc., vol. ix, No. 11, '99). Digitalis is especially indicated in simple dilatation. It is not contra- indicated except in the advanced stages of myocardial degeneration. Huchard (Mf'd. Mod., Feb. 17, 1900). Insufficient attention is paid to the selection of suitable patients for digitalis. When inequality, irregularity, and insuf- ficiency of the pulsations are absent, or when there is no dropsy of the cellular tissues and serous cavities, contra-indica- tion for digitalis exists. A permanently infrequent pulse is not a eontra-indica- tion. A strong contra-indication to digi- talis is the presence of myocardial lesions. Tlius myocarditis, senile cachexia, fatty degeneration, etc., call for the very greatest care in the use of this drug. Aortic incompetence is, generally speak- ing, a contra-indication. Dyspepsia very often causes digitalis to disagree. A ca- chectic condition is a contra-indication. Potain (Jour, de M6d., Apr. 10, 1900). The underlying principle which should govern the clinical use of digitalis is its iiidiiect influence, tliroiiyh Uie adrenals, on the heart and vasomotor system. The practical bearing of this principle may be illustrated by the following few examples: — 1. In uncomplicated dilatation of the heart, failure of the cardiac muscle to contract adequately, i.e., in loss of car- diac poiecr, the secretion of the adrenals would logically be indicated, since we have seen that, as does suprarenal ex- tract, it increases this power to a greater degree than any agent known. We know that this is precisely where digi- talis is at its best, particularly when the riijht heart is dilated — the side first reached by the adrenal secretion. 2. The word "uncomplicated" must be qualified here, however. We have a valvular lesion with dilatation, the heart doing its best to do its work notwithstanding the obstruction. Yet the incTcased resistance — mitral in most cases — keeps it dilated, and the organ ia already showing slight signs of hyper- trophy. It requires help — more "dy- namism," as Brown-.S(5quard called it fifty years ago when he advanced the view that the main factor of the heart's contractile energ}- was in its venous blood. What greater help could we give it than the secretion of the adrenals, its main source of contractile power? Digitalis, we know, is of great value in just such cases. 3. Mitral stenosis or insufficiency are types of cardiac disorders to which ref- erence has just been made. Yet in many instances the valves of both sides of the heart are diseased and passive resistance to the admission of blood to the right heart occurs, causing passive hyperaemia and venous stasis. The se- cretion of the adrenals raises the gen- eral vascular pressure, thus forcing more blood toward the heart; and slows cardiac action, — thus giving it more time to dilate and to admit more blood. The relief digitalis affords in such cases is well known. 4. Conversely: We have to deal with a heart which has reached the stage of full compensation: i.e., hypertrophy. It has succeeded — too well perhaps — in mastering the valvular obstruction in the sense that it has acquired the power of forcing a relatively adequate pro- portion of blood past the obstruction. Would an increase of adrenal secretion in the blood, which would raise the vas- cular pressure, i.e., the peripheral re- sistance to the circulation of blood, and thus increase the labor of the heart, benefit such a case? We know that digitalis is harmful under these condi- tions, and that it can actually promote hypertrophy. 5. The case is one of arteriosclerosis, with more or less advanced calcification of the aorta and of the coronaries per- haps, and also of a few or many arter- ies (of undeterminable limits in the liv- ing subject). — all complicating a cardiac disorder. The pulse is hard and small, indicating circulatory resistance some- where. The secretion of the adrenals, which increases the general vasocon- 478 DIGITALIS. THEEAPEUTICS. striction and, simultaneousl!), the power of the heart's contractions, thus greatly augmenting the centrifugal pressure of the blood-stream, is therefore indi- cated. Digitalis is known to be unsafe in such cases. 6. The case is one of aortic regurgita- tion. Owing to a lesion of the aortic valves, a reflux of blood into the ven- tricle occurs during diastole. The ad- renal secretion, by slowing the heart, lengtlieus the diastole and affords more time for regurgitation; again, by caus- ing general vasoconstriction, it increases the resistance to the blood-current and helps to detain the blood in the ven- tricle. It tends greatly, therefore, to increase the trouble — as does digitalis. Charles E. de M. Sajous (Monthly Cy- clo. of Praet. Med., Sept., 1904). In arteritis digitalis is a powerful auxiliary, assisting to control the mor- bidly increased action of the heart and arteries, but it should not be used to the exclusion of general antiphlogistic measures. Some consider digitalis is beneficial in mitral obstruction, while others hold it is indicated more especially in mitral re- gurgitation. It has been observed of eminent service in cases where, after death, the symptoms were seen to be due to mitral regurgitation, and little, if at all, to mitral obstruction. One should try digitalis in every mitral case, even in pure mitral stenosis. Inefficiency may be due to irregularity arising from fatty degeneration ; and the indications for its use are less conspicuous in aortic disease with insufficient compen.sation than in purely mitral cases, though in failinj,' lieart from aortic disease it may render excellent service. In iiTitable heart where much hypertrophy exists, digitalis may prove serviceable, and may totally fail to afford any relief. It is often valualjle in quelling attacks of pal- pitation. It is useful in fatty heart and arterio-capillary fibroses inducing hy- pertrophy of left ventricle. Ringer and Sainsbury ("Iland-ljook of Therap.," -97). ANEUEisii AND ATHEROMA. — A num- ber of writers have lauded the use of digitalis in aneurisms and in general capillary atheroma, with a view, as stated, of "quieting the circulation." Such, however, must be considered as open to severe censure, since increased blood-pressure maj% in the one case, tear open the thin wall of the aneurismal sac, and in the other rupture an ather- omatous cerebral capillary. If there be increased resistance to the circulation in aneurism or in general capillary atheroma, and the heart has not sufficient power to meet this, digi- talis may be useful, but must be em- ployed with extreme caution. H. C. Wood ("Princ. and Prac. of Therap.," '94). Contra-indicated because it increases intra-arterial pressure. Roth ("^Modern Mat. Med. and Therap.," '95). Digitalis is contra-indicated in aneu- rism and all diseases accompanied by high tension, and where there are changes in cardiac muscle or atheroma of blood-vessels, except for temporary use in emergency. Foster ("Prac. Therap.," vol. i, '90). Deopst; Hydrocephalus. — In the dropsy of visceral disease and in the serous accumulations of inflammatory origin digitalis is often of service, but preferably it should be used in connec- tion with some other diuretic, such as broom or squill; a minute portion of cantharides added to digitalis infusion insures a satisfactory diuretic effect. But the best results invariably accrue to administrations in the dropsy of cardiac disease and subacute nephritis. In the United States the remedy has never been employed with the same freedom as abroad; and in England and Scotland patients were formerly — and even yet in some districts — fairly drenched with an infusion made with "two handfuls" of leaves, drank ad libitum until ultimatvj narcosis, vomiting, and purging oc- DIGITALIS. THEKAPEUTICS. 479 curred. The quantity that may be given without danger is sometimes surprising, but the character of the malady in which it is exhibited should be taken into ac- count. For instance, so satisfactory has it generally proved, in large doses, in the treatment of hydrocephalus, that many of the older practitioners to-day deem it a specific. Nervous Diseases. — Although no direct action is produced on brain-tissue by digitalis, it may be imagined some alteration in cerebral function may fol- low changes induced in the vascular system; hence the apparent benefit oftentimes experienced from the em- pirical employment of the drug in vari- ous forms of mental alienation and in epilepsy. For nearly a century the remedy has been considered in Germany as an almost specific in mania. In epilepsy, though it has produced no cure, it is evident that the use of digitalis ought not to be too hastily forsaken. In mania it is often ex- hibited with good efTect. Barton ("Cul- len's Treatise on Mat. Med.," vol. ii, '12). The use of digitalis should be limited to those cases where the malady is de- pendent upon disease of the heart and particularly where there is increased fullness and pulsation of carotids and temporal arteries. Foville (Waring's "Prac. Therap.," '95). Careful examination of literature re- veals opinions about equally balanced as to good or ill effects of digitalis in epi- lepsy; it may, therefore, be concluded that the subject demands more careful and detailed attention than has hitherto been given it. In many cases detailed it is evident that the dose employed was too small to be productive of benefit; in many more the drug, at best, was only palliative. In the north of Ireland where the drug still obtains a reputation as a specific, the doses employed are very large. Diseases of Kidneys. — In the treat- ment of albuminuria digitalis has found many advocates; but, as will be readily understood on recalling its pliysiological relations, it cannot be held a remedy for what is at best but a mere symptom, ex- cept its activity is directed toward the primary lesion, and that referable in- disputably to the central organ of circu- lation; and even here it should be em- ployed only most watchfully and cau- tiously. Where the kidneys are involved with any morbid process having its in- ception in the cardiac apparatus, indi- vidual susceptibility and idiosyncrasy are likely to be highly developed. In acute stage of Bright's disease digitalis poultice and dry cupping often afford relief; and the infusion may also be employed in Vs-ounce doses, repeated every two hours for twenty-four hours, or as long as ursemic symptoms are urgent. The drug should be promptly discontinued once the urine begins to flow, and diuresis continued with the aid of mild, diluent beverages. In passive renal congestion, too, which is generally associated with cardiac disease, digitalis may be indicated. Digital is of service in granular de- generation of kidney by increasing the quantity of urine passed and lessening the amount of solids voided. It is also of senice in relieving the tension of renal capillaries. Webster ("Dynamical Therap.," '93). Because it is claimed that digitalis is a drug which increases the force of the heart and contracts the vessels of the peripliery — except those of the kidneys — it is employed indiscriminately as an ideal diuretic in Brighfs disease, not- withstanding the contra-indications ob- servable in capillary tension and cordy pulse. Such irrational therapeutics can result in naught but harm. It seems almost foolhardy to use it in chronic nephritis accompanied with high periph- eral blood-pressure, as it usually is, 480 DIGITALIS. THERAPEUTICS. unless preceded by a short course of nitroglycerin to relieve the peripheral tension. English (Med. and Surg. Kep., Aug. 22, '96). Decidedly beneficial in chronic form of Bright's disease, where there is car- diac dilatation. In early stage of the malady, accompanied by cardiac hyper- trophy and high arterial tension, it is doubtful if digitalis is indicated, either alone or in combination. Butler ("Text- book of Mat. Med., Therap., and Pharm.," "96). Ukinart Calculi, etc. — Digitalis, from its effect primarily upon the cir- culation, and secondarily upon the renal organs, is often a valuable adjunct to antilithic remedies. It is not itself in any sense a solvent of gravel or calculi, nor is there any evidence of remarkable power in mitigating pain or otherwise alleviating the symptoms that accom- pany maladies of this class; but Barton nearly a century since noted that the drug, in many instances, in a most re- markable manner relieves the trouble- some dysuria which is dependent upon stone or gravel. Cardialgia. — Here, though often recommended in doses from 10 to 20 minims three or four times daily, little can be generally expected, though by its action on the heart it may alleviate pain contingent upon some cardiac disorder. Dyspnoea; Asthma. — In the treat- ment of maladies of this class, too, the drug has found a place, but in uncom- plicated forms it is inferior, both as to safety and efficacy, to other drugs. Where these are connected with disease of the heart or functional palpitation, relief may be afforded, and when accom- plished the digitalis should be with- drawn, since now cither opium or hen- bane, or both, will better answer the purpose. In spasmodic asthma it is oc- casionally serviceable, and it was very extensively employed in the latter part of the last and beginning of this cen- tury. Phthisis. — Fifty years ago the rem- edy — like pretty nearly everything else at some time during its therapeutic life — was regarded as a panacea for phthisis; it was even declared that by means of fox-glove it was as possible to arrest pul- monary inflammation with as much cer- tainty as an intermittent could be by means of cinchona or cinchonal deriva- tives. It is now, however, very rationally rejected as a cure, and merits only to be regarded as one of the many means oc- casionally useful in this malady, and which may sometimes assist more im- portant measures. In hsemoptysis, as in other hemorrhages, it is sometimes of great service. Pneumonia. — In pneumonia, how- ever, digitalis is often distinctively of the utmost value, particularly in main- taining the heart's action where there is adynamia, and for the promotion of the excretion of waste through the kidneys. Another fact not generally noted is that many cases of pneumonia result fatally, not from the pulmonary con- gestion, but from urtemic poisoning; this fact is entirely lost sight of because the attention of the practitioner is gen- erally absorbed by the primary lesion. (Sajous.) Series of eight hundred and twenty-five cases of pneumonia treated with infusion of digitalis: — B Digitalis-leaves, GO to 00 grains. Water, 52 drachms. Simple syrup, 12 drachma. — M. A tablespoonful every half-hour. This continued for two or three days aborts the disease and reduces the mortality to 2.00 per cent. Petrosco (Trans. XI In- ternat. Med. Cong., '94). [lluchard states that Roumanian digi- talis may possess properties varying greatly from that of other countries. Ed.] DIGITALIS. THERAPEUTICS. 481 The effect on the pulse and tempera- ture is slight, and, in view of the danger- ous nature of the remedy, it is not worth the risk. Lowenthal (Centralb. f. d. Gesara. Therap., '94). Tlie remedy imr excellence. Recoveries will and do occur in greater numbers when treated by large and persistent doses of digitalis. Paulison (Med. Age, Sept. 10, '94). Seventy-four cases of croupous and thirty-four of lobar pneumonia treated with large doses of digitalis most sat- isfactorily. Only one death: that from lobar pneumonia. Fickl (Wiener med. Woch.; Med. Age, Oct. 10, '94). Twenty-one adults and thirteen chil- dren suffering from cataiThal pneumonia treated with large doses of strong in- fusion of digitalis. The adults bore the doses well, but the children frequently exhibited evidence of gastro-intestinal disturbance. Favorable results in eighteen cases. Ordinary or small doses of digitalis have no influence upon the pulse or upon the progress of acute pulmonary disease. Strong infusions are harmless, and have very favorable influence upon the process of the disease, and may even cut it short if adminis- tered at the onset. Contra-indicated in children of one year and under, and in old people. Bloch (Wratsch, Nos. 1.5, IG, '94). Often of great value in various acute diseases, such as adynamic pneumonia and adynamic fevers, by maintaining the heart's action. It can have no effect upon the diseases themselves, but may help most opportunely to sustain the heart during a crisis or a period of strain upon it. H. C. Wood ("Princ. and Prac. of Therap.," '94). In congestion of the lungs with high fever it is often a valuable remedy in relieving venous stasis. In the second stage of pneumonia it is of the greatest importance, being of use here to stimu- late the contractile force of the cardiac muscle when the intraventricular press- ure becomes stronger than the unaided muscle can resist, and dil.itation is im- minent, if not already begun. The main indication for the drug is the increase in intensity of the second pulmonic sound. Butler ("Text-book of Mat. Med., Therap., and Pharm.," '9G). If the patient is strong, under 40, with no concomitant organic disease, prefer- ence must be given to the treatment by baths; under opposite conditions, espe- cially when the heart is feeble, digitalis should be given in doses of 45 and 85 grains of the powdered leaves a day, ex- hibiting it every two hours infused in water with the addition of rum and syrup of orange-peel. Slight vomiting and vertigo are not contra-indications, but the treatment must be continued till the pulse becomes abnormally slow or irregular. It is doubtful whether the enormous doses given by Petrescu are free from risk, and whether the artificial lowering of temperature by them is of real value. The maximum dose should not exceed 45 grains daily of the powdered leaves. Earth (La Sem. Mfd., July 22, '96). Pleurisy. — That digitalis may be a remedy of value in pleurisy where there is effusion, goes without saying, but some believe it is indicated at even an earlier period, on the theory that it combats hyperremia. This, after all, is only an indorsement of the practices of Sir Thomas Watson, Aitken, and Xie- meyer, who all held that the drug was especially adapted to the pre-exudative stage; and, even a quarter of a century back, the view that the drug is anti- phlogistic and adenagic had by no means become obsolete. ExornTHALMic Goitre. — Disritalis has also been employed in exophthalmic goitre occasionally with considerable suc- cess. Cases of exophthalmic goitre in young subjects, purely functional in character, have been cured by digitalein; and the cardiac irregularities and dilatation of the cervical vessels ameliorated even in incurable oases. Cawasjce ("Prac. Vade Mec.," Bombay, '91). In exophthalmic goitre it sometimes quiets the heart and lessens the pulse- 4S2 DIGITALIS. THERAPEUTICS. rate. Stevens ("Manual of Therap.," •94). Digitalis occasionally proves efficient as a heart-tonic In exophthalmic goitre. Biddle ("JJat. Med. and Therap.," '95). Patients with Graves's disease may improve under a long course of the drug, but generally this treatment fails. Hale White, Lond. ("Mat. . Med., Pharm., and Therap.," '95). Alcoholisii and Deliriuii Tke- MEXS. — Enormous doses of digitalis are often tolerated by alcoholics, and espe- cially those suffering with delirium tre- mens, probably "because the heart has by long habit become very much be- numbed to the use of stimulants." Digitalis is wonderfully effective, par- ticularly where there is low arterial pressure. Is undoubtedly less serviceable in delirium tremens characterized by high arterial tension. Butler ("Text- book of Mat. Med., Therap., and Pharm.," '96). Seventy cases were treated by the late Mt. Jones, of Jersey, without the pro- duction of any alarming symptoms; but other observers were not so fortunate, and in two instances the patients fell back dead, although up to that moment there had been nothing to indicate serious danger. It must be remembered that, if a patient dies suddenly when taking digitalis, the death is always at- tributed to the treatment; whereas it any other drug were given the result would probably be attributed to the disease. Murrell ("Manual of Mat. Med. and Therap.," '90). The following conclusions appear to be established: That digitalis may be given in large doses in delirium tremens witliout danger. That it very often does good, producing speedily, in most cases, refreshing, quiet sleep, and even when it fails it will generally calm undue ex- citement. Tliat some cases appear to bo uninfluenced by the dnig, tliough there yet remains to be ascertained the forms of the disease that are most amenable thereto. Under this treatment some severe asthenic cases, in which, owing to the great prostration present, death ' seemed imminent, have rallied astonish- ingly, and ultimately recovered; the evidence of this is too strong to be dis- puted. Under the influence of digitalis the weak, rapid, and fluttering pulse has grown steady and strong, the skin has become comfortably moist and warm, and, simultaneous!}' with the improve- ment in the circulation and state of the skin, the general condition of the patient has improved. On the other hand, personal experience in many instances has evidenced that sthenic forms of the disease are also amenable to the drug. Ringer and Sainsbury ("Hand-book of Therap.," '97). As AN Anapheodisiac. — It has been remarked that the drug is held to be anaphrodisiac; but it is likewise ac- credited with aphrodisiac properties. If the supposition is true that digitalis has a direct affinity for the genital plexus, it may act either way according to dose and method of administration; it may also, in the same way, render the tissues involved either anaemic or hyperaemic. Hence it has been used in spermator- rhoea and gonorrhosa, for its effect on the minute blood-vessels of the tissues and its supposed anaphrodisiac proper- ties. It is a serviceable anaphrodisiac in spermatorrhoea, in conjunction with cold bathing of genitals. Foster ("Prao. Therap.," vol. i, '90). Few remedies arc of more avail in arresting spermatorrhoea than digitalis in 1-drachm or 2-drachm doses of the infusion, twice or thrice daily. Ringer and Sainsbury ("Hand-book of Therap.," '97). Febrile Maladies. — Every few years there appears to be an attempt to rehabilitate digitalis as an antithermic and antipyretic, and a wonderful amount of evidence favorable thereto is elab- orated. The general application of the drug in this direction has been attended with many fatalities, and many more have occurred that have never found DILATATION OF THE HEART. VARIETIES. SYMPTOMS. 483 record, owing to the ignorance of tlie prescriber and friends of the patient. The writer saw, during one summer., three fatalities that could be traced directly to the maladministration of digitalis given as an antipyretic in mild cases of intermittent and remittent fever. In typhus and typhoid the agent has been most lauded, but all the evi- dence adduced in its favor will not ex- cuse the practitioner who employs em- pirically only. Hernia. — The writers of the early part of the century were wont to recom- mend the use of this drug in very large doses for the reduction of incarcerated hernia. Thirty years ago appeared in the Lancet, London, a statement that if suppuration of a gland have begun, digi- talis would prevent the formation of ab- scess. This is undoubtedly true in many instances, owing to promotion of in- creased absorption and elimination. G. Aechie Stockwell, New York. DILATATION OF THE HEAET. Definition. — Increase in the size of the lieart, due to enlargement of one or more of its cavities. Clinically, "dilatation" is applied to an enlarged, but failing, heart displaying the phenomena of "ruptured •compensation." Varieties. — "Simple" dilatation is the term used to denote that condition in which the walls of the heart remain of comparatively normal thickness. Inas- much, however, as the cavities, and con- sequently their walls, are more extensive than normal, simple dilatation is asso- ciated with a certain amount of hyper- trophy. Dilatation is 'liypertrophic" when the heart-walls are thicker than normal. Another name is "active" dila- tation; and viewed from the opposite fitand-point it becomes "eccentric hyper- trophy." In "atrophic," or "passive," dilatation the walls are thinner than normal. Most cases of dilatation are essentially chronic in their development and pro- gress. Some, however, are acute. Symptoms. — Usually the earliest indi- cation to the patient of his trouble is shortness of breath. This at first is ap- parent only upon exertion, but in well- developed cases it becomes a source of great suffering. Hardly more than one word can be uttered without a pause for breath; and sleep, if obtained at all, is possible only in the vertical position (orthopncea). The ordinary automatic respiration has sometimes to be supple- mented by voluntary efforts; so that when sleep does come the dyspnoea be- comes aggravated and soon wakes the patient. Another early symptom is palpitation with a sense of discomfort or oppression in the cardiac region. It is singular that the powerful heave of an hypertropliied heart does not seem to obtrude itself upon the consciousness of the patient so much as the feeble flutter of dilatation. There may also be a cough, with white, frothy, serous expectoration. The poor circulation in the brain is evidenced by more or less mental slowness and easy fatigue, with impaired memory, despond- ency, ill-temper, and attacks of faintness. In the digestive tract the passive conges- tion of the stomach is evidenced by fer- mentation, heaviness, nausea, and even vomiting. The bowels are usually slug- gish, and the urine is scanty and high- colored, with a deposit of urates. In mild degrees of dilatation the com- plexion is pale, in more advanced cases dusky or cyanotic with blue lips and finger-nails. The extremities are apt to be cold to the touch, and the sluggish- ness of the capillary circulation is illus- 484 DILATATION OF THE HEART. SYMPTOMS. trated by the slow return of color to any point of the surface after firm pressiire: the shape of the examiner's hand is, as it were, stenciled upon the cyanotic sur- face. The labored breathing is noticed even while the patient is at rest, but becomes striking upon the least exertion. CEdema invades first the ankles, thence creeps upward to the thighs and pu- denda, and finally invades even the face and arms. Ascites and hydrothorax are often present. It is not unusual to find a considerable amount of fluid in one side of the chest, while the other pre- sents merely the signs of oedema. The eyes are somewhat prominent and glassy. Frequently the liver is much enlarged, reaching even to the level of the navel. This change in its size may be more or less obscured by the ascites present, but in that case can often be demonstrated by a quick, though gentle, pressure of the fingers inward (ballottement). In some cases the spleen is also found to be en- larged. Cardiac dilatation, to a moderate ex- tent, is far from uncommon in early life; indeed, in childhood the heart may be said to dilate with especial ease. The dilatation may be found out apart from any valvular affection; it is due to blood-pressure in a flabby, ill-nourished, or degenerated heart, and may occur without there being any resistance to the passage of blood from the heart. Acute infections, such as broncho-pneu- monia, diphtheria, and acute rheuma- tism are particularly liable to cause this. In any such ca.se of acute disease where the dilatation is rapid, a recumbent posi- tion should be enforced, and on no pre- tense should the patient be allowed to lift even his head from the pillow. The diet should be regulated so that those foods that tend to ferment and fill the stomach with wind should be forbidden; baked apples, grapes, oranges, and acid fruits arc to be avoided. The patient Bhould be fed with milk, custards, strong soups, yelk of egg, and rusk. In the matter of drugs, if the case be a rheu- matic one, and sodium salicylate being taken, it is well to combine with it 5 to 10 grains of iron animonio-eitrate. Strychnine is of great avlue, and iron perchloride with solution of strychnine, given in full doses well diluted with aerated water, is recommended. Eustace Smith (Practitioner; Amer. Jour. Med. Sci., June, 1902). The pulse is of great importance both in regard to diagnosis and prognosis. It is apt to be frequent, ill-sustained, and irregular in both force and rhythm. The number of radial pulsations may be con- siderably less than the number of heart- beats as coimted with the stethoscope. The pulse-wave is apt to be small, but in cases where previous high tension, as in arteriosclerosis, has dilated the periph- eral arteries, the wave may be of con- siderable volume. Any approach to ten- sion in the arteries is of favorable import The phenomenon known as bigeminal pulse is quite frequent in cases of dilata- tion. Often the second and weaker of these twin cardiac impulses fails to reach the radius in perceptible strength. In- spection of the cardiac region shows no such bulging as may be present in cases of hypertrophy, except when the pre- cedent hypertrophy has left its traces behind it. It may be difficult to locate the apex-beat by the eye, or the impulse may seem to be diffuse and not to im- pinge upon exactly the same point with every beat. Over other portions of the heart than the apex the intercostal spaces may some- times be seen to protrude and recede with the action of the heart, and sometimes, an extensive wavy motion may be ob- served over the cardiac area. Wlien the right ventricle is dilated, there is more than a usual amount of impulse in the epigastrium below and to the right of the xiphoid cartilage. DILATATION OF THE HEAliT. DIAGNOSIS. 485 Upon palpation the heart-beat is found not to be of a strong and heaving char- acter, but feeble and resembling a quick tapping or slapping of the chest, some- times with more or less of a tremulous sensation imparted to the hand. Even when the eye has detected the apex-beat, the hand may not be able to distinguish it. The most satisfactory mode of prac- ticing palpation is by resting the whole hand, as lightly as possible, over the prfficordium, and then testing the im- pressions thus received by firmer pressure and by digital touch. Percussion shows an increase in the area of cardiac dullness varying some- what according to the portion or portions of the heart mainly dilated. Increase in the size of the right ventricle makes the heart broader than normal, but not much longer. The right limit of dullness may, in such a case, reach or even extend be- yond the right nipple. Enlargement of the right auricle is associated with in- crease of dullness at the right edge of the sternum, corresponding to the second and third intercostal spaces. The dilated left ventricle presents an area of cardiac dullness not much wider toward the right than normal, but extending do\\'nward to the seventh or eighth intercostal space, and perhaps an inch or two to the left of the normal position of the apex. By means of auscultation we maj', in the first place, be able more exactly to locate the position of the apex-beat than by either inspection or palpation, assum- ing that it corresponds to that point where the first sound of the heart is loud- est. The first sound of the heart in cases of dilatation may be louder than normal, but it is devoid of muscular quality, be- ing short and valvular; that is, closely resembling the normal second sound of the heart. It is heard with more dis- tinctness in the aortic area than is the first sound of the hypertrophied heart. Frequently there is also heard a systolic murmur at the apex, due to regurgita- tion through the mitral valve or tricus- pid, because the auriculo-ventricular opening is dilated as well as the ven- tricle, and consequently has become too large for the valve, even though normal, to close it efficiently (relative insuf- ficiency). The second sounds at the base of the heart are of variable character in diff'erent cases. If they are tolerably sharp and distinct they are somewhat reassuring, as indicating that the ven- tricles still possess muscular power. Another important point (W. II. and J. F. H. Broadbent) is the length of the pause between the first and second sounds of the heart as compared with the pause separating one cardiac cycle from another. If the first and second sounds are separated by a shorter interval than in health, we must infer that the dilated ventricles are able to make only an in- effective effort at systole, while, if there is a longer pause between the first and second sounds of the heart, it is evident that the cardiac muscle still possesses sufficient vigor to make a prolonged ef- fort to overcome the obstacles which it meets in propelling the blood-current. 'Wlien tricuspid regurgitation exists, the veins in the neck are dark and turgid. Their valves show like knots. Often act- ual pulsation in them may be demon- strated, especially if the patient takes a horizontal position. Pressure upon the congested liver magnifies the engorge- ment of the jugulars. Diagnosis. — From pure hypertrophy dilatation can be clearly distinguished by the general aspect of the patient, and the evidences of imperfect and failing circu- lation already detailed. In both condi- tions the area of cardiac dullness is in- creased, but in dilatation we do not ob- 486 DILATATION OF THE HEART. DIAGNOSIS. serve the strong heaving impulse of hy- pertrophy. In general, it may be said that the two are opposites. Hypertrophy is an exaggeration of the normal state, while dilatation is a condition of weak- ness and failure. The first sound of the hypertrophied heart at the apex may not be so loud or distinct as in dilatation, being low and muffled, and, as already stated, it may be inaudible at the base; but there is present in it a muscular qualitj', dis- tinguishable in a less degree over the apex of a normal heart, and not heard in cases of dilatation. The hypertrophied heart must at last, however, enter into the state of dilata- tion, — unless its owner is the victim of intercurrent disease, — and the important practical question for diagnosis in most cases is to determine what degree of de- terioration has already been reached and how much longer the circulation can be maintained. Very valuable information in doubtful cases with regard to the integrity or otherwise of an enlarged heart may be obtained by causing the subject under examination to make somewhat brisk muscular exertion, as by ascending and descending a flight of stairs or by hop- ping six or eight yards upon one foot. The degenerated heart will become unnaturally accelerated and irregular, while a well-nourished heart will act even better than before. In certain cases retraction of the lung, 83 in chronic phthisis, leaves a compara- tively-normal heart more exposed than in health and might occasion a mistake of the condition for one of dilatation. Factors in this diagnosis would be the history of the case, the signs of pulmo- nary disease, the absence of venous stasis in other parts of the body, and the fact that the border of the lung near the heart did not extend inward over the cardiac area on full inspiration, as under normal conditions it should. Mediastinal tumors may cause dullness in the cardiac region, but they are apt to extend upward and to the right or left side; and the heart-sounds are not audible over them in the same way as over the dilated heart. In thoracic aneu- rism we should expect to find a heaving impulse in the neighborhood of the base of the heart, with other positive signs of aneurism and without the changes in the cardiac sounds and impulse or in the general circulation seen in dilatation. A more difficult question is to dis- tinguish pericardial effusion from cardiac dilatation. In certain cases this seems to the writer almost impossible, although in the great majority of instances a defi- nite conclusion can undoubtedly be reached. In pericarditis we are more apt to have a history of an acute onset with fever and pericardial friction-sounds, and perhaps, also, knowledge of a nephritis or tuberculosis or acute pneumonia as etiological factors in the production of pericarditis. The pericardial effusions give an area of dullness somewhat more pear-shaped than that seen in dilatation of the heart, which is, more or less, quadrilateral. Pericardial effusion also raises the apex- beat upward and outward toward the third or fourth spaces in the neighbor- hood of the left nipple, and it renders the heart-sounds less distinctly audible than in dilatation. It may also cause a paradoxical pulse. Yet, in case of val- vular heart disease with a fresh attack of rheumatism, a recent pcricarditic fric- tion-sound, and evident failure of com- pensation, it may be very difficult to determine whether the increased area of dullness on the right side of the sternum DILATATION OF THE HEART. ETIOLOGY. 487 is referable to pericardial effusion or to dilatation of the right ventricle. In the cases already spoken of there has been a question of mistaking the en- larged area of dullness in the cardiac region due to other causes for a dilated heart. There is a contrary danger in cases of emphysema that a dilated heart may not be recognized because of un- natural pulmonary resonance encroach- ing upon the true cardiac area. Here we may be saved from error by the his- tory of chronic bronchitis, and of al- ready-established and slowly-increasing dyspnoea, as well as by the characteristic pulmonary signs. Etiology. — Increase in the cavities of the heart must be due either to abnormal weakness of their walls or excessive labor in the propulsion of the blood-current. Among obstacles to the circulation should be enumerated valvular disease, arteriosclerosis, chronic interstitial ne- phritis, atheroma, and congenital nar- rowness of the aorta. Contrary to what might be presupposed, thoracic aneu- rism does not cause change in the heart- walls, unless associated with aortic re- gurgitations. Pericardial adhesions may cause dilatation of the heart, more es- pecially when the outer surface of the pericardium is fastened to the chest-wall or diaphragm. Exophthalmic goitre and tachycardia cause cardiac dilatation, as may also ex- cesses in tobacco and venery, great anxi- ety and despondency, loukn?mia, and chlorosis. Causes in 300 cases: Avtcriosclerosia in 50 per cent.; chronic nephritis in 13.4 per cent.; valvular lesions in 12.4 per cent.; adhesions in the pericardium in 7.0 per cent.; excessive muscular work in 3.8 per cent.; tumors in 1.9 ppr cent.; aneurisms in O.O.i per cent. Ladeur (Jlontrcnl Med. Jour.. Jfay, 'O.'i). Principal causes, other than disease of the valves, myocardium, and pericar- dium: 1. Organic changes in arterial system. 2. Overfilling of circulation. 3. ' Foreign substances in the blood. 4. Causes that act on general cardiac nerv- ous system. Arteriosclerosis the most important factor. J. Stewart (Montreal j Med. Jour., Apr., '95). j Acute dilatation of the heart can I occur in acute rheumatism. Four eases I in which no valvular lesion could be ! found. The lack of resistance of the myocardium doubtless permitted the dilatation to occur. Dilatation is di- ! visible into two classes: one due to pri- mary atony of the myocardium, to be treated by digitalis; the other due to secondary atony of the myocardium, ! following vasoconstriction and arterial I tension. Huchard (Jour, des Praticiens, Apr. 27, 1901). Habitual severe and sustained physical exertion may cause cardiac dilatation, as seen in both athletes and in men follow- ing laborious occupations. Sudden dila- : tation may, indeed, ensue upon a single violent or prolonged muscular effort. In many cases of this sort it is presumable ! that the myocardium was previously in a vulnerable condition; but j'et dilata- \ tion may occur in young and apparently healthy men after mountain-climbing, and, after a period of due rest, be com- i pletely recovered from. In other cases, however, especially in persons with less elasticity of constitution, the lesion is a permanent one and progresses to a fatal termination. In ten runners, who had just reached the goal, apex seemed to have deviated to the left from two to three centime- ti'es. In one, alTectcd with aortic in- sufficiency, apex lowered and notable in- crease of prtrcordini dullness, evidently connected with dilatation of right cavi- ties. Among all the men arterial press- tu-e lowered. Mechanism seems to relate to overtaxing, general fatigue, and to se- creted toxic products. Teissier (Le Bull. Mfd., Dec. 19, '94). Excessive work thrown upon normal right ventricle presents fairly-distinctive symptom, — namely, pain, localized in the 488 DILATATION OF THE HEART. ETIOLOGY. region of the second and third left costal cartilages; usually dull, but may be acute; sense of tightness in prsecordia. In the adolescent type of dilatation in- crease of size upward and to the left, giving increased area of relative cardiac dullness in third, second, and soiuetimes first left interspaces. F. Stacey Wilson (Birmingham Med. Rev.; Sept., "94). Cycling tells primarily and distinct- ively on the heart and circulation. Ben- jamin Ward Richardson (Asclepiad, Third Quarter, '94-'95). Several subjects in which death had occurred from heart-strain. Marked dila- tation of coronary veins and their sub- epicardial branches. Microscopically, dilatation seen to extend to capillaries between individual muscle-bundles. In- termuscular connective tissue granular and cloudy. Muscle-cells showed vacuo- lar degeneration. Venous congestion and oedema of muscular bundles and con- nective tissue. Banti (Centralb. f. allg. Path. u. patli. Anat., B. 0, Isios. 14, 15, '95). Segmentary dissociation of the myo- cardium in a fatal case of strained heart. Fibre seemed to have its continuity broken at the level of the intercellular cement. Ffilex Ramond (Le Bull. Med., Dec. 8, '95). Pulse after violent use of bicycle in some cases reached 250; aften ten hours' rest, heart still accelerated: a sign of beginning insufficiency. Mendelssohn (Med. Press and Circular, Jan. 15, '9G). Study of the lesser degrees of cardiac weakness and dilatation. After fatigue the heart is in a temporarily-relaxed condition, similar to that of the skeletal muscles after severe exertion. After wrestling the heart may be temporarily dilated, and, as the pulse indicates, may contract with much diminished force. The temporary and physiological relaxed condition of the organ merges by inter- mediate dcgrccB into one of actual dila- tation. Clinical observations indicating three phases of patliological relaxation of the heart; — 1. A premonitory stage characterized by palpitation, excitability of the heart's action, feeling of fatigue, and slight an.tiety. Cases of this kind should not be regarded as merely nervous. As etio- logical factors the following are men- tioned: Rapid growth at puberty, sex- ual excesses and masturbation, physical and mental overwork, mental troubles, anaemia, alcohol and nicotine, fatty in- filtration, previous illnesses, and prema- ture old age. 2. The first stage of actual relaxation. This is divided into an acute, a subacute, and an intermittent form; such cases are often labeled as cardiac neui-asthenia. 3. This class embraces the ordinary cases of actual dilatation, on which so much has been written. The early stages should be especially sought for. The early stages of cardiac dilatation should be recognized, just as much as the early stages of pulmonary tuberculosis, so that the condition may be opposed in time. Concordance with Gerhardt and Friintzel that palpation is more important than percussion for esti- mating the size of a relaxed heart. One must feel in the intercostal spaces for the left ventricle several times and with the patient in different positions, but especially in the leaning-forward posi- tion made use of by Gumprecht. Wliit- wicki and Seeligmtiller have observed a marked difference in respiration accord- ingly as the patient lies on his left or his right side. This nuiy bo an impor- tant symptom of dilatation of the left ventricle. In one case was noted on re- peated occasions an increase of twelve to twenty inspirations in the minute when the patient turned from his right on to his left side. L. Fcilchcnfeld (Brit. Med, Jour., from Berl. kliu. Woch., Feb. 28, '98). Case in a bicyclist who had been in the habit of taking prolonged rides and who had accompliahed several century-runs. Marked hypertrophy and dilatation of the heart, the latter being predominant. In addition a systolic murmur was audi- ble over the cardiac area, with its great- est intensity at the apex. The patient readily becomes dyspnceic; the heart-beat is ordinorily 38 to 40, but under the induence of the slightest excitement or exertion it increases to 80 or 90. J. M. Taylor (Phila. Med, Jour,, Apr. 10, '08). Active dilatation of the heart, or DILATATION OF THE HEART. ETIOLOGY. 489 hyperdiastole, is frequently met with. Normally the heart-musele dilates act- ively within certain limits in order to receive tlie incoming blood-stream. Under some circumstances this hyper- diastole is increased beyond the normal. It then amounts to an active dilatation of the heart. The conditions that cause this may be nervous, or alteration in the blood, but particularly those condi- tions in which, as in anaemia, there is a demand by tlie tissues for a larger quan- tity of blood. This demand cannot be met by merely increasing the number of pulsations, as the blood would not re- main sufficiently long in contact with the tissues. It can be met only by in- creasing the amount of blood driven out at each stroke. Hyperdiastole may be seen under physiological circumstances at times, as in normal persons, after climbing mountains. It is often seen after hot baths, during digestion, and, at times, during pregnancy. H. Herz (Deutsche med. Woch., Feb. 22, 1900). Weakness and dilatation of the heart due to chronic changes in the myocar- dium is caused by various types of chronic nutritional diseases, and is of frequent occurrence in such affections. Microscopical changes may not be ap- parent, or we may observe interstitial myocarditis, or fatty, granular, or pig- mentary degeneration. We cannot ex- pect a normal and naturally acting heart in a chi-onically diseased and de- bilitated body. Perfect metabolism and normal innervation are essential to pre- serve the heart miiscle in its normal histological condition. Dilat;vtion is caused by overstrain of the cardiac muscle, and the amount of stress which the cardiac muscle can stand is rela- tive, depending entirely upon its con- dition, this depending in turn upon the general body condition. Slight grades of dilatation occur in all the severer types of antemia and are conmion in chronic gastro-intestinal disorders. G. W. McCaskcy (Proc. Amer. Med. As- soc. Amcr. jNlcd.. May 10. 1!)03). Other causes are acute nephritis, as after scarlet fever, rheumatic pericarditis and myocarditis, pneumonia, and ty- phoid fever. Influenza certainly may precipitate dilatation, if it does not act- ually cause it. Detective development of thorax im- portant in the etiology of pseudohyper- trophies of adolescence. Thorax elon- gated and constricted; heart forced downward, ape.x sometimes as low as fifth intercostal space. Huchard (La Semaine Med., Nov. 3, '94). Connection between kidney disease and cardiac hypertrophy attributed to pri- mary toxicity of the blood. De Domini- cis (Wiener med. Woch., Nov. 17 to Dec. 1, '94). Role ascribed by some authorities to ordinary growth in production of organic cardiac conditions, notably hypertrophy, cannot be demonstrated. Potain and Vaques (La Semaine Med'., Sept. 25, '95). High tension in the systemic arteries, aortic stenosis, and aortic regurgitation cause a predominant change in the left ventricle as compared with the other cavities. Results of examinations of 139 vessels of all sizes. In smaller arteries thicken- ing affecting both muscular and fibrous coats. Thickening greater in small ves- sels than in larger. With chronic granu- lar kidney hypertrophy of the muscle and of the fibrous tissue of whole arterial system connected with left side of the heart and of muscles of the heart. W. Howship Dickinson (Lancet, July 20, Aug. 3, '95). In certain graye states of cardiac dila- tation, and in advanced valvular disease, the blood-pressure as tested by Hill's instrument may be enormou.sly high: a fact accounted for by admitting that the ventricle is called upon to work at its highest pressure. Nicholson (Brit. Med. Jour., Apr. 13, 1901). In aortic regurgitation the dilatation is beneficial with certain limits. Inas- much as a certain portion of the blood pressed into the aorta with each systole is at once allowed to return to the ven- tricle, the total amount of blood pressed out with the systole must be greater than in health, or there will inevitably be a 490 DILATATION OF THE HEART. ETIOLOGY. diminution in the normal amount in the arterial system. In its final development aortic insufficiency presents dilatation of all the cavities of the heart. In case of mitral regurgitation there is also dilata- tion of the left ventricle, because a leak in the mitral valve during s3'stole over- distends the left auricle, and during dias- tole the blood rushes into the left ven- tricle imder more than normal tension, enlarging its cavity. The usual and chief effect of mitral lesions, ho'^ever, is en- largement of the right side of the heart: at first of the right ventricle, and, when it begins to fail, also of the right auricle. The right auricle seldom undergoes much hj'pertrophy; any increase in its size is apt to be a pure dilatation. Hypertrophy is never primary in a hard-working heart, whether increased labor be due to resistance from within, from without, or to nervous stimulation and augmented action. Primary dila- tation is a compensatory element. Re- sidual blood dilates the cavities, and diminishes the extent to which each fibre is called upon to contract. J. G. Adami (Montreal Med. Jour., May, '95). The stress of initial stenosis, pulmo- nary stenosis, and chronic pulmonary disease falls upon the right side of the heart. Predominant dilatation of the right ventricle makes the heart globular in shape. Temporary dilatation of the heart may occur under both physiological and pathological conditions. It cannot be explained as only apparent and ascribed to the action of respiration, for ordinary respiration docs not sensibly modify the area of the cardiac dullness, and may occur four or five times in a minute. The phenomenon may be explained by suddenly increased intracardiac pressure or by diminished tonicity of the ventric- ular wall. G. SC-e (La Mfd. Mod., June 4, '91). Reticulated condition of the myocar- dium obscn'cd in the case of a woman afflicted with mitral obstruction and re- gurgitation, who died, at the age of 40, after eighteen months of chronic asys- tole. The interstitial spaces of the myo- cardium were found to be dilated with- out signs of an inflammatory process. The authors explanation is that a chronic interstitial redema had stretched apart the nmscular fibres, and that the condition was a result of venous and lymphatic stasis. Maurice Letulle (Bull, d'e la Soc. Anat., No. 25, '93). Acute dilatation of the heart occur- ring in the course of cancrura oris. The area of cardiac dullness had rapidly ex- tended, the apex was beating an inch and a half external to the nipple, and over area there was heard for the first time a loud, blowing, systolic murmur. The principal point of interest in the case is the rapidity with which the heart dilated. When the patient came under observation it was noted that her heart was healthy and its area of per- cussion normal. In the course of the illness the apex of the heart could be seen getting carried farther and farther daily, and all at once a mitral systolic murmur developed, and the pulse be- came rapid and irregular. The heart dilated owing to malnutrition of the mj'ocardium, either from fever or from the poisoned blood, and the mitral sys- tolic murmur that developed was ady- namic rather than cndocarditic. Thomas Oliver (Edinburgh Med. Jour., Mar., '98). An examination of the minute struct- ure of the myocardium in dilatation may show either interstitial myocarditis or fatty degeneration, or there may be no change in the heart-fibres appreciable even with the microscope. In certain of these cases it would seem probable that the nervous ganglia connected with tlie heart may be at fault. In marked dilata- tion the pectinate muscles themselves are flattened into mere tendinovis cords. [The accompanying illustrations are from photographs of specimens in the Warren IMuseum in the Harvard Med- ical School, for advice and assistance in obtaining which T am indebted to the courtesy of Dr. William V. Whitney, Curator. Heuman Vickery.] DILATATION OF THE HEART. ETIOLOGY. 491 ^ Fig. 1. — Dilnteil left vciitrklc with a cardiiic aueurism at apex. Case of chrouic interstitiiU myocarditis in a man aged S+. Fig. 2. — Excessive dilatation, witli livpirir.'iiliv, i.r ilic right ventricle. Valves of piiliuonary artery united to form a smooth tlbrous diaphragm wltira small opening In the centre. Left ventricle laid open, not enlarged. Case of a boy aged 14. Cyanosis, dyspncea, sudden death. 492 DILATATION OF THE HEART. ETIOLOGY. \. Fig. 3. — View of right ventricle of s.iine lieait. Fig. 4.— Left vciitrleic ftiently dllatod, but Its walla of norimil tlilclciiess. Aorta extromaly atlicromntoiiB and cnlargi-il. Man ngi'd 44. Cardlne eyniiilonis of pain, dyspnooa and pill [iltnt Ion (Vir ii-n years. IJcatli In n Bulzure. DILATATION OF THE HEART. PROGNOSIS. 493 Prognosis. — It will be seen from what has gone before that dilatation of the heart is a condition which it is not proper to generalize when considering any individual case. The state might be said to bear the same relation to heart conditions that jaundice holds to the liver and digestive tract. Each case should, therefore, be carefully consid- ered on its own merits or demerits. The most acute transitory form of dilatation is probably that which occurs in athletes and others under great or long-continued effort. The majority of these persons, if in good health and well trained, seem to escape permanent injury. It will be found, however, that a certain important proportion of those who engage in violent and desperate competitive physical exertions, as for in- stance, a long boat-race, suffer for years thereafter from discomfort in the cardiac region, with some tendency to irregu- larity of the pulse. Those who train athletes should ap- preciate this possibility. The first de- gree of dilatation and consequent venous stasis is shown by pallor, for this reason: as the left ventricle becomes tired, blood accumulates in the right side of the heart, and the systemic veins in more than normal amount, yet not exceeding the capacity of the venous system. As a consequence of this increase of blood in the venous channels, there is less blood than normal in the arteries, caus- ing a pallor which does not advance to cyanosis until a much greater amount of blood is present in the veins. If, then, a person engaged in vigorous exer- cise changes from the ordinarj- pink flush of countenance to a decided pallor, the limit of safe exertion has been reached. Cyanosis conveys a still more imperative warning. With regard to the more common and usually slowly-developing forms of dila- tation, it should be said that there may be many degrees of the disease in dif- ferent persons. Here, too, sudden prog- ress in the wrong direction may occur, as the result of overstrain, — changing a moderate into a severe case. In gen- eral, it may be said that the patient does not often survive a well-marked condi- tion of cardiac dilatation for more than twelve or eighteen months. The factors upon which we should lay weight in determining the reserve power Fig. 5. — Dilated loft ventricle showing tiabeculie flattened nnd indistinct. Mitral valves exten- sively destroyed and covered with large vege- tations. of a dilated heart are of two kinds: ra- tional and physical. If the disease has come on in one whose habits can be greatly changed for the better, with re- gard either to overindulgence in alco- hol, tobacco, the pleasures of the table, and such like, or sorrow, anxiety, over- work, and long hours of sustained effort, then the chances are somewhat more favorable than if the subject has led a physiologically blameless life. The judiciousness or unsuitableness of the treatment heretofore adopted should also 494 DILATATION OF THE HEART. TEEATMEKT. be considered. And those who have previously undergone one or two attacks of cardiac failure are to be regarded in a more dangerous condition than dur- ing their previous illnesses. Irregularity in the pulse is not neces- sarily of evil import, but a great fre- quency of the pulse-rate is discouraging. Of course, any degree of vigor in the cardiac impulse is a welcome discovery, as is also a sharp and decided quality in the second sounds at the base of the heart. The case may be considerably affected in its course by our ability to obtain for the patient a fair degree of sleep and maintain a sufficient mitrition of the body. It is oftener possible to produce a cer- tain degree of improvement than to maintain it, to say nothing of complet- ing the recovery. A fatal termination may be preceded by attacks of syncope, often most alarm- ing; but death is more apt to come at the end of a comatose condition than with extreme suddenness. Embolism and thrombosis may also prove terminal factors. Prognosis in acute cardiac inflamma- tion of a severe type is mucli worse in childhood than in later life. There are three reasons for this: (1) the frequency with which both the endocardium and pericardium are involved, (2) the great tendenoj' to acute dilatation, and (3) the liability of these attacks to be compli- cated with pneumonia. Holt (Archives of Pediatrics, Dec, '99). Treatment. — Absolute rest in bed is very desirable if the patient is able to enjoy it. In many cases, however, the sufferer cannot assume the horizontal position, but is obliged to sit either propped up in bed or in a chair where he may bend his knees. For such un- fortunates, sleep is often best obtained by providing them with a shelf or rest in front of them at about the level of the elbows, on which they may lean, bending forward. There are special tables made with a leaf reaching over the bed. In primary weakness and dilatation of the heart which develop chiefly in anaemic and scrofulous children, they should he taken away from school at once, kept absolutely quiet in fresh air (preferably at the sea-side), and given the best possible diet suitable for their age and digestive power. Martins (Con- gress of Inter. Med., Carlsbad, Apr. 11 to 14, ■99). The diet is of nearly equal importance with bodily rest. It should be bland, easily digested, and given in small amounts at intervals of two or tliree hours. Some cases have seemed to do well on a purely-milk diet, particularly such as have suffered from high arterial tension. In most, however, a vai'iety of rather concentrated, but simple, viands is preferable. Thus we may allow eggs, fowl, underdone beef or mutton, beef- juice, and gruels made with one-half milk and one-half water. Alcohol as a beverage or long-continued tonic is use- less and harmful. It should be reserved for emergencies, imless, indeed, the pa- tient has become so accustomed to it (hat a small amount of whisky or dry wine is almost necessary to stimvilate the appetite and digestion. It is the view of some that habitual alcoholic stimula- tion is more desirable in old age than in earlier life; but the writer's experience has satisfied him that, in the condi- tion under consideration, great caution should always be used in regulating the administration of alcohol. Constipation and flatulence interfere with abdominal respiration and impede the venous circulation. Laxatives are consequently of great value, and more especially hydragogic cathartics. En- DILATATION OF THE HEAliT. TREATMENT. 495 largement of the liver increases the ad- visabilitj' of their employment. In suit- able cases the relief from a purge is al- most magical. It seems to produce the same mechanical effect that venesection would without the loss of strength which the latter measure involves. The fa- vorite drug is mercury, either in the form of blue mass or the mild chloride. This may be followed the next morning by a dose of sulphate of magnesium or sodium in concentrated solution. It is said that the advantage of mercury over other ^cathartics is that it not only de- pletes the veins, but dilates the capilla- ries, and thus lessens the obstruction which the weakened heart has to over- come. Another efficient and not very unpleasant remedy for the same purpose is composed of equal parts of bitartrate of potassium and compound jalap pow- der, of which the dose is 1 or 2 tea- spoonfuls. By far the best cardiac stim- ulant in this condition is digitalis. It should be given in etlicient doses. If the desired effect is not obtained with ordi- nary amounts, the remedy should be gradually pressed until either there is improvement or nausea interferes with its further administration. In some cases it may be given by means of an enema when the stomach altogether rejects it. Its well-known cumulative action should be remembered, and it should not be longer continued if nausea begins or the amount of urine diminishes. In fact, practically, one must be ready to sus- pend it about as soon as it produces a marked satisfactory effect (see Digi- talis). As substitutes for digitalis, tincture of strophanthus, caffeine, and sulphate of sparteine may be employed, their probable efficacy being in the order named. rdlet:? of cactinn. Vi.« grain each, one being given everv two hours during the day; especially efTeetive in weak and dilated heart. Kola cordial as a cardiac tonic. Campbell (Montreal Med. Jour., June, '95). Sparteine sulphate successfully used in cases of passive dilatation of the heart, especially without marked valvular le- sion. It is often necessary to perma- nently continue the drug, but no increase of dose is necessary. The dose is '/i to 1 grain every four hours. P. M. Chap- man (Birmingham Med. Rev., May, '99). In subacute dilatation of neurotic or antemic young people, where baths and exercises are not available, nutrients like malt, iron, quinine, and the alka- loids of nu.\ vomica may check the dila- tation and restore the heart's tone. In general, strychnine or brucine, in '/«■ to 'Ao-grain doses are good nerve-tonics, but, as they contract both heart and arterioles, are undesirable for contin- uous use. T. E. Satterthwaite (iledical News, Dec. 28, 1901). Strychnine is often of great value and may be combined with any of these or given independently. Iron is useful for its beneficial effect upon the nutrition of the heart-wall. Quinine and arsenic are advised in certain cases. It is hardly safe to give the latter to subjects in whom fatty degeneration is suspected. On the other hand, arsenic sometimes ap- pears particularly efficient in cases where there is cardiac pain. Minor forms of cardiac dilatation found in anfcmic girls just past the age of puberty. They sutler from menor- rhagia, constipation, and flatulence. In these cases the action is, as a rule, rapid, and the first sound is exaggerated and seemingly irritable. Best results come from strychnine and digitalis in moder- ate doses for a week or two, to be fol- lowed by a prolonged course of iron. Beverly Robinson (Amer. Jour. Med. Sci., Aug., 1900). Massage may do good in two ways, both by promoting general nutrition and by assisting in the propulsion of the blood. The Schott method of treat- 496 DILATATION OF THE HEART. TREATMENT. ment may be of advantage in less-alarm- ing cases where there yet remains some muscular integrity in the heart. Oertel's method of treatment is suitable in so far as the amount of liquid ingested may often be limited to advantage, but un- suitable with regard to the forced mus- cular effort he advised. ■ Climbing is more useful for obesity with fatty over- growth of the heart than for conditions of cardiac dilatation. Accumulations of fluid in the abdominal or thoracic cavi- ties should be withdrawn. It is some- times surprising how much benefit will follow the removal of twelve or sixteen ounces of water from the chest or a few quarts from the abdomen. In well-marked cyanosis with consid- erable enlargement of the liver half a dozen leeches may give relief. They may be applied directly over the liver and the subsequent bleeding should be encouraged by warm, wet compresses. Blood-letting is a very important remedy when the heart is dilated and there are passive congestions and dropsy. It is especially valuable in dilatation of the right heart when there is still considerable tension. Venesec- tion is not to be performed in the very young or old. Leeches to the epigas- trium may be employed when venesec- tion would be too great a shock. The amount of blood to be withdrawn de- pends upon the plethora of the patient and the eflect noticed. Allyn (Univer- sity Medical Magazine, Dec, '99). In many bad eases of dilatation of the right heart, with cyanosis and orthop- noea, when nothing but a large vene- section appears to hold out a promise, one, two, or three doses each of 10 or 12 grains of digitalis, given at intervals of three or five hours, will contract the heart and restore pulmonary and gen- eral circulation; on the other hand, in chronic conditions of weak heart, of either muscular or nervous origin, or of iniiullicicnt action caused by pulmonary obKtruction, — as in chronic broncho- pneumonia or in tuberculous infiltra- tion, — small doses of digitalis, that is, from 4 to 6 grains daily, or its equiv- alent, may be given for weeks and months and even years without any hesitation. Such doses may be ordered while the patient is not expected to be seen for weeks or months. In most per- sonal cases prescribed either from four to six doses daily of Squibb's or any other good fluid extract or the solid extract of the "Pharmacopceia" in the shape of pills, 1 '/. grains (0.1 gramme) daUy, usually Vj grain (0.03 gramme) three times a day, almost always in pills, rarely by itself, often in combina- tion with sparteine, or strychnine, or arsenic or other drugs, as the case may require. Patients who take digitalis in this way do not show a cumulative ef- fect, nor are they getting accustomed to it to such an extent as to lose the benefit of its action. The indications for the use of digitalis are the insufficiency of the heart-muscle and the incompetency of the mitral valve. Chronic myocarditis is no con- tra-indication. Large doses may over- exert the inflamed muscle; that is why digitalis in large doses is very badly borne in acute myocarditis; small doses are often serviceable when the flrst onset is passed. Aortic insufficiency has been declared a contraindication to digitalis by some, an indication by oth- ers. It is certain that these observers had difl'crcnt cases to deal with. Aortic insufficiency, when incipient or moderate, is easily compensated, gives no uneasi- ness to the patient, is not complained of, and is seldom observed when recent. This is the time when such doses of digitalis continued a long time prove of permanent service. Only those, how- ever, can be thus benefited whose cases are recognized early, cither accidentally or through careful self-observation by th<- patient. When, however, the case is old and compensation greatly dis- turbed, with considerable peripheral venous obstruction, even digitalis will not sufflee to restore the equilibrium between the action of the heart and the cnpillary circulation of distant organs. A. .rucol.i (Medical News, Jan. 11, 1902). DILATATION OF THE HEART. DIPHTHERIA. 497 The legs in some instances are im- mensely distended with fluid. BulliE are apt to form, which burst spontane- ously and exude dropsical fluid. Large amounts of water may sometimes be drawn from the lower extremities through Southey's capillary trocars or by means of longitudinal scarifications. A practical objection to the latter method is the great danger of erysipelas attacking the scarified tissues. Apart from th»t, the constant dripping day and night torments the patient and soon causes more or less eczema of the skin. But the relief to the circulation is, in some instances, worth even the immense amount of trouble and the considerable risk thus entailed. For the attacks of syncope to which these patients are liable, the subcutane- ous injection of digitalis, nitroglycerin, ether, alcohol, or strychnine is neces- sary. Marked relief and apparently val- uable stimulation are sometimes ob- tained by the inhalation of oxygen-gas, which has once or twice seemed to the writer actually life-saving in its efficacy. In such cases, however, a fatal termina- tion is merely delayed, not absolutely prevented. Herman Vickert, Boston. DILATATION OF THE STOMACH. See STOMAcn, Disorders of. DIPHTHERIA.— From the Greek: <)i^Oi'pa, a skin or membrane. Definition. — Diphtheria is an acute infectious and contagious disease pro- duced by the presence and development of the Klebs-Loeffler bacillus. As it occurs in man, it is usually characterized by the presence of false membranes upon the surfaces primarily attacked, espe- cially the mucous membranes of the nose, pharynx, larynx, or trachea. There can no longer be any question of the specific relation between the great ma- jority of cases of the disease known since the time of Bretonneau as diphtheria and the bacillus with which Klebs and Loeffler have identified their names. The bacillus is regularly obtained in cultures from afFected throats; it can readily be isolated; and when pure cult- ures are injected in animals they repro- duce the essential features of the disease met with in man. Welch and others, by inoculating the mucous membranes of guinea-pigs, have even succeeded in producing the false membranes so closely associated with the disease in man. All the constitutional effects and character- istic lesions, except the formation of membrane of diphtheria, have likewise been produced by the injection in ani- mals of the toxins produced by the spe- cific bacillus. In experimental diph- theria, induced either by the injection of cultures of the Klebs-LoefBer bacillus or of its toxins, the most striking feature is the production in animals of the paralyses due to nerve and muscular de- generations, such paralyses reproducing most exactly tlie phenomena so often observed in clinical diphtheria. This feature of the experimental process has so impressed itself upon those most in- terested in laboratory researches that some propose to define diphtheria as an acute infectious disease, produced by the action of the Klebs-Loeffler bacillus, and characterized by the development of nerve-degenerations. AVliile this teaching may be most in harmony with the combined evidence of clinical observation and laboratory re- search, it does not yet seem advisable to so far depart from the conceptions of diphtheria which have heretofore ob- tained. The appearance of false mem- brane has long been regarded as almost 493 DIPHTHERIA. ^'AKIETIES. diagnostic; it still belongs to the great majority of cases, and can readily be appreciated, while the nerve-degenera- tions, if they appear at all in clinical diphtheria, are met with only in the later stages of the disease, long after the question of diagnosis will have been de- termined. Varieties. — The classification of the acute inflammations affecting nose, throat, etc., has not yet reached a satis- factory stage. The distinctions based upon the presence or absence of pseudo- membranes have lost their significance. TTlaile the great majority of pseudo- membranous inflammations of these parts are due to the action of the diph- theria bacillus, a considerable number of such inflammations are produced by the action of other bacteria, especially the streptococci and staphylococci. On the other hand, the action of the diph- theria bacillus is not always attended by the production of pseudomembranes. The intensity of the local action of the bacilli varies greatly, and it has been found that this diphtheria bacillus may be the cause of simple inflammatory processes, formerly designated as catar- rhal, which present no appearance of false membranes. Moreover we find that the all-important question in any case, both with reference to prognosis and treatment, is the presence or absence of the diphtheria bacillus. We, therefore, abandon the former classification into catarrhal and pseudomembranous proc- esses and speak of: — 1. Diphtheria, or true diphtheria, in which we include all oases of acute in- flammations affecting mucous mem- branes associated with the presence of the diphtheria bacillus in sufficient number to constitute a probable causa- tive agent. Thus, if a culture from a flore throat show the presence of the diphtheria bacillus, that case is at the present time accepted as diphtheria, whether there be or not pseudomem- brane present, and no matter what other bacteria be associated in the culture with the diphtheria bacillus. It must, how- ever, be noted that the presence of the diphtheria bacillus without further clin- ical evidence does not constitute diph- theria any more than the presence of pneumococei in the mouths of healthy persons constitutes pneumonia. Following conclusions are based upon a study of 1075 cases, comprising chil- dren of all ages from one to eighteen j'ears, among whom were encountered 134 cases of clinical diphtheria and from whom were obtained 8000 cultures. Of these children, 275 were kept in absolute individual isolation, and under condi- tions admitting of the most careful over- sight, in which the chances of reinfection were reduced to the minimum. While the Klebs-LoefHer bacillus is undoubtedly present along with staphylococci and several other varieties of bacilli in every case of diphtheria, its mere presence is no guide as to its virulence or non- virulence. This bacillus, or one morpho- logically identical with it, is present in the throats in nearly one-third of all the children and possibly adults. It is found as frequently in the throats and noses of those who have never had clin- ical diphtheria as in those who have sus- tained acute attacks of the disease, but in the former is often of variant type. J. H. Adair (Northwestern Lancet, Sept. 1, '99). From a study of the throat cultures of 285 healthy individuals, 7 of which showed the presence of diphtheria bacilli, and of 190 Iiealthy boys whose throat cultures showed the presence of the Klebs-LocfTler bacilli in only 10, the fol- low ing conclusions have been drawn: 1. Diphtheria bacilli are seldom found in the tliroats of those who have not been' exposed to diphtheria. 2. The bacilli are more frequently found in those who have been exposed, especially in persona living under poor hygienic conditions or DIPHTHERIA. VARIETIES. 499 in institutions. 3. The conditions of institution life which favor the growth of the bacilli in healthy throats are the living togetlier ot a large number of persons in a limited air-space. 4. Healthy individuals with virulent bacilli in their throats can spread the disease. They are just as dangerous as mild or convalescent eases of diphtheria, and ought, therefore, to be detected and isolated. 5. Cultures ought to be made among those who have been exposed to diphtheria; (a) by physicians among the members of a family who have been exposed; (6) by inspectors in the schools; (c) by the health officers under any circumstances when they think the disease is being or may be spread by such individuals. F. P. Denny (Boston Med. and Surg. Jour., Nov. 22, 1900). Not only are there definite and dis- tinct species of diphtheria bacillus, but each species has distinct subspecies and varieties with characteristics which con- tinue to persist under different condi- tions. Thus, varieties as well as spe- cies remain separate, and when grown imder similar conditions the species show no tendency to become converted the one into the other, while the varie- ties gradually change, approaching a common norm. Since in a series of ten cases of clinically typical diphtheria only one varietj' of the specifically viru- lent diphtheria bacillus was obtained from the throat of each case through- out the course of the disease, since from different parts of the same patient only one variety was isolated, and since pseudovarieties were found no more fre- quently at the end than at the begin- ning of the disease, it is safe to infer that specifically virulent bacilli do not readily, if ever, change into any form of non-virulent diphtheria bacilli in throats or noses of people during an attack of diphtheria. In a second group a number of healthy throats were ex- amined and many distinct varieties of diphtheria-like bacilli were found, all of which, however, in serial pure culture, retained their characteristics. From a third group the inference was drawn that not only does a variety of the ba- cillus retain its characteristics for some time in the same throat, but that it may be transferred to other throats without losing its individuality. Finally a number of cultures were examined which had been kept in the laboratory for years. These were freshly inocu- lated every few days, and but few changes were found in the general shape and properties of the bacilli, as com- pared with the original observation. A. W. Williams (Jour, of Med. Research, June, 1902). 2. Pseudodiphiheria, in which we in- clude all cases resembling diphtheria but not showing the presence of the diphtheria bacillus in cultures from the affected parts. Such pseudomembra- nous inflammations are commonly seen as complications of the acute infectious diseases, especially scarlet fever and measles. Cultures from such cases regu- larly show the presence of streptococci or staphylococci or both. The strepto- cocci are especially frequent. Pneumo- cocci and other bacteria have been found. The site of the diphtheritic process, whether nose, tonsils or pharj'ns, or larynx, materially affects the symptoms and course of the disease; we therefore, in our description, speak of nasal; pharyngeal, or tonsillar; and laryngeal diphtheria. In the eifort to further classify their cases some divide them upon the basis of the bacteriological findings in cultures from the throat. Thus, when the culture shows diph- theria bacilli practically alone, they designate the case as bacillary diph- theria; when cocci are present in con- siderable numbers with the diphtheria bacilli, as coccobacillary diphtheria, etc. This method would be highly satisfactory did the clinical course and outcome of the disease correspond to the bacteriological findings, but they do not. The presence of cocci in the cultures does not show tJiat they will 500 DIPHTHERIA. SYMPTOMS. play any important part in the disease, and the complications produced by their action — such as pneumonia and nephri- tis — seem to be as frequent in cases that give apparently pure cultures of the diphtheria bacillus from the throat as in those that show many cocci as well. When we have to do with a systemic in- fection with streptococci as well as the diphtheria bacilli, we speak of the cases as "mixed infections"; but the distinc- tion is based upon the clinical symptoms of the disease and not upon the results of the bacteriological examination. We find it most advantageous to divide the cases into mild, severe, or septic, accord- ing to the character of the symptoms presented. Corresponding to these three forms of diphtheria, Monti presents a classification based upon the character of the exudate in the throat: — 1. A fibrinous form in which the diph- theritic products are only placed upon the mucous membrane, not incorporated with it. Virchow, Weigert, and Cohn- heim call this the croupous form. 2. A mixed form, called also the phlegmonous form, in which the fibri- nous exudate lies deep in the tissues as well as upon the mucous membrane. A septic, or gangrenous, form, in which a fibrinous pseudomembrane is formed in the deep tissues of the mucous membrane, the process really consisting of a necrosis of the tissues and a mingling of the dead particles with the diphthe- ritic products. Similar classifications are presented by other Continental writers; but we have not yet found it of advantage to attempt to classify our cases by the local appear- ances of the throat. Certainly the dis- tinctions that Monti makes call for very nice and rather difficult discriminations. Symptoms. — These vary sulTiciently with the site of the lesions to make it of advantage to consider the local forms separately. 1. Nasal Diphtheria. — Diphtheria of the nasal cavities is, in most cases, simple extension from the fauces, or larynx. It may, however, occur as a primary affection. It is characterized by more or less complete obstruction of the nares; a thin, muco-purulent, and often bloody discharge from the nostrils; and a more or less marked toxtemia. Pseudo- membrane may be developed and may be visible through the anterior nares, but, as a rule, we see no membrane. The nasal discharge is usually very irritating and the nares become excoriated. The degree of the toxaemia varies markedly. Usually it is very moderate, the temperature is not high (100° or 101°), the prostration is not marked, and the chief danger of the cases seems to lie in an extension of the process by con- tinuity of tissue, to the pharynx or larynx, or the development of pneu- monia. The affection is often protracted, the discharge from the nose and the obstruc- tion persisting for weeks, despite careful treatment. Lennox Browne reports a total mortal- ity of G3.4 per cent, in a series of cases of diphtheria involving the nose, and at- tributes to the nasal affection more im- portance than to the laryngeal. Few writers or clinicians can agree with this opinion. In practically all the cases of the series reported other parts were in- volved besides the nares, and the mor- tality-record is a tribute to the gravity of extensive diphtheria rather than to the danger of the nasal affection alone. In infants, however, nasal diplithcria fre- quently proves fatal. It may readily be the origin of a pharyngeal or laryngeal process. It may, furthermore, be the DIPHTHERIA. SYMPTOMS. 501 means of communicating the disease to others. Primaiy diphtheria of tlie nose is dis- tinct from diphtheritic rhinitis when complicating faucial diphtheria. It usually involves both nostrils, but rarely spreads into the pharynx or larynx. It differs from the so-called "membranous" or croupous rhinitis chiefly bacteriolog- ically, but more carefully, and frequent examinations tend to show the same relation between these two as between membranous croup and laiyngeal diph- theria. The diagnosis is not difficult on a careful rhinoscopic inspection and is coiToborated by one or more bacteriolog- ical examinations. The constitutional disturbances are usually mild except during the onset, when they resemble, and are usually mistaken for, a violent coryza. Antitoxin is not usually admin- istered on account of the mildness of the disease, but to shorten its deviation and diminish the danger of infection. W. Scheppegrell (Trans. Amer. Med. Assoc, May, 1903). 2. Pharyngeal, or Tonsillar, Diphtheria. — (A) Mild Cases Without Memlrane, or Catarrhal Diphtheria. — During the prevalence of an epidemic of diphtheria, especially in institutions, a certain number of cases may be ob- served in which, without the appearance of pseudomembrane, the pharynx and tonsils become reddened and somewhat swelled, the children complain of slight soreness of the throat and have a rise in temperature, biit do not appear or feel very ill; yet cultures made from such throats show the presence of the diphtheria bacillus. Such cases we have learned to class as true diphtheria. The mildness of the affection is attributed either to the small number of bacilli present, to a diminution in the viru- lence of the bacilli, or to an increased resistance on the part of the patient. In many of these cases the nose is involved as well as the pharynx and tonsils, and there is consequently a thin, watery, irri- tating discharge from the nostrils. In the course of a few days all symptoms subside, and the bacilli disappear, or they may persist for weeks without fur- ther symptoms. Series of 20 children in which the ba- cillus was found in 6 on admission, while in the other 14 cases it was discovered at times varying from a few days to several weeks after admission. The infants in whom the bacilli were present in the mouth presented no symptoms, either general or local. These bacilli often re- mained for several weeks, and even months (in one case two and a half months), in an indolent condition, al- though in several cases they declared themselves in a virulent manner. Of the 6 children who arrived at the hos- pital with diphtheria bacilli already in the mouth, only 1 came from a family in which there had been a case of diph- theria five weeks previously; 2 came from a house infected by measles, and the remaining 3 had not been in con- tact with any eases of infectious disease. In 12 cases the bacteriological examina- tion was supplemented by inoculation of animals. The bacilli found in cases were so virulent as to cause the death of the animals in from twenty-four to forty-eight hours, while in the other 6 cases the virulence was only of medium intensity. Heubner (Jahrb. f. Kinderh., B. 43, 8.54). The bacilli derived from cultures from such cases may prove to be fully virulent, and any such case may readily be the means of communicating a severe or viru- lent type of the disease to others. The patients themselves may show al- buminuria during the course of their mild attack, or they may later develop the paralyses belonging to the severer types of diphtheria. The latter out- come is, fortunately, rare. From the catarrhal process in the throat and nose there may arise by ex- tension a diphtheritic laryngitis either catarrhal or pseudomembranous in char- 503 DIPHTHERIA. SYIIPTOJIS. acter, which may be followed by stenosis or other grave sjinptoms. (B) Mild Cases, with MembranCf of Pharyngeal, or Tonsillar, Diphtlieria. — These cases are characterized by the de- velopment of more or less pseudomem- brane upon the tonsils, fauces, or phar}-nx, and a moderate toxaemia. The onset of the trouble is marked by sore throat; a moderate fever, 100° or 102°; and a slight prostration. Fpon examin- ing the throat we usually find one or both tonsils reddened, swelled, and pre- senting upon their surfaces one or more patches of pseudomembrane. These patches may be small and difficult to distinguish from the yellow plugs seen in follicular tonsillitis. The membrane is usually firmly adherent to the under- ling tissue, and, if removed, leaves a bleeding surface. The area covered by membrane may sometimes be marked off from the surrounding tissues by a zone of congestion. The membrane is usually white-gray, or grayish-green in color, sometimes yellow, and the patches are of irregular form. It is sometimes thick and heavy, sometimes so thin as to be translucent. Over against this descrip- tion of diphtheritic membrane we might set the characters of pseudomembrane not diphtheritic, but the more painstak- ing the description, the more evident would it become that it is perfectly im- possible to distinguish one from the other by simple inspection. Nothing short of a bacteriological examination will enable us to make the distinction with certainty. The presence of the LoeHler bacillus is a sure sign that tlie accompanying pseudomembranous inflammation is diph- theritic; the bacillus of diphtheria may be present without causing symptoms of the disease; the bacillus may disappear when the symptoms cease, or may con- tinue in a virulent state for months upon the fauces of the infected person. Loeffler (Lancet, Sept. S, '94). With such appearances in the throat there is usually a distinct swelling and tenderness of the submaxillary and cer- vical lymph-nodes. The extent of membrane in the mild cases is usually limited, and there seems little tendency toward spreading; but, on the other hand, we may see cases in which tonsils, fauces, and pharynx are covered with membrane and yet the con- stitutional depression is slight. After the onset in a mild case the membrane may extend somewhat, so as to involve the fauces or pharynx; but may remain limited to the tonsils. The throat continues sore, the temperature shows some elevation, and the children feel moderately sick. In the course of three to five days the membrane begins to separate, either gradually or in masses, the throat clears up, the temperature falls, the glandular swelling subsides, and in a week or so the patient is well again. A mild diphtheria may be accom- panied by albuminuria, and may be fol- lowed by nephritis or paralysis, but, as a rule, the cause is benign and the out- come satisfactory. We must, however, be prepared at any time to see an appar- ently mild case of diphtheria change character and become a virulent infec- tion. From a mild tonsillar, or pharyn- geal, diphtheria a severe diphtheritic laryngitis may be developed. The most troublesome features of these mild cases of diphtheria is the difficulty of maintaining proper quaran- tine. If adults, the patients do not re- gard themselves sick after the first day or two, and can hardly be made to under- stand that oven when well they may be the source of grave danger to others. If the patients are children, the par- ents find it difficult to take a serious view DIPHTHERIA. SYJIPTOMS. 503 of an apparently trifling sore throat and are often unwilling to take the necessary precautions to prevent the spread of the disease. It cannot be too emphatically laid down in such cases that the clinical phenomena arc no test of the virulence of the bacteria present. From an appar- ently mild case Para obtained the most virulent bacillus he has yet met with, and employed its toxins in the produc- tion of antitoxin of unusual strength. It has likewise long been well known that an apparently mild case of diph- theria may communicate a malignant in- fection to others. The mild cases should be quarantined just as faithfully as the most severe, and should be allowed freedom only when the specific bacteria have disappeared from the throat. (C) The Severe Cases. — In these the manner of onset may be sudden, with chill, vomiting, fever, and severe sore throat, the temperature rising to 103°- 104°, and the prostration being marked, or the affection may begin as a mild case and gradually develop the severe symp- toms, the invasion being very insidious. If seen at the beginning, there may be little membrane visible in the throat, only a small patch or two upon the ton- sils, exactly similar to that described in the mild cases; the throat will, how- ever, be more reddened and the swelling more marked. The submaxillary and cervical lymph-nodes will be swelled and tender. The child locks and acts sick. The elevation of temperature may not be in keeping with the degree of consti- tutional depression, oftentimes being only 101° to 102°. As the disease de- velops, the membrane rapidly extends, until the tonsils, pharynx, uvula, and fauces are covered with a thick gray, green, or even black layer of necrotic material. If anv effort be made to re- move it the underlying tissues bleed freely. The membrane fills the rhino- pharynx, involves the nasal cavities, and may even appear in the nares. With the involvement of the nose there is seen a thin, acrid, often bloody and foul-smell- ing discharge from the nostrils. The membrane may also invade the mouth and appear upon the lips. In one case seen at the Foundling Hospital, the ex- tent of gray membrane upon the lips, cheeks, and tongue was so marked as to suggest the possibility that the child had been drinking carbolic acid. Mechan- ical removal of the membrane in such cases does no good whatever; it seems only to open up a fresh surface to the attack of the virulent bacilli, and the membrane is reproduced with almost marvelous rapidity. At any time the inflammatory process may involve the larynx, giving rise to laryngeal diph- theria, or it may involve the middle ear through the Eustachian tubes; in rare cases by extension through the lacrjTnal duct or by accidental inoculation the conjunctiva is involved. With the increase in the local process the lymph-nodes of the neck become more swelled and tender, until it seems that they will surely suppurate, but they rarely do so. The constitutional depres- sion becomes more and more marked. The pulse becomes more rapid and feeble; the strength fails steadily. Eight hundred consecutive cases of dipl\theiia observed. Less than half of the cases in which the pulsc-iate ex- ceeds 100 recover. The pulse-rate and the mortality appear to be very much in a direct ratio to each other, and recov- ery is improbable when the pulse gets above InO. Extreme slowness of the pulse is less significant; but in children bradycardia does at times presage evil. Variations of rhythm and volume occur in some 10 per cent, of all cases, and are a useful premonition of cardiac com- 504 DIPHTHERIA. SYIIPTOMS. plications. A systolic murmur at the apex of the heart is heard in about one case in ten; its significance depends en- tirely upon its cause. This is far more commonly mitral insufficiency, due either to weakness and inadequate contraction of the cardiac muscle, or to dilatation of the left ventricle, but in rare instances to an endocarditis ot diphtherial origin. Hibbard (Boston Med. and Surg. Jour., Jan. 27, Feb. o, "98). The temperature may not at any time be very high, 101° or 102°, or it may reach 103° or 105°. The swelling and tenderness of the throat render swallow- ing painful and sometimes almost im- possible. The tonsils may almost meet in the median line, the nostrils may be plugged and even respiration seriously interfered with. At times in the early days of the disease we may see fluids regurgitate through the nose, when any attempt to drink is made, and it may be difficult to determine whether the regiir- gitation is due to the obstruction of the throat by the swelled tonsils or to an early paralysis of the pharyngeal muscles. As the diphtheria advances, the urine becomes scanty and high colored, and contains albumin in some quantity; at times an acute exudative nephritis is de- veloped, with large quantities of albu- min, casts, and even blood. The onset of the complication may bring, in its train, all the symptoms of an acute ne- phritis. Examinations made for albuminuria in 279 cases of diphtheria, it being found in 131 ; rate of mortality, 50.37 per cent. No evidence of albuminuria could be discovered in 148 cases, — the rate of mor- tality here being 14.2 per cent. Cases free from albuminuria thiis afTord a more favorable prognosis. Baginsky (Archiv f. Kinderh., B. 10, H. 3-C, '93). Kcsults of examination of 1000 urines in diphtheria liy botli Eeliling's test and the phenyl liydrazin test. In 230 cases examined reaction was noted in 2r> per cent, of all cuhchj in those that recovered it was obtained in 19 per cent.; and in the fatal cases in 77 per cent. In cases without false membrane no reaction was obtained. In a second series of 96 cases a positive reaction was obtained in 33 cases by both tests. The glycosuria was often associated with albuminuria. A certain number of cases were examined before and after the injection of antitoxin, and it was found that for a few days after the injection a slight glycosuria sometimes occurred. Hibbard and Morrissey {Jour, of Exper. Med., Jan., '99). Diphtheritic albuminuria has no other relation to diphtheritic paralysis than that both complications are more prone to occur when the diphtheritic intoxica- tion is most intense. E. F. Trevelyan (Lancet, Nov. 24, 1900). The mind may remain clear through- out; but, as a rule, with the deepening of the toxaemia the patients become dull and listless. In the severest cases stu- por or delirium may be developed. Coma is rarely seen. Convulsions may occur either early or late in the disease, from the toxaemia of the diphtheria or from iirsemia. In some cases the patients die from the diphtheria toxasmia alone; but in most of the fatal cases one or the other of the complications is the direct cause of death. Most important of these is the pneumonia. Although most often seen in laryngeal cases, pneumonia is a common sequel of diphtheria, either nasal or pharyngeal. The onset of the broncho-pneumonia is usually marked by a decided rise in the temperature, a quickened respiration, and some cough. Not till the pneumonia has advanced to the consolidation of large areas do definite physical signs attest its presence. Usually we hear more or less numerous fine crackling rales over one or both chests posteriorly. Later there may be scattered areas of dullness, with brnn- DIPHTHERIA. SYMPTOMS. 505 chial voice and breathing. For evidence of the onset we must depend upon the rational rather than tiie physical signs. The development of pneumonia is al- ways a grave and often a fatal complica- tion. In but few fatal cases do we fail to find a more or less extensive involve- ment of the lungs, and in the greater number it plays an important part in the unhappy outcome. If the view at present generally held, that the complicating pneumonia is de- pendent upon the action of streptococci and not upon that of the diphtheria bacillus itself, and therefore antitoxin- can only indirectly affect its onset or its violence, be true, then the problem of further reducing the mortality of diph- theria must depend upon the solution of the prevention and treatment of this complication. At present it is of im- portance to watch for signs of its onset and to be prepared to take measures to limit its extension and enable the pa- tient to bear the attack. The most malignant eases of diphtheria die within forty-eight hours of the onset of the disease, and even in these we find more or less extensive areas of broncho-pneu- monia. Most of the fatal cases termi- nate after five or ten days, the patients being exhausted by the toxemia of the disease or the pneumonia. In the more favorable cases improve- ment usually begins about the fourth or fifth day. The change is shown in both the blood and the general condition. In the throat the membrane ceases to extend and begins to separate. The separation begins upon the edge of each patch, the separated portions forming loosened tags in the nose or throat, or the membrane may come away en masse in the form of casts of the afTected parts. The surface beneath the membrane is at first raw and bleeding, but is usu- ally quickly covered by new epithelium. On the tonsils, however, ulcers are formed, which, healing slowly, leave irregular, depressed areas of cicatricial tissue, giving to the tonsils the ex- cavated appearance so often seen after severe diphtheria. With the separation of the membrane the purulent discharge from nose and mouth gradually ceases, but a catarrhal secretion may continue for weeks afterward, such catarrhal secretion still containing virulent ba- cilli. With the change in the local condi- tion the temperature gradually falls, the pulse improves, the glandular swellings subside, the dullness or stupor disappear, and at the end of the second or third week the patient is convalescent. The patients are usually left very anoemic, and the return to health is likely to be slow. From time to time we see cases in which the formation of membrane con- tinues for two or three weeks, the course of the disease is protracted and recovery correspondingly delayed. In other cases the broncho-pneumonia persists long after the disappearance of all evidences of the diphtheria, and may either cause death from exhaustion or may slowly dissolve. 3. Cases of Mixed Infectiox, or Septic Diphtheria. — Under this head are grouped those cases in which bac- teriological investigation shows the pres- ence of the diphtheria bacillus, together with other pathogenic bacteria, usually streptococci, in some cases pneumococci, and in which these additional organisms seem to exert a definite influence upon the course of the disease. Most of these cases are fatal and in post-mortem ex- aminations systemic infection with strep- tococci or pneumococci is said to be found. The appearance of the mem- 506 DIPHTHERIA. SYMPTOMS. brane in these cases does not differ essentially from that seen in the severer forms of infection with the diphtheria bacillus alone. It may be white, yellow, gray, or oliTe colored, or, where hemor- rhages accompany the inflammatory process, more or less black. The mem- brane is usually extensive, covering the tonsDs, pharynx, fauces, and uvula. The swelling of the affected parts is usually very marked, the oedema being pro- nounced, the tonsils often so filling the throat as to preclude examination of the pharjTix and giving rise to dyspha- gia and dyspnoea. There is the same muco-purulent or bloody discharge from the nose and mouth; the nares are ob- structed and the patients often breathe only through the mouth. A peculiar sickening, sweetish foetor is character- istic. The lymphatic nodes and cellular tissues of the neck are most commonly swelled and indurated, the process in many cases leading on to suppuration and occasionally to gangrene. The press- ure upon the veins of the neck may produce congestion of the head and swelling of the face. The swelled, dusky features, with the sanious discharge from nose and mouth, is characteristic and im- pressive. The constitutional symptoms are those of a profound septicaemia. The tem- perature often runs as high as 104° or 106°, but may not be remarkable. The pulse is rapid, feeble, and compressible. With the feebleness of the pulse, the extremities may be cold and pale, in marked contrast to the dusky face. Vomiting and diarrhoea are common, and may be persistent. The urine con- tains considerable albumin and casts, and in some cases blood. The quantity may be diminished; suppression may occur and cause death from uraemia. GiJdema of feet or hands may be seen. The liver and spleen may both be en- larged. The cerebral symptoms are marked. The patients are usually dull and stupid, indiilerent to their condi- tion or surroundings, but at times they are delirious and extremely restless, tossing continually from side to side or crying out as though in pain. Broncho- pneumonia is very common and usually hastens death. At any time during the course of the disease the larynx may be involved by extension. The cases, as a rule, terminate fatally within a week, sometimes within forty-eight hours. Eapid failure in the strength of the heart marks the fatal progress of the disease, and the end may be brought about by sudden and unexpected syn- cope. If they survive the first violence of the infection, these cases are espe- cially liable to complications attributed to the pathogenic action of the strepto- cocci, such as suppuration of the cervical lymph-nodes and cellular tissues, bron- cho-pneumonia, and nephritis. Results of the examination of 234 cases of membranous angina baeterio- logically : — 1. Loefflei's bacillus was absent in 20 cases, there being present staphylococci, streptococci, pneuniococci, and bacillus coli communis. Two died, — 1 of menin- gitis. Excluding this 1, the mortality was 3.84 per cent. 2. Loelller's bacillus occurred alone in 102 cases; mortality 28,— 27.4.'> per cent. 3. Loefller's bacillus found in associa- tion with the staphylococcus pyogenes in 70 cases; mortality 25,-32.89 per cent. 4. Loedler's bacillus found with .strep- tococcus i)yogenes in 20 cases; mortality 0,-30 per cent. 5. LocHler's bacillus with streptococ- cus and pneumococcus (Frllnkel's) in 7 cases; mortality 3, — 43 per cent. 0. Loedler's bacillus with bacillus coli comuuinis found in 3 cases, all of which ended fatally. ]3e Blasi and Russo- DIPHTHEIilA. SYMPTOMS. 507 Travail (Riforma Med., Nos. 179, 180, '9G). 4. Laryngeal Diphtheria. — The clinical picture of laryngeal diphtheria does not present such variety as is seen in diphtheria of the pharj'nx and tonsils. The local effects, due to the anatomical form and structure of the larynx and its physiologic^ function, predominate over the constitutional symptoms. The mu- cous membrane of the larynx possesses but little absorptive power; so that as long as the diphtheritic process is lim- ited to the larynx the toxsemia is slight. From what has been already said it is evident that we may have laryngeal diphtheria: — 1. As a primary affection. 2. As an extension of a process be- ginning either in the nose or the throat. It may also occur: — 3. As a complication of other infec- tious diseases, especially measles or scar- let fever. In the latter relation it is less common than the pseudomembranous laryngitis produced by the action of staphylococci or streptococci (pseudo- diphtheria), and occurring as a complica- tion it presents itself in one of the two preceding ways, either primarily, or sec- ondarily to diphtheria of the nose or throat. Diphtheria of the larynx begins gradu- ally with a hoarse cough and voice, and perhaps a slight stridor with inspiration. The temperature is usually low, — 99° to 101°, — and the child does not appear very sick. The early stages are not to be clinically distinguished from acute catar- rhal laryngitis, except that the onset of the latter is usually more abrupt and the temperature higher, — 102° to 103°. The course of diphtheritic laryngitis has the following rather characteristic se- quence of symptoms: Croupy cough, croupy inspiration, aphonia, stridulous expiration, suprasternal and infrastemal recessions, restlessness and jactitation, and cyanosis. The cough becomes more and more hoarse, the voice, at first hoarse, fails steadily until the aphonia becomes complete; the stridor, at first only affecting inspiration, shows itself with expiration and becomes louder. With the increase in the local symptoms, the temperature may continue low or may mount step by step to 104° or more. At the end of the first or second day the symptoms of laryngeal stenosis become well developed. The voice is sunk to a whisper or lost altogether, the cough is very hoarse and short (tight), there is loud stridor with both inspiration and ex- piration, and every effort to fill the chest grows slower and more labored. With each inspiration there is more or less marked depression of the suprasternal, and supraclavicular spaces and the epi- gastrium. The finger-tips are blue, the lips livid, the face pale, the forehead and perhaps the whole body bathed in per- spiration as the child struggles to over- come the increasing obstruction to res- piration. The perfect clearness of mind is in marked contrast to the dullness or stupor usually seen in severe types of diphtheria elsewhere. As the agony in- creases, the child sits up, supporting the shoulders by the arms to give free play to all the accessory muscles of respira- tion, or, wild with fear, throws himself from side to side or up and down in a vain effort to shake off the tightening grip upon his larynx. It cannot be too strongly laid down that the laryngeal stenosis seen in these cases is largely the result of spasm of the laryngeal muscles excited refle.xly by the inflammator}' process and in small part the result of mechanical obstruction by membrane or the swelling and oedema that accom- pany it. Often we see fatal cases of 50S DIPHTHEKIA. COMPLICATIONS AND SEQUEL.*;. laryngeal diphtheria, in which the ste- nosis has required operative treatment, showing only a fine granular membrane, the lumen of the larynx still wide. How much swelling and oedema may disap- pear at the time of death we cannot say, but certainly membrane alone rarely obstructs the larynx. This view is strengthened by the common experience that any excitement greatly intensifies the severity of the stenosis. A child may sleep quite comfortably though breath- ing stridulously and with some labor; waken it and with the first frightened cry the larj'nx closes as though in a vise, and, unless the child be quickly quieted, operative relief will soon be re- quired. This point is dwelt upon at such length for the purpose of enforcing its consideration in treatment. Quiet will do a great deal in controlling ad- vancing stenosis. Vomiting will, for a time, relax the spasm, but in true diph- theria the stenosis rapidly returns. At any time the severity of the stenosis may relax, the symptoms all gradually subside, and the patient go on to make a good recovery, but, unless relieved by treatment, the cases usually end in death by suffocation. In such a case the cyanosis deepens, the respiration be- comes more and more labored, the vio- lent struggles for air cease, the patients sink into stupor, convulsions develop, and death soon follows. Such an outcome is most common in infants, who usually succumb in from twenty-four to forty-eight hours from the onset. In other cases the course is slower; the disease reaches its height in from two to three days and terminates within a week. Broncho-pneumonia is a common com- plication of laryngeal diphtheria. It may develop as the result of direct ex- tension of the memljrane from the larynx to the trachea and bronchi, or it may result from the inspiration of the inflammatory exudate containing patho- genic bacteria. The mode of its devel- opment cannot be clinically determined. Its presence is indicated by heightened temperature, more rapid respiration, greater cyanosis, usually numerous coarse or subcrepitant rales over both chests posteriorly, and more marked prostration. It makes the prognosis much more grave in any case and fre- quently causes death when the stenosis has been relieved by operation. It was one of the late Dr. O'Dwyer's observa- tions that, in descending diphtheria, when the membrane passed from the trachea into the median bronchi, this invasion of a new territory was marked by a rapid rise of temperature which, in turn, was soon followed by developing pneumonia. When laryngeal diphtheria develops secondarily to diphtheria of the nose or throat, or as a complication of the in- fectious diseases, the symptoms above described are superadded to those of the original affection, and the patient is all the less likely to survive. Complications and Sequelae. — Otitis media is an occasional complication of diphtlicria. It is developed by direct extension of the inflammatory process through the Eustachian tubes and be- longs to cases in which the rhino- pharynx is involved in the diphtheritic process. The middle ear ia very commonly alTeeted in diphtheria; but the onset of the invasion is free from jjronounced syinptoniH, and is mild in character throughout; it is not an extension along the Euslaoliian tube, but ia an afl'ection of tlie nuicous cavities of the car com- plicating diphtheria: one of the symp- toms of a general infection. Lommel (Archives of Otol., Apr., '!)7). DIPHTHERIA. COJIPLICATIONS AND SEQUELS. 509 In some cases the car affection is of the severest type and there is consider- able destruction of the drum-membrane. It may even result in gangrene. Pneu- monia, as already noted, is the most fre- quent and dangerous complication. It is most common in laryngeal diphtheria, but may follow any form of the disease. It is attributed to the action of the pyo- genic cocci, especially the streptococci, though Stephens and Kanthack, Wright, More, and others have demonstrated the presence of the diphtheria bacillus in the lungs. During a period of two and one-half years there were treated at the South Department of the Boston City Hospital 157 patients who had measles and diph- theria. Of these, 54, or 34 per cent., died. (The death-rate in the uncompli- cated diphtheria patients for practically this same period was less than 13 per cent.) From these cases one must conclude that the existence of diphtheria or the possibility of its onset should be con- sidered in every case of measles, for the congestion of the mucous membrane of the tonsils and air-passages caused by the measles process renders it especially vulnerable and an unusually good field for the growth of the bacilli of diph- theria. Nasal or laryngeal obstruction arising during an attack of measles al- most certainly means diphtheria. If the initial fever of measles disappears, and there is later a sudden rise of tempera- ture, or if the cough of measles becomes "brassy" in quality or paroxysmal in character and is accompanied by an elevated temperature, the possibility of diphtheria must be considered. If the initial fever persists and aphonia devel- ops, diphtheria is probably the cause. Uncomplicated measles in very excep- tional cases may produce aphonia, but aphonia with or without a rise of tem- perature usually means diphtheria, and aphonia with a rise of temperature al- ways means diphtheria. Uncomplicated measles is usually accompanied by a more or less abundant serous nasal dis- charge; but if this discharge become.s purulent or muco-purulent in character, or if there is partial or complete nasal obstruction accompanied by a glairy dis- charge, diphtheria should be suspected and cultures taken. But if the patient's general condition in addition to the above symptoms suggests diphtheria, antitoxin should be given at once with- out awaiting the results of cultures. In all obscure cases the patient should be given the benefit of the doubt — and anti- toxin. If an epidemic of measles occurs in an institution in which large numbers of children are cared for, each child as it develops measles should be given an immunizing dose of antitoxin, and all inmates of the institution should be carefully watched for the earliest symp- toms of either disease. D. N. Blakely and F. 6. Burrows (Boston Med. and Surg. Jour., July 25, 1901). The affection takes the form of bron- cho-pneumonia and is commonly met with in the lower lobes, but may be seen in any part of the lungs. The areas are scattered and separate or may merge into one another till considerable portions of both lungs are consolidated. This com- plication usually develops at the height of the disease, but may occur at the very beginning, within the first twenty-four hours, or may arise during convalescence after the throat is clear. Its onset is marked by increased temperature; dis- turbance of the pulse-respiration ratio, — namely, from a relation of 1 to 4 to 1 to 3; greater prostration and the signs of a diffuse bronchitis; only when con- siderable areas are involved do we ob- tain the signs of consolidation. Pleurisy is rarely met vnth. Em- pyema may develop, especially in septic cases. Emphysema is frequently seen in laryngeal cases; it may be interstitial and may extend to the cellular tissues of the neck, but is commonly vesicular. The heart is more seriously affected in diphtheria than in any other of the acute 610 DIPHTHERIA. COMPLICATIONS AND SEQUEL-E. infectious diseases, and many of the fatal cases are due to rapid or sudden heart failure. It follows tonsillar or pharyn- geal diphtheria frequently, and is rare after other forms. Goodall, in a recent study of these cases, gives three types of the affection: — 1. Heart-failure while the exudate is stni present in the throat and before other symptoms of paralysis present themselves. It is then due to the direct action of the diphtheria toxins upon the nerve-mechanism of the heart. 2. Heart-failure after the disappear- ance of membrane, but during the time of other symptoms of paralysis, when it may be due either to disturbed innerva- tion or to fatty changes in the heart- muscle, such as are met with in other fevers. 3. Heart-failure during convalescence, some time after the disappearance of membrane; it is then probably caused by degeneration of the heart-muscle or of the pneumogastric nerve (neuritis). Careful autopsies made of twenty-two cases in wliieh death was due to some cardiac complication. In eight of these cases the vagus, stained by Marchi's method, showed evidence of degeneration. The cells in the nucleus showed no change, even when there was marked degeneration of the fibres of the nerve. The myocardium in these cases was not systematically examined, but the weight of the heart was found to be almost con- stantly increased. If four weeks have elapsed without any indication of car- diac trouble, there is little likelihood of its appearance at a subsequent period of convalescence. J. J. Thomas (Boston City IIosp. Med. and Surg. Reports, '98). Whether occurring early or late in the disease, the symptoms of involvement of the heart are, in general, the same: the pulse becomes either more rapid or more often slower; it may be intermittent or irregular; in any case it is much weaker. The patients are greatly prostrated, may refuse food, and may vomit repeatedly. The surface of the face and extremities may be pale and cold, or there may be dyspnoea without cyanosis. There may be some precordial distress. After con- tinuing in this condition for hours or daj's the patients may rally, the heart gradually resumes its normal action, the sj'mptoms disappear, and recovery ensues. More often the alarming symptoms grow worse and the patients succumb to the cardiac weakness. Death may be caused by sudden syncope induced by slight ex- ertion or excitement. In some of the cases the patients are regarded as thor- oughly convalescent and may be up and about, when sudden and unforeseen pa- ralysis of the heart results in instant death. The cardiac affection, while most often seen after severe diphtheria, may be a sequel of the mildest cases. Htem- orrhages into the skin or from mucous membranes may be met with during the height of the disease. They are most frequent from the nose and may be so severe as to require plugging of the pos- terior nares. They may occur from other mucous membranes: the stomach, intes- tines, or rarely the bladder. In the skin the hffimorrhage may give rise to pete- chiiB or may infiltrate considerable areas. The petechice are most often seen upon the abdomen and lower extremities, but may occur upon any part of the body. They are caused by changes in either the blood or the vessels or both, and are usually seen in the severer types of tox- temia. The hocmorrhages are in some cases sulTicicnt to seriously exhaust the patient and may even cause death. A study of 040 cases emphasizes the great fretnicncy of heart murmurs and of irregularity of the pulse. The prog- nosis docs not depend on the mere pres- ence of these signs, but upon the severity of the infection, the length of time without treatment, the rate and degree DIPHTHERIA. COMPLICATIONS AND SEQUEL.,E. 511 of irregularity of tlie pulse, and tlie pres- ence of the graver signs of cardiac disturbance. Moderate disturbance of tlie heart is very common; severe com- plications are infrequent. Frequent examinations of the heart are necess»ry to really determine its condition, because of the marked changes in rhytlim from one hour to the next. Examination of the heart and pulse in the second and third week of the ill- ness are necessary, that being the time when severe heart complications most frequently occur. Broncho-pneumonia is a more fre- quent fatal complication of diphtheria than heart disease; sudden death from heart disease is very rare when patients are kept in bed for a proper period. Prolonged rest in bed is necessary in all severe cases; it is not necessary to keep all patients in bed who have cardiac murnmrs and a pulse which is somewhat inegular and increased in rate. One should be governed by the stage of the illness and the patient's general condi- tion. If no serious heart ti-ouble has developed within four weeks the patients are usually safe from this complication. Heart murmurs and inegularity are of long duration in many cases, and make it necessary to watch the condition of the heart long after convalescence in all severe cases. F. W. White and H. H. Smith (Boston Med. and Surg. Jour., Oct. 20, 1904). Thrombosis and embolism are among the rarer complications of diphtheria. They may affect the extremities, giving rise to the usual symptoms: sudden pain, numbness, and coldness of the limbs, fol- lowed by paralysis, redema, and even gangrene. Some of the cases of cardiac paralysis may be caused by thrombosis or embolism of the vessels of the heart. Affecting the cerebral arteries, throm- bosis, embolism, or hajmorrhage may give rise to hemiplegia. In very rare cases the stomach may be involved in the diphtheritic process; but, apart from such involvement, gastric symptoms are common. Persistent vom- iting is a frequent and grave occurrence in severe cases. It may be due to the fever and toxaemia, or to nephritis or to heart-failure. Diarrhoea is often met with during the height of the disease, and may persist for some time after the diphtheria itself is improved. It may be due to entero- colitis or may be dependent upon the constitutional condition, especially in the septic cases. The local lesions are not severe and have no direct relation to the diphtheritic process. As already noted, haemorrhages may occur from either stomach or intestine in rare cases. The kidneys are more or less affected in all severe cases of diphtheria. The lesion may be an acute degeneration, marked by more or less albumin in the urine, or acute exudative nephritis with albumin and casts, but without dropsy or ura?mic symptoms. Very rarely an acute diffuse nephritis with diminished urine containing albumin and casts, or suppression of the urine, drops)', and uraemia may be seen. The albuminuria usually comes on during the height of the disease, con- tinues for a time, and disappears rapidly with improvement in the local symptoms. Only in the rare cases in which acute dif- fuse nephritis develops are the renal com- plications likely to persist. Marked al- buminuria is always an evidence of a grave infection, while not of itself a serious complication. It is most com- mon in the septic cases, and belongs dis- tinctly to pharyngeal, or tonsillar, diph- theria. In very rare cases there may be hosmorrhagcs from the kidneys. Mention has already been made of the fact that, pathologically and experiment- ally, the most characteristic lesion of diphtheria is that affecting the nervous system and giving rise to paralysis of various groups of muscles. Clinically, 51Z DIPHTHERIA. COMPLICATIONS AXD SEQUEL.-E. paralysis is infrequent, but in its distri- bution, tj-pe, and course, none the less characteristic. In 2-14:8 cases collected by Sanne paralysis was noted in 11 per cent.; in a series of 1000 cases reported by Lennox Browne in 14 per cent.; in 1071 cases belonging to preantitoxin days studied by Goodall, after deducting a mortality of 33. S per cent., he says he observed paralysis in 125 of the 709 sur- vivors, — 17.6 per cent, of the latter num- ber, or 11.7 per cent, of the whole num- ber; in 33S4 cases, treated by antitoxin, comprised in the Report of American Pediatric Society, paralysis was met with in 32S cases, — 9.7 per cent, of the whole number. Of the 2934 cases that recov- ered, 276 — or 9.4 per cent. — showed pa- ralysis, while, of the 450 fatal cases, paralysis was observed in 52, or 11.4 per cent. Simply taking the totals of these figures without relation to the question of treatment, we have 852 cases of pa- ralysis occurring among 7903 cases, or in 10.7 per cent. Secondary paralysis occurs very fre- quently. Out of 1316 cases admitted into Park Hospital, 275 showed distinct diphtheritic paralyses and pareses. One case of diphtheria out of every five pa- tients thus suffered from some paralytic trouble, which was most frequent in eases between three and eight years. There were 80 deaths among the cases that suffered from paralysis, and 64 of these had cardiac paralysis. The average day upon which the cardiac paralysis appeared was the seventh. Average duration of life after cardiac paralysis in cases which died was four days. There were 21 cases of diaphrag- matic paresis and paralysis, of which 11 terminated fatally and 10 recovered. There were 110 cases where the palate alone was affected, and 50 cases in which the palate was paralyzed in con- nection with other muscles, the largest number being associated with the exter- nal rectus, and next to that the dia- phragm. Meyers (Lancet, Sept. 22, 1000). Paralysis usually complicates the se- verer cases of pharj-ngeal diphtheria, but may be seen after milder forms, and it has even been reported as following affec- tions of the throat so mild as to have attracted little or no attention. The time of the onset of paralytic s}Tnptoms varies greatly in different cases. It may occur at the height of the disease in the latter days of the first week or the beginning of the second, but is usually seen some time after the throat is altogether clear during the third or fourth week of the disease, and may occur as late as the tenth week after the onset. In the cases reported by Goodall the paralysis was observed from the sev- enth to the forty-ninth day. In 171 cases of diphtheritic paralysis collected by Eoss the following distribu- tion was observed: Palate affected in 128; eyes in 77, in 54 of which the muscles of accomodation suffered; lower extremities in 113; upper extremities in 60; trunk or neck in 58; muscles of respiration, 33. Of the 328 cases reported to the American Pediatric Society the distribution was specified in 187. Of this number in 120 involved the throat (palate, pharynx, and larynx); in 14 the extremities; in 11 the eyes; in 32 the heart; in 1 the muscles of respira- tion; in 1 the sterno-mostoid; and in 8 the paralysis was general. Paralysis caused by iiiultiple neuritis, in the majority of cases, nuist be at- tril)\ited to the toxic effects of the prod- ucts of the Klebs-Locdier bacilli. It occurs in from 10 to 25 per cent, of cases. The treatment of the original disease, by antitoxin, or otherwise, does not ap- pear to have any influence upon the subsequent development. Fraiieis TTulicr (Pediatrics, June 1, '09). The nervoiis system studied in nine f,'iiiiioa-pigs which had been injected with illlcrcd diphtheria broth in varying DIPHTHERIA. COMPLICATIONS AND SEQUELS. 513 quantities, and also in a number of children who died of the disease. Per- sonal conclusion reached that the paral- j'ses may be eitlier central or peripheral in origin. In tlie former case, the ante- rior liorn cell first becomes the seat of degenerative changes, as evidenced by abnormal staining reactions, while the nerve-fibre is still normal in appearance. A secondary descending atrophy of the nerve, however, follows upon tlie disease of the central cell. In the latter, or peripheral tj-pe, of which the common palate paralysis is an example, the mus- cles paralyzed are those in connection with peripheral nerve-fibres which come into close relation with the seat of toxin-formation in the throat and naso- pharynx. The central paralyses are toxoemic in origin; the peripheral are due to local and direct irritation. Foul- erton and Thomson (Edinburgh Med. Jour., Jan., 1002). The frequency of paralysis is in direct proportion to the severity of the general infection, although a severe palsy may follow a mild type of diphtheritic intox- ication. The location of the membrane is of considerable importance as an etiological factor, diphtheria of the posterior nares especially predisposing to both local and widespread palsy. Tlie proportion of cases followed by paralysis is variously estimated at from 10 to 30 per cent. Peter (Jledical Xews, Feb. 14, 1903J. In the series published by Goodall, the palate alone was first affected in 66 per cent, of the 125 cases, and in combination with other muscles it was involved in 12 per cent. more. In a little over one-half of the cases the pa- ralysis was limited, and in 12 per cent, it was generalized. The affection of the throat is therefore much the most com- mon. It may occur alone or be followed by paralysis of other parts: the eye, the extremities, the trunk, or neck. In some cases it precedes the cardiac paralysis, but, as a rule, this most grave form of diphtheritic paralysis appears unan- nounced. Absence of the patellar re- 2- fle.xes is observed in most cases of diph- theritic paralysis, even when there is no loss of power or sensation in the lower extremities, and is regarded as a sign of the probable appearance of paralysis else- where. In most of the throat cases the uvula and soft palate alone are involved. Nasal voice and regurgitation of fluid through the nose evidence the loss of power in these parts, and upon inspection we see the uvula hanging straight downward, relaxed, and motionless upon the back of the tongue. Sensation as well as mo- . tion is gone, and there will be no re- sponse to irritation. If the pharyngeal muscles are involved, there is difficulty in swallowing, and, if the larynx suffers, there will be aphonia and severe cough- ing upon attempt at swallowing anything by reason of the entrance of food or drink into the imperfectly closed organ. The latter class of cases is very likely to prove fatal through the development of pneumonia from the inspiration of for- eign material. In the extremities — arms, legs, or neck — we see more or less com- plete loss of power and sensation. The paralysis may not, however, be general- ized in these parts, but appears at times to attack only the muscles supplied by a particular nerve-trunk, or even a branch of a main nerve. The paralysis may be so extensive as to render the patient per- fectly helpless. When the trunk is in- volved, the gravest danger arises from implication of the muscles of respira- tion. Usually the diaphragm is first involved, but the intercostals may suf- fer. If the diaphragm is paralyzed, the respiration is entirely thoracic; if the intercostals, then the diaphragm alone must do the work. Either affection is characterized by attacks of urgent dyspnoea, with cyanosis. The wind be- ing perfectly clear and respiration main- 514 DIPHTHERIA. COMPLICATIONS AND SEQUEL-E. tained only by the greatest effort on the part of the victim, the distress is often terrible. The danger of suffocation is imminent. Such an attack may pass off and there be no return; but more often they recur in a short time. The patient may remain in this condition for several days, before death finally ends the struggle. Few of these cases recover: only eight in thirty-three of Boss's series. At any time there may be involvement of the pneumogastric nerves as well as the phrenic, the new invasion declaring itself by attacks of abdominal pain, vomiting, and feeble and slow or irregular pulse. At other times the heart may continue to act quite normally despite the respira- tory distress. We have already spoken of the purely cardiac type of this affection, for it is impossible on clinical grounds to sepa- rate from one another the cardiac failure due to changes in the myocardium from that produced by involvement of the pneumogastric or other cardiac nerves by the neuritis. Furthermore, the two conditions are often associated. It may be well again to point out the suddenness with which cardiac paralysis may occur by quoting from the Eeport of the Amer- ican Pediatric Society the follomng para- graph: "Observations of some of the individual cases are interesting, particu- larly those of cardiac paralysis. It is twice stated that the child had gotten up and walked out of the house, where it was found dead. "Twice death occurred after sitting up suddenly; once, on jumping from one bed to another. One patient of twenty years got up contrary to orders and died soon afterward. Another patient was apparently well, until he indulged in a large quantity of cake and candy, soon after which cardiac symptoms developed and he died shortly." ^Vhen the eyes are affected there is indistinctness of vision usually resulting in inability to read, caused by paralysis of the muscles of accommodation. The pupils may be dilated or sluggish in ac- tion from involvement of the sphincter iridis. Strabismus or ptosis from pa- ralysis of the extrinsic muscles of the eyes are rarely seen. One hundred and fifty cases of post- diphtheritic paralysis of accommodation obsen-ed. Paralysis set in two to three weeks after the beginning of the diph- theria in the throat, lasted about four weeks, and always disappeared sponta- neously. The degree of paralysis was not always proportionate to the intensity of the disease, and ranged from -|- 1 D. to -)- 6 D. for five letters at 9 inches. All the cases except six presented an hj'peruietropia of 1 to 3 D. This was explained on the ground of childhood hypermetropia. The onset is sudden, the recovery grad- ual. Rarely is there paralysis of the sphincter of the pupil. Moll has ob- served it only four times. Accompanying paralyses were as fol- low: Sixteen times paralysis was double and three times unilateral of the sixth pair. Diplopia must be tested for with colored glass. Once a unilateral ptosis. Once insufficiency of the right internal rectus with asthenopia in a chlorotic subject. In the majority of the cases paralysis of the velum palati and the pharynx. The fundus was always normal. H. Coppey (Arch. d'Ophtal., No. 2, p. 117, '97). Diphtheria is rare in nursing infants, especially soon after birth ; should there be distinct contagion, the infant will contract diphtheria easily; the mortal- ity is much higher among nursing in- fants, because of their decreased resist- ance and the diflieulty in forming the diagnosis; the l)acilli enter by the mouth; nasal diplil-lieria is secondary from the pharynx, while laryngeal and pulmonary complications are very rare. The treatment consists of prophylactic DIPHTHERIA. DIFFERENTIAL DIAGNOSIS. 515 injections of antitoxin in times of epi- demic, and larger injections later, re- peated when necessar)', with some local treatment; and, finally, in spite of the antitoxin treatment, the mortality reached 00 per cent. Cristeanu and Bruckner (Archives de MC-d. des Enfants, Nov., 1901). The frequency of paralysis is in direct proportion to the severity of the general infection, although a severe palsy may follow a mild type of diphtheritic in- toxication. The location of the mem- brane is of considerable importance as an etiological factor, diphtheria of the posterior nares especially predisposing to both local and widespread palsy. The proportion of cases followed by paralysis is variously estimated at from 10 to 30 per cent. Peter (Medical News, Feb. 14, 1903). Facial and glossal paralyses have both been reported, and in some of the sever- est types of general paralysis the sphinc- ters of the bladder and rectum are said to have been involved. If the case does not result fatally either directly from the paralysis or from the diphtheria itself or other complications, the paralysis will surely recover. In none of the cases observed by Goodall was the paralysis permanent. The time required depends upon the degree and extent of the paralysis. Those in which the throat alone is affected usually re- cover completely within a week or two. Cases of multiple or generalized paraly- sis may require three or four months to regain normal power. Differential Diagnosis. — The bacterio- logical investigations inspired by the identification of the Klebs-Loeffler ba- cillus have greatly simplified the ques- tion of the relationship of the various pseudomembranous inflammations. The fact of not finding diphtheria ba- cillus in cases of clinical diphtheria always due to some error in technique. Important practical point: On the sur- face of membrane bacilli frequently die; therefore, if the culture be taken directly from the surface, in majority of cases a negative result will be obtained. If the wire be passed through the membrane or along its edges a positive result is almost invariably reached. McCollom (Boston Med. and Surg. Jour., May 9, '95). Loelller bacillus present in much more than 73 per cent, of real clinical diph- therias. F. G. Novy (Med. News, July 13, '95). We now know definitely that there are but two great types: the one termed pseudodiphtjieria, produced by strepto- cocci or staphylococci and belonging to the acute infectious diseases, — measles or scarlet fever, — and true diphtheria, pro- duced by the specific bacillus, and usu- ally a primary and independent affection. On the other hand, these investigations have added complexity to the problem of diagnosis of throat affections by showing the presence of the specific bacilli of diphtheria in many cases of sore throat free from membrane and previously passed over as simply "catarrhal" sore throat, and also in many of the cases of a fairly definite clinical type, formerly classified as follicular tonsillitis. There are some angina; which, al- though resembling diphtheria, are not caused by Loefllers bacillus. A typical lacunar tonsillitis may appear absolutely indistinguishable from ordinary follicu- lar tonsillitis, and sometimes the diph- theritic process may start in the lowest parts of the tonsils and so escape de- tection. It is well to isolate cases of lacunar angina, and during an epidemic of diphtheria they should be looked upon with much suspicion. It is better that diplitheria should be diagnosed too often than that cases of true diphtheria should be overlooked. Vierordt (Berliner klin. Woch., Feb. 22, '97). In the shifting of the lines that has followed these revelations a considerable degree of mental confusion has been en- gendered and an uncertainty fostered that has led many to lose all faith in the 516 DIPHTHERIA. DIFFERENTIAL DIAC4N0SIS. results of clinical observations. If it is necessary to rearrange the lines of classi- fication somewhat, it is not required that we abandon all our former conceptions or no longer trust to careful observation. In the great majority of cases thorough examination and careful consideration of all the factors concerned will enable one to reach a positive diagnosis without awaiting the results of a bacteriological examination, although the latter should always be employed if possible. For the sake of clearness we shall follow the order adopted in the description of clin- ical s}Tnptoms. Nasal Cases. — The only cases that are difficult of diagnosis are those of primary nasal diphtheria. The thin, irri- tating, muco-purulent discharge, often brownish from the presence of blood, is quite different from the abundant, ropy mucus seen in simple catarrhal inflam- mation. Excoriation of the nares and eczema of the upper lip produced by the discharge are suggestive of diphtheria. Careful inspection may show the pres- ence of more or less white or grayish- white exudate on the mucous membrane, in which case the diagnosis of diphtheria may be safely advanced. Furthermore, the diphtheritic cases are accompanied by some slight rise of temperature, anorexia, and a distinct degree of con- stitutional depression not seen in cases of simple inflammation. Finally, these cases are much more often seen in insti- tutions where the children are more or less constantly exposed to diphtheritic infection than in private or dispensary practice. Pharyngeal, on Tonsillar, Cases. — These often present difficulties in di- agnosis, but a full consideration of all the factors in any case will usually lead to a correct judgment. The most difli- cult cases are the milder ones, where there is little or no membrane and the constitutional sjTnptoms are slight. The question of exposure should be consid- ered in every case. Children gathered in hospitals or asylums or attending schools are especially exposed to diph- theritic infection, and in them any form of sore throat may justly be looked upon with suspicion. So far as the catarrhal form of diphtheria is concerned, even with a history of exposure, there is no way of making a diagnosis of diph- theria in the early stages except by bac- teriological cultures. The after-course of some of these cases — in which we may see invasion of the larynx, broncho-pneu- monia, nephritis, or paralj'sis — -may show them to have been diphtheria, when no suspicion has previously been enter- tained. When diphtheritic membrane is pres- ent in the throat, it usually presents cer- tain definite characters. It begins as a thin, translucent deposit upon one or both tonsils. Gradually or rapidly it becomes thicker, and assumes a white, gray, or grayish-green, brown, or — in malignant cases — black color, and ex- tends peripherally to cover a larger and larger area. It is firmly attached to the mucous membrane or underlying tissues and cannot be easily rubbed off. If re- moved by force, a raw, bleeding surface is left, and in a very short time the mem- brane is reproduced in its original or even a greater extent. Beginning upon the tonsils, the membrane rapidly ex- tends to other parts: the lateral walls of the pharynx, the fauces, or uvula. Upon any of these parts the membrane presents the same characters as at the original site. This extension of the mem- brane is most characteristic of diph- theria. The only cases in which we are likely to see such extension of a pseudo- diphtheritic membrane are the throat in-^ JJIPIITIIERIA. DIFFEKENTIAL DIAGNOSIS. 517 flammations accompanying other infec- tious diseases, measles, small-pox, and — most of all — scarle^ fever. The great majority of the membranous throat af- fections seen in the early stages of these diseases are produced by the action of streptococci or staphylococci. When a similar process is seen as a late complica- tion of infectious diseases, it is more probably true diphtheria. The early temperature in diphtheria is not usually high; it is, in fact, gen- erally lower than in pseudodiphtheria, with an equal amount of membrane. A high temperature in the beginning is, therefore, an indication that the case is not diphtheria. On the other hand, the prostration is greater in diphtheria than in pseudodiphtheria. The pulse is feebler; the patients look and feel sicker than they do when suffering from pseudodiphtheria. The presence of a nasal discharge of the character de- scribed as belonging to nasal diphtheria and marked swelling and tenderness of the cervical lymph-nodes help to dis- tinguish some cases in the early stages. Later we look for the development of the typical complications or sequelae of diphtheria: invasion of the larynx, broncho-pneumonia, albuminuria, or some of the manifold forms of paralysis. The occurrence of any of these processes is usually sufficient to make the diag- nosis certain, although it is not impos- sible that any of them except the paraly- sis may be seen in cases of pseudodiph- theria. Paralysis subsequent to throat inflammation is seen only in diphtheria. Pseudodiphtheria is, in the great ma- jority of cases, a milder disease and of shorter course than diphtheria. As al- ready remarked, the primary throat in- flammation of scarlet fever most closely resembles true diphtheria. In fact, in every case where diphtheria is suspected, the possibility of scarlet fever must be borne in mind and examination made for the eruption. Oftentimes it will be found at the very first examination; at any rate, a brief delay will suffice to de- termine the question, as the eruption of scarlet fever so quickly follows the ini- tial symptoms. It may even happen that the throat symptoms of measles may simulate diphtheria, and especially if the eruption be delayed for a number of days. Here, however, there is rarely any membrane at all, and the presence of conjunctivitis, with the simple mucous discharges from nose and throat, should be sufficient to prevent mistake. Fur- thermore, if Koplik's observation of the occurrence of an eruption of peculiar bluish-white specks upon a reddish background on the mucous membrane of the mouth previous to the appearance of the regular skin exanthem of measles be proved correct, it should furnish another basis for differential diagnosis. Laryngeal Cases. — When the laryn- gitis appears as the extension of a pre- vious process in nose or throat, except in the case of measles or scarlet fever, we can safely put it down as diphtheritic. The pseudomembranous throat inflam- mations of measles and scarlet fever often involve the larynx, trachea, and bronchi, although the processes are not diphtheritic. In any other case such extension is almost conclusive evidence that we have to do with diphtheria. The greater difficulty is prevented by the primary cases of laryngitis in children. The characteristic feature of diphtheria of the larynx is its progressive, unre- mitting dyspna^a with aphonia. The disease steadily advances to laryngeal stenosis and death from strangulation, unless relieved by treatment. Simple catarrhal, or non-diphtheritic, pseudo- membranous laryngitis, on the other 518 DIPHTHERIA. DIFFERENTIAL DIAGNOSIS. hand, usually siioTs frequent and de- cided remissions — its crises belonging to the night, the day showing decided remission of aU the symptoms. As in the pharyngeal cases, early high tem- perature belongs rather to the pseudo- diphtheria. If laryngeal examination be possible and we can see and determine the character and extent of the mem- brane in the larynx, we ought to be able to reach a positive diagnosis; but, un- fortunately, such examination is not practicable among yoxmg children, who furnish the great majority of the cases of acute laryngitis. Of 283 cases of acute laryngitis subjected to bacterio- logical examination by the New York Board of Health, 229— or SO per cent.— proved to be true diphtheria; so that in the city, at least, the diagnosis in any such case would incline to diphtheria. Differential Diagnosis. Diphtheria. 1. Exposure to infec- tion from previous case of diphtheria. 2. Greatest liability in early years: first to fifth year. 3. Membrane either seen from first upon pharynx, fauces, or uvula, as well as tonsils, or rapidly extends to these parts. 4. Membrane firmly attached to underly- ing tissues, and not easily rubbed ofl. 5. If membrane be re- moved, leaves bleed- ing surface. 6. If removed, mem- brane is very rap- idly reproduced in an even greater amount. PseudcKliphtheria. 1. No such exposure: arises independently. 2. Occurs at any age. 3. Membrane limited to tonsils. 4. Membrane loosely attached and easily removed. 5. Membrane may be removed without such bleeding. 0. Reproduction of membrane not so rapid or extensive. 7. Discharge from nose, thin, irrita- ting, often bloody, and produces eczema of upper lip. S. Submaxillary and cervical lymph- nodes swelled and tender. 9. Membrane may be seen upon buccal mucous membrane, tongue, angles ol the mouth, or lips. 10. Onset gradual ; temperature low at beginning. 11. Constitutional de- pression is more marked, the pulse weaker, and chil- dren more pros- trated. 12. Course longer : usually five days to a week before marked improve- ment is seen. 13. Albuminuria com- mon and severe ne- phritis frequent. 14. Larynx often in- volved by extension. 15. Paralysis of more or less extensive groups of muscles may occur, as a complication or se- quel. 7. Nasal discharge not so common, and is simple, muco-pur- ulent. S. Swelling of lymph- nodes not so marked in primary cases; is regularly met with, however, in throat inflammations of scarlet fever, etc. 9. Not seen upon these parts. 10. Onset more sud- den ; temperature higher. 11. Constitutional symptoms usually in proportion to temperature; more moderate. Pulse rapid, but not weak, and depression not so marked. 12. Course shorter, ex- cept in cases com- plicating infectious diseases; is usually three or four days. 13. Much rarer. 14. Larynx rarely at- tacked secondarily, except in measles or scarlet fever. 15. No such paralysis seen. While it is true that, as many authori- ties maintain, in 95 per cent, of the cases which an expert after careful con- sideration would pronounce diphtheria, cultures will show the presence of the specific bacillus, it must be frankly ad- DIPHTHERIA. DIFFEKENTIAL DIAGNOSIS. 519 mitted that there are many ca.5es in which the most careM observation can- not determine positively the question whether a given case is true diphtheria or pseudodiphtheria. Thus, in Scien- tific Bulletin No. 1, of the New York Board of Health, we find it stated that "Baginsky, in Berlin, found the diph- theria bacillus in 120 out of 154 sus- pected cases; Martin, in Paris, in 126 out of 200; Park, in New York, in 127 out of 244; Janson, in Switzerland, 63 out of 100; and Morse, of Boston, in 239 out of 400. Thus, from 20 to 50 per cent, of the cases sent to diphtheria hospitals did not have diphtheria." If these figures approximate the truth, it is evident that we cannot trust with safety to clinical observations to de- termine the specific relation of cases of throat inflammation. On the other hand, the routine use of cultures from all cases of sore throat regularly shows the presence of the diphtheria bacillus in a considerable number of cases in which there were few or none of the features regarded as characteristic of diplithcria, and in which there was, therefore, little or no suspicions of the presence of the specific bacillus. While so far as the individual case is concerned, it may be remarked that the cases in which the diagnosis is most dif- ficult are the mild cases, those least likely to be attended with grave conse- quences to the patient himself, the fact should also be recognized that these mild cases are quite as dangerous to others as severe ones, and should, for the sake of the community, be subjected to strict quarantine. It is, therefore, essential to accurate work and proper care, as well as proper prophylaxis, that cultures should be made from all cases of sore throat. In no other way can we stand upon solid ground with relation to treatment, or hope to eventually gain control of the wide-spread and dangerous infection. [Scientific Bulletin, No. 1, Health De- partment of the City of New York, is the source from which the great part of the material of this section is drawn. W. P. NonTnitup and David Bovaird.] Methods of Making Bacteeiolog- ICAL Examinations. — An immediate microscopical examination of the exu- date in cases of suspected diphtheria will often justify a positive diagnosis. A bit of membrane removed from the throat by a swab is smeared upon a cover-glass or slide, dried, fixed by heat, and then stained with LoefHer's methy- lene-blue solution. With an oil immersion lens we may then be able to determine the presence of bacilli sufficiently characteristic to warrant a positive diagnosis. The ba- cilli under such conditions do not have the characteristic features which are presented by cultures upon suitable media. They are much more irregular in size, shape, and staining properties. Positive judgment is, therefore, much more difficult and uncertain. Failure to find the bacilli by this method would in no way prove that the case was not diphtheria. The uncertainties of the method are so pronounced that it is rarely employed. Jlcthod adopted by Chicago Health Department for making early diagnosis of diphtheria consists in spreading a little mucus from the throat on a slide, allowing it to dry, then staining and examining microscopically iiuniediately. In about 50 per cent, of cases a suffi- cient number of bacilli is found to war- rant a diagnosis. In case the Klcbs- I.oeffler bacilli cannot be found in this way, patients lose little by waiting for incubation of cultures. During four years the mortality of 38 per cent, from diphtheria, not including laryngeal cases, has fallen in Chicago to 6.7 per cent., in- 520 DIPHTHERIA. DIFFEEEXTIAL DU.GXOSIS. eluding all forms of the disease. This is thought to be due to the improved methods by which early diagnosis is made possible, and the early use of anti- toxin. W. K. Jaques (Jour. Amer. Med. Assoc., Oct. 29, '9S). With modification of Neisser's stain by Concetti it is possible to arrive at a very early bacteriological diagnosis. The method is as follows: A sterilized glass or iron rod has twisted upon its end a small piece of absorbent cotton, impregnated with glucose glycerinated agar-agar. The rods are kept in steril- ized test-tubes, ^^^len a culture is to be made, it is removed, the affected part swabbed with the end containing the culture-medium, and the rod at once re- placed in the tube. It is then placed in a thermostat and kept at a temperature of 36° to 37° C. In four or five hours' time there will have been sufficient growth to make a smear. The latter is stained with a methylene-blue solution consisting of metliylene-blue, 1 gramme ; alcohol, 20 cubic centimetres; distilled water, 450 grammes; acetic acid, 5 grammes. This solution should remain on the slide not more than two or three seconds. The spread is then washed with water, after which it has an in- tense-blue color. A counterstain is em- ployed consisting of 2 grammes of vesu- vin in 1000 grammes of water. This so- lution is heated, and filtered while still warm. The specimen should be exposed to the action of the vesuvin from 15 to 20 seconds and then washed in water. It displaces the methylene-blue. If no Loeffler bacilli are present, the gross appearance of tlie smear is brown. The presence of tlie true or pseudobacilli gives a mixed blue and brown color. Under the microscope the pseudobacilli are stained brown in their entirety. The true bacilli liave a brown stain, but the ends of the bacilli present the char- acteristic blue points, which is the chief differential test. A. L. Goodman (Med. Record, Feb. 10, 1901). While in fcrliiin Krnall percentage of cases the dipht licria bacillus fails to appear in the first cultures, the fiiilure i» generally duo to a conjoined infection with the septic micrococci. Apart from these instances, the fact that diphtheria is not present can be based on one negative culture up to the tenth day of the disease. The reasons for requesting a comfirmatory culture in negative eases are: 1, where there is no growth what- ever on the culture media; 2, where there is complete contamination and liquefaction of culture media, in cases which are clinically diphtheria; 3, cases where there are suspicious bacilli; 4, in croup cases where the membrane is lim- ited to the larynx and the duration of the disease is less than five days. Dry- ness of culture media, scanty growth and the recent use of antiseptics with satisfactory growth of other organisms than the diphtheria bacilli, do not alone furnish sufficient grounds to demand a comfirmatory culture. J. S. Billings, Jr., (N. Y. Med. Jour, and Phila. j\Ied. Jour., Sept. 12, 1903). The best culture-medium for routine work is the Loeffler blood-serum, coag- ulated by heat in test-tubes in such a way as to give an extensive slanting sur- face for inoculation. The swabs used In obtaining the infected material from the throat are made by wrapping a small quantity of absorbent cotton about the end of a small steel rod six inches in length. The swabs so made are inserted into test-tubes, which are then plugged with cotton and the whole sterilized by exposure to dry heat at 150° C. for one hour. To make a satisfactory culture a good view of the throat must be ob- tained and the swab rubbed upon the surface covered by membrane, or — in the absence of membrane — upon the in- flamed parts. In laryngeal cases where no membrane is visible it usually suffices to make the application of the swab either to the tonsils or as low in the pharynx as possible. In such cases if the first culture fail to show the pres- ence of diphtheria bacilli, it is always well to repeat the process, as a second or third culture may show the bacilli pre- UIPHTHKKIA. DIFFEKKNTIAL DIAGNOSIS. 521 viously absent from the accessible parts of the throat. Care must be taken in inoculating the swab not to allow it to touch the tongue or any other part or surface than the one upon which the presence of the bacilli is suspected. Otherwise contaminating bacteria are in- oculated upon the culture-media and the value of the culture for diagnostic pur- poses destroyed. To carry out these directions in young children it is necessary that they be care- fully held. The best method is to have the mother or nurse hold the child upon her right side, the child's face turned toward the light and the head resting upon her right shoulder, one of the hold- er's arms about the patient's legs, the other controlling the arms. The physi- cian can then usually insert a tongue depressor and control the head with one hand, while with the other the swab can be properly directed. With very fractious children it may oven be necessary to have a second assistant hold the child's head. Failure to take pains in making a proper application of the swab is accountable for many of the unsatisfactory results ob- tained from cultures. The swab having been properly inoculated, the cotton stopper is withdrawn from the mouth of the tube containing the solidified blood- serum and the swab then rubbed gently over the surface of the culture-medium, care being taken not to break the smooth surface of the medium. The swab is then withdrawn, the cotton stopper, which must have been held so as to have escaped contamination from any outside source, replaced in the mouth of the culture-tube, the swab dropped into its tube again and confined by its own stop- per. The culture-tubes are (hen ready for incubation. Koplik has described a. rapid method of incubation and examina- tion in which he allows only two or three hours' incubation at 37° C, at the end of which time he asserts that the growth of the diphtheria bacilli is more charac- teristic than at any other period of in- cubation. There is no positive criterion by whicli the true diphtheria bacillus can be rec- ognized in culture after twenty-four hours. The pseudodiphtheria bacillus is, culturally, practically indistinguishable from it, difTering only in its lack of virulence. Hoffman considers the pseudo- diphtheria bacillus a constant inhabit- ant of the mouth. Roux and Yersin found it twenty-si.\ times in fifty-nine children of a village on the coast of France in wliich diphtheria was entirely absent. Bech discovered it twenty-six times in sixty-six Iiealthy cliildren. In view of this, what value can a method possess by which, in the required time of twenty-four hours, it is impossible to distinguish the true diphtheria bacillus from a constant inhabitant of the mouth? The length of the bacilli has been fre- quently regarded a characteristic feat- ure, but very long bacilli with all the qualities of the Loeffler bacilli, except that they were non-virulent, were found in the conjunctival sac. The true diph- theria bacillus in culture, especially on white of egg, exhibits a sort of giant- growth, and presents true brandling, a phenomenon also observed in the growth of the conjunctival bacillus. In view of all these facts, it is plainly not pos- sible to distinguish the virulent from the non-virulent bacillus, and too much importance should not attach to bacterio- logical diagnosis without determination of virulence, especially when the diag- nosis is made within twenty-four hours. Schanz (Hcrl. klin. Woch., Jan. 18, '97). Upon blood-scrum and agar the xerosis bacillus resembles closely the diphtheria bacillus. It is not pathogenic for ani- mals. It grows more abundantly on LoefTler blood-scrum and on peptone-agar than the pseudobacillus. Neisser's method of staining decolorizes the xero- sis and pseudobacillus, while the diph- 522 DIPHTHEKIA. DIFFERENTIAL DIAGNOSIS. theria bacillus retains the stain. Bouil- lon is rendered acid by the diphtheria bacillus, alkaline by the xerosis bacillus, and it is not affected by the pseudo- diphtheria bacillus. E. Franke (Munch, med. ^Voch., Apr. 19, '9S). When there is no special reason for haste, it is usually more convenient to adopt the method followed by the New York Board of Health, of twelve hours' exposure, the cultures are kept at body- temperature over night and are ready for examination in the morning. It is not possible to determine the pres- ence or absence of diphtheria bacilli in the cultures upon the blood-serum from the gross appearances; but if it is found that the culture-medium has been lique- fied during the incubation, it can safely be said that contaminating bacteria are present in such numbers as to render the culture valueless. The diphtheria ba- cilli or cocci do not liquefy the medium. The true diphtheria bacilli do not grow in fluid antitoxic serum, nor do non-virulent pseudobaeilli that render bouillon acid, while virulent organisms that render bouillon alkaline grow equally well in liquid antitoxic serum and normal sei-um. All forms grow ex- cellently upon antitoxic serum that has been coagulated at 70 degrees. De Mar- tini (Centralb. f. Bakt., Parasit., u. Infr., Jan. 30, '97). Upon the centre of a clean cover-glass is placed a drop of sterile water. With a sterile platinum loop a number of the colonies, wbich show themselves as fine, granular elevations upon the culture sur- face, are swept off. The loop is then im- mersed in the water upon the cover-glass and its contents spread evenly over the glass. Tlie preparation after being al- lowed to dry in the air is fixed by pass- ing it three times through a moderate gas-flame. It is then stained by cover- ing it with Loeffler's alkaline methylene- blue solution and allowing it to stand for ten minutes. The cover-glass is then washed, dried, and mounted in Canada balsam. The following is recommended as a dif- ferential stain for the diphtheria ba- cillus: — {A) One gramme of methylene-blue (Gi"ubler's) is dissolved in 20 cubic cen- timetres of 96-per-cent. alcohol, Avhich is then mixed with 950 cubic centimetres of distilled water and 50 cubic centime- tres of glacial acetic acid. (C) Two grammes of vesuvin are dis- solved in 1 litre of boiling distilled water and filtered. The cover-glass preparations are stained in A for I to 3 seconds, rinsed in water, and stained in B for 3 to 5 seconds, washed in water, dried, and mounted. Stained in this manner, the bacilli are brown, and contain two, or rarely three, but never more, blue corpuscles. The corpuscles are oval, not round, in shape, and their diameter appears greater than that of the bacilli in which they are situ- ated. Neisser {Zeitschr. f. Hyg., vol. xxiv, No. 3, p. 443, '97). The examination is made with a Via oil immersion lens. In a large propor- tion of the cases we see an almost-pure culture of the diphtheria bacillus; next most frequently cultures of cocci, single double, or in chains; in some cases the cocci and bacilli are about equal in num- ber, and in a small number only a few diphtheria bacilli are seen scattered among great numbers of cocci. From time to time we see in the cultures ba- cilli which closely resemble the diph- theria bacilli, but with certain definite points of distinction, and pseudodiph- theria bacilli. The diphtheria bacilli seen in such cover-glass preparations vary in length from 1.5 to 6.5 millimetres, and in diameter from 0.3 to 0.8 millime- tres. They occur singly or in pairs, rarely in chains of three or four. The rods are straight or slightly curved and are not usually uniformly cylindrical through- out their length, but arc swelled at the ends, or pointed at the ends and swelled DIPHTHERIA. DIFFERENTIAL DIAGXOSIS. 523 in the middle. The variety in size and shape even from the same culture is char- acteristic. When in pairs, the bacilli may lie with their axes in the same line or forming an acute or obtuse angle; sometimes they are crossed. The bacilli show no spores, but may contain highly,- refractile bodies, especially in their swelled portions. When grown upon blood-serum and stained in the manner above described, the bacilli stain in a peculiarly-characteristic way. Lack of uniformity, both in the individual ba- cillus and in the numbers of groups, is marked. Thus, different parts of a ba- cillus take the stain unequally; so that the ends are dark blue, while the centre shows little or no color, or vice versa. Likewise bacilli lying side by side show marked difference in coloring, one being much more deeply stained than the other. This lack of uniformity in the staining of the bacilli seems to belong to a certain period of their growth; it is usually marked after the twelve-hour in- cubation, but many disappear entirely in older cultures. Mention has already been made of ba- cilli found in cultures resembling the diphtheria bacillus and yet not possess- ing the specific pathogenic properties of that bacillus, and therefore termed pseu- dodiphthcria bacilli. This term is most unfortunate, since these bacilli bear no relation to the throat inflammation termed pscudodiphtheria. As seen in cover-glass preparations, these bacilli are shorter, plumper, and more uniform in size and staining. They are most often met with in cultures from the nose. When obtained in pure cultures, these bacilli have been shown to be devoid of virulence. As seen under the microscope, the uni- formity in size, shape, and staining is sufficiently marked from the variations in these points noted with reference to the diphtheria bacillus to enable prac- ticed observers to recognize them readily. In the diagnosis of diphtheria the sim- ple microscopical method of examining the exudate is a great deal better than any clinical method. All that is needed is a good microscope, with an Abbfi con- denser and oil-Immersion lens. Also a few slides are required, and some LofHer alkaline blue. If one meets with a sus- picious ease, all that is necessary is to ask for a whalebone or stout stick and wrap a bit of absorbent cotton on the end. This swab should be rubbed on the exudate very firmly; then it can be put in an envelope or other simple container and examined in the office. To do this, one should moisten a clean glass slide with a drop of water and rub the swab around in it for a minute. Then the swab sliould be burned and the prepara- tion dried. When it is thoroughly dry, it is passed through a flame three times at such a rate that the exudate is baked and will not wash off. On the other hand, it should not be heated so that the preparation is distorted and scorched. After heating, one should run on the slide a drop or two of Lflffler's blue, sufficient to cover the dried exudate, then wash off the stain, dry thoroughly with blotting-paper, and drop on a little cedar-oil and examine. The whole process takes about a minute or two. If the case is diphtheria, the first thing that will attract the eye are masses of fibrin stained deeply blue. These masses are stringy in texture. In these masses of fibrin and outside pecul- iar bacilli may be seen. They are al- ways more or less curved. They are never of perfectly even width. They are often clubbed at one or both ends, or they may taper at one or both ends. These organisms never take the stain evenly; the substance of the bacilli appears much denser in places, so that the organism appears to have bands or stripes. Bacilli often appear broken in the middle, or there seems to be an achromatic juncture. But what is far more characteristic is 524 DIPHTHERIA. DIFFEEEN'TIAL DIAGNOSIS. the presence of little black or bluish- black points very often situated at one or both poles of the bacUlus, with occa- sionally a little point in the middle. If these point-bearing bacilli are found in the fibrin, one can be very certain that the case is diphtheria. There are many other organisms foimd in diphtheritic membrane by this method, but if they contain chromatin granules and are curved and irregular in outline, they are diphtheria bacilli. If the case is ton- sillitis, by the same method single round cocci or streptococci or diploeocei are to be found, but no chromatin point-bear- ing little rods will be seen. A diagnosis of diphtheria should not be made unless these chromatin points are found. The preparation shotild be properly heated, and it is most impor- tant that the stain be good. A poor stain will not differentiate the chroma- tin points. Chromatin points appear in other organisms, as has been seen in long bacilli grown on potato and found in water, but the organisms were three or four times longer than the diph- theria bacillus; they were straight and of even width, except where the chro- matin points bulged through the con- tinuity, so that the organism resem- bled a jointed bamboo cane. It is said that a bacUlus which is pathogenic for mice also exhibits chromatin spots. But it is rare to find such organisms in the throat, and much rarer to find them in pseudomcmbrane. R. L. Pitfield (Univ. of Penna. Med. Bull., Sept., 1901). Whenever we find the characteristic bacilli above described present in the cover-glass preparations, we can safely set the case down as one of true diph- theria, however few the bacilli may be in number in the smear, or with what- ever other bacteria combined. If the diphtheria bacilli are found at all, a second culture usually shows them greatly exceeding in numbers any other form of bacteria present, and the cases will be found to present the clinical symptoms of diphtheria. In any case, to render the bacteriolog- ical diagnosis complete, it would be nec- essary to obtain the diphtheria bacilli in pure culture and test their virulence by inoculation of susceptible animals. In routine practice this is done by in- oculating half-grown guinea-pigs with from V4 to V2 per cent, of their body- weight of a forty-eight hours' culture of the bacilli grown at 37° C. in simple nutrient or glucose alkaline broth. In carrying out such experimentation many precautions are necessary to render such work accurate and trustworthy. Much time and labor are consumed in the proc- ess. For our purposes it is suiRcient to know that the great majority of those who have carried on such experiments under proper conditions with bacilli de- rived from pseudomembranes and pre- senting the morphological and staining characters of diphtheria bacilli have found the bacilli fully virulent. So long as the bacteriological diagnosis is reinforced by clinical evidence of the presence of false membrane and the symptoms of diphtheria, we can safely trust to the examination of these cover- glass preparations. We find, however, that the examina- tion of healthy throats has led to some remarkable results. In the throats of those who have been exposed to diph- theria, but have remained perfectly well, we may find characteristic and fully viru- lent diphtheria bacilli; in others we may find the pscudodiphtheria bacillus al- ready spoken of, or a bacillus which, while presenting the cultural and mor- phological characters of the diphtheria bacillus, proved in inoculations to be non-virulent. Thus, in a series of 330 healthy throats examined by the New York Board of ITealth, in 8 virulent characteristic diph- theria bacilli were found, in 24 non-vir- ulent characteristic diphtheria bacilli, DIPHTHERIA. ETIOLOGY. 525 and in 27 non-virulent pseudodiph- theria bacilli. Since Hoffmann's obser- vation of these bacilli, so closely resem- bling the Loeffler bacillus, but devoid of virulence, a great deal of attention has been given to this subject. Opinion is still divided as to the relation of these non-virulent bacilli. On the one hand, they are regarded simply as degenerate or attenuated forms of the diphtheria bacillus; on the other, they are repre- sented as a distinct species. The identity of the pseudodiphtheria bacillus seems to be now established. In form these are smaller, shorter, and thicker than the diphtheria bacillus. When seen in stained smears the bacilli are often observed to be lying parallel to one another, in contrast to the irregu- larly-angular disposition of the diph- theria bacillus. In their growth in broth the pseudodiphtheria bacilli de- velop alkali, where the Loeffler bacillus forms acid. They are never virulent. These differences are, by most authori- ties, considered sufficient to warrant the belief that they are a separate species. The other class of non-virulent bacilli found in the throat present all the char- acters of the Loeffler bacillus except their virulence. Roux and Yersin believed these bacilli to be simply attenuated forms of the diphtheria bacillus. It was shown that they are particularly likely to be met with in the throats of those who have had diphtheria some time be- fore, or have been exposed to diphtheria. It was also found that the diphtheria bacillus could be so attenuated by vari- ous methods of growth as to deprive it of its virulence. No one, however, has yet been able to restore virulence to any of the non-virulent forms met with, and the question must be considered as still open. There are 70 varieties of diphtheria and pseudodiphtheria bacilli from the standpoint of agglutination by anti- diphtheritic serum. This property is an inconstant characteristic of the true Klebs-Liifller bacillus, and is in no way related to its virulence. Certain varie- ties of this organism can be aggluti- nated by the serum of horses immunized by cultures, while they do not react to the serum of horses immunized by tox- ins. The pseudobacillus conducts itself toward these sera precisely as does the true organism, and by this means can- not be differentiated from it. Ch. Lesieur (Comptes Soc. de Biologic, Aug., 1901). Etiolo^. — As early as 1879 Klebs is said to have observed the presence of a peculiar bacillus in cases of diphtheria. In 18S3 his observations of the presence of this bacillus in the pseudoraembranes from the throats of those dpng of epi- demic diphtheria were reported and brought to general attention. In 1884 Loeffler published the results of his ob- servations. He had found the bacillus present in the great majority of cases diagnosticated as diphtheria, had been able to obtain the bacillus in pure cult- ure, had inoculated it upon the abraded mucous membranes of suscejjtible ani- mals and thereby produced pseudomem- branous inflammation, often followed by death; he had injected bouillon cultures of the bacillus subcutaneously and had found characteristic lesions after the death of the animals so treated. In 1888 d'Espine found the bacilli present in fourteen cases of typical diphtheria, and proved them to be absent in 24 cases of mild sore throat, not presenting the clin- ical characters of diphtheria. In the same year Roux and Yersin reported that they had found bacilli presenting the characters described by Loeffler in all cases of typical diphtheria. They showed that wlien inoculated upon the healthy mucous membrane of the trachea 526 DIPHTHERIA. ETIOLOGY. of rabbits no effect was produced; but, if the membrane \rere previously abraded tbe symptoms of pseudomembranous lanTigitis in men followed. Congestion of tbe mucous membrane, the formation of pseudomembrane, swelling of the glands and cellular tissues of the neck, dyspncea, stridor, and asphyxia. From that time on numerous observations were made in France, Germany, and America, until, in 1891, Welch declared that all the conditions necessary to the demon- stration of the specific relation of the Klebs-Loeftler bacillus to diphtheria had been met: (1) its constant presence in cases of true diphtheria, (2) its isolation in pure culture, and (3) the production of all the symptoms of the disease by the Inoculation of pure cultures in suscep- tible animals. Since that time evidence has been accumulated from many sources, till there can no longer be any doubt that the essential cause of diph- theria is the growth and development of this bacillus within the body. The de- velopment of the disease must, there- fore, be dependent in every case upon the presence and action of the diphtheria bacillus. The disease is common in all parts of the land. In the cities it is usually en- demic, the frequence and virulence of the disease varying from year to year; in rural communities it usually occurs as distinct epidemics, each new outbreak being dependent upon the introduction of the disease from without. It may also occur sporadically. It does not, how- ever, in any case arise de novo. Each new case is developed by infection, how- ever remote, from some previous one. The infection may be either direct or indirect. Direct infection is undoubt- edly most common. The bacilli arc usually present in great numbers in the discharges from the throat or nose of the patients, in the saliva, and in the membranes which may, from time to time, be coughed up. They are not, so far as evidence is had, present in the breath of the patients, but may abound in the air of the room or rooms inhabited by them. The bacilli have even been reported as present in the urine of patients. The genitals of every female child who contracts diphtheria in its throat should be examined. Coues (Boston Med. and Surg. Jour., May 12, '9S). Direct contact with the discharges from the nose or throat of those suffering from diphtheria is most dangerous. Many a physician has fallen victim to diphtheritic infection received by allow- ing a child to cough in his face during the process of examination. Kissing the patients may likewise be the means of infection in many cases. While severe cases are usually due to the action of virulent bacilli and may, therefore, be especially potent in trans- mitting the disease, it is not to be for- gotten that apparently mild cases may harbor bacilli just as virulent and just as much to be avoided. As already re- marked, the most virulent bacillus Park has met with was derived from a mild case of diphtheria. The cases of virulent pharyngeal diphtheria are most danger- ous on account of the quantity of the discharge. Purely laryngeal cases have little or no discharge, and are conse- quently less likely to spread the infec- tion. The bacteria may linger in the throat for weeks after the disappearance of all clinical symptoms and the patients con- tinue throughout the period to be sources of infection. In 245 of 405 caHcs the diplitlieria ba- eilli disappeared within three days after the complete separation of the false mem- brane; in 100 cases the diphtheria bacilli DIPHTHERIA. ETIOLOGY. 527 persisted in 103 cases for seven days; In 34 cases for twelve days; in 10 cases for fifteen days; in 4 for three weeks; and in 3 for five weeks. In many of these cases the patients were apparently well many days hefore the infectious agent had disappeared from the throat. N. Y. Health Board {Annual, vol. i, "95). Indirect infection may cecur by means of the clothing of the patients, the bedding, carpets, wall-paper, draper- ies, eating- or drinking- utensils, tongue- depressors, swabs, instruments of any kind used upon or about the patient, anything that has come in contact with the infectious discharges. Children's toys or books are especially likely to be contaminated and become means of car- rying the germs to others. In some cases persons who are them- selves perfectly healthy, but who have been in contact with diphtheria cases are found to harbor the bacilli in the nose or throat and may be the source of infec- tion to others. On several occasions the development of a series of cases of diph- theria in a single nursery of the New York Foundling Hospital has led to the examination by cultures of the throats of all children in that nursery, with the result of usually finding two or three who, while apparently healthy, had typ- ical germs in their throats. The isolation of these children would at once break the succession of cases of diphtheria previously observed. It may also happen that physicians or nurses transmit the germs either by their hands or clothing from one case to another. The frequent occurrence of diphtheria in the families of physicians is sufficient evidence of the need of care. [If diphtheria is suspected or ascer- tained, the physician should, before en- tering the sick-room, remove his coat and vest, and cover his body, neck, and extremities with a blouse or a sheet fastened around his neck and body. When the physician has completed his examination, and is about leaving the family, he should bathe his head, face, beard, and hands in an antiseptic lotion, as one of corrosive sublimate or carbolic acid. All articles not required for the comfort of the patient, as carpet, cur- tains, pictures, and decorations, should be removed, and all persons except the physician and those who nurse the pa- tient should be excluded from the sick- room. J. Lewis Smith and F. M. War- ner, Assoc. Eds., Annual, '94.] Apart from the question of the trans- mission of the disease from case to case, many other factors may influence the development and spread of diphtheria. Sex apparently has no influence, but age materially influences the suscepti- bility. Nursing children are, happily, remarkably immune. The greatest sus- ceptibility lies between the ages of two and five years; from five to ten many cases are seen; after ten the suscepti- bility diminishes very rapidly, and in adults it is but slight. The following table of 14:,688 deaths occurring in New York in ten years, tabulated by Billing- ton, illustrates these points: — Under one year 1,214 From one to five years 9,622 From five to ten years 3,212 From ten to fifteen years. . . 311 Over fifteen vears 329 Total 1-1,688 The season of the year exerts some influence. Thus, in England and Wales the average number of deaths for each quarter of the year, from 1870 to 1893 inclusive, was as follows: First quarter, 1000. Second qtiarter, 819. Third quarter, 847. Fourth quarter, 1192. (Thome.) Diphtheria is, therefore, more com- mon during the cold months of fall and winter than during the spring and sum- 528 DIPHTHEKIA. ETIOLOGY. mer. The same fact is borne out by Bosworth's analysis of 1S,6SS deaths from diphtheria occurring in Xew York d\iring thirteen years. Of these 10,769 occurred from October to March, and 7919 from April to September, inclusive. Result of an extended epidemiological inquiry into the incidence of diphtheria, during the twenty years of 1877-96, in the city of Catania (population in 1896, 116,000). During the nine years of 1877- 85 the deaths per 10,000 at all ages were 15.8, while in the nine years of 1886-94 they fell to 7.1, and in the four years of 1893-96 they were only 2.7. These two nine-yearly periods were characterized by a sudden rise in the mortality and a slow decline, but the maximum in the first period (1879) was 34 per 10,000, while in the second period it was 16. Taking the whole twenty years, the influence of season is very marked. The lowest month is August (4.8), and the highest is January (12.25); and taking the summer quarter as June, July, and August, it is 5.71; while the autumn and winter quarters are 10.9 each, and the spring 8.3. The meteorological ele- ments which differentiate the seasons are temperature, relative humidity, and rain-fall. Taking the whole twenty- years' period, it is shown by curves of temperature, relative humidity, and rain- fall that the two latter agree directly with the diphtheria death-curve, while the first agrees with it inversely. The important consideration is the cause of this marked diminution in diphtheria mortality. Serum-treatment is virtually not practiced at all, and disinfection is little followed. It is in general sanitary improvements that the explanation is to be looked for. Giagunta (Gior. d. Soc. ital. d'ig.. No. 8, '98). The massing of cliildren in schools, asylums, and hospitals produces condi- tions favorable to the development and spread of diphtheria, doubtless by in- creasing the chances of infection. The Bchools have often been pointed out as the sources of epidemics of diphtheria, which could only be controlled by clos- ing the institutions concerned. Out of 654 convalescent hospital cases, the bacillus was found in 309 after the entire disappearance of the membrane. Among 107 of these, cultivations from the throat gave negative results for some days, and then the bacillus wotild reappear. Since the same fact was ob- served in discharged eases, this reap- pearance was hardly due to reinfection. The following list shows the time the bacillus was present: — Dirlitheria B«oilh\s Present After Oisiipiioaranoo of Membrane. ■• m •• . ..." 10 to 20 " 5t " . . . . " 20 to SO •• •• 41 " . . . . " 30 to 60 " 6 " . . . . " 60 to 120 " Disinfectants for the throat had been carefully applied. The use of anti- diphtheritic serum did not prevent the persistence of the bacillus in the upper respiratory tract. Holger Prip (Zeit. f. Hyg. u. Infectsk., B. xxxvi, H. 2, 1901). The following section from the Bul- letin of the New York Board of Health is of interest in this connection: — "It has been the practice of the De- partment to plot upon a city map the location and date of every case of diph- theria in which the diagnosis had been settled by bacteriological examination. After several months the map presented a very striking appearance. Wherever the densely settled tenements were lo- cated, there the marks were very numer- ous, while in the districts occupied by private residences very few cases were indicated as having occurred. It was also apparent that the cases were far less abundant, as a rule, where the tenements were in small groups than in the regions of the city where they covered larger areas. At the end of six months there were square miles in which nearly every block occupied by tenement-houses con- tained marks indicating the occurrence of one or more cases of diphtheria; and in some blocks many (15 to 35) had oc- curred. DIPHTHERIA. ETIOLOGY. 529 "As the plotting went on, from time to time the map showed the infection of a new area of the city, and often the subsequent appearance of an epidemic. It was interesting to note two varieties of these local epidemics: in one the sub- sequent cases evidently were from neigh- borhood infection, while in the second variety the infection was as evidently de- rived from schools, since a whole school- district would suddenly become the seat of scattered cases. At times, in a certain area of the city from which several schools drew their scholars, all the cases of diphtheria would occur (as investiga- tion showed) in families whose children attended one school, the children of the other schools being for a time exempt." A number of epidemics have been traced to infected milk, the infection arising from the presence of diphtheria among those engaged in handling the milk. Certain English observers have also claimed to have discovered a specific disease among milch cows, characterized by an eruption of vesicles and pustules upon the udders and teats, accompanied by the presence of the diphtheria bacillus in the local lesions, and capable of being reproduced by infections of the bacilli. Outbreak of dipbtlievia which was traceable to the milk obtained from a particular dairy. Ernest Hart, in 1SS7, gave a summary of 14 epidemics of this disease traceable to milk. Since then a number of cases have been described, Init none which show more conclusively the possibility of milk dissemination of the disease than this epidemic, which oc- curred in Parramatta, a suburb of Sj'dney. The population of the town numbers 10,144, and the location and drainage of the place are excellent. The water-supply is above suspicion. The outbreak of diphtheria occuiTcd in Oc- tober. From the 8th to the 20th of that month 40 cases of diphtheria occurred. In 46 of these the milk supply was derived from a single daiiw, and in the customers 2- supplied from this dairy, aside from the diphtheria cases, there were 05 cases of sore throat. E. S. Stokes (Australasian Med. Gaz., Oct. 20, 1903). Other outbreaks of diphtheria have been attributed to bad drainage, defect- ive sewers, or the presence of an abun- dance of decomposing organic matter. It is also held that certain domestic animals — pigeons, cats, etc. — are susceptible to diphtheria and may be the means of transmitting it to man. However much or little insanitary sur- roundings may contribute to the devel- opment of diphtheria, the active and essential cause must be the diphtheria bacillus, and our hope of limiting the ravages of this disease must be based upon control of the individual cases, each of which is a focus for the farther spread of the infection. The tenacity to life of the bacillus outside the body is remarkable. Hof- mann found that it would live for one hundred and fifty-five days on blood serum; Loeffler and Park for seven months; and on gelatin Klein found it living after eighteen months. On bits of dried membrane found living bacilli after fourteen weeks. Park after seven- teen, and Eoux and Yersin after twenty weeks. Abel says that, dried on silk threads, they may live one hundred and twenty-two days and upon a child's play- thing, kept in a dark place, he found the bacilli alive after five months. The period of incubation of diphtheria varies from two days to a week. It is doubtless affected by the number and virulence of the organisms present and by the resisting power of the patient. In most cases it is impossible to determine the time of exposure, nuich less that of infection. Second attacks of diphtheria are rare, but do occur. In one case ob- served at the Xew York Foundlinsj Hos- pital, a boy of 4 had croup in March. 34 530 DIPHTHERIA. PATHOLOGY. The diphtheria bacilli were demon- strated in cultures from the throat. Antitoxin was given and he recoTered. Twenty-five days later, having been ap- parently well in the meantime, he devel- oped tonsillar diphtheria, which ex- tended to the larynx, pneumonia devel- oped, and death followed, thirty-four days from the conclusion of the first at- tack. Pathology. — The bacteriological in- vestigations of recent years have materi- ally affected our views of the pathology of diphtheria, "^^e have learned that the local lesions of the mucous mem- branes really constitute a very subsidiary part of the process. In them the diph- theria bacilli grow and multiply, devel- oping in their growth certain organic substances, termed toxins, which are readily absorbed into the circulation and by their action produce constitutional symptoms and remote affects more char- acteristic of the disease than the local lesions themselves. The diphtheria ba- cilli have been found not only upon the mucous membranes, but in the lungs, liver, spleen, lymph-nodes, kidneys, and even upon the valves of the heart. They are not, however, present in great num- bers in any of these organs; in fact, they are, except possibly in the case of the lungs, so few in number as to be demon- strable only by means of cultures. Their presence in the viscera does not excite characteristic lesions of these parts, and seems to be an accidental accompaniment rather than an essential part of the dis- ease. The action of the toxins, on the other hand, is characteristic and impor- tant. These substances have been iso- lated and studied especially by Brieger and Fraenkel, Roux and Yersin. They have been found to be allied to the al- bumins, and have been designated as toxalbumins. In experimental inocula- tions in susceptible animals, as shown by Welch and Flexner and others, they have been found to produce all the char- acteristic features of diphtheria except the membrane, especially the character- istic post-diphtheritic paralysis. The most striking of their remote effects are produced in the lymph-nodes and liver. In the lymph-nodes they produce a dis- tinct hyperplasia; in the liver necrosis or death of small areas of liver-cells, focal necroses, similar to those seen in the liver in typhoid fever and other in- fectious diseases. We must, therefore, believe that the presence of these soluble poisons in the circulation constitutes a very important , feature of diphtheria. These toxins, as I already noted, are elaborated in the local I lesions of the mucous membranes, and not by the bacteria that may be present in the various viscera. The quantity and quality of the toxins generated seem, as a rule, to be proportionate to the severity of the local process. The following results are reached from a study of the constitution of the diph- theria poisoning: I. The diphtheria ba- cillus produces two kinds of substances: (a) toxins and (6) toxons, both of which combine with the antitoxin. Toxins and toxons have been found in three fresh bouillons in the same quantitative rela- tion. 2. The toxins, and probably also the toxons, are not simple bodies, but they break up into various subdivisions, which differ in their affinity for the anti- toxin. Three groups can be distin- guished: prototoxins, deuteroto.xins, and tritotoxins. 3. This division does not exhaust the complication, for it must be assumed that each species of toxin con- sists of exactly two equal parts of dill'er- ent character, which have the same rela- tion to the antitoxin, but differ in their destructive influence. They probably differ from each other like dextrorota- tory and levorotatory substances. 4. One of these constituents is called x-modiflca- tion, and this is readily transformed in DIPHTHERIA. PATHOLOGY. 631 all toxins into to.\oids. This transfor- mation begins already in the incubator. Owing to the disappearance of one-half of the poison, the complete raetamorpho- sis into to.xoid causes a semivalent toxin to remain, called hoemato.xin. 5. The sec- ond modification, beta-modification, is in the different species of poisons, prototox- ins, deutcrotoxins, and tritotoxins of variable permanency. The beta-modiii- cation of the deuteroto.xins ia the most stable. This explains the fact that after a time diphtheria-bouillon reaches a stage of definite toxicity that is perma- nent; whence only those poisons that have entered this state should be used as diseased toxins. G. In the change of toxin into toxoid the affinity of the anti- toxin is not in the least modified, and the toxoid of the prototoxin, for example, binds the antitoxin in the same way as the prototoxin itself does. The varieties of poisons combining less promptly with the antitoxin are less readily destroyed by the latter than those that combine with it more promptly. 7. Regarding the significance of the Lq and the L-t- dose, it is to be noted that the Lo dose is sub- ject to greater variation than the h + dose. 8. The facts developed are best ex- plained by assuming that in the toxin- molecule two independent atom-com- plexes are present. One of these is hap- tophorous, which causes the binding of the antitoxin to the corresponding lateral chain of the cells. The other is tox- ophorous; I.e., the cause of the specific action. The same is true of the toxons. 9. The haptophorous group is responsible for the combination of the toxin-mole- cule with the cells and thus of render- ing the latter amenable to the influence of the toxophorous group. 10. The effects of the haptophorous and tox- ophorous groups can in certain cases be separated experimentally. Morgenroth has shown that the nen-ous system of the frog fixes tetanus-poison in the cold; disease-phenomena do not arise under these circumstances. If the frogs, which have been treated at proper intervals, first with poison and then with anti- toxin, are placed in the incubator, tet- anus develops even when all the circu- lating poison has combined with the antitoxin, and even when the latter is present in excess. The haptophorous group thus acts already in the cold, the toxophorous only after the application of heat. 11. The temporal difference in the action of the haptophorous and tox- ophorous groups explains also the incu- bation period. 12. The toxophorous group is iiioie complicated and less permanent than the haptophorous. The anti-bodies produced by the influence of the poison act exclusively on the haptophorous group. By combining, through the medi- ation of this haptophorous group, with the entire toxin-molecule, they prevent the toxophorous group from acting upon, the organs. 13. The specific antitoxin can also be produced with toxoids, but the immunity cannot be used to procure curative serum. The toxons probably play an important rule: In natural im- munity, i.e., in the form in which, not the poisons isolated, but the causative agents themselves are the factors. Tox- oids are decomposition-products of the prepared toxin. 14. It is probable that prototoxins also are, under certain cir- cumstances, capable of bringing about a direct cure, by displacing the poison from the tissue-elements by reason of their stronger affinity for the latter. Paul Ehrlich (Deiit. med. Woch., Sept. 22, '98). Catarrhal Diphtheria. — As we have already seen, the local effects of a diphtheritic inflammation vary greatly. In catarrhal diphtheria we see simply redness and some swelling of the mucous membrane of nose, throat, tonsils, or larynx, usually with an increased secre- tion of the mucous glands. Xone of these would show macroscopically in the rare cases, when death follows such a process. Oertel has, however, found in these cases degeneration of *he epithelial cells of the mucous membranes similar to those seen in pronounced cases of diphtheria. The DirnTHERiTic Membrane. — The membrane is most frequently seen upon the tonsils, soft palate, uvula, phar}Tix, 532 DIPHTHEEIA. PATHOLOGY. nares, larynx, trachea, or bronchi. lu scTere cases it may appear upon the lips, especially at the angles of the mouth, the buccal mucous membrane, and the tongue. Very rarely it appears in the oesophagus, stomach, or intestines. In fact, the freedom of the cesophagus, when the diphtheritic membrane may be seen completely covering the pharjTix and tonsils and extending throughout the whole respiratory tract even to the ter- minal bronclii, is most remarkable. Even in the severest cases the membrane usu- ally stops abruptly at the beginning of the oesophagus. It is also possible to observe a true diphtheritic membrane upon abraded cutaneous surfaces; upon woimds, as in tracheotomy; or upon the conjunctiva or the genital mucous membrane. The color of the membrane may be white, gray, greenish white, yellow, or more or less black, when there has been hsemor- rhage from the affected surfaces. It may be thick and elastic, so as to be stripped off in sheets, or thin and diffluent. The thicker membrane is observed iipon the surfaces covered with columnar epithe- lium, with a definite basement-mem- brane, such as the nose, larynx, trachea, and bronchi. Here, too, it is but loosely attached; so that it is often thrown off in casts during life, or after death may easily be stripped off from the under- lying surfaces. Upon the tonsils, pharynx, uvula, and fauces, where the epithelium is of the squamous variety and without a basement-membrane, the diphtheritic membrane is much more closely attached. Often in these situa- tions we see, after death, no distinct membrane, but a diffluent exudate, which may be easily washed off, leaving a dis- tinctly-ulcerated surface beneath. Microscopically the membrane or exu- date is found to consist chiefly of fibrin. mingled with epithelial cells from the mucous membrane, pus-cells, red blood- cells, granular material, and bacteria. The superficial parts of the membrane are granular in character, while beneath we find a more or less distinct net-work of fibrin, inclosing within its meshes the cells, granular material, and bacteria. The bacteria are the diphtheria bacilli together with streptococci or staphylo- cocci, and rarely pneumococci. The in- flammatory process may be superficial or may extend irregularly into the mucous membrane, in some cases involving the submucous tissue and even the muscular coat. The bacteria may likewise pene- trate deeply into the tissues, but are usually most abundant in the superficial parts of the membrane. The epithelial cells of the mucous membrane undergo degeneration, their protoplasm becoming granular, their nuclei fragmented, and the cells ultimately breaking up into granular material. The pathological process is, therefore, a coagulation-ne- crosis involving the mucous membrane more or less deeply. The pseudomembrane is cast off in masses or is gradually disintegrated, with more or less destruction of the mucous membrane. The process of separation is usually attended by a more abundant cellular exudation beneath the pseudo- membrane. Except in the gangrenous cases apart from the tonsil, in which there may be extensive destruction of the tissues, the integrity of the mucous membrane is completely restored, leav- ing no traces of the preceding disease. Gangrene is not properly a part of the diphtheritic process, but is brought about either by especially-unfavorable condi- tions affecting the vitality of the patient and by the invasion of unusually-virulent bacteria other than the diphtheria ba- cilli, probably the streptococci. DIPHTHERIA. PATHOLOGY. 533 The seat and distribution of the mem- brane vary greatly in different cases. The point of importance with reference both to symptoms and prognosis is the involve- ment of the larynx. Of 1000 cases ana- lyzed by Lennox Browne, the larynx was involved in 159, in only 4 of which num- ber was the affection limited to the larynx. In a similar analysis of 109 cases by Holt, the larynx suffered in 4G, in 10 of which the disease involved either the larynx, or the larynx with the trachea or bronchi. Holt gives no purely nasal cases in his series; 2 are given by Bro^vne. In the great majority of cases the mem- brane is found upon the tonsils or the adjacent parts, the pharynx, uvula, and pillars of the fauces. Six hundred and seventy-two of Browne's 1000 cases showed such distribution. Since extension of the membrane usually increases the severity of the case and the probability of death, the clinical records of Browne show the comparative frequency of the various forms better than tables which are largely formed from autopsy records. Laryngeal cases are also much more frequently met with in children's hospitals or asylums than in dispensary or private practice. In cases involving the nasal cavities the process is often catarrhal, and there may be no macroscopical lesion after death. In many such cases, however, there may be membrane in the rhino- pharynx, the adenoid tissue of the vault of the pharynx being a favorite seat of the disease. When membrane is devel- oped in the nose, it is usually thick and but loosely attached; so that it may readily be thrown off as casts of the nares. LTpon the tonsils the membrane may be found only in the crypts, resembling a follicular tonsillitis, or it may be in scattered patches, or may completnly cover the surface. It is closely adherent. The tonsils are swelled and may even meet in the median line. In most cases the membrane spreads to the surround- ing jjarts: the phar^-ngeal walls, the fauces, or uvula. The epiglottis is also frequently involved in these cases, even when the larynx is not affected. The membrane often extends into the rhino- pharjTix and thence may pass to the Eustachian tubes and the middle ear. Upon the uvula or fauces the membrane is usually thicker and more loosely at- tached than that upon the tonsils. The uvula is swelled and cedematous. The epiglottis, if involved, is swelled and thickened and one or both surfaces may be covered with membrane. After death the membrane upon these parts does not show as clearly as during life, and we are apt to find a more or less marked ulcera- tion of the parts. The epiglottis fre- quently shows considerable destruction of the mucous membrane. Microscopic- ally the pathological process may extend deeply into the submucous or even the muscular coats of these parts, but the ulceration rarely extends beyond the superficial epithelium. In cases where the membrane appears upon the pharjTi- geal walls it will be found to stop short at the level of the cricoid cartilage, the esophagus being perfectly normal. The appearances in the larynx are quite different from those met with in the throat. The laryngeal process may be simply catarrhal, even when there is abundant membrane in the throat and there have been marked laryngeal symp- toms; so that the larynx after death may appear normal, or there may be a slight congestion of the mucous membrane and the vocal cords after death. In other cases we see a finely-granular deposit upon the cords and mucous membrane, and the ventricles of the larvnx niav he 534 DIPHTHEKIA. PATHOLOGY. filled by a yelloTrish-white exudate, but there is no distinct membrane. Again we may see a distinct membrane mask- ing the cords, obliterating the ventricles, and covering the mucous membrane be- low. When there is either exudate or pseudomembrane present in the larj-nx, it is rarely limited to that part, but will be found to extend into the trachea and bronchi, and even the lungs. In the trachea we may see scattered areas of membrane, or the membrane may line the whole extent of the respiratory tract. There is usually a much more distinct membrane in the trachea than in the larjTix itself. Upon these surfaces the membrane is but loosely attached; so that it may be coughed up in complete % ■:■>>'.:'' -Aour one. It was more marked in the 24-hour one. The fi.xed connective-tissue cells in all periods, from 1 to 24 hours, appeared swelled. At no period were there discernible signs of fragmentation of the nucleus nor of proliferation of the cells. The number of wandering cells seemed to vary di- rectly with the length of the period up to 24 hours. In 1-hour and 2-hour sec- tions the majority showed almost a uni- form staining with ha;matoxyIin. Frag- mentation of nucleus was seen most markedly in 24-hour sections, though it was also seen, but to a less degree, in lO'/.-hour .sections. In cells apparently endothelial in character the chromatin net-work stained faintly with haimatoxy- lin, but was distinct. They were present in all sections, perhaps in greatest num- bers in the latest ones. In most sec- tions there were signs of cloudy swelling of the superficial muscular fibres. In the second series treated with toxin and a half-neutralizing dose of antitoxin it was impossible to be sure of the reality of cedema before 5 '/'; hours after injec- tion. This period was increased up to 24 hours. Connective-tissue fixed cells ap- peared swelled in twenty minutes' sec- tion, and this swelling was present in all sections. The changes in the wandering cells seemed to be similar to those in Series 1. The results of the third series treated with toxin and fully-neutraliz- ing dose of antitoxin were practically the same as in the second series. The points elucidated by this research seem to be: (1) that the cellular changes are degenerative, and that there is no indi- cation of proliferation of affected cells; and (2) that antitoxin, whatever may be its antagonistic effect generally, does not locally act as a chemical antidote to the toxin. J. J. Douglas (Brit. Med. Jour., Sept. 3, '9S). We have, as yet, no means of determin- ing accurately the dose of antitoxin suit- able to each case of diphtheria. It de- pends upon the severity of the case, the time of injection, and to a slight extent upon the age of the patient. We judge of the severity of the case by the location and extent of the membrane and the de- gree of constitutional depression. The tendency is constantl}^ toward the use of larger doses of the antitoxin. In the early days of its use the antitoxin was comparatively weak and large quantities, as much as 20 cubic centimetres, were required for a single dose. Many of the unfavorable results at first reported were doubtless due to the large quantities of horse-serum which it was necessary to inject. It was also a difficult and painful procedure to introduce such quantities of fluid hypodermically. The antitoxin now used is many times stronger; so that even the largest doses rarely require more than 5 cubic centimetres. This concen- tration of the serum leaves us mucli more free in increasing the power of the first injection. For children under two years of age, DIPHTHERIA. TREATMENT. ANTITOXIN. 553 severe cases, including all larjmgeal cases, are usually given 1000 units, mild cases 600 to 700 units for the first dose. For children over two years, in severe cases, including all laryngeal, 1500 to 2000 units are employed, in mild cases 1000 units for the first dose. Some physicians employ stronger doses than these; as much as 3000 units may be given at a single injection. If no marked improve- ment follows the first injection, the dose may be repeated in from twelve to twenty-four hours. Third injections may be given, but are rarely necessary and are of little benefit, as the antitoxin has but little influence by that time. In communities in which diphtheria is prevalent, 60 units sufficient to afford protection. Among 10,000 thus treated only 10 acquired diphtheria. To those who developed diphtlieria after the GO units and had a mild attack, neverthe- less 150 units should be given. When infection is virulent, GOO units: a full curative dose. Several doses at inter- vals more serviceable than a single large dose. Behring (Deutsche med. Woeh., Nov. 15, '94). Quantity required in a case varies from 1000 to 4000 units of Behring's standard, according to the weight of pa- tient and severity of the disease. W. H. Park (Med. Fortnightly, Dec. 2, '95). From 1 '/» to 2 V: drachms are enough for benign cases taken at the onset; 4 to 6 drachms in severe cases or when they have passed several days; up to 1 ounce or even beyond in very severe cases. When breathing is embarrassed tracheotomy may be rendered unneces- sary by an injection of 4 to 6 drachms, followed by another of from 2 '/a to 4 drachms if improvement is not satisfac- tory. Better to inject at onset a dose of serum stronger than necessary, cut- ting short the malady rather than to inject weak doses at intervals. In in- fants under 1 year old as many as 15 minims may be injected as the child numbers months. In adults not neces- sary, unless case extremely grave, to inject more than 4 to 6 drachms the first time. Rous (Med. Press and Circular, Mar. 20, '95). That GOO units the most beneficial dose proved by the collective investigation of the Deutsche medicinische Wochenschrift, bearing upon 10,312 cases. Average per- centage of G per cent, of deaths when 000 units used, average percentage of 14.6 when 1000 units used. (Annual, '9G). Obseivation on a series of cases of diphtheria that occurred in hospital, a wide-spread epidemic being imminent. In this outbreak none of the children waa removed, but all that had been in any way exposed, 110 in number, were promptly immunized. The doses admin- istered ranged from 250 to 500 units, according to age of child. Four or five of these children had sore throats with small patches on the following day. Each of these and all that had already developed the disease received 1000 units each. The result was a prompt recovery in every instance and no new cases have appeared in the institution since. About same time 41 cases of diph- theria appeared in rapid succession in another institution. All were more or less complicated with measles and scar- let fever. Four initial cases did not receive the serum-treatment and all died. The remaining 37 cases received anti- to.xin treatment and but 2 died. Deduct- ing the fatal cases, without a single ex- ception, the 174 antitoxin-treated cases developed no sequela;, either those re- ceiving curative or immunizing doses. J. H. Lopez (Med. News, July 30, '93). Children under eight years of age are given an initial dose of 500 immunizing units, to be repeated at intervals of six hours if the fever does not fall, if the strength of the patient does not improve, or if the local manifestations are spread- ing. To children over eight years of age, 1000 immunizing units are given as an initial dose, and repeated at intervals of eight to twelve hours if necessary. J. H. Musscr (Univ. Med. Mag., Mar.. 1900). For fifteen years before the diphtheria antitoxin was used the average number of deaths yearly was 2373; for the four years since the use of antitoxin the average was 1341. In mild cases, seen early, 1000 units are recommended; in 554 DIPHTHERIA. TKEATMENT. ANTITOXIN. mild cases, seen late, 1000 to 2000 units; in severe cases, seen early, from 2000 to 4000 units; and in severe cases, seen late, an initial dose of not less than 3000 or 4000 units. W. H. Park (Phila. Med. Jour., Mar. 31, 1900). A clinical study of 2093 cases shows that the recovery of the patient depends almost entirely on whether or not anti- toxin is administered early enough and in sufficient quantity. The amount of diphtheritic membrane alone is an im- perfect guide ; it is often necessary to continue giving antitoxin after this has disappeared, for evidences of toxaemia sometimes outlast the false membrane. Clinical experience teaches that the effects of antitoxin are only salutary, and that there is no danger in giving too much. It also teaches that the sooner the total amount of antitoxin required can be given, the better. In the cases mentioned, therefore, 4000- unit doses were given and repeated every four hours as long as was neces- sary. In some exceptionally severe and late cases 4000 units were given every two hours, and in some cases 8000 units every four hours. Some patients thus received large quantities of antitoxin, and some moribund and apparently hopeless cases were saved from death. Indeed, some of the recoveries that have attended this mode of treatment were so wonderful that only those who saw them could appreciate them. F. G. Bur- rows (Amer. Jour. Med. Sci., Feb., 1901). The injections of antitoxin may be made upon almost any part of the body, now that the quantity of serum used is comparatively small; the abdomen, thighs, or back may be preferred. An hypodermic syringe capable of holding 5 cubic centimetres is most convenient, but the ordinary hypodermic may be used in emergency. Some slight pain, red- ness, and redema may be seen at the site of the injection, but nothing more, if proper care be taken in making the in- jection. Reduction of poHt-injcetion accidents by heating the scrum. In 189.'3-90, out of 1365 patients treated with unheated serum, 208, or 15.2 per cent., suffered from post-injection accidents. In 1897, however, of 251 patients injected with the warmed serum, accidents were mani- fested in only 12, or in 4.7 per cent. The method of preparing the serum is as follows: It is collected under condi- tions of as perfect asepsis as possible, and without the addition of any anti- septic, and is put into small flasks of the capacity of ten cubic centimetres, closed with a cork and a capsule of caoutchouc. These flasks are kept for twenty minutes at a temperature of be- tween 138° F. and 139° F. The heated serum is no way inferior to that not so treated. Spronck (Gaz. Hebd. de M6d. et de Chir., Apr. 21, '98). General eruptions may be seen in a large percentage of the cases in which antitoxin is used, if watch be kept for them. The eruption is in the form of an urticaria, as a rule, and develops about the tenth day after the injection. It may be transient and give no trouble or may continue for several days and be very annoying. Temporary albuminuria has been re- peatedly noted after immunizing doses of antitoxin, but this disturbance of the kidneys has always passed off without symptoms or sequelas. Swelling of the joints has also been reported in some cases, but must be very rare. These sequelfo of the use of anti- toxin seem to be dependent upon the quantity of serum employed in the injec- tion, and have certainly been much less frequent since the concentration of the antitoxin has allowed the use of smaller quantities of the serum. The effects of the antitoxin upon the diphtheritic process may be almost im- mediate, and should be evident within twenty-four hours in all cases. Although it has no bactericidal power whatever, it affects both the local and the general condition. In the throat an advancing DIPHTHERIA. TREATMENT. ANTITOXIN. 555 process stops or at once begins its retro- gression. The amount of discharge les- sens, the swelling diminishes, the mem- brane ceases to spread, begins to soften, and becomes looser. The favorable in- fluence is quite as marked in the larjiix as upon other parts. The stenosis is re- lieved, as a rule, and the membrane is more rapidly thrown off. The general testimony is that, of the laryngeal cases, a much smaller proportion requires operative treatment for the relief of the stenosis since antitoxin has been used. If intubation is resorted to, the tube is more often coughed out, or can be removed earlier than under any other form of treatment. In 1892 the mortality of 5540 cases of intubation was G9.5 per cent.; 30.5 per cent, recoveries. In the cases treated with antitoxin and operated upon, the mortality was 27.24 per cent. The mor- tality of laryngeal diphtheria at present rests at 21.12 per cent.; 60 per cent, approximately have not required intu- bation; and the mortality of operated cases is at present 27.24 per cent. Mc- Naughton and JIaddren (Med. News, May 15, '07). In Boston the mortality in the intuba- tion-cases has fallen since 1895 from 83 per cent, to as low as 23 per cent, in those cases intubated this year. There have been 15 cases of diphtheria of the eye. In only one case there was de- struction of the eye, and this organ was not in nomial condition at the beginning of the attack; it is believed that there would have been a number of cases of blindness had it not been for the anti- to.xin. Large doses should be given early in the disease. J. H. McCollum (Boston Med. and Surg. Jour., Aug., '98). In the epidemic of diphtheria at Col- chester during 1901 one of the most marked features was the fall in case- mortality at the isolation hospital after the routine use of antitoxin. Previous to July IGth antitoxin seems to have been employed only in the bad cases, and the mean case-mortality during this period was 25.9 per cent., while during the same time the mean case-mortality among patients treated at home was only 10.8 per cent. From July 10th onward antitoxin was administered as a routine measure. There was immedi- ately a remarkable diminution in the ease-mortality, and for all the cases up to the end of December the mean case- mortality became 5.8 per cent. It is notable that the case-mortality among the cases treated at home during the same period not only did not diminish, but was rather higher than before, — viz.: a mean of 14.5 per cent. The diminution in the number of deaths, therefore, at the isolation hospital was not due to a diminution in the severity of the disease, but must be ascribed to the use of antitoxin; it was, moreover, abrupt, and coincided exactly with the administration of antitoxin. Bacteriological examination of the throats of the school-children proved of considerable value in controlling the epi- demic. All children coming from houses in which a ease of diphtheria had oc- curred were examined, and were not admitted to the various schools until notified as being free from diphtheria bacilli. As regards the Hofmann bacil- lus, the opinion is expressed that it has no relation with the true diphtheria bacillus. Diphtheria bacilli were found to persist for a long period in the throat; in healthy children who had not been attacked up to ninety-four days; among those who had suffered from an attack up to eighty-seven days. Graham-Smith (Jour, of Hygiene; Treat- ment, May, 1902). The constitutional effect of the injec- tion is as marked as the local. Usually the temperature falls within twenty-four hours, the pulse improves, the mind is clearer, and the patient is evidently bet- ter in every way. Rich temperature with con-csponding rapidity of pulse, varying according to age and form of disease, fell following day and was normal third day when no 556 DIPHTHERIA. TREATMKNT. ANTITOXIN. complications present. Distinct dispar- ity between temperature and pulse fre- quently present. Disturbances of the circulatory system, among 154 cases, caused no deaths and did not in any noticeable way hinder recovery. Variot (La Semaine M§d., Mar. 6, '95). Rise of temperature always an im- portant one; return to normal then very gradual, but temperature often remains very high; repetition of injection caused renewal of the effect produced. Kurt Miiller (Berliner klin. Woch., No. 37, '95). Prompt fall of temperature accom- panied by remarkably improved sub- jective sensations, typically altered course of fever. Heubner (Weber die Erfolge der Heilserum-behandlung bei Diphtheric, '95). Temperature of 106.6° F. twenty hours after injection in a child and later on the disparity noted by Variot between tem- perature and pulse. Legendre (Annual, '96). Rise in temperature after injection not only with antidiphtheritic serum, but also with artificial serum of Hayem and with the serum of non-immunized animals. Hutinel, Debove, and Sevestre (Annual, '96). The cases apparently severe or fatal are transformed into mild ones. Bag- insky tells us that, in recording the ef- fects of antito.xin upon the various types of diphtheria, he found it necessary to require his assistants to write their judg- ment of the severity of the cases upon the admission card, when each case was first seen, since the antitoxin in most cases completely changed the picture. The time of the injection has a most vital relation both to the immediate ef- fect and to the ultimate outcome of the case. In experimental work an animal can usually be saved from a fatal dose of diphtheria toxin, if antitoxin is given within forty-eight hours, but not later. Clinically good results can usually be had if antitoxin is given within three days of the onset of the diphtheria, hut later than that its influence is greatly lessened. In the "Antitoxin Eeport of the Ameri- can Pediatric Society" the mortality of first-day injections was 4.7 per cent.; of second day, 7.4 per cent.; of third day, 8.8 per cent.; of fourth day, 20.7 per cent., and of fifth day, 35.3 per cent. Report of the American Pediatric So- ciety's collective investigation into the use of antitoxin in the treatment of diphtheria in private practice. Result as influenced by the time of in- jection: 5794 cases with 713 deaths, — a mortality of 12.3 per cent., including every case returned; excluding 218 cases moribund at the time of injection, or dying within twenty-four hours of the first injection, the mortality was only 8.8 per cent. Of the 4120 cases injected during the first three days there were 303 deaths, — a mortality of 7.3 per cent., including every case returned. If, again, the mori- bund cases are excluded, there were 4013 cases with a mortality of 4.8 per cent. After three days the mortality rises rapidly, and does not materially differ from ordinary diphtheria statis- tics. Results as modified by age of the pa- tients: The highest mortality is found to be under two years; but including all cases returned, even those moribund when injected, the death-rate was but 23.3 per cent. After the second year there is a steady decline in mortality up to adult life. Of 359 cases over 15 years old, there were but 15 deaths. Paralysis: Out of 3384 cases paralytic sequelce appeared in 328 cases (9.7 per cent.). Of the 2034 cases which recov- ered, paralysis was present in 276, or 9.4 per cent. Of the 450 cases which died, paralysis was noted in 52, or 11.4 per cent. Sepsis: This is stated to have been present in 362 out of 3384 cases, or 10.7 per cent. It was present in 145, or 33 per cent., of the fatal casCH. Nephritis: Nephritis was present 350 times, or in 10 per cent, of the cases. The statements on this point are not quite satisfactory. DIPHTHERIA. TREATMENT. ANTITOXIN. 557 Whole number of cases of laryngeal diphtheria, 1704; mortality, 21.12 per cent. (SCO deaths). The cases occurred in the practice of 422 physicians in the United States and Canada. Operations employed: — (a) Intubation in 637 cases; mortal- ity, 20.05 per cent. (IGO deaths). (6) Tracheotomy in 20 cases; mortal- ity, 45 per cent. (9 deaths). (c) Intubation and tracheotomy in 11 cases; mortality, 03.03 per cent. (7 deaths). Number of States represented, twenty- one, the District of Columbia, and Can- ada. Non-operated cases, 1030, — 00.79 per cent, of all cases; mortality, 17.18 per cent. (178 deaths). (Archives of Pediat- rics, July, '96.) In Japan, prior to serum-therapy, the mortality was 50 per cent.; after its use in 353 cases the mortality was 8.78 per cent. Of 110 cases in which injections made within forty-eight hours after in- vasion, all ended in recovery. Of 33 eases treated after eighth day of the disease 11 were lost. Kitasato ("Serum Treat, of Diph.," '96). In GOO cases of diphtheria treated, one-half were given antitoxin, the other half had no antitoxin. The Klebs-Loef- fler bacillus was found in all cases. The cases were treated in the same hospital, had exactly the same food, drugs, and stimulants. In the 300 cases treated with antitoxin there were 129 tracheotomies; 60 died, the death-rate being 20 per cent. In the 300 cases treated without anti- to.xin there were 199 tracheotomies and 158 deaths, — a death-rate of 52.7 per cent. The earlier the ferum is used, the better the results; however, it is of value even when given laic. In 20 per cent, of laryngeal cases, even when there is dyspnoea, it lessens the necessity for operation. Clubbe (Brit. Med. Jour., vol. xi, p. 1177, '97). Statistics from the Imperial Board of Health in Berlin: The reports, gathered from April, 1895, to JIarch, 1896, were furnished by 258 physicians from 204 institutions. Of 9851 cases of diphtheria treated with antitoxin, 1489 proved fatal, or 15 '/, per cent. After deducting the absolutely hopeless cases, which perished within the first twelve hours after they were seen, the mortality is reduced to 14 Vio per cent. Adding to these 9851 cases the result of a former report (Jan- uary to April, 1S85) and 1328 cases from March to July, 1890, published later, a total of 13,137 cases, divided over eight- een months, furnished a mortality of 20S2, or 15 •/,„ per cent. Of these, 4085 patients, or 42.6 per cent., presented the laryngeal variety, 2744 of which were operated upon, with a mortality of 32 Vio per cent. The mortality of cases treated on the first day was 0.6 per cent.; that of those treated on the second day, 8.3 per cent.; of those treated on the third day, 12.9 per cent.; of those treated on the fourth day, 17 per cent.; and of those treated on the fifth day, 23.2 per cent. Dieudonne (Internat. Med. Mag., Dec, '97). During the year 1896 there were ex- amined at the laboratories 7832 cases that had been certified "diphtheria." Of these cases, 50G8 had diphtheria bacilli in the throat and 1302 suffered from pa- ralysis of a more or less marked kind. Of these cases, 1096 had been treated with antitoxin, and there were 273 deaths among them; 266 received no antitoxin (that is, they were most of them mild cases in all probability), and there were 49 deaths. In 1704 of the cases examined in which no diphtheria bacilli were found, there were 177 cases of paralysis with 59 deaths; 89 of these cases were treated with antitoxin — 31 deaths. There were, moreover, 88 not treated with antitoxin, 28 of these suc- cumbing. G. Sims Woodhead (Brit. Med. Jour., Sept. 3, '98). There is no longer any doubt as to the curative action of antitoxin in diph- theria. Of 1.5,792 cases injected during 1002 with antitoxin furnished free of oliarce by the Dopartnient of lloaltli or by its inspectors, 1S60 died, a case fatal- ity of 11.8 per cent. If the cases mori- bund when injected (722 in number) are deducted the case mortality is further reduced to 7.5 per cent. 55S DIPHTHERIA. TEEATMElfT. ANTITOXIN. The one fact, important if not new, brought out in this report is tlie great advisability — the almost imperative necessitT — of the earliest possible admin- istration of antitoxin. Of 1702 eases injected on the first day of the disease, only So patients died (including mori- bund cases), a case mortality of 4.9 pei cent. Comment is unnecessary. J. S. Billings, Jr., (N. Y. Med. Jour, and Phila. Med. Jour., Dee. 12, 1903). Coupling the danger of delay with the harmless nature of the antitoxin, it is quite plain that antitoxin should be given in every case where the diagnosis of diphtheria is probable. Only in mild cases may we wait for the bacteriological diagnosis. Especially in all laryngeal cases shoidd the immediate use of anti- toxin be advised. Xo harm is done if the case is not diphtheria, and, if it is, a great advan- tage is gained. We may safely assume that the use of antitoxin is harmless, for if all the re- ported cases of sudden death or aggrava- tion of cardiac or renal disease or other unfavorable influence were accepted as proved, they could not, for a moment, be weighed against the accumulated evi- dence of the curative effect of antitoxin in diphtheria. Effect on the kidneys of small pre- ventive doses (2 to 3 centimetres) of diphtheria antitoxin studied in 73 cases, and shows no deleterious influence. No traces of albumin were discovered in the urine. Also report of a case of severe scarlet fever and nephritis in which diphtheria supervened, and larger doses of tlie antitoxin (10 centimetres) were administered. The diphtheria was arrested at once, and the nephritis also seemed to be favorably affected and re- trogressed, although more slowly. Ro- janski (Botkine's Gazette, No. 30, '90). Since the introduction of the antitoxin treatment the incidence of paralysis following diphtheria has certainly in- creaned. The reason of tliis is believed to be that patients now recover, or, at any rate, live long enough to show symp- toms of paralysis, who without antitoxin would have died at an earlier period. Though the number of cases of paralysis, relatively as well as absolutely, has in- creased, the number of fatal cases has diminished. If the serum-treatment were commenced early enough, the number ot cases of paralysis would be lower instead of higher than before. E. W. Goodall (Brit. Med. Jour., Sept. 3, "98). Antitoxin has been given in large doses in guinea-pigs and rabbits, but a case has never been seen in which by itself it had produced any paralytic symptoms. The heart fails earliest and most fre- quently because it is the organ which really gets least rest. This condition of overwork and ill nutrition is the great factor even in those paralyses that ap- pear later. The poison does its work, but it is only when muscle and nerve are called into functional activity that the damage is unmasked and the tissues give way under a strain which in health they would readily stand. Cases of paralysis are now not so fre- quent as formerly; and those which do occur are less severe. The antitoxin should be used before degenerative changes have been set up, and enough antitoxin should be given to neutralize not only the lethal action of the diph- theria toxin, but also its local and pa- ralysis-producing action. Sims Wood- head (Brit. Med. Jour., Sept. 3, '98). Influence of antitoxin on diphtheritic paralysis summarized as follows: Up to the present the percentage of paralysis has increased, on the whole. There is some evidence that large doses — i.e., not less than 4000 units — of antitoxin are more effective than small ones, both in preventing paralysis and diminisliing the mortality due to it. Tlio earlier anti- toxin is given in diphtheria, the less likely is paralysis to follow. Should it occur after early injection, it will prob- ably be mild and of comparatively short duration. The type of paralysis has be- come less dangerous to life. Finally, diphtheritic paralysis has become more prone to attack the young. The full value of antitoxin is only obtained by DIPHTHERIA. TREATMENT. ANTITOXIN. 559 using it early and in efficient doses. Woollaeott (Lancet, Aug. 20, '99). Conclusions regarding action of diph- theria to.xin on the nervous system are: the essential lesion is parenchymatous degeneration of the peripheral nen-es, the slight changes in the anterior-horn cells are held to be secondary or of ca- chectic origin, while the vascular altera- tions play but a subordinate rOle in the pathogeny of post-diphtherial palsy. Bielschowsky and Nartowski (Neurol. Centralb., July 1, 1900). That evidence has been so fully pre- sented in the articles by Welch, Biggs and Guerard, and the Report of the American Pediatric Society, already re- ferred to, and is so complete, that no attempt is made to introduce it here. There are certain definite limitations of the efficiency of the diphtheria anti- toxin. It has already been pointed out that not all the lesions of diphtheria are produced by the action of the diphtheria bacillus or its toxins. Certain of them, especially the bron- cho-pneumonia and nephritis, are be- lieved to be due to the action of strepto- cocci. Diphtheria associated with streptococci is the gravest form met with; in chil- dren it is the most frequent determining factor of broncho-pneumonia. E. Roux (Universal Med. Journal, p. 289, '94). In the severe and most highly infec- tious forms of diphtheria accompanied by marked hypercemia and swelling of the faucial and adjacent surfaces, strepto- cocci occur not only in the superficial, inflamed parts, but in the deeper, con- tiguous tissues, as the submaxillary and perilaryngeal glands and the adjacent connective tissue. In some cases these adventitious germs, by penetrating deeply, cause not only a cellulitis which may end in suppuration, but set up a bronchopneumonia. H. Barbier (Gaz. Mfd. de Paris, Sept. 30, '94). Organisms present in 32 fatal cases: LoefTlcr's bacillus only, 37.5 per cent.; with streptococci, 2.5.0; with staphylo- cocci, 18.7; with streptococci and staphy- lococci, 18.7. In all cases staphylococci pyogenes aurei found. No fatal results took place when only cocci were present. Shuttleworth (Lancet, Sept. 14, '95). By mixing cultures of the strepto- coccus with those of the Klebs-Loeffler bacillus, a considerable increase in the virulence of the latter is observed. The dose necessary to kill a guinea-pig was much less than that required for a cult- ure of the diphtheria germ. If the dose was decreased to the point of permitting life for two or three weeks, there was observed, besides emaciation, a diminu- tion of the secretion of urine, which be- came sanguinoleni. The autopsy showed especially-profound alterations in the kidneys, visible to the naked eye. The glomerules were swelled, and projected above the cut surface. The microscope showed the shedding of epithelium from the urinary tubules and the presence in their lumen of numerous altered red globules. These lesions cannot be ob- tained with pure cultures of the strep- tococcus, but only by adding to the diphtheria cultures the toxins of strepto- cocci obtained from cultures four weeks old. Bonhoff (Hygienische Rundschau, No. 3, S. 97, '90). In eases of mixed infection the symp- toms of ptomaine poisoning due to the Klebs-Loeffler bacillus may be preceded by those due to staphylococci and strep- tococci, which latter may even subsist before the onset of the graver symptoms. If the Klebs-Loeffler bacillus is the "prin- cipal invading germ," then "antitoxin will bring the crisis of the disease within twenty-four hours. If it is the strep- tococcus, there will be a long, hard fight." Streptococcic angina is marked by pain, and is not benefited by anti- toxin. Jaques (Lancet, Jan. 1.5, '93). Upon these processes the antitoxin can have no direct effect. By lessening the depression produced by the diph- theria, antitoxin may enable the patient to resist the further attack of the strepto- cocci or other pathogenic organisms; it cannot be expected to do more. It has also been urged against the antitoxin that diphtheritic paralj'sis is quite as fre- 560 DIPHTHERIA. TKEATMENT. AIJTITOXIN. quent after its use as it was without anti- toxin. To this two reasonable replies have been made: One, that the nervous sys- tem is most susceptible to the action of the diphtheria toxins and therefore most difficult to protect; so that, while anti- toxin can save the life of the patient, it cannot protect him from the particular effect of his disease. The other is the in- genious suggestion that by saving the lives of many who, suffering from severe diphtheritic infection, would, in all prob- ability, have died under any previous form of treatment, antitoxin increases the number of those in whom we should rea- sonably expect to see diphtheritic paraly- sis develop. In order to determine the relation be- tween forms of the Klebs-Loeffler bacil- lus and the severity of the disease, twenty-seven eases studied. The follow- ing conclusions submitted: 1. The short Klebs-Loeffler apparently produces a toxin of greater virulence than the longer forms, although local manifestations may not be so extensive. 2. The long Klebs-Loeffler bacillus and the strepto- cocci when found alone (together) give rise to a mild type of the disease. 3. The streptococcus is found associated with the short bacillus in the most se- vere cases; possibly by causing a more intense inflammatory reaction it opens avenues by which the toxins of both are more readily absorbed. 4. The beneficial action of antitoxin in cases in which the Klebs-Loeffler bacillus is not present may be due to tlie fact that, although the local effect of different microbes varies, there are many features of similarity in the constitutional symptoms produced by them. W. J. Class (Jour. Amer. Med. Assoc, Apr. 30, '98). The streptococcus and the dijihtheria bacillus enhance each other's virulence, and diphtheria antitoxin has no effect after scpticEDmia has developed. Hence the neccBsity of beginning antitoxin treatment at the first indication of diph- theria infection, before tlie streptococcus has had time to get in its work and increase the virulence of the diphtheria bacillus and to be reciprocally affected. P. Hilbert (Deut. med. Woeh., Apr. 14, •9S). The method of administration of the antitoxin and its mode of action are such that it in no way interferes with the use of any other form of treatment that may be regarded beneficial. Being given hypodermically, it does not disturb the stomach or interfere with feeding or medication. Fish, of St. Louis, has re- cently reported experiments going to prove that antitoxin given by mouth is effective. Similar experiments made by Park gave negative results. It is doubt- ful whether any advantage would be gained if it were possible to introduce the antitoxin in this way. Antidiphtheria serum given by the mouth has proved eminently satisfactory in nine cases. The effect was quite as good as if the serum had been given hypodermically, and no evil results fol- lowed, — no gastric disturbance, no skin eruption, and no joint or renal affection. Before deciding as to the dose required, however, further experience is desirable. In the first five cases the dose given was the same as would have been given hypodermically. De Minicis (Gaz. degli Osped., July 19, '90). For curative purposes the administra- tion by the mouth should be restricted to exceptional cases; but for prophy- lactic purposes this method should re- ceive the preference. J. Zahorsky (N. Y. Med. Jour., Mar. 19, '98). Laryngeal stenosis may call for further treatment. The general testimony is that antitoxin exerts a marked, in some cases a marvelous, influence upon diph- theritic stenosis. It is also agreed that since the general use of antitoxin a greater percentage of laryngeal cases have escaped operative interference than were before, and of those finally operated upon a greater number had recovered. DIPHTHERIA. TREATMENT. ANTITOXIN. 5G1 The triumph of antitoxin has been that of intubation as well. (See Intubatiox.) Tracheotomy has practically passed out of use in diphtheritic stenosis of the larynx. Many forms of treatment were for- merly combined with the use of antitoxin, but, as the power of the antitoxin has been more fully demonstrated, the tend- ency to rely upon it has become stronger. At the present time, apart from the general treatment — diet, rest, etc. — after giving antitoxin we confine our efforts to the careful cleansing of the nose and throat and the use of stimu- lants. Advantages of intubation in diph- theria. It is rapid and requires no anaes- thetic; there is no operation; the res- piration takes place through the nat- ural openings. In these days of anti- toxin, if there is skilled assistance to rely on during the absence of the opera- tor, it has enormous advantages over tracheotomy, but these quickly disappear when skilled assistance is absent, and it must not be forgotten that tracheotomy- tubes can now be removed after a much shorter period than formerly. Hughes (Scottish Med. and Surg. Jour., June, '97). There is still some doubt as to the method of taking out the tube after intubation. There are disadvantages at- tending the thread method, and espe- cially because the fixing of the tubes thus produced docs not allow of its free play, and Iicnce causes erosion of the parts. The extractor, on the other hand, is hardly possible in private practice, as a sudden stoppage of the tube by mem- brane may cause sufTocation unless the tube can be withdrawn without delay; it also requires considerable skill, espe- cially where a small tube sinks deeply into the larynx. Where attempts at extraction cause a small tube to sink farther down, jiressure with the thumb on the trachea, just below tlie cricoid cartilage, where the end of the tube can be felt; the cough thus produced forces the tube out. This method of expression never fails. The pressure may be made with both thumbs, the finger finding support on the neck; it should be di- rected inward and directly upward. If more powerful pressure is e.xerted, the tube may be forced, not only into the mouth, but even completely out of it. No disadvantages attend this method. Trumpp (MUnch. nied. Woch., Jan., '98). Conclusions based on treatment of 100 cases of laryngeal diphtheria with anti- toxin in conjunction with intubation: Antitoxin should be administered early, without waiting for a bacteriological diagnosis. Tonsillar exudate attended by a croupy cough or partial aphonia is an indication for a full dose of 1500 to 2000 units of antitoxin. Antitoxin adminis- tered twelve hours or more prior to oper- ative interference will reduce the mor- tality of intubated cases at least .50 per cent. Early operation urged. Results are summarized as follows: Number of operations, 100; recoveries, 69; deaths, 31 ; mortality under 3 years, 49 per cent. ; mortality over 3 years, 19 per cent. ; com- plicating measles, 8 eases, 5 deaths. Shurly (Jour. Amer. Med. Assoc., May 19, 1900). Intubation has become more common since the introduction of antitoxin, for ca.ses are less severe and tracheotomy does not so often become necessary. Primary tracheotomy is indicated in children under 1 Vj years with out- spoken rickets, serious collapse, wide- spread pharyngeal ulceration, severe dyspnoea and oedema of the larynx, spas- modic or mechanical obstruction in the larynx, large oedcmatous swellings (such as subcutaneous emphysema of the neck), bronchial stenosis, or continued dyspncea after intubation. Secondary tracheotomy is indicated when the tube has been in several days and dyspnoea continues after the fourth intubation, when membranes close the tube, when laryngeal abscess occurs, when the thy- mus or bronchial glands arc enlarged, when frequently changing the tube gives no relief, when the child cannot swallow sufiScicnt food, and when dyspncea fol- lows intubation twice, five or six days after intubation, in children imder 2 years. Intubation should be performed 562 DIPHTHEKIA. DISLOCATIONS. early, all indications for tracheotomy must be overcome, everything must be prepared for a possible tracheotomy, patients must be kept in a veil-steamed atmosphere, the smallest tube should be introduced but once, bromides should be given before extubation, and all should be ready for a new intubation when ex- tubation is done. In children under 2 years the tube is left in on an average of 2 to 4 days; from 2 to 4 years, 3 to 6 days; over 5 years, 3 to 4 days. In- tubation may be done experimentally, preliminary to tracheotomy or during tracheotomy, and before or after clos- ing the tracheotomy wound. In private practice intubation is only justified when the physician has had experience, anti- toxin has been given, and a good nurse secured. It is only indicated, then, when no bronchial stenosis exists, the larynx is not swollen or ulcerated, and no indi- cations for tracheotomy are noted. The tube is left in as long as no indication for secondary tracheotomy appears and the child bears it well. Eahn (Jahrbuch f. Kinderh., Feb., 1902). The results of intubation after the ad- ministration of antitoxin have been most brilliant. Whereas two-thirds of such cases died before the use of antitoxin, with it about two-thirds recover. The indications and technique of the opera- tion are described in the article on In- tubation. Tracheotomy should be resorted to only when no trained intubator can be had or intubation has been tried and has failed. The Continental prac- tice of resorting to a secondary trache- otomy if a tube has been worn four days rests upon no rational basis and should be abandoned. By using hard-rubber tubes, the perfection of which was one of O'Dwyer's last labors, we may leave the tubes in the larynx for months without danger of harm. W. P. NORTHHUP, David BovAinn, New York. DISLOCATIONS. Definition. — A dislocation is a perma- nent, abnormal, total, or partial displace- ment from each other of the articular portions of the bones entering into the formation of a joint. A sprain is a temporary, partial dis- placement, reduced immediately and spontaneously. In total, or complete, dislocations the articular surfaces are completely sepa- rated, or touch each other only at their edges. In ball-and-socket joints the dislocation is said to be complete when the centre of the globular head is dis- placed beyond the rim of the concave socket. Lesser forms of displacement are termed partial, or incomplete, luxations, or subluxations. A diastasis is a subluxation in which the separation occurs in a plane perpen- dicular to that of the articular surfaces, without lateral gliding of one upon the other. The most frequent examples of this condition are the so-called "sub- luxation" of the head of the radius in children, and the tibio-fibular diastasis in Pott's fracture. A dislocation is complicated by in- juries to surrounding tissues of sufQcient importance to affect materially the symp- toms, prognosis, diagnosis, or treatment. It is rendered compound if the laceration of the soft parts establishes a communi- cation between the cavity of the joint and the outside air. Symmetrical dislocations on both sides of the body (viz., both shoulders, both hips) arc termed double. If they occur in the one bone (jaw, vertebne), they are called bilateral. Varieties. — Dislocations are classified, accoi'ding (o their etiology, as traumatic and spontaneous. Traumatic disloca- tions are caused, not only by external vie- DISLOCATIONS. NOilEXCLATUKE. SYMPTOMS. 563 lence, but also by muscular force. Such, for example, as the forward dislocation of the mandible. Spontaneous disloca- tions are due to pathological processes in or about the joint which so weaken its normal supporting structure that luxa- tion occurs gradually (or suddenly) and without recognizable trauma. Occurring in extra-uterine life these dislocations are termed pathological, while, if their ori- gin is prenatal, they are congenital. Nomenclature. — Usually the distal member of a joint is said to be dislo- cated, — the most notable exception is the so-called dislocation of the outer end of the clavicle (acromio-clavicular joint); and the direction of the dislocation is that taken by the dislocated bone: thus a backward dislocation of the humerus means that the head of the humerus has been dislocated backward from the gle- noid cavity, and lies behind it (unless it has been shifted by a secondary or con- flecutive displacement). Sometimes, how- ever, we speak of a dislocation as of the joint itself, dislocation of the elbow, of the knee; here, again, the direction of the dislocation being that taken by the distal segment. Thus, instead of saying a "backward dislocation of the humerus," we might say "a backward dislocation of the shoulder." Subvarieties are named, according to the new anatomical posi- tion of the distal segment, as subcoracoid, dislocation of the humerus, iliac (or dor- sal) dislocation of the thigh. Finally, it is well to bear in mind the distinction between "typical" and "atyp- ical" dislocations, typical dislocations being those in which the attitude of the limb is characteristic, and atypical those in which, owing to the laceration of some opposing structure, whose integrity is usually preserved, the characteristic po- sition is not present. An "atypical" backward dislocation of the hips is the so-called "everted dorsal," in which, ow- ing to the rupture of the outer branch of the Y-ligament, the thigh is everted instead of assuming the usual attitude of inversion and adduction. Symptoms. — Deformity is always pres- ent. The displacement of the articular surface changes the normal contour: a change which can be accurately verified by ascertaining by palpation the abnor- mal position of the various bony promi- nences; moreover, the new position of the head of the bone makes a new and abnormal centre for the movements of the joint, and, in connection with the restricting influence of untorn lijraments Fig. 1. — Diagram to show the action of a ligament in limiting the range of motion in a dislocation. {Slimson, "Dislocations.") or bony prominences, gives rise to a more or less characteristic attitude and restric- tion of motion in certain directions. The comprehension of the causes which produce this constrained attitude and restricted motion, while of great as- sistance in diagnosis, is, in many cases, absolutely essential to intelligent manip- ulative treatment, for those same forces that aid our diagnosis we must take into account in our efforts to effect reduction. These forces are purely mechanical. The dislocated bone plays the part of a lever whose long arm extends from the attach- ment of certain ligaments to its distal cxtremitv and whose short arm is that 564 DISLOCATIONS. SYMPTOMS. DIAGNOSIS. part of the bone between this point of attachment and the head of the bone. The figure shows how the ligaments opposite the side toward which the bone has been displaced are piit on the stretch by attempts to move the lower part of the limb in the same direction, so long as the head of the bone impinges upon the outer edge of the articular surface or some similar obstacle. Hence the abnormal attitude and restriction of motion in some directions — and possibly abnormal mobility in others, be it noted — and hence, also, the inference that such an Fig. 2. — Diagram to show the effect of atti- tude upon tlie measured length of the arm (1) in dislocation of the right shoulder and (2) when the bones are in a normal position; B, B', the acromion. (American Tcxt-buuk of Hurypiy.) obstacle is not to be overcome by brute force, but rather by strategy and dex- terity. Shortening or lessening of a limb is another aspect of the deformity. As a sign, however, it is most unreliable. Fig. 2 indicates the relative positions of the bones in a subcoracoid dislocation of the shoulder as compared with the normal joint. With the arm abducted, the short- ening is marked, but in adduction there is little or no shortening; indeed, there may be some lengthening. Crepitation of a fibrous quality may be elicited during manipulation by friction of the bone over fibrous or cartilaginous structures, and means nothing. True bony crepitus means, of course, a fract- ure. Pain is always present, and is due to two causes. There is the primary pain caused by the laceration of the tissues at the moment of the dislocation. This soon passes away. Any persistent pain is due to pressure on nerves, and can only be relieved by the removal of that press- ure. Loss of Function. — This is usually complete, and due partly to the pain and partly to the fixation caused by the changed relations of the bones. Symptoms of Old Unreduced Disloca- tions. — Deformity of contour and atti- tude, as well as restriction of motion, will persist as long as the dislocation remains unreduced; but, as the parts tend to adapt themselves to their altered condi- tions, the disability becomes progress- ively less, as a general rule, until the functions of the limb can be fairly-well performed. But several conditions may interfere with this restoration of func- tion. An excessive production of callus may limit the motions of the joint or even ankylose it in an awkward position; the head of the bone may be progress- ively displaced farther from its normal situation, and the disability thus become greater instead of less; or an intractable neuralgia or oedema may result from pressure on adjoining nerves or vessels. Diagnosis. — The one demonstrative sign of dislocation is the recognized pres- ence of the head of the dislocated bone in an abnormal position. One may mak& the same inference from the negative evi- dence; namely, the absence of the head of the bone from its normal situation. Thus, in backward dislocation of the ribs or the sternum the diagnosis is made by the absence of the heads of the bones- DISLOCATIONS. DIAGNOSIS. ETIOLOGY. 565 from where they should be, and not by their presence where they should not be. In such localities as the fingers or knee the head of the bone may be seen; else- where it may be felt, as in the jaw (for- ward) or the shoulder; or, again, the diagnosis may only be ascertained by finding an indefinite mass which par- takes of the motions imparted to the bone. Measurements may help; but, as above noted, are liable to be fallacious. In typical dislocations the attitude of the limb and the limitation of motion are usually the first hint the surgeon ob- tains of the nature of the case; but, we repeat, the only conclusive evidence is the discovery of the head of the bone out of its normal place. Differential Diagnosis. — The dif- ferentiation of a simple dislocation from a fracture at or near the articular surfaces is often difficult, sometimes impossible. If the fracture is through the neck of the bone (without impaction) the dislocated head will not move with motions im- parted to the shaft of the bone; but will, on the contrary, give rise to a bony crep- itus, unless some soft parts are inter- posed. But if the fracture consists sim- ply of the splintering of an articular edge, or the tearing off of a tuberosity, the fragment may be pushed or drawn away and give no evidence, except per- haps a weakness in the joint, a lack of certain motions, or a tendency to recur- rence of the dislocation, for which we can only assign the fracture as a probable cause. The statement that mobility is in- creased in fracture and decreased in dis- locations is misleading and inaccurate. In fractures mobility is not increased, but created where before it was not. In dislocations it is decreased in some direc- tions, but it is not infrequently increased in others; and, indeed, with sufficient laceration of all the soft parts it may be increased in all directions. A disloca- tion may be readily differentiated from a contusion or sprain by examination under ether. Etiology. — Pbedisposinq Causes. — Normal predisposing causes exist to a greater or less degree in all joints; other- wise no joint not diseased could be dis- located: a theory long since rejected. These causes mainly exist in the con- formation of the bony surfaces which make up or surround the joint. In some positions there is little resistance to a dislocating force properly applied. Thus, the wide-open jaw may be dislocated for- ward by a relatively-small force, there being but the slightest resistance of bone and ligament to overcome. Or, again, the normal angle at the joint, as at the elbow, predisposes to dislocation by ap- plying a transmitted force (from the hand) in a direction oblique (upward and inward) to the long axis of the joint, and thus tends to force the articular surfaces over each other in an abnormal direc- tion. Moreover, certain outljang promi- nences may aid dislocation by acting as fulcra to pry out the head of the bone, as does the olecranon in hyperextension of the elbow and the acromion in hyper- extension of the shoulder. Some joints are also more frequently exposed to ex- ternal violence than others. Patholog- ical predisposing causes are fracture or disease of the bones, disease of the liga- ments or atrophy of muscles that act as ligaments, and distension of the joint with fluid. Immediate or Determining Causes. — External violence may cause disloca- tion directly by acting upon the articula- tion itself, as a dislocation of the humerus by a blow upon the shoulder, or indi- rectly by force transmitted through the shaft of the bone, as in the same dislo- 566 DISLOCATIONS. PATHOLOGY. COMPLICATIONS. PROGNOSIS. cation caused by a fall upon the out- stretched hand, or more complexly by leverage, as when a fall upon the shoulder dislocated the inner end of the clavicle upward by leverage exerted on the first rib as a fulcrum. Muscular action may also be exerted either directly or iridirectly. Thus, yawning is a common cause for disloca- tion of the lower jaw. In fact, certain persons can voluntarily dislocate one or other of their joints. The most common example is the backward sublvixation of the first phalanx of the thumb; but there are also a few subjects who can throw out their larger joints, as, for example, a man who is at present traveling about exhib- iting his power of dislocating both hips and both shoulders. Pathology of Recent Dislocations. — In joints relaxed by paralysis or effusion (and in the jaw) dislocation habitually takes place without laceration of the cap- sule. In all other cases (excepting the voluntary dislocations before mentioned) the capsule is torn. In enarthrodial joints the rent is on the side toward which the round head of the distal bone is displaced. In other joints any or all of the ligaments may be torn. The firmer bands, instead of giving way themselves, may strip up the periosteum or tear away the bony prominences to which they are attached. Opposing muscles put upon the stretch may act in the same way. The bones may also be broken by impact on each other; thus fracture of the olec- ranon occurs in anterior dislocation of the elbow, and a mutual bruising of the head of the humerus and shattering of the rim of the glenoid cavity in disloca- tions of the shoulder. Complications. — Fractures worthy of the name of complications may occur. Some, indeed, such as fracture of the anatomical neck of the humerus, may prove insurmountable obstacles to reduc- tion. External wounds, especially if they compound the dislocation, may prove serious complications. Adjoining vessels may be ruptured and give rise to fatal hemorrhage or to occlusion and gan- grene, or to traumatic aneurisms. The rupture of nerves, of which the most common is circumflex at the shoulder/ may cause permanent paralysis and an- esthesia. The viscera are rarely injured unless by some other associated trauma. In old imreduced dislocations the lac- erated connective tissue about the head of the bone becomes thickened and forms a pseudocapsule, while the periosteum on which the head of the bone now rests is stimulated and throws out a ridge of bone so as to form a new articular cavity, sometimes lined with fibrocartilage. The muscles and ligaments shrink or elongate to adapt themselves to their changed cir- cumstances, and thus a comparatively useful new joint may be formed. In the meanwhile an opposite train of events takes place in the old joint-cavity. It is obliterated either by adhesion of the cap- sule or by filling up with granulation- tissue. Thus not only is the dislocated bone fixed in its new position, but also the old socket is obliterated and rendered unfit for its reception. It is important to note that the scar may include neigh- boring vessels or nerves and by pressing on them give rise to neuralgia or oedema without any direct pressure by the bone itself, and, moreover, the tearing of this tissue in attempts at reduction may re- sult in fatal injuries to vessel or nerve. Prognosis. — deduction is usually fol- lowed by repair of the damage done, and within a few weeks Ihe joint is as useful as ever. Occasionally, however, a perma- nent laxity of the capsule remains, which allows the dislocation to recur on more or less slight provocation, and with each DISLOCATIONS. TREATMKNT. 567 recurrence the tendency grows more marked. Occasionally, also, without any unusual evidence of injury to the nerves at the time of occurrence of the accident, a dislocation may be the starting-point of an intractable neuralgia, or it may pre- dispose the joint to rheumatism. The complications above mentioned render the prognosis more grave. In old unreduced dislocations the prognosis is different for every individual case. In some the new joint will become fairly useful, in others not so; yet the prospect of relief by operation is none of the brightest. Treatment. — A recent dislocation should be immediately reduced unless great inflammatory reaction, swelling, or shock render the infliction of ^ain or the use of anaesthetics inadvisable. Anaesthetics are of use to overcome the resistance of the muscles which, con- tracted by pain or fear of pain, oppose the manipulations necessary for reduc- tion, or in case the patient cannot or will not suffer the pain incident to those ma- nipulations. Reduction may usually be effected in "primary" anjesthesia. Ether is safer than chloroform for this purpose. The choice of the method of reduction depends upon the recognition of the ob- stacles to reduction. Aside from mus- cular opposition, the usual obstacle is the resistance offered by untorn ligaments or portions of the capsule to motion in certain directions. Other obstacles are interposition of the ligaments or mus- cles, and these may be of such a nature as to demand operative interference. The older methods of reduction by means of direct pressure on the head of the bone or traction by hand, by pulleys, or by electric force have been, in great measure, superseded by the more scien- tific and practical method of reduction by manipulation, in which, by a succes- sion of gentle movements, the head of the bone is brought opposite the tear in the capsule, the opening is enlarged by relaxation of its sides, and the head of the bone slipped into place by leverage on the untorn portions of the capsule and ligaments, aided, if need be, by trac- tion and pressure on the bone. In old dislocations the manipulations useful in recent cases are much less likely to succeed, owing to the firm adhesions binding the head of the bone in its new situation and the obliteration of the dis- used articular cavity. Moreover, strong ' traction may be required to overcome the contraction of the muscles. Interference ! in such cases is unavoidably blind and uncertain, and involves much more ex- tensive laceration than took place at the time of the original injury. So many accidents have followed attempted re- duction by manipulation in these cases that, if cautious manipulation fails to effect reduction, it is better to leave the dislocation unreduced in the majority of cases; or, if the loss of function is so great as to induce the surgeon to run the risk, an open arthrotomy may be done with the hope of dividing the opposing structures, opening up the old socket, and replacing the dislocated bone. The accidents which follow ill-advised j attempts at reduction are usually fract- ure of the bone or rupture of vessek, leading to haemorrhage, gangrene, or aneurism. More rarely injury to large , nerves has occurred, and even complete 1 avulsion of a limb has been recorded. ; After-treatment. — After reduction the joint need usually be kept immobilized : only a few days, and excessive motions avoided for a few weeks. Some disloca- tions require special dressings {cff., clav- icle). Gentle passive motion should usu- ally be begun within at least three weeks to prevent adhesions. 568 DISLOCATIOXS. CONGENITAL. TREATMENT. Habitual dislocations have been cured at the inner end of the clavicle by peri- articular injections of alcohol (Stimson) and at the shoulder bv injections of tinct- ure of iodine. But this method of pro- ducing adhesions offers so grave risks of anl-cylosing the joint that in the more important joints it is advisable, if the tendency cannot be overcome by the pro- longed wearing of an immobilizing ap- paratus, or one which allows only slight motion, to excise, or take a '"reef" in, the lax portion of the capsule. Congenital Dislocations. — Under this head are included all dislocations sup- posed to have existed at birth — although sometimes not diagnosed for months or years — and to have been caused by a mal- development .of the joint, hydrarthrosis, paralysis, etc. Dislocations produced traumatically in utero or during delivery are excluded. Congenital dislocations of the hip cover about 90 per cent, of all cases. They are more usual in females than in males. One or both joints may be in- volved. The typical cases are caused by a defective development of the Y-carti- lage and acetabulum, which permits the influence of the weight of the body, or the contraction of the muscles, to drag the head of the bone out of the socket on to the dorsum of the ilium. Pubic and obturator dislocations are very rare. As the child begins to walk the head is pushed farther upward until it is finally arrested and a new joint formed. The head of the bone is small and deformed and the real acetabulum obliterated. Compensatory changes ap- pear in the pelvis, which is tilted for- ward, and the lumbar spine, which is curved forward. If one hip alone is in- volved, there is an additional lateral curvature, and the child limps; if both are involved, there is no limp, Ijut tlic gait is peculiar. The tilting of the pel- vis can be made to disappear by placing the child upon its back and flexing the thighs. The prognosis as to the utility of the limb is fair. The patient will probably be able to get about, and the deformity will grow no worse. Treatment. — Inasmuch as operative treatment has a very high mortality and often enough gives but little or no relief, while, on the other hand, some cases — double as well as single — reach adult life, undiagnosed and untreated, with com- paratively-slight deformity and no dis- ability except a waddling gait, it is proper — Hoifa and Lorenz to the contrary not- withstanding — to institute treatment by palliative measures. For unilateral dis- locations an elevated sole to the shoe, and, if necessary, an apparatus to pre- vent the head of the femur from riding up any higher on the ilium, fulfill the indications. Or in cases under 5 or 6 years of age — single or double — pro- longed traction, for even as long as two years, may produce material and per- manent improvement. Mikulicz claims to be able to effect reduction by ma- nipulation. An injection of a 10-per- cent, solution of zinc chloride above the head of the bone has been advocated for the purpose of strengthening, by new bony formation, the upper rim of the new acetabulum. Of the operations, that of Lorenz is a type. He makes a vertical antero-ex- ternal skin incision, divides the fascia lata transversely, separates the muscles, frees the bone by a cross-cut in the an- terior surface of the capsule, gouges out the old acetabulum, making a strong up- per rim to it, and replaces the bone by extension, aided by a traction apparatus. Immoljilization is replaced by passive motion at the end of four weeks, and the DISLOCATIOXS. PAXHOLUUICAL. SPECIAL. 569 child begins to walk with assistance two weeks later. No further apparatus is used. In difficult cases Lorenz advises a preliminary course of two weeks' ex- tension by a thirty-pound weight. Congenital shoulder dislocations are to be treated according to similar principle. The anterior knee dislocations are easily reduced, and a good functional re- sult may be predicted. Pathological Dislocations. — Paralytic ("myopathic") dislocations occur usually in the shoulder, where the deltoid and scapular muscles form such important accessories to the joint. Dislocations by effusion, erosion, or other articular processes occur in the course of the eruptive, continued, or rheumatic fevers. The hip is commonly affected. Special Dislocations. Dislocations of the Lower Jaw. — The dislocations may be single or double. Upward or backward dislocations are very rare. In the former the condyle is driven through the base of the skull, in the latter back through the anterior wall of the external auditory meatus. Forward Dislocations. — The lower jaw projects forward, the mouth cannot be closed, the condyles may be seen and felt in front of the eminentia articularis. The glenoid fossa is empty. In unilateral dis- locations the chin is deviated to the op- posite side. The pain is usually not great. The usual cause of forward disloca- tions is a wide opening of the mouth in yawning, laughing, or introducing some large object. It is more frequent in women than in men. When the mouth is wide open the external lateral ligament is relaxed and the external pterygoid muscle draws the condyle, and the inter- articular cartilage with it, well forward on the emincnta articularis. A slight overaction of this muscle carries the con- dyle over the summit, whence it plunges forward and upward under the zygoma, and is then held by the balance of forces between the muscles pulling upward and forward and the external lateral ligament pulling upward and backward. The in- terarticular cartilage accompanies the condyle, at least part of the way. The capsule is not torn. Reduction is accomplished by opening' the mouth more widely to relax the liga- ment and then pressing the condyle back- ward and then a little downward. A fairly-successful method is by grasping the jaw on either side with the thumbs on the molar teeth and the fingers un- der the jaw outside. As the jaw snaps back the thumbs must be quickly slipped into the hollow of the cheeks to avoid be- ing bit. Reduction of one side at a time is sometimes easier. Anesthesia may be required to overcome the contraction of the muscles. Not infrequently this dislocation tends to become habitual. To overcome this the meniscus may be sutured in place. Injection of tincture of iodine has been proposed. Dislocations of tue Spine. — Dislo- cation of the lumbar and dorsal vertebrae is almost always complicated by and con- founded with fracture. Extension and local pressure have occasionally effected reduction; operative treatment should be resorted to in hopeful cases. Dislocations of the occiput (from the atlas) and the atlas (from the axis) have been diagnosed post-mortem. Lac- eration of the vertebral arteries and the medulla, with or without fracture of the odontoid process, causes instant death in most cases. Dislocation of the Lower Cer- vical Vertebrae. — This may be double or single, complete or incomplete, for 570 DISLOCATIONS. STERNUM. RIBS. CLAVICLE. ward or back-ward, or bilateral in oppo- site directions. If the dislocation is uni- lateral (forward), the head is turned to the opposite side, on which side the mus- cles are contracted. On the side of the dislocation the dislocated bone may be felt, and its spinous process is deflected toward that side. In bilateral forward dislocations the head may be bent far forward and the dislocated bone (usually the fifth) felt in the back of the neck, or the head may be extended and the bone palpable within the pharjTix. The symp- toms depend upon the amount of injury to the cord. Damage to the cord above the third cervical vertebrffi causes death by cutting off the phrenic nerves. Be- low this point the result will be a paraly- sis more or less durable according to the nature of the lesion. The mechanism of the unilateral for- ward and bilateral dislocations in op- posite directions is abduction (lateral flexion) and rotation, by -which the in- ferior articular process of the upper ver- tebra is lifted over the superior process of the lower one. Bilateral forward dislo- cations are caused by hyperflexion, back- ward by hyperextension and direct press- ure. Treatment. — Reduction should be at- tempted at once. Unilateral dislocations are to be reduced in the way they were produced; i.e., by abduction and rota- tion, aided by direct manipulation, so as to lift the disarticulated bone back into place. Traction and local pressure have proved effectual in the reduction of bi- lateral dislocations. After the reduction the patient should be kept quiet for some weeks. A plastcr- of-Paris splint for head and neck is ad- visable. These means failing, if there seems any hope of recovery by renewing the pressure from the cord, the dislocation should be cut down upon aseptically and an attempt made to reduce it by remov- ing such ligamentous or bony obstacles as may exist. Dislocations of the Sternum:. — Dislocations- — forward or backward — of the body from the manubrium are usu- ally accompanied by serious interference with respiration and circulation. From fracture the diagnosis is made by finding the second costal cartilages attached to the manubrium and torn from their ar- ticulation with the body. Inasmuch as the injury is due to great violence, direct or indirect, the associated injuries play a large part in the prognosis. Reduction is effected by dorsal flexion and direct pressure. Dislocations of the ensiform proc- ess are a tilting either forward or back- ward. The symptoms are pain and per- sistent vomiting. Pressure with the fingers or with a sharp hook introduced underneath the skin will reduce the dis- location. Dislocations of the Ribs and Costal Cartilages. — The ribs may be dislocated forward from the spine or for- ward or backward from each other or from their costal cartilages. The car- tilages may be dislocated from the sternum. The symptoms and treatment are the same as of fracture of the ribs. Reduc- tion, followed by the application of a tight head-band of adhesive plaster three- fourths of the distance around the chest. Chondro-stcrnal dislocations usually recur. Dislocations of the Inner End of THE Clavicle. — The clavicle may be dis- located forward, backward, or upward, in this order of frequency. Forward dislocation may be complete or incomplete. The head of the bone is DISLOCATIONS. CLAVICLE. 571 prominent and may be displaced inward. The shoulder sinks downward and in- ward. The arm is useless. There is local pain. This dislocation is usually caused by a forcible depression and pushing backward of the shoulder, by which the centre of the clavicle comes to rest on the first rib, and on it as a fulcrum the inner end is pried upward and forward. By pulling the shoulder upward and backward and pressing on the dislocated bone reduction is affected; but reten- tion is often diiTicult. Dorsal decubitus with a figure-of-8 bandage aboiat the two shoulders, the turns crossing in the back, may prove effective or may be reinforced by direct pressure by a molded plaster-of- Paris splint, a hernial truss, or a pad re- tained in position by adhesive plaster, or a figure-of-8 bandage, crossing in front. If all precautions fail and the dislocation becomes habitual, two or three biweekly injections of alcohol with immobiliza- tion may be attempted, or the capsule exposed and shortened. Backward dislocations may be either complete or incomplete. The head of the bone passes backward and may compress any of the important structures at the root of the neck. This dislocation may be caused by direct violence or by forc- ing the shoulder forward and inward. Eeduction is effected and maintained by drawing the shoulder backward and out- ward and retaining it in that position. Upward dislocation is caused by de- pression of the shoulder. The head of the bone rests on the episternal notch, having passed behind the sternal head of the sterno-mastoid. Reduction is made by drawing the shoulder upward and out- ward and pressing the head of the bone down. Here, again, retention is diffi- cult, and Malgaigne's patellar hooks have been suggested as an adjunct to the treatment. DiSLOCATIOXS OF THE OUTER EnD OP- THE Clavicle. — The usual variety is up- ward or upward and outward. Rarely a subacromial dislocation occurs. The so- called subcoracoid dislocations are prob- ably mythical. Upward Dislocation. — The acromial end of the clavicle rises more or less above the acromion, and may be dis- placed outward over it. There is fre- quently fracture of the articular edges. The usual cause is a blow on the shoulder. Fig. 3. — Adhesive-plaster dressing for up- ward dislocation of acromial end of clavicle. {American Textbook of Surpery.) Reduction is easy, retention difficult. Although non-reduction causes almost no loss of function and but little de- formity, Stimson's retention dressing is recommended for its simplicity and ef- ficiency (Fig. 3). A long strip of ad- hesive plaster three inches in width is placed with its centre under the point of the flexed elbow and its ends carried up in front of and behind the arm, cross- ing over the end of the clavicle, and se- cured to the front and back of the chest. DISLOCATIONS. SUBACROMIAL. SHOULDER. respectively, while the bone is held in place by pressure upon the clavicle and elbow. Recurrence can be readily detected through the plaster. For additional se- curity the forearm should be supported in a sling, and the arm bound to the chest. Care must be exercised not to cause pressure sores over the bony prom- inences at the elbow. SuBACEOiiiAL Dislocations. — A few cases are recorded in which the outer end of the clavicle was forced down and caught under the acromion. Direct vio- lence and muscular action are the re- applied obliquely in the bony surface and directly on the capsule of the joint, through which the head of the bone is then forced. Tarieties. — Four divisions may be made according to the direction in which the head of the bone leaves the socket, and these subdivided according to the point at which it comes to rest, or accord- ing to the position of the limb, as fol- lows: — rSubcoracoid (most common). Anterior J Intracoracoid (exceptional). (Subclavicular. Fig. 4. — To show the range of positions that may be taken by the head of the humerus after primary displacement forward or downward in any of the directions between the arrows. {Stimson, "Dislocations.") corded causes. Reduction was easy by drawing the shoulder outward, and there was tendency to recurrence in only one case. Dislocations of the Shoulder. — These dislocations are as numerous as all other dislocations taken together. They are rare in youth and old age, and more frequent in men than in women. This frequency is explicable by the exposure of the joint to trauma and its conforma- tion. The glenoid cavity covers such a small part of the head of the humerus that, in extreme degrees of abduction, extension, or flexion, any force trans- mitted through the shaft of the bone is Posterior. / Subglenoid (uncommon). .,' Erecta (very rare). (Subtricipital. \ Subacromial (rare). 1^ Subspinous (very rare). Upward Supraglenoid (very rare). In the anterior dislocations the dis- placement is also more or less downward (and, of course, inward), and in the down- ward ones it is usually also forward and inward. Thus, the two classes merge into each other. The term "subglenoid" is restricted to those cases in which the head of the bone is very low, others of this class being called "subcoracoid." DISLOCATIONS. SHOULDER. 573 The accompanying figure (Fig. 4) will demonstrate the different positions as- sumed by the head of the bone in the anterior-and-downward dislocation. Anterior Dislocations. — The sub- divisions of this variety are dependent on the increasing amount of inward dis- placement of the head of the bone, and grow less frequent in the same order; namely, subcoracoid, intracoracoid, and subclavicular. Subcoracoid. — The head of the hu- merus lies beneath the coracoid process, in contact with it or at a variable dis- tance — a finger's breadth at most — below it. The head may be displaced inward until three-fourths of its diameter lies to the inner side of the process (farther in- ward would be subcoracoid) or it may be simply balanced on the anterior edge of the glenoid fossa. The elbow hangs away from the side and the deltoid fullness of the shoulder is lost (Fig. 5). The axis of the humerus is sure to pass to the in- Qer side of the glenoid fossa, and palpa- tion reveals the absence of the usual bony resistance below the outer side of the acromion, and the presence of an abnormal resistance below the coracoid process, in the axilla, which partakes of rotary movements communicated to the arm. Voluntary movement is usually lost. Passively the arm can be abducted, but not adducted; so that the elbow touches the chest, while the fingers rest on the opposite shoulder. Measurement in abduction shows shortening. The diagnosis is usually easily made by finding the glenoid cavity empty, the head of the bone beneath the coracoid, and by eliciting the above-mentioned sign. If there be fracture of the ana- tomical neck the head will not partici- pate in movements imparted to the shaft, and crepitus can usually be elicited. Causes. — Direct violence, by a blow under the shoulder, indirect, as by a fall upon the hand; by leverage in forcible abduction and outward rotation; or by muscular action in any of the above ways. Pathology. — The capsule is torn at its inner and lower portion, or, more rarely, stripped up, and with it may be torn the circumflex nerve, the posterior circum- flex artery, and subscapularis (Fig. 6). In "typical" cases the outer and upper portions of the capsule remain untorn and aid in determining the abduction. Fig. 5. — Subcoracoid dislocation of the left shoulder. [Stimson, "Dislocations.") The supraspinatus, infraspinatus, and teres minor may be torn away (in decreas- ing order of frequency) from the great trochanter or there may be avulsion of more or less of the trochanter itself. With avulsion of the trochanter the ten- don of the long head of the biceps may slip to the outer side of the bone and oppose reduction (rarely). This tendon may also be torn. The head of the humerus is often bruised and ground by impact with the edge of the glenoid cavity, which, in turn, is splintered. 574 DISLOCATIOXS. SHOULDER. TKEATMENT. Treatment. — In uncomplicated cases reduction is usually easy by Kocher's metliod, as follows: — The elbow is flexed to a right angle and pressed closely to the side; then the forearm is turned as far as possible away from the trunk, — external rotation of the arm (Fig. 7). Maintaining the external rotation, the elbow is carried well for- ward and upward, — flexion of the arm (Fig. 8); and finally the hand swept After a long, steady pull, manual or elas- tic, the deltoid may yield and allow the head of the bone to be pushed back into place. Or, after a few moments of trac- tion, the arm is violently adducted over the closed fist in the axilla (this is safer than the heel). If anfesthetics are used all of these violent measures should be executed very cautiously. Dr. Cole suggests a method which he claims is successful in a large number of Fig. 6. — Subcoracoid dislocation on a cadaver, showing rupture of lower part of subseapularis. (B. Anger; Stimsoti, "Dislocntions,") over until it touches the chest, — inward rotation (Fig. 9), — the elbow being si- multaneously lowered. Anesthetics may or may not be necessary. If, after the "first movement," the head does roll out in front of and below the acromion, the attempt will fail. Direct manipulation of the head may be of assistance. If Kocher's method fail, traction •downward and outward (never upward and outward, on account of the danger of lacerating the vessels) should be tried. cases. The surgeon, standing by the patient's side, holds the arm abducted and the elbow flexed, and, while distract- ing the patient's attention, gently oscil- lates the arm. As the deltoid is seen to relax, a sharp blow is delivered into the fold of the elbow and the arm rotated sharply outward, thus rolling the bone into place. If judicious attempts at reduction by these methods fail, even under anais- thesia, an open arthrotomy should be DISLOCATIONS. SHOULDEIt. TREATilENT. 575 done for the purpose of discovering and removing the obstacle to reduction. In intracoracoid dislocations the head Fig. 7. — Kocher's mptliod of reduction by manipulation. First movement, outward rota- tion. (A^ppi, "American Text-took of Sur- gery.") is displaced farther inward and the symp- toms are those of the subcoracoid, except that the head of the humerus is felt farther displaced and the shoulder is Fig 8 — Kocher s method of reduction. Sec- ond mo\ement ele\ation of elbow {Appi, "Amci ican Tcxtlonlx of Surgery.") more flattened. The arm may be fixed in horizontal abduction. The cause of this particular dislocation is, as a rule. an unusual amount of laceration of the capsule and subscapularis, which allows the head of the bone to slip higher into the axilla. Keduction by outward trac- tion is easy unless the subscapularis or a torn portion of the capsule intervene. In such cases operation is the only re- course. In subclavicular dislocations the same forces acting more energetically force the head of the bone up under the clavicle. Downward dislocations include all cases in which the head of the bone lies Fig. 9, — Kooher's jiiftliod vl reduction. Third movement, inward rotation and lower- ing of elbow. {Appi, "American Textbook of Surgery.") below the glenoid fossa. In subtricipital dislocation, of which one case is recorded, the head of the humerus was displaced secondarily backward and upward be- hind the long head of the triceps. Subglenoid Dislocations. — The symp- toms are those of subcoracoid disloca- tion; but abduction and flattening of the shoulder more marked. The head of the bone is palpable below its socket. The upper part of the greater tuberosity is habitually torn awav. The usual cause 576 DISLOCATIOXS. SHOULDER. TKEATHENT. is forcible abduction follo-n-ed by rota- tion or impulsion. Treatment. — Traction in moderate ab- duction with direct pressure. Litxatio Euda. — Yery rarely, by forc- ible elevation of the arm the head of the bone is displaced so far downward that the extremity maintains its erect posi- tion. It is reduced by upward traction until the head falls into place. Posterior Dislocations. — The two va- rieties differ only in the extent of dis- placement. Symptoms. — The arm is adducted and rotated in, the elbow being directed slightly forward. The shoulder is flat in front and full behind (when the head of the bone may be felt). Passive motion is restricted, volxmtary motion absent. The cause is direct pressure outward and backward, or the pressure exerted in the same direction along the adducted and inward-rotated humerus. The outer side of the capsule is torn and the external and internal scapular muscles more or less lacerated or avulsed with fragments of the tuberosities. The head of the bone lies on the outer edge of the glenoid fossa, or farther back be- neath the spine of the scapula, or on the infraspinatus. Treatment. — Kcduction is accom- plished by traction and direct pressure forward. Avulsion of the subscapularis makes recurrence probable. Unreduced dislocations backward are accompanied by an unusual amount of disability. UpvMrd Dislocations. — These are ex- tremely rare. The head of the bone is forced upward between the coracoid and acromion, usually to above the clavicle. The arm is almost immobilized in adduc- tion and slight extension. Reduction may be efFocted by downward traction. Complications of Dislocations of the Shoulder. — Compound dislocations are very rare, and are commonly caused by direct violence. The skin-wcund is usu- ally in the axilla. Aside from ooniplica- tions which may exist not dependent on the dislocation, the great dangers are from laceration of the main arteries (fre- quent) or nerves (unusual) and from sup- puration. The treatment consists of en- larging the wound until the extent of damage can be fully appreciated and, as far as possible, repaired. Meanwhile the wound should be thoroughly irrigated with "normal" salt solution. The dislo- cation may now be easily reduced. In most cases thorough drainage should be provided for, and in some cases it may be advisable to excise the head of the humerus to this end to oppose ankylosis. Fractures of the various bony promi- nences of the scapula and humerus have commonly a purely pathological impor- tance. Fractures of the anatomical or surgical neck of the humerus are impor- tant, but often difficult to diagnose. The diagnostic points of fracture of the ana- tomical neck are the recognition of the head in the axilla and its failure to move with the shaft, the maintenance of near-by normal range of motion and the normal position of the greater tuberosity. Crepitus may sometimes be elicited. In fracture of the surgical neck the signs are quite the same, except that the tuber- osity is displaced with the head, and, with it, fails to move with the shaft, and crepitus is more easily elicited. In either case the upper fragment may be reduc- ible by direct manipulation. This fail- ing, if the fragments can be approxi- mated, the arm may be immobilized for three or four weeks in an appropriate position with the hope of obtaining union and effecting reduction at the end of that time by manipulation. But the better plan ia probably to do an open arthrotomy and reserve the upper frag- DISLOCATIOXS. SHOULDER. UNREDUCED. ELBOW. 577 ment except in such fractures of the surgical neck as can be reduced, and to this end the use of a strong right-angled hook inserted into a hole drilled at the lower end of the upper fragment, may be of great service (McBurney). Or a fairly- useful false joint may sometimes be ob- tained at the point of fracture. Injuries to Vessels and Nerves. — The axillary itself is very rarely rupt- ured, and hence the radial pulse may persist, even though there be serious damage to the arteries about the joint. This damage is usually due to ill-advised attempts at reduction, and is recognized by the rapid extravasation of blood down the arm and into the axilla. Treatment is by pressure, ligature of the axillary or subclavian, or disarticulation of the shoulder. The mortality is very high. The circumflex nerve is often torn, with a resulting temporary or permanent dis- ability of the deltoid and anaesthesia of the shoulder. Treatment of Old Unreduced Dis- locations. — If the dislocation cannot be reduced after loosening adhesions by forcible (yet judicious) rotation and trac- tion, operation is advisable for reduction by division of the soft parts, or for exci- sion of the head of the bone. A very serviceable joint may be obtained by the latter method; but as the line of di- visions of the bone runs below the tuber- osities, rotation is practically lost. Habitual dislocation has been cured by reefing the anterior portion of the capsule. Eieard advises the usual an- terior incision between the deltoid and pectoralis, supplemented by a horizontal one along the clavicle and dissection back of the anterior part of the deltoid. Dislocations of the elbow stand second in order of frequency, and are most common in persons under twenty- five. Among the great variety of forms of dislocations of both bones, the back- ward are by far the most frequent. The divisions and subdivisions are as follows: — 1. Dislocations backward : and outward, and inward. 2. Lateral dislocations : Incomplete! '"7"'-, ' 1. outward. Dislocations of I ^ i ^ f » i both Bones ; Complete | outward. of the Fore- ^ 3. Forward dislocations : arm Incomplete (first degree). Complete (second degree). "With fracture of the olec- ranon. 4. Divergent dislocations. Antero-posterior. Lateral. / Backward f^°«^'j;Pl<^t« ^^^' Dislocations! wl'''*" ^ o ". P 1 e t e (second of Ulna) ^ '•^eree). Alone 1 b_.,(.1j^j,„i and Outward (behind the HMlius). Inward (one case). 1. Backward. 2. Outward. 3. Forward. Dislocations \ ,, , • ; 4. By elonjration (the subluxation K a d 1 us \ • - - -'^- ^ Alone of children). With fracture of the ulna. Dislocations of Both Bones Bacl'ward. — The inward and outward subvarieties are of no practical importance. Si/mpto7ns. — The elbow is swelled and partly flexed. The olecranon may be felt displaced backward from the epicondyles and the head of the radius may be recog- nized behind the external epicondyle as a bony point which rotates with the fore- arm. The trochlear surface may be prominent in the bend of the elbow; the tendon of the biceps behind. Passive flexion and extension are moderate. There is abnormal lateral mobility in full extension. The cause is most commonly a fall upon the outstretched hand forcing the two bones backward. The coronoid proc- ess of the ulna is either broken or lifted •37 578 DISLOCATIONS. ELBOW. TREATMENT. over the trochlear surface by hyperexten- I sion or by abduction, which increases the normal outward deviation of the fore- arm and a twist which swings the process downward and then backward. Pathology. — The internal lateral liga- ment is torn, and the external one either torn or stripped away with the perios- teum from the external condyle. Hence, in old dislocations reduction is effectually prevented by the mass of callus that forms beneath this elevated periosteum behind the external condyle. The front of the capsule is torn, the epitrochlea (internal epicondyle) may be broken by muscular action, or the muscles attached to it may be ruptured. Fractures of the head of the radius and coronoid process are rare. The latter, however, does not interfere with the action of the brachi- alis anticus, as that muscle is attached to the base of the process: a part not interested in the fracture. Treatment. — Forcible flexion is to be condemned as unscientific and less likely to succeed than pressvire on the dislo- cated bones combined with traction of the forearm in moderate extension or h}'perextension. Usually the dislocation is easily reduced. Sometimes anesthet- ics are necessary. After reduction the limb should be immobilized by bandages and a sling for about three weeks, after which mild massage and active motion will gradually remove the stiffness. Early passive motion will not hasten the result, and may even increase the ex- cessive production of callus which, in children, sometimes goes on even after reduction and may cause serious limita- tion to the motion of the joint. Lateral Dislocations. — Incomplete dis- locations in either direction are said to be frequently overlooked or mistaken for fractures. The cause of lateral disloca- tions is usually a fall upon the hand by which the normal outward angle at the elbow is increased by tearing of the in- ternal lateral ligament and a downward movement of the ulna, directly away from the trochlea. The head of the radius then glides either outward or in- ward, as the case may be, the ulna fol- lowing. In incomplete inward dislocations the forearm is pronated and slightly flexed; its long axis parallel to and a little to the inner side of that of the arm. The olec- ranon and external condyle are promi- nent, and the head of the radius can be felt displaced downward and inward, resting below the trochlea (the greater sigmoid cavity of the ulna embraces the epitrochlea). Flexion and extension are but little interfered with. Eeduction is made by traction and direct pressure. In unreduced cases there is very little disability, and operative interference is probably inadvisable. Incomplete Outivard Dislocations. — The forearm is pronated and slightly flexed, and its long axis is to the outer side of and parallel to that of the arm or else in abduction. The ulna is displaced so that the central ridge of the greater sigmoid cavity has passed beyond the outer rim of the trochlea; the radius lies partly below or entirely beyond the ex- ternal condyle. The internal condyle and olecranon are prominent. Treatment. — The ridge of the sigmoid cavity must be unlocked from the groove between the trochlea and capitellum. This is done by traction or hypercxten- sion (or by abduction, if the head of the radius rests below the external condyle and can be used as a fulcrum). Then the bones are pushed easily into place. The broken epitrochlea may lodge in the groove of the trochlea and efFcctually prevent reduction. Even if the disloca- DISLOCATIONS. ARM. 579 tion be not reduced, tlie joint may be quite useful. Complete outward dislocation occurs in three forms. In the simplest form the bones of the forearm are displaced di- rectly outward, the inner edge of the olecranon resting against the outer side of the external condyle. If, now, the forearm is flexed and strongly pronated, the second form (subepicondylar) is pro- duced, in which the anterior surface of the ulna looks inward and its sigmoid cavity embraces the outer side of the external condyle, while the radius lies above it, with its head in front of the epicondylar ridge. In the third form (supra-epicondylar) the dislocated bones are moved still further upward and back- ward, so that their articular surfaces lie external to and behind the supinator ridge. Reduction is usually easy, owing to the extensive laceration to ligaments; but, even if unreduced, the elbow re- mains fairly strong and mobile. Forward Dislocation. — This rare in- jury is usually caused by direct trauma to the back of the flexed elbow. The olecranon was broken in about a third of the cases. If this is the case, the ulna and radius are displaced forward and up- ward in the anterior surface of the humerus; but, if the olecranon remains intact, it may rest on the trochlea, or, the triceps being torn away, it may pass to the front of the humerus. Reduction by traction appears to liave been easily accomplished. Divergent Dislocations of the Radius and Flna. — In the antero-pos- terior variety the ulna lies behind and the radius in front of the humerus; in the transverse the ulna is displaced in- ward and the radius outward. The usual cause seems to be abduction followed by internal rotation and impulsion. Reduc- tion has failed in one-quarter of the cases. Dislocation of the Ulna Alone. — The forearm is usually extended and ad- ducted. Flexion is painful; rotation free. The trochlea is prominent in front and the olecranon behind, while the head of the radius remains in place. The cause of the injury appears to be hyperexten- sion or abduction, followed by adduction and inward rotation. The rational method of reduction is by supination, abduction, and hyperextension (von Pitha). Dislocation of the Radius Alone. — Of the dislocations backward, outward, and forward the last is the most frequent, being, in fact, of not unusual occur- rence in connection with a fracture of the shaft of the ulna from a fall upon the hand. The head of the bone is displaced upward in front of the external condyle. The orbicular and anterior ligaments are torn. Abduction is possible, while supi- nation, flexion, and adduction are all limited. Adduction and pressure ap- pears to be the best method of reduction; but the orbicular ligament may be inter- posed and require operative interference. The backward and outward dislocations are very rare. They necessitate a fract- ure of the ulna or a rupture of the inter- osseous membrane. The downward dislocation (dislocation by elongation, subluxation of young chil- dren) is of frequent occurrence. The clinical history is quite characteristic: a child, usually under three years of age, is pulled by the hand; it cries out, and refuses to use the limb, which hangs with the forearm partly flexed and pronated. The region of the head of the radius is sensitive to pressure, and sometimes an interval can be felt between the radius and the condyle. All passive motions, except supination, are free. On forcible 580 DISLOCATIONS. AKM. WKIST. HAND. Bupination a slight click may be felt and the symptoms are at once relieved. Du- verney's theory of downward displace- ment with interposition of the annular ligament is most in accord with the facts. Old Uneeduced Dislocations of THE Elbow. — Adhesions and new bone formation verj' soon immobilize the joint. If this immobilization occurs in exten- sion, the position may be improved by forcible flexion, with or without fracture of the olecranon. A more accurate method, however, and one likely in many cases to afEord fairly-good functional re- Fig. 10. — Diagrammatic, to indicate the de- formity in [A) dislocation of the wrist back- ward and (/?) CoUes's fracture of the radius. {SHmaon.) suits, is arthrotomy. The chief obstacle to reduction will be found to be the new bone in the great sigmoid cavity. This may be removed and adhesions divided through two lateral incisions, or a U- shaped incision with division of the tri- ceps or olecranon. Dislocations of tue Lower Radio- Ulnau Joint. — The ulna is spoken of as the dislocated bone. It may be dislo- cated forward or backward. The latter variety is caused by exaggerated prona- tion, and the former by direct trauma. Both are easily reduced. Dislocations of the Carpus from THE Radius. — These may be complete or incomplete; forward, backward, or out- ward. In the incomplete form the cunei- form maintains its relations to the tri- angular fibrocartilage, while the scaphoid and semilunar are dislocated from the radius. In one case the semilunar alone was not displaced (backward). These dislocations may be complicated by fract- ure of the anterior or posterior ("Bar- ton's fracture") lip of the radius; but this in no way complicates the treat- ment and is a purely secondary matter. The more common Colles fracture of the lower end of the radius was long con- founded with backward dislocation. The differential diagnosis is easily made by attention to the relations of the styloid process of the radius with that of the ulna and with the projecting mass on the back of the wrist (Fig. 10). Reduction in either case is made by dorsal flexion and direct pressure, and after reduction the diiferential diagnosis is easy. The spontaneous forward dislocation of Madeburg occurs slowly in adolescents as the result of absorption of the anterior part of the articular surface of the radius. The ulna is abnormally prominent; dorsal flexion is limited. Dislocations of the Carpal Bones. Dislocations have been reported of each of the carpal bones except the cuneiform. If the bone cannot be pressed into place, and gives rise to annoying symptoms, it had bettor be removed. A few dislocations of the second row of carpal bones upon the first have been reported. CARPo-METAOAnrAL Dislocations. — The first metacarpal is the one most commonly dislocated; the dislocation is usually backward and incomplete. The base of the dislocated bone forms a dis- tinct prominence on the back of the DISLOCATIONS. FIXGERS. 581 hand; this is readily reduced, but as readily recurs. To prevent recurrence, extension of the finger (and also abduc- tion, if it be the thumb) and direct press- ure on the head of the bone must be maintained by a dorsal splint for one or two weeks. Habitual dislocations of these joints are often quite painful. Fig. 11. — Simple complete dislocation of the thumb. (Farabciif.) Dislocations of the Thumb and FlNGEHS, — Metacarpo-Phalangeal Dislo- cations of the Thumb. — Lateral (one case) and forward dislocations present no es- pecial points of interest. The latter are easily reduced by hyperflexion and trac- tion. Backward dislocations of this joint, however, have long been the sub- ject of controversy, and are treated in some of our latest text-books in a manner none too accurate. This dislocation may be incomplete, complete, or complex. In- complete backward dislocations may be produced voluntarily by many young persons. It is reduced at will. In the complete form the phalanx is carried backward and upward on the dorsum of the metacarpal, usually by forced exten- sion, the anterior ligament is torn away from the metacarpal bone and drawn backward with its sesamoid bones along, and even past, the articular surface of the head of the metacarpal, while the tendon of the long flexor slips to one side of the head, usually the inner, al- though it may exceptionally remain in place. The first phalanx is in extension at a right angle, the terminal phalanx in flexion, and the head of the metacarpal prominent in the thenar eminence (Fig. 11). In the complex form (produced from the complete by forced flexion of the thumb) the glenoid ligament, and the two sesamoid bones with it, are turned upward so as to lie between the phalanx and the head or dorsum of the meta- carpal. The thumb is in straight exten- sion, parallel and posterior to the meta- carpal; its base can be felt as a promi- nence behind, and the head of the meta- carpal protrudes in front. The sesamoid bones stand at a right angle to the ar- ticular surface of the phalanx, and can- not be folded under it, thus offering a great — often insurmountable — obstacle to reduction. The essential point of re- duction, therefore, is to avoid the trans- formation of the complete into the com- plex form. The extension must be main- tained or even increased and the thumb pressed bodily downward until the an- terior edge of its base, following the glenoid ligament, overlaps the articular surface of the metacarpal, when it can he turned into place by flexion. If this fail, a combination of rotation with the Fig. 1-2.— Complex dislocation, {larabruf.) downward pressure may succeed: a sort of unbuttoning of the head of the meta- carpal from the grasp of the glenoid liga- ment and the attached heads of the short flexor. If, however, the dislocation has become complex by the interposition of the glenoid ligament, the same method may yet succeed; but much more for- 582 DISLOCATIONS. PEL^aS AXD COCCYX. HIP. cible downward traction is necessary to carry the edge of the ligament over the end of the metacarpal bone ahead of the phalanx before instituting flexion. If all manipulations fail, the joint must be opened through a longitudinal anterior incision, and the centre of the glenoid ligament nicked deeply enough to allow it to be drawn over the head of the meta- carpal, after which the dislocation may be readily reduced. Metacarpo-phaJangeal dislocations of Fig. 13. — Doi6al dislocation of femur. {Cooper.) the fingers present the same features as those of the thumb, save that they usu- ally have no sesamoid bones. Dislocation of the 'phalanges may occur in any direction. Reduction is usually ea.5y, though it is possible that the thick anterior ligament may be interposed, as in the metacarpo-phalangeal joint. Dislocations of the Pelvis and Coccyx. — Dislocation of the pubic and sacro-iliac symphyses occurs in connec- tion with fracture of the pelvis, the symp- toms and treatment of which it does not materially complicate. The coccj'x may be dislocated forward or backward. The pain is usually in- tense. Diagnosis and reduction are ef- fected by rectal tottch. The tendency to recurrence can only be remedied by exci- sion of the bone. Dislocations of the Hip. — These form from 2 to 10 per cent, of all dislo- cations; they occur at all ages and are more common in men than in women. The head of the femur may leave its socket in any of the four principal direc- tions, after which it assumes various po- sitions by secondary displacement. In "typical" dislocations the Y-ligament re • mains untorn and determines the char- acteristic attitude of the limb (Bigelow) Compound dislocations are rare. The varieties are as follows: — C " Typical " ilovsal (comprising tlie Dislocations | iliac and " iscliiatic, " and those Backward 1 "upon the doreuni ilia" and [ " into the ischiatic notch "). C Anterior obliqne. Dislocations J Everted dorsal (comprisinf!: the Back^Yard I " suprasj)inons " and some of [ the ''supracotyloid"). Dislocations Downward / Obturator, and Inward \ Perineal. Disloca t i o n s ^ ( Ilio-pectineal . Forward > Suprai)ul)ic \ PuViic. and Upward J [ Intrapelvic. Dislocations directly upward (supracotyloid or subspinous). Dislocations downward on the tuberosity of the ischium. Backward Dislocations. — The dorsal form is by far the most common of the dislocations of the hip. The thigh is adductcd, rotated inward, and more or less flexed; so that the knee rests upon the front of the opposite thigh when the patient is recumbent, and there is appar- ent shortening (Fig. 1 3). The upper and outer part of the thigh is broadened, and the trochanter is above N6]aton's line (a DISLOCATIONS. HIP. TKEAT.MEXT. 583 line drawn from the antero-superior spine of the ilium to the tuberosity of the ischium). The head of the femur may be obscurely felt in the buttock. The actual shortening cannot easily be determined on account of the difficulty of placing the two limbs in symmetrical positions. Voluntary movement and fric- tion are lost; passive flexion and adduc- tion alone are possible. The characteristic position and limita- tion of motion readily distinguishes the dislocation from a fracture of the neck of the femur. Etiology. — The dislocation is usually produced by violence transmitted along the shaft of the femur while the thigh is flexed, adducted, and rotated inward; or the head of the bone may be thrown out of place by exaggerated adduction, in- ward rotation, and slight flexion; or, again, the dislocation may result second- arily from an obturator dislocation by the same three motions. Pathology. — The head of the bone usu- ally tears through the capsule low do^vn behind, passes below and then upward behind the obturator, and rests finally on that muscle close behind the acetabu- lum, or, more rarely, it leaves its socket higher up, pushes the obturator ahead of it outward or upward, and lies on the edge of the acetabulum itself. The cap- sule is irregularly torn behind, the liga- mentum teres is ruptured, the quadratus femoris and gemelli are usually torn, the two obturators and pyri forms less fre- quently. Earely the head of the bone rests on the great sciatic notch or the dorsum ilia. The edge of the acetabulum may be shattered and the head of the bone split. Treatment. — The surgeon must en- deavor to relax the Y-ligament and other untorn portions of the capsule, to bring the head of the bone opposite the rent in the capsule (if necessary) and then to lift or pry it into place. To do this the patient is laid flat on his back and the pelvis steadied by an assistant or by the surgeon's foot. The patient's knee is then flexed at a right angle, the thigh rotated inward and flexed to or a little beyond a right angle, and then lifted bodily upward, rotated a little outward, and extended in abduction. The lifting and outward rotation should replace the bone with a distinct jump. Or the patient may be laid on his face on a table, whose edge comes just above the groin, so as to leave the lower ex- Pifrifamis Oil.Int. Fig. 14. — Dislocation below, and then be- hind and above, the obturator internua. (Stimson.) tremities dangling. The sound limb is now held horizontally by an assistant, and the dislocated one allowed to hang vertically downward. The surgeon grasps the ankle of the dislocated limb, flexes the knee to a right angle, and, while diverting the patient's attention, swings the limb gently from side to side. Under the influence of gravity the mus- cles soon relax and the bone may slip into place of itself or aided by a sharp quick pressure downward on the calf. If these methods fail, ether should be administered and reduction attempted several times by the first method. Fail- ing again, try traction in slight flexion and adduction, aided by direct pressure on the great trochanter. 584 DISLOCATIONS. HIP. If the limb is too strongly flexed or too soon rotated outward the dorsal dis- location may be tranformed into a thy- roid one. If this occurs, the dislocation must be restored to its original form by reversing the movements: flexion in ab- duction and outward rotation, followed by adduction and rotation inward. Everted Dorsal Dishcaiions. — If the outer branch of the Y-ligament is rupt- ured, the limitation to abduction and outward rotation is, in great part, re- moved, and the head of the bone is free to rise higher than before. Hence, when this rupture occurs, if the head remains behind the acetabulum only slight flexion and adduction persist, while, if it has moved upward and forward near to or above the antero-inferior spine of the ilium (in which position it can be felt), there will be extension, abduction, and slight outward rotation: the so-called everted dorsal. Eeduction is effected by converting the dislocation into the com- mon dorsal form and treating it as such. Anterior Oblique Dislocation. — In Bigelow's one reported case the head of the bone was high above the acetabulum and the limb crossed the opposite thigh, everted, and with the knee extended. Reduction as for everted dorsal disloca- tion. Dislocations Downward and Inward. — In both the obturator^or thyroid — and perineal varieties the head escapes through a rent in the lower and inner ])art of the capsule to lodge on the ob- turator foramen, or to proceed farther and rest on the perineum. In either case the limb is flexed, abducted, and rotated outward. It cannot l)e extended and can only be adducted after flexion. The limb is shortened, the trochanteric re- gion flattened, and adduction tense. The head of the femur may Rometimos be felt on the foramen, always if it is in the per- ineum, in which latter case the abnor- mality of the position of the limb is much greater. Several patients are reported to have walked immediately after receiving a thyroid dislocation. The common cause is violence received on the back of the pelvis while the thigh is somewhat flexed and abducted; but it may be extreme abduction alone. In perineal dislocations the laceration of the soft parts must be extensive. Eeduction is made by flexion of the hip to a right angle, traction with adduc- tion, and then inward (or outward) rota- tion while lowering the knee. Manipu- lation may succeed with no rotation at all. Dislocations Upward and Forward, and Inward and Forward (Suprapulic). — The limb is extended, markedly everted, and slightly abducted. The head of the femur is commonly to be felt in the groin (ilio-pectineal form) or may be above the pubes. The psoas-iliac and the great vessels are stretched across the head or may be ruptured. The head of the bone may have left the socket at its upper and inner part by hyperextension, or by ab- duction and outward rotation, or the dis- location may be secondary to an ob- turator dislocation. lieduction. — The head is to be drawn downward past the pubic ramus by di- rect traction in the axis of the limb as it lies; then flexion is instituted while pressure is made against the head to pre- vent its moving upward again; and fi- nally inward rotation replaces the bone. Dislocations Directly Upward {Supra- cotyloid). — In the few recorded cases the bead had been forced directly upward and lay just Ijencatli the antero-inferior spine of the ilium. The limb was everted and abducted. Some of the patients have been able to walk with a limp. These cases bear a close resemlilance DISLOCATIONS. KNEE. TREATMENT. 585 to everted dorsal dislocations. Xo defi- nite rules for reduction have been laid down. Dislocation Downward Upon the Tuber- osity of the Ischium. — This dislocation is very rare because of the ease with which it may be converted into a dorsal or thyroid dislocation. The thigh is sharply flexed and abducted. Keduction is easy by traction in flexion. Complications of Dislocations of the Hip. — Compound dislocations are very rare. Injury to the femoral vessels may oc- cur in forward and inward dislocations. Fracture of the neck of the femur is usually caused by overzealous attempts at reduction. Ankylosis with the limb in a favorable position is the best that can be hoped for, except possibly in the young, when excision of the head of the bone may give some useful motion. Treatment of Old Unreduced Disloca- tions. — Of the operative procedures, re- diiction by arthrotomy gives a long list of deaths as opposed to two successes (by Parkes), while excision of the head, or of the head, neck, and trochanter, and sub- trochanteric osteotomy have frequently decreased the disability. In many cases, however, the patients do reasonably well without operation, and these persons need expect no cure from the knife. Dislocations of the Knee. — These occur rarely and, in order of frequency, forward, backward, outward, inward, and by rotation. The dislocation is fre- quently compound, and the prognosis rendered much more grave by a compli- cating injury to either of the popliteal nerves or to the popliteal vessels. Even if, after reduction, pulsation reappear in the arteries of the foot, gangrene may supervene from thrombosis caused by laceration of the inner coats of the artery. Forward dislocation may be complete, or, more commonly, incomplete. AMien complete, the tibia may be displaced some distance upward over the front of the condyles. If the dislocation is com- pound, the wound is posterior and trans- verse. The cause is direct violence or hj^Dcrextension of the knee. Reduction is easily made by traction and pressure. Backward dislocations may be com- plete or incomplete. The leg is usually either extended or hyperextended, and may be deviated to one side. The patella may be dislocated outward. The usual cause is direct violence. Eeduction is effected by traction and pressure. Even ■nnthout reduction a fairh'-useful limb has resulted in several cases. Lateral dislocations are outward or in- ward, complete or incomplete. The pa- tella is usually deviated toward the side of the dislocation. The incomplete form is usually caused by abduction or (in- ward) by adduction. Eeduction by trac- tion and pressure. Dislocation by rota- tion is said to be incomplete when one condyle revolves around the other, com- plete when both revolve around a central axis. There m-ay be additional backward or outward displacement. The rotation is said to be outward or inward accord- ing to the direction in which the toes turn. Eeduction is easy. All knee-dis- locations should be kept immobilized for several weeks after reduction. DlSLOCATIOX OF THE SEMILUNAR Cartilages. — Either cartilage may be detached from any of its ligamentous attachments, and so displaced in any di- rection, or it may be lacerated. The symptoms are those of any loose body in the joint, sudden painful lock- ing, usually after some given movement. The displacement may be recognized by palpation along the articular edge of the tibia. The cause of displacement is a 586 DISLOCATIONS. PATELLA. FIBULA. dislocation, a sprain, excessive rotation, or flexion. Treatment. — The locking may be re- lieved by forcible manipulation or by pressure upon the displaced cartilage. Various braces have been devised to pre- vent recurrence, either by opposing the displacement directly or by preventing the motion which occasions the displace- ment. These methods failing, the car- tilage may be removed or sutured into place through an exploratory incision alongside of the patella. Dislocations of the Patella. — The patella may be dislocated outward or in- ward or rotated around its long axis, or Fig. 15. — Diagram of the various dislocations of the patella. {Stimson.) the two forms may be combined. Dis- placement upward or downward is purely secondary to rupture of the ligamentuin patella or the quadriceps tendon, and need not be here considered. Outward dislocation is complete or in- complete, and accompanied by various degrees of rotation (Fig. 15: 1, 2, and 3). The patella is readily felt in its new posi- tion, though it may be difficult to deter- mine whether the outer or the inner border is directed forward. Muscular ac- tion or direct violence are the causes of the dislocation, and hydrarthrosis and ligamentous weakness are predisposing causes. The fibrous exjjansion of the vastus internus is ruptured, and the mus- cle itself may be more or less torn. Re- duction is made by direct pressure dur- ing extension of the knee and flexion of the hips. Incomplete dislocations are those in which, during extension or flexion, the patella moves outward on to the external condyle. Outiuard, Edgewise, or Vertical Dislo- cations {by notation). — In these the pa- tella is moved outward and its inner edge backward into the intercondylar groove; so that its articular surface looks outward and more or less forward, or completely forward (Fig. 15: 4 to 7). The causes and treatment are the same as for out- ward dislocations. Inward dislocations present the same features, mutatis mutandis, as the out- ward, but they are much less frequent. Habitual dislocations are usually the result of some deformity, such as genu valgum. They are controlled by correct- ing the original deformity or by appa- ratus, or by tightening up the loose lat- eral ligaments (by operation). Dislocation of the Fibula. — The upper end may be dislocated outward and forward, or backward, or upward. These dislocations are all rare. The first form seems to be caused by muscular ac- tion of the long extension of the foot; the second (in more than half the cases) by action of the biceps, and tlie third by an injury resemliling Pott's fracture, in which the fibula, instead of being broken, was forced upward. A complicating fracture of the tibia may exist. Recurrence is likely, al- though reposition is easy, and hence im- mobilization should be maintained for several weeks. The lower end may be dislocated back- ward. This is quite as rare as the dislo- cation outward in connection with Pott'a fracture is common. DISLOCATIONS. DYSEXTERY. 5S7 Dislocation of the Ankle (Tibio- Tarsal) Backward. — By extreme plantar flexion the lateral ligaments are torn, the foot slips back, and the astrag- alus is caught behind the tibia. (Incom- plete dislocation is a frequent accompa- niment of Pott's fracture.) The malle- oli may be fractured. The lengthening of the heel and shortening of the foot may only be determined sometimes by careful measurement. Fonvard. — Bare. Caused by pressure on the heel or by exaggerated dorsal flexion. Inward. — Two varieties. In the one the astragalus is pried out by suppura- tion and adduction, and the foot moved directly inward and forward; in the other (thought to be secondary to a back- ward dislocation) the foot is turned over so that its plantar surface faces directly inward. Keduction is easy. Outward. — Appears always to be asso- ciated with Pott's fracture. Subastragaloid Dislocations. — The other bones of the foot may be dis- located from the astragalus outward, in- ward and backward, forward, or back- ward. The first two are the most com- mon. About 50 per cent, are compound. About 50 per cent, of attempted reduc- tions have succeeded. Complicating fractures are not infrequent. Xotwith- standing the persistence of the displace- ment, a good functional result may be obtained in some unreduced cases. Pri- mary and secondary excisions of the as- tragalus and amputations give various re- sults. Dislocations of the Astragalus. — The varieties are forward, backward, out- ward and forward, inward and forward, and by rotation. There is frequently ■ more or less rotation in connection with the other displacements. Outward and Forward. — This is the most frequent form. The foot is ad- ducted and inverted and the external malleolus prominent. The astragalus rests on the outer cuneiform and cuboid bones, or even on the fifth metatarsal. Its posterior part is still in contact with the articular surface of the tibia. Eeduc- tion by traction on the foot and pressure on the astragalus is usually easy, unless the bone is rotated. Inward and Forward. — The foot is ab- ducted and everted and the astragalus lies in front or below the malleolus. Re- duction may be prevented if the tendon of the tibialis anticus embraces the neck of the dislocated bone. Forward. — Very rare. The cases re- ported have no features in common. Backward. — There may be lateral dis- placement. In about 50 per cent, of cases the bone was broken at the neck and only the posterior fragment dislo- cated. There may be flexion of the ter- minal phalanx of the great toe. Reduc- tion was effected in one-third of the simple cases. Botatory. — Dislocation by rotation alone may take place about the vertical or transverse axis (in these latter there is always some displacement forward and inward) or about the antero-posterior axis. Dislocations of the Tarsus and Metatarsus. — These dislocations re- semble those of the carpus and meta- carpus {q. v.). The external cuneiform alone has not been dislocated individu- ally. Lewis A. Stimson, Edward L. Ketes. Jr., New York. DYSENTERY.— Gr.,f^i..-, difficult, and fj'Tfpoj', intestine. Definition. — An acute or chronic in- flammatory disease, which usually affects 588 DYSEXTEKY. VAKIETIES. SYMPTOilS. the large, but sometimes the small, in- testine. The structures implicated are the solitary and more rarely the agmi- nated nodules, and the general enteric mucous membrane. Under this name are described several diii'erent forms of intestinal flux, which in the acute stage are characterized by fever and accom- panied by tormina and tenesmus. Varieties. — Several different forms of dysentery are distinguished partly upon anatomical and partly upon clinical and etiological grounds. A division into endemic, epidemic, and sporadic has been made. It is probable that the endemic, or tropical, form owes its origin to a definite species of micro-organism, the amoeba eoli. The epidemic and spo- radic varieties are of uncertain etiology. For clinical purposes a separation into catarrhal, diphtheritic, and amoebic dys- entery may be made. General Symptoms. — The first symp- toms of dysenterj' usually set in without prodromata. A natural movement is fol- lowed by several diarrhoeic stools with- out either pain or tenesmus. The size of the movements gradually diminish, they become admi.xed with mucus and blood, and are accompanied by colic, bor- borygmi, and tenesmus. It sometimes happens that the disease is ushered in with bloody and mucous stools, pain, and tenesmus. In light grades constitu- tional symptoms are scarcely present; in severe ones the disease begins with chill, fever, loss of appetite, nausea, and faint- ness. The evacuations remain diarrhojic and contain only mucus, when we have to deal with a mild catarrhal inflamma- tion, or they become admixed witli blood, pure bloody, pseudomemliranous, or pur- ulent, indicating more severe lesions. The several kinds of dysentery present difTerent stages. The epidemic and spo- radic forms may be separated into ca- tarrhal, diphtheritic, and ulcerative stages. The endemic form, and espe- cially the amcebic variety, appears in the ulcerative stage almost e.xclusively. The last also shows a greater tendency to be- come chronic and to relapse. Special Symptoms. — (A) Calarrhal Dysentery. — In this form prodromata, except dyspepsia and slight abdominal pains, are rare. Diarrhoea is the most constant initial symptom and at first it is not painful. The characteristic feat- ures of the disease — colicky and griping abdominal pain, frequent stools, and straining — are usually developed within the first thirty-six hours. The consti- tutional symptoms are, as a rule, insig- nificant; tlie temperature is little ele- vated; the pulse rarely exceeds 100; the tongue is, at first, furred and moist, but later becomes red and glazed; nausea and vomiting may be present. The ab- domen may be flat and hard and the thirst excessive. There is constant de- sire to go to stool. The stools present the following characters: During the first twenty-four or forty-eight hours they consist of more or less clear mucus and blood, with small, scybalous masses. Under strict regimen, as early as the second day, they may be composed en- tirely of mucus and blood, and their con- sistence may be so viscid that the bed- pan may be turned upside down in many cases without spilling the contents. The number of stools in twenty-four hours varies from 15 to 200. Tliis condition may persist for one or two weeks, the mucus becoming gradually more opaque, of a grayish-white color, the blood pro- gressively diminishing in quantity, and a little gray, green, or brown pultaceous detritus, or fluid ftecal matter, appear- ing in the stools. As the disease sub- sides, fffical matter again makes its ap- pearance, increasing in amount until DYSENTERY. SYMPTOMS. 589 fully-formed fecces are passed, showing neither mucus nor blood. In the more prolonged cases wholly pultaceous, yel- low-brown or greenish (spinach) evacua- tions may intervene between the bloody, mucoid stools and the passage of formed faeces. Microscopical examination of the stools shows in the first bloody, glairy discharges a predominance of red blood- corpuscles. AVith these are associated leucocytes and cylindrical epithelial cells in small numbers, and constantly large round or oval epithelioid cells. In later stages the stools contain fewer red cor- puscles and more leucocytes; in the pul- taceous material cellular elements are scarce. Bacteria are more abundant in the later stages; amcebje are absent; oc- casionally the Cercomonas inteslinalis is seen in large numbers. The duration of the disease is variable; according to Flint, the milder cases terminate in about eight days; severe ones may last as long as a month. The disease rarely becomes chronic. Amcebic dysentery lias so rarely been described in children that the diagnosis is probably never entertained by the practitioner. Within a short space of time five cases were identified and suc- cessfully treated by the author at the Johns Hopkins Hospital. The patients ranged in age from 2 to 5 years, and ilhistrated a moderately severe type of the disease, with the exception of one child who was very seriously sick. The clinical picture in these cases was very indefinite. The appetite and gen- eral health were good, fever and ac- celeration of the pulse were hardly notice- able, and the blood-examination showed only a very moderate anncmia of the sec- ondary type. Stools varied from two to six in twenty-four hours, were rarely associated with pain, and presented nothing characteristic to the eye. They were of every degree of consistence, and might, or might not, show admixture of blood. The odor was always most offen- sive. Microscopically, three very typical structures are to be found, namely: live amoebiE containing red blood-cells, Charcot-Le3-den crystals, and numerous eosinophile cells. The presence of either of tlie latter elements should make the observer extremely suspicious of amoebic dysentery, as they occur in no other condition except helminthiasis, which can easily be excluded. The presence of the amoeba is, of course, final. S. Am- berg (Bull. Johns Hopkins Hosp., Dec, 1901). (B) Diphiherilic Dysentery. — The pri- mary variety presents somewhat differ- ent symptoms, depending upon the stage — whether acute or chronic — of the dis- ease. In the acute stage the symptoms often from the outset are severe. There may be high fever, great prostration, ab- dominal pain, and frequent discharges, with tormina and tenesmus. The grip- ing pain and straining are the chief sources of sufEering. Delirium may set in early, and the clinical features resem- ble severe typhoid. Osier states that he has known this mistake to be made on more than one occasion. The pulse, in the majority of cases, is but little, and sometimes not at all, accelerated. Fever, except in the severe cases, is not a prom- inent feature. Flint states that great frequency of the pulse denotes gravity and danger, but that the converse does not always hold good. The discharges are frequent and diarrhoeal in character; blood and mucus may be found early, and sloughs may make their appearance. The presence of pseudomembrancs and of necrotic portions of the intestinal coats is characteristic of the diphtheritic form of inflammation. The other in- gredients are common to both the ca- tarrhal and the diphtheritic varieties of inflammation. Upon microscopical ex- amination the cellular elements are found to be relatively few in numbers, those most constantly present being cylindrical epithelial cells, showing more 590 DYSENTERY. SYMPTOMS. or less fatty degeneration. Eed blood- corpuscles and leucocytes are observed, especially where much blood and mucus are admixed, and large numbers of leucoe3i;es in the purulent discharges. Fibrin also occurs, and bacteria appear in great numbers. When improvement begins feculent matter appear in the stools. The duration of the disease from the date of attack to convalescence varies from four to twenty-one days. When death takes place it usually re- sults from asthenia. The pulse becomes weaker and accelerated, the tongue dry, the face pinched, the skin cool and cov- ered ^s-ith sweat, and the patient sinks into a drowsy condition. Consciousness may be retained until the end. (C) Chronic Dysentery. — This condi- tion usually succeeds an acute attack. Clinically the chronic forms of diph- theritic are not sharply marked off from those of amoebic dysentery. The latter disease may be subacute from the outset and fail to present an acute period. The lesions in the intestine will depend upon the origin: if amoebic, then ulceration with little tendency to healing is the rule; if diphtheritic, then pigmented cicatrices or these together with imper- fectly-healed ulcers are met with. The intestinal walls are thickened and the sigmoid fle-xure may be palpated as a hard, resistant tube. The disease pre- sents protean symptoms and cannot always be sharply separated from chronic diarrhoea. Its course may extend over months and even years. Many of the characteristics of the acute disease are wanting. The composition of the stools is variable; blood, necrotic tissue, and pseudomemljranes are rarely found. There are periods of improvement and exacerbation; the patient loses weight and strength, becomes emaciated, suf- fers from periods of psychical depres- sion, and may become bedridden. The degree of emaciation may be extreme, and a severe secondary anamia some- times develops. The evacuations — which vary from five to twelve or more in the twenty-four hours — take place usually without tenesmus, and with only slight colicky pains. They are lluid, of greenish-yellow or brownish-black color, now and then admixed with blood and mucus. Sometimes the stools are puru- lent. Indiscretions in diet are followed by an increase in the colicky pains. (D) AmceMc Dysentery. — The symp- toms presented are very variable. What characterizes the disease are an "irregu- lar course marked by periods of inter- mission and of exacerbation of the diar- rhoea, a tendency to chronicitj', and the frequent occurrence of abscess of the liver" (Lafleur). For clinical purposes Lafleur groups the cases under (a) grave or gangrenous forms; (b) dysentery of moderate intensity (showing periods of intermission and of exacerbation); (c) chronic forms. Ivartulis recognizes ca- tarrhal and ulcerative stages in the diseases. The catarrhal stage, in contra- distinction to epidemic dysentery, is relatively of infrequent occurrence. This stage tends to pass into the more severe or ulcerative form. In the ca- tarrhal stage the dejections are yellow, bile-stained, and of mushy or lluid con- sistence. When the stools arc small, then mucus, which may be blood-stained, appears. As the intensity of the symp- toms increases clumps of mucus and blood are more abundant; still later the stools present a beef-water appearance, in which clear clumps, resembling frog- spawn, — altered starch-grains, — float. With the advance of the ulceration they become more copious, watery, and less homogeneous; there is less blood and a great deal of shreddy material appears DYSEXTEKY. bYilPTOMS. 591 admixed with the mucus. Fragments of necrotic tissue from the bases of the ulcers, — small, grayish-yellow masses, — which always contain amoebje, are pres- ent. When there is great and rapid sloughing, then the stools are greenish, grayish, or reddish brown and are still more variegated in appearance. In con- sistence they are watery or pultaceous and in odor penetrating and highly offensive. In the chronic form the stools are homogeneous, watery, or gruel-like; they contain few or many flakes of clear mucus, but seldom any blood or necrotic fragments of tissue. The microscopical examination of the bloody, mucoid stools shows red blood- corpuscles, leucocytes, oval and round epithelioid cells, cylindrical epithelial cells in small numbers, crystals of am- monia-magnesian and earthy phosphates, Charcot's crystals, occasionally blood-pig- ment, and amoebae. At later stages the cellular elements are less numerous, the amorphous detritus increased, and elastic tissue may be met with. In the liquid stools of the chronic form few formed elements except amoebae occur. With each exacerbation there is an increase of the cellular elements. In the grave form the stools are, at first, numerous, twenty to thirty in twenty-four hours; as the disease ad- vances they diminish to a dozen or less, and in fatal cases, toward the end may not exceed three or four. Abdominal pain and tenesmus are fre- quently present at the outset, especially in severe cases, but may be entirely ab- sent. Vomiting and nausea are only oc- casionally observed. Fever is an incon- stant symptom and ranges from 99° to 101° or 102°. With the development of complications (liver-abscess, etc.) it is more persistent and tends to become more regularly intermittent. The pulse, in most instances, follows the variations in temperature. In the fatal stage of gangrenous dysentery the pulse becomes rapid, — 120 to 140 or more — thready, and compressible; and at the same time the temperature tends to fall below nor- mal. Anaemia, of greater or less severity, appears in all cases; albuminuria of slight grade is of frequent occurrence, and hyaline casts are sometimes found in the urine. The examination of the stools for the amoebae coli is very important and should never be omitted. Sometimes a single examination sutfices to demonstrate ac- tively-moving amoebae. In chronic cases, however, repeated examinations may be required. In cases of liver- and of lung- abscess the diagnosis of the intestinal disorder may be established by finding the amoebae in the aspirated contents of the former or in the sputa derived from the latter. In making the examinations for amoeba; it is advised that the stools be passed into a warm bed-pan and kept at the body-temperature during the ob- servation. The examination should be made at once or very soon after collect- ing the faeces, and the most favorable parts should be chosen for the examina- tion. A warm stage greatly facilitates the examination. Special S3'mptoms referable to com- plications are apt to arise. Those most commonly met with are in connection with liver- and lung-abscesses, peritonitis with or without perforation of the iu- testine, and intestinal haemorrhage. The duration of the disease in uncom- plicated cases varies from six to twelve weeks. Recovery is tedious, relapses are frequent, and there is a constant tend- ency to chronicity. In uncomplicated cases recovery may be expected when the freces become formed and amccboe disap- pear from the stools. 592 DYSEXTERY. COMPLICAXIOXS. DIAGNOSIS. ETIOLOGY'. Complications. — A local peritonitis may arise by extension, or a diffuse in- flammation, which is usually fatal, may foUow perforation. A local inflamma- tion about the c^^cum gives rise to peri- tj'phlitis; if about the rectum, periproc- titis. The regional lymphatic glands may be swelled and hypertemic, and rarely do they undergo suppuration. A serious complication is pylephlebitis af- fecting the veins of the intestine and mesentery, owing to the danger of em- bolic abscess of the liver. The abscesses, in these cases, may be single or multiple. Intestinal stricture is a rare sequence; amyloid degeneration of the viscera and dropsical conditions are uncommon con- sequences of chronic dysentery. The dis- eases associated with dysentery which have been noted are rheumatic swelling of the joints, malaria, typhoid fever, pleurisy, pericarditis, and endocarditis. Case of severe dysentery complicated with infectious pseudorheumatism, ar- thritis, with sero-purulent effusion of the left knee, necessitating arthrotomy and drainage of the articular cul-de-sacs. J. Brault (Lyon MCd., Jan. 27, '95). The sequelae of the disease as met with in the Philippine Islands are the following: Chronieity; chronic gastri- tis and indigestion ; obstinate constipa- tion; paralysis (partial) of the large intestines, due either to obliteration of the glands and lack of secretion or to lack of innervation and blood-supply; aneemia from lack of assimilation of food; association of malarial fever; typhoid fever; neuritis; atrophic cir- rhosis of the liver; chronic parenchy- matous nephritis; abscess of the liver; metastatic abscesses of other organs, as of the lungs and kidneys; inanition; toxaemia; dilatation of the stomach and intestines. S. M. Long (N. Y. Med. Jour., Mar. 30, 1001). Diagpiosig. — The diagnosis of dysen- tery usually involves no great difficulty. The characteristic evacuations are path- ognomonic. The diseases from which it is to be discriminated are local affections of the rectum, such as syphilis and epi- thelioma, which may produce tenesmus with the passage of mucoid and bloody stools, and hemorrhoids, and a discharg- ing intestinal abscess, in which certain of the symptoms are simulated. Etiology and Epidemiology. — Dysen- tery is one of the four great epidemic dis- eases of the world. In the tropics it destroys more lives than cholera, and it has been more fatal to armies than pow- der and shot (Osier). From the ac- counts furnished by history and the numerous ones supplied by physicians in the last three centuries bearing upon its epidemiologj', it may be concluded that, just at present, dysentery has at all times had the widest distribution over the globe and that no considerable part has been exempted from a visitation. To quote Ayres, "of dysentery it may be said that, where man is found, there will some of its forms appear." The present geographical distribution of dysenteric and diaTrha3al diseases ia compared by Ilirsch with that of the malarial diseases, with which, in respect to the manner of their endemic preva- lence, the frequency of their epidemic outbreaks, and the varying severity of their type, they are in correspondence. Like the malarial diseases, they reach the maximum of diffusion and of inten- sity, and more especially their greatest severity as an endemic, in equatorial lati- tudes; in subtropical countries there be- gins to be noticed a decrease in the ex- tent and seriousness of endemic and epi- demic incidence; while in still higher latitudes they almost disappear as en- domic diseases and show themselves merely now and then in epidemics over an area at one time large and another DYSENTERY. ETIOLOGY. 593 time small. In one point they differ from malarial diseases, namely: that they attain to higher latitudes of the cold zone, appearing as epidemics in re- gions that are quite free from malaria. The endemic form of dysentery has al- ways existed in Africa and India, but the place of its natural home is not known. Its present distribution includes Africa in its entire extent, except for a few lo- calities. Both natives and Europeans are affected. In South Africa it prevails se- verely in Bechuanaland, Natal, and the Transvaal. In the north it appears in Egypt, especially along the coast and the Nile delta. In Asia it prevails to a great extent along the Arabian coast of the Eed Sea as well as of the Gulf of Aden and the Persian Gulf. It exists in Syria, Asia Minor, and extends into Mesopo- tamia and Persia. Endemic dysentery is widely disseminated in India and the Indian Archipelago and exists in China. In Japan it assumes a milder form, while the epidemic variety is very destructive. The disease prevails in the tropical and subtropical parts of South America, but it fails to reach the wide diffusion which it presents in Africa and India. In Guiana it is found in the mountainous regions and in the tropical parts of Brazil in a severer form. In Valparaiso and La Serena in Chile the disease has a home. Foci appear in Paraguay and in the tropical provinces of Argentine Re- public. In Peru it occurs along the marshy districts of the Amazon and in some of the mountainous regions, being endemic in the city of Cero de Pasco at an elevation of 13,000 feet. Venezuela does not escape; in Uruguay it is almost unknown. In Central America the dis- ease prevails in Panama, Costa Rica, Nicaragua, Salvador, Honduras, and Gautemala. It is diffused over Mexico and appears at elevations of 6000 feet. 2- It assumes the severest forms in the West Indies, especially in Cuba and Hayti, and prevails to a greater or less extent in Guadeloupe, Martinique, and Barbadoes. In Europe endemic dysentery occurs over limited areas only, and is present in the more southernly-placed countries. Thus it is known in Greece, but is endemic in the Ionian Islands and the Cyclades. In Turkey it is common, in Bulgaria and Roumania, along the Donau, also, while the southern provinces of Italy and Sic- ily are the most severely affected regions in Europe. France, Switzerland, Bel- gium, the Netherlands, and Great Britain are free from endemic dysentery. In Germany there are no definite foci of occurrence, but a number of cases of the disease have been observed at Weimar and Kiel. The same facts are true of Austria, which, in general, has escaped, although cases have been reported from Prague, Graz, and Vienna. The distribution upon this continent, and especially in the United States, of the endemic form of dysentery is, at present, difficult to estimate. If we ac- cept this variety as synonymous with tropical and amcebic dysentery, a much closer study of the disease than yet made will be necessary in defining the limits of its prevalence. Cases have been re- ported from Maryland, Massachusetts, Pennsylvania, Texas, Ohio, Alabama, and Georgia. But it seems probable that many of the so-called sporadic cases oc- curring in this country, and, perhaps, not a few of the epidemic ones, may be shown to be of this kind. With the exception of the investigations of the disease car- ried out in Egypt, Germany, Austria, and Italy, the American cases above referred to have been the most thoroughly studied. The epidemic form of dysentery is oftenest confined to a single locality, a 594 DYSENTERY. ETIOLOGY. \'illage or a towTi, witli no extension to the country aroimd. Instances are not rare in which the epidemic attacks a single detached establishment, such as a prison, a hospital, a poor-house, a sol- diers' barracks, or, under certain circum- stances, a sliip, while there are no cases of dysentery outside these, or merely oc- casional cases (Hirsch). It happens much more rarely that the disease achieves a greater diffusion, and most rarely do pandemics arise. Mention has already been made of the prevalence of dysentery as an epidemic disease, espe- cially in earlier historical times. Great epidemics have not appeared in recent years. The countries which have been most severely visited are Italy, France. Ireland, Denmark, and Norway and Swe- den. In the United States, dysentery in an epidemic form, except during the "War of the Eebellion, has not in late years reached serious proportions. According to Woodward, it prevails annually among the civil populations in all parts of the United States. It occurs both in the form of sparodic cases and of small local epidemics which fasten upon different districts in different years. Sporadic dysentery, which is distin- guishable both from the endemic and the epidemic forms, is of very uncertain oc- currence. This variety of dysentery is attributed by Kartulis to the action of mechanical and chemical irritants upon the intestine, and arises as a secondary condition in the course of other diseases, Buch as acute, infectious, and chronic dis- eases of the heart, kidneys, and liver. By most writers the occasional cases of dysentery met with in all countries are included under this term. Various telluric conditions have, from time to time, been supposed to influence the prevalence of dysentery. Of late years the search has been made for micro- organisms to the action of which the disease might be attributed. With what success this line of investigation has been piirsued will be stated in other parts of this article. It is a well-known fact, and one borne out by the best statistics, that both the epidemic and the endemic forms prevail especially during the hot seasons. Great diurnal variations of temperature — warm days and cold nights — have been supposed to predispose to the develop- ment of the disease, but in Egypt the facts observed are in direct opposition to this view. The degree of atmospheric moisture seems without influence: Hirsch states that, of 12 G epidemics of dysen- tery, 65 occurred during moist weather and 61 during continued drought. The elevation and configuration of the sur- face seem also without particular signifi- cance, although low-lying and marshy localities are more subject to visitations than high and dry ones. There is good reason to believe that the dissemination of the virus of dysen- tery takes place, in large part, through the water. And, although the same con- clusive evidence of water-infection has not been brought for this disease as has been brought for cholera, yet there are many convincing observations at hand which bear out this belief. Numerous ovitbreaks both of the endemic and epi- demic varieties, among troops and in- habitants of towns, have been traced di- rectly to contaminated drinking-water; and the replacement of the polluted by a wholesome supply has been quickly fol- lowed by a cessation in the spread of the disease. Observations which indicated a more contagious character, a transmis- sion from person to person, arc not want- ing. But whether, in these instances, the virus may not have been carried by water, wasb-linoii, or food is not corfainly knoAvn. DYSENTERY. ETIOLOGY. 595 The demonstration of parasitic organ- isms bearing an etiological relation to dysentery has been done certainly only for the endemic variety. Several differ- ent bacterial organisms have been de- scribed in association with the epidemic dysentery. The proof of their essential causal relationship with the disease has yet to be brought. The several micro- organisms will be considered with their respective diseases. Amcebic Dysentery. — This affection is also known as endemic and tropical dysentery, and as amcebic enteritis. It is characterized clinically by irregular diar- rhoea, a variable course often marked by periods of intermission and exacerbation, a special tendency to chronicity, and the development of liver-abscess, and ana- tomically by ulceration and thickening of the large intestine. Morbid Anatomy and Etiology. — This form of dysentery has been known ana- tomically for more than a century: since the writings of John Hunter, who ob- served the disease in Jamaica. The prin- cipal contributions upon its pathology has been made by Councilman and La- fleur,Krusc and Pasquale,Kartulis, How- ard and Hoover, Fle.xner and Harris. The lesions in the intestine are of two kinds: (1) a general catarrhal inflamma- tion of the large gut, which does not dif- fer from catarrhal colitis due to other causes; (2) the specific focal lesions (ul- ceration) caused by the presence in the tissues of the amoeba coli. The specific lesions are located oftenest in the sigmoid flexure, somewhat less often in the CEPCum and ascending colon, and more rarely in the descending and transverse colon and rectum (Kartulis). The verm- iform appendi.x may be the scat of ulcera- tion; most rarely does the dysenteric process pass beyond the ileo-ca?cal valve and attack the lower end of the ileum. The amoebae are present upon the sur- face of the intestine and in the interior of the crypts, where by continued irri- tation they bring about destruction of the epithelium; they may then be ob- served to penetrate through the inter- glandular tissue into the depth. They set up an active inflammation in the mucosa, shown by the hyperemia, ec- chymosis, and swelling of the glandular epithelial cells. The farther extension of the amceba takes place after the par- tial destruction of the muscularis mu- cosae. The organisms now reach the submucosa, where the principal damage is inflicted. The number of amcebae in the submucosa is considerable; their presence excites a reactive inflammation, and soon a solution of the tissues in which lie. Thus a cavity is formed which, sooner or later, is followed by ne- crosis and removal of the overlying mu- cous membrane. '^Ticn this happens, an ulcer is the result. The lymphoid folli- cles are not especially attacked; they simply share the fate of the surrounding tissue. The muscular coat offers some resistance; it is not generally destroyed, but the amoebae pass through it in cer- tain places, enter the intermuscular tis- sue, and there repeat the part they play in the submucous tissue; the structures overlying the infiltration, deprived of their nourisliment, undergo necrosis. The ulcers increase by this continual process of undermining; but the typical course and appearance of the ulcer may be completely changed through the ac- tion of the bacteria in the intestinal canal. The ulcers are, for the most part, un- dermined. Often the defect in the mu- cous membrane is small and altogether inconsiderable, while the cavity in the submucosa and deeper tissues is large, and sinuous tracts, sometimes connecting 596 DYSENTERY. ETIOLOG'X. several ulcers, are met with. Again, sim- ple ulcers, with little or no undermining of the mucous membrane and limited to the submucosa, exist. Both forms may be associated. More rarely still, large sloughs, which may consist of the mu- cous or muscular coats, are encountered. The part of the intestine involved be- comes much thickened, partly through the infiltration present in the submucous and other coats, and partly in virtue of a thickening of the peritoneal coat; ad- hesions between adjacent intestinal loops and deformation also occur. According to Councilman, fibrinous exudation upon the surface of the mucous membrane (diphtheritic or croupus membrane) does not take place in uncomplicated cases, while Kartvilis describes its occur- rence. The amcebas occur in greater or less numbers in intimate association with the ulcers and even in adjacent parts. They are found in the tissue-spaces, within the crypts of Lieberkuhn, in definite lym- phatic vessels, and in the veins. The mere presence of amosbaa in the stools is not sufficient evidence of the existence of amojbic dysentery. As early as 1870 Lewis and Cunningham found amoebae in the stools of persons sick of cholera in India. They have even been found in the stools of healthy persons (Grassi, Kruse and Pasquale, Minckc and Roos, Schuberg). Losch (in 1875) gave the first accurate account of the organism which he found in the stools of a dysen- teric patient, and he studied the intestine removed at the autopsy. R. Koch ob- served amoebffi in sections of the intestine of a number of cases of dysentery occur- ring in Egypt and India, and suggested a causal relationship between them. Soon afterward (1885) Kartiilis was able to find them in more than five luindrcd cases of endemic dysentery prevailing in Egj'pt, while they were absent in other diseases. Similar organisms were also found in the contents or walls of amrebic abscess of the liver. The results of Kartulis's studies have been abundantly confirmed in this country by Osier, Coun- cilman, Lafleur, Simon, Dock, Eichberg, Howard, Musser, Stengel, Flexner, Wil- son, Harris, and others. The amajbte coli (s. dysenterias) re- sembles in many ways the amoebfe occur- ring in the stools of healthy beings. The average size of the latter is from 13 to 36 microns, of the former from 10 to 50 microns. The structure of the two forms is also similar. In a state of rest they appear as slightly-refractive and faintly- granular spheres; in the active state a separation into structureless ectoplasm or hyaloplasm and a more refractive, granular, endoplasm or granuloplasm takes place. The pseudopodia are ex- truded slowly and may be easily ob- served; change of position does not al- ways follow the extrusion. Nuclei are present and often visible, even in the fresh state. This description suffices for the non-dysenteric as well as for the dysenteric varieties; in the latter there is found, in addition, contained within the endoplasm, vacuoles, bacteria, and red blood-corpuscles. The chief constit- uent, from a diagnostic stand-point, is blood-corpuscles, as these never occur in the amoeba3 found in healthy persons; both the vacuoles and bacteria may, how- ever, be present. Nothing definite is known of the mode of propagation, but it is believed that multiplication takes place by division. The amoebiB are very little resistant; the stools, etc., must, therefore, bo ex- amined soon after their evacuation. Their number quickly diminishes in ma- terial outside the body, and at the end of from six to twenty-four hours thej DYSENTERY. ETIOLOGY. 597 are often no longer to be found. They have not been certainly successfully cul- tivated outside the body in a pure state, although they may have been cultivated along with other micro-organisms (Kar- tulis, Celli, and Fiocco). The evidences for the belief in the causal relationship between the amoeba coli and endemic dysentery is summed up by Kartulis as follows: "The con- stant presence of the organism in cases of endemic dysentery (with the excep- tion of the so-called 'Cochin-China diar- rhoea'; see below); its presence in the walls of the dysenteric ulcers and absence from other kinds of intestinal ulcers; the successful production of dysentery in cats by the injection of fa;ces containing amcebffi into the rectum and even of pus from liver-abscesses free from other mi- cro-organisms; the negative results of similar injections (excepting in the ex- periments of Celli and Fiocco) of other micro-organisms obtained from dysen- teric stools; and, finally, the failure of healthy stools containing amoebiE to pro- voke dysenteric lesions in cats." [The recognition of the amcebse in sec- tions of liardened tissues and their dis- tinction from swelled and degenerated tissue-cells are not always easy. Alallory has introduced a special staining method in which thionin is used, and Harris em ploys toluidin-blue, in order to differ- entiate these organisms from other cells Simon Flexner.] The endemic dysentery of warm cli mates is probably generated by aniraa parasites, is not contagious, and is some times also found in temperate regions, The amceba seems to be the principa factor in its causation, and the patho logical changes produced are most likely due, in part at least, to the bacteria de- veloped i» situ or transported there by the wandering amceba;. The direct pa- thogenic action of these corpuscles has not yet been satisfactorily established. Wegener (Rivista Inter. d'Igiene, Sept., Oct., '92). There are three forms of the organism: (1) the Amrcba coli fclis (Losch), which is the true amoeba of dysentery; (2) the AnKLha coli mitis, the cause of the diar- rha^a in the second case; and (3) the Amaba coli vulgaris, the form observed in healthy persons. Calomel in small doses appeared to be the best method of reducing the number of amoeba; in the stools. Quincke and Eoos (Berliner klin. Woch., No. 45, '93). The amceba dysenteriie is distinct from the non-infectious form, or amoeba coli. The former, when coupled with bacteria, is the cause of dysentery and of some liver-abscesses. There still re- main other liver-abscesses which must be classed as idiopathic, and in which cli- matic conditions must be looked on as playing a large part. Among the many questions which are yet to be solved concerning the amoeba; are the following: Whether their virulence is constant or can be lost and acquired; how they gain access to the human body; how the bacteria aid them; where the bacteria come from; how the dysenteric ulcers begin ; whether the predisposing causes of cold and indigestion work on the human organism or on the bacteria; whetlier there is not also a systemic infection, as well as a local process; in what way the amoebae gain access to the liver, whether along the portal system, the lymphatics, the peritoneum, or the bilc-passagcs. There are certain cases which point to each mode, but in multi- ple abscesses the propagation is along the blood-current, either from the ulcers or backward from an original single focus. Kruse and Pasqualc (Zeit. f. Hygiene u. Infectionskr., Feb. 8, '94). Chronic-dysentery amoebie are not pathogenic to cats except when the in- testinal mucous membrane has been in- jured, as by a sublimate solution. The amcclice are not the cause of dysentery, but irritants which prevent the heal- ing process in lesions already existing. Kovac (Zeit. f. Heilkunde, B. 13, H. 6, '94). Biological and clinical study of 235 cases of diarrhoea and dysentery. The 598 DYSENTERY. ETIOLOGY. amoeba found S6 times, most fi-equently in cases of typical diarrlicea, less often in simple catarrhal enteritis, and least frequently in sporadic dysentery, whether mild or fatal. The pathogenic impor- tance of the amoeba denied, experiments upon cats having shown that the amoeba swallowed up numerous microbes, and that, where amoebte were numerous, but a small number of microbes were met with. Opinion expressed that the amoeba prevents the development of bacteria and permits healing of the lesions, thus explaining the vegetating form of the ulcerations observed by Councilman and Lafieur. The amoeba prevents an acute evolution of the process, which, in turn, explains why amoebic dysentery is of a chronic type, as assumed by many authors. Cassagrande and Barbaglio- Eapisardi (Gaz. degli Osp., No. Gfi, '95). Cats injected with portions of the stools showed only a mild follicular en- teritis. Small portions of a dysenteric stool were mixed with peptone solution, and of two cats injected at the same time with the same stool, one remained liv- ing, while the other died after six days. There were practically no differences in their bowel changes from those seen in uninjectcd cats. The fifth and sixth eats injected remained living; so that the results were not characteristic. In no case were amoebce obtained by culture, or seen upon microscopical examination. A streptococcus that was obtained, and which grew in the form of a streptobacil- lus, reacted to a dilution of 1 to 100 of blood-serum from the patients with dysentery, but it reacted in just as high a dilution with the blood from patients who had no dysentery. No description could cover, in a broad sense, the forms that one is likely to meet in the contents of the intestines. Ascher (Deut. med. Woch., Jan. 20, '99). Conclusions concerning the parasitol- ogy of tropical dysentery: 1. No bacte- rial species yet described as the cause of dysentery has an especial claim to be regarded as the chief micro-organism concerned in the causation of the disease. 2. It is unlikely that any bacterial specicB that is constantly and normally present in the intestine or in the en- virons of man, except where the disease prevails in an endemic form, can be re- garded as the probable cause of epidemic dysentery. 3. The relations of sporadic to epidemic dysentei-y are so remote that it is improbable that the two diseases are produced by the same organic cause. 4. The pathogenic action of amoeba coli in many cases of tropical, and in eert-ain examples of sporadic, dysentery has not been disproved by the discovery of amcebfe in the normal intestine and in diseases other than dysentery. While amcebffi are commonly present and are concerned in the production of the le- sions in subacute and chronic dysentery, they have not, thus far, been shown to be equally connected with the acute dysenteries even in the tropics. In the former varieties bacterial association probably has much influence upon the pathogenic powers of the amceboo. Simon Flexner (Phila. Med. Jour., Sept. 1, 1900). Six cases of the ordinary type of so- called amojbic dysentery, in which the blood did not react with Shiga's bacillus. This tends to indicate distinctly that the disease is separate and distinct from the dysentery as met with in the tropics. William Osier {Jour. Amer. Med. Assoc, Jan. 5, 1901). No bacterial species yet described as the cause of dj'sentery has an especial claim to be regarded as the chief micro- organism concerned with the disease. It is imlikely that any bacterial species that is constantly and normally present in the intestine or in the environs of man, except where the disease prevails ill an endemic form, can be regarded as a probable cause of epidemic dysentery. The relations of sporadic to epidemic dysentery are so remote that it is im- probable that the two diseases are pro- diiced by the same organic cause. The pathogenic action of the amccba coli in many cases of tropical and in certain examples of sporadic dysentery has not been disproved by the discovery of amoeba in the normal intestine, and in diseases other than dy.sentery. While amoeba are commonly present and are concerned in the production of the le- sions of subacute and chronic dysentery, they have not thus far been shown to DYSENTERY. ETIOLOGY. 599 be equally connected with the acute dysenteries, even in the tropics. In the former varieties bacterial association probably has much influence on the pathogenic powers of the amoebiB. Simon Flexner (Jour. Amer. Med. Assoc, Jan. 5, 1901). The most frequent complication of dysentery in the Philippine Islands is malaria. A malarial spleen and active malarial parasites were found in 4 out of 6G cases of chronic amoebic dysentery which came to autopsy, and once in 12 cases of subacute (non-amoebic) dysen- tery. In 157 cases of chronic and sub- acute dysentery among soldiers sick in the First Reserve Hospital, Manila, in which blood examinations were made, the malarial parasites were found in 36, or in nearly 23 per cent. J. J. Curry (Boston Med. and Surg. Jour., Feb. 21, 1001). ^^■llen the first case of amcebie dysen- tery was found in Johns Hopkins, very careful inquiries were made as to the patient's possible connection with things tropical. Now, however, that many cases have been seen there is no ques- tion that the disease may occur in those who have never been outside of Balti- more. The disease has been observed especially in children and others who have taken gutter-water or who have had their hands covered with material from the gutters when eating. It would seem, then, that the frequent amoeboe seen in such water have some connection with the pathogenic amoebre. MacRae (Proceedings Amer. Med. Assoc; Med- ical News, June 14, 1902). Complications. — Involvement of the poritonexim in the chronic cases with deformation of the intestine has ah-eady been mentioned; through the formation of adhesions definite kinking of the bowel may result. Perforation of the bowel, leading to peritonitis, is a rela- tively-rare complication, and peritonitis without previous perforation apparently still rarer. Small haemorrhages in the intestinal mucosa, in the region of the ulcers, are frequent, but large hremor- rhages seem uncommon. In one of Coun- cilman and Lafleur's cases about one hun- dred and twenty-five cubic centimetres of clotted blood were passed per rectum on the last day of illness. By far the most important complications are abscess of the liver and of the liver and lung. A very important, but unusual, sequel of liver-abscess is perforation of the inferior vena cava. Flexner has described two such cases. Although the data at hand for computing the frequency of amcebie abscess of the liver in endemic dj'sentery are, as yet, too few to admit of definite conclusions, yet, according to Kartulis (based on observation of 500 cases of liver-abscess), 55 to 60 per cent, were of dysenteric origin; Councilman and La- fleur found liver-abscess 6 times in 15 cases, Kruse and Pasquale 6 times in 57 cases of amoebic dysentery. Kartulis states that liver-abscess, which is so com- mon a complication of endemic d)'sen- tery, is infrequent in the epidemic form. Hence the statistics of British and French physicians covering this subject, in which the proportion of 1 case of liver- abscess for every 4 or 5 of dysentery oc- curring in the East, probably relate chiefly to the amcebie form. ITepato-pulmonary abscess occurred four times in Councilman and Lafleur's cases. Following pulmonary abscess, pleurisy and pyothorax or pyopneumo- thorax (Flexner) may supervene. The amoebaj were found in the contents of the hepatic and pulmonary abscesses and pyothorax. In abscess of the lung the organism appears in the sputa. Kartulis has encountered abscess of the brain and spleen in amoebic dysentery; in neither situation was he able to demonstrate amccbffi. The question of the existence of amoebic hepatic abscess without evidence of previous intestinal lesions is still an 600 DYSEKTERY. COCHIN-CHINA DIAKKHCEA. open one. Kruse and Pasquale mention two cases, but admit that they are not conclusive. Flexner has described an un- doubted case. The etiologj' of the so- called idiopathic, or tropical, liver-ab- scess is still wrapped in obscurity. Kesults of examination in a ease of abscess of the liver follo^ying dysentery in which the amojba was found in the pus drained from the abscess. The amcebse from the abscess were somewhat larger than those described by Kartulis; they were circular, sometimes ovoid, but while in movement had an irregular outline. The alterations in contour and change in locality were as remarkable as in some forms of pond amoeba;. Motion continued active for hours; in two in- stances for ten hours. In the stools the amoebae were rare in the brownish liquid; more frequent in the small sloughs passed. In form and other characters they were like the organisms in the pus from the liver-abscess. Osier (Johns Hopkins Hosp. Bull., vol. i, No. 5). Statistics showing that suppurative hepatitis is almost always the conse- quence of dysentery; there is but a single pathogenic element concerned in the production of both diseases. Proof: if dysenteric faeces containing living amoebae be injected into the rectum of cats typical dysentery will be produced, the animals dying usually in from thirty- nine hours to nine days, though some may survive and even recover; 7 out of 1 1 of those injected showed amoeba; in the evacuations. The classical altera- tions of dysentery were found at au- topsy. Zancarol (Le ProgrOs MC-d., June 15, '95). Dysentery in the Philippines has been of such a character as to make the fol- lowing facts worth noting: 1. Dysen- tery, as it is seen here, i» not a single, but consist.? of two distinct and sepa- rate diseases. 2. Acute dysentery does not produce abscess of tlie liver, nor does it produce ulceration of the colon. 3. Its fatal result is due to inflammation of the bowel, rapid elimination of the watery fluids of the body, toxicmia and exhaustion, much after the manner of cholera, though requiring four, six, and twelve days before its termination or crisis. 4. Amoebic dysentery differs from acute dysentery anatomically, pathologically, and etiologically. The only similarity between them is: the colon is the locus riiinoris rcsistentio! for both the bacillus of Shiga and the amceba. Here all similarity ends. The bacillus of Shiga leaves no other lesion behind, save its effect upon the mucous membrane of the colon and enlargement of the adjacent glands. Tlie amceba of dysentery invades the three layers of the colon, producing pinched-out ulcers, or ulcers with undermined edges. It also passes to the liver and produces characteristic lesions. There are two varieties of the amceba which differ in no respect save as to size. The pathog- enic variety is somewhat larger than the non-pathogenic. These two varieties of the amceba have been the cause of all the confusion regarding the amoeba as an etiological factor in amoebic dysen- tery. Finally, in regard to the dysen- teries produced by the Shiga bacillus and amosba: (1) the duality of dysen- tery is proved; (2) acute dysentery is the result of infection with the bacillus of Shiga; (3) it is infectious in the same way as the bacillus of typhoid fever is infectious; (4) amoebic dysentery is caused by an amoeba; (5) there are both a pathogenic and a non-pathogenic amoeba, which fact has produced much confusion regarding the amoeba as an etiological factor; (6) the lesions of amoebic cl3'sentery differ from those pro- duced by the bacillus of Shiga; (7) the therapeutic agents generally used for the treatment of acute dysentery are in no way curative; (8) magnesium sul- phate should be included in this list; (9) quinine solution is a specific for the amoebic dysentery, but its employment in rapid, acute, ulcerating cases is fraught with danger, and from the na- ture of the lesions it cannot be retained for a sufficient length of time to pro- duce beneficial effects. M. II. Bowman (Phila. Med. Jour., from N. Y. Med. Jour., Aug. 17, inOl). CociiiN-CiiiNA DiARUHUcA. — This is a form of dysentery which occurs in DYSEXTERY. CATAERHAL. 601 Cochin-China and some other tropical countries. Normand in 1S7G found, in the stools of soldiers who returned from Cochin-China to Toulon and who were suffering from chronic diarrhoea, two forms of nematodes (Anguillula slerco- ralis and Anguilhda intestinalis) after- ward shown by Leuckhart to be the suc- cessive generations of a single species to which he gave the name Rhahdonema strongyloides. Further studies have ren- dered doubtful its etiological relation to the disease. The parasite is often absent at the beginning of the affection, while it is not infrequently found in the stools of healthy persons. Calmette has studied more recently this form of enterocolitis, and has made it probable that the bacil- lus pyocyaneus, alone or in association with the streptococcus, is the cause of many cases. He also demonstrated the bacillus pyocyaneus in the drinking- water at Saigon and Gokong. Calmette was able to produce hemorrhages and ulceration of the stomach and intestine in rabbits by injection of cultures of the bacillus pyocyaneus. L. F. Barker has reported several cases, from the Johns Hopkins Hospital, of enteric infection and inflammation caused by this bacillus. In one instance an extensive diphtheritic inflammation of the oesophagus, stom- ach, and intestine existed. As a cause of diarrhoea and dysentery in infants it has been met with by Adami and Williams in Canada, and of an epidemic of the same diseases in Albany, N. Y., by Blumer and Lartigan. In the case of Europeans, a large num- ber of species of micro-organisms found, among which are the colon bacillus and an amoeba. In natives (Cochin-Chinese) the number of species is less numerous, probably as a result of the more simple and almost entirely vegetable diet. Two species regarded as important found: a coccus having all the properties of the streptococcus erysipelatous and the bacil- lus pyocyaneus. A. Calmette (Archives de MC-d. Kavalc, Sept., '03). The combination of the colon bacillus and the proteus bacillus is the essential cause. In northern Europe the epidemic is decidedly diderent from those seen in tropical climates. Chaltin (Archives Med. Beiges, Apr., '04). Catarrhal Dysentery. — This is a disease of the intestines, affecting princi- pally the large bowel, which occurs spo- radically or epidemically. It is the form of dysentery met with most frequently in temperate climates. Morbid Anatomy and Etiology. — The p.rea of intestine involved may be large or small; sometimes the affection is limited to a circumscribed area or areas, at others the mucosa in its entire extent is in- volved, even including the stomach. The colon is most often the seat of the lesions. Woodward questioned the existence of an isolated affection of the small intes- tine, while ISTothnagel claims to have met with cases in which the pathological process stopped abruptly at the ileo- caecal valve, the large gut having entirely escaped. The general mucosa and the solitary lymphoid nodules, especially, are affected. In the acute stage the affected part of the mucous membrane is red- dened, especially about the lymphoid nodules and plaques, and small extrava- sations of blood may appear. There is an excessive production of mucus and a rich desquamation of epithelial cells. The villi and solitary nodules are swelled, the latter becoming unduly prominent. The microscopical picture agrees with the macroscopical appear- ances: there is hypera^mia, swelling, and desquamation of epithelial elements and round-celled infiltrations of the mucosa. The swelled lymphoid nodules show an increase in cells, the chief ones being of the large epithelioid variety occupying the germinal centres. Extravasations of 602 DYSENTERY. CATARRHAL. blood are present in the mucosa about the nodules. The submueosa shows changes only in the severest grades. In more protracted cases ulceration, limited to the nodules or extending into the ad- jacent mucosa, appear. The chronic cases are characterized by pallor of the general mucous membrane; pigmented spots appear, and at one time the mucous membrane is atrophic, at another hyper- trophic. In the latter instance, in the most marked cases, a pol)'poid condition of the affected mucous membrane may exist. The causes of this disease are twofold, namely: agents of (A) intoxication and of (B) infection. (.4) All caustic chem- ical agents which act directly upon the mucous membrane (acids, alkalies, etc.) and others brought by the blood and eliminated by the intestine (mercury, ricin, etc.) and the more indefinite chem- ical substances which are found, under some circumstances, in the ingested food. (B) Bacteria play an important role in the causation of this disease. Booker's study of the summer diarrhoeas of chil- dren is most convincing in this respect. "Xo single micro-organism is found to be the specific exciter of the summer diarrhffia of infants, but the affection is generally to be attributed to the result of the activity of a number of varieties of bacteria, some of which belong to well-known species and are of ordinary occurrence and wide distribution, the most important being the streptococcus and proteus vulgaris." As to the mode of entrance into the mucosa, Booker 6a)'s: "In the superficial epithelium of the intestine is apparently to be found the chief protection of the mucosa against the invasion of bacteria. When the epithelium is preserved, bacteria are not found in the mucosa beneath, whereas they may be seen entering it in places where the epithelium has been lost or injured." Gartner's bacillus en- teriditis is capable of provoking acute en- teritis; and acute enterocolitis is asso- ciated as a secondary affection, with a variety of specific infections (cholera, ty- phoid fever, tuberculosis), intestinal dis- eases, and other infectious processes (sepsis, influenza, pneumonia, scarlet fever, measles, diphtheria, etc.). Seven cases of endemic dysentei-y in •wliich a large aerobic bacillus was isolated. It developed well on ordinary culture-media, liquefying gelatin, curd- ling milk, and producing gas. It is motile, somewhat like anthrax morpho- logically, but is decolorized by Gram's method. Inoculated into animals, it produces a htemorrhagic septiccemia with ulceration of the colon. Roger (Comp. Rend, de Biol., ser. xi, 1, '99). The specific cause is an organism much like the bacillus coli, and which is agglu- tinated by the blood of dysenteric pa- tients. An antitoxic serum prepared with which 266 eases were treated, with a death-rate of 12 per cent., the death- rate during the same period under ordi- nary treatment in 1736 cases being 34 per cent. Shiga (Report by Surgeon Eldridge to the U. S. Marine-Hosp. Serv- ice, 1900). In Fiji dysentery is endemic and most prevalent in May, June, and July: the season of di-y weather and scanty water- supply. While under some circumstances tlie mortality is high, — 40 per cent., — the average death-rate is 7 per cent. C. W. Hirsch (Edinburgh Med. Jour., Jan., 1900). Among 277,000 eases of malarial dis- ease recorded by various writers, 3054 were registered as pernicious fever, and, of the 1317 of those which were more definitely classified, only 8 were consid- ered to be as belonging to the pei-nioioua dysenteric class. Knnallis and Carda- niatis (Prngn-'s MOd., May 19, 1000). In Manila dysentery is very common. Investigation has conclusively shown the two types of dysentery: one dependent upon a si)eciflc bacillus said to resemble the bacillus typhosus or the bacillus DYSENTERY. CATARRHAL. 603 eoli communis, the other being the ordi- nary amoibic dysentery of the tropics. R. P. Strong and W. E. Musgrave (Jour. Amer. Med. Assoc, Aug. 25, 1900). Analysis of the waters of Landerncau (Brittany) in the midst of an affected region. The nutritive gelatin plates of Ellsner showed colonies of the colon bacillus, the method of P6r6 also. The bacillus resembled Eberth's bacillus, but was distinguished by the lactose test, which difTcred from the reaction with Eberth's bacillus. F. Lenoble (La Prosse M6d., Oct. 27, 1900). Comparative study of several cultures of bacilli obtained from cases of dysen- tery. These organisms were designated Manila cultures, Kruse's bacillus, Shiga's bacillus, cultures of a Porto Rican, and Strong's bacillus. The differences of growth are slight, and probably depend upon purely accidental circumstances. A comparison of the morphologj' of the bacilli shows only very minor differ- ences. Kruse has not observed motility at any time in liis culture; Shiga states his to have been feebly motile, while those of the author were at first slightly motile, but soon became quiescent in artificial cultivation and did not regain motility. Strong's observations coincide with the author's. Vedder and Duval, under the direction of the author, have succeeded in demonstrating flagella by Van Ennengheim's method in several cultures. The serum reactions have been of the greatest importance, and are, moreover, unmistakable in signifi- cance; they indicate close relationship between the bacilli from Japan, Manila, Porto Rico, and Germany, and they further render probable the identity of the epidemic dysentery of this country with that of the East and Germany. Flexner (Brit. Med. Jour., Sept. 21, 1901). Shiga's bacillus dysentcria; is found in the latter half of the first week of the disease in the fresh stools; in the later stages of the disease it is rather difficult to cultivate. It disappears more or less completely ns the patient improves. If there is a relapse it again appears in large numbers. One finds the bacilli in almost pure culture in fresh catarrhal or diphtheritic areas in the bowel; in fresh conditions they are found more superficially in the lesions; in the old infection, the colon bacillus and other micro-organisms overgrow them. The bacilli are often found in the mesenteric glands, but the author has never found them in the liver or spleen. He exam- ined five cases of parotitis which oc- curred in the course of dysentery, and was unable to find the bacilli in ex- tirpated portions of the glands or in juices of the gland. The urine, blood, and milk are always sterile. Because of the localized character of the disease one finds in dysentery no tumor of the spleen, no eruption, and no infiararaa- tory conditions of the bone and bone- marrow, etc., such as are found in ty- phoid fever. The agglutinative reaction he has tested in hundreds of patients and found it generally parallel in in- tensity with the severity of the disease. It appears in some instances in dilution as great as 1 to 130, and so on down, very mild cases being negative at 1 to 10. He has seen the reaction present as long as eight months after the at- tack. Jt is now, however, of impor- tance in diagnosis in many instances, because it is very likely to be absent in very mild or doubtful cases. He dis- cusses the relation between the typhoid serum reaction and the prognosis, and then states that, after making quan- titative investigations on the agglu- tinating power of the blood in dysen- tery, be found that its intensity is prac- tically parallel with the severity of the disea.se excepting in very grave cases, which are commonly fatal, in which the reaction is usually but slightly marked. Agglutination appears only in the sec- ond or third week of the disease, and reaches its highest point in convales- cence. It sometimes appears as late as the sixth week, and this late appear- ance makes it of little importance in diagnosis. The bacteriological diagnosis of a case of dysentery may be made by carrying out the agglutination test of a culture with immune scrum, by culti- vating on glucose agar, and in milk. If agglutination occurs at once, if there is no gas-production, and if milk has 604 DYSENTERY. DIPHTHERITIC. not coagulated, the dysentery bacilli may be considered to be present. K. Shiga (Deutsche med. Wochen., Oct. 24, 1901). Dysentery is due to the increase in the \-irulence of micro-organisms that ordinarily inhabit the intestine. The writer does not consider it due to a specific organism. Bertrand {Revue de Jled., July 10, 1902). DiPHTHEBiTic Dtsenteet. — An in- flammatory disease of variable and un- certain etiologj', which affects especially the large intestine, sometimes involving the small gut, which may or may not be attended with fever; is characterized by mucous, serous, or bloody stools, and is accompanied with tormina and tenesmus. The anatomical lesions consist of necrosis of the mucous membrane, the deposit within its substance and upon its surface of a fibrinous pseudomembrane, and the formation of ulcers. This occurs (a) as a primary disease, in which form it prob- ably gives rise to the great majority of the cases of epidemic dysentery; (&) as a secondary and terminal affection in many acute and chronic diseases, the chief ones being acute general infections and chronic renal, cardiac, and hepatic disease. Certain cases of sporadic dysen- ierij, the result of the action of chemicals and metastatic bacteria upon the intes- tinal mucous membrane and indirectly of mechanical irritants (coprostasis, in- testinal worms), belong to this class. Morhid Anatomy and Etiology. — The pathological process begins with hyper- emia and swelling of the submucosa and mucosa. The unique character of the dis- ease begins with the appearance of small grayish-white membranous patches upon the surface of the mucous membrane. These increase in size and become con- fluent. At first they are readily removed with the finger; at a later stage they are more adherent. They tend to appear, by preference, upon the more prominent and projecting parts of the mucosa; thus, in the small intestine along the tips of the valvule conniventes; in the large, corresponding with the insertion of the longitudinal muscular bands. At a later time and in severe cases the intervening mucous membrane may become covered. Upon microscopical examination, in the earliest stages of the disease the blood- vessels of the submucous and mucous coats are congested and contain an in- creased number of polymorphonuclear leucocytes; the superficial epithelial layer is necrotic, and fibrin and leuco- cytes are present on the injured surface. Somewhat later the necrosis has ex- tended and involved the deeper parts — glands and interglandular tissue — and the fibrinous membrane is thicker and intimately bound up with the necrotic tissue. Many kinds of bacteria are pres- ent in the necrotic and exudative ma- terial. The swelling of the submucosa may reach a high degree, due to oedema, cellular infiltration, and a deposit of fibrin. The blood-vessels of the mucous membrane become plugged by hyaline thrombi. The separation of the dead tissue leaves an ulcer behind. The young ulcers do not extend deeper than the submucosa coat; later, and by continued destruction, the muscular coat may be exposed. Perforation of the intestines is, in this form of dysentery, unusual. Ecchymoses occur in the neighboring mucosa. Even the deepest ulcer may, through the formation of granulation- tissue, heal. In these cases the wall of the intestine becomes thickened; the muscle hypertrophic; the scars have a pigmented appearance, and, through re- traction of the cicatricial tissue, de- formity and often stenosis of the bowel arise. 'J'hc points of pi'cdilcction of the path- DYSENTERY. DIPHTHERITIC. 605 ological process are the flexures (sigmoid, splenic, hepatic), the ascending colon, and caecum. In the Crimean War the rectum, sigmoid flexure, and descending colon were the principal points of attack. The small intestine is only rarely affected in its lowest parts, and this in severe cases; in certain secondary forms of dys- entery it may be attacked alone. Klebs was the first to describe short bacilli in the crypts of Lieberkuhn in diphtheritic dysentery. Since this time a large number of bacteria have been described in association with the disease. None of these appear to be specific, and the circumstances of the disease make it easy to isolate different bacterial forms. From what has already been said it is not probable that diphtheritic dysentery is caused by a single micro-organism. As regards the question of etiology of epidemics, whether in a given epidemic a single species of micro-organism is to be regarded as the cause, and in different and widely-removed ones the same spe- cies will be found, cannot be answered at present. Thus far a very small num- ber of epidemics have been studied with modern bacteriological methods. Zieglcr described small bacilli in the crypts of Lieberkuhn and the underly- ing mucous membrane. Marfan and Lion cultivated from the mesenteric glands, pericardial fluid, and heart's blood of two cases the bacillus coli communis. Babes has cultivated the streptococcus, proteus vulgaris, and other organisms from dysenteric cases. Maggiori studied, in 1891, an epidemic which occurred in Italy. He found in the mucous stools of all cases the bacillus coli communis, in association with proteus vulgaris. More rarely pyococci, bacillus fluores- cens, and pyocyaneus were obtained. Ogata investigated an epidemic which prevailed in Japan. He found small ba- cilli, which lay in the protoplasm of cells; they were present in the base of the ulcers. Cultures from fifteen cases gave a short, non-pathogenic, liquefying ba- cillus. From eleven cases Ogata culti- vated a bacillus which also liquefied gelatin, but was pathogenic. Guinea- pigs, inoculated subcutaneously, develop haemorrhages and ulcers in the intestine. Rectal injections produced more pro- nounced results. Condorelli, Maugieri and Aradas describe a bacillus which they obtained from an epidemic and also iso- lated from the drinking-water; Bertrand and Baucher studied an epidemic at Cherbourg and isolated several different bacteria, none of which appear to be spe- cific. Silvestri described diplococci which caused diarrhoea in dogs. Colli and Fi- occo found that in the dejections of dys- enteric persons the bacillus coli com- munis is always present; with it is often associated a typhoid-like bacillus; more rarely the streptococcus and proteus ba- cillus. The introduction of this bacillus coli, either alone or in association with the other bacteria, by means of the mouth or rectum, into cats, gives rise to dysen- tery. According to these writers, the association of the bacillus coli communis with the other bacteria mentioned leads to its conversion into the bacillus coli dysenteric. Celli has more recently ex- pressed the idea that the primary in- jury to the intestine is produced by the toxin of the bacillus dj'senterie, which is followed by the injurious action of pyo- genic cocci contained within the intes- tine. Ciechanowski and Norrak have failed to confirm this view by experi- ments, although they found large num- bers of streptococci in the stools of cases of sporadic dysentery. The bacillus pyo- cyaneus, according to Blumer and Larti- gan, may be associated with epidemics of dysentery in this country. 606 DYSEXTERY. TREATMENT. Treatment. — The hygienic rules which are observed in the prevention of other infectious diseases and especially of cholera have been employed with excel- lent effect in controlling epidemics of dysentery. The emplo}Tnent of filtered and boiled water has reduced the num- bers of cases and the spread of the dis- ease in the tropics. The same principles are applicable to the treatment of articles of food (vegetables, fruits, etc.) which come into contact with water. Other prophylactic measures consist in the use of suitable clothing which obviates the injurious influence of rapid changes in temperature and humidity of the air and the proper disposition of the dejecta from the sick. In armies in the field intemperance and all forms of excess should be severely repressed. For the purification of water everj' available method should be used, but the most practical and certain is boiling. Soldiers willingly adopt these precautions if tea or coffee is served out to them for use with the water. As the sanitary service is not adequate to cope with the necessary work of disinfecting hospitals and the sanitation of battle- fields, there should be organized in time of peace a special service for those pur- poses which should be in a condition to set to work from the very beginning of mobilization. A service of this kind was tried with success by the Russians in 1877. Antony (Thirteenth Inter. Med. Congress; Brit. Med. Jour., Sept. 8, 1900). The direct treatment is, in part, di- etetic , in part therapeutic. In acute cases the diet is to be restricted to milk, whey, and broths, and during convales- cence great care is to be exercised in pro- viding only the most digestible articles of food. In the use of a diet of milk, which often will be the chief article, the appearance of curds in the stools is the indication to dilute or partially peptonize the milk before it is administered. Di- luted egg-albumin may supplement milk or even take its place for a few days if there is much intolerance to the latter. Sometimes milk is made more acceptable by dilution with lime or Vichy water. The quantity of milk, for an adult, ad- ministered in twenty-four hours should be from 2 to 3 ^/„ quarts. Whatever the food, it is advisable to give it in small quantities and at frequent intervals. The patient even in chronic cases should be confined to bed; in acute cases no especial persuasion will be required. For the relief of the abdominal pain, the external application of fomentations or turpentine stupes will sometimes suffice; but the internal use of opiates may be demanded. AVlien the pain is low down in the bowel then enemata of opium or suppositories containing some form of this drug or of cocaine may be resorted to. "When a case is seen earlj', especially if there has been constipation, a purge should be administered. This can be either castor-oil or, what is preferable, a saline. By this means the frecal contents of the large intestine, which tend to pass continuously over the inflamed area, should be efl'ectually removed. The saline selected should be given in suf- ficient doses to promptly produce abun- dant dejections, and it is then to be dis- continued. There may be a marked dim- inution in the frequency of the dysen- teric evacuations, and great relief of the tormina and tenesmus following the operations of the purgative. The use of a saline is contra-indicated by feebleness of the patient; in such cases castor-oil is to bo preferred. Nincty-flvo cases treaicd at llydera- liad, India, by sulphate-ot-magnesium iiietliod. The number of days under this licatment before the dysenteric synip- tmim disappeared was never more than 5, DYSENTERY. TliEATMEXT. 607 and in many eases 1 or 2 only. Leahy (Lancet, Oct. 4, '00). [Saturated solutions of magnesium sulphate urged by many observers: To an ounce of saturated solution of mag- nesium sulphate 10 drops of dilute sul- phuric acid are added; this is given every hour or two until it operates freely and the stools have become feculent, free from blood and nuicus, and the pain and tenesnu)s are relieved. W. W. John- ston, Assoc. Ed., Annual, '91.] Mortality reduced from 5 to 10 per cent, to practically 7iil, by avoiding all irritants and stimulants; rendering the intestinal canal aseptic by preventing the decomposition of contents; by counter- acting acidity of the blood by alkalies and thus quieting the abnormal action of the intestinal glands. Diet restricted to arrowroot-milk and trinitrate of bis- nuith, Dover's powder, and soda inter- nally. Bahadurji (Brit. Med. Jour., Oct. 24, '91). Drachm-doses of a saturated solution of Epsom salts, in combination with 10 minims of dilute sulphuric acid, every hour, are strikingly cfTcetive. V. G. Thorpe (Brit. Med. Jour., Feb. 2G, '98). Sulphate of soda or sulphate of mag- nesia may be given in drachm doses evei-j' quarter- to half- hour for the first four or six doses, and afterward at longer intervals until the motions assume a good yellow color. With the saline a little quinine and perchloride of mercury may be combined if desired. Scries of 555 consecutive cases treated in this way, with only G deaths. For chronic or re- lapsing cases the saline treatment is not nearly so efUcacious, and, after one or two doses of the salt, castor-oil, bismuth, etc., should be given. Buchanan (Brit. Med. Jour., i, p. 30G, 1900). Salines used in 855 cases in Bengal. There were only 9 deaths: a mortality of only a little over 1 per cent. The following mixture was used: — B Sodii sulphatis, 1 drachm. Aquae foeniculi, ad 1 ounce. This was given four, six, or eight times a day (each dose represented 1 drachm of the saline) as the case re- quired. No dose was repeated on the following day till the stool had been in- spected. The saline was continued till every trace of blood and mucus had dis- peared completely in two or three days; in others they returned on the third or fourth day, necessitating a repetition of the saline. The saline treatment is advocated for acute cases only. It is not considered a safe method for chronic or relapsing cases with ulceration of the colon. In cases in which either the symptoms or the history point to the disease being either chronic or relapsing, the saline was used for one or two doses during an exacerbation of the chronic state, and then the case was treated with soda and bismuth or with salol, with an occa- sional dose of castor-oil. For stools containing seybala nothing is so good as a dose of castor-oil guarded by 10 minims of laudanum. When the patient can be admitted to hospital, the saline is the best method of treating acute dysentery, but it should not be applied in a routine fashion in out-patient practice, on ac- count of the possibility of many patients having had previous attacks, and hav- ing their bowels in a state of unhealed ulceration. The success which has this year attended the treatment of the chronic cases in due to careful dieting on rice-water (mar), and boiled milk and tyre (dahi), the use of anthelmin- tics (a large proportion of the inhabit- ants of this part of Bengal harbor both round and tape- worms), and the careful occasional use of the saline, with Dover's powder and the intestinal anti- septics. W. J. Buchanan (Brit. Med. Jour., Apr. 13, 1901). The oldest method of treating dysen- tery which has been found at all successful is that by a large dose of calomel. The next treatment in point of time was castor oil — an exceedingly good one. Then came the administration of ipecacuanha, in doses of 30 grains of powder. In the recent epidemic in South Africa the remedies most in favor were magnesium sulphate and sodium sul- phate. In many .subacute cases nothing acts so well as a change of scene or climate. Brunton (Lancet, July 4, 1903). 608 DYSEN'TERY. TREATilENT. Among the drugs used to combat the disease, ipecacuanha still maintains its reputation in the tropics. It is usually administered after a preliminary dose of laudanum or morphine, which is followed in half an hour by from 20 to 60 grains of ipecaeijanha. Should the dose be re- jected, it is repeated in a few hours. This mode of treatment was not satisfactory during the TVar of the Eebellion, and Osier has failed to see in sporadic cases the marked effects claimed for it by the physicians in the tropics. Experience in Bengal has given great faith in ipecacuanha in large doses. Castor-oil should be given the night be- fore and, after the bowels have moved in the early morning, tincture of opium, fol- lowed in fifteen or twenty minutes by ipecacuanha in a dose of 25 or 30 grains. The patient should lie undisturbed for four or five hours. Should vomiting oc- cur, ipecacuanha to be repeated in half an hour and also if the stool has not much changed for the better within twenty-four hours. Ipecacuanha in pill, in doses of from 3 to 5 grains, is utterly useless. W. J. Buchanan (Practitioner, Dec., '97). Ipecacuanha tried several years in Nicaragua, Central America. Notwith- standing its vaunted efficacy, no case de- rived much benefit from it. Patients suf- fering from dysentery cannot always retain large doses, as stated in text- books. Half-ounce doses of a saturated solution of magnesium sulphate and 15 minims of dilute sulphuric acid every two hours, with milk diet, caused all traces of blood to disappear from the stools in twenty-four hours, and there was, of course, a complete absence of the dis- tressing nausea which is always present in the treatment of ipecacuanha. T. R. Wiglesworth (Brit. Med. Jour., Feb. 26, •98). Ipecac ia indicated in almost every form and type of acute dysentery owing to its simplicity, its safety, and its certainty, compared with any other method. The promptitude with which the inflammation is stopped. The rapid- ity with which repair takes place (a) by resolution or (h) by granulation and cicatrization. Conservatism of the con- stitutional powers. Abbreviation of the period required for convalescence. De- crease in the frequency of recvu'rence. Decrease in the frequency of abscess of the liver. Diminution of mortality in cases treated. The chief objection to ipecac is its frequent rejection from the stomach. Its administration in the form of compressed pills coated with salol is recommended to avoid this untoward feature. William Roberts (Jour. Anier. Med. Assoc, April 11, 1903). Corrosive sublimate, in doses of Vioo grain, repeated every two hours, has been recommended by Ringer. Bismuth in large doses — Va to 1 drachm every 2 hours, amounting to 12 to 15 drachms in 24 hours — often has a beneficial effect. Its effects are more pronounced in the chronic than in the acute cases. The administration of antiseptic sub- stances by the mouth for the purpose of disinfecting the intestinal canal has been emploj'ed. For this purpose benzo- naphthol is the drug to be chosen when there is suspicion of liver or kidney dis- ease, and in their absence it is as effective as betanaphthol and resorcin, which are also employed as intestinal antiseptics. The dose of benzonaphthol is 40 to 80 grains, given during 24 hours, in divided doses every 2, 3, or 4 hours. Betanaph- thol and resorcin are given in quanti- ties of from 30 to 50 grains in 24 hours in much the same way. The naphthol preparations, being insoluble, must be given in capsules or dissolved in oil and emulsified. Resorcin is soluble and can be readily administered. Naphthalin (20 grains per day) and salol (30 to 40 grains per day) are used for the same purpose. Opium is an invaluable remedy for the relief of pain and to quiet the peristalsis, but should l)c employed cautiously. It is to be administered hypodermically in the form of morphine, according to tlie needs of the patient. DYSENTERY. TREATMENT. 609 Sulphur successfully used in the treat- ment of dysentery. Twenty grains of sublimed sulphur are combined with 5 grains of Dover's powder; to be given four-hourlj'. In all of the cases that have been treated with sulphur the re- covery has been rapid and the patient has seemed to derive relief more speed- ily from his pain and straining than with other methods of treatment. The cure with sulpliur seems to be more cer- tain and stable, as chronic conditions and relapses have not occurred. Blood and mucus are easily stopped and the motions quickly become faecal. In some cases the number of motions per diem did not at once diminish, but the pain and straining were lessened and the character of the motions became more feecal and contained little or no blood. Aa soon as the diarrhoea becomes less, it is advisable to give the powders less frequently. G. E. Richmond (Lancet, June 15, 1901). Three acute and fifteen chronic cases of amoebic dysentery were treated with sulphur of natural spring in the Philip- pines. The acute cases were given one bath daily and plenty of the water to drink. In a month two were cured ; the third, an alcoholic, had to be returned to medicinal treatment. The chronic cases were given two baths daily and the water to drink, and all were cured in from three to six weeks. The springs contained water at 220° F. and 92° F., with a large percentage of sulphur. T. H. Weisenburg (Phila. Med. Jour., March 14, 1903). Irrigation of the bowel is both ra- tional and useful. To overcome the ex- treme irritability of the rectum in the acute cases a suppository or solution (4 per cent.) of cocaine should be intro- duced as a preliminary measure. The irrigation is made ^ith the long rectal tube, the patient being in the dorsal po- sition, with a pillow under the hips. The substance to be injected is water at 100° alone or containing some astringent drug: alum, acetate of lead, sulphate of zinc or copper, nitrate of silver, or tan- nin. Tannin, in 0.5 per cent, solution, is highly recommended by Kartulis, who also uses this drug in combating amoebic dysentery. Osier regards nitrate of sil- ver as the best, although not in the very acute cases. In the chronic form it is, perhaps, the most satisfactory treatment. The solution, in this class of cases, is to be made 20 to 30 grains to the pint, and, if possible, 3 to 6 pints of fluid are in- jected. At times the irrigation causes much pain and is immediately rejected. Iodized starch internally tried in more than a hundred cases, giving a mixture of equal parts of iodized starch, oil of cinnamon, and oil of fennel, about 1 grain four times a day. At the same time irrigations with a solution of iodized starch to which are added a few drops of chloroform, tincture of iodine, and oil of cinnamon given. Kotschorowsky (Se- maine M6d., No. C2, '96). Two severe cases in which 1-pcr-cent. solutions of creolin used, with excel- lent results, in severe dysentery. A pint and a half of the solution was used night and morning. Creolin is worthy of an extended trial in dysentery. George Johnston (Treatment, June 24, '97). Antipyrine used in a case of severe acute dysentery, by rectal injection three times a day of a solution of 75 grains dissolved in 'A pint of water. Sedative action of the antipyrine greatly allevi- ated the patient, who gained strength and soon recovered. Ardin-Delteil (Bull. Gen. de Th6r., Jan. 30, '98). Rectal injection of pcnnanganat« of potassium in the strength of 8 grains to the quart effective. Half of this quantity is given at a dose, and is allowed to re- main in the bowel from half a minute to two minutes. The water is cither cold or warm, according to the needs of the case. If large quantities of mucus are present, an injection of a pint of water containing 30 grains of bicarbonate of sodium is to be previously used. Gasti- nel (Jour, do Mud. de Paris, Nov. 19, •99). 39 610 DYSEXTERY. TEEATMEXT. Metbvlene-blue as a parasiticide aims at the pathogenic cause; as analgesic, it reduces the hyperexcitability of the large intestine; as a cholagogue, it has a very pronounced cholagogic effect. It is administered in warm injections of a litre or of half a litre at first until the intestine becomes tolerant, containing in solution from 1 to 2 decigrammes of the drug. Two to four injections are given daily. Berthier (La 'M6d. Moderne, Oct. 10, 1900). Inflation of the rectum with carbonic- acid gas acts at once by ansesthetizing, relieving the tenesmus which character- izes dysentery, and stimulates the circu- lation, thereby relieving inflammation. It is a more effective means than tJie well-known aqueous or starchy enema ta. A. Rose (X. Y. Med. Jour., July 14, 1900). Powdered cinnamon an excellent reme- dial agent in all cases ranging from ordi- nary diarrhoea to severe cases of dysen- tery. It may be given in teaspoonful doses mixed with a little milk to mold it into the shape of a bolus, and chewed night and morning. A. X. Wilkinson (Brit. Med. Jour., Feb. 10, 1900). Ko-sam (brueea Sumatrana) is very useful in the treatment of dysentery of Cochin China. There were 799 radical cures after a period of from three to si.x days. Only 8 cases resisted the treat- ment. Ten grains are given the first day, 12 grains the second, third, and fourth, if necessary. The active principle of the plant appears to be quassine. Mongeot (Tribune Med., June, 1900). In amoebic dysentery- the use of qui- nine irrigations was introduced by Losch, who found that solutions of 1 to 5000 destroyed the organisms. Stronger so- lutions—! to 2500, 1 to 1000, and 1 to 500 — are borne well and may be injected three or four times a day. Corrosive sub- limate in solution of 1 to 500 or 1 to 3000, and nitrate of silver, 30 grains to the quart, are also beneficial, but must be used more cautiously. 11. F. Harris has scon benefit result from the use of hydrogen peroxide in some cases. The ordinary commercial hydrogen peroxide is diluted from four to eight times with water and about a quart injected twice daily. The treatment is continued for one week and then the quantity gradu- ally diminished. Fifty-four cases treated by enemata of corrosive sublimate, 1 to 5000, of which 6 ounces were injected three times a day; later on a solution of 1 to 3000 was in- jected twice daily. The fluid was not retained usually longer than ten min- utes. Cases cured in from 1 to 3 days. In no case was there any sign of systemic poisoning. Lemoine (Bull. G6n. de Thfir., Jan. 30, '90). In dysentery of the newborn small doses of calomel, flushing the colon with a weak solution of creolin, and giving the child nothing but pure cold water prove rapidly eft'ective. Gibson (St. Louis Med. Era, Sept., 1900). In Xatal success attended the use of mercury perchloride in mixture with bis- muth and opium. Milk was found un- suitable. Beef-tea and bread with butter satisfy, and leave a residue which ap- pears to cause but little colic or rectal irritation. Post-mortem observations show that great risk must frequently accompany the giving of rectal injec- tions, especially when combined with abdominal massage. The co-existence of enteric fever ■\\itli dysentery was more than once unexpectedly disclosed in the mortuary tent. W. Watkins Pitch toid (Brit. Med. Jour., Xov. 1, 1900). For any of these measures to be effect- ive in amoebic cases, they must be con- tinued until the amoaboa disappear. In order to decide this an intermission of a couple of days is made in the treat- ment. If at the end of this time amoebre are still present the procedures must be renewed. In the gangrenous cases little good can be looked for from the injec- tions, and, indeed, they are not without danger of precipitating a fatal termina- tion by causing perforation of the al- ready-much-injurcd intestine. Wlien tenesmus is slight an enema of DYSENTERY. DYSMENORRHCEA. 611 thin starch containing V2 to 1 drachm of laudanum affords great relief; for the more severe tormina and tenesmus the hypodermic injection of morphine is the only satisfactory remedy. Case of colostomy for the cure of dys- entery. The idea of the operation is: (1) to give the bowel a complete rest by not allowing the fseeal mass to pass ovpr it, and (2) irrigation can be carried out with better success. Previous to the operation the patient suffered consider- able pain, with high fever; these sub- sided two days after the operation, and amoeba eoli also disappeared. W. N. Sullivan (Jour. Amer. Med. Assoc, Dec. 8, 1900). During the period of convalescence tonics containing some form of iron and a nourishing, but unirritating, diet are to be ordered. The recuperation of the patient's strength is to be facilitated by these and other well-known means. Method of obtaining and testing therapeutic serum for use in dysentery. The horse or ass was used as the im- mune animal, an antiseptic (carbolic acid) was added to the serum, and the testing was carried out on guinea-pigs and mice. The author has treated 470 cases of dysentery since 1S97; of these, 258 had the serum. It was injected into the side of the chest, and the dose varied from C to 10 cubic centimetres in mild cases to 15 to 20 cubic centimetres in serious ones. Usually the site of the injection showed no change. An erup- tion around the site occasionally fol- lowed (37 per cent.); this was very rarely found all over the body (2.5 per cent.), and sometimes there was pain in the joints (knee, elbow, wrist). If -the treatment was carried out in the early stages of the disease, the diarrhoea dis- appeared and in two or tliree days nor- mal stools were passed; but, if it was given at the time when the stools were muco-sanguineous, the diarrhoea was only diminished, and the duration of the illness was somewhat shortened. With the serum the mortality was from 12.5 to 8.5 per cent.; with medicinal treat- ment it was 35.6 per cent. K. Shiga (Brit. Med. Jour., from Sei-i-Kwai Med. Jour., June 30, 1001). SiiioN Flexxer, Philadelphia. DYSMENOKKHCEA. — Gr., ^fj, difR- cult;/r<-Ma(a, menses; SLjxd pel r, to flow. Definition. — Dysmenorrhoea is not a disease, it is only a symptom. The term has often been used in a very loose way to signify any or all the painful or other disagreeable sensations which may be as- sociated with the abnormal performance of the function of menstruation. The headaches, the pains in the joints and muscles, the backaches, the nausea and vomiting which are of such frequent occurrence at the menstrual epoch do not constitute dysmenorrhoea, though they are doubtless influenced by the same cause which produces dysmenorrhcea. This symptom must be referred to the pelvic organs, to their nervous system, and to their vascular sj'stem; in other wordSj dysmenorrhoea is pain in the pel- vic organs which is experienced in con- nection with the function of menstrua- tion. It is a sj'mptom of a pathological condition. A woman who is in' perfect physical condition menstruates without pain. Dysmenorrhcea may, therefore, be de- fined as a deviation from normal men- struation, menstruation meaning essen- tially a monthly congestion of the vascu- lar system of the pelvis in obedience to a recurring impulse, with the shedding of more or less of the endometrium and the discharge of glandular secretions, the tension of the vascular system being re- lieved by the discharge through the uter- ine canal of a greater or smaller quantity of blood. S3nnptonis. — The pain of dysraenor- rh(va differs as to the time of its occur- 613 DYSMENOKEHCEA. SYMPTOMS. rence, its intensity, its duration, and the conditions which produce it. It occurs most frequently during the day or the two or three days which precede the menstrual flow. In ovarian dysmenorrhoea, usually within twenty-four to forty-eight hours before flow appears the patient is seized with sharp, darting pains in one or both ovarian regions, generally the left. This pain remains constant or increases, until finally a show of blood takes place. The pain is not in the median line, but on either side, and in this respect the pain differs from that due to a uterine cause. Munde (Med. Brief, May, '96). Eeport of 20 cases of intermenstrual dysmenorrhoea, besides 25 collected from literature. The pain generally occurred from 12 to 16 days after the beginning of the previous menstruation and continued from 2 to 4 days, reached its maximum on the first or second day, was often dif- ferent in character from the menstrual pain, and was rarely accompanied by dis- charge. Attributed to awakening of menstrual activity for the coming men- strual period. Malcolm Storer (Boston Med. and Surg. Jour., Apr. 19, 1900). With many women the beginning of the flow means the relief of tension and the relief also of pain; with others it continues, sometimes diminishing, some- times retaining its acuteness until the pelvic congestion has subsided. There are two conditions present in anteflexion which are responsible for the pain. One is the swelling of the uterine mucosa which accompanies the flow, the other the condition of abnormal sensi- tiveness at the internal os. The tissues at the OS internum are apt to be more rigid than normal and the nerves in an extremely-hypertesthetic state. The in- creased congestion which accompanies the onset of menstruation and the ten- sion of the tissues generally irritate the nerves ond aggravate the pain. This is tlie case during the first few hours of the flow. Later the tissues become re- laxed, and the canal, to a certain extent, straightened, and the pain disappears. After a time varying from twelve to twenty-four hours relaxation has oc- curred, the flow is more profuse, and the pain has largely ceased. Davenport (Bos- ton Med. and Surg. Jour., June 2, '98). In intensity it may be a simple ache, a feeling of distension within the pelvis, or it may be an acute, continuous, neuralgia- like sensation. It is often spasmodic in character, with a feeling of contraction or bearing down in the uterus, and may be relieved when a clot or gush of blood is ejected froin the uterine cavity. The acuteness of the pain is also governed by the temperament of the patient, a highly- organized sensitive person suffering more than a phlegmatic, insensitive one. It is more frequently experienced in damp than in dry weather, at the sea- shore rather than at the mountains, dur- ing an ocean-voyage rather than on a journey inland. The more scar-tissue there is in and around the uterus, the greater the flexion of the organ, and the narrower the cervical canal, usually the more constant will be the occurrence of pain. The customary classifications which can be verified by anyone with a few years of practical experience are, for the most part, satisfactory, but the writer has adopted the following as the results of his experience, viz.: — 1. Dysmenorrhoea from congestion. 2. Dysmenorrhoea from obstruction. 3. Dysmenorrho3a from neuroses. 4. Dysmenorrhea from endometrial hypertrophy. 1. Dysmenorrhoea from congestion. This is the simplest of all the varieties. Congestion is always and necessarily a feature of menstruation; that is, the cur- rent in the pelvic vessels is then more rapid or the tension or volume is greater, or perhaps all these elements are com- bined. When the degree of this con- gestion is greater than can be readily tolerated by the person, pain is one of DYSMENORRHCEA. SYilPTOMS. 613 its results (the other results need not concern us now), and this pain will last as long as the congestion continues, and will recur as frequently. Tolerance of this condition to a greater or lesser ex- tent is acquired by many women, just as other disagreeable experiences become tolerable when habitual and inevitable. In some cases the pain seems limited to one or both ovaries, in others to the uterus, and in others it seems to be dis- tributed through the pelvis. 3. Dysm.enorrhcea from obstruction. There has been much discussion for many years concerning this variety, some writers going as far as to say that the vascular system of the pelvis was so ac- commodative that dysmenorrhoea from obstruction was not possible. Clinical facts do not warrant such a statement. Obstruction of the outflow of blood is, perhaps, not so great when the womb is flexed backward or forward as was claimed a few years ago by Sims, Hewitt, and others, especially if coagulation of the blood within the uterus does not oc- cur; but, if such coagulation does take place (and in some cases also in which it does not), d3'smenorrhcea will be a very pronounced symptom. With stenosis of the cervical canal the same difiiculty to the outflow of the menstrual product is also frequently ob- served. With imperforation of the hy- men or of the os internum or externum obstruction to outflow is complete. A certain portion of the transuded blood is reabsorbed, but the remainder persists, distending the vagina or the uterus or botli, sometimes producing a very large tumor, and invariably resulting in great pain, which in some cases has led to a fatal result. Pain from incomplete development of the pelvic organs, especially the uterus. is also to be referred to obstructive dvs- menorrhoea as its origin, and, as in cer- tain cases of congestive dysmenorrhoea, the bad symptoms are not limited to pain. Dysmenorrhcea from inflamma- tory exudate is an acquired symptom, the exudate binding the pelvic organs into a more or less firm mass, which tends to become firmer as the contraction, which time brings with it, takes place. The pain in such cases is not limited to ob- struction to outflow; indeed, there is no such obstruction apparent in some of the cases, the flow being profuse in some in- stances and scanty or absent in others. The remarks concerning inflammatory exudate will also apply to scar-tissue, which, by its presence, will often effectu- ally obstruct the passage of the menstrual blood-current. To this variety of dys- menorrhoea might also be added those cases which are so often seen that de- pend upon perverted or imperfect nutri- tion and in which constipation is an ever-present accompanying symptom. 3. Dj'smenorrhoea from neuroses. There may be at least two types of this variety; in one of them the neurosis is the sole discoverable source of trouble, in the other it is secondary to disease of some other character within the pelvis. Hysteria is at the foundation of many of the cases of the first-mentioned vari- ety, the pain connected with menstrua- ation being, to a great extent, simulated or imagined. When we realize, however, the inti- mate anatomical relations which the s}Tn- pathetic nerves of the pelvic organs bear to the nerves and ganglia of the rest of the organs of the body, we are quite pre- pared to believe that painful sensations in those organs miglit be transmitted to the organs of the pelvis. So far as I know there have been no exact investigations upon this subject. The referred or re- flected pains from the pelvic to the other 6U DYSMEXORRHCEA. ETIOLOGY AND PATHOLOGi. organs have been much discussed and a Tariety of conclusions has been reached. The neuroses in the pelvis or pelvic organs which occasion dysmenorrhoea may constitute a use of language which is somewhat misleading. Of course, all pain is the evidence of nerve-irritation or a neurosis. The form which is here to be considered is that in which, aside from mere congestion or obstruction as an at- tendant of the menstrual experience, there is a direct irritation of nerve-tissue which is not apparent apart from the menstrual epoch. Such, for example, is the case when the unusual pressure due to the congestion of menstruation is ex- perienced by the sacral nerves as they pass through the pelvis, the tissues being already the seat of inflammatory exudate. The tissues are squeezed and contracted by this exudate; but the addition of the menstrual congestion introduces a further element of press- ure, which causes irritation of the nerves which are infringed upon, and pain is experienced, which radiates in the di- rection of the imprisoned nerves. This condition is not infrequently found in insane women; it is probably a factor in producing insanity, and such insanity cannot be expected to ameliorate perma- nently until the source of trouble is re- moved. 4. Dysmenorrha?a membranosa. This is a somewhat rare form of dysmenor- rhoea, but one which has long been recog- nized, and is described by all writers of gyn.Tcological treatises. Dysmenorrhoea membranosa is due to an hypertrophied condition of the endo- metrial decidua; that is, of the exfolia- tive portion of the uterine mucous mem- brane which is shed at each menstrual epoch. This membrane varies in thick- ness and density in extreme instances, showing a perfect cast of the cavity of the uterus. Separation of the membrane from its underlying attachment and its expulsion from the uterus mean an unusual amount of uterine work and severe pain as an almost constant accompaniment. It usually occurs, too, in women whose nutrition is defective, and is conse- quently a matter of more serious impor- tance than if it were among the robust and well nourished. It is, of course, a form of obstructive dysmenorrhcea, but its peculiarities are so marked that it may be well to continue to consider it a dis- tinct variety. Etiology and Pathology. — Anything which prevents or disturbs the eqiiilib- rium of the normal conditions described will cause dj'smenorrhcea. It is of ex- ceedingly frequent occurrence. It is a matter of great surprise that so many women should present this symptom, which appears with some of them at the advent of puberty and continues with varying intensity imtil the termination of menstrual life, while with others it disappears with pregnancy, with the phj'sical changes attending mature life, or as the result of surgical treatment. That it should occur so frequently, and especially in communities in which the highest intellectual development has been reached, is not a flattering com- mentary upon the results of modern civilization. Still, this is counterbal- anced by the fact that dysmenorrhroa is usually curable by judicious ineaus. A tlioroiigli revision of our views on tliis subject 1ms become necessfiry in the light of recent experience. More than ".'5 per cent, of the cases of painful men- struation are not dependent upon ana- tomical causes. The pain is really due to tetanic contraction of the circular muscle at the os internum, such as oc- curs in other sphincter-muscles in neu- rotic subjects. Menge's theory that dysmenorrhoea is due simply to an ex- aggeration of the contractions of the longitudinal muscular fibres, which al- DYSMENOREHCEA. ETIOLOGY AXD PATHOLOGY. 615 ways accompany normal menstruation, does not hold, for, if the symptoms were due purely to mechanical obstruction, it should invariably disappear after child- birth, which is not the case in nervous and hysterical women. Uterine colic cannot be due only to the passage of dots, since in many typical cases of dj'smenorrhffia there is a free escape of fluid blood. Moreover, the pains are often most severe from twelve to twenty-four hours before the flow ap- pears, instead of on the second or third day, when it is most profuse and clots usually appear. Theilhaber (Centralb. f. Gyniik., No. 3, 1902). Dysmenonhoea is seemingly on the increase and is developed in proportion to the strenuousness of the human exist- ence. The period of p\ibcrty should claim the attention of the physician as a promising field for preventive gynoe- eology, as it is at this impressionable period that the foundation for future suffering is laid. It is the duty of med- ical men to urge the necessity of propeily caring for the physical side of the schoolgirl, not permiitting the mental faculties to be trained at the expense of the physical side. While mindful of the great value of surgery in the treatment of certain well- defined pathological conditions in the pelvis, still there is a growing tendencj- to abuse its application in reference to dysmenonhoea, and as a whole the re- sults obtained through its intervention are nothing of which we can be proud. A more careful study in analysis of these cases with especial reference to the etiological facts should be made, with especial reference to the value of the application of the general hygienic laws, electricity, massage, exercise, etc., in contradistinction to the reckless and loose surgical measures resorted to in their treatment. Dilatation and curet- ting is of value in well-defined cases but as a routine procedure is wofully abused. In the light of recent experience ob- structive dysmenorrha?a is rare, and the mechanical side of dysmenorrhrra is not looked upon as an etiological factor with the same degree of frec|Ucnoy now as in the past. There is a close dual relationship ex- isting between the generative organs and tlie general health, and in the treat- ment of dysmcnorrhtea, it should be constantly remembered. S. M. D. Clark (Xew Orleans Med. and Surg. .Jour., Aug., l'J04). Women in the savage or barbarous state and women who are constantly en- gaged in out-of-door labor are seldom sufferers from this cause, though their pelvic organs may be defective in struct- ure and though they may habitually be subject to experiences which would un- failingly cause dysmenorrhcea or even complete suppression of the menstrual function in women of less robust organ- ization. This is, in part, owed to the in- creased power of resistance to physical ills which is favored by an out-of-door life, and, in part, to the greater insensi- tiveness to pain of women in the lower strata of social and intellectual develop- ment. "With those who are sufferers the underlying causes are various, and demonstrate the important role which the reproductive organs play, not alone in the propagation of species, but in the experiences of daily life. One hundred and twelve eases of dys- menorrhoea examined. One of the most striking points is the very large num- ber of sterile women; 44, or a fraction less than 40 per cent., belong to this class. Of those who had been pregnant, 12 had never had a child at full terra; 15 more had had a miscarriage since the last full-term child was born, leaving less than 37 per cent, of the total num- ber whose last pregnancy had come to full term. These figures would seem to indicate that, in a large proportion of patients suffering from dysmenorrhoea, there were present lesions which also interfered with conception. One hun- dred out of the 112 suffering from pain- ful menstruation were found to have some marked organic lesion of the pelvic organs. William S. Gardner (Atlanta Med. and Surg. Jour., Dec, '0.5). 616 DYS3IEX0KRHCEA, ETIOLOGY AKD PATHOLOGY. The causes may be classified as follows, ■viz.: heredity, disease, occupation, and trauma. 1. Heredity. "With many women the defects in the structiu'e of the reproduct- ive organs are congenital and necessitate dysmenoirhoea. Inflammatory diseases of the ovaries and the Fallopian tubes and adhesive de- formities of the uterus are at times the causes of dysmenorrhoea. In 100 of Kelly's operations on tubes and ovaries the appendix was found adherent in 21 cases, and in 7 it required removal. Out of 58 personal cases in which inflamma- tory appendages had to be removed, the appendix showed enough evidence of dis- ease to justify removal in 20 cases. In 9 of these the adhesions between the ap- pendix and the right appendage were very intimate. A. MaeLaren (Amer. Gynsee. and Obstet. Jour., July, 1900). It does not avail that the remainder of the physical organization is normally developed; indeed, one frequently sees women of the finest physique and superb presence whose incomplete pelvic appa- ratus condemns them to semi-invalidism during a considerable portion of each month. On the other hand, puny, delicate women with normally-developed pelvic organs suffer with dysmenorrhaaa on ac- count of their perverted general nutri- tion, their flabby muscular system, and their low-ebb vitality, to which the re- curring monthly congestion brings a strain which they are ill fitted to bear. The defective organization may in- clude any portion of the genital appara- tus; in the vulva it may take the form of an impermeable hymen, producing an absolute barrier to the discharge of im- prisoned blood; in the vagina it may consist of bands and septa with almost equal obstruction to the outflow of the monstnial fluid; in the uterus it may be an almost-impervious cervical canal, an occluded os internum or externum, less frequently a rudimentary corpus uteri or one with its two halves uncoalesced or its canal obliterated; in the tubes or ovaries the structure may be rudiment- ary or the seat of some form of con- genital disease. Stenosis may be due to swelling of the mucous membrane occurring only at the time of menstruation, and consequently impossible to diagnose at other times. Treub (Centralb. f. Gyniik., July 17, '97). Dysmenorrhea should be divided into dysmenon-hceal endometritis and uterine spasm. The first includes all forms in which there is any local mechanical ob- stacle; all other cases are uterine spasm, which aflfects the sphincter of the uterus, • — that is, the cervix. Of 1G7 patients observed, 37 complained of painful men- struation. In 32 a local cause was dis- covered, but in the 5 others, virgins, the afi'ection was spasmodic. Besides there were 21 who had manifest stenosis without painful menstruation. Among these subjected to curetting there were 17 w-ith dysmenorrhoea, but only 1 had marked stenosis. Of these last, 8 were completely cured by curetting; of the 9 others, 7 returned with a relapse of their old trouble, and 2 received absolutely no relief. De Leon (Centralb. f. Gynftk., July 17, '97). Membranous dysmenorrhoea has no connection with pregnancy or abortion, is not productive of sterility, and can become cured spontaneously. The fibri- nous membranes are to be regarded as true dysmenorrhojic membranes, and are not dependent upon an indamniation of the uterine mucosa. Fibrinous mem- branes are the product of necrosis orig- inating in hsemorrhagc and transudation. Kollmann (Wiener klin. Rund., Apr. 29, 1900). In all cases thus connected with he- redity, defective organization, etc., recur- ring monthly congestion produces ten- sion in poorly-conditioned structures. DYSMEXOREHCEA. PROGNOSIS. IREAT^IENT. 617 and, if the tension in the vessels is suffi- cient to result in transudation of their contents, the outlet being imperfect or wanting, pain will be the inevitable result. 2. Disease. Disease of one kind or an- other may cause dysmenorrhoea, whether the disease occurs before or after puberty. Before puberty there are many forms of disease which arrest the development of the pelvic organs and result in dysmenor- rhcea. The exanthemata seem to be es- pecially productive of this effect. Why this should follow has not been satisfac- torily explained. Measles, scarlet fever, small-pox, all have their victims in whom such a result has been observed. Of the diseases subsequent to puberty which produce dysmenorrhcea there are those which are local and others which are general. Of the former may be men- tioned fibroid tumors either within the uterine canal, tn its muscular substance, or within its peritoneum, and inflamma- tory disease of the tubes of the ovaries or of the pelvic peritoneum. All these diseases may, by their obstructive effect, prevent free discharge of blood during the menstrual epoch, and produce pain. Of the general diseases may be men- tioned typhoid fever, certain diseases of the liver and gall-bladder, ana?mia, etc. The same result is often seen in cases in which there is excessive development of fat. Women who become very obese are very frequently sufferers from dj's- menorrhcea. 3. Occupation. Some occupations are especially prone to result in dysmenor- rhcea. Those who work in a very hot at- mosphere, like cooks and laundresses; those who are constantly exposed to cold and dampness, like fishwives or workers in mines (unwomanly occupations); those who work in poisonous substances, — copper, arsenic, lead, phosphorus, and sulphur; those who are confined for long hours in factories, stores, and tene- ment-house "sweat-shops" are, in many instances, sufferers with dysmenorrhcea. 4. Trauma. Dysmenorrhoja from this cause is, in most cases, the result of diffi- cult parturition, the genital organs sus- taining severe injuries and cicatrization and contraction ensuing. The hardened tissues are anaemic and the necessary elimination of blood is accomplished with difficiilty and pain. Occasionally there are direct injuries to the genital organs, apart from parturition, which also produce deterioration of the tissues of those organs, and are likewise followed by painful menstruation. Prognosis. — The prognosis in dys- menorrhcea varies with the conditions and varies also with the treatment. If it depends upon structural defects, and those defects are remediable, a cure will result. It sometimes persists during the whole menstrual life, but with many women it gradually becomes tolerable, as all ills which are long endured become tolerable. With regard to prognosis much will depend upon the general condition of the subject, great improvement in that direction often leading to menstruation, which is less painful or not painful at all. The prognosis in cases in which drug- treatment alone is used is very uncertain; while such treatment is proper enough simply as a means of relieving or be- numbing pain, it has nothing more than a temporary and palliative effect when the pain is due to an anatomical fault or defect. Treatment. — It might be quite appar- ent from the foregoing that, while the treatment may be either medical or sur- gical, the latter, however, will usually give the more satisfactory and radical results. Jlodern £rvncccolocrv is cast in 61S DYSMEXORKHCEA. TREATMENT. surgical lines, and while it would be folly to deny that many mistakes have been made in its name (for mistakes are al- ways made in the development of a new department of knowledge), it has ap- proached nearer to fundamental condi- tions by directly attacking tissues which are involved in disease than have other methods of treatment which are more circuitous in their course. Considering the subject of treatment, therefore, as divisible into palliative and radical, the former will include the methods by means of drugs (which occa- sionally may produce a permanent re- sult), and the latter (which do not in- fallibly produce a cure) those methods which involve surgical procedures. Of course, a judicious combination of both medical and surgical means will often prove efficacious. Of the drugs which may be given to relieve the pain of menstruation, mor- phine combined with atropine should be reserved for very rare cases whether given by the mouth or hypodermically. It should be given in the smallest possible doses, Vs grain sufficing to relieve pain in most cases as well as a larger quantity. One must not forget the seductive influ- ence of this drug, especially upon real nervous, hysterical women. Many women find relief from the pain in ques- tion by drinking hot herb-teas: chamo- mile, scutellarium, boneset, flaxseed, etc. These can do no harm and arc innocent as to the formation of drug-habits. More or less meritorious preparations are much in vogue, but in some cases they seem to be entirely inert, either from instability or want of uniformity in the preparation or some peculiarity in the patient. escalate of cerium, in 0-grain doses every hour, considered speciflc for the dysnienorrhoea of well-nourished, robust women, in cases where the pain eomes at or before the beginning of the flow. Chambers (Jled. Record, July 7, 'SS). Apiolin is especially indicated in spas- modic and congestive dysmenorrhcea, in doses of 3 minims in capsules, three times a day. Hill (Med. Standard, June, •91). In non-inflammatory cases viburnum prunifolium gives brilliant results, not to be obtained from any other remedy except morphine. A teaspoonful of the fluid extract three times daily to be given. Sehwavtze (Ther. Gaz., Aug. 15, '94). Manganese is a most valuable remedy in unmarried women, and a trial ex- tending over three months is recom- mended before relinquishing its use. Its action appears to be upon the neiTea or nerve-centres concerned in the men- strual function rather than upon the blood. Administration of manganese does not interfere in any way with iron and vegetable tonics, but rather en- hances their efTeets. Tlie black oxide is tlie most convenient form of prescrip- tion. If nausea is produced the drug should be given in a small dose: 1 grain at a time gradually increased. A 3-grain dose is found to be as efficacious as a larger one. Charles O'Donovan (Med. News, Nov. 27, '97). The following formula has given good results: — R Tincture of hydrastis Canadensis, Tincture of viburnum prunifolium, of each, equal parts. M. Ten drops to be taken every two hours. Lutaud (Jour, de MCd. de Paris, Jan. 2, '98). Cases in which the flow is ushered in by severe cramp-like pains for three or four days preceding the menstruation V:-drachm doses of the fluid extract of viburnum prunifolium in hot water three times a day may bo given, and on the morning of the expected period a full dose of magnesium sulphate. If the pain comes on in spite of this, 5-grain doses of antipyrine, repeated every two hours for three doses, if necessai-y, will often relieve it. Arthur A. Browne (Montreal Med. Jour., Apr., '98). In dysmenorrhcea thyroidin is "a uterine and ovarian anodyne and seda- DYSMENORRHCEA. TREATMENT. 619 tive, as it arrests the different impres- sions at their formation." One grain of thyroidin is given in capsules thrice daily, for two days before menstruation is due ; the quantity is increased to 2 grains thrice daily during the flow. Re- lief is afforded in over 80 per cent, of eases. The treatment is efficient when the uterus and ovaries are in normal position. Any pathological lesion must be remedied by proper surgical meas- ures. Stinson (Amer. Jour, of Obstet- rics, July, 1002). The various currents of electricity have all been vaunted as useful means of treatment, and in many cases they are prompt in producing relief. Especially is this true of the faradic current, but if the cause of the trouble lies in a defect of structure it would be unreasonable to ex- pect a permanent result from electrical treatment so long as the cause remains. Other palliative measures are warm hip-baths in which the patient may sit ten to fifteen minutes, the temperature of the water being sufficient to produce relaxation of tissue, and hot mustard- water foot-baths, which must be used only long enough to produce a glow of the skin. Hot salt-baths calm the pains of dys- menorrhoea and notably diminish men- strual flow. Mironoff (Ejenedelnoya, No. 3.5, '9.5). In ovarian dysmenorrhoea all remedies which are likely to relieve pelvic conges- tion should be employed, such as hot injections and sitz-baths, hot-water bags to the lower part of the abdomen, and saline laxatives. Internal medication is of very little avail. In cases, however, in which menstruation is not profuse the mother-tincture of Pulsatilla in 5-drop doses every three hours is very useful. :»Iunde (Med. Brief, May, '9G). With mud-baths and the medicated waters of Kreuznach, Aix, Toplitz, Schwalbach, and other well-known Euro- pean resorts useful results have been obtained, but they are not available for the majority of our American patients. A change of residence, especially from the sea-shore or near the sea-level to an elevation of one or two thousand feet, will often give permanent relief. The writer has repeatedly seen women who menstru- ate with great discomfort at the sea- shore, while on sea-voyages, or in a damp atmosphere imder some other conditions. Of course, if there is no anatomical lesion one usually becomes habituated to at- mospheric conditions after a few months or years. If the pain is due to a neurosis the treatment should be addressed to the nervous system, — the bromides, hyoscya- mus, aconite, and the coal-tar prepara- tions being employed. If the general nutrition is at fault it is hardly necessary to say that it should be improved by a carefully-selected diet, suitable exercise, cheerful companion- ship, and alwaj's and above all by the use of approved laxatives to keep the bowels freely open. Again and again has the writer found a constipated habit at the bottom of a history of painful menstru- ation. The majority of cases of dysmenorrhoea in school-girls is functional in origin. Environment should be such as would be most conducive to their general health. They should be kept out of school dur- ing their first menstrual year, and those of a nervous temperament for a longer period of time. They should have calis- thenic training for the special develop- ment of the muscles of the back and ab- domen, and should be warmly clothed. If there is any tendency to pain during menstruation, the young patient shoiild be put to bed and kept there the entire period. Pine (Northwestern Lancet, Dec. 1.5. 'Sni. The field of surgical treatment for dysmenorrhcea is a large one and fre- quently will result in the happiest conse- quences. The chief objects of surgical treatment are to relieve obstruction, to 620 BYSMEXORKHCEA. TREATMEKT. produce stimiilation, and to improve local nutrition. The causes of obstruction have been mentioned, and should be removed as completely as possible; an imperforate hvmen shoiild be divided or dissected away; obstructing bands in the vagina should be cut and a series of vaginal dila- tors worn until the normal caliber of the vagina has been restored. Bands and constrictions at the os externum or in- ternum should be divided, a narrow cer- vical canal should be dilated and cu- retted,, especially when the glands are the seat of exuberant or unhealthy secretion. [The most efficient treatment for ordi- nai-y forms of dysmenorrhoea is careful dilatation, with the steel dilator, to the extent of an inch or an inch and a quar- ter, using careful antiseptic precautions. After the dilatation it is well to insert an intra-uterine pencil containing 10 grains of iodoform. Munde and Wells, Assoc. Eds., Annual, '89.] Slow dilatation urged as being equally effective and less dangerous than rapid dilatation. Talbot (Araer. Jour, of Obstet., Jan., '89). Rapid dilatation for the relief of dys- menorrhoea depending upon flexion or ob- struction is advocated, in the absence of contra-indications. Goodell (Amer. Lan- cet, July, '89) ; Dickman (Kansas Med. Catalogue, June, '89) ; Townsend (Amer. Jour, of Obstet., Dec, '89) ; Madden (Satellite of the Annual, Sept., '89). Repeated curettings at short intervals advocated for membranous dysmenor- rhoea. After each curetting the canal should be carefully treated to an applica- tion of pure carbolic acid. Reamy (N. Y. Med. .Jour., June 10, '93). For membranous dysmenorrhoea, scari- fication of the OS externum at intervals of three or four days between the periods is recommended. Just before the flow is expected the cervix is dilated, the in- terior of the uterus thoroughly curetted, and a spiral-wire stem introduced; this is worn continuously during at least three subsequent periods, the patient be- ing directed to take hot vaginal douches even when menstruating. Duke (Med. Press and Circ, July 10, '95). Dysmenorrhoea is successfully treated by applications to the mucous membrane of the uterine cavity. The treatment consists in the injection of 10 minims of 3-per-cent. mixture of Churchill's tinct- ure of iodine and water into the uterine cavity every four or five days during the intermenstrual period, beginning about five days after the flow has ceased, and giving the last treatment about five days before the next period begins. As an injector a fine glass tube, curved an inch from one end and ex- panded into a funnel shape at the other, is used. A piece of sheet rubber covers this end, and by the pressure of tlie finger the contents are passed into the uterine cavity. A speculum is not neces- sary, the majority of eases being un- married. The pain and exposure made necessary by the use of a speculum is objected to. Langstaff (Brooklyn Med. Jour., May, '97). The spasmodic variety is by far the most common, as there is frequently lit- tle to be detected beyond the symptom of severe spasmodic pain. Some relief may be obtained by sedatives externally or internally, but there is always the danger of setting up an opium or chlo- ral habit; it is better to dilate the uterus, either by tents or solid instru- ments. The use of tents is not free from danger, both from sepsis and from fracture or tearing away of a piece of the tent upon extraction. To effect rapid dilatation the solid dilator well regu- lated is to be chosen. The uterus can be easily secured by the vulsellum for- ceps if a sound is previously introduced into the cavity, and a series of dilators can then be passed rapidly, with the re- sult that the patient is relieved, at least for many months. Murdoch Cameron (Brit. Med. Jour., Oct. 24, '97). In sterile married women prescription of abstinence from marital relations for longer or sliorter time, followed by free dilatation immediately before their re- sumption, often proves successful in cur- ing dysmenorrhoea. Bicycling is of ad- vantage, and if growing girls, especially when anicmic, were systematically en- DYSMENORRHCEA. TREATMENT. 621 couraged to practice that exercise in moderation, we should by and by have less spasmodic dysmenorrhoea. Connel (Brit. Med. Jour., Oct. 24, '97). In every case, without e.xception, gen- eral treatment must be most thoroughly tried first. At the time of puberty many girls get far too little e.xercise, and too little care is taken to keep them warm, especially at night. It is essential that the feet be kept warm during the night whenever there is uterine dysmenorrhcea, or, indeed, whenever there is any pelvic trouble. As soon as there is the slightest appearance of the "period" the girl must be kept rigidly in bed, and not allowed to get up until the pain is entirely gone. A large poultice should be kept over the abdomen. A brisk saline draught at tlie commencement, or, if possible, twelve hours before, and then a mild diapho- retic, with a small dose of bromide of sodium or potassium, if the patient be strong, or if weak some aromatic spirit of ammonia are best. In regard to the local treatment there is more or less difference of opinion. The stem-pessary is unscientific; it can only relieve, seldom cures, and may do harm. Dilatation consists of two kinds: slight and great. The first is suitable in the case of married women, when flex- ion is not great, and it is used in the hope that by distending the canal impreg- nation may take place, and the dysmen- orrhcea thus be cured. An antesthetic is not required. Overdilatation may be done with tents or the rapid forcible method. Whatever instrument is used in the rapid method, the stretching ought to be canied out while the uterus is fixed by tenaculum in its natural posi- tion; not when it is drawn to or out- side the vulva. Keith (Med. Press and Circ, Oct. 27, '97). Obstruction from the presence of tumors within the uterus which may cause excessive pain can be relieved only by their removal, and the requisite oper- ations must also be performed if the dys- menorrhcea is caused by displacements of the uterus or its incarceration by inflam- matory exudate. Any less radical form of treatment for such conditions has, in the experience of the writer, proved to be only time-consuming and futile. The causes of dysmenorrhoea may be either e.xtra-uterine or intra-uterine. The treatment differs markedly in the two classes of cases, and what would relieve in one would be worse than use- less in the other. Three factors are con- cerned in the production of the pain of dysmenorrhoea, viz.: contraction of the muscular fibres of the uterus or Fallo- pian tubes; increased spasm or blood- pressure in the tissues of uterus or ap- pendages, — congestion; neuralgia of the uterus or the appendages. The cause is to be treated. Nearly all cases are bene- fited by rest at the periods, hot vaginal douches during and between the periods, and, in inflammatory cases, tampons of glycerin and ichthyol, and saline aperi- ents. Morphine and alcohol will give great relief, but must never be recom- mended; the administration of alcohol to young women at such times is to be blamed for much of the secret drinking that prevails. The drugs most useful are bromides and belladonna, antipyrine and cannabis Indica, and both viburnum prunifolium and viburnum opulus. Op- erative measures should only be resorted to when other and less severe remedies have failed. In cases due to spasmodic contraction of uterus or stenosis of cer- vix (if there be no signs of extra-uterine disease) dilatation is often of some serv- ice, but is seldom of more than tempo- rary benefit. In cases due to chronic pelvic peritonitis, binding down and matting together the uterus, ovaries, and tubes, — cases in which the ovaries are cystic and the tubes, perhaps, occluded and the uterus retrovertcd and adherent to the rectum, — very marked and per- manent benefit results from a "conserva- tive operation" on the appendages. The abdomen should be opened, the uterus, ovaries, and tubes freed from the adhe- sions, and after ignipuncture of the cys- tic or sclerosed ovaries the fundus fixed to anterior abdominal wall. In grave and otherwise incurable lesions of the appendages, such as abscesses of the ovary or pyosalpinx, the removal of the diseased organ is strongly indicated. Martin (Brit. Med. Jour., Oct. 24, '97). 62-2 DYSMEXOREHCEA. ECLAIIPSIA. The use of pessaries for the relief of displacements, while it frequently modi- fies the dysmenorrhoea, seldom cures the displacements; hence such means are used with far less frequency than for- merly. The same may be said of the cut- ting operations -(vhich were once so popu- lar for the relief of dysmenorrhcea sup- posed to be the results of anteflexion of the uterus. Stimulation of the uterus and im- provement of its nutrition are often effectively produced by the passage of graduated sounds into its canal, the use of the steel dilators, curettage, and oc- casionally by the abstraction of blood from the cervix with leeches, or by punct- ures or scarification, especially when the cervix is congested and the menstrual flow is scanty. Andrew F. Currier, New York. DYSPEPSIA. See Stojiach, Dis- orders OF. DYSTOCIA. See Parturition. EAEACHE. See Middle Ear, Dis- eases OF. ECLAMPSIA.— Gr., ex?.a,u^(C, a shin- ing forth. Synonym. — Puerperal convulsions. Definition. — Eclampsia is a symptom- atic disorder characterized by convulsive or epileptiform seizures that suddenly come on prior to, during, or after labor. Symptoms. — The physician who sys- tematically examines the urine not alone for albumin and casts, but also for urea, and who keeps check of the amount of urine passed in the twenty-four hours is not likely to be caught napping even in those cases in which, although there never has been a suspicion of renal im- pairment, the kidneys are nevertheless diseased. Pari passu with diminished excretion of urea the risk of toxnemia increases, and the most dangerous form of eclampsia — that which develops sud- denly (without much premonition) and passes into coma and death — frequently depends on urinary insufTiciency as re- gards excretion. The clinical history of cases of the form of toxfcmia under consideration is variable. As a rule, there exists a pre- monitory symptomatology, consisting in cephalalgia and dimness of vision or alteration from that which is normal in the person. Instances of convulsions during preg- nancy observed in wliicli every fit was regularly preceded by transitory amauro- sis, as well as by osdenia of the face, which was also of short duration. Two sets of convulsions occurred during preg- nancy: the first about the end of the seventh month, four attacks taking place within twenty-four hours; the second in the course of the eighth month, when two fits were observed. After the last convulsion a healthy child was delivered. The motlier made a good recovery. The two prominent symptoms above men- tioned developed before each of the six fits. Olshausen has been able to collect only three cases of eclampsia in which the fit was preceded by an aura, as was this case. Eabczewsky (Przeglad Chir- urgicuwy, vol. ii, Pt. 3, '95). Rarely are convulsions unheralded. In the vast majority of cases thei-e were prodromal symptoms. Frequent urinary analyses, both qualitative and quantita- tive, should be made, and, if albumin is found or the amount of the solids greatly diminished, suspicion should be aroused. Any abnormal symptoms — such as head- ache, disturbances of vision, or oedema — ECLAiU^SIA. SYMPTOMS. 623 should put U3 on our guard. WTien such symptoms appear the patient must be put on a milk diet with large quantities of sterilized water; hot baths employed, and the bowels kept active by catharsis and saline enemas. The continuance of these symptoms demands induced labor. In post-partum eclampsia, if the pa- tient is plethoric and vigorous, venesec- tion is the best remedy; if anaemic and weak, veratrum, accompanied by the transfusion of the salt solution, is indi- cated. H. D. Thomason (Med. Record, May 23, '9C). Albumin and casts may or may not be present in the urine according to whether a nephritis complicates the pregnancy or not. Should the premoni- tory symptoms be aggravated elimina- tion of urea is defective, as shown by the recognized tests. Insufficiency on the part of the kidneys may be determined by measuring the amount of urine passed in the twenty-four hours. Vascular ten- sion is apt to be increased except in women of an anfemic type; cedema, as a rule, accompanies organic renal dis- ease. The symptomatology of the eclamptic seizure is characteristic. The wide-open eyes, fixed in vacant stare: the contracted pupils, the rapidly opening and closing lids, the clonic convulsions. These sjTnp- toms accompany, ordinarily, the first seizures. The heart's action becomes ir- regular, the face is cyanosed, the breath- ing stertorous. Soon the convulsions be- come tonic in character; the eyes are fixed; opisthotonos may set in. Much importance attached to severe frontal or unilateral headache, associated with insomnia, as one of the earliest symptoms of eclampsia. F. B. Earle (Illus. Med. Jour.,, Mar., 1900). The number of seizures arq variable, as many as one hundred and twenty-five in the twenty-four hours have been noted. The duration of the seizures is from about thirty seconds to a minute, and in the intervals the woman is con- scious; or else the first seizure merges into coma and ends in death. Generally, after delivery of the fojtus the convul- sions cease. Earely eclampsia develops after delivery. In the course of four and a half years, among 44S0 cases of childbirth, the pro- portion of cases of eclampsia was 4.9 per thousand. Of the 44S0, 23S3 were pri- niiparce and 2097 multipara; 10 of these cases of eclampsia were primiparae, and 6 multipara; that is, equal to 72.7 per cent, of primipartE to 27.3 per cent, of multipara;. Braun found the percentage of primiparffi 80.3; Lijhlein, 85.4; Schauta, 82.0; v. Winckel, 70.8; and Olshausen, 74 per cent. Women attacked with eclampsia were, for the most part, young. The first convulsive seizure oc- curred before labor in 2 cases, during labor in 15, and after labor in 5 cases. The extent of the discrepancy as to ante- partum eclampsia is well brought out by the following figuies: Lohlein gives 4.7 per cent.; Strumpf, 7.4; v. Rosthoi-n, 9.1; Schauta, 14; v. Winckel, 23; Braun, 24; and Olshausen, 40 per cent. The convulsions ended at the termina- tion of labor in 8 of the 22 cases. The duration of the convulsions was, on the average, one minute. The severity of an eclamptic seizure is only to be meas- ured by its influence on the respiration and the action of the heart. There was albuminuria in the whole of the cases. Knapp (Monats. f. Geburts. u. Gynilk., B. 3, May and June, '90). Xature frequently teaches us the line of action — spontaneous abortion occur- ring and the eclampsia ceasing. Inasmuch as convulsive attacks may persist after delivery, or even in rare cases may appear for the first time after delivery is completed, the plan of hurry- ing on labor with the object of checking the attacks must necessarily be often completely incflK-acious. We may, there- fore, conclude that it is not in the evacuation of the uterus that the cure for eclampsia is to be sought. The toxic condition of the blood dominates every- thing else, and it is on the degree of 624 ECLAMPSIA. ETIOLOGY AND PATHOLOGY. toxicity, which is so difficult to de- termine, that the prognosis of the disease depends. Maygrier (Jour, de Mfd. de Paris, Aug. S, '97). The victims of nephritis who become pregnant rarely go to term, but abort a dead fcetus, the result of interstitial alter- ations in the placenta. Etiology and Pathology. — Modem be- lief teaches that eclampsia is the result of a toxaemia. The acceptance of this broad term has done much toward the adoption of a rational method of treat- ment. The definitions which for long prevailed in medical literature simply complicated the topic. Thus the view that eclampsia depended on pressure of the gravid uterus on the renal ves- sels, while negated by the fact that such pressure exercised by ovarian and fibroid growths was unaccompanied by eclampsia, and, further, that the gravid uterus, when risen above the pelvic brim, exerted no such mechanical interfer- ence with the kidneys, led the mind of the observer far astray from a strong presumptive etiological factor, which is deficient excretion of toxic products em- anating not alone from the kidneys, but also from the liver. The eclampsia symptom-complex is de- pendent on a peculiar irritation change in the psychomotor centres of the cere- bral cortex (subcortical centres). This zone develops during gestation on an existing disposition, which may be either congenital or acquired. Herd (MUn- chener med. Woch., No. 5, '91). Puerperal eclampsia originates from a renal insufficiency causing a high arterial pressure, this again reacting on the mo- tor areas of the brain, producing the characteristic epileptiform manifesta- tions in the parts of the body presided over by the centres which are subject to the abnormal blood-pressure. R. Max- well-Trotter (Brit. Med. Jour., May 9, 'DO). Though the pathogenesis of eclampsia is unsettled, it belongs solely to the preg- nant or puerperal state. It is not apo- plectic, epileptic, or hysterical in char- acter. It depends upon toxtemia due to overproduction of toxins and under- elimination by the emunctories. These toxins probably have their origin in the ingesta, in intestinal putrefaction, in foetal metabolism — one or all — and there is co-existing sluggishness, impairment, or suspension of elimination. When the prodromes of eclampsia appear, the kid- ney should be interrogated as to its functions and all symptoms carefully watched. W. W. Potter (Amer. Jour. Obst., Nov., '97). The cause of pregnancy-kidney is prob- ably an autointoxication of the organism by a product of metabolism during preg- nancy. The overloading of the organism with this virus gives rise to eclampsia. The changes which occur in the kidneys, liver, and other organs in the eclamptic are of a secondary character. Saft (Archiv f. Gynak., vol. li, p. 2). While the urine of healthy pregnant women has been reported as sterile, germs may be cultivated from it: the same organisms obtained from the urine of eclampsias. These urines are but feebly toxic when injected subcutane- ously in massive doses into animals. Bar (Obstetrics, Jan., '99). The bulk of evidence is distinctly in favor of the belief that a profound tox- femia, originating in the bodies of the mother and foetus, causes eclampsia. The exact agent has not been isolated. An excessive amount of serum-albumin in the urine, accompanied with kidney d6- hri-s; is a symptom of moment. The amount of urea excreted is a valuable index. A diminution in its amount in- dicates a retention of toxins. Jaundice is an especially grave symptom, and, lifEmatogcnic in origin in these eases, points to a grave toxreniia. E. P. Davis (Amcr. Gyntec. and Obstet. Jour., July, '99). Study of 59 cases of eclampsia in the Imperial Maternity at Kieff. Eclampsia shown to be a primary disease of the kidneys due solely to nutoinfection of the patient by the accumulation of waste-products in the maternal and fcetal blood. It is essentially a disease of prcg- ECLAJIPSIA. ETIOLOGY AND PATHOLOGY. 625 nancy, not of parturition, and it always tends to interrupt gestation. Abuladse (Monats. f. Geburts. u. Gyn., Sept., '99). Case of eclampsia complicated by a marked erythema multiforme of a bul- lous character. Kaposi ascribes ery- thema multiforme to: (o) Change of seasons, {b) Angioneuroses which occur principally in women, (c) Instability of the vasomotor centres, (d) Autoinfec- tion: i.e., to.\ic substances which have entered the blood as the result of some internal disease, as chronic nephritis. The case cited probably comes under the last division. J. D. Voorhees (Jled. Record, Oct. 7, '99). In the Boston Lying-in Hospital dur- ing the last fifteen years 90 cases have occurred, although in 11 no convulsions appeared. There were 79 cases of true eclampsia in G700 deliveries: an aver- age of 11.7 to the thousand. Of these, 57, or 72.2 per cent., were primiparre, and 22, or 27.8 per cent, were multiparse. Newell (Boston Med. and Surg. Jour., Nov. 9, '99). There is no uniform causal factor for puerperal eclampsia. Even slightly toxic products in the blood of women in child- bed are sufficient to irritate the vaso- motor centres, which are then in a con- dition of increased excitability. E. Herz (Wiener med. Woch., Nos. 3, 7, 8, 1900). Case in which the rapidity of death after the fits suggested cerebral haemor- rhage. Free haemorrhage was discovered on the surface of the convolutions of the left hemisphere and widel)' distributed hosmorrhages in the liver: subscapular, interlobular, and intralobular. Case in which sudden and rapidly fatal asphyxia was caused by cerebral htemorrhage, which nearly destroyed the bulb and the floor of the fourth ventricle. Boissard (Bull, de la Soc. d'Obstet. de Paris, Feb. 15, 1900). The etiology of puerperal eclampsia is still a mooted question. The bacteria which were supposed to be the germs causing eclampsia are found in all preg- nant women. When the blood of the eclamptic patient is examined, micro- organisms are rarely found, and from observations one can find no positive proof that any one germ has been iso- lated which will cause eclampsia. The universal opinion at present ia that eclampsia is due to a profound toxoemia, and tlie origin of this toxaemia is still unknown. Beattie (Jour. Amer. Med. Assoc, Aug. 24, 1901). The toxic theory of eclampsia is now the one generally held by most obste- tricians, and in this connection the fol- lowing points may be mentioned: 1. That in every case of pregnancy more or less toxaemia exists, and that the blood intoxication becomes more profound toward the end of gestation. 2. That, although the eclamptic state is due to a toxaemia, the toxic agent which excites the convulsions is probably not always the same; there seems to be different types of the disease. 3. That the toxins may be produced in greater abundance in some cases (twin pregnancies), and that they are generally more virulent in primiparte than in multipara;. In the primipara mechanical pressure on the renal vessels may possibly come more into play, while in the multipara a cer- tain degree of immunity against the toxin may have been acquired from previous pregnancies (Allbutt). 4. That in spite of very grave toxtemia no alarming symptoms will occur so long as elimination by the kidneys is suffi- ciently active. Of the nature of the toxins nothing is known, and there is no clear evidence to show where they are formed. Lange noted that, out of 25 pregnan- cies in which the usual hypertrophy of the thyroid did not occur, albuminuria occurred in 20. Large doses of thy- roidin were administered to pregnant women in whom the physiological en- largement of the gland had occurred, and a marked diminvition in the size of the gland resulted. One might therefore conclude that the normal hypertrophy of the thyroid gland in pregnancy is the result of a demand for extra secretion to meet the wants of increased metab- olism. With a continuous supply of artificial secretion the gland was re- lieved of the additional strain and re- sumed its former size. Hallion observed 626 ECLAilPSlA. ETIOLOGY A^'D PATHOLOGY. similar effects. H. 0. Xieholson (Lancet, June 29, 1901). Of all the theories advanced as to the cause of eclampsia and the pre-eclamptic state, none have appealed to us as strongly as that which takes into con- sideration urinary inadequacy, with the attendant diminution of the secretion of the solid elements of the \irine. In other words, with an ever-increasing experience, we feel as morally sure as clinical experience will allow us that this dire condition is due to the poison- ing of the system by urea or one of its congeners. S. Marx (Med. Examiner and Pract., March, 1903). The idea that it is a renal disease seems to be abandoned, and it is now generally attributed to the circulation of poisons in the blood, either from the alimentary canal or due to metabolism in the body of the mother or of the foetus, or of both. In health such poi- sons are either at once expelled from the body or rendered innocuous by its natural organs of defense,— the liver, kidneys, thyroid, and other glands,— but a breakdown of any one of these throws the whole mechanism out of gear. In most pregnant women the de- fensive power proves adequate ; in some, though there is disturbance of function in early months, adjustment results and the symptoms of intoxication pass off; in a few the poisons accumulate, and eclampsia or other serious troubles result. Fothergill (Practitioner, Feb., 1903). As in the course of more extended knowledge, the etiological factor of eclampsia was recognized as being asso- ciated with hydramia of the blood and with toxemia, not alone has the pressure theory been exploded, but so also have the vague and insuPTiciont terms uraimia and urincemia been discountenanced by the modern writer, teacher, and practi- tioner. During pregnancy the blood alters both in (juantity and quality. There is an increase in the white cells and a de- crease in the red. Albumin and iron fall below the normal. The blood becomes more water}', so to speak. Careful histological studies made of the various organs in a large number of cases of puerperal eclampsia. In the vessels were found large multinucleated cells, which were considered to be cells derived from the placenta, and also multiple capillary thrombosis. From these facts the conclusion drawn that the disease is essentially due to the pres- ence in the blood of a coagulating fer- ment formed either by the degeneration of the free placental cells found in the blood or by degenerative changes in the placenta itself. Schmorl (Virohow'a Archiv; St. Louis Med. and Surg. Jour., May, '96). Chamberlent, working under the direc- tion of Tarnier, in 1892 performed a series of experiments on the blood of eclamptic women and published the fol- lowing conclusions: — 1. Pregnancy tends to the retention of poisons in the body, for the urine of the pregnant woman is less poisonous than normal. , 2. In eclampsia the elimination of physiological poisons is hindered, and the urine is less poisonous than normal. It is also less poisonous than the urine of normally pregnant women. 3. The blood-serum of the eclamptic is considerably more poisonous than nor- mal, and its toxicity is in direct pro- portion to that of the urine. The poison is by some believed to have its origin in the fojtus and placenta; but the commonly-accepted view is that the poison is of maternal origin from im- paired metabolism, together witli reten- tion from impaired cliiiiinative capacity of the kidneys. The albuminuria of eclampsia is prob- ably secondary, following the direct ac- tion of the poison on the renal epithelial colls, in tlie effort at elimination. Its almost universal presence in the eclamp- tic renders it a sign of some importance. Only about one-eighth of eclamptics sub- scqiicntly develop nephritis, the albumin disappearing from the urine in from a few weeks to a few months after the attack, depending largely on the hygienic conditions which surround the patient. ECLAMPSIA. PROGNOSIS. 627 While a patient with nephritis may and does sometimes have eclampsia, it is by no means the invariable rule. J. L. Rothrock (Northwestern Lancet, Nov. 15, '97). That the blood-serum of eclamptics is more toxic than normal cannot be proved; but, on the contrary, the blood- serum of eclamptics produces, when in- jected into animals, the same symptoms caused by normal serum. Both blood-serums produce dissolution of blood-corpuscles and hemoglobinuria; both affect most powerfully when in- jected continuously. Volhard (Monats. f. Geburts. u. Gynilk., B. 5, H. 5, '97). Certain substances injected directly into the foetus or the amnion are rapidly absorbed by the maternal or- ganism, provided the foetus is living, but much more rapidly from the fojtus than from the amnion. From this it would seem that the foetus secretes certain toxic substances into the blood and am- niotic fluid. Secondly, if the foetus be dead, substances injected into either am- nion or fcetus do not seem to pass into the maternal circulation. This would seem to throw considerable light upon the various phenomena of eclampsia, and especially as showing that the death of the fcetus is followed by cessation of the convulsive seizure. Baron and Castaigne (Arch, de Med. Exp6rimcntale, Sept., '98). A large coccus, round or oval in shape, and of remarkable individual mobility, believed to have a definite connection with the etiologj' of the disease. Found in the blood of forty-four eclamptics. Lewinowitsch (Centralb. f. Gyniik., No. 46, '99). The systemic cell-activity in the pregnant woman is greatly increased. Excrementitious material accumulates rapidly in the sj'stem, and at any time the balance between secretion and ex- cretion may become disturbed and a toxaemia or poisoning ensue. If this is apt to occur in a woman conceiving with normal or healthy excretory organs, all the more so is it likely to supervene in a woman who conceives in the presence of an organic disease of one or another of the excretory organs — especially the kidneys. Thus then we may witness eclampsia develop during the pregnancy of a woman with kidneys diseased from the start or in women in whom possibly there has never been a suspicion of renal impairment. Eclampsia is not common in women the subjects of chronic kidney disease before pregnancy; where kidney symp- toms are present they usually develop suddenly; kidney-lesions may be ab- sent; albuminuria is in many cases the effect and not the cause. The kidneys are not the only excretory organs whose failure to perform elimination properly may produce eclampsia. Ptomaine poi- soning should not be forgotten. J. P. Boyd (Albany Med. Annals, Nov., '95). Prognosis. — The prognosis in modern times has been greatly altered for the better. AVhereas formerly the maternal mortality ranged about 30 per cent., now- adays there are series of cases recorded with as low a rate as 5 per cent. Some observers in a limited number of cases report no deaths. The foetal mortality remains about 50 per cent. In 52,328 oases of labor occurring within a period of 2 years there were 325 convulsions. The mortality was 19.38 per cent. Among 248 patients who survived the attacks, 54 subsequently developed other conditions; in 13 there were psychoses, generally ending in re- covery; in 5 pneumonia, 3 pleurisy, and in 22 kidney trouble persisted. In 71.1 per cent, operative interference became necessary, including 108 forceps deliv- eries. 19 versions, 13 operations to lessen the size of the child, 2 induced abortions, and 7 Cesarean sections. Liihlcin (Wi- ener mcdizin. Woch., Sept. 19, "91). It the amount of urea in the blood is twice the normal, recovery is probable, while if it very nearly approach the physiological proportion the termination is generally fatal. This is also the case wlicn the amount of the urea is five or six times the normal. More importance should be attached to the hepatic than 628 ECLAMPSIA. TREAT JJLKjST. to the renal lesions. Butte (Revue H#d. de I'Est, Mav, '93). Seiies of 5000 labors in which there were 50 cases of eclampsia, — i2 in pri- mipane. Twelve mothers died: 10 from eclampsia, 1 from nephritis, and 1 from sepsis. Geuer (Centralb. f. Gynak., No. 42, '94). Maternal mortality in eclampsia, 30 per cent.; foetal mortality, 46.6 per cent. Tarnier (Annual, '9C). Series of 42,007 confinement cases 137 — 0.321 per cent. — of which sufTered from eclampsia, 19 being already unconscious and many others having had many fits before being admitted to the clinic. Of the mothers, 109 — 79.5 per cent. — were primiparse; 113 (97 I-parje) were not more than 30 years old. One only had had eclampsia in a previous (first) con- finement (IV-para; Csesarean section). Twins are noted 12 times; hydro- cephalus, hydramnion, and low lateral placenta, 1 each; abnormal rotation, twice; abnormal pelves, 9 times; 3 breech cases. The attacks commenced before labor in 16.78 per cent., during it in 02.04 per cent., and after delivery in 21.10 per cent, of the cases; and while 53.17 per cent, had less than 5 fits, the average number of fits in 126 was 8. Omitting the 34 children of 29 post-partiim cases, of the remaining 115, 37 — 32.1 per cent. — were still-boni, and 56 — 48.6 per cent. — were premature. In 50.7 per cent, of the whole, or G4.7 per cent, of the cases before delivery, empty- ing the uterus had a good effect. Of 27 deaths (19.7 per cent.), 17 only were due to eclampsia alone (12.4 per cent). The mortality of multipara (6 = 21.4 per cent.) was greater than that of primip- arse (21 = 19.2 per cent.). The relative mortality of cases commencing before, during, or after childbirth was 30.43 per cent., 18.82 per cent., and 13.79 per cent. The proportion of deaths is compara- tively low, and with the fact shown that delivery without too active interference tends to stop the fits is sufficient to warrant the adoption of conservative treatment for eclampsia. The practice of the A'ienna clinic for many years has been a [irojihylactic milk diet for all albuminuric pregnant women; if this fail, the induction of labor by bougie or colpeurynter. On the outbreak of eclamp- sia hot baths, linden-tea, wet packing, chloroform, and delivery as soon as may be without incisions. Schreiber (Arch, f. Gyn., li, 335, '96). Treatment. — The treatment of eclampsia may be considered to advan- tage under the following headings: (1) prophylactic; (3) medicinal; (3) sur- gical. Prophylactic Treatment. — If the preg- nant woman has been carefully watched by the medical attendant, only excep- tionally will eclampsia develop, because the institution of certain prophylactic measures or early resort to certain sur- gical measures will nullify or prevent the development of certain phenomena which apparently underlie or enter into the causation. Thus, it is not sufficient, after a perfunctory fashion, to examine the urine for albumin, but the total amount passed and the amount of urea contained in it should be ascertained at intervals. Further still, explicit direc- tions should be given in regard to the necessity of securing free action of the sudoriparous glands by means of fre- quent baths, and thorough action of the intestinal canal should be maintained. When the excretory organs of the body are acting physiologically those elements of tissue-waste Avhich, retained in the body, favor the development of eclamp- sia, are excreted. AVhcn skin, bowels, and kidneys are clogged, the reverse holds true, and sooner or later, in preg- nancy, symptoms appear which, if not properly appreciated and when possible eradicated, are forerunners of eclampsia. When urinalysis reveals the presence of kidney disease — whether organic or func- tional — steps should be taken at once to modify the symptomatology for the bet- ter by recourse to hygiene and dietetics, and, such measures failing, after reason- ECLAMPSIA. TREATilENT. 629 able interval medicinal and surgical treat- ment enter the foreground. The presence of albuminuria is un- doubtedly of great value, but too many physicians trust to it alone, and the ex- aminations are made only at long inter- vals. The medical man may usually feel secure so long as the ureal elimination is near the normal, — 400 or 500 grains per diem; but this is not, alone, an abso- lutely reliable guide. A most important and neglected element in the prognosis is the daily quantity of urine. If every pregnant woman were taught to measure the urine once or twice weekly during the later months of pregnancy, and im- pressed with the necessity of keeping it at or above three pints per day, convul- sions in childbed would be almost un- known. C. Jewett (Brooklyn Med. Jour., Aug., '99). Chief among the hygienic measures stand hot baths and gentle catharsis; foremost among the dietetic measures ranks milk diet (associated with the ad- ministration of an assimilable and non- astringent form of iron). Milk treatment is most efficient from a prophylactic point of view, though it does not necessarily cause the other alarming symptoms, besides the fits, to vanish. The alleged disappearance of albuminuria docs not necessarily occur, even after prolonged treatment by milk diet. The same may be said of the oedema ; this treatment seems to have no effect on it. The above facts are em- phasized, because some obstetricians have very naturally given up milk diet on account of persistence of albuminuria and oedema. Such a step is a mistake, for, if the treatment be continued, labor will proceed without any fits coming on, though the legs remain swelled and the urine albuminous. FcrrC (Jj'ObstOtrique, Nov. l.i, "OG). Analysis of 48 cases. The uterine douche alone was sufficient to check the infective process in 15 cases. Explora- tion and curettage of the uterus were fol- lowed by a rapid fall of temperature in 8 cases, a gradual fall in 10 cases, a tem- porary increase followed by a rapid fall in 2 cases, and no effect on the tempera- ture in 13 cases. A. W. W. Lea (Med. Chronicle, Aug., '99). There are three main channels through which toxic substances may be got rid of, viz.: the bowels, the skin, and the kidneys. In eclampsia the urinary sys- tem is chiefly at fault, but the two other channels must not be neglected. Hot pack or bath to produce free action of the skin, with enemata to promote elim- ination of toxins by the bowels, and, to get the kindeys to act, large saline in- jections are advocated. The solution used was 1 part of bicarbonate of potash to 1 of common salt: 1 drachm to the pint of sterilized water at 100° F. The bicarbonate of potash is added to obtain the diuretic action of the potash salts. The apparatus used is an aspirator trocar and cannula, a few feet of rubber tubing, a test-tube-shaped filler, and a piece of adhesive plaster. The injection is made conveniently under the edge of the breast before deliverj'; the lax ab- dominal wall, after delivery. From 1 to 4 pints may be employed. Absorption begins at once, and is complete in fifteen or twenty minutes. In seventeen cases saline injections were employed to in- crease the flow of urine, and so aid elimi- nation by the kidneys. Analysis showed a marked increase in the daily excretion of urea and uric acid, and there is prob- ably a corresponding increase in the ex- cretion of the poison which causes the disease. Jardine (Practitioner, Dec., '99). It has been definitely shown that the vagina is sterile in healthy women. Therefore, it they get infected at labor it is through some intravaginal manipu- lation. Prophylaxis reduces itself to two measures: (1) Clean hands and in- struments. (2) Avoidance of vaginal examinations. With regard to the ster- ilization of tlie hands, Stewart's method is the best. Vaginal examinations can usually be dispensed with. It is to be regretted that this practice is not more usual. Brodhend (Medical Record, April 23, 1904). 630 ECLAMPSIA. TREATMENT. Where, notwithstanding these meas- ures, the evidences of organic kidney dis- ease become intensified, or where, these evidences lacking, the symptoms sug- gestive of impending eclampsia develop, time for action has come, justifiable de- lay having reached its limit. In the past and even to-day expectancy has been and is too often the cause of untoward re- sults. "With the exception of the fulminating type of eclampsia — where art almost al- ways fails, it may be stated that prompt action, of the nature to be described, will, in the vast proportion of cases, prevent the development of eclampsia. Medicinal Treatment. — In the pres- ence of the prodromal symptoms of eclampsia, but little reliance can be placed on drugs. Where urinary insuffi- ciency exists, indeed, it is very question- able if the routine administration of drugs do not harm. Certainly the potas- sium salts are very likely to irritate the kidneys. The ingestion of large amounts of water by mouth and repeated intro- duction of warm normal .saline solution into the blood-stream will accomplish more than any and all drugs together. Van Eenssalaer suggests venesection, canied to the point of tolerance, and then followed by the subcutaneous injec- tion of a normal salt solution. This method need not be confined to the plethoric, but even a weak pulse and profound coma do not contraindicate its use, for the rapid introduction of the warm salt solution following venesection counteracts the effects of bleeding, filling the vessels and stimulating the heart. From a pint to a quart of blood can be safely withdrawn from the veins of a patient of average weight, providing the injection of the salt solution is followed up at once. J. L. Rolhrock {North- western Lancet, Nov. 15, '97). Series of cases of puerperal eclampsia treated by rest, pure milk diet, injec- tions of morphine to control convulsions. and the regular administration of thy- roid extract in doses of 0.30 gramme (5 grains), repeated, if necessary, every three or four hours. The symptoms, especially headache, albumin in the urine, oedema, amblyopia, etc., began and steadily continued to disappear. Thy- roid extract is also of value to prevent convulsions in women who give a his- tory of eclamptic seizures during pre- vious pregnancies. H. 0. Nicholson (La Semaine Mfidicale, May 21, 1902). As regards treatment in the early stages, when there are Increased tension of pulse and diminution of urine thyroid extract should be given twice or thrice daily, and proteid foods should be en- tirely forbidden at first. Iodide of po- tassium in small doses has been re- garded as a specific for puerperal albu- minuria; the iodine has been proved to be picked out by the thyroid gland and may be elaborated into the active iodothj'riu. It has been suggested to give infusions with iodide of potassium instead of ordinary saline infusions in cases of eclampsia. If convulsions have already occurred, then the use of thy- roidin by the mouth will not be rapid enough. Liquor thyroidii, or, better still, fresh thyroid juice, from 10 to 15 minims, should be given by hypodermic injection and repeated every hour or two if not followed by signs of improve- ment. For the immediate treatment of the convulsion morphine is the best remedy. It inhibits the various proc- esses of metabolism, and this gives op- portunity to the thyroid gland to re- cover itself. The dose should be large: not less than Va grain for the first injection. H. 0. Nicholson (Lancet, June 29, 1901). Intravascular antisepsis appeals to the mind of every scientific observer of septic conditions of the blood. An in- travascular antiseptic or germicide must be destructive to bacteria and at the same time not injure the patient. For- maldehyde possesses this specific influ- ence, as shown by experiments on ani- mals. Maguire used solutions upon himself as strong as 1 to 500 without any liromolytie changes. Case of septi- ECLAIIPSIA. TREATMENT. 631 ceeraia personally treated with success by formalin injections, using an aqueous solution, 1 to 5000. FormaUn in nor- mal salt solution would be better than aqueous solution, althougli no haemoly- sis follows the infusion of formalin in distilled water. Theoretically, however, salt solution is preferable. Barrows (New York Medical Journal, Jan. 31, 1903). The saline irrigation — if a number of quarts are used at a time — promotes di- uresis and diaphoresis and indirectly en- forces intestinal peristalsis, and such irri- gation should become the established custom not alone in face of impending eclampsia, but also in the presence of eclampsia. "\ATiere the pulse of tension exists venesection — too seldom resorted to nowadays — is called for. Saline transfusion should be resorted to if the patient is in a collapse and death seems imminent. Tliese hypoder- mic injections of warm sterilized water, salt (1 per cent.), to the amount of one- half pint, into the vascular tissues of the axillre W'ill be readily absorbed. G. Covert (Chicago Medical Times, Apr., '98). Inasmuch as eclampsia is undoubtedly a to.xnomia, one should look for good re- sults from the intracellular transfusion of saline solution. Bacon's apparatus consists of a glass funnel and long rub- ber tube, which is connected by means of a Y-shaped glass tube and two short rubber tubes with two aspirator needles. The solution can be injected into the two axillte at the same time, and thus the main objection against the intracellular contrasted with the intravenous method may be in great part obviated. Edgar (Glasgow Med. Jour., Apr., '99). Three cases of eclampsia treated by saline infusion. As soon as the patient rouses sufTiciently, drachm doses of Ep- som salts every hour are given. The salt solution usually acts wonderfully in stimulating the kidneys; but, if neces- sary, diy and wet cups may be used with Va ounce of infusion of digitalis every four hours. The diet is exclusively milk. To stimulate the skin, the hot- air bath or the wet pack is used. Tonics are given during convalescence. Allen (Amer. Jour, of Obstet., May, '99). The experiments of Tarnier, Ludwig, and Savor certainly show that the tox- icity of the blood-serum is increased in eclampsia, while, on the other hand, those of Charrin and Volhard seem to prove just as conclusively that it is not. In treatment, prophylaxis stands pre- eminent. When the trouble has devel- oped the treatment may be summed up in one word, "elimination," and nothing will give such immediate results as bloodletting, followed by infusion or transfusion of saline solution. If the patient be ansemic, do not bleed, but use the saline injection. The results of such treatment observed to the eflfect that: (1) the patient's general condi- tion will improve; (2) the cyanosis, muscular twitching, and rigidity will have ceased; (3) the pulse, which before was hard and bounding, will have lost its tenseness, and the attendant coma, be it never so deep, will slowly, but surely, be lifted. The writer says, in conclusion, that if bloodletting, together with saline infusion or transfusion, were more generally emplojed, better results would be obtained in the treatment. E. T. Abrams (Amer. Jour, of Obstet- rics, Jan., 1903). Possibly veratrum viride administered hypodermically every two or three hours in the dosage of 10 minims, until the pulse-rate is materially lowered (down to 60 or 40) will accomplish the same result as venesection, and at times the free use of this drug will render unnecessary re- sort to active surgery, except where the symptoms are very urgent, when we are amply satisfied that dallying with drugs should cease. Twenty-six cases with no deaths treated with veratrum viride by the mouth or subcutancously until pulse had been lowered below CO and con- vulsions controlled, after which the fol- lowing mixture given: — 632 ECLAMPSIA. TKEATJIEiS'T. IJ Acidi benzoic!, 2 drachms. Potass, bicarb., V: ounce. Spirit, aether, nit., 1 ounce. Spirit. Mindereri, 2 ounces. SjT. limonis, q. s. ad 6 ounces. M. Sig.: A teaspoonful every four hours. R. C. Newton (N. Y. Med. Jour., Dec. 14, '95). The toxins causing uremia are varied and numerous. In eclamptics the urine is less toxic than normal, while the blood- serum is more toxic. The foetus is an additional source of waste-products and an additional cause of danger to the mother. The indications for treatment are to remove the to.xic materials in every way practicable. Veratrum viride in cases where the pulse is strong enough to warrant its employment will be found useful. The depressing action of pilocar- pine makes it a dangerous drug. Many patients with eclampsia die from over- medication. Labor should be induced or delivery hastened when other methods fail to control the convulsions. P. W. Van Peyma (N. Y. Med. Jour., Feb. 22, '96). The method by which veratrum viride is supposed to do good in cases of puer- peral eclampsia is a double one. Chiefly from the action of its alkaloid, jervine, it powerfully depresses the circulation, and so bleeds the woman into her own vessels, relieving by this means conges- tion of the cerebral and spinal vessels and reducing in all probability any spasm of the renal blood-vessels which may be present, thereby causing marked increase in the flow of urine. In addi- tion to this action, jervine also acts as a powerful .sedative to the motor tracts of the spinal cord, and so directly quiets nervous excitation, while the copious sweating which often follows its admin- istration aids in relieving the blood of impurities, the kidneys of congestion, and relaxes the peripheral blood-vessels. Editorial (Therap. Gaz., Mar. 10, '00). Veratrum viride used with marked BuccesB. The remedy notably diminishes the frequency of the pulse, and convul- BJonH rarely occur when the pulse is kept at or below 00. Of 100 patients treated by veratrum viride in the writer's practice, 92 were saved. Parvin (Universal Med. Jour., Oct., '913). During the attack itself chloroform administered. As soon as the attack passes, 15 drops of the fluid extract of veratrum viride are given hypodemiic- ally, and a drachm of chloral in solution by enema. Two drops of croton-oil di- luted with a little sweet oil are placed upon the tongue. Diaphoresis is induced by hot packs and extra bed-clothing. A pint or more of decinormal salt solu- tion should he injected by gravity under the breast, or several quarts of the solu- tion by enema. If convulsions recur, the veratrum may be repeated in 5-drop doses if the pulse is quick and strong. If the face is congested and the pulse full, venesection enough to reduce the pulse should be employed. The chloral may be repeated during the attack two or three times. Stimulants are to be used if the pulse is weak and rapid. If the convulsions cease and the patient is in a stupor, but can be aroused enough to swallow, dessertspoonfuls of concentrated solution of Epsom salts should be given every fifteen or thirty minutes until free catharsis takes place. B. C. Hirst (Med. Record, Mar. 4, '99). In five personal cases of eclampsia there was not a single convulsion after ether had been thoroughly given, though in these eases many convulsions had fol- lowed other lines of treatment. The harmlessness of continuous and thorough anaesthesia is emphasized. In the five cases anfesthesia was kept up from eight to twenty-four hours, deeply enough to keep the patient quiet, and there was not a single symptom that showed that any of the women was any the worse for the anoesthetie. J. P. Reynolds (Boston Med. and Surg. Jour., Nov. 9, '99). Veratrum viride is the remedy par ex- cellence in eclampsia, acting to reduce arterial tension and to soften the rigid OS, thereby removing the causes pro- ducing the malady. F. L. Brighara (Amcr. Gynrec. and Obstct. Jour., Dec, '99). Nitroglycerin, in the dosage of Vu grain, hypodermically, repeated pro re ECLAilPSIA. TREATMENT. 633 nata will tend to relieve the cephalalgia. When the convulsions appear suddenly morphine, 1 grain hypodermically, is called for until chloroform anesthesia to the surgical degree is secured; but otherwise opium and its derivatives should not be countenanced, because of their tendency to inhibit secretion from the intestinal canal and from the kid- neys, thus defeating the prime thera- peutic aim, which is to increase secretion and excretion. Case of puerperal infection treated by Marmorok's antistreptococcic serum with very successful results. Other drugs were used with no beneficial effects; but, upon beginning the serum-treatment, im- provement was steady and rapid, and four days after the first injection the temperature was normal. R. de Seig- neaux (Centralb. f. Gynilk., Dec. 16, '99). The pathological features and symp- toms that require treatment are: The toxajmia, ana;mia, the convulsions, the labor-pains, hypersensitiveness of the nervous system, to avoid causing oedema of the lungs, heart-failure, and high- tension pulse. For tlie toxtemia, elimination by pur- gation with calomel, accompanied by magnesium sulphate in Vj-ounce doses of the saturated solution. In antepar- tum cases this purgation, with an occa- sional dose of calomel, must be kept up until the child is born. One of personal cases carried on in this way after the patient had had eight convulsions for seven weeks, when a healthy child was born, and thrived. In 2 cases it hap- pened that when the morning course of salines was omitted, owing to the bowels having moved early in the morn- ing, convulsions came on again at night. In 1 of them, after the patient had been kept free from convulsions for a week. In case of unconsciousness, 2 minims of crotonoil may be introduced through a stomach-tube. Normal saline solution given subcu- taneously acts very well as a diuretic. K. C. Mcllwraith (Canadian Pract. and Rev., June, 1901). The serum-treatment has no place in the routine treatment of puerperal sep- sis; it should be used only in desperate cases after failure to obtain improve- ment by other and usually more efiB- cient methods, and if no improvement is shown after use for two or at moat three days and the injection of 40 to 00 cubic centimetres (10 to 1.5 flui- drachms), it should be discontinued. Its use is not free from danger, it usually lowers the pulse and temperature, but at the same time it has a correspond- ingly depressing effect upon the patient, and it has not apparently lowered the mortality of the disease. With regard to the general treatment of puerperal sepsis, early curettage of the uterus carefully performed as soon as the diagnosis is established is of pri- mary importance, and the same result is not accomplished by any other method of procedure. Following curet- tage, and sometimes in place of it in the mild cases, intra-uterine douches have proved to be of much value. For constitutional treatment, one must mainly rely on stimulation, tonics, and forced feeding, with moderate diuresis and catharsis. F. A. Higgins (Boston Med. and Surg. Jour., May 2, 1901). These few drugs failing to control the premonitory symptoms or eclampsia sud- denly developing, measures of a surgical nature are called for. Surgical Treatment. — Where the symptoms which forebode the develop- ment of eclampsia do not yield to the dietetic, hygienic, and medicinal treat- ment outlined, the surgical measure de- manded is evacuation of the uterus. In eclampsia occurring during partu- rition delivery should be effected as quickly as possible under deep anresthe- sia. When possible, without loss of time, the cervix should be widened by hydrostatic dilators, and the smallest possible incision, ^^^len the condition of the cervix is the cause of delay after artificial dilatation, incision as deep as may be necessary should be made. Hicmorrhage arising from this cause may be controlled by tampons of gauza or by pressure-forceps. In such cases, 634 ECLAMPSIA. TREATilEXT. considering the amount of hsemorihage from the incision, there can never be any question of adopting venesection. Wlien the patient is unconscious, no attempt should be made to make her swallow; a suitable stomach-pump should be iu- variablj- used for the introduction of nourishment or medicine. Anaesthetics should be used to the surgical extent only during the operation of emptying the uterus, and either chloroform or ether may be used. The most exact asepsis is required; infection prolongs the convulsion stage of eclampsia. P. Zweifel {Centralb. f. Gyntik., Nos. 4G to 48, '95). In the Prague hospital the rule is to deliver as rapidly as possible consistent with avoiding injury. A mi.xture of chloroform, ether, and alcohol is an espe- cially safe preparation, the anaesthetic being administered not only during the operative proceedings, but also to mod- ify the convulsions. Morphine is also constantly employed. The prolonged warm bath and the hot wet pack are very important. The only beverage per- mitted is lukewarm milk. Knapp (Monats. f. Geburts. u. Gyniik., B. 3, May and June, '90). Albuminuria is a premonitory sign too important to be overlooked. Termina- tion of the delivery is in all cases de- sirable, and it must be rapidly brought about in serious cases. Therefore from the beginning of the attacks we must act continuously in that direction. In very urgent circumstances we must not hesitate to dilate the cen'ix. If this accouchement ford is difficult, too slow, or impossible without too much injury, we must have recourse to Cesarean sec- tion. N. Charles (Jour. d'Accouohe- ments, Oct. 11, '90). In puerperal eclampsia the chief aim is to empty the uterus of its contents as quickly as possible. The cervical canal should be dilated, first by means of Hegar's graduated sounds and afterward with the fingers, until the orifice has attained a diameter of three centimetres. Podalic version, according to the Jirax- ton-Hick8 method, is then practiced and one loot extracted. This done, the uter- ine orifice is again dilated by separating its edges on one side by means of the child's leg, upon which the hand of the operator exerts (the foot being already extracted from the wound) energetic lateral pressure, and on the opposite side with the hooked inde.x of the other hand. When dilatation of from eight to ten centimetres has thus been obtained, it only remains to extract the child. As soon as the umbilical cord has been severed the placenta should be detached and the uterus compressed with the two hands for about an hour; this com- pression suscitates the uterine contrac- tions, preventing any serious hfemor- rhage. Drejer (Sem. M6d., Oct. 31, '96). Acceleration of labor by safe methods, large doses of morphine to suppress the attacks, avoidance of administering med- icine by the mouth, stimulation of dia- phoresis by external remedies — all these appear to promise most success in treat- ment. Veit (Festschrift f. Carl Ruge,'96) . Whenever albumin is discovered in the urine of a pregnant woman, she should, without delay, be put upon a strict milk diet, for albuminuria is to be regarded as a symptom of the state of autoin- toxication which results in eclampsia. Tarnier says that he has never seen eclampsia supervene in pregnant women suffering from albuminuria who have been for seven days upon a strict milk diet. During the convulsions tlie tongue is best preserved from injury by placing a folded handkerchief between the teeth, which pushes the tongue back, and also prevents the teeth from closing. The pa- tient should be placed immediately under the induence of chloroform. A rectal injection of about GO grains of chloral should next be given; it is advisable to begin with a large dose rather than repeated small doses. If necessary the injection of chloral may be repeated sev- eral times, giving as much as 2.50 to 300 grains in twenty-four hours. The in- halation of chloroform should be con- tin\ied during the attacks. Bleeding is reserved for the rare cases which are dis- tinctly "sthenic" in type. As a diuretic agent, half a pint or more of a saline solution containing 1 per cent, of chlo- ride of sodium, may be injected into the buttock, and the injection repeated scv- ECLAMPSIA. 635 eral times. No interference is required until the cervi.x is fully dilated, when the child may be extracted with forceps or by turning. Delivery by such forcible methods as rapid dilatation or incision of the ccrvi.x is condemned. Oui (L'Echo M6d. du Nord, May, 'i)7). The treatment consists in controlling the convulsions by profound narcosis, speedy evacuation of the uterine con- tents, and diaphoresis, with a view to re- establish skin function and reduce tlie tension. Kedarnath Dass (Indian Med. Record, April IG, '98). The nearer the term, the easier the pro- cedure of emptying the uterus; the same statement applies to the multipara over the primipara. The steps of the pro- cedure are, in brief, the following: Un- der the most absolute asepsis of patient, instruments, and hands of operator and assistants, ordinarily under chloroform antesthesia, the cervix is dilated by the steel-branched or other dilator. Great care is requisite not to rupture the mem- branes. The cervical canal is then firmly packed with sterile gauze, and the upper portion of the vagina as well. The woman is put to bed and if she complain of much pain codeine should be used freely in suppository (gr. ii to iv repeated every four to six hours), for reflex nerv- ous irritability must be controlled. At the expiration of about twenty-four hours, under absolute asepsis and chloro- form ansEsthcsia, the gauze is removed, and, if the cervix has softened and is dilatable, manual dilatation is resorted to. If the cervix has not softened and the symptoms are not urgent the canal should be repacked for a further period of about twenty-four hours. Dilatation by the hand having been accomplished to the requisite degree — that is to say, until the closed fist can be withdrawn with ease, the membranes being intact, elect- ive version is performed, followed by im- mediate extraction, else the lower uterine segment may close on the fcetal head. When the membranes have ruptured de- livery from the brim by axis-traction for- ceps is indicated. After delivery — when the pulse is full, strong, bounding — uter- ine venesection is allowable until the pulse becomes soft. 'Where, on the other hand, the pulse after delivery is rapid and weak, no time should be lost in the thorough uterine tamponade. 'Where eclampsia develops without pre- monitory symptoms, or where delay with the premonitory symptoms has ruled, there is no time for the preliminary tam- ponade. Under absolute asepsis and chloroform anaesthesia manual dilatation is at at once instituted, associated, in very rare instances, with the Diihrssen incisions, the uterus being then emptied. In post-partum eclampsia there is no scope for surgery, and dependence must rest on drugs (veratrum and the nitrites), on repeated high saline rectal irrigation, and in free catharsis, using elaterium or croton-oil. 'Whether the case be of the sthenic or asthenic type, these rules hold good, except that in the latter type hy- podermoclysis of saline solution should be added, and in the latter venesection. Egbert H. Grandin, New York. ECZEMA.— Gr., fx^to'. to boil over. Definition. — Eczema may either be an acute, subacute, or chronic inflammatory disease of the skin, usually characterized in its earliest stages by the appearances of erythema, papules, vesicles, or pustules, or a combination of two or more of these lesions. It is attended with a variable degree of thickening and infiltration of the cutaneous tissues, terminating either in discharge with the formation of crusts or in absorption or in desquamation. Varieties. — The primarj-, or element- ary, varieties are the er}'thematous, papu- lar, vesicular, and pustular; or the first 636 ECZEMA. SYMPTOMS. outbreak may show a mixture of these several types. In many cases the begin- ning lesions or type soon lose their char- acters and the disease develops into the common clinical varieties: eczema ru- brum or eczema squamosum. Other clinical or secondary types met with are eczema fissum, eczema sclerosum, and eczema verrucosum. Symptoms. — The erythematous tj'pe of eczema — also called eczema erj'thema- tosum — is most frequently seen upon the face, although it may make its appear- ance upon any other region or may be more or less general. It begins as a single hypersemic area, or several areas may appear simultaneously, usually upon one region. The areas may be email or large, irregularly outlined, ill defined, and attended with slight or con- siderable swelling and even oedema. There is more or less itching and burn- ing. The eruption soon becomes pro- nounced, the parts reddened, somewhat thickened, and here and there a little scaly. There may also be, here and there (as a result of rubbing or scratching, or spontaneously) a tendency to serous ooz- ing. The affected skin is harsh, dry, and reddish or violaceous in color. It often persists in this form, and the skin may become considerably thickened and in- filtrated. The swelling and oedema which are often first present may sub- side, to a great extent at least, or these symptoms may reappear from time to time whenever there is an acute exacer- bation. The parts may become quite scaly, and constitute a mild or well- marked scaly eczema: eczema squamo- sum. Occasionally, as a result of con- stant irritation, rubbing, and scratching, or from other causes, the parts become moist, markedly inflamed, with more or less crusting, consUtuting eczema ru- brum. The papular type of the disease, or ec- zema papulosum, presents itself as one or more aggregations of closely-set papules, pin-point to pin-head, or slightly larger, in size. The disease may also show itself as more or less discrete papules, with here and there aggregations. In color the lesions are bright- or deep- red or violaceous, with often a few vesicles or pustules interspersed. Itching is usually intense. The extremities, and the parts, especially about the joints, are its favor- ite sites. The course of this type is es- sentially chronic, some lesions disappear- ing and others appearing, and thus per- sisting for several months or indefinitely. In some instances, especially in some areas, the papules become so thickly crowded that a solid patch results, be- coming more or less scaly — eczema squamosum. Or at times such a patch may develop into eczema rubrum. The vesicular type of the disease, or eczema vesiculosum, may show itself on one or more regions, and consists of ag- gregated or closely-crowded pin-point to pea-sized vesicles, with here and there discrete lesions, and at times with pap- ules and pustules interspersed. It is usually a markedly-inflammatory type, with considerable cederaa and swelling. Solid sheets of eruption may form. The vesicles usually rupture in the course of a few hours or days, new outbreaks oc- curring, or a raw weeping, more or less crusted surface resulting. The oozing may be continuous or the process may decline, to remain quiescent or to break forth rapidly with repeated vesicular crops. Considerable thickening may take place and with the oozing and crust- ing make up a picture of the common clinical type: eczema rubrum. The face and scalp of infants, the neck, flexor sur- faces and fingers are the more common sites for the vesicular type. Its course is ECZEJIA. SYilPTOMS. 637 usually chronic, with several acute ex- acerbations, or, as already described, it may pass sooner or later into the com- mon clinical type: eczema rub rum. The pustular variety of eczema, or ec- zema pustulosum or impetiginosum, is less frequently met with than the other varieties of the disease. Its common site is the scalp, especially in infants. It may develop from the vesicular variety, or, as more commonly the case, begin as closely-set pin-point to pin-head, or larger sized pustules; or a mixture of vesicles and pustules may be noticed. In symptomatology it is similar to eczema vesieulosum, except that the lesions, in- stead of containing serum, contain pus. As in the vesicular type, the same dis- position to the rupture of the pustules is observed, and there is often a tendency to develop into the type known as eczema rubrum. More or less crusting is usually a conspicuous feature. The ill-nourished and strumous persons are its most com- mon subjects. The type is essentially chronic. The squamous type of eczema, or ec- zema squamosum, is a clinical variety frequently met with, characterized by redness, infiltration, and more or less scaliness, with, especially when about the joints, more or less Assuring. The itch- ing is variable, sometimes intense, and at other times slight. This variety is usually a development from the ery- thematous or papular types, and, like other types of the disease, is persistent and chronic. Eczema rubrum, the oozing type of eczema, or somewhat dry, raw-looking type of eczema, usually results from a pre-existing vesicular or pustular eczema. It is characterized by a red, weeping, ooz- ing, raw-looking surface, with more or less infiltration of the cutaneous tissues. In some cases there is a combination of weeping raw surface with crusted areas. In other cases the weeping nature of the disease is a conspicuous feature, crusting scarcely having time to form: eczema madidans. Its most frequent sites are the face and scalp of children and the legs of adults; in the latter in those espe- cially advancing in years. In these cases of eczema of the lower legs varicose veins are often present as a precursory and concomitant condition. It is essentially chronic, showing little, if any, disposi- tion to disappear spontaneously, al- though it may be somewhat variable. The degree of inflammation varies from time to time. The fissured type of eczema, or eczema fissum or eczema rimosum, is that type of eczema in which cracking or fissuring of the skin is the most conspicuous feature. It is common about the joints, especially about the fingers, and in most cases is a part of an apparently slight erythema- tous eczema. Fissuring may occur in any type of the disease, especially when about the joints; but in most cases it is but slight in character. It is a persistent tj'pe of the disease, usually disappearing in part or more or less completely in warm weather. A somewhat analogous or allied variety of eczema is the so-called crackled eczema. This is usually a mild subacute erythematous eczema, involving large regions or the entire surface, numerous superficial cracks through the upper epiderm showing over the fissured surface. Eczema sclerosum and eczema verru- cosum are somewhat rare varieties of the disease. These types are usually seen about the ankles, lower leg, or feet. They commonly result from a pre-existing papular eczema. In many respects these types are analogous in their symptom- atolog}-: there is considerable thickening and board-like hardness, with, as a rule. €38 ECZEMA. SYMPTOMS. much infiltration, but with the inflam- matory element slight or comparatively so. The surface is roiigh, hard, and somewhat horny to the feel, and in the verrucous variety there is added to these several symptoms a variable degree of papillary hypertrophy, the surface hav- ing a distinctly-warty appearance. Both types are essentially chronic and rebell- ious to treatment, demanding the strong- est application. Infantile Eczema. — The disease is common in infants and young children. It is unusual, comparatively speaking, in children past the age of 6. Even in those cases in which the disease begins in the first or second year and is persistent, it tends to decline spontaneously toward the age of 5 or 6, or even earlier; or at least at this period it will usually respond rapidly to any mild or indifferent appli- cation. The disease presents no special characteristics in the young, except that in the majority of such cases the inflam- matory element is apt to be more marked. In by far the larger proportion of cases the face or the face and scalp are the seat of the disease; eczema of the region of the genitalia and anal cleft is also not infrequent. All cases of infantile eczema will usually do well under treatment, al- though a disposition in many cases is shown toward relapse till the age of 4 to 6 is reached. In eczema in infants and young chil- dren occurring about the legs and arms, usually as a vesico-papular or papular eruption, discrete and patchy, the dis- ease is often obstinate, — much more so, as a rule, than in those cases where the disease is limited to the face or face and scalp. The vesicular, vesicular-papular, and moist or crusted inflammatory type — eczema nibrum — seem most frequent in the young. Eegional Eczema. — It is usual to de- scribe eczema as it appears upon difl'erent regions, as, for instance, the hands, face, scrotum, legs, etc.; but the disease in reality difl'ers little, certainly not materi- ally, as it occurs upon different parts. The description of the several types of the disease as already given suffices. It is noted that the most common seats for eczema in those of the active age, be- tween 21 and 50, is about the hands, less freqttently about the face or the scalp; the scrotum is not an uncommon site, and also the anal region. There is a remarkably-obstinate form of clironie eczema, whicli attacks the palms, and, thougli more rarely, the soles sometimes also. The disease commonly takes its origin in the centre of one palm, though it is generally not long until both are implicated. There are hard, sca-ly patches of infiltrated skin, involving more or less of the surface; there is ragged and uneven scaling, while in the natural lines of flexion, or inde- pendent of these, are deep and painful cracks. The hands feel hot, and burn and itch at times. This morbid condi- tion advances sometimes along the fingers toward their tips, the pulp remaining, as a rule, immune. A symptom ob- served in the feet which is not so evi- dent on the palms is the existence of a band of congestion beyond the scaly area, fading imperceptibly into the natural tint of sound skin. Though met with in both sexes, this variety of eczema is most commonly encountered in women, and in them about the menopause. Janiieson (Edinburgh Med. Jour., Jan., '98). In a recent analysis of 10,000 mis- cellaneous skin cases in the writer's pri- vate practice, 32.01 per cent, suffered with eczema. Neurotic eczema is fre- quently observed in infancy, in connec- tion with cutting of the teeth; in child- hood it is less common; its most fre- quent time of occurrence is between 20 and 55 years of age. Various forms or phases of nerve disturbance are seen in connection with neurotic eczema, and ECZEMA. GEXKliAL SVilPTOMATOLOGV. ETIOLOGY. 639 they may be considered under the fol- lowing heads: (1) neurasthenia, or nerve-exhaustion; (2) nervous and mental shock; (3) reflex phenomena (o) of internal origin or (6) peripheral; (4) neuroses, (a) structural or (6) func- tional. The eruption is apt to come first upon the hands and face, less commonly on the feet. But from its starting-point it may extend over large surfaces. Neurotic eczema upon the hands is very apt to exhibit vesicles; but on the adult face the eruption is quite as likely to as- sume and maintain the erythematous form, with vesicles, and often without moisture, unless scratched. The groups of lesions have a tendency to be pretty sharply defined, in more or less her- petic patches, which may present mainly solid papules, or, when torn, a raw sur- face. It is intensely itchy, and the spasms of itching are sometimes fearful and utterly uncontrollable. L. Duncan Bulkley {.Jour. Amer. Med. Assoc, Apr. 16, '98). In eczema about the finger-nails the matrix or the bed of the nail may be affected, primarily, or by contiguity from eczema on the back of the finger. The first sign is the redness of the supra-ungual tissue, which becomes painful to pressure. Rarely, so much serum may exude that the nail is lifted up, and finally falls off. Striations are noted in the nails, with punetiform de- pressions. The whole nail may be raised from its bed or a depression may appear in the median line. If the ec- zema is chronic the nails will be de- formed. W. Dubreuilh and D. Freche (Jour, de M(5d. de Bordeaux, Apr. 14, 1901). In those past the age of 50 the most common site is the lower leg, although eczema of the face is not infrequently met with. General Symptomatology. — The sub- jective symptoms in eczema are itching, burning, and a sensation of heat. These may be .severally present, or, as is more commonly the case, one is predominant. The degree varies, sometimes slight and ' at other times almost unbearable. As a rule, there are no constitutional symp- toms so-called in eczema cases. In ex- tensive general acute eczema there may be slight febrile action and sometimes slight chilliness at the outbreak of the attack. The degree of inflammatory ac- tions varies in the same case from time to time and in different cases. The dis- ease may be acute both in type and ita course, running to an end in several weeks or one or two months. As a rule, however, whatever the type of the in- flammatory process — acute, subacute, or chronic — the disease is persistent and long-continued, with, in most cases, little, if any, tendency to disappear spon- taneously. Seasons often have an influ- ence, the disease usually being less active or partly or completely disappearing in the summer weather. On the other hand, there are cases of the disease met with that are at their worst in summer time, and frequently disappear in the colder weather; such instances are, however, exceptional. Etiology. — The consensus of opinion points to both external and constitu- tional causes as active factors in most cases of the disease. The possibility and even probability of this disease's being due to a parasite is more or less seriously entertained in some quarters. In eczema the staphylococcus aureus present in practically pure culture in a large series of examined cases and in- vaded the deeper layers of the skin. Ec- zema may therefore be considered to be due to a staphylococcic infection. W. Seholtz (Deutsche mcd. Woch., Julv 26, 1900). In some ordinary forms of eczema efflorescences appear which contain no micro-organisms or some the pathogenic nature of which is not demonstrable. In such cases the etiology depends probably upon mechanical or chemical irritation. In other cases ordinary streptococci or 640 ECZEMA. ETIOLOGY. staphylococci are seen which can be ob- served at any time in any portion of the healthy skin. These bacteria, invading the skin where there is an eczema, may arouse additional inflammation, the se- verity of which depends upon the pa- tient's idiosyncrasy and the virulence of the germs. Jadassohn ("Wiener med. Blatter, Aug. 23, 1900). Bacteriological studies of 74 cases of this disease showed 23 types of coccus. Absolutely typical eczematous lesions were produced by two of these: the diclimactericus eczematis albus flavens and monoclimaetericus eczematis vives- cens, while a third strongly suspicious form might be called triclimactericus eczematis tenuis. P. G. Unna (Wiener klin. Eund., Sept. 16, 1900). Gilchrist and Sabouraud have noted the frequency with which streptococci occur in skin lesions. Personal method by which it was possible to detect small numbers of this organism. Sabouraud's medium is used and inoculated by means of a long capillary tube from which the fluids or crusts to be investigated are aspirated. In more than 100 cases it was possible to detect staphylococci in 53.7 per cent.; 27 of these cases were eczema, and in these streptococci were present 17 times. In order to deter- mine in what proportion of normal skins streptococci were present, 160 areas in 55 human beings were studied, and streptococci were found in 7.5 per cent. They are most frequent in the axilla and on the back. These strepto- cocci resemble exactly those found in skin lesions. The artificial forma of dermatitis are sometimes sterile, and sometimes bacteria in considerable num- bers can be obtained from them. Fred- eric (Mlincliener mod. \Voclien., No. 38, 1901). Among the constitutional influences which are or seem to be of some impor- tance as predisposing or active factors are gout, rheumatism, disorders of digestion or assimilation, dentition, struma, gen- eral debility, and loss of nervous tone. Importance of the vital relations of the cclI-protopla«m in the epithelial ccIIb, and of the cellular secretions or excre- tions in destroying noxious agencies, on the one hand, and promoting the health of the tissues, on the other, are in danger of being overlooked, in conse- quence of the long discussions wliich take place concerning the bacteriology of eczema, many of which are unsup- ported by exact observations or bac- teriological research of any sort. Les- lie Roberts (Brit. Jour, of Derm., Jan. and Feb., '99). ilany Fi-encli clinicians regard eczema as being due to internal causes, among which digestive functions play an ex- tremely important rOle. Series of in- vestigations into the chemical charac- ters of the gastric contents in such cases, with a view to finding additional evidence in support of this proposition. In almost all cases he finds disordered absorption and deficient motility. The gastric juice also shows hypo-acidity, hydrochloric acid being reduced in amount. In many instances there is dilatation, while absorption is consid- erably prolonged. Abnormal fermenta- tions were a striking feature in hia cases, producing excess of lactic, butyric, and acetic acids. The prevalence of such gastric disturbances the author consid- ers should be borne in mind in all eases of eczema, in order that general treat- ment may be employed as well aa the local methods indicated for the skin. This also points to the importance of dietary, not only to reduce the tendency to abnormal fermentation, but also to obviate any arthritic complication, for, as is well known, eczematous conditions often accompany gouty symptoms. It is quite possible also that certain indi- vidual peculiarities of digestion or ab- sorption may have to be counteracted, as there is a certain amount of evidence to show that the ingestion of certain articles of food, such as game, spiced and very salt articles of diet, etc., may be the immediate cause of an attack of eczema. Mcynet (These de Lyon, 1901; Brit. Med. Jour., Jan. 11, 1902). For a time tho idea of a pathogenic microbe of eczematous eruptions, so strongly advocated l)y Unna, seemed to ECZEMA.. PATHOLOGICAL ANATOMY. DIAGNOSIS. 641 account for tlicm, but unfortunately tliis theory has not been confirmed by pre- cise observations, and must be aban- doned, at least provisionally. But if we apply ourselves to the clinical analysis of facts, we perceive that true eczema- tous eruptions arise now in consequence of extenial irritations, again from vari- ous into.\ication3, autointo.\ications, or- ganic diseases, nervous shocks, etc. The most divergent causes appear to possess the power of evoking them. We are dis- posed for the moment to view true vesic- ular eczema as a pure cutaneous reac- tion. Brocq (Ann. de dermat. et do syphil.. Mar., 1003). Immoderate habits in the use of cer- tain foods, drinks, and drugs also in- directly or directly have an influence, such as alcoholic drinks, narcotic drugs, and excessive tea- or cofEee- drinking. Overwork, especially of a mental char- acter, in those of hereditary eczematous tendency will often be provocative of an attack. That the hereditary disposition to the disease exists in many families cannot be denied. Among the external exciting factors may be mentioned cold and heat, espe- cially the former; sharp, biting winds; and too liberal use of certain soaps; the handling of dyestuffs, chemical irritants, and the like; vaccination, and exposure to certain plants. Having the hands fre- quently in water, as with washerwomen, the handling of sugar and flour, and re- peated antiseptic cleansing of the hands often bring about the various conditions of eczema of these parts known respect- ively under the names of washerwomen's itch, baker's itch, and grocer's itch, and surgeon's eczema. So far as known the disease does not possess contagious prop- erties, and in a disease so frequent as this if such existed it would have been clearly demonstrated. In some cases of markedly inflamma- tory eczema, especially when of the pus- tular type, swelling of the neighboring lymphatic glands is noticed, but this rarely leads to suppurative change, the swelling and pain disappearing as soon as the inflammatory symptoms have abated. In some cases of eczema a con- dition of f urunculosis is occasionally ob- served. Pathological Anatomy. — Eczema is es- sentially a catarrhal inflammation of the skin, and is seated chiefly in the rete and papillary layer; in long-continued and severe cases the lower part of the corium and even the subcutaneous tissue may be more or less involved, but never destruct- ively. Hyperaemia and exudation are to be found in all cases, either as punctate, localized, or more or less diffused. The vascular changes are the same as ob- served in all inflammations. Diagnosis. — Eczema is to be distin- guished chiefly from erysipelas, psoriasis, seborrhcEa, sycosis, scabies, and ring- worm. Erysipelas. — Markedly acute eczema about the face sometimes presents early in the course of the attack a resemblance to erysipelas, but in the latter disease the border is sharply defined and elevated; it usually starts from one point and spreads rapidly, and is accompanied by systemic symptoms of more or less violence. Psoriasis as commonly met with is not difficult to differentiate. The numer- ous, variouslj'-sized, sharply-defined scaly patches, of general distribution, of psori- asis make this disease sufficiently char- acteristic. The face and hands are rarely involved, or only to a slight extent, at least, in psoriasis, while these regions are favorite sites for eczema. The psoriasic eruption often is seen most markedly on the extensors of the arms and legs, espe- cially about the elbows and knees; ec- zema is more common in the flexures. Psoriasis is usually markedly scaly, ec- 642 ECZEMA. PROGNOSIS. zema rarely so. In occasional instances psoriasis is limited to the scalp, appear- ing here as several or niimerous vari- ously-sized scaly areas, resembling squamous eczema of this part. The same differential characters can be here recognized, if the case is studied, as when seated upon other parts. Moreover, a careful examination ■«ill usually disclose the presence of several small or mod- erately sized characteristic psoriasic patches on the limbs, especially about the elbows and knees. Eczema of the scaly type is usually seated upon one region, is rarely generalized in its dis- tribution, and the area or areas are rarely sharply defined. Itching is the rule in eczema and is often absent or slight in psoriasis. In many cases of chronic scaly eczema there is often a history of gummy oozing which does not obtain in psoriasis. The eruption produced in the parasitic disease scabies and pediculosis is essen- tially eczematous in many of its char- acters, but is usually multiform, consist- ing of papules and pustules, the latter often being large in size. The distribu- tion of the eruption in these parasitic diseases will often be sufficiently char- acteristic, and suspicion may be con- firmed by the finding of the pediculus in pediculosis or by the burrow in scabies. Seborrhoea at times bears close resem- blance to a mild eczema, more especially as it occurs on the scalp. The sebor- rhosic disease is, however, rarely inflam- matory, except accidentally so; the scales are greasy, and there is lack of infiltra- tion and thickening. Sycosis. — Eczema of the bearded face may be mistaken for sycosis, but this latter disease is essentially one of the hair-follicles — folliculitis barba; — and limited to the hairy region of the face, and is rarely itchy. Eczema, on the other hand, is seldom limited to this region, but extends on to the non-hairy parts of the face, is not follicular, and is very itchy. Eingworm can scarcely be confounded with eczema, as eczema is seldom sharply defined, rarely ring- shaped, but is diffused, with no tendency to clear up in the centre. In cases of a doubtful character microscopical exam- ination of the scales will be sure to differ- entiate. Dermatitis. — Dermatitis is some- times with difficulty distinguished from eczema, as the symptoms of mild derma- titis are essentially the same as those of eczema; in fact, these cases may be looked tipon as artificial eczemas. Ec- zema rarely, if ever, shows large vesicle- or bleb- formation as found in the severe types of dermatitis, more particularly from rhus. The history of the case will , often throw light upon the diagnosis. In those eczematously inclined, however, what may be a true artificial dermatitis in the beginning may terminate in a veri- table stubborn eczema. Among other diseases that should not be confounded may be mentioned rosa- cea, erythema, urticaria, herpes zoster, lichen planus, lichen ruber, and impetigo contagiosa. Prognosis. — Eczema, while often most intractable, cannot be said to be incur- able. It may recur like any other dis- ease to which a person may be prone. Under favorable circumstances mild cases yield quite readily. During the course of treatment the disease may show slight relapses, but each succeeding one is usually noted to be of a milder and less obstinate character. It is difficult, in the individual case, to state an opinion, especially as to the duration of treat- ment. Several factors should influence the prognosis: the extent involved, the duration, previous variability, the nature of the exciting and predisposing causes, ECZEilA. TREATMENT. G43 and whether these can be readily man- aged, and, finally, and of great impor- tance, the care and attention the patient gives to the carrying out of the treat- ment advised. Treatment. — There has been great di- versity of views as to the methods of treatment, — e.g., as to whether it should be external or constitutional. The con- servative course, and that which seems to give the best results, is that which places reliance upon conjoint local and systemic measures. It is not improbable that there are some cases met with which persist without any constitutional cause, or the latter has already disappeared, and in such instances external treatment alone will bring about permanent relief. There are certain general or hygienic measures which should receive attention. The diet should be plain, but nutritious, all fancy dishes and indigestible meats and foods being avoided as much as pos- sible. It is very important to watch the digestive functions and the action of the kidneys in all forms of eczema. The diet is also very important, and in the majority of cases proper food is the most efficacious internal remedy. The diet should be based somewhat upon the diathesis of the patient, but it mainly consists in the prohibition of all alco- holic beverages save a small quantity of wine with a little water. Cofl"ee and tea are diminished in quantity; fish, crabs, clams, and oysters may be given in pref- erence to red meats. The patient is not allowed to take asparagus or cucumbers. Eggs, milk, and other light articles of diet are exceedingly useful. All fer- mented drinks are absolutely prohibited, and also all acid fruits. BaiTazzi (Re^nie de Thi'rap. Jledico-Chir., June 1, '90). Treatment includes both constitutional and local measures. The diet must al- ways be carefully directed, and. for the purpose of furnishing best possible nerve- nutriment, an increase in the digestible fatty matter and phosphates should be ordered. Some caution may be required in regard to the former, but with a little care the amount of fat of meats and oils, and also fresh butter, can be added to tlie dietary. The phosphates are found abundantly in the preparations of whole wheat, such as eruslied wheat, wheat- ena, wheatlets, wheat-germs, Pettijohn's breakfast-food, etc., as also in bread made from the whole wheat-flour, some of which should be taken, if possible, three times daily. Jlilk, however, if properly taken, proves of the most signal advantage. It should be taken wann, pure, and alone, one hour before each meal, and also at bed-time, if sufficient time has elapsed for the stomach to be perfectly empty, which is at least four hours after a hearty meal. This pre- cludes the possibility of adding liquor or eggs to the milk, and especially should there never be a cracker or anything else eaten with or near it. The indica- tions for local treatment differ materially in different cases. L. Duncan Bulkley (Jour. Amer. .Med. Assoc, Apr. 10, '98). Pork and salted meats, veal, pastries, strong acids or acid fruits, gravies, cheese, sauces, condiments, etc., and the excessive drinking of tea or coffee are to be eschewed. Beer, wine, and spirits are also to be avoided. Out-door life is to be commended in suitable weather, and exercise, especially systematic in character, are of great value. As to constitutional remedies, it may be said that there are no specifics, al- though arsenic seems at times of special value in chronic, sluggish, papular, and erythemato-squamous types. Each case must be carefully studied, and the pre- disposing factor or factors, if possible, discovered, and the treatment suitable instituted. When the itching is so in- tense as to prevent sleep, recourse may be had to the bromides, phenacetin. chloral, sulphonal. trional. and the like; opiates are apt to cause aggravation. If pruritus is present an absolute milk diet must be ordered. Xo medicine 644 ECZEMA. TREATMENT. should be given until the case has been under observation for some time, since there are few drugs which may not in- crease pruritus. The urine must be ex- amined for uric acid, sugar, albumin, oxaluria, phosphaturia, and peptonuria, and the patient's organs and functions thoroughly overhauled. The most harm- less cutaneous antispasmodics are asa- fcetida and musk in doses up to 30 grains, and valerian in various forms. Opium is generally contra-indicated, be- ing itself a frequent cause of pruritus. For the insomnia, sulphonal or trional in doses up to 30 grains in twenty-four hours is much surer and generally well borne by the skin. Arsenic is useful in chronic cases, but does not suit acute cases or chronic during subacute ex- acerbations, with the exception of some varieties limited to the extremities or the head. In cases with a gouty diath- esis, bicarbonate of sodium acts well. The dose must be moderate if given for a long time. Sulphur in small doses is very useful with young anaemic, "lym- phatic," or tuberculous patients. It is contra-indicated in neurotic or cardiac cases, or when the eczema is recent and acute. It is best given as natural sul- phur-waters. Besnier (La Belgique M6d., May 6, '97). In the attempt to get relief from the itching, which can seldom be obtained by local measures alone, the plan of treatment should be a soothing and pro- tective one. Zinc ointment with 1 or 2 per cent, of carbolic acid or creasote, or with 5 to 10 per cent, of ichthyol, or tincture of camphor, is always a safe and generally beneficial dressing, but to be of service it should be kept thickly applied, spread on lint in moist places, and bound on firmly. In the acutely inflamed, and especially in the erythem- atous forms of the eruption, there is nothing better than the well-known cal- amin and zinc lotion, freely sopped on many times in the day. In the ery- thematous eczema of the face a tannin ointment, 'A to 1 drachm to the H drachms, with 2 per cent, of carbolic acid, is cfTcctive. The use of very hot water for a brief application, followed by an appropriate ointment, should never be forgotten. In old cases of eczema of the scrotum the effect of this treatment is sometimes very remarkable. L. Duncan Bulkley (Jour. Amer. Med. Assoc, Apr. lU, 'OS). In the chronic eczema of infants good results have been obtained from the in- ternal administration of arsenic; 1 drop of a mixture of equal parts of Fowler's solution and distilled water may be given in milk after the midday meal, and gradually increased to 6 or 7 drops to infants of two j'ears and over. In suck- lings and infants under two years of age, 1 drop of Fowler's solution of the strength of 1 in 3, gradually increased to 5 drops, may be given. The treat- ment usually lasts si.xteen or eighteen weeks. Neuberger (Archiv f. Derm. u. Syphilis, vol. xlvii, '99). In chronic eczema the itching can often be allayed by the use of bran- baths, one being taken each night. The water in which bran has been boiled can be poured into a long bath, and hot water can be added until a temperature of 95° to 98° F. has been reached, or if the patient has not such a bath a wash- ing basin filled with the bran-water can be used. Such a bath or sponging adds enormously to the comfort of patients, and by diminishing the tendency to scratch indirectly helps to a cure. R. M. Simon (Birmingham Med. Review, Feb., 1900). Among the tonics that are often of value may be mentioned codliver-oil, hypophosphites, quinine, nux vomica, the vegetable bitters, iron, arsenic, and manganese. Arsenic should never be given in the acute type, or in any case in which the disease is of the spreading or active character. Among alkalies, especially useful in gouty and rheumatic cases, may be mentioned sodium salic- ylate, potassium bicarbonate, sodium bicarbonate, and the lithium salts. Case of eczema of scalp in a man of rheumatic tendencies, rheumatism dis- ai)poaring with ay)pearance of eruption; cure by salicylic acid. C. E. Lockwood (Universal Med. Jour., Apr., '95). ECZEJIA. TREATMENT. 645 Among alteratives that occasionally are resorted to may be mentioned calo- mel, colchicum, arsenic, and potassium iodide. In some cases rather free action of the kidneys is desirable, and recourse may be usually had to potassium acetate, potassium citrate, and, in exceptional cases of more or less general eczema, to the oil of copaiba. Laxatives form a very important class in the treatment of this disease, as indigestion with more or less active constipation is often a striking symptom. The various salines, and aperient mineral waters, castor-oil, cascara sagrada, rhubarb, and aloes, and other vegetable cathartics are useful. Eczema is probably an excretory in- flammation; object of treatment to relieve skin by shifting the stress of elimination to sound organs; in gouty persons salines that act on the bowels and kidneys; dermatitis once started, liowever, becomes complicated by in- vasion of numerous micro-organisms; hence mild local applications, creolin ointment ('/= drachm to 1 ounce of vase- lin), or a weak creolin lotion ('/= drachm to the pint of water) will suffice for a cure. David Walsh {^led. Press and Circ, Oct. 23, ''Jo). In this class of cases the several di- gestives and bitter tonics are often pre- scribed with advantage, such as pepsin, pancreatin, papoid, muriatic acid and gentian, quassia, calisaj'a, and other bit- ter tonics. Arsenic is best given by the mouth in doses of Vm grain of acid, arsen. lodo- thyrin and thyroid-gland tabloids are extremely valuable in some of the ec- zemata. Oiiphorin is useful in climac- teric eczema. The internal treatment of acute eczema is very unsatisfactory. Locally, the best results are usually ob- tained by the free application of dust- ing-powders, during the erythematous and early papular stages. Those are zinc, bismuth, boro-tannate of alu- minium, and dermatol. For itching, a lotion of thymol (1 in 400), acid, car- bolic. (1 in 50), and menthol spirit (1 in 50 to 1 in lOOj, may be used under the powder, care, however, being taken not to apply it to the face or scrotum. In the papulo-vesicular stages, ordinary earth-clay, \\'ith from 1 to 2 per cent, of acetic acid, 1 per cent, of resorcin, or 1 per cent, of thymol, is one of the best applications. Lassar's paste, turaenol paste, and thiol or ichthyol paste are also valuable. When the crusts form, salicylic acid, in a vehicle of olive-oil, is useful, and an especially good formula is: — IJ Zinci oxidi, 1 part. Bismuth, subnitrat., 1 part. Unguent. lenient., 4 parts. Unguent, simpl., 4 parts. The squamous forms, with their al- most absent peeling processes, are to be treated by the tar preparations. R. Ledermann (Berliner klin. Woch., Feb. 4, 1901). External Treatment, — In the local management of eczematic cases soap and water must be used with judgment. In the acute and in many subacute cases these cleansing agents should be em- ployed as infrequently as circumstances will permit. . Water sometimes not only delays the cure, but absolutely prevents cases from getting well. When it becomes neces- sary, an oily preparation containing a few di'ops of carbolic acid is to be used. John Edwin Hays (Pediatrics, Apr. 15, '98). In cleansing eczematous surfaces and removing secondary products plain water or soap and water should be avoided, if possible. If the former has to be era- ployed it should be as hot as can be borne, and the surface over which it has been used should be dried quickly and thoroughly and the selected dress- ing immediately applied. All detergent fluids should be warmed before use. Olive- or cotton-seed oil will cleanse al- most as well as soap and water, and, if the part is carefully wiped, but little preasiness remains. Or thin strained rice-milk cleanses well and is soothing to tender and acutely-inflamed surfaces. Before anv line of local treatment can 646 ECZEMA. TEEATMENT. be begun all secondary products — crusts, scales, etc. — must be removed. This can be accomplished by saturating them with oil. W. M. Nelson ^!^Iont. Jled. Jour., Apr., '9S). In the treatment of periungual eczema boric-acid or salicylic-acid washes and a dusting-powder used. Eesorcin may give good results in chronic inflamma- tion. W. Dubreuilh and D. Freche (Jour, de M6d. de Bordeaux, Apr. 14, 1901). Cleanliness may often be maintained by gently rubbing off with cold cream, petrolatum, or almond-oil. Even in such cases, however, occasional washing is necessary, both for the sake of clean- liness and in order to get rid of the products of the disease and to remove the messiness which has resulted from the applications. A remedial application should always be made immediately after washing has been employed. In some cases, especially those of a chronic and scaly and markedly-sluggish character the use of soap and water is resorted to frequently and has often a therapeutic value; indeed, in some such cases the green soap — sapo viridis — may be occa- sionally or frequently used with advan- tage. Notwithstanding the nearly universal dictum of the hai-nifulness of water, the value of baths containing tar, or taken after the latter has been well painted over the alTeeted regions, in- sisted upon. After this is effected Vene- tian talc is to be copiously dusted all over and around the area. Lassar (Der- matol. Zeitschr., B. 2, H. (5, '95). A current of steam of 104° to 122° F. directed to the affected parts of the skin in eczema removes crusts and scales, oc- casions increased scaling of the epider- mis, favors the absorption of superficial and deeper infiltrations of the skin, di- minishes or even entirely stops formation of pus on the surfaces deprived of epi- dermis, and at the same time produces increased regeneration of tissues where, on account of chronic processes, the con- ditions for healing are very unfavorable. A convenient apparatus consists of a thick copper cylinder containing two or three glasses, the bottom one being heated with an alcohol-lamp. On the top are two openings, — one for pouring in water (closed by means of a screw) and the other for a bent tube. Accord- ing to the sensibility of the skin, the tube is kept three to five inches from it. The si'aiwe lasts fifteen to thirty min- utes. A. Liberson (So. Russian Med. Gaz., Nos. 51, 52, '95). Applications are to be made in ec- zema two or more times daily, and when possible the continuous application is to be advised. In the selection of external remedies for a particular case common sense must be employed. In those cases in which the type of disease is acute or subacute mild remedies are to be used. In the milder erythematous variety dusting- powders of zinc oxide, talc, starch, and kaolin are soothing and beneficial; they may be used alone or immediately follow- ing the application of one of the washes named below. The conjoint use of black wash or boric-acid lotion with oxide-of- zinc ointment or any mild ointment may give beneficial results. Or the simple oxide-of-zinc ointment with 20 to 30 grains of boric acid or 3 to 5 grains of carbolic acid to the ounce may be used. A compound lotion of calamin and zinc oxide, like the following: — IJ Calaminse, 1 V2 drachms. Zinci oxidi, 1 ^/„ drachms. Glyccrinas, 10 minims. Acidi carbolici, 20 grains. Aqu£E, 6 ounces. — M. is valuable, and may be dubbed on the surface repeatedly or by means of linen or lint kept wet with it and closely ap- plied to the diseased surfaces; or a boric- acid lotion with 1 or 2 drachms of car- bolic acid to the pint, will be found bene- ficial, and especially applicable if the die- ECZEJIA. TREATMENT. 647 eased surface is large; or a boric-acid Bolution (15 grains to the ounce) may be made of the above calamin-and-zinc lo- tion. A so-called salicylic-acid paste, with or without 5 to 10 grains of carbolic acid to the ounce, is often of great ad- vantage: — IJ Acidi salicylici, 10 grains. Amyli, Zinci oxidi, of each, 2 drachms. Petrolati, 4 drachms. M. Make ointment. In vulvar eczema only emollient prep- arations should be employed — bran- water, marslimallow or chamomile in- fusion; a little boric acid can be added to the boiled water and serve as a basis for these lesions. Following the lotion a cataplasm of cornstarch or potato- starch, made with hot boric water and applied cold, is indicated. Little coin- presses of tarlatan soaked in borated bran-water recommended, to be placed between the lesser lips of the vulva. The dressing ought to be renewed after each urination. During the day borated cotton should be applied to the parts. As a curative to be applied during the intervals between acute attacks, the fol- lowing is suggested: — B Vaselin, C V4 drachms. O.xide of zinc. Starch, of each, 1 Vi drachms. Salicylic acid, 1 '/» drachms. — M. The parts must have been previously bathed with borated bran-water and dried with cotton. Lutaud (.Tour, de Mod. de Paris, Jan. 12, '9G). A small piece of buckskin placed be- tween the ointment and the other part of the dressing greatly ameliorates the condition. Its good elTects are ascribed to the ttexibility of the buckskin, which allows it to be molded to every part of the surface; to the ease with which it can be cleansed; to the fact that it does not markedly absorb the ointment used, and that therefore the part remains moist; and to the safety with which it can be removed, the newly-formed epi- dermis not being torn away. Davezac (Jour, de Mcd. de Bordeaux, No. 51, '97). The following recommended to allay pruritus in eczema of the scalp: — B Acidi salicyl., grains. Menthol, 12 grains. 01. lini, Aq. calcis, of each, 1 ounce, if. Sig.: For external use. Stein- liardt (Amer. Pract. and News, Mar. 15, '98). Tincture of iodine is useful in eczema which resists other methods of treat- ment. A solution of cocaine (5 per cent.) is first applied, after which the iodine is applied every evening. HefTe- man (Semaine Medicale, May 13, 19U3). An ointment of alumnol, 20 to 40 grains to the ounce of cold cream, or zinc-oxide ointment is also valuable. One containing V2 to 1 drachm of bis- muth subnitrate is also of benefit. A compound calamin ointment may be used in some cases with great advan- tage: — I> Calamin, 1 drachm. Amyli, '/j drachm. Acidi salicylici, 10 grains. Ung. zinci oxidi, q. s. ad 1 ounce. — M. Diachylon ointment, if a well-made one is procurable, is often serviceable. The soothing salve-mulls of zinc oxide and boric acid are extremely valuable in some cases. In some cases of eczema in which the grade of inflammatory action is subacute, stronger applications may be resorted to, although even in this class of cases it is advisable to begin the treatment with the milder applications already named. These latter may finallj% if necessary, be made stronger and more stimulating by the addition of white precipitate, red pre- cipitate, calomel, resorcin, or tar. Of the mercurials, 5 to 30 grains to the ounce is the usual proportion called for; of resorcin, 5 to 20 grains, and of tar, '/j to 2 drachms of the tar ointment to the ounce of mild ointment. Oil of cade may also be used V2 to 2 drachms to the 648 ECZEMA. TKEATMEXT. ormce of ointment. A tarrj- ointment such as the following may also prove use- ful in these cases: — ]? Liquor carbonis detergens, Vs to 2 drachms. Cerat. simp., q. s. ad 1 ounce. [Liquor carbonis detergens is made by mixing together 9 ounces of tincture of soap-bark and 4 ounces of coal-tar, allow- ing it to digest for eight days and then filtering. Hen'rt W. Stelwagon.] If required to name one remedy only for eczema, writer would choose tar; if two, tar and lead; if three, tar, lead, and mercury. If weak enough, and used freely enough, tar solutions will almost invariably cure eczema. Common tar- water and solutions of carbolic acid are very useful; but the solution of coal- tar sold under the name of liquor car- bonis detergens is the most convenient and most certain remedy. It should be used, however, in extreme dilution. A teaspoonful to a pint of water is a com- mon strength, but often it is prescribed much weaker. It should be so weak that it does not smart, and it should then be employed like water. The parts should be bathed with it, and rags soaked in it should be laid over them, and frequently wetted from outside. Oil silk should not be used; at any rate, not in large pieces. Jonathan Hutchin- son (Arch, of Surg., vol. i, p. 104, '99). Tar preparations are contra-indicated in children, milder applications should be used. Ointments aggravate acute ec- zemas; a lotion of boric acid, menthol, and carbolic acid (1 per cent.) in spiritus vini Gallici is of value. In moist eczema with crusts, after removal of the latter, compresses of silver nitrate (1 in 400) are applied twice daily for two hours, and in the intervals diachylon ointment. Cases of universal eczema are treated in bed, vagelin being applied several times a day, and the inside of the night-dress dusted with starch. Rille (Wiener klin. Rund., Mar. 18 and 25, 1900). lodol-ariBtol, 5 to 20 or more grains to the ounce of ointment-base, may also be commended. In some instances pre- liminary paintings for several days with a saturated sohition of picric acid has proved of advantage, waiting for the films or scale thus formed to come up, and then applying a mild ointment for a few days, and then res\iming the picric- acid painting. Picric acid is indicated in those forms of eczema in which the inflammation is acute and superficial, and where the le- sions are mostly epidermic. The kera- toplastic action of the remedy cannot display itself in the chronic forms ac- companied by induration of the skin and particularly by epidermic thicken- ing; picric acid is incapable of modifying these chronic lichenoid eczemas. On the other hand, the keratogenic properties of the agent find an excellent field of action in acute eczemas with swelling of the integument, superficial ulceration, and weeping. Under its influence the inflammation rapidly subsides, and the acid forms (on contact with the ulcer- ated and oozing surfaces) a protective layer composed of coagulated proteid substances and of epithelial dC'brls, un- der which healing takes place rapidly. Picric acid has the further advantage that it immediately stops itching; this elTect is produced in chronic as well as acute forms of the disease. In acute eczema a cure is effected in from ten to fifteen days. Aubert (ThOse de Paris, No. 34, '97). In some instances applications of dressings of a more or less fixed character are of advantage, such as the gelatin dressing, tragacanth dressing, and aca- cia dressing. GELATfN Dressing: — IJ Gelatin, 15 to 25 parts. Zinc oxide, 10 to 15 parts. Glycerin, 15 to 35 parts. Water, 50 parts. To this may be added 2 parts of ich- thyol. This is heated over a water-bath each time it is to be employed, a good coating painted on with a brush, and when ECZEMA. TREATMENT. 649 partly dry — in one to five minutes — the parts wrapped with a gauze bandage. The whole dressing becomes dry and fixed, and may remain on from two to six days, and then soaked off, cleansed, and a new dressing reapplied. In some cases the larger quantity of gelatin and smaller quantity of glycerin may prefer- ably be incorporated, and then the gela- tin coating will dry more quickly and will form a suificient dressing without the gauze bandage, although this latter seems to be of real advantage in keeping the gelatin from becoming soiled and from being rubbed off. If the gauze is not used a small quantity of a dusting- powder may be applied over the gelatin. The above is especially applicable in the treatment of eczema of the lower legs. Other drugs may be added, but cer- tain medicaments exercise an inhibitory influence on the setting of the gelatin, and if used should always be used with a dressing more rich in gelatin and with less glycerin and less water; such reme- dies are resorcin, salicylic acid, and car- bolic acid. '\^nntc precipitate, sulphur, and acetanilid may also be incorporated in such dressings. TH.\GACAXTn Dressing. — Pick's trag- acanth dressing — linimentum exsiccans — is also a useful fixed dressing in the cooler weather. It consists of IJ Tragacanth, 5 parts. Glycerin, 2 parts. Boiling water, 95 parts. To this can be added 2 per cent, of boric acid or 2 per cent, of carbolic acid, and 5 to 10 per cent, of zinc oxide or cala- min, or equal parts of both. This is smeared in a thin coating over the diseased area and allowed to dry on, which usually requires several minutes. The parts can then be bandaged or be sprinkled with some indifferent dusting- powder. It is a more simple dressing than the gelatin application, requires no preparation, but is, upon the whole, less useful. Other medicaments may be added in addition to those already named. Acacia Dressing. — This constitutes another fixed dressing that is readily ap- plied and which may be used on dry parts. A good formula is the follow- ing:— 1^ Mucilage of acacia, 5 or 6 parts. Glycerin, 1 part. Zinc oxide or calamin, or a mixt- ure of both, 2 parts. Carbolic acid or any other drug may also be added if desired. This is painted on with a brush or smeared over in a thin layer with the finger; it dries in a few minutes. If at all sticky or for further prevention against this, a dr)' powder of zinc oxide or talcum can be applied over it. Another method of treating these cases w'hich can at times be employed with great benefit is by means of the so- called salve- and plaster- mulls (made by Beiersdorf). These are variously medi- cated. The mild salve-mulls and the moderately strong salve-mulls, and the moderate strength plaster-mulls are adapted for the subacute cases. While especially useful in some cases, occa- sionally their action is not so satisfactory. Their disadvantage is their costliness. In eczema of a chronic sluggish type strong applications must be usually made before a result is brought about. The different remedies and combinations referred to in speaking of the treatment of the subacute type may be first tried; later, when necessary, treatment may as- sume a bolder character, various reme- dies being used in stronger proportion. Of value in many of these cases may be 650 ECZEilA. TREATMENT. mentioned — ointments of calomel, 40 to SO grains to the ounce; white precipi- tate of about the same strength; salicylic- acid ointment, 20 to 60 grains to the ounce; resorcin, about the same propor- tion; sulphur, 10 to 60 grains to the oiince (used at first with caution); tar ointment, either in official strength or somewhat weakened; or the liquor car- bonis detergens, with simple cerate or as a wash, pure or diluted. Zinc-oxide paste containing 1 to 2 per cent, of yellow oxide of mercury is recommended in the squamous or the milder grades of papular or vesicular eczema of children. L. Leistikow (Monats. f. prakt. Derm., Sept. 1, 1900). Silver nitrate applied in the form of a 1-per-cent. solution favorably aiJects eczema in all its forms. J. C. Dunn (Med. News, Sept. 29, 1900). An ointment of 20 to 40 grains of pyrogallic acid to the ounce may be cautiously tried in obstinate cases. The same may be said with regard to chrysa- robin; but this latter should not be used about the face. The various fixed dress- ings referred to in the treatment of the subacute variety will also be of value in the chronic tjrpe. Collodion may also be used as a basis for fixed dressing in local- ized areas of disease. The stronger salve- and plaster- mulls and the medicated rubber plasters, the latter especially in the sclerous and verrucous forms, are also of distinct advantage in these cases; in sluggish, thickened areas repeated shampooing with green soap and hot water, rinsing off, and immediately fol- lowed by a mild ointment applied as a plaster acts admirably in some instances. Painting such areas with solutions of caustic potash, 1- to 5-per-cent. strength, allowing to act for a few minutes, then rinsing off and applying a mild ointment is a somewhat similar method of treat- ment which is serviceable at times. In some obstinate cases thoroughly stirring the skin with a strong remedy, insti- tuting a substitutive inflammation, and then applying mild remedies will not in- frequently bring about the desired result. Superficial scarification of patches of eczema employed in certain selected cases. The patches are scarified in par- allel lines, one to one and a half milli- metres apart, in one direction only, by a very pointed instrument penetrating to the superficial layer of the dermis. These areas are then encouraged to bleed and bathed with boiled water, and then covered with tarlatan dipped in boiled water. On reaching home cold potato- starch poultices are applied until the next treatment — generally three or four days later. Before beginning the treat- ment the patches are prepared by the ap- plication of continuous cold plain starch poultices. Six to si.xteen treatments suffice for a cure. A reaction is set up in the patches, but no scars result. This treatment is to be used only in special cases characterized by isolated disks in limited number. Jacquet (Bull. G6n. de Therap., Jan., '98). In infants the face or face and scalp are by far its common site. The disease may, however, occur upon any part at any age. The treatment in regional ec- zema is essentially the same as the treat- ment of eczema of any part, common sense suggesting selection or avoidance which the character of the region may suggest; as, for instance, upon hairy parts, as the scalp. Ointments containing large percentages of pulverulent sub- stances, such as the so-called salicylic- acid paste, should not be employed, as they would tend to produce crusting, matting, and messiness. In treating a case of infantile eczema the search for the cause should go hand in hand with the treatment, which is otherwiHc only palliative; carefully ex- amine both child ond motlier. In an acute eczema of a few days' standing decided ameliqration may be obtained by calomel. Some cases are benefited by judicious use of codlivcr-oil and iron. ECZEMA. ELATEKIUM AND KLAIERIX. 651 The local treatment is very important for the comfort of the patient. The crusts can be removed by salicylated oil. Washing with water should be strictly interdicted, oil being used as a substi- tute. The local conditions can now be treated very happily by Lassar's paste: — R Zinc, oxid., Pulv. aniyli, of each, 2 drachms. Petrolatum, V2 ounce. In acute cases, boric acid, 10 to 20 grains to the ounce, or in less acute cases salicylic acid, 10 grains to the ounce, may be added. Ichthyol, 5- to 10-per- cent, should be added in the older cases, where the skin is thickened and scaling is excessive. In all cases the applica- tion should be changed two or three times daily, every precaution being taken to see that the skin is kept covered and scratching prevented. Alger (Araer. Med.-Surg. Bull., Aug. 1, '90). Favorable results obtained in the treatment of eczema by red solar light. The eruptive regions, previously covered with thin silk stuff of an intense-red color, were exposed directly to the solar light as long as possible (four hours in one case). In all the patients thus treated there was a rapid disappearance of the symptoms. W. "Winternitz (Sem. M«d., Aug. 15, 1900). There are two special forms of eczema which occur at the change of life — and the commonest, that which comes most before practitioners, is acute eczema of the head and face. There is usually considerable flushing, sweating, and other nervous phenomena, headaches, and disturbances of the digestive tract — dyspepsia and constipation. A spare woman at that time of life suddenly be- gins to flush in the face, perhaps after taking a meal; later the disorder be- comes a little more acute; she gets an acute eczema of the scalp, and it spreads down all over her face. For that condi- tion there is no drug or combination of drugs which is of such service to re- lieve the symptoms, not only the eczema, but all the symptoms mentioned, as ichthyol. It can be given in tabloids covered with keratin, which does not dissolve until it gets into the intestine. The dose should be 2 'A grains, to begin with, after each meal. At the end of two or three days it should be increased to 5 grains, then to 7 Vj grains, and then to 10 grains. If the patient tastes it much, the dose should be reduced a little. With regard to local treatment, this form of eczema requires rather more active treatment than is needed at any other time. Such cases usually bear fairly strong applications of sulphur and resorcin. The other form at change of life is the very acute eczema which occurs about the vulva and anus. Malcolm Morris (Lancet, May 4, 1901). Hexry W. Stelwagon, Philadelphia. ELATERIUM AND ELATERIN. — Elaterium is a sediment deposited from the juice of the squirting cucumber {Ecballium elaterium, A. Rich). This sediment, when dried, appears in fri- able cakes about Vio of an inch in thick- ness, flat or slightly curled, and of a pale-green, graj'ish-green, or grayish- yellow color, the yellow tinge appearing when the drug is old. Its odor is feeble and its taste bitter and slightly acrid. It is partly soluble in hot water. It is offi- cial in the B. P., but not in the U. S. P. Elaterin (elaterinum— r. S. P., B. P.) is the active principle of elaterium, be- ing found therein in amounts varying from 5 to 40 per cent. It is a neutral principle and appears as small, white, or yellowish-white crj'stals, without odor. but of a very bitter and acrid taste. It is freely soluble in chloroform, slightly soluble in ether and alcohol, and in- soluble in water. Elaterin is preferred for administration because of the great variability in strength of different speci- mens of elaterium. Dose and Physiological Action. — The dose of elaterium is '/, to Vi grain. Elaterin is given in doses of Vao to 'A, grain, preferably in granules; a tritura- 652 ELATERILM AXD ELATERIN. ELEPHANTIASIS. tion of elaterin (10 per cent.) is official, the dose being '/„ to 1 grain. Elaterium is a decided irritant to the mucous membranes and also to the skin. When given internally its chief action, in man, is to produce profuse watery stools. When given in proper doses, these large water evacuations occur with- out undue pain or any apparent gastro- intestinal irritation, and for these reasons elaterium claims first rank as an hydragogue purge. Poisoning by Elaterium. — In large doses or in debilitated persons its use may produce so much prostration and ex- haustion as to demand the exhibition of stimulants and other supporting meas- ures. In addition to nausea, vomiting, excessive purging, and exhaustion, the use of too large doses of this drug may even be followed by death from gastro- enteritis. Debility from old age or other cause and gastro-intestinal irritation or inflammation contra-indieate its use. The subcutaneous use of elaterium, al- though capable of producing catharsis, is not advised, on account of the severe local irritation and inflammation thereby induced. Treatment of Elaterium Poisoning. — The treatment of poisoning by this drug is practically that of gastro-enteritis. Morphine should be given liypodermic- ally, and hot applications (stupes or flax- seed poultices) should be made over the abdomen to allay the pain and control the irritation and diarrhoea. Especial care should be had in the selection of a proper diet. Bland, easily digested, and unirritating articles of food should be selected. Predigcsted foods arc espe- cially useful in these cases. Therapeutics. — In general, elaterium is indicated in conditions demanding fluid depletion; the use should not be continued if the stomach becomes dis- ordered or the appetite impaired. It ought never be used in cases of debility or marked exhaustion, and may be fol- lowed with advantage by alcoholic stimu- lants soon after its action is manifest. Its use is suggested in cerebral conges- tion on account of its depletant and re- constant eft'ects. In poisoning by nar- cotics and in acute alcoholism elaterium is indicated when the emunctories are not acting freely. Ascites and Dropsical Effusions. — In these affections elaterium is a drug of great value, though one whose use de- mands much care and judgment. In dropsy depending on aortic, obstructive, or regurgitant disease it is especially use- ful, given in small doses at first, about Vo grain, on alternate mornings at say 5 o'clock, so that its action is finished by noon. This is claimed, by Hyde Salter, to quiet the heart, relieve the dyspnoea, lessen the pulmonary conges- tion, and diminish the hydrothorax. UEiEMiA. — Urasmic poisoning is much benefited through the use of elaterium, as it aids the elimination of the urtemic poison by the bowel. It is especially in- dicated when ura2mia is associated with dropsical effusion. Liquid Effusions of Inflammatory Origin. — Under this head belong pul- monary oedema, pleurisy, and pericardi- tis, in all of which the hydragogue catharsis induced by elaterium may be beneficial. ELEPHANTIASIS —Gr., E?.E<^>ag, an elephant. Definition — Elephantiasis is a chronic endemic and sporadic hyperplasia of the skin and subcutaneous tissues, following an inflammatory embolus of the lymph- and blood- channels, and resulting in an inordinate enlargement. Symptoms. — The legs are involved ELEPHANTIASIS. SYMPTOMS. 653 most frequently; the genitalia of both sexes follow closely, while many other parts — the face, body, and extremities — are occasionally attacked. Case of congenital elephantiasis. Men- tal development considerably below par. Had congenital hypertrophy of the face, eyelid, and scalp, confined to right side. The right eye had become diseased in Congenital elephantiasis of the face and scalp. {Coley.) early childhood, and had been removed. The hypertrophy seemed confined chiefly to the skin and subcutaneous tissue; the upper eyelid was greatly thickened and pendulous, reaching down to the upper of the alfE nasi. There was a well- marked, irregular depression in the re- gion of the squamous portion of right temporal bone, and in one place a slight loss of bony substance. Over the poste- rior portion of the right parietal bone was a soft, flabby tumor of the scalp about the size of a small hen's egg, freely movable, and covered with a nor- nuil growth of hair. Coley (N. Y. Med. Jour., June 20, '91). Three cases of elephantiasis of the upper lid, in one of which both eyes were afTected. Goraud (Annales de la Polyclin. de Bordeaux, Apr., '92). The right leg is more often attacked than the left, occasionally both are in- volved; the scrotum is affected with greater frequency than the penis in the male, and the labia majora and minora than the clitoris in the female. Elephantiasis of the vulva observed in a mulatto woman who was four months pregnant. The tumor encroached upon the vaginal orifice so much {the clitoris and labia majora and minora being all involved) that delivery at term would have been impossible. Hence the mass was removed with the knife, being first constricted with an elastic ligature tied under three long pins passed beneath the tumor. Bleeding vessels were thus se- m ■*v ',r) Case of elephantiasis of the scrotum. {I'thcinann.) o\ired separately and the wound closed by sutures. Pregnancy was not dis- turbed. Mundfi (Araer. Jour, of Obstet., Oct., '95). Case of a man, 19 years old, in whom the foreskin and scrotum began to en- 654 ELEPHANTIASIS. SYMPTOMS. large at the age of 4, continuing until it had reached the enormous size shown in illustration. Operation successfully performed. L'themanu (Deutsche med. Woch., Dec. 5, '95). Form of chronic enlargement of the testes frequently met with in the inhab- itants of warm countries, and associated, in many instances, with elephantiasis of the scrotum and lower extremities. This form of testicular enlargement, which is associated with swelling and induration of the epididymis and spermatic cord, even when existing alone, is held to be invariably of the nature of elephantiasis, and not due to any malarial influence. After castration and during an opera- tion for hydrocele, it has been found that this condition is the result of a dis- tension of the lymph-vessels of the tunica albuginea, epididymis, and cord, and of an excessive proliferation of the con- nective tissue. The filaria undoubtedly plays a considerable part in the genesis of such morbid conditions. Le Dentu (Revue de Chir., Jan., '98). Xo inconTenience or pain accompanies the disease in the majority of cases, but very often when the scrotum is the part attacked stomachic and nervous distress is encountered. Eadiating pains may be observed in the seminal nerves, thus causing intense nausea and vomiting. Hydrocele may be induced. The prodromic stages differ according to whether the elephantiasis occurs in hot or cold climates. In hot countries there appears a preliminary fever termed "elephantoid fever," which is preceded by pains of great intensity in the lumbar region, accompanied with retching and vomiting, cold shiverings located along the spine, followed by fever and profuse perspiration in successive alternations. The colder atmospheres do not occasion such marked distress during this early stage. In patients BufTering from elephantia- sis once or twice a month there is an excess of fever. The local symptoms ac- companying the fever are those of lym- phan!,'itis with ganglionic enlargemcnta. These attacks of lymphangitis with fever coincide with the invasion of the con- nective tissue of the hypoderm and of the associated lymph-channels by mi- crobes. The visible lesions are the result of hundreds of febrile crises, each ac- companied by a fresh advance of cedema. Each new oedematous deposit is prob- ably followed by local organization of the emigrated embryonal cells in adult connective tissue. Tropical elephantia- sis is usually due to the Filaria sail- puinis hoininis. Sabouraud (Annales de Derm, et de Syphil., May, '92). The course of the affection, whether occupying the leg or elsewhere, is char- acterized by frequent exacerbations. Deeply-seated, recurrent forms of derma- titis, or attacks of an erysipeliform (or true erysipelas, the streptococcus of erysipelas being found in some cases) in- flammation, with, at times, involvement of the lymphatics (from which milky or chylous discharges may be noted with or without puncture) are encountered. While these phenomena are primarily localized in the deeper tissues, the skin does not seem to be attacked until later, when it presents nodular increase in size. With proper measures these symptoms abate, only to reappear at some later period. At each successive attack the part is noted to have increased in size to an appreciable extent. These recur- rences of fever and oedema may appear at intervals of weeks only, while months or years may intervene between each recru- descence. At times the recurrences of these phenomena may be so frequent or so close that the previous inflammation has not had time to disappear. As each attack leaves an increase in size we may, after a time, find a gigantic enlargement of the part involved. These inflamma- tory phenomena may not always be ob- served, as the part may often be found to increase in size without their apparent assistance. It is diflicult to cause pitting in these structures, owing to the general ELEPHANTIASIS. DIAGNOSIS. Goo hyperplasia. The skin, as previously noted, does not appear to participate in this process early, but later it becomes likewise affected. It is tightly stretched, glossy or waxy, with pigmentary changes of color varying from brownish red or pinldsh red to one of dusky brown. Upon its surface may be seen an accumu- lation of sebaceous material, with here and there desquamations of epithelium. The linear fissures of the skin may in- crease so greatly that enormous sulci may be formed. Hard or soft tubercles may appear upon its surface at various parts, either showing some scaly desquamation at their summit or becoming denuded of epithelium; they present numerous bleeding-points or the top of the tuber- cles may be one bleeding surface. In fact, many cases seem to present a chronic eczema upon the skin of the thickened part, and this appears to fol- low its usual characters. In other cases shallow ulcers, which resemble ordinary breaks of continuity, may be found at points over the affected skin. The parts around the joints form decided strictures, and the overlapping enlargement thus causes deep fissures in which a milky or chylous exudation, intermixed with se- baceous discharge, cause painful m.acera- tion of the inclosed skin. At certain points the lymphorrhagia may be so ex- cessive as to cause great depression of vitality. While this increase occurs in the softer parts of the affected structures, the bones alike share the enlargement in all their dimensions, and glandular involvement is often noted. The leg resembles closely its counterpart in the elephant both ex- ternally and in size-proportion. The ■weight becomes out of all proportion to other parts of the body, and while sub- jective sensations are, for the most part, encountered during the inflammatory attacks, they may be observed after the affected portion has been allowed to re- main in one position for an indefinite period. Pain is then found to follow ex- cessive fatigue, and tearing, stabbing sensations are reverberated throughout the affected leg. When other parts — such as the scrotum and penis or the labia and clitoris — are involved, the same process intervenes and the enlargement hangs down between the legs, and may weigh many pounds. The penis usually becomes indistinguishable in the large mass and an opening or groove is left through which the urine trickles. The face (cheeks and nose), shoulders, arms, forearms, and the hands may share in the tumefaction, but do not show the same complications observed when the leg or genitals are involved. Other en- largements of enormous extent are de- scribed, such as the elephantiasis telangi- ectodes of Virchow, which is of congen- ital origin and affects the vascular tissues. Elephantiasis lyniphangicctatica coii- frenita is a very rare congenital anom- aly of the skin. In the majority of pases the infants afTccted by it have been still-born, or have died soon after birth. In only a few instances have they survived and come under clinical observation: and in such cases the area of skin implicated by the disease has been small. In a case obscn-ed by the writer, a microscopical examination revealed a marked hypertrophy of the white fibrous tissue of the corinm and subcutaneous tissue, with a new forma- tion of fibrous elements like a fibroma. This fibrous stroma was broken up by dilated lymphatic spaces and channels, containing leucocytes and plasma-cells. Many of the deeper cells of the Mal- pighian layer were pigmented, and pig- ment granules were present in a number of the connective-tissue spindles in the upper part of the corium. E. VoUnier (.\rchiv f. Dcrmat. u Syph.. .Tune. 1003). Diagnosis. — Cases of elephantiasis after reaching their full development are 656 ELEPHANTIASIS. ETIOLOGY. easily recognizable. The enlargement, with difficulty to cause pitting; the ap- pearance of warty or keloid-like tumors; the history of repeated attacks of ery- sipelas, deep dermatitis, or a recurrent eczema, should be sufficient to draw at- tention to this affection. Care shovdd be taken not to confound elephantiasis with pendulent tumors, such as overhanging forms of fibroma, which may closely resemble the enlarge- ment found in the former affection. En- largements due to eczema or syphilis will usually present symptoms of both of these conditions sufficient to prevent error if care be taken. Acromegaly and myxcedema present symptoms which will be sufficient, if carefully studied, to make a proper diagnosis of these conditions. Constriction of a limb by means of band- ages happens very frequently, and, as en- largement may follow, close examination will reveal the reason for this increase. In fact, close attention to every detail should be carefully studied, when the diagnostic differences of the several simi- lar affections may easily be detected. Etiology. — While the affection may be observed in any country, certain regions, owing to their climate, are noted for the prevalence of an endemic type of ele- phantiasis, while sporadic types prevail in other countries. It attacks both sexes, although the male, however, three times more frequently than the female. Age does not seem to influence its appearance, but middle or adult life shows the largest number of cases. Congenital types may be noted. The influence of heredity has been shown by many recorded cases. Change of climate seems to lessen the tendency of the disease, and cases are benefited in which the affection has proceeded for some time. Unhygienic surroundings — such as malarious districts or parts bor- dering upon the sea — exert a deleterious influence. The fair types of mankind do not show as marked a tendency to the affection as do the darker types. The mosquito is thought to play an important part in the production of elephantiasis. Encroachments of large tiunors, as well as pressure of various kinds, upon the veins and lymphatics are also considered as predominating eti- ological factors. Case in which, two j'eais before, the patient had acquired syphilis and suf- fered from suppurative buboes in both groins, the left side being the worse; she treated the afl'ection herself. A year later she first noticed an increase in the labium majus of the left side, and this has steadily gone on until it is the size of the list. In both groins there are scars, that on the left being deeper and more extensive. This case regarded as having an important bearing on the treatment of bubo. The extensive de- struction of the inguinal lymphatic ves- sels was the result of neglect of early incision and antiseptic treatment of the suppurative buboes. The elepliantiasis described is due to the obliteration of the lymphatics. INI. Schreider (Denn. Zeit., B. 2, H. 5, '95). Case of elephantiasis observed in a little girl 3 years old. Her grandmother had had several attacks of lymphangitis of the legs, followed by elephantiasis. The mother of the child never had either of these diseases or erysipelas. A fall upon the abdomen is thought to have an etiological relationship to the disease of the child. When the baby was born a deformity of the face was found which was due to an abnormal production of a soft, clastic, uniform, and indolent tis- sue, which spread from the zygoma to the external commissure of the eyelids and back to the insertion of the ear posteriorly from the mastoid process to the inferior border of the thyroid carti- lage. A number of these eases observed, and the explanation advanced is that, streptococci having found their way into the fcetal circulation through the pla- centa, an inflammatory process was set ELEPHANTIASIS. PATHOLOGY. 657 up in tlie foetal tissues, resulting in the overgrowth of tissue. Jloncorvo (Pedi- atrics, Dec. 1, '97). Two cases, one certainly preceded b}- syphilis and the other accompanied with symptoms which were in all probability tertiary; in both excellent results were obtained by iodide of potassium, in one after amputation of the enlarged left labium. In the great majority of in- stances chronic ulcerative processes of the vulva with elephantine thickening are of syphilitic origin. Bamberg (Ar- chiv f. Cyniik., I3d. Ixvii, H. 3). Unilateral clcpliaiiliasis of the face and neck. {Moncorvo.} Pathology. — The changes of elephan- tiasic areas are more directly located in the subcutaneous tissues, the upper and lower strata alike sharing in the charac- teristic phenomena. The skin, although presenting tliese changes, is more mark- edlj' alTccted where papillary outshoots are observed. Upon cutting into the afTectcd areas there is observed a yellow- ish or grayish mass, which in some places shows a resemblance to fnttv nr lardn- ceous deposits, while in others gelatinous formations are simulated. Exuding lymph may be observed at many points. The changes from the normal are of a distinct hypertrophy: there is decided proliferation of the epidermis, with hy- perplastic increase of the corium, while the fibrous elements of the subcutaneous tissue are observed in hardened bands or meshes or noted to be soft or liquefied. Distended lymph - spaces are found throughout the microscopical section. All the soft parts, the blood-vessels, lymphatics, nerves, and their component parts, as well as the bony structures, share in the general enlargement and cell-infiltration. At times, the muscles and the glandular structures of the skin participate in the increase of size. Obstruction is clearly the influence in ■ the production of elephantiasis. The presence of the Filaria sanguinis hom- inis in the lymph-vessels is directly the cause in endemic varieties of this condi- tion. Manson states that the parent- worm occupies some portion of the lymph-trunk, at which point it dis- charges the ova into the stream of lymph; these are then carried forward to some of the grandular structures, in which they find a lodgment. When hatched they enter the general circulation. Abstracted from the blood by the mosquito, and deposited again into a water-stream, the ova again reach man when contami- nated water is employed. The more ag- gravated the symptoms, the more numer- ous are the parasites in the lymph-chan- nels. Haamorrhage and discharge of lymph may be observed in these types. In sporadic types of the affection, in which the obstruction may be induced through encroachment of large tumors or other forms of pressure upon the veins nnd lymphatics, the same features are 658 ELEPHANTIASIS. PROGNOSIS. TKEAXJMENT. developed. Although they are iudistin- guishable, there is no mistaking the con- dition. Eczema of a most chronic vari- ety, frequent attacks of erysipelas or other forms of deep dermatitis, as well as tight bandaging of a part may also be the inducing factors. Prognosis. — Although the disease does not tend to shorten life, much discom- fort, as well as intercurrent maladies, may place the affected person in an un- enviable condition. Endemic cases may be greatly benefited by a change from a malarious or sea district. Sporadic types are likewise improved by change of climate. The discomfort may alone be caused by the weight of the affected part, which may often be removed by surgical measures, thus insuring relief. Early cases should be immediately removed to other regions; if this is done, a favorable result will be reached early. This step often arrests even cases of long-standing. Treatment. — In endemic cases which are preceded by the preliminary fever, with its accompanying phenomena, re- course must be had to the measures gen- erally adapted to most febrile manifesta- tions. Salines, acetanilid, quinine, and cinchona, which influence miasmatic fevers and their consequent complica- tions, should be administered. Tonics will be demanded in many cases in which the depressing effects of recurrent at- tacks of erysipelas or deep inflammations are experienced. Codliver-oil, with or without the hypophosphites, iron, strych- nine, certain mineral acids (hydrochloric or sulphuric), and possibly arsenic may be found beneficial. Again, all complica- tions should be remedied as they appear in the several cases encountered. All cases of this affection should be removed from countries in which the disease is endemic or where malarial or other miaBmatic atmospheres are found. Spo- radic cases are to be removed as well to some healthy climate. Iodine (or its preparations) and mercury have been recommended for their absorbent quali- ties. Sterilization of drinking-water at all times may have an indirect influence in the prevention of this disease. Surgical interference, of one kind or another, may be productive of some fairly-good results. Large growths of enormous weight have been removed by this means. The penis and testicles have been restored to their normal conditions in a large number of cases. Series of sixty operations successfully performed. The weight of the tumors varied from one and a half to thirty- nine pounds. The usual incision is made along the penis, which is thoroughly decorticated; and by vertical incisions over the cords, down to the fundus of the tumor, the testicles are enucleated, and, all blubbery material being care- fully removed, the organs are placed on the pubes in a wrapping of gauze. The upper ends of the vertical incisions are joined to the wound over the penis. Lateral oblique incisions are made through healthy skin and fat along the sides of the tumor; they pass down- ward, so as to meet just in front of the anus. The mass is then carefully dis- sected off, exposing, on its removal, the accelerator urina; in the middle and the limbs of the pubic arch at the sides. All bleeding vessels are ligatured. One now sees the decorticated, but turgid, penis; the testes with cords of, it may be, eighteen inches' length; and a large triangular wound, fairly representing the superficial dissection of the anterior halt of the perineum. The akin and fat bounding the wound on cither side are raised up from the fascia lata, over llie hamstrings, for a distance of about three inches. The testes arc united to each other in the middle line by three or four interrupted sutures. The edges of the sliding lateral (laps are then brouglit together over the testes by a series of strong quilt-sutures. The penis ia covered by the anterior end of the ELEPHANTIASIS. 659 tliigh-flaps, and by Haps raised from above the pubes, with or without the addition of Thiersch grafts. Tlie whole wound-area is dusted with iodoform, and covered with suitable dressings, it is essential that the dressings be kept in place by well-applied bandages. Heal- ing takes place throughout by first in- tention in about eight days. Havelock Charles (Indian Med. Record, No. 5, '97). The cicatrical tissue following this treatment always gives a protective cov- ering to the structures. Surgeons have abandoned the use of the ligature be- ■cause of the likelihood of causing more disturbances to the already-obstructed ■circulation. The method of treatment generally resorted to by surgeons at the present day is compression. This may be considered as equal in value to ligature, •but it is less likely to provoke other con- ditions likely to promote enlargement. Pressure may be applied by the use of ■some form of bandaging. Elastic band- ages, such as those advocated by Martin, or ordinary muslin of close texture, to in- sure firmness, may be applied to the en- larged areas, beginning at its lower and approaching the upper part in gradual pressure. This means has been followed, however, by untoward consequences, such as gangrene at one point or an- -other, and should be carefully watched. Marked success from hypodermic in- jections of calomel in a case of elephan- tiasis in a woman 39 years old. Al- though the patient developed symptoms of syphilis, yet the latter occurred after the appearance of elephantiasis. The author concludes that intermuscular in- jections of calomel have a beneficial ef- fect on elephantiasis, but they must be continued for a considerable time, with frequent interruptions. Tiptseff (Medit- zinskoje Obozrenije, vol. Ivii, No. 9, 1902). J. Abbott Cantrell, Philadelphia. EMPHYSEMA. See Pulmonary Em- physema and Index. EMPYEMA, THOKACIC— Empyema: GT.,i-u7ii'ch', to suppurate. Definition. — Empyema is an accumu- lation of pus in the pleural cavity inde- pendent of the lung-tissue. Varieties. — The various Icinds of sup- purating pleurisies are pulsating em- pyema, multilocular empyema, tubercu- lous empyema, double empyema, putrid empyema, and interlobular pleurisy. A\Tien a collection of pus is so situated as to be synchronous with the heart-beat, it is denominated pulsating. In cases of pleuritic adhesions and the circumscribed diaphragmatic pleurisy, we often have encysted collections, which are usually many in number. Tubercu- lous empyema occurs in scrofulous sub- jects and is often localized, with caseous masses. Double empyema occurs simul- taneously on both sides, while interlobar pleurisy is the inflammation in the vis- ceral pleura, or that covering the lung, and pyajmic exudation accumulating in the interlobar fissures. The interlobar empyemas are not pri- marily abscesses of the lungs, but of the pulmonary pleura; but necessarily as- sume the form of abscesses of the lung if not circumscribed by adhesions or evac- uated early. Tiie putrid empyema is a form resulting from neglect and long ex- posure to the various pyogenic micro- organisms, such as saprophytes, and the streptococci and staphylococci, resulting in pyjemia and septicemia. Symptoms. — In most cases of empy- ema there is a history of exposure to dampness or overheating. A chill comes on, then fever, and pain in the side. The disease may not have been regarded as serious or a relapse may have occurred. In a few days dyspnoea and unusual 660 EMPYEilA. SYMPTOMS. restlessness call the attention of the pa- tient again to his chest. In a month or two the clinical picture has gradually changed; the patient, perhaps florid and plethoric, may have become emaciated and morose, a short loose cough suggest- ing the presence of consumption, which apparently becomes confirmed when night-sweats are noticed. The aspect of the face and the posture is that of ex- treme exhaustion. The physical signs are pain in the side affected. This may be one of the first s)'mptoms; but the most marked of these is discomfort due to dyspnoea and to the absorption of pus. The skin may be clammy and bathed in a cold perspiration. The respiration is about 40 to the minute; temperature from 103° to 105°. There is dullness on the affected side, with change of sound under auscultation and percussion when sitting, when lying down on the back, or if the patient be turned on one side. Twenty patients examined with spe- cial care in regard to the change of level of a pleuritic exudation as the patient's position is altered. Anything that might, by acting as a damper upon the thorax- wall, give rise to apparent dullness, such as pillows, mattress, supporting hands placed against the back, etc., was avoided, many of the apparent changes in the level of dullness being due to these agents. The thorax-wall must be set in vibration and give cliaracter to the per- cussion-sounds. If a damper is so ap- plied as to stop these vibrations, a dull note results. A normal thorax, if per- cussed in the position a pleuritic patient assumes, will give a dull note on certain lines. In only one case out of the twenty did the examination reveal any change in the line of dullness. Strauch (Virchow's Archiv, June 1, '89). liy far the most important aid in diag- nosing that empyema has followed pneu- monia is the temperature. The usual thing, if empyema follow, is for the tem- perature to fall when the crisis takes place, for it to remain down two or three days, for it then to rise again, so that it soon becomes from 2 to 4 or 5 degrees above normal in the evening and about 1 or 2 degrees in the morning; this con- tinues until the pus is evacuated. Some- times the apyrexial interval is only one day, sometimes it is four or five days, and sometimes there is not strictly an apyrexial interval, for the temperature does not fall at the crisis to normal, but only to nearly normal, and then soon begins to rise again, so that instead of an apyrexial interval we have an inter- val of lower temperature. There is a fall of temperature at the pneumonic crisis with a subsequent rise in about a third of all the cases in which empyema fol- lowed pneumonia. In many cases there is no apyrexial in- ter\-a!, and probably in some of these pus is present from quite early in the illness. W. Hale White (Lancet, Nov. 10, 1900). Empyema in children usually follows lobar pneumonia, after a varying inter- val. The infection is usually with the pneumococcus. Spontaneous cure, even when aided by tapping, is rare. Opera- tion should not be delayed, as time lost is strength lost, and the issue is largely one of nutrition. The best form of operation is in general the subperiosteal resection of an inch of the eighth or ninth rib in the posterior axillary line, the evacuation of pus and fibrin masses, and tube-drainage. Irrigation at or after operation is not usually advisable. Routine after-treatment in fresh cases should be tube-drainage, the tube being progressively shortened, and removed when the cavity is nearly healed. Where failure to heal seems to depend on fail- ure of the lung to re-expand, treatment by valve or suction apparatus is indi- cated. This is especially of value in the more chronic eases. The mortality is about one in seven; in small children it is much greater than in those over five years. The causes of mortality are, in the main, beyond our control. The- great majority of cases heal even when tlio healing is delayed for many months. (Chronic empyema, in the strict sense,. is rare in children. The closure of the cavity depends mainly on nutrition and EMPYEMA. SYMPTOMS. 661 on adequate drainage. Recurrence may take place from faulty drainage at any time, and it may occur years after ap- parently sound healing, without obvious cause. Deformity of the chest is usually temporary, and yields to treatment. Long-continued discharge from the cav- ity is not infrequently followed by chest deformity and scoliosis of a severer type, permanent, and sometimes extremely se- vere. Cotter (Boston Med. and Surg. Jour., July 17, 1902). fremitus on the affected side. If a finger-tip of the left hand is held in an intercostal space over the region and a finger-tip of the right hand is held in a corresponding intercostal space on the sound side, and the patient is told to count audibly, no sound-waves seem to be transmitted to the finger placed in the intercostal space on the affected side, and the fin^rer on the sound side feels the im- Lower part of thoracic walls on the right side. A, pectoralis major; B, pectoralis minor; C, serratus magnus; D, external oblique; E, rectus ab- dominis; 3, third costal cartilage; 4, fourth costal cartilage; 5, 5, fifth costal cartilage; 6, 6, sixth costal cartilage; 7, seventh costal cartilage; 8, eighth costal cartilage; 9, ninth costal cartilage; *, placed just above Mr. Marshall's spot; t, aponeurosis, common to external oblique and pectoralis major and covering rectus; J, xiphoid appendix. Skodaic resonance is a term used to indicate Skoda's discovery of an area near the clavicle which is always free from the extreme flatness found in em- pyema, — unless this area be also invaded in cases where the dullness is found in all portions of the chest, in which case the cavity is full of pus. This is also accom- panied by a disappearance of the vocal pact or vibratory motion communicated through air by the sound-motion. The sjTnptoms of serous effusion vary slightly, and yet this wave-motion may be com- municated better by serum than by pus. The variety of sounds heard in the early stages of pneumonia upon ausculta- tion is followed by a complete loss of sound on the affected side in empyema. 662 EMPYEiLi. SYMPTOMS. The respiratory murmur is nil. The bronchial murmur above may be per- ceptible. The most-marked cases are the only ones in which all of these signs and B3rmptoms obtain; for, with a small ac- cumulation of pus, very little more than the rise of temperature and dyspnoea exists. The final termination of a case not recognized and treated would be a pointing and rupture externally or in- ternally. The most usual points of rupt- ure have been the weakest and least re- sietant: i.e., internally, above into the bronchi or trachea; and, externally, at the free spots of Marshall or of Traube. The point on the right side which is com- paratively free from muscular covering is called the free spot of Marshall, while that on the left side, as in this case, is called the region of Traube. (See wood- cut.) [The spontaneous discharge of em- pyema without any untoward results was observed by me in the case of a young girl, aged 8 years, who had been attacked with influenza, and, later, with severe pleurisy, accompanied by high temperature, weak and rapid pulse, night-sweats, and hectic, showing great absoi-ption of pus. In the course of time, a prominence about the size of a hen's egg was noticed on the right side near the costal cartilage. After a simple incision the pus was fully evacuated through the opening, which remained patulous for about three years. The examination of the patient now shows a slight lateral curvature of the spine, with a lack of development of the mam- mary gland on the right side, but with a considerable cliest expansion and very Blight impairment of the lung. The pa- tient is rapidly developing into woman- hood and has regained her health and strength. The discharge of pus in the left side was observed by me in a boy at Annis- ton, Ala., in whom a serous pleural ef- fusion bad been aspirated, and had been treated by niodifntlon nlso. The degen- eration of serous exudation into pus was verified in this ease. Osier has stated that he has never seen a case of sero- fibrinous effusion degenerate into puru- lent pleurisy, but, according to W. M. Pirt, literature shows many similar cases, The region at which the pointing oc- curred in this case was in the left inter- costal space, immediately below the apex of the heart. I performed the operation of resection of a portion of the sixth costal cartilage on the left side, and se- cured drainage with a strip of gauze passed daily through the fistulous tract. The patient made a good recovery, also; and, being young and vigorous, over- came the tendency to scoliosis. Tlie last report from him showed that there had been no redevelopment of pus, and that the fistula had been closed. J. Mc- Fadden Gaston.] The Marshall and Traube regions are points of least resistance and, although higher than the pus sometimes reaches, may be considered the most available for spontaneous discharge. It is for this reason, and because the region of Traube is least liable to complications with the diaphragm, pleura, and abdominal wall, that Jaccoud, of Paris, selected it for the introduction of a trocar. J. H. Cox has reported a case in which spontaneous evacuation took place in front between the sixth and seventh ribs. Recovery followed. The pus may discharge through the intercostal spaces, but fail to reach the surface at the point on account of mus- cles; then it burrows beneath them. In regard to the spontaneous escape of pus in thoracic empyema, a case has been re- ported in which it took place at the um- bilicus. This location of tbc weak point is a corroboration of tlie theory that pus escapes at the point of least resistance, and not always at the point of the lowest pressure. (J. G. Willis.) [I witnessed the case of a man at the Atlanta Polyclinic, who had a whole EMPYEMA. DIAGNOSIS. ETIOLOGY. 663 quart evacuated from the incision made into an axillary abscess communicating witli an empyema. The patient was lost sight of after the first evacuation by me, and it is supposed that he must have been relieved by the use of a gauze drainage and packing at that time. J. McFadden Gaston, Jr.] Diagnosis. — The diagnosis may be made from the extreme dullness and lack of respiratory sounds, when the tempera- ture remains elevated. But an explora- tory puncture is advisable to determine definitely a case of empyema. Subphrenic pyothorax can be recog- nized by the results of high and low aspiration, in a large percentage of all cases. High punctures, in the fifth inter- costal space, show a collection of pus or serum, while low punctures, as the eighth intercostal space, yield pus which is always ichorous. Scheurlen (Charit6- Annalen, vol. xiv, p. 158, '89). Two eases of pulmonary abscess simu- lating empyema. KaufTmann (Birming- ham Med. Review, Oct., '93). Case of subdiaphragmatic abscess con- taining pure culture of bacillus coli communis observed which simulated em- pyema. F. Tilden Brown (N. Y. Med. Jour., Feb. 2!), '90). In the New York Foundling Hospital during the last ten years there were 82 cases of empyema, and G9 of these were under two years of age. In 28 cases there was no involvement of the lung. Clinically, it is at times most difficult to diagnose and locate the pus. In oppo- sition to the course of empyema in adults, in children the disease is short and critical, some cases dying within forty-eight hours, and the mortality, in all cases of children, is very high. The rational signs are the same as those of pneumonia, and the only positive sign is the finding of pus with a large ex- ploring-necdlc. Practically all pleural effusions in infancy are either purulent from the beginning or soon become so, and when pus has been found drainage is called for. D. Bovaird (Med. News, Dec. 2.'?, '99). Pleuritic efTu.«ion and a camified or hepatized lung should be borne in mind, and they may be excluded when the ex- ploring needle reveals pus. At times cases of empyema may be confounded with ordinary intramural abscesses, as when they occur near the axilla, and are incised. We have found several cases among negroes treated late and who had been neglected. Etiology. — Pleurisy with its usual sequeltc of pleural effusion is the most common etiological factor. The inflam- matory complications of pneumonia are also among the causes. There are four main groups of cases of empyema in children. The first is the metapneumonic, the diplococcus pneu- monia: playing chief role as etiological factor. In the second group the only micro-organism found in the pleuritic ex- udates is the staphylococcus pyogenes or a streptococcus. The third group is due to the tubercle bacillus, and the fourth is the so-called putrid or fcetid empyema. Henry Koplik (Med. Record, Jan. 25, '90). It is impossible to state with accuracy the percentage of cases in which pneu- monia is followed by empyema, but it is interesting to note that out of 325 con- secutive cases of empyema in the med- ical wards of Guy's Hospital, there were 41, or 12.C per cent., in which it ap- peared that the empyema followed a lobar pneumonia. W. Hale White (Lan- cet, Nov. 10, 1900). Clinical study of one hundred and tliirty-five cases. When the streptococ- cus is present and is due to suppurative or pytemic conditions outside the chest, it is usually of a virulent type and has a correspondingly bad prognosis. In the metapneumonic eases the prognosis of streptococcus is little worse than that of Innceolatus. The particular organ- ism present is a less cogent factor in determining the need of operation than the fever, prostration, chills, the quan- tity of pus-cells present, and the tend- ency to refill after operation. The grad- ual development of pus after .successive aspirations can usually be predicted from the presence of streptococci or 664 EMPYEMA. PATHOLOGY. PROGNOSIS. pneumocoeci in the first fluid Avithdrawn, even though that be a clear serum. But pus may also appear when the earlier tappings are sterile. C. F. Withington (Boston Med. and Surg. Jour., Nov. 6, 1902). Trauma may also give rise to the effu- sion. Tubercular empyema may follow the perforation into the pleural cavity of a tubercular peripleuritic abscess, origi- nating in a tubercular osteitis of the ribs or vertebrEe. Tuberculosis is thought to be caused by pleurisy; on the other hand, Germain See and others are quoted by J. C. Cas- tillo, of Lima, Peru, as regarding three- fourths of all pleurisies tuberculous in their origin. The most frequent cause of pleurisy is, as has been said, the bacillus of Koch. Children are especially liable to em- pyema following pneumonia ; pneumonia caused empyema in 50 per cent, of per- sonal cases; all were of severe type. A tuberculous family history exerts little influence on empyema. In about one- sixth of the cases the empyema was sac- culated; the pneumococcus was found in 50 per cent, of the cases in which examination was made; the strepto- coccus in 22 Vj per cent. ; the staphylo- coccus in 8 per cent.; the tubercle ba- cillus in 4 per cent.; and no bacterium in 10 per cent. The pneumococcus pro- duced the most virulent infection. J. A. Hartwell (Med. News, July 13, 1901). Pathology. — When the inflammatory process sets in, the pleura becomes thick- ened, and this, besides the inhibition of the lubricating secretions that occurs, gives rise to a friction-sound: one of the first symptoms of pleurisy to present it- self, as well as one of the last to dis- appear. The lubricating fluid is rather in- creased as an effort on the part of nature to repair the damage done to the surfaces by their congested, uneven thickening. This fluid becomes gradually so plentiful that at times it is sufficient to form serous effusion. If the inflammatory product should continue or if pyogenic microbes invade the cavity, suppuration results, and we have empyema. Case of calcareous empyema followed by death. Post-mortem the lung was collapsed and the pleura thickened and coated on its whole internal surface by a thick crust of calcareous deposit, in- cluding the upper surface of the dia- phragm. The sour, milk-like odor of the discharge toward the last suggested that lactic-acid fermentation was taking place within the cavity. T. Carwardine (Bris- tol Medico-Chir. Jour., Mar., '98). Report of 81 cases of empyema in children. Examination of the pus was made in G9. In all but 4 of the 69 the diploeoecus was found, either pure or in combination with some other organ- ism. P. S. Blaker (Brit. Med. Jour., May 23, 1903). Prognosis. — Cases seen early result favorably under proper treatment; hence the rule that cases of empyema should never be allowed to grow old. Six hundred and lifty-six cases of em- pyema in children, with one hundred and four deaths. The younger the patient, the greater the risk of fatal termination. The sooner the purulent effusion re- moved, the quicker the recovery. Dan- ger to life is chiefly due to complica- tions: pericarditis, peritonitis, septi- Cfemia. Wightman (Lancet, Nov. 30, '95). Considerable practical prognostic im- portance attaches to the bacteriological study of the pus of empyema. Thus, empyema in childhood, caused by the pneumococcus, is quite benign and runs a rapid course to recovery, while that caused by the streptococcus runs a slower course and is more serious. Tuberculous pleuritis is a chronic process usually ter- minating fatally, or lasting for years until tuberculosis or an intercurrent affection carries off the patient, or he gradually succumbs to prolonged hectic amyloid disease and asthenia. Errors in diagnosis may be caused by tlie tendency to RcdimcnlaUon of the pus, when an ex- ploring-nccdle may withdraw clear fluid from the upper layer instead of pus. EMPYEMA. TItEATilENT. 665 Joseph McFarland (Pliila. Med. Jour., Sept. 8, 1900). Very much depends upon the nature of the infection. The readiness with which tlie compressed or retracted lung returns to fill the cavity marks the difference between a case of favorable and rapid progress to complete healing and a pro- tracted one, ending possibly in extensive rib resection with deformity. As to the bacteriology, the two main features are the comparative frequency of staphylo- cocci and the rarity of the diplococcus pneumoniae. Some doubt must remain as to the exact relationship which the bac- teria bear to the production of pus. W. F. Hamilton (Montreal Med. Jour., Oct., 1900). In all cases the most serious conse- quence of the affection is deformity, and in children lateral spinal curvature is likely to occur. Pyasmia and septicaemia will result from putrid empyema; and general miliary tuberculosis may follow a localized tuberculous pleurisy which becomes purulent. Eupture into the bronchi, trachea, lungs, with immediate death from suffocation, or into the stom- ach after perforating the diaphragm, are among the possibilities. Treatment. — The satisfactory results obtained by Murchison in the treatment of pleural effusions by incision would seem to point to the surgical treatment of many cases, before empyema has set in, as a valuable measure. For this pur- pose also the use of blood-letting, blis- ters, and medication may be employed to abort the inflammatory process suffi- ciently early in the progress of pleurisy that an empyema need not follow. Blis- ters and purgation with salines and mer- curials should be actively employed, in order that the parts undergoing inflam- matory changes may be relieved of the fibrinous element of the blood, tending to retard resohition. Opiates, and espe- cially the camphorated tincture of opium, may be used to relieve pain and hasten the resolution. Carbonate of am- monia, turpentine, and digitalis are all also of value. [I would strongly urge, especially in children, of an early recourse to the fol- lowing preparation; — 1} Hydrargyri chloridi raitis, 1 grain. Pulv. ipecac, tt opii, 10 grains. Quininee sulphatis, 10 grains. Pulv. camphora;, 1 grain. M. Divide into powders No. x. Sig. : One powder every two hours. In adults: — R Hydrargyri chloridi mitis, 6 grains. Pulv. ipecac, et opii, 30 grains. Quinina; sulphatis, 30 grains. Pulv. camphorse, 6 grains. M. Divide into capsules No. xij. Sig.: Take one every two hours in day-time, and two capsules at intervals while awake at night. This should be followed with two tablespoonfuls of oil and one teaspoon- ful of turpentine. The bowels are thus emptied, and the turpentine has a beneficial effect upon the bronchial tubes. I have seen many cases of incipient pleurisy aborted in this way, and the most alarming symptoms of high tem- perature and rapid respiration controlled. J. McFADDBaj Gaston, Jr.] The full and free evacuation of the pleural cavity is not expedient when the pressure has been great, and the lung is pressed upon in such a manner as to displace the heart. In such a case the gradual evacuation by aspiration is pref- erable. Aspiration should be limited to one or two trials, for empyemas of the meta- pneumonic type, as seen in children and adolescents. For all other cases free in- cision and drainage are indicated. Ran- Bohofl (Ohio Med. Jour., Aug., '93). Cases in which pus contains large masses of lymph, or pus, thick and creamy, heal best. OfTcnsivencss of pus does not much infliience healing. Delay is advisable when there is negative press- ure in the pleura, and when expansibility 666 EMPYEMA. TRK\TMENT. of the lung and contact of layers of pleura can be induced by simple aspira- tion and cure effected. Otherwise harm will result from delay. Resecting a piece of rib, free incision of pleura, and con- tinuous drainage indicated. Pollard (Brit. Med. Jour., Nov. 2, '95). In children chloroform is the prefer- able anresthetic, but deep narcosis is contra-indicated, owing to the danger of pus being drawn into the other lung from a ruptured bronchus. In adults with general empyema two inches of the seventh and eighth or eight and ninth ribs in the posterior axillary line should be resected. In children the same length of the seventh rib. Simple incision, with our present knowledge, is rarely ad- visable. The operation is indicated as soon as diagnosis is made. Irrigation of the abscess-cavity with bichloride so- lution, 1 to 5000, or carbolic acid, 1 to 100, is indicated, unless drainage is per- fect and no sepsis is present. In chil- dren the solutions may be weaker. The mortality from the empyema proper was 15 per cent, in personal cases. Earlier and more radical treatment would re- duce it to one-half that proportion. J. A. Hartwell (Med. News, July 13, 1901). The best method of securing counter- pressure and antisepsis at the same time is by the injecting of a saline solution through the one tube Injections of pero.xide of hydrogen in 50-per-cent. solution puts a rapid stop to the formation of pus in the thoracic pavity, and has been strongly recom- mended as an injection in empyema whenever injections must be used. Edi- torial (.Tour. Respiratory Organs, Sept., '89). The safest method of procedure con- sists in replacing gradually the pleuritic exudate by an innocuous fluid: a solu- tion (O.Ofi or 0.07 per cent.) of sodium chloride (common salt). After with- drawal of a small portion of the exudate the same quantity of salt solution is introduced into the pleural cavity. By repeating this operation several times, entire exudate may be replaced by saline solution. The injected liquid dis- appears by reabsorption as fast as the lung dilates, and the consequences of a sudden diminution of the intrathoracic pressure need not be feared. S. Lewa- chew (Times and Register, Apr. 11, '98). Immediate relief to syncope has been secured by the reverse action of the as- pirator and the injection of the same fluid which has been drawn out. The practice of aspiration in cases of empyema has still a great number of advocates, and it is probable that an at- tempt to evacuate the pleural cavity in this way is attended with good results when resorted to early in the progress of suppuration. The packing of the cavity with iodo- form or plain gauze in order to secure drainage has been advocated by Ranso- hoff, Laplace, and other surgeons. The experience of most practitioners is that a pleural sero-fibrinous effusion does not often degenerate into a purulent collec- tion, and many attribtite the pus to the failure of antiseptic precautions in as- piration. In several cases the following points of interest were noted: Although the pleura had been full of fluid for twelve months, rapid rc-expansion oecuiTed. After thirty-seven tappings the fluid be- came as clear as at first, in spite of admittance of air. The advice given in text-books to abandon paracentesis after two or three trials should be modified. Tlicre is no risk if the operator is careful to keep the instruments aseptic. West (Brit. Med. Jour., Apr. 27, '95). Paracentesis Thoracis. — Aspira- tion or simple puncture with a long hy- podermic needle is performed as fol- lows: — 1. The skin in the intercostal space selected is cleansed with soap and warm water, followed by alcohol, and a car- bolic-acid solution of G to 100. 2. The needle is asepticized by passing through an alcohol-lamp. 3. The skin is held up and the fact ascertained that there is space enough EMPYEAIA. TREATMENT. 667 between the upper surface of the rib and the course of the needle. 4. The needle is then suddenly plunged so as to penetrate the pleura. 0. After removal of the needle the wound is closed with collodion and cotton. When a vacuum instrument cannot be secured, the surgeon should use devices at his command in preference to await- ing the more convenient forms of appa- ratus. He can attach a rubber tube to a trocar and cannula, if he is careful to hold the finger upon the outlet of the cannula as he removes the stylet. It would be well to insert a rubber tube into an antiseptic solution, so that the fluid may be carried into it, and no concern need then be felt as to the fluid ceasing to flow, when air would enter if the ex- ternal orifice of the tube were out. The exact directions in paragraph No. 3 are based upon the course of the inter- costal artery, which is in a groove on the inferior surface of the rib, while the skin should be raised so that a valvular open- ing shall be made. When the needle is removed, the puncture is not open con- tinuously and shuts out the air. The thorough preparation of a patient even for so simple a procedure as aspira- tion, is necessary. The best and most efficacious drug is strychnine nitrate injected hypodermic- ally before an operation. The combina- tion of V;s grain of strychnine, with ^f^ grain of morphine, Vk,o grain of atro- pine, and '/< grain of cocaine hydro- chlorate, may be injected preparatory to aspiration. The patient is placed on the sound side, and the arms folded over the chest, so as to draw the scapulsc away from the vertebra?. This afTords a safe method of selecting the interspace between the sixth and seventh rib in the posterior axillary line. It may be found at the extreme angle of the scapula, and with a space comparatively free from muscles, where the ribs are some distance apart. The most expedient course, however, is to count the ribs also, and to have a needle at least three inches in length which is attached to a Potain or Dieula- foy aspirator. The most dependent portion of the collection should be selected in small ac- cumulations. The diaphragm has its lowest attach- ment behind at the twelfth rib and on the sides about the ninth or tenth, but the collection of pus may be incapsulated so as to present definite indications for puncture as low as the eighth intercostal space in the middle axillary line; behind this point, we may find the ninth inter- costal space clearly dull, from fluid. In such cases the area of pulmonary reso- nance on the sound side should be care- fully noted as a comparative guide. The diaphragm has been shown to be higher, if possible, in some cases of em- pyema, on the afCected side, than on the sound side. The oigan will rise when the compression is removed; hence the advice of Stokes to go above the eighth interspace in cases of resection, incision, or puncture. The sixth interspace in the midaxil- lary line or the eighth in the posterior axillary line near the border of the latis- simus dorsi muscle and at the angle or point of the scapula is the point of se- lection of F. S. Dennis. The advisability of the three operations (thoracentesis, thoracotomy, thoracoplasty) depends upon the age of the patient, the charac- ter of the fluid, and especially, in the latter, upon the fact that it may be a life-saving operation. CRoswell Park.) IxcisiON. — It is advisable to have all in readiness in cases where empyema is €68 i:.\iP\\EiLA.. TRJiATilJCNT. suspected, and an exploratory puncture or aspiration is made, to incise at this point should pus be found to exist. Especially is an incision necessary in cases -n-here numerous punctures have been necessary to find the pus. It should be made where the needle is and before it is withdrawn. A- groove may be made in the needle of the aspirator, as suggested by Kebbel, so that the blade can be started from this exact point as guided to the pus by the groove. All Buch incisions should be near the upper border of a rib. There are five classes of cases in which surgical interference is to be considered: 1. Large cavities in which the lung, fastened to the vertebral column by thick false membrane, is entirely and permanently collapsed. In these cases the operation is useless and dangerous. 2. Large cavities in which the lung, though condensed, still preserves a slight vesicular murmur. Intervention is then sometimes useful, particularly in young patients and when the cavity does not extend beyond the third rib. 3. Cavities from eight to twelve centimetres in diameter; these present the most favor- able conditions for cure. 4. Simply fistulous tracts of greater or less length; if short and straight, the results will probably be good; the prognosis be- comes less favorable when the fistulse are long and tortuous. 5. Cases in which there are moderate-sized cavities with fistulous tracts communicating with them; in these the prognosis is favor- able. Bouilly (Revue de Chir., Apr. 10, •88). The ordinary drainage tube is often responsible for the continuance of dis- charge when used to drain the pleural cavity, its mere presence acting as an irritant. Brinkman (Penna. Med. Jour., Jan., 1903). The method of simple incision in the intercostal space parallel with the ribs has been sufficient often to allow a drain- age-tube to be inserted, and in this way many have found that the resection of ribs is unnecessary. Free incision when done early is very successful; the removal of a portion of a rib is never necessary in acute cases, and a fatal issue at any age is rather a result of the neglect to recognize the true nature of the case than of the op- eration itself. Lewis ilarshall (Lancet, Dec. 21, '95). Below the age of 23 it is unnecessary in empyema to remove portions of ribs, but above that age it is essential in or- der to insure contraction of the abscess- cavity. In urgent empyema it is best to use no chloroform, but to freeze the skin with ehlorideof-ethyl spray. In pa- tients above 23 portions of ribs may be removed whenever the breathing is suf- ficiently relieved to bear chloroform. J. 0. Renton (Practitioner, Jan., '90). Simple incision of the chest-wall, tho- racotomy, may be employed, the site of the incision being determined according to the position of the collection of pus. An opening in the lowest part of the pleural cavity is not the most suitable. It is not advisable to wash out the cavity, at the time of operation at all events; such a procedure is not devoid of danger. The more efficient way of treating an empyema, especially in chil- dren, is to incise and remove a portion of a rib. A. Primrose (Canadian Praot., Mar., '90). Empyemata healed by expansion of the lung, ascent of the diaphragm, and con- traction of the chest-wall. In all recent cases there is more or less complete re-e.\pansion of the lung on the with- drawal of the pressure which has been exei-ted by the fluid. Full expansion in the lung should, therefore, be main- tained at the time of the operation. J. E. Winters (Prac. Med., Mar., '90). Valved tube successfully used for draining the pleural cavity after incision in empyema, with the object of prevent- ing the falling in of the chest-wall and diminished expansion of the lung. W. M. Ilutlon (Lancet, London, Feb. 0, '97). Report based on seventy-five cases, observed chiefly in St. Mary's Hospital for Children. In simple cases the treat- ment was as follows: Excision of about one and one-half inches of the seventh or eighth rib in the posterior axillary line; light ether anajsthcsia is usually EMPYEMA. TREATMENT. 66» employed; tlie purulent coagula are re- moved; short rubber tubing, cut partly across, doubled and held by large safety- pins, is used for drainage; abundant gauze dressing is applied and changed when saturated. If the patient's con- dition contra-indicates general antesthe- sia, an incision into the chest may be made between two ribs under eucaine ansesthesia. Aspiration is only used to give temporary relief to patients who are in great distress from the pressure of the fluid, or temporarily to relieve the second side of a double empyema after the first side has been opened. The patients are allowed out of bed as soon as practicable, and the expansion of the lung is encouraged by forced expiration. Irrigation is only used where there is a foul-smelling discharge from necrotic lung-tissue. Secondary operations are not done until good opportunity has been given for healing — usually three or four months should have elapsed after the primary operation — and if there should have been no noticeable improvement for a month. In the sec- ondary operation the expansion of the lung should be encouraged by incising, stripping back, and, if necessary, re- moving portions of the thickened pul- monary pleura. The examination of forty-four cases at long periods after operation indicates that recovery is usu- ally complete in the simple cases, and that there is surprisingly little deform- ity in most of the severe cases. Dowd (Medical News, Sept. 13, 1902). Alfred Sheen, of Cardiff, Scotland, has been successful in securing permanent cures by the method that we have out- lined above, and the consensus of opinion seems to be that the most radical meas- ures are not indicated. When resection is practiced, a small-sized piece of rib, sufficient for one drainage-tube, has been found to answer all the purposes of drainage. The most important and at the same time the most ingenious operation de- vised to accomplish this has been by Dr. Carl Beck, of New York. lie uses an elevator by which the rib may be cut and denuded of periosteum at the same time. The indication for the operation is, of course, in children, or those patients in whom a drainage-tube could not be in- serted between the ribs. The indorse- ment of John Ashhurst, of Philadelphia, is very strong in favor of operative inter- ference in cases of empyema, and the mortality he reports is especially small. The practice of iacision and drainage, of resection of ribs with the insertion of drainage-tubes, of the siphon-apparatus introduced by Biilau, all subserve the purpose intended. Thoracotomy performed in 76 cases of empyema, of which 89 per cent, were cured; about 71 per cent, were able ta work within two months. The point of election for the incision is the lateral surface of tlie thorax, just below the axilla, selecting the fourth, fifth, or sixth rib. A tube carried in at such- point will always enter the free cavity, and, with the patient in the proper lat- eral position, allow the pus to flow out, a portion of the rib, about 1 Vio inches, being previously removed. If disin- fectant washes are indicated, salicylic- or boric- acid solutions are preferred. A bandage covering the whole thorax is used, in connection with special move- ments of the body and rest in bed on the side, inclining to the back. Koenig^ (Pittsburgh Med. Review, Oct., '91). Even if the operation for empyema does not effect a cure, it does not make the patient worse. In the large majority of cases operations give great relief, and in a certain proportion, particularly in the young, they give a perfect cure. Very rarely do they cause death. J. Ashhurst (Intemat. Med. Mag., June, ■94). Costal trephining is simple of per- formance and harmless. Preferably per- formed on eighth and especially ninth rib in widest portion, posteriorly seven centimetres from costal angle. Cromi of trephine one centimetre in diameter. Several openings may be made, either in 670 EMPYEMA. TREATMENT. the same or adjacent ribs. Rev (Lvon MM., June 23, '95). In operating for empyema iu children, circumscribing of the inferior and poste- rior borders of the healthy lung advised, followed by resecting, on the diseased side, the rib situated two or three centi- metres above this limit, near the verte- bral column. Sehultz (Jahrb. d. Hamb. Staatskr., vol. xiii, p. 2G0'). Case of subphrenic abscess followed by empyema successfullj' treated by resec- tion of a rib, drainage, and packing. McNaught {Brit. Med. Jour., May 22, ■97). Generally speaking, the case should be a law unto itself, and the surgical means at our command should be accompanied by early out-door exercise and gymnastic performances, especially in children and young adults. The deformity sometimes following the operation may be treated by Sayre's jury-mast, and by the ordi- nary remedies and measures for scoliosis. Skyphosis or Lordosis. — Since 1883, Dieulafoy has practiced thoracentesis 180 times on 69 hospital patients and 200 times in his private practice, and never once has he seen the liquid become purulent after the operation. Whenever the liquid reached 1800 grammes (60 ounces) thoracentesis was imperative. Treatment by irrigation of the pleural cavity is severely condemned by most authorities. [The employment of irrigation in the cavity of the che.st after the removal of purulent collection by incision or other- wise is a precarious measure. Even ster- ilized hot water has been attended with marked vital depression, amounting in some eases to collajjse. The introduc- tion of iodoform with glycerin by swab- bing over the surface or upon gauze tampons within the pleural cavity is not attended with the inconveniences of general irrigation, and proves more ef- fective in correcting septic development. J. McFadden Gaston, Assoc. Ed., An- nual, '90.] Xumber of cases of empyema with fistula treated by warm baths. If the fistulous opening is below the level of the fluid, it is evident that if the pa- tient inspires and expires freely there will be a current of water into and out of the pleural cavity much stronger than can be obtained by simple irrigation. Clumps of coagulated blood and fibri- nated masses are by this means washed out which could not have been removed by simple lavage. The baths were given in boiled water cooled to the temperature of the body, and lasted ten or fifteen minutes. The general condition of the patients was much improved, and no accident was observed to follow this treatment. Zeman (Rev. de Thfr., May 1, '97). Case of empyema in a child success- fully treated by irrigation by submer- sion, according to Zeman's method, after resection. S. S. Adams {Pediatrics, July 1, '98). Irrigation with a 4-per-cent. solution of bicarbonate of sodium used in a case of empyema in which incision, drainage, and lavage with boric-acid solution had failed to prevent reaccumulation of pus. Daily irrigation with the bicarbonate solution for five days eff'ected a cure. L. Betances (La Revista M&l. de Siinto Domingo, Anno 1, No. 2, 1902). Authors agree in the following dan- gers in aspiration or irrigation of the pleural cavity, viz.: Hemiplegia, follow- ing cool solutions; death following as- piration; fatal results also in cases of the use of an anaesthetic; unusual depression from the sitting posture during aspira- tion, relieved by assuming the reclining position. The cautions given have been to use warm solutions, or, better, no solu- tions at all; and to stimulate with cog- nac, strychnine, etc., previous to thora- centesis. [Richard II. Harte, of Philadelphia, has never had an unpleasant result from washing out an old empyema; but it nuist be remembered, ho says, that a oon- siderable number of cases are on record in which an injection, which may have KMPVJiJbV. TKEATilENT. 671 been frequently repeated willioiit serious consequences, has led to sudden death, or to the most alarming symptoms, prob- ably from the sudden increase of press- ure within the cavity, caused by a par- tial closing of the outlet or by the use of too large a tube. The nature of the fluid employed can have had nothing whatever to do with these results, as equally bad results have followed the use of pure water. ("International En- cyclopaedia of Surgery," Ashhurst, vol. vii. Supplement.) These results emphasize the risks at- tending intrathoracic irrigation. J. Mc- Fadden Gaston.] Interlobar Pleurisy. — This form is best treated by the excision of the fifth and sixth ribs, as shown in examples treated by Segond and others. The sur- geons who have discovered interlobar pleurisies in time for treatment have generally made their resections too low. The autopsies in some cases showed Rochard's former statement correct in regard to their location. Most published cases have recovered without operation, the pus having been expectorated. Case operated on in which death oc- curred some days later, the pus being found between the lobes of the right lung. Gerhardt (Brit. Med. Jour., Sept. 9, '93). Cases of long standing with fistulae, deformity, and great rigidity of the cos- tal walls, may require what is known as the Leti^vant-Estlander operation, an operation first suggested by Letievant and practiced by Estlander. The opera- tion has been variously applied to any resection of ribs for the purpose of the approximation of the walls of the chest. The most important distinction to be made, however, is that originally the op- eration included more than one rib and several inches of length in the resection. [Frederick S. Dennis has awarded the credit of the first suggestion of resection of the ribs to Dr. Warren Stone, of New Orleans, while Dollingcr (Annual, '90) and others state that LctiC-vant first suggested it. The two suggestions were probably original so far as each of the above sur- geons were concerned. Many operations have been done in this way, as seen in the case of W. W. Keen. J. McFasder Gaston, Jr.] The operation of Schede consistB in the complete removal of the muscles and tissues adherent or attached to the ribs, with the exception of the skin, the fascia, and the parietal pleural, and these are stitched together and form the only pro- tection to the chest at the point of the operation, and the only hope of restoring the tissue lies in the granulating process. The incision is a U-shaped one, ex- tending from the axilla in front down- ward to the limit of the pleura and back- ward and upward to the second rib, lift- ing the scapula in the removal of the bony flaps. This operation has been ad- vised as a modification of Estlander's operation, in cases where the pleura is much thickened and where the walls fail to respond to ordinary means of reducing the cavity of the chest. Estlander's operation — which consists in removing, not only a certain length or a certain number of ribs, but all the ribs lying in the wall of the empyema — performed twelve times, the results being nine cures and three deaths, one from tuberculosis, the second from car- diac disease, and the third from albu- minuria. J. Boeckel (Revue Chir., Apr. 10, '88). Extensive thoracoplasty by Schede's method performed in a case of thoracic empyema of twelve years' duration. Sec- ond operation performed three months after first. Recovery was without inci- dent, though slow. Eight months after the second operation the wound broke open again and discharged a small quantity of pus. By a third operation some more of the chest-wall at the upper posterior angle was removed. A cavity three and one-half inches long and as 672 EilPYKMA. TREATMENT. thick as the thumb was found. This was nearly obliterated by granulation- tissue. W. W. Keen (Annals of Surgery, June, "95). One hundred and twenty-nine cases of empyema treated by resection of the chest-wall, in which 56.3 per cent, were healed, 20 per cent, improved, 3 per cent. Fig. l.^-Schede's incision for thoracoplasty. {Keen.) unchanged, and 20 per cent. died. There is little oi" no tendency to spinal curva- ture or to impairment of function of the corresponding upper extremity follow- ing these operations. Voswinkel (Deut. Zeit. f. Chir., B. 4.5, S. 77). Deformity observed resulting from re- moval of the fourth, fifth, si.xth, and seventh ribs. This consisted of a large depression of the whole left side, begin- ning about two inches below the clavicle and extending below the free border of the ribs. There was a marked degree of lateral curvature. L. Emmett Holt (Archives of Fed., Jan., '96). In the treatment of empyema success obtained by removing the whole of the chest-wall covering the cavity (Schede) and breaking up and loosening of the contracted pleura; (Delorme). Jordan (Med. Record, May 14, '98). Christian Fenger, of Chicago, holds that there are certain cases in which Schede's operation is required; viz., after milder measures, such as incision, drain- age, and Estlander's operation have been fruitlessly employed. He reported a suc- cessful case in which this operation was performed after other measures had been unsuccessfully resorted to during seven years. Eoswell Park, of Buffalo, states that the treatment of empyema should be based upon the same principles as are applicable to other abscesses. In acute cases presenting streptococcic and staphy- lococcic suppuration it may be sufficient in a few instances to simply aspirate. A summary of the treatment to be em- ployed in cases of empyema may include the following features: — (a) Prophylaxis. 1. Care should be taken to jugulate, if possible, all cases of incipient pneu- monia, pleurisy, and bronchitis. Fig. 2. — Schede's incision for thoracoplasty. The solid line sliows tlie incision made by Keen. The dotted line shows the portion of the bony and muscular ehest-wall removed. The posterior line should be farther back. {Keen.) 2. All penetrating wounds of the chest, whether from gunshot wounds or stab wounds, should be hermetically sealed. EMPYEMA. TREATMENT. 673 3. Collections of blood-serum or air may be evacuated early by aspiration. 4. Children should be carefully ex- amined in cases of continued fever, sweats, and hectic, and prompt measures taken to remove the possibility of puru- lent collections, by exploration. (6) Operative treatment. 5. Incision and drainage. 6. Trap-door for exploration in cases of tuberculous deposits of caseous ma- terial. 7. Estlander's operation for the old and stubborn cases of fistulous empyema. 8. Schede's operation for thickened pleurse, and resistance to the recourse to Estlander's operation or to Delorme's, Qu6nu's, or Gaston's modifications of flap-operations. 9. Iodoform or plain sterilized gauze tamponage for stimulating the granula- tion and securing constant drainage. 10. Permanganate-of-potash solutions for offensive discharges. Thfi successful results which have fol- lowed Estlander's and Sehede's opera- tions in certain severe cases of empyema have led some surgeons to take the too extreme position of advocating resection of the rib in all cases. Incision, the insertion of a drainage-tube, and irriga- tion with mild antiseptic solutions con- sidered as the treatment most suitable for the great majority of cases. Edmund Andrews (Jour. Amer. Med. Assoc, Mar. 4, '99). Pulsating Pleural Effusions. — The term has been recognized for an em- pyema occurring, according to Tillmans, almost entirely on the left side. There have been sixty-eight cases collected, and these have occurred in the hands of a few men. The only mistake that might prove fatal could be to open a thoracic aneurism, thinking that it was an em- pyema. The general indications of em- pyema may be conclusively corroborated by an exploring needle or aspirator. The treatment is the same as in any ordinary case of empyema. Tubercular Empyema. — A large proportion of the cases of empyema are essentially cases of cold abscess, or, more properly, tuberculous abscess. In these, free incision, free drainage, and excision of a rib are required. Park has resorted to scraping with the sharp spoon, and in some he has cauterized the diseased sur- face with a 50-per-cent. solution of zinc chloride. In several cases death would V k, Fig. 3. — Kesult yK, operation. have occurred had it not been for some such radical operation. In tulicrculous oases radical operation indicated — thoracotomy with resection — if exploratory puncture show bacteria of suppuration. If there are no bacteria of suppuration, aspiration advised to relieve pressure and allow the lung to expand. If the case is of long standing, and the compressed lung is inexpansible, palliative measures are indicated. Baum- ler (Deutsche med. \Voch., Xos. 37, 3S, •94). Tuberculous purulent pleurisy has been cured by thoracentesis followed by 674 EMPYEMA. ENCEPHALITIS. injections of corrosiye sublimate and boric acid through the same needle (or cannula) of a Dieulafoy or Potain as- pirator. To summarize the treatment of em- pyema, the following propositions seem tenable: — 1. Empyema is best prevented by promptly evacuating all considerable in- flammatory effusions. 2. In the diagnosis of these effusions, by means of exploratory aspiration, the skin should be punctured by a tenotome at the point where the needle is to be driven in. 3. Serous effusions are best evacuated by aspiration. If they reaccumulate after the third evacuation, they should be subject to continuous siphon-drainage, the puncture being made by a small tro- car and cannula, the latter being of such size that a small drainage-tube may be slipped through it. 4. Recent empyemata are best treated by continuous siphon-drainage, the tube being introduced through a cannula of at least the diameter of the little finger. 5. When, because of a narrow inter- costal space or because of constant block- ing with fibrinous material, siphon- drainage thus provided is inadequate, an inch of one of the ribs (usually seventh or eighth) should be resected, and a drainage-tube the diameter of the thumb should be used. 6. When the conditions are such that it is obviously impossible for the lung to expand under the influence of siphon- drainage and respiratory exercises, De- lomie's operation of stripping the pseudo- membrane from the compressed lung should be attempted. 7. When Delorme's operation is im- practicable, a resection of the ribs (Est- lander) or of the chest-wall and thick- ened pleura (Schede), corresponding in extent to the size of tlie underlying cavity, is indicated. Edward Martin (Ther. Gaz., Aug. }5, 1900). Decortication of the lung. In this operation the thickened pleura is re- moved from a lung, wliich in conse- quence of a pleural exudate has been more or less collapsed. It was first per- sonally used in 1S93. It is indicated for old empyemata, in which there is no tuberculosis of the lung and the patient has sufficient strength to withstand a major operation. It is a better opera- tion than Estlander's, as by it there is a restoration of the function of the lung and a closure of the suppurating cavity. The diseased pleural membrane is dis- sected away — not only that which covers the lung, but that portion lining the wall of the thorax and covering the diaphragm. The operation should be made as thorough as possible, and to this end a large opening in the chest is necessary. It should be so made as to admit of rapid closure after the opera- tion, as this facilitates expansion of the lung, wliich is brought about by respira- tory movements. Respiratory exercises should be employed in the after-treat- ment. G. R. Fowler (Med. News, June 15, 1901). J. McFadden Gaston, J. McFadden Gaston, Jr., Atlanta. ENCEPHALITIS. — Gr., eyx£7 /*->;, a tumor. Definition and Varieties. — Encephalo- cele, or hernia cerebri, means a protrusion of a portion of brain-substance with its membranes through an aperture in the skull, congenital in origin, and usually situated in the occipital region in the median line, less frequently in the naso- frontal rc.gion, and rarely in other situ- ations. Meningocele and hydrencephalo- ccle are closely allied conditions. Men- ingocele means a protrusion of a portion of the membranes of the brain through an opening in the skull, the sac thus formed being distended by cerebro- spinal fluid. Hydrencephalocele means a protrusion of the membranes and brain- substance, which also contains within il a cavity continuous with the lateral ven- tricles of the brain, and filled with cere- bro-spinal fluid. The latter condition is the gravest and the most frequent in occurrence of the three, encephalocele being next in frequency, and meningo- cele the rarest. All of these conditions are of very rare occurrence. Forms of acquired hernia cerebri will more prop, erly be considered elsewhere, in connec- tion with the various causes of this con. dition. Symptoms. — In the three forms enu- merated the disease is congenital, and is developed at some period of intra-uter ine life; and at birth presents a tumor of varying size, generally situated in the occipital region, or in the naso-frontal region in the median line. In almost all cases the hernia emerges through an opening in the line of one of the cranial sutures. Tlie naso-frontal hernias leave the cranium between the frontal and nasal bones and form a tumor in the median line in the region of the glabella. The nasoethmoidal hernias leave the cranium between the frontal and nasal bones on the one side and the lateral mass or labyrinth on the other, which is forced or displaced downward toward the nasal cavity. The tumor appears externally in the region of the border between the osseous and cartilaginous portions of the nose, hanging down toward the tip or the wing of the nose. The naso-orbital hernias leave the cranium between the frontal, ethmoid, and lacrymal bones. In the region of the latter they enter the orbit and pre- sent at or near the inner canthus of the eye. The naso-cthmoidal and naso-orbital varieties are probably not distinguish- able from each other, as they leave the 692 EXCEPHAT.OCELE. SYMPTOMS. cranium at the same place, namely: the nasal notch of the frontal and the cribri- form plate of the ethmoid bone. Chris- tian Fenger (Amer. Jour. Med. Sci., Jan., '95). Cephalhsematoma represents one of the risks through which the child must pass during labor. The tumor consists Palatine hydrencephalocele in a newborn child. (Yirchow, Die Krankhaften Gescliwiilste.) of an infusion of blood between the peri- osteum and bone, forming either two projections over the parietal bosses or more commonly a single projection upon one side. It is important to distinguish this condition from a sero-sanguinolent effusion, which is much more common, and which is present at birth. This tumor is soft, but less fluctuating, and can be indented by the finger, as in oedema. It appears on the presenting portion of the foetus, therefore is formed before its expulsion, and disappears shortly after birth — within one or two days. It never limits itself, as does the cephalhffimatoma, to the border of the bones. The characteristics of the sero- sanguinolent tumors are exactly oppo- site to those of cephalhematoma. It is due to a circular compression at tlio base of the part which corresponds to the ring of the pelvis during engage- ment, and always appears before the presenting part. Queircl (Annalea do GynCc. et d'Obstet., Jan., 1901). Of 93 cases collected by Houel, 68 cases were occipital, 16 were fronto-nasal, and 9 occurred in other situations; while of 105 cases collected by Schatz, 59 were occipital and -16 frontal. These hernial protrusions may occur in other situa- tions. Thus, in the frontal region in- stead of emerging between the cribiform plate of the ethmoid and the frontal bone, such a protrusion is sometimes lo- cated in the interfrontal fissure high up, or in the anterior fontanelle; less fre- quently they occur in the sagittal suture, or between the temporal and parietal bones, thus appearing upon the side of the head. The frontal tumors are smaller, as a rule, than the occipital growths, and are covered with a more vascular skin covering; so that they may give the appearance of certain forms of nffivus. In extremely rare cases the opening has existed between the sphe- noid and ethmoid bones, or between th& sphenoid and its greater wing. Encephalocele. (Holt, "Diseases of Infancv and Childhood.") The tumor may thus appear in the pharynx, or in the mouth, or protrude through the spheno-maxillary fissure, or into the orbit, causing displacement of the eye. The physical characteristics of the three- forms of congenital tumor differ ENCEPHALOCELE. SYMPTOMS. G93 according to the size of the opening in the skull and the nature of their con- tents. Owing to possible error in diag- nosis, all tumors of this kind should re- ceive most careful physical examination, Nasofrontal meningocele. [Unit, "Diseases of Infancy and Childliood.") especially if any surgical interference should be contemplated. (a) Encephalocele presents the small- est tumor of the three, usually rounded or oval with a broad base, and having a pretty firm resistance to the touch. Occipital meiiiiigocLle. [Uutl, -DiiirdSCS Of Infancy and Childhood.") Sometimes the tumor is marked by a median furrow, dividing it into two lateral halves. The tumor is opaque, does not fluctuate, has distinct pulsation synchronous with the heart's action, and pressure upon it causes symptoms of cerebral compression, such as nausea, vomiting, irregular respiration, strabis- mus, and even convulsions. (6) Meningocele appears as a more uniformly round or oval pedunculated tumor, usually small at birth and subse- quently increasing more or less in size. Diagram of meningocele. (Holt, "Diseases of Infancy and Childhood.") It is translucent, fluctuates distinctly, does not pulsate, is made intense on the crying of the child, or during forced ex- piratory eff'orts, and it is reducible upon pressure. Hydrencephalocele. {Uolt, "Diseases of Infancy and Childhood.") (c) Hydrencephalocele presents the largest tumor of the three forms of this condition. The tumor is lobulated, pendulous, and more or less peduncu- 694 ENXEPHALOCELE. DIAGNOSIS. PKOGNOSIS. TREATMENT. lated; and there is fluctuation, translu- cency of parts of the tumor, according to the amount and location of the liquid contained within it, and usually absence of pulsation. The surface of the mass is covered with hair if the tumor is small, but if large the hair is only about its base, being absent over its. fundus. It is liable to increase of size and to final rupt- ure with rapid collapse or convulsions prior to death. Pressure does not pro- duce the marked signs of cerebral com- pression observed in cases of encephalo- cele. In some cases some form of pa- ralysis may also be present, with micro- cephalus and hydrocephalus. Differential Diagnosis. — Any of these conditions may possibly be confounded with cephalhfflmatoma, serous or seba- ceous cysts, abscesses, ntevi, and polypi. Such mistakes having been made, it is most important that the most careful ex- amination should precede any surgical interference; but, with ordinary care and attention to the physical characteristics of these forms of hernia cerebri, mistakes of this kind should never occur. The diagnosis, therefore, is usually a simple matter, and is readily made upon careful examination of the tumor. The fact that these conditions usually occur in the median line, that meningocele is redu- cible, that encephalocele is attended by signs of cerebral compression when press- ure is made upon the tumor, and pul- sates distinctly, and that all of them are made tense upon forced expiration, should separate them from any of the above conditions. In many of the cases the edges of the bony opening through which the protrusion occurs can be felt by palpation, with partial reduction by pressure. I/ydrencephalocele can hardly be confounded with any of the above affections, owing to its large size, its pendulous, pedunculated, and lobulated conformation, with semitranslucency, and its strictly congenital history. All of these cases are apt to be associated with other deformities, and some form of paralysis is frequently present in cases of hydrenceplialocele. Etiology and Pathology. — The excit- ing causes of these three forms of con- genital malformations are practically un- known. It is probable that injury to the mother may account for some of the cases. The influence of certain maternal impressions may operate here, by in- ducing an arrest of development. The most widely accepted view of the pathology of these states is that they are all due to a primary intra-uterine hydro- cephalus, and that the resultant in- creased intracranial pressure during the closure of the cranial cavity causes a por- tion of the intracranial contents to be forced outside, an aperture being main- tained. Other possible causes are am- niotic adhesions to the scalp of the foetus, and arrest of development in the bones concerned. This arrest of bony develop- ment may be caused by amniotic adhe- sions. However, the fact that these pro- trusions occur in the median line favors hydrocephalus as the causative condi- tion. Prognosis. — The prognosis is unfavor- able, except in cases of small meningo- cele amenable to operation, and in cases of small encephalocele, some of which live for many years. Ilydrencephalocele is usually a fatal condition, death occur- ring in from a day or two to several weeks. Treatment. — Meningocele has been frequently aspirated, and the injection of iodine into the sac in the form of Morton's solution has been practiced. Many forms of operation have been tried in these cases, and successful operations have been reported from all of them, but, EXCEPHALOCELE. TREATMENT. 695 even in the successful cases, chronic hy- drocephalus has often followed. Attempts at the removal of encepbalo- cele by operation have been made by Lichtenberg, Czcrny, and tlie author. Lichtenberg's patient died from the op- eration; Czerny's patient survived the operation, but died later from apparently independent causes. Personal case in which the patient made a permanent recovery: that of a Swede, in whom was found a tumor filling the post-nasal space above the soft palate. On palpation the tumor seemed somewhat compressible, and would, upon pressure, appear to decrease in size so that it could be pushed up into the left half of the posterior nares. The pedicle could be traced to the roof of the nose. Cerebral hernia suspected. Hypodermic needle twice inserted with negative results and diagnosis of ordi- nary polypus and not basal hernia made. An attempt made to remove the growth in the usual way witli the wire snare and the pedicle divided. After with- drawal of the snare slight hfemorrhage occurred, but neither coughing nor sneezing brought forth the tumor. The hoemorrhage soon ceased, but was im- mediately lollowcd by dripping of a clear watery fluid, of which about a teaspoon- ful was collected. The fluid was cere- bro-spinal. The basis of the plan of op- eration now was to secure the pedicle for transfixion and ligature as close to its exit from the cranium as possible. The operation of the osteoplastic or tem- porary resection of the superior maxilla as devised by von Langenbeck was ac- cordingly executed. Ten weeks after the operation the wound was so nearly closed that collodion dressing could be applied over the fistula lending into the antrum, which remained open for about three months, but secreted little and did not interfere with the patienfs work as coachman. The microscopical examination showed distinctly that the tumor was a cysto- encephaloccle. Although no layer of white brain-substance was present, there was no doubt that this cavity was a contin\iation of a ventricle, probably the third ventricle. Its regular shape, and the fact of its being entirely surrounded by a layer of cortical brain-substance, made it distinctly difTerent from the serous cavities which are found in her- nias of the brain as well as of the spinal cord, developed from, or an exaggeration of, the subarachnoid lymph-spaces. The distance between the eyes a point in diagnosis. It is possible that a basal cerebral hernia might cause a broaden- ing of the root of the nose and a corre- sponding increase in the distance be- tween the inner walls of the orbits, just as occurs in sincipital hernias. Chris- tian Fenger (Amer. Jour. Med. Sci., .Jan., '95). Treves operates in these cases only when rupture is threatened. Schatz (Berliner klin. Woch., No. 28, '8.5) gives statistics as follows: 3 recoveries in 24 occipital tumors not operated on, and 6 recoveries from 35 operated on by in- jection, clamp or ligature, or excision. Six recovered out of 46 frontal tumors without operation, while 2 recovered out of 14 operated on. The tendency at present is to operate upon these cases, although the results are not very encour- aging. When the tumor is not small, it should be supported by gentle pressure, — or a collodion dressing may be applied over it, as advised by some surgeons. In the case of a small encephalocele it is better to apply gentle pressure, and to wait in order to find out if it inclines to enlarge. In this form the patient may live many years and experience no dis- comfort from the condition. Cases of spontaneous cure of encepha- locele and meningocele have been re- ported. This is effected by gradual gro^-th of bone around the opening, with retraction of the sac. The opening in some cases becomes entirely closed. This is, however, of very infrequent occur- rence. Charles M. ITat, Philadelphia. 696 ENDOMETRITIS. VAKIETIES. SYMPTOMS. ENCHONDKOMA. See Tumobs. ENDOCARDITIS. See YALvaLAB Diseases and Index. ENDOMETRITIS.— Gr., h'Sov, within, and urrpa, the uterus. Definition. — An inflammation or hy- perplasia of the uterine mucous mem- brane involving, to a greater or less ex- tent, the parenchyma of the uterus. Varieties. — It is convenient, both in a clinical and a pathologic sense, to divide the disease into two varieties, viz.: (1) interstitial or functional endometritis; and (2) glandular or functional endome- tritis, or hyperplasia. Either of these two varieties may exist in the acute and chronic form, but the chronic form may follow a mild and overlooked acute at- tack, or may supervene in a gradual man- ner without being preceded by a recog- nizable acute attack. Tliere are three varieties of endome- tritis: the glandular, interstitial, and fungous. The form described as endo- metritis decidua is a combination of the glandular and interstitial forms, while gonorrhoea! endometritis is of the inter- stitial variety and similar to senile endometritis. Winckel (Munchener med. Woch., July al, '94). Endometritis is exceedingly rare; only about one case in fifty that come to the clinics is really endometritis. II. A. Kelly (Med. Record, May 21, '98). Patients with painful endometritis are apt to complain of general ncn'ous symp- toms rather than local; hence they are often regarded as purely neurotic. This error is also due to superflcial examina- tions and the failure to test the sensitive- ness of the endometrium, the uterus being regarded as normal because it is not enlarged. Tliere is an intimate re- lation between the sympathetic nerves of the pelvis and the lumbar plexus, as shown by the pains on the inner aspect of the thighs in connection with painful endometritis. SneguirefT (.Archiv f. Gynilk., B. 59, H. 2, 1900). Symptoms. — The symptoms may be divided into (1) disturbances of the sex- ual fimctions, (2) intermenstrual dis- charges, (3) pain and discomfort in and about the uterus or radiating from the uterus, (4) reflex disturbances, and (5) general symptoms. Menorrhagia is one of the most fre- quent symptoms in the early stages and in the glandular variety it often persists for a long time as the most prominent one. The flow may be moderately increased in amount, or be a profuse hemorrhage with the passage of clots; it may be pro- longed, or may recur too often. In the later stages of septic or interstitial en- dometritis the menses are sometimes scanty. In certain acute attacks the menstrual flow is suppressed. Dysmenorrhoea is common in cases connected with flexion, puerile cervix, or inflammation of the appendages. Dysmenorrhoea and menorrhagia from wliicli many young girls suffer are due to endometritis, and the chief causes leading to this condition are tight cor- sets, exijosure of the feet to wet and cold, chronic constipation. A. Lapthorn Smith (Amer. Medico-Surg. Bull., May 30, '96). Dyspareunia and sterility may be pres- ent under the same conditions. Sterility in woman is most frequently due to catarrhal endometritis, resulting from a previous miscarriage. The prin- cipal causes are: the absence of a suit- able liabitat for the ovum in the uterine cavity; obstruction of the cervical canal by mucus; and increased alkalinity of the cervical secretions, corresponding to an exaggerated alkaline condition of the vaginal mucus. W. P. Manton (Amer. Jour, of Obst., No. 4, '92). Leucorrhoca is usually noticeable in the glandular variety and in the early stages of the septic. In the former the corpus secretes a thin, and the cervix a thick, clear mucus, both of which may bo transformed into minute white co- ENDOMETRITIS. DIAGNOSIS. 697 agula, at the external os, by the acid vaginal secretion, and appear at the vulva as a white or greenish-white dis- charge. In some cases the mucus is intermittingly tinged with blood. The leucorrhcea may last throughout the month, or only for a few days after the cessation of the monthly flow. In the septic variety the discharge is at first purulent, but later becomes muco-puru- lent, and in time may be mucous or even watery in character. It sometimes has a disagreeable odor. Pain may be felt in the sacral or lum- bar region, and may extend across the back or up the spine to the occipital region, or down the course of the sciatic nerve. Cutting or cramping pains across the lower abdomen or pubic region may be complained of, depending upon pain- ful uterine contractions due to the expul- sion or attempted expulsion of uterine discharges. Irritability of the bladder or rectum, or pain in the vagina or pubic bones, may be prominent. Feelings of weight in the vagina, and sensations as of prolapse of the pelvic organs are pres- ent in some cases. Intercostal neuralgia is not uncommon. Menstrual pain of a burning or aching character may be felt in the pelvis and back, or the pain may be suprapubic and colicky. It may last one or more days oi throughout the period, and even for sev- eral days afterward. '\^1ien the mucous membrane is exfoliated the uterine con- tractions are frequent and excessively painful, and last until the membrane is expelled. Gaseous distension of the intestines, constipation, impaired digestion — with its accompanying reflexes, photophobia, and pain in the eyes after prolonged at- tempts at reading — are the ordinary re- flex disturbances. Jlental depression, worry, and the various manifestations of hysteria and neurasthenia are sometimes classed among the reflexes, although they are, as a rule, largely dependent upon other conditions and circumstances. Chills, fever, and the other general sjTnptoms of inflammation and sepsis are observed in acute endometritis. In chronic cases ana;mia and nervous debility are often present. Diagnosis. — Endometritis must be dif- ferentiated from angioma, tuberculosis, carcinoma, and myoma of the uterine mucous membrane. Besides the symptoms, tenderness of the uterus, as evidenced by bimanual palpation, and sensitiveness of the endo- metrium at the internal os and fundus, as demonstrated by the passage of the sound, are of diagnostic value. The withdrawal of the sound may be followed by a moderate flow of blood or mucus. Differential diagnosis between catarrh limited to the cervix and cervico-cor- poreal catarrh: (1) thin, purulent dis- charge indicates catarrh of corporeal en- dometrium; (2) cervical catarrhs sel- dom occur in multiparre; (3) reflex symptoms point to trouble of mucosa; (4) cervical catarrhs are rare in virgins, cervical and corporeal catarrh still more so. Van Tussenbroek and de Leon (Archiv f. GynUk., B. 47, '94). Endoscopy recommended in the study of cndo-uterino alTections; the technique is not dillicult. Bumm (La Semaine MCd., June 15, '95). [It is certainly doubtful whether the examination of the uterus by the endo- scope affords information that justifies the dangers of carrying infection to the uterine cavity. E. E. Montgomery, Assoc. Ed., Annual, '00.] The pronounced tenderness of the en- dometrium on the touch of the sound is characteristic of painful endometritis. As a rule, only certain localities (fundus and tubal insertions) give rise to the attacks of pain. The use of the curette brought recovery; a glandular hyper- plasia could generally be found in the 698 EKDOMETRITIS. ETIOLOGY. debris. Pinkuss (Monats. f. Geb. u. Grn., B. 11, S. 90S, 1900). It is difficult to distinguish AXGiOiiA from hemorrhagic glandular endome- tritis except by the aid of the curette, which, in the latter case, will bring out some of the hyperplastic mucous mem- brane. In TUBERCULOSIS of the endometrium the curette will find necrotic, cheesy par- ticles and perhaps tuberculous tissue. An accompanying bilateral salpingitis and pelvic peritonitis with encysted ascites, particularly in virgins, indicate the condition. Tuberculosis elsewhere, and a slowly progressive anaemia, add probability. In CARCINOMA and sarcoma watery discharges, fcetor, gradually-increasing metrorrhagia, rapid progress and the mi- croscopical examination of the findings of the curette are diagnostic. Carcino- matous infiltration of the cervix produces a globular enlargement that affects the supravaginal portion as much or more than the vaginal. Carcinomatous ulcer- ation is excavated, fissured, pale red or grayish, with vascular spots that are fri- able and bleed easily upon being touched. A tenaculum tears it easily and causes abundant haemorrhage, but will hold firmly in an inflamed cervix. ^V^len there is cystic degeneration the tenacu- lum may tear out easily, but it causes a flow of mucus from the lacerated follicles with or without some hemorrhage. The inflamed cervix is usually soft and elastic, the carcinomatous either hard or friable. Two cases of endometritis closely simulating cancer of the fundus in order to emphasize the fact that the micro- scope as a means of exclusion is quite as valuable as in the positive diagnosis of cancer. The microscopical examina- tions of uterine scrapings in cases of suspected carcinoma may be of value in differential diagnosis either as a posi- tive or negative factor. It is positive when the examination shows without • question the presence of cancer; it is of just as great value when it as cer- tainly reveals the benign nature of a pathological process which has given rise to symptoms characteristic of can- cer. Anspach (Univ. of Penna. Jled. Bull., May, 1901). Small intra-uterine and submucous mtomata usually cause marked enlarge- ment of the uterine cavity, and can sometimes be felt by the sound. Digi- tal examination of the endometrium through the dilated and incised cervix is of great value in discovering this, as also of other conditions, although the pro- cedure is a mutilating one and only ad- visable in rare instances. Etiology. — Acute endometritis may re- sult from trauma or taking cold during the menstrual congestion, such as sup- pression of menstruation from exposure to cold, excessive coitus, overexertion, or blows upon the lower abdomen during' menstruation. It may also be caused by infection, such as inoculation by gonor- rhceal pus during or following coitus, in- fection of retained secundines, or the ex- tension of sepsis from vaginal inflamma- tion. Bacteriological examination of the en- dometrium in twenty-five cases of endo- metritis made and fourteen distinct spe- cies of micro-organisms were found. Brandt (Med. Chronicle, Apr., '92). The pyogenic form is most common in puerpera;. The streptococcus pyogenes is nearly always the active agent, though staphylococci, gonococci, and the bac- terium coli commune may be etiological factors. DiJderlcin (Centralb. f. Gynilk., No. 20, '95). ICiidometritis is the result of infection with pathogenic micro-organisms which are carried into the uterus' during the puerperal stale, by means of examina- tions with unclean instruments; by moans of sterilized instruments used in the vagina which has not been disin- fected; by the gonococcus in about 35 jier cent, of the cases, and by the bacillus ENDOMETKITIS. ETIOLOGY. 699 of tuberculosis in 12 per cent. Every case should be submitted to radical treatment by means of the sharp curette and drainage with iodoform gauze. J. T. Jelks (Inter. Jour, of Surg., Feb., '90). One hundred and seventy-nine cases of puerperal endometritis studied and placed in three principal groups: — 1. Pyogenic form due to streptococcus pyogenes (74 cases) ; the pyogenic form due to staphylococcus pyogenes aureus (4 cases). 2. Gonorrhoeal form (50 cases). 3. "Putrid" form due to saprogenic bacteria (50 cases). Six fatal cases recorded, and in all the infection was due to streptococci. In some of the eases the infection appeared to be of a mi.\ed form. KrOnig (I'Ob- stetrique, Jan., '97). Endometritis may also follow trauma- tism with immediate or subsequent infec- tion, such as lacerations of the cervix during labor or by instrumental dilation, curettage of the endometrium, the in- troduction into the uterus of strong irri- tants, the use of intra-uterine stem- pessaries or poorly-fitting vaginal pes- saries, irritating and unclean tampons, etc. Experiments demonstrating the bac- tericidal property of vaginal secretion. With the exception of the gonococcus, bacteria cannot vegetate for any con- siderable length of time in the uterine canal. Menge (Deutsche med. Woch., Nos. 40 and 48, '94). In twenty-nine cases of endometritis of body no trace of bacteria found by micro- scopical examination or cultivation. Dis- ease of mucous membrane not therefore kept up by bacteria in this region. This docs not exclude the fact that disease of the mucous membrane arises from acute septic or gonorrheal infection. Bumm (Centralb. f. Gynllk., No. 20, '95). Secretion obtained from the cavity of the uterus of 00 cases and examined microscopically and by cultures with the following results: In 21 patients, mostly cases of fungoid endometritis, no bacteria were found, and in most of the cases repeated examinations gave negative re- sults. Seven of the 21 cases showed the presence of bacteria of some kind after frequent intra-uterine manipulation, probably due to inoculation by the in- struments. The bacteria, however, were not pathogenic. The 39 remaining cases in which bacteria were found may be divided into two groups: those in which staphylococci were found and those in which non-pathogenic bacteria were pres- ent. Streptococci were absent in all cases examined. S. Gottschalk and Rob- ert Immerwahr (Archiv f. Gyn., No. 3, p. 400, '90). Case of a woman in which cause of endometritis was found to be the pres- ence of oxyuris vermicularis in the vagina and uterus. E. M. Simons (Centralb. f. Gynilk., July 1, '99). Repeated examinations of the cast from a ease of membranous dysmenor- rhoea showed numerous fresh venous thrombi in the uterine mucosa, sim- ilar to the thrombi found in the de- cidua in cases of premature separation of the placenta. Curetting and caustics were not curative, but cardiac tonics, gj-mnastics, diet, baths, brought about recovery. Gottschalk (Deutsche med. Wochen., Nov. 20, 1903). Traumatism or reinfection may con- vert a chronic into an acute endometritis. Poisons, such as phosphorus and the es- sential oils, are occasional causes. Glandular endometritis may be caused by interference with the menstrual func- tion by taking cold, overexertion, coitus, laborious or sedentar)' occupations, uter- ine displacements, obstinate constipa- tion, etc. The same causes may act dur- ing puerperal involution or after abor- tion. There is no specific organism for endo- metritis of pregnancy, which is always secondary and always in existence be- fore the pregnancy. The glandular form of endometritis is an hyperplasia of the mucosa, of which the causes act indi- rectly upon the endometrium, such as onanism, sexual exccs.'ses, psychical in- fluence*, diseases of the ovaries, etc. The interstitial form is the result of infection or direct interference with the endometrium. The glandular form is 700 EXDOMETEITIS. PATHOLOGY. more frequently the cause of sterility than the interstitial variety. Veit (Zeit. f. Geburts. und Gyuak., B. 32). Excessive coitus, masturbation, ova- ritis, uterine fibroids, infiammation in neighboring pelvic organs, and interfer- ence with uterine drainage by stenosis may lead to it. Gonorrhoea of the uterus produces in all cases an inflammation of the mucous membrane, designated as an interstitial endometritis with suppurative catarrh, and in a not inconsiderable number of cases the chronic course leads to increase in the number of glands. Wertheim (Centralb. f. Gynak., No. 20, '95). Mycosis of the cervical canal is prob- ably a more frequent cause of obstinate catarrh than is generally supposed. Calpe (Centralb. f. Gyniik., No. 27, '95). Endometritis fungosa may sometimes be found in virgins. The first character- istic symptoms appear with the first mensti-uation. Infection with micro-or- ganisms, masturbation, and traumatisms are etiological factors. Latour (Kevue Inter, de M6d. et Chir. Prat., No. IS, '90). Number of cases observed in which there was chronic catarrhal inflamma- tion of the virgin uterus, and such marked eversion of the cervical lips as to give the appearance of an ordinary puerperal laceration of the cervi.x. In most instances the e.xcision of the hyper- trophic mucous membrane and curetting of the endometrium will effect a cure. P. F. Mundu (Amer. Medico-Surg. Bull., May 30, '90). Underlying a virginal or senile endo- metritis there is frequently a condition of malnutrition, spoken of in a general way as "lithoemia." Matthew D. Mann (Amer. Medico-Surg. Bull., May 30, '90). Chronic septic inflammation may result from one or more acute attacks or from infection by objects introduced into the vagina or uterine cavity whether by oper- ation, examination, or improper at- tempts at medication. Some eases of foetid endometritis in aged women may be due to recurrence of Himplc endoiiietritis of earlier life, or may be looked upon as the result of a necrotic process accompanying the elim- ination of fibromyomata from the uterus. It appears from five to fourteen years after the menopause, and attacks women , who have borne children rather than nullipari-e. Maurange (La Presse M§d., Jan. 26, '95). Case of endometritis in a person who was undoubtedly a virgin and who had not been subjected to previous local in- strumentation never seen. Howard A. Kelly (Amer. Medico-Surg. Bull., May 30, '96). Bacterial infection is by no means necessary for the production of many cases of chronic endometritis, although this condition may be the result of in- vasion by organisms, especially those of sepsis and gonorrhoea. Warbasse (Amer. Jour. Med. Sci., Feb., '98). Pathology. — The mucous membrane of the cervical cavity presents the same changes as those of other mucous mem- branes. Cervical endometritis exhibits anom- alies of secretion with reddening and swelling of mucosa. Gradual narrowing of OS; retention of secretion; contrac- tion. In consequence of retention, atro- phy of mucous membrane. Ruge (Cen- tralb. f. Gynak., No. 26, '95). Kuge divides endometritis into the glandular, interstitial, and mixed varie- ties. The glandular variety is charac- terized by an increase of the adenoid elements, the interstitial variety by an increase in the fibrous tissue, with more or less destruction of the glands; in the mixed form there is an increase of both the interstitial and the glandular struc- ture. H. J. Boldt (New York Med. Jour., Bee. 20, 1902). The alkaline mucous discharge that hangs from the cervix, together with the congestion and infiltration, often pro- duces an exfoliation of the squamous epithelium of the vaginal portion, with reproduction in the form of cylindrical epithelium. This condition is called simple erosion. The infiltration and swelling of the submucous tissues causes more or less of a rolling out, or eversion, Fi^.2 Fig. 3 ,^mm^.^^ Mi'- ■•- '\ Wii :r-^ r ■ :■ ,-. .- ; ^: f ■-■■ :,' s ■■■■ ' ::::^f^M^^O:- ^ n ^ Fig. 4 Ficj. .5 ,■; .■^-'■*irvii-vx§» \^^" ^- Comparative Histology of Endometritis (Zweifel.l Fiq.l. Normal Mucous Membrane. Fiq 2.Beqinning Erosion of Corvix. Fiq 3. Glandular Endometritis Fiq 4. Acute and Chronic Interstitial Endometritis, Fiq S. Chronic Interstitial Endometrit:s. ENDOMETRITIS. PATHOLOGY. 701 of the mucous membrane of the cervical 1 cavity, which is more pronounced on a lacerated cervix. More or less folding of the mucous membrane may give the ap- pearance of a papillary or granular sur- face, which is called papillary erosion. Pockets may form in these folds and, to- gether with the everted cervical glands, may become occluded, giving rise to a cystic condition called follicular erosion. These follicles may become so numerous, or one or two may become so large, that the normal cervical tissue is either dis- placed or replaced by them, and cystic degeneration thus results. Sometimes localized hyperplasias are present, with projection of glandular polypoid masses. (See Colored Plate.) The uterine mucous membrane above the internal os has somewhat different characteristics from those of other mucous membranes which have different functions. Its glands are simple depres- sions or epithelial tubules that extend to the muscular walls underneath. Instead of being imbedded in firm connective tis- sue as are the cervical glands, they are surrounded at their inferior extremities by muscular fibres projecting from the muscular walls, which constitute an ill- defined muscular structure called the muscularis mucosa;. In the interglandu- lar or intertubular spaces or fluid are found delicate connective-tissue fibers and round or oblong cells resembling lymph-cells. When subjected to intense prolonged congestion an infiltration of serum takes place, raising the epithelial surface and causing a proliferation of the epithelial cells, with enlargement, as well as wrink- ling, twisting, or bending of the glandu- lar tubules; or in severe cases a forma- tion of new depressions or tubules, some of which may become closed by bending or swelling at their orifices. In some cases the epithelium prolifer- ates within the glands, forming more than one layer. Round-cell infiltration and formation of new interglandular tissue may take place, particularly if mild septic infection intervene. In such cases agglomerations of glands sur- rounded by a small amount of connective tissue project from the surface, forming polypoid masses, which may spring from every part of the mucous surface. Histologically, the epitlielium covering the mucous surface is composed chiefly of large, nucleated leucocytes; it is swelled and somewhat distorted. The uterine glands may be normal in part, but the mouths of the glands are very much swelled ana there are many pus- cells present. In chronic endometritis the mucous membrane is highly granular and has an appearance like that of polypi. The term granular endometritis is highly improper, and should be abandoned. Only fortj'-nine cases of endometritis found in eighteen hundred gyniECological cases at the Jolins Hopkins Hospital. The treatment consists in dilating and curetting the uterus. Thomas S. CuUen (Med. Record, May 21, '98). Decidual cells are never found in the stroma of the endometrium in the gland- ular forms of endometritis. Cells re- sembling the decidual are found in the interstitial and mixed forms of endo- metritis, but only in the superficial lay- ers. These cells lie at some distance from one another among the compara- tively normal cells of connective tissue. Trtvilladaroir (Roussky Vratch. Mar. 6, i!m4). The uterine walls are usually also congested, and some round-cell infiltra- tion takes place about the blood-vessels, wliich, in time, leads to the formation of adult connective tissue. Contraction in this connective tissue may finally cause anaemia of the uterine walls and more or less atrophy of the muscular fibres. The mucous membrane is hyperaemic, softened, thickened, and dark red in 702 EXDOilETRITIS. PATHOLOGY. color. In places it may have a mottled appearance, due to minute extravasa- tions of blood. The surface is smooth, sometimes irregular, and is moistened with a thin, clear, grayish or pinkish mucus. The pouting mouths of the con- gested and enlarged glands are -risible. The uterine walls are slightly thicker and the uterine cavity somewhat longer than normal (from 2 ^/^ to 3 inches deep from the external os to the fundus). This condition is that of glandular en- dometritis, or hyperplasia of the endome- trium, and is seldom the result of infec- tion. It is, as a rule, chronic. During the menstrual periods the con- gestion is intense, and there is more or less extravasation of blood in the inter- glandtilar spaces, and an extensive ex- foliation of the epithelium. When the congestion results suddenly from causes acting during or just before the menstrual period, it is also intense and accompanied by interglandular ex- travasation and blood-stasis that inter- fere with the menstrual discharge, and which, if not relieved, runs into the chronic form. In ac«/e septic endometritis the blood- vessels of the endometrium are engorged and increased in number. There is con- siderable exfoliation and proliferation of the epithelial cells, sometimes to such an extent as to cause a superficial ne- crosis. The interglandular spaces are crowded with round cells, leucocytes, and cocci which may extend into the muscularis mucosae and, if streptococci be present, a short distance into the uter- ine walls. Congestion, extravasation of blood, serous and round-cell infiltration take place throughout the uterine tissue, and a fibrinous exudate may appear on the peritoneal surface. Eighteen cases of infectious diseases, showing ttiat the blood-vceaels of the endometrium were inlcnnely congested, particularly the small veins and the cap- illaries. Ecchymoses, either in patches or disseminated all over the surface of the mucous membrane, were present. The glandular epithelium was swelled, the cells were desquamated, and the lumina of the glands filled with cells, mucus, and blood-corpuscles. The glands frequently penetrated very deeply into the muscular layer, this being a charac- teristic sign of endometritis. An haemor- rhagic endometritis was found to be pres- ent in all of these cases. Massen (Gaz. de Gyn., Mar. 15, '91). There is a more or less abundant flow of pus from the endometrium. In chronic septic endometritis round cells and leucocytes crowd the inter- glandular spaces, compressing the glands and in places penetrating and destroying them. After a time the formation of contracting adult connective tissue com- presses and obliterates some glands, and obstructs the mouths of others, convert- ing them into small cysts. The epi- thelium in the atrophic glands and on the surface also degenerates; so that in old and senile cases the mucous mem- brane may be represented by a thin layer of sclerotic connective with only vestiges of epithelial structure. The uterine walls, at first hyperaemic and infiltrated to a greater or less depth with serum and round cells, are thicker and softer than normal, but later, owing to the contraction of the inflammatory tissue, become hardened. The atrophy of the muscular tissue and absorption of the serum, as well as the senile changes, may finally lead to a diminution in size of the entire organ. Endometritis occurring in connection with abortion may interfere with the atrophy of the decidua, and masses of decidual cells may be found in the en- dometrium in connection with the round- cell infiltration. In some cases the menstrual conges- tion is 80 great that an acute attack is ENDOMETKITIS. PROGNOSIS. TREATMENT. 703 practically lighted up at each period. The stroma-cells are enlarged and re- semble decidual cells, and the tissues are crowded with leucocytes. The conges- tion is so great that there is an abundant extravasation of blood in the intergland- ular spaces, which loosens the superficial portion to the extent of causing its ex- foliation in places or even entire, as a more or less complete cast of the uterine cavity. After the menopause the cervix may become stenotic, and the discharges be retained. The uterine cavity may then become distended, and the uterine walls attenuated by an ofEensive and purulent fluid. The menopause does not e.xercise a curative influence upon endometritis and its resulting leucorrhoea. Jacobs (Amer. Jour. Med. Sciences, Apr., '94). The characteristic pathological features of acute senile endometritis are a thick- ened endometrium, the free surface of which is devoid of its epithelial layer; increased vascularity with peculiar ar- rangement of small blood-vessels; small round-celled infiltration; diminished glandular elements; degeneration of the coats of the arteries of the muscular layer of the organ; in not one section examined from various parts of the organ could there be found any increase of con- nective tissue. L. H. Dunning (Jour. Amer. Med. Assoc., Nov. 3, 1900). Prognosis. — The prognosis of acute metritis in the puerperal state or after abortion is grave. The patient may die of septicaemia, or the disease may extend to the Fallopian tubes, ovaries, and peri- toneum, or into the veins or lymphatics of the broad ligament, or it may result in chronic endometritis and subinvolution. When not connected with pregnancy the disease seldom terminates fatally, but is apt to extend to the adnexa or become chronic. Acute cervical metritis mav end in re- covery, but, as a rule, becomes chronic. Chronic cervical metritis may get well, but, as a rule, it persists for a long time. It can ordinarily be cured either by local treatment or operation. Chronic corporeal endometritis of the septic variety is apt to get well if there is good drainage through the cervix. Without adequate drainage it becomes chronic and is liable to spread to the adnexa. In the non-puerperal uterus the risk of the inllammation spreading to the tubes is little save when the cervical canal is obstructed or the infection gon- orrhoeal in nature. W. P. Carr (Vir- ginia Med. Semimonthly, Jan. 8, '97). The prognosis of foetid endometritis is favorable, though recurrence may occur after curettement. Mansange (Arch, de Tocol. et d'Obstet.; Centralb. f. GynUk., No. 21, '97). In cases of long standing the septic condition can be removed, but the endo- metrium and myometrium can seldom be restored to a normal state. The sterility is apt to be permanent. Chronic glandular endometritis can generally be cured by treatment. Mild or recent cases may get well spontane- ously, but severe cases usually persist for a long time, or until the menopause. Treatment. — For acute metrilis due to suppression of the menses the flow should be re-established if possible in the early or congestive stage. As soon as possible after the suppression the patient should take a warm sitz-bath (100° F.), and go to bed. Hot drinks, hot poultices to the abdomen and groins, and hot-water bags or bottles to the feet and legs should be employed. In married women scarifica- tion of the cervix may be used with bene- fit. The production of slight nausea by means of tartar emetic, ipecac, or lobelia is useful as a sedative to the congested pelvic organs. If the menstrual flow is re-established by these means within a 704 ENDOMETRITIS. TREATMENT. day or two, the patient may leave the bed after the flow has ceased, but should lie down two or three hours in the middle of each day, and take but little exercise for three or four weeks. At the time of the next period she should keep to the bed and repeat the hot applications, etc., if the flow does not appear on time. The bowels should be kept open by salines. If the menses are not re-established within two or three days after their sup- pression, the patient should remain in bed for a week or ten days, apply counter- irritants over the iliac and suprapubic regions, and take copious hot douches (115° to 120° F.) two or three times daily in the recumbent posture. She should secure a daily evacuation of the bowels and, if practicable, introduce small cot- ton tampons, saturated with a 10-per- cent, solution of ichthyol in boiled glycerin, high up into the vagina every other day, and leave them for about eighteen hours. Tonics and an easily- digested diet should be prescribed. Acute metritis following labor or abortion calls for a thorough evacuation of the uterus by the fingers or curette, and, if septic symptoms persist, antisep- tic intra-uterine douches every twelve hours (Vaooo of corrosive mercuric chlo- ride followed by sterilized water or 1-per- cent, creolin) and vaginal douches of the same character every six or eight hours. Treatment of beginning endometritis by means of medicated steam recom- mended. Resorcin at Vm and varying in temperature from 104° to 140° F. is used. But slight dilatation of the cer- vical canal is required, and accidents are thus avoided. The exudations become coagulated and are excreted by means of contractions, causing a mild form of colic. Sordes (.Jour, de MCd. de Bor- deau.K, Sept. 1, '9.5). Excellent roBults obtained in seven out of eight cases of septic endometritis after labor and abortion by the injection of superheated steam into the uterine cavity. The apparatus consists of a metal can with a spirit-lamp and a ther- mometer which registers up to 200° C, some rubber tubing, and a catheter. The application lasts about half a minute, and never over a full minute. By means of a tap, the current of steam can be in- terrupted while the catlieter is being adjusted before use, lest scalding or burning should occur. The temperature of the steam must be a little above boiling-point, about 110° C. The jet of steam is followed by no bad effects and gives little or no pain. Uterine contrac- tions are actively stimulated and ill- smelling discharges cease. Steam kills the bacteria in the endometrium, and as it coagulates albumin all blood-vessels and lymphatics are sealed up, and fresh granulations can develop under the pro- tective covering. Kahn (Centralb. f. Gyniik., No. 49, '96). Excellent results obtained from tinct- ure of iodine in post-partum endometritis. It acts best when used in the early stages and as often as once or even twice daily. As soon, however, as the signs of acute inflammation subside and the secretion diminishes, the remedy should be ap- plied less frequently. Pains of varying character usually follow this mode of treatment. The method of application is as follows: The patient lies on her back, and a speculum is introduced into the vagina. If the cervix is blocked with mucus, the os is drawn down with a volsella, the portio vaginalis is irrigated, and the parts dried with aseptic cotton- wool; the canal is then swabbed with the pure tincture of iodine. In cases in which the corpus uteri is also involved the remedy is applied in the same way as to the cervix. A. Solowjev (Wratch, No. 12, '97). Bromine-vapor most satisfactory agent in the treatment of endometritis. It is introduced into the uterine cavity through a double-current catheter at- tached to an atomizer, dirriises rapidly, and exerts a remarkable curative action in cases of acute ondomotritis and sal- pingitis. Nitot (LaGynOcologie,Oet., '97). A steam-jet at a temperature of 100° C. in endometritis and in various septic and chronic inllnmmatory conditions ad- ENDOMETRITIS. TREATMENT. 705 vocated after use in thirty-one cases. Used carelessly, there is some danger of obliterating the lumen, but with ordi- nary precautions it is perfectly safe. Johnson (Boston Med. and Surg. Jour., Mar. 16, 1900). When the attack follows an operation, an ice-bag should be kept on the lower abdomen for twenty-four or thirty-six hours, the infected surfaces be thor- oughly disinfected by a strong antiseptic, and one of the above-mentioned antisep- tic douches be used either to the endome- trium or vagina as required. As the inflammation subsides, hot douches, laxatives, tonics, rest in bed, etc., are indicated. In chronic uterine inflammation all causes of the diseases and all conditions that perpetuate it should receive atten- tion. Septic forms require active antiseptic treatment. In those forms of chronic endometritis in which hsemorrhage is a prominent symptom, especially where an exact diafjnosis is required, the curette is advisable, ^^'^lere leucorrhcea is the chief characteristic, or where the curette has failed, a powerful caustic is re- quired; and, of those which have proved cfTeetual, chloride of zinc is perhaps the most certain. But we may liope in the near future to see it replaced by some better method, possibly by formalin and atmocausis. Symly (Glasgow Med. Jour., May, 1902). In puei-peral septic endometritis the insertion into the uterine cavity of tampons of iodoform gauze soaked in 1 to 8 glycerin ichthyol and thickly powdered with naphthalin gives prompt and satisfactory results. Poliansky Prakt. Vratch, May 31, 1903). Displacements should as far as possible be corrected, stenosis relieved, and pelvic inflammatory conditions and tumors be treated or removed. Most marvelous results acliieved in htemorrhage depending upon chronic en- dometritis with chronic peritonitis, by the hypodermic use of a solution con- taining 1 '/, drachms each of crystallized phosphate and sulphate of soda dissolved in 4 ounces of distilled water. Erom 1 to 1 Vi drachms of this solution is to be injected into the buttock or thigh twice a week. The solution must be made fresh and filtered each time. ChCron (Jour. Amer. Med. Assoc., Apr. 28, '88). Application of an ethereal solution of iodoform to the cervical canal recom- mended in obstinate cases. Dolfiris (Bull. Gen. de Ther., No. 11, '97). The patient should remain in bed dur- ing a portion or all of the menstrual period, and take more than ordinary care of herself after abortions or confinements. WTien menstruation is imminent or present, treatment should be withheld. An exception to this rule would obtain should the flow be very profuse or pro- tracted. In the presence of an acute inflammatory process intra-uterine treat- ment should be withheld. In malignant disease of the cervix, the possibility of a severe hcemorrliage attending local treatment of whatever character must be anticipated and provided for. In all cases the risk of inflammatory reaction in pelvic structures remote from the cer- vix must be taken into consideration. Currier (Trans. Med. Soc. State of N. Y., Feb., '90). Stress laid on the complications which endometritis may set up in a patient who becomes pregnant. The acute form is generally secondary. Chronic endo- metritis attacks the decidua vera. The cause of endometritis is usually gonor- rhcea. Syphilitic endometritis is prob- able. Endometritis cannot be treated as long as the pregnancy lasts. Only when syphilis is suspected can benefit be de- rived from drugs. After delivery or abortion the endometritis can be treated by the free use of the curette. The in- creased vascularity of the decidua vera explains the frequency of hasmorrhages during pregnancy. The decidua rcflexa is rarely attacked: hence the placenta is usually found healthy, and the child may be delivered alive. Tarnicr (Jour, des Sagcs-fcmmcs, .Tan. 1, '01). Chronic glandular endometritis, alone or in connection with chronic septic or 706 ENDOMETRITIS. TREATME^'T. interstitial endometritis, and all menor- rhagic cases uncomplicated by pelvic peritonitis should be curetted. Dilatation, curetting, irrigation, and draining recommended as the best and most rapid method of obtaining a cure. Waldo (X. Y. Med. Jour., Feb. 13, '92) ; Baldy (Med. and Surg. Rep., Mar. 12, "92) ; Xoble (Annals of Gynsecology and Psediatry, June, '92) ; Garrigues (Times and Register, Apr. 30, '92) ; Gossmann (Muncliener med. Woch., May 31, '92) ; Thielhaber (Miinchener med. Woch., June 28, '92) ; Goffe (Virginia Med. Monthly, Sept., "92). Sixty-five cases of endometritis fun- gosa treated by curetting; 92.2 per cent, completely cured; 13.8 per cent, much improved. Should be performed with patients in Sims's position. Hans Vogel- baeh (Inaugural Dissertation, '9-1). The most thorough results are ob- tained when both the curette and the sharp spoon are used, especially the smallest-sized instruments, which can be inserted into the cornua of the uterus and between the rugse. Where there is marked glandular hyperplasia, early re- currence is apt to follow the most vig- orous scraping unless the raw surface is thoroughly cauterized at once. R. Werth (Archiv f. Gynilk., B. 49, H. 3, '95). In 297 eases treatment consisted of dilatation and curettage of the uterine cavity, followed by thorough application to the endometrium of 50-per-cont. solu- tion of chloride of zinc in the worst cases, and of a solution of iodized phenol in milder cases. A sterilized drain was tlien inserted tlirougli the internal os, the patient put to bed, and all precau- tions taken against inflaiiiniatory reac- tion. A repetition of the cauterization with milder solution, if thought best, usually resulted in a permanent cure in the course of two or three weeks. There were 197 cures and 94 cases of improve- ment out of 297 operation.^, only C being mentioned as discharged unimproved. The best hope for a permanent cure of chronic endometritis would result from impregnation and normal delivery. Paul F. Munde ("Report of Gyntccological Service at Mount Sinai Hospital," '95). In acute catarrhal endometritis elec- tricity is an effective remedy, faradiza- tion and the negative pole of the gal- vanic current fulfilling the requirements of local treatment. In chronic catarrhal endometritis the positive pole of the gal- vanic current and zinc electrolysis, com- bined with faradization, are also effect- ive. Acute septic or speeifie endome- tritis demands gentle dilatation and thorough irrigation with antiseptic solu- tions. In chronic endometritis resulting from septic or specific infection, cu- rettage, gauze drainage, and subse- quently irrigation. Senile endometritis can best be overcome by dilatation and drainage brouglit about by means of the negative pole of the galvanic current, and, when necessary, irrigation of the cavity with a saturated solution of boric acid or Thiersch's solution. A. H. Goelet (Amer. Jour, of Obstet., Sept., '95). Curettage has proved disappointing; if the infection of the mucous membrane is recent, curetting is very liable to open up new channels of infection, carrying the inflammation to deeper parts; if, on the contrary, the infection is an old one. the deepest portions of the endometrium have probably become affected, and those laj'ers curettage could not remove without destroying the entire mem- brane. In eases of septic and of acute puerperal infection, curettage is, there- fore, useful only for the purpose of removing foreign material, retained and adherent (Kbris, etc. H. T. Byford (Wisconsin Med. Recorder, iii. No. 11, 1900). When the curette is employed due care should be exercised. Eough manipula- tion and undue pressure upon the uter- ine surfaces have been followed by un- toward results. Curettage should be avoided when there is tenderness in the tissues beside the uterus. Temporary uterine paralysis occasion- ally occurs during the operation of cu- retting under chloroform mircoaia, which might lead one to think that ho had perforated the uterine wall and was mov- ing the curette freely in the peritoneal cavity, were it not for the absence of shock, as manifested by the normal pulse, ENDOMETRITIS. TREATMENT. ror respiration, and appearance of the pa- tient. Geyl (Arch. f. GynUk., II. 3, '88). Four eases noted where death has oc- curred from septic peritonitis after cu- retting. Reeves Jackson (Annals of Gynec., Apr., '88). Case of death reported resulting from an intrauterine injection of perchloride of iron. The patient was curetted for endometritis, and, owing to the bleeding, the following day iron was carefully in- jected drop by drop. She died two hours later. At the post-mortem clots were found in the uterus and thrombi in the iliac veins. Pletzer (Provincial Med. Jour., Aug., '92). The greatest danger of the curette does not lie in perforating the walls ot the uterus, but in salpingitis, the ex- citation of peristaltic movements, and the forcing of material into the peri- toneum. The worst procedure that can be imagined in this connection is to fol- low curetting by injection. Landau (Med. Press and Circ, Dec. 5, '94). Case in which perforation with curette ended in death. Ratlay (These de Paris, '95). [Uterus punctured in a number of cases and in none of them have any ab- normal symptoms resulted. E. E. Mont- gomery, Assoc. Kd., Annual, '9G.] Regeneration of endometrium after curetting varies widely, according to manner in which operation performed. Where tliere is marked glandular hyper- plasia, early recuiTence apt to follow most vigorous scraping unless raw sur- face cauterized at once. When liquor ferri applied after curetting, regenera- tion of epithelium delayed. R. Werth (Archiv f. Gyniik., B. 49, H. 3, '95). Fifteen days a minimum limit for the uterine mucosa to reproduce itself so as to be physiologically active after cu- retting. Bossi (Gaz. degli Osp., Feb. 2, '95). Exfoliative endometritis and polypoid endometritis may require more than one curettage. In a large proportion of cases the cer- vical canal is small or bent, and must be kept diluted for several weeks subse- quently to promote uterine drainage. Introduction of a gauze pad or drain into the non-puerperal uterus for the purpose only of drainage is unnecessary and possibly open to objection. While the presence of a pad of gauze in a flabby, septic uterus after curetting may produce contraction of that organ, still it acts as an obstacle to the escape of septic discharges. H. C. Coe (Amer. Gyntec. and Obstet. Jour., June, '95). In others it is necessary to use strong astringents and antiseptics to the endo- metrium, to counteract the tendency to a recurrence of the hyperplasia or the sepsis. The hot vaginal douche twice daily acts beneficially as a sedative to the pel- vic circulation, and aids in keeping the vagina clean. Local treatment may be commenced in two or three weeks after the operation. If the cervix is small or bent, a round dilator, or male urethral sound Xo. 13 to No. 15, should be passed through the internal os once or twice a week. In order to avoid infection, the patient should take a large hot vaginal douche shortly before the treatment, and the gynagcologist;. should wipe out and dis- infect the vaginal fornices and cervix through the speculum before intro- ducing the disinfected sound. After the sound is withdrawn a 50-per- cent, solution of ichthyol in glycerin may be applied to the endometrium, or, if the case has been an ha3morrhagic one, pure lysol or carbolic acid, or a 20-per- cent, solution of chloride of zinc, every ten days to two weeks. Carbolic acid most efficient and safest application. Does not bum deeply enoiigh to destroy subnnieous tissue. Not good practice to make traction upon organ and pack it every other day. A. P. Dudley (Amer. Jour. Obstet., Sept., '05). Treatment by chloride of zinc given up because of the tendency of this ngcnt to produce cicatrization of the surface. A. Jacobi (Med. Record, Oct. 19, '95). 708 ENDOMETRITIS. TREATMENT. More general use of nitrate of silver i advocated in the treatment of endometri- tis. The application of the nitrate of silver should be made carefully and thoroughly, and to do this it is abso- lutely necessary that all unhealthy se- cretions should be removed previously from the interior of the uterus, and the latter be left clean and dry. For mild cases and those seen early 5- or 10-grain solution of nitrate of silver used, but the more chronic cases require much stronger solutions or even a light touch- ing with the solid stick. William H. Eobb (N. Y. Med. Jour., Dec. 5, '96). Applications of nitrate of silver are followed immediately by an apparent im- provement or cure; but further observa- tion will show that the treatment has left an atrophic, non-secreting, and irri- table endometrium. There is no such objection to the use of the curette. L. J. Brooks (X. Y. Med. Jour., Dec. 5, '96). Three-per-cent. solution of lactic acid injected into the vagina overcomes the odor that may be present in cases of leu- corrhoca, changes the color of the dis- charge, and may be used without danger in ambulatory practice and in cases of salpingo-oijphoritis. In certain cases the intra-uterine employment of a stronger solution may be substituted for the use of the curette. Ilkewitsch (Centralb. f. GynUk.; Texas Med. News, Dec, '97). Naphthalin gives excellent results in cases in which there is no general septi- caemia. After drying the endometrium with dry tampons, or curetting in re- tained placenta, a long strip of iodoform gauze (3 per cent.) is dipped into ichthyol-glycerin (1 to 8), squeezed out, and powdered abundantly with finely- powdered naplitlialin. This strip is then used to tampon the uterus, leaving the tampon in position for from six to twelve hours. The temperature usually falls to normal two or three hours after remov- ing the tampon; the discliarge loses its fijetidity and recovery is inaugurated. If tliia docs not occur, a second tampon should be inserted twelve hours after the removal of the first. Kirzner (Med. News, July 28, 1900). Sircdey's method, viz., the injection of a 12 to 1000 solution of picric acid into the uterine cavity by means of Braun's syi-inge used in 21 cases. The solution is prepared with hot water, allowed to cool, and decanted. It may be kept sterile for an indefinite time. The cerv- ical canal is disinfected with cotton im- pregnated with iodoform-ether, and the syringe is introduced into the cen'i.'c, and~ about 2 cubic centimeters injected into the uterine carity. The vagina is tamponed with iodoform gauze, tlie plug being worn till the next day. The va- gina is washed daily with a hot solu- tion of potassium permanganate. The writer also disinfected the external gen- itals and irrigated the vagina before the introduction of the speculum. The cases were thus treated until the gonoeocci disappeared. Picric acid proved very efficient and non-toxic and showed a marked antibacterial action against gonoeocci. The injections far from be- ing caustic, were analgesic. Serra (Eiforma Medica, June 24, 1903). When there is tenderness or irritation in the tissues beside the uterus, curettage and intra-uterine medication are liable to do more harm than good. In such cases a copious hot vaginal douche (120° F.) should be taken at or near the noon hour, followed immediately by two hours of rest in the recumbent position, and another douche at bed-time followed by the introduction into the vaginal vault of a tampon saturated with a 10-per-cent. solution of ichthyol in glycerin. The tampon is removed when the noonday douche is taken. Laxatives, tonics, massage, regulated out-of-door exercise, and restriction of coitus are useful adjuvants. Endometritis with stenosis and py- omctra (so-called senile endometritis) should be treated on the same principles as any pus-cavity, viz.: dilatation of the cervix for drainage, and the washing out of the uterus with antiseptic solutions once or twice daily. Henry T. Byfoud, Chicago. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE c...-,«,«.oo